Evaluating Teaching Methods about Obstetrical Emergencies among Comadronas in Urban Guatemala


Background: Indigenous traditional midwives attend 60% of all births in Guatemala where maternal deaths are the highest in Central America at 95 deaths per 100,000 births, and 90% of births in rural areas where maternal deaths are as high as 290 deaths per 100,000 births. Understanding how low-literacy traditional midwives, called “comadronas” in Spanish, learn and retain knowledge is critical to addressing the country’s maternal deaths. A paucity of data exists on comadrona knowledge of obstetrical emergencies in urban Guatemala.

Methods: A pretest posttest design was used to evaluate the effect of a culturally sensitive teaching on knowledge of obstetrical emergencies among urban comadronas. A Checklist from the American College of Nurse Midwives (ACNM) was used to assess and compare knowledge about obstetrical emergencies before and after the teaching. Participants also interpreted drawings of obstetrical emergencies used for knowledge retention.

Results: Seventeen urban comadronas participated in a one-day educational session in San Raymundo, near Guatemala City. The mean pretest score was 3.06 with a SD of 1.436 compared to the mean posttest score of 5.13 with a SD of 1.147. Change in knowledge was a statistically significant with a p value of 0.01. Participants understood simple, color drawings from Guatemala better than complex, black and white drawings from the U.S.

Discussion: Future teachings about obstetrical emergencies should present information orally in the native language of low-literacy urban participants. Future teachings also should use simple, color drawings of obstetrical emergencies from Guatemala for knowledge retention.

Key Words: Guatemala, traditional midwives, obstetrical emergencies, education


Guatemala is a small, developing country with disparate populations. Nearly 17 million Guatemalans live in a 42,042-square-mile area slightly smaller than Tennessee (Central Intelligence Agency [CIA], 2020). About half of the population are descendants of indigenous Mayans who have lived Guatemala since 12,000 BC, speaking 21 different dialects. The other half of the population are predominately Spanish-speaking Ladinos descended from Spanish conquistadores who invaded Guatemala in 1523 (Summer et al, 2019). Teaching Guatemalan comadronas about obstetrical emergencies may warrant different approaches, one for urban Ladinos and one for rural indigenous Mayans.

Indigenous Mayans are considered a marginalized group due to facing higher poverty rates (Nieves Nelazques et al, 2018), being more likely to live in rural areas with less access to resources (Chary et al, 2013) and facing worse health outcomes than Ladinos. Indigenous women endure a higher Maternal Mortality Rate (MMR) than Ladinos, accounting for 70% of maternal deaths annually (Martinez et al, 2017; Stollack et al, 2016). Indigenous Mayans also suffered disproportionately during the Guatemala’s civil war from 1960 to 1996 (Public Broadcasting System, 2011). Indigenous Mayans comprised 83% of two million injury victims (Hernandez, 2017) and 73% of 200,000 mortalities during the longest civil war in Latin America (McFarland, 2012). The country’s most recent MMR is predictable in the aftermath of Guatemala’s 36-year civil war. The MMR was 72nd highest in the world at 95 deaths per 100,000 births in 2017 (CIA, 2020).

In addition to disparate urban and rural populations, Guatemala lacks a consistent maternity care system. Obstetricians attend births in hospitals but the country’s institutional capacity for to medical services can only accommodate 20% of births (Goldman et al, 2001). Further, doctors charge more than twice the average monthly household consumption while comadronas ask for half what doctors charge and will accept payment in kind from patients without money (Goldman et al, 2001). Instead of going to the hospital, most Guatemalan women prefer to birth at home with comadronas (Juarez, 2020), who are well-respected community leaders often spiritually called to their vocation (Goldman et al, 2001). Guatemala doesn’t offer university training for midwives. The most highly educated midwives are called parteras. They receive training at birth centers often from foreigners. Comadronas, who are apprentice-trained and have low literacy, attend the majority of births (Fahey, 2013; Hernandez et al, 2017; Kestler et al, 2013, Walker 2015). Comadronas attend 90% of births in rural areas (Summer et al, 2019) and 60-70% of all births (Zeltzer, 2018) In 2018, 23,320 comadronas were registered with the Guatemalan Ministry of Health (Zeltzer, 2018).

