Approximately 80% of deliveries in Guatemala occur at home and the births are attended by comadronas (midwives). Comadronas are not formally trained; instead, they learn through unofficial apprenticeships lasting anywhere from 3 to 6 months. They are preferred over physicians for various reasons: they are more affordable and available, are often part of the community, and are set apart from Western medicine (many women are understandable so, skeptical of foreign aid). However, comadronas and modern medicine are not mutually exclusive; in fact, most women receive routine prenatal care through health clinics, including prenatal labs, ultrasounds and vaccinations. High risk pregnancies are referred to Obstetricos for management, and some comadronas are aware that the hospital is available for emergencies.
For many women, becoming a comadrona was a result of “a vision” and the influence of a higher power, rather than a desire or passion. For Nicolasa, becoming a midwife was not a choice. One night, at the age of 16, she had a dream that she was comadrona and attending to a delivery. The next morning, she told her mother, who in response told her she was given “a calling” and must pursue it. Nicolasa had no desire to follow this path and brushed off her mother’s urging. The dream recurred, week after week. Still, Nicolasa refused. After a month, “bad luck” started to happen to her family. First her uncle fell off the roof, next her grandfather passed away, and then her younger sister fell ill. It could have been a coincidence, but Nicolasa could not carry the burden of ill-fate any longer and reluctantly sought a comadrona for guidance.
7 years later, Nicolasa met me at my first delivery at El Hospitalito. She brought in a young woman who had been in labor for 12 hours. She was approximately 43 weeks pregnant (a situation not uncommon as most comadronas do not induce labor as many believe that spontaneous labor occurs only when the infant is “ready”). The patient and Nicolasa were planning on delivering at home, but at 8cm dilation, her membranes ruptured, revealing thick meconium. Nicolasa had her start pushing to expedite delivery, but there was no descent of the fetal head or further dilation after an hour. The exhausted pair and family came into the hospital frustrated and fearful that they would be met with a cesarean section. They weren’t. (A cesarean section is a rather risky procedure here – anesthesia is 30 minutes away, there is no blood bank or ventilator, and the nearest ICU is 2 hours away). After 3 hours and with reassurance and patience, the infant delivered through thick meconium and intermittent deep variable decels. The patient did well, while the infant required significant bronchial suctioning (a nerve-racking first time for me) and O2 for labored breathing and grunting. The infant looked like a little old man, with a slight greenish tint, but was otherwise normal. We monitored both mom and baby for a night and they left the next morning for home, where they will stay in confinement for the next month.