Various public health organizations and independent volunteers have come through Santiago Atitlán over the years, and they have been fairly successful in promoting maternal and child health. In addition, the Guatemalan government has taken on the WHO millennium goals (albeit 10 years later) by organizing public health education initiatives and financing local health departments and public hospitals. The end result is that women in rural towns, like Santiago Atitlán, seek annual Pap smears and regular prenatal care and vaccinate their children – and it is affordable. Unfortunately, the public health providers have yet to emphasize the importance of continuity of care.
It was puzzling. I was seeing pregnant patients for their first prenatal visit in the Consulta Externa and they were far along into their second trimester, only to hear that they had been following a comadrona. I was performing ultrasounds thinking that it was their first anatomy evaluation in their third trimester only to find out twenty minutes later that they had just had an ultrasound the week prior. I was evaluating women in the ER who were just seen at the Centro de Salud for the same complaint. It took me a week to recognize the pattern: women believed that appropriate prenatal care involved seeing as many physicians, nurses, comadronas as possible. It was thoroughly confusing; and in my US-state-of-mind, a waste of resources
In Santiago Atitlán alone, there is a private non-profit hospital (El Hospitalito), a free government run clinic (Centro de Salud), a private local NGO (Rxiin Tnamet) and solo-practicing comadronas. Each neighboring town has its own Centro de Salud and access to the large public free hospital 2-3 hours away. None of these organizations communicate and there is no central health record system. (Actually, women are suppose to carry a manila card that was provided to them at their first centro de salud visit that is suppose to contain all the pertinent labs and visits but no provider actually fills them out… it would be too obviously useful). Many women bounce to and from each available resource and are told inconsistent information about their pregnancy, which in turn is regurgitated in pieces. It is like a schizophrenic game of telephone.
For me, the frustration goes back to this idea of wasting resources because ultimately, the cost of this inefficient system falls on the patient and families themselves. Women come to El Hospitalito and spend a month’s (or more) salary to pay for a safe delivery with a physician. The cost of the delivery is not bundled – they pay for every instrument opened, piece of gauze used, bag of IV fluids, ultrasounds, blood tests run, and hours spent on their admission. The cost of every repeated test falls on the patient, who is not educated enough to know the difference. And there stands the organizations, proud of their atruistic contributions but at times too introverted to see the flaws of disconnected medical care.