The government has offered since 1955 training programs for comadronas that have been modified several times (Goldman et al, 2001). Currently, the government program is 15 hours a day for eight days and is taught by a nurse with at least one year of education (Goldman et al, 2001). Topics include basic hygiene and how to identify “signs of danger” so complicated cases can be transferred to hospitals (Zeltzer, 2018) Practicing midwifery is illegal without the government training (Goldman et al, 2001). Licensing for midwives was introduced in 1935 (Goldman et al, 2001). In exchange for attending government trainings programs, comadronas are supposed to get a stamp to sign birth certificates, a duffle bag with birth supplies, and a Birth Log with simple color pictures of “signs of danger” to remind comadronas when to transfer patients to the hospital, however, government programs are not consistently offered (Thompson, 2014). Nearly 70% of Guatemala’s comadronas have attended the trainings (Goldman et al, 2001). Unfortunately, the trainings have not changed comadrona knowledge (Summer et al, 2017)

Criticism of the government programs are that they are culturally insensitive because they are presented in Spanish with written material and condemn comadrona practices (Maupin, 2008; Walsh, 2006) Understanding how to best educate low-literacy indigenous Mayans, such as comadronas, is essential to curtailing the country’s MMR, as comadronas are crucial health care providers that are uniquely poised to 1) detect obstetrical emergencies that occur in homes births, 2) intervene if their training permits, and 3) refer patients to hospitals in they cannot intervene themselves. Methods from a new government training in 2014 and three non-governmental teachings for comadronas will be reviewed.

Previous literature has demonstrated a significant change in knowledge among rural comadronas after attending non-governmental programs when they were intensively trained (Thompson, 2014) or when the trainings were culturally sensitive because they were presented orally in the native language of participants (Garcia et al, 2012; Garcia & Dowling, 2018) A paucity of data exists regarding change of knowledge among comadronas in urban Guatemala.

Further, limited data is available about knowledge retention among comadronas in urban and rural Guatemala. A follow up study in 2017 with comadronas in Sarstun, one of the most remote areas of Guatemala, on the Belize border with some of the worst health outcomes in the country, revealed comadronas did not retain knowledge eight years after a non-governmental culturally sensitive teaching. A small sample of Sarstun comadronas in 2009 initially showed a change in knowledge when tested immediately after the non-governmental teaching (Garcia, et al, 2012). When retested on the same material in 2017, Sarstun comadronas did not retain knowledge about addressing postpartum hemorrhage (PPH), which is the leading cause of maternal death in Guatemala (Pan American Health Organization, 2017). More data is needed at a closer interval to further explore this finding.

In addition, none of 13 comadronas from Sarstun who participated in the original non-governmental training in 2009 still had laminated Take Action Cards in 2017 to remind them of steps for addressing PPH. The cards display complex, black and white drawings of obstetrical emergencies to encourage knowledge retention after the 2009 training. The cards were part of the ACNM’s Home-Based Life Saving Skills (HBLSS) Curriculum. Granted, revisiting Sarstun comadronas ideally should have occurred in a closer interval than eight years, as literature shows knowledge retention decreases after six months (Garcia et al, 2010; Weiss-Laxer, et al, 2009; Mosby, et al, 2015) However, Sarstun comadronas may not have kept their Take Action Cards, regardless of the interval between trainings, because Sarstun comadronas may not have understood drawings on the cards. One elderly comadrona held her Take Action Card upside down during the 2009 non-governmental teaching, casting doubt of whether the cards were culturally competent and aided in initial understanding and later knowledge retention.

Comadronas might better understand simple, color drawings from a slightly new government training program introduced in 2014. The government trained nearly 3,000 comadronas to identify obstetrical emergencies, called “signs of danger” in Guatemala (Lopez et al, 2014). Comadronas who attended the 2014 government trainings were given Birth Logs with simple, color drawings to remind them of the “signs of danger” (Garcia & Dowling, 2018). Comadronas who participated in the 2017 non-governmental trainings appeared to understand the simple, color drawings from Guatemala better than complex, black and white drawings from the U.S. (Garcia & Dowling, 2018). However, this interpretation was based solely on observation, not on data. A paucity of data exists about reinforcing knowledge retention with drawings among indigenous low-literacy indigenous Mayanas, such as Guatemalan comadronas.

This study has two aims. One is to evaluate which drawings best reinforce teaching about obstetrical emergencies among urban comadronas. The other aim is to evaluate the affect of a culturally sensitive teaching on knowledge about obstetrical emergencies among urban comadronas.

Theoretical Framework

Dr. Madeline Leininger’s Theory of Culture Care Diversity and Universality provided the framework for this mixed-methods observational study. Leininger’s theory holds that combining

generic (or emic) cultural care beliefs, values, patterns and expressions with professional (or etic) care practices is essential for culturally congruent care (McFarland & Wehbe-Alamah, 2019). In other words, generic beliefs from inside the culture and professional health factors from outside the culture in diverse environmental contexts greatly influence health and illness outcomes (McFarland & Wehbe-Alamah, 2019). For this reason, this study began with focus groups to understand the generic care practices of comadronas in urban Guatemala before presenting professional teaching methods from the ACNM. Previous focus groups with comadronas from rural Guatemala informed this culturally sensitive teaching. Data from this focus group will guide future culturally sensitive teachings, following an action research format.

