El Hospitalito runs a Club de Mujeres Embarazadas that provides charity prenatal care for women in the underserved neighboring villages. A physician goes out to each town monthly and visits with every pregnant patient, while the pharmacy provides free prenatal vitamins and folate and the nurses provide nutritional counseling. The patients are either delivered by the town comadrona (midwife) or a physician at the hospital.
Today, I went to Chacayá, a small town approximately 30 minutes from Santiago Atitlán. In this town, everyone knows everyone, and Victor, the medico (health provider) has every patients’ health record locked in his filing cabinet memory. Here, there are no street names or house numbers. Most people describe their houses by the color or the distance from the nearest landmark (a tienda or escuela or distinctive tree). To keep track of where his patients live, Victor has a colorful map of the town, where “blocks” are sectioned off and designated a color. Each house within each section has a number from 1-25. Patients then lead him to their house, where he makes a mental note of its location and puts a color-coded thumbtack (blue for low weight children, red for pregnant, red+black for high risk pregnancy) on the map. The patient is then told to memorize their section color and house number. He informs me that “this allows us to find the women when they call and are sick or when they are in labor”.
Currently, there are 14 pregnant women ranging from 8 weeks to 39 weeks. One patient, a 16 year old G1P0 at 39.4wks came in complaining of diffuse body itching, worse on the palms and soles of her feet and at night and dark urine. Symptoms began 4 days ago. No rash. No epigastric or right upper quadrant pain or nausea/vomiting. No other medical history and otherwise uncomplicated pregnancy thus far. There is no lab, but I didn’t need bile acids and LFTs to tell me that she likely had cholestasis of pregnancy. There was a fetal heart rate and good fetal movement by her account. But, again, no ultrasound and no fetal monitoring capabilities. I counseled her with Victor as my Tzu’utujil interpreter, gently telling her that she had an increase risk of stillbirth with this diagnosis and telling her that I thought her labor needed to be induced. She matter-of-factly told me that she planned on delivering with a comadrona, who do not induce labor. I recommended delivery with me at the hospital but was met with resistance from her family. I bit my lip and held in my discontent, and quickly scribbled a prescription for Benadryl (the pharmacy cannot afford Ursodiol) and let her leave. If all goes well for her, she will never have to see me again.