Materials & Methods

Participants & Setting

Several weeks before the study Refugee International volunteers advised nurses at the local Ministry of Health (MOH) about the study. MOH nurses then recruited both Ladino and indigenous comadronas for the study when comadronas came to the MOH for monthly government trainings. No differences in recruitment strategies were practiced for Ladino or indigenous comadronas. Refuge International, is a non-government organization that has maintained three clinics in Guatemala for more than two decades. The founder started Refuge International after attending a medical mission in San Raymundo as a Family Nurse Practitioner student in 2000. Refuge International has a locally run board so the non-profit enjoys a strong relationship with the community.

Seventeen comadronas from San Raymundo participated in the one-day non-governmental teaching at the Refuge International health clinic. San Raymundo is a suburban community comprised of at least 47,000 Ladino and indigenous Mayans who live in a city, town and 10 outlying villages nearly 30 kilometers north of the capital city of Guatemala (National Institute of Guatemalan Statistics [NIGS], 2018). Nearly 31,605 people live in the municipality of San Raymundo, and 15,447 people live in the town of San Raymundo (NIGS, 2018).

The culturally sensitive teaching occurred in a large indoor cafeteria with tables and chairs where comadronas could sit comfortably. An Internal Review Board at the University of Utah gave the study an exempt status. The study met all nine of the ACNM’s Global Health Competencies and Skills. These include the following competencies, global understanding, clinical practice, health equity and justice, professionalism/ethics, communication, leadership, organization & program management, teaching/learning, research/continuous quality improvement, and health system strengthening (ACNM, 2018).

Data Collection

When comadronas arrived at the non-governmental, culturally sensitive teaching, the purpose of the study was explained in Spanish, and comadronas were told that their participation would be seen as consent. All questions about the study were answered, and comadronas were told they could leave at any time. Comadronas then filled out demographic and background data sheets in Spanish. Demographic data included gender, age, years as a comadrona, languages spoken, years of formal education, attendance at government trainings, and ability to read, write and count. Ethnicity was determined based on language spoken. Background data included distance from hospitals, reasons for transferring patients to hospitals, and level of comfort referring patients to hospitals. Finally, participants were asked to identify obstetrical emergencies for the pretest. Answers were compared to a checklist based on the HBLSS curriculum.

A panel of three, doctorly prepared nurse researchers established content validity of demographic and background data sheets, and Fog Index of 0.35, which indicates participants needed three and a half years of education to understand questions on the data sheets. The local community has provided input into the study design and instruments during debriefings after past educational sessions with comadronas. Refugee International volunteers asked questions verbally to illiterate comadronas, and recorded the answers on paper. Volunteers also translated information into Kaqchiquel for indigenous comadronas.

After data collection, comadronas were given juice and cookies while an oral teaching based on the HBLSS curriculum was provided about recognizing obstetrical emergencies, such as antenatal, intrapartum and postpartum bleeding, breast, uterine, urinary or vaginal infections, preeclampsia, birth delay and grand multiparous patients. Role playing and laminated Take Action Cards with drawings of obstetrical emergencies were used to reinforce the teaching. Role playing including scenarios, such as comadronas performing the test for Costal Vertebral Tenderness on each other’s backs and asking, “Does this hurt?” to inspect for urinary tract infections. Another scenario was comadronas demonstrating what they would do if a patient was bleeding too much after birth. The Take Action Cards have complex, black and white drawings of the obstetrical emergencies to remind comadronas what they learned.

Examples of Take Action Cards:
Simple Color Drawings of Antepartum Signs of Danger from the Guatemalan Ministry of Health
Complex Black & White Drawings of PPH from the HBLSS

After the teaching, which was designed to be culturally sensitive by being presented orally in the native language of participants, comadronas were asked again to identify obstetrical emergencies for the posttest. Finally, comadronas were asked to determine the meaning of two sets of drawings of obstetrical emergencies, one in color from a government Birth Log, and one in black and white from the HBLSS.After the teaching, comadronas were thanked for their participation and given birthing kits with blue chux to put under patients, plastic exam gloves, tape measurers, iodine, umbilical cord tape and clamps, scissors and razor blades for cutting umbilical cords.

All participants stayed for the entire teaching. Comadronas requested more information about hypertension and neonatal resuscitation in future teachings. Comadronas were told the next non-governmental teaching would include information about hypertension, and participants would be given blood pressure cuffs if they brought data from their Birth Logs to the future non-governmental teachings.


Change in knowledge was measured by comparing participants’ answers to a 10-item checklist of obstetrical emergencies that included antenatal, intrapartum and postpartum bleeding, breast, uterine, urinary or vaginal infections, preeclampsia, birth delay and grand multiparous patients, defined as having had five previous children. A pretest and posttest were used to evaluate knowledge based on limitations of the Primary Investigator’s time in Guatemala. The pretest/posttest was designed, validated and field tested in various locations throughout the developing world with positive results by nurse researchers who created the HBLSS (Barger et al., 2015) Pretest and posttest scores were the total number of correct answers from the checklist. Scores ranged from 0 to 10. Understanding of drawings of obstetrical emergencies was measured by assigning a percentage of the number of drawings participants correctly identified.


Measures of central tendency and frequencies were calculated by hand, not with a statistical package, to evaluate background and demographic data. A paired t test was used to compare number of correct answers on pre and posttests to measure change in level of knowledge Percentage of correct interpretation of drawings was used to analyze if participants understood the intended meaning of the drawings.


Among the 17 participants, five spoke Katchiquel and 12 spoke Spanish. The mean age of participants was 52, varying from 80 to 40. The mean years of comadrona experience was 22, ranging from 45 to three years. While many participants had attended government trainings, their mean level of formal education was 5.5 years, varying from none to 12 years. Indigenous Mayan participants were less literate and lived somewhat farther away from hospitals than Ladino participants. Indigenous Mayan participants lived an average of 29 kilometers from hospitals while Ladino participants lived an average of 25 kilometers from hospitals. All Ladinos participants could read and write, and eight could count. Three Indigenous participants could not read and write, and four could not count.

Indigenous Mayan participants were less trusting of hospital transfers and less frequently sent patients to hospitals than Ladino participants. Nine Ladino participants felt “very comfortable” and three felt “comfortable” with hospital transfers. Further, 11 Ladino participants had sent patients to hospitals. In contrast, two Indigenous participants felt “very comfortable,” two felt “comfortable,” and one was “not comfortable” with hospital transfers. No Ladino or indigenous participants were “slightly uncomfortable” sending patients to hospitals. Finally, three of indigenous participants had transferred patients to hospitals.

Regarding identification of obstetrical emergencies, the mean pretest score was 3.06 with a SD of 1.436 compared to the mean posttest score of 5.13 with a SD of 1.147. The time interval between the pre and posttest was two hours. Change in knowledge was statistically significant with a p-value of 0.01. Participants also understood 90.4% of simple, color drawings of obstetrical emergencies from a government Birth Log and 78.7% of complex, black & white drawings from the HBLSS.


Educating comadronas about obstetrical emergencies in Guatemala may warrant two approaches, as half the population lives in rural settings and half resides in urban areas. Comadronas, who are mostly indigenous and have low literacy, attend the majority of births in their country where the MMR is the highest in Latin American at 95 deaths per 100,000 births (CIA, 2020). Previous studies have demonstrated that intensive training and culturally sensitive teaching provided orally in the native language of participants changed rural comadrona knowledge about obstetrical emergencies. This study showed that a culturally sensitive teaching presented orally in the native language of participants changed urban comadrona knowledge about obstetrical emergencies. In addition, urban comadronas understood simple color drawings of obstetrical emergencies from Guatemala better than complex, black and white drawings from the U.S.

Limitations of the study are that Kaqchiquel comadronas may have been less likely to participate, leading to potential selection bias. Kaqchiquel comadronas may have been less likely than Ladino comadronas to go to the MOH where nurses speak Spanish, and thus less likely to learn about the study. Further, Kaqchiquel comadronas may have been less likely to understand the teaching, which was provided in Spanish and translated into Kaqchiquel, which could lead to a potential measurement error on the pretest and posttest. In general, Kaqchiquel comadronas were less literate, lived further way from hospitals, were less trusting of hospital transfers and less likely to transfer patients to the hospital than Ladino comadronas. This finding is consistent with other literature reports.


Future teachings about obstetrical emergencies should continue to provide information orally in the native language of rural and urban participants. Future teachings should continue to consider what drawings of obstetrical emergencies rural comadronas best understand for knowledge retention, simple color drawings from Guatemala or complex, black and white drawings from the U.S. In both urban and rural settings, follow up testing for knowledge retention should occur at regular intervals, such as every six months, and comadronas should be encouraged to keep data in their Birth Logs to evaluate whether teachings about obstetrical emergencies are changing practice. Ultimately, a change in comadrona knowledge should lead to correct identification and timely referral of obstetrical emergencies in order to address the country’s MMR.


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Evaluating Teaching Methods about Obstetrical Emergencies among Comadronas in Urban Guatemala by Kimberly Garcia, DNP, MSN, BA