Healing Hands



Life and Death Mural in the town's center

The comadronas of ACAM are well connected.  They speak highly and frequently of health providers in the United Status who 1) help obtain funding through grants, 2) offer their own expertise during day or week-long medical volunteerships, 3) Donate medical supplies and clothing, and 4) often times when here, Provide trainings to the midwives.  Most of their volunteers come through acquaintances of Nikki May, a certified nurse midwife in Massachussets, to whom the midwives refer every day as though she were their holy savior.  Of course that's an exxageration, but...Perhaps she is.

The Mayans have had a long tradition of midwifery.  Some communities have the good fortune of passing on this tradition to the younger generations, who can replace them as they grow older.  The Mam area of Quetzaltenango is one such place.  The youngest midwife at ACAM is 15 years old.  The oldest 76.  And unlike the United Status where to be a midwife, the cost can be exhorbitant, here the education is free.  After a year of theory and a year of practicum, the midwives begin tending to birthing women.  They learn about complementary medicine, such as herbal teas first –recipes that have been passed down from their mothers and grandmothers.  Preservation of this craft is very important to them.  

Herbal Salves at ACAM

I am astounded by their practice since this is the first time I have seen natural birth take place in the way I was taught during Doula training.  Women walk around most times until they are 10cm dilated.  Birthing women eat whatever pleases them and drink teas during labor.  They are told sometimes to climb the steps in ACAM to help the labor process.  And through it all, they are courageous and strong.  Hospital San Juan de Dios, the public hospital in Xela, doesn´t charge for childbirth.  But many women in the Area Mam don't have the same trust in the hospital that they have in the comadronas in their community, where they are willing to pay Q400 (50USD).  Each midwife earns Q100 (13USD) each shift they work; and most work just one per week, totaling an income of 13USD per week.

My Portraits of the Midwives - I couldn't resist making them laugh

The midwives are warm, generous, welcoming, and wise.  They boast that I am a very agreeable American, willing to eat everything they offer me; unlike with other foreigners with whom they are nervous and worry over them because of their very high needs.  It's selfish, but it warms my heart to hear that I will be missed by them.  They say they have grown accustomed to me being here and will be sad to see me go.  There is no doubt that I will feel that sadness as well, since they have become my family.

Donas Santos Mendez, Cristina, Emelda, Azucena, Antonina (From left to right)

Dona Antonina´s Beginning

Antonina's own experience began when she was pregnant with her 3rd child who was in breech position.  The midwife performed manual external version of the baby -- a process by which a midwife turns a baby gently but firmly using her hands positioned on the mother's belly -- to correct the position.  (Technology and fear of being sued have convinced many American doctors that they are incapable of doing the same, so they usually defer to a cesarean in cases like this.)  The midwife then instructed Antonina to do the same on her own, if the baby was restless and stubborn enough to turn himself around again.  And so she did.  For her this was a very empowering moment in which she realized that she is capable of healing with her own hands.

She tended to her first patient in the home, when no comadronas could be found in the community.  With no formal training, her experience was limited to past invitations by neighbors to see the birth of a family member.  And yet SHE was now at the helm of the childbirth of a dear friend.  When her friend´s pains came stronger and more frequently, the husband asked, ¨Antonina, you will be the one to receive our baby.  Please help us.¨  Reluctant to do so at first, she directed family members to get a Schiller (razor), bedsheets, towels, and hot water.  And in an instant, she held a newborn she had helped birth, in her hands for the first time.  News spread in the community.  And as a consequence, the flow of requests have been consistent for nearly 30 years.  Antonina works 3 of the 7 shifts, and from what I see, is the midwife whom the patients most request.  And during her shifts, I have been lucky to play a big role in births.

Midwives : My Maya Mama Antonina, Cristina, Ofelia

 

Maria's Childbirth

Antonina and Ofelia were the receiving midwives on this day.  Antonina spent many hours by the mother-to-be´s side, coaching her through contractions, offering herbal tea to help reduce the pain, and recounting birth stories to the mother and family who all sat in the birthing room.  It was a time of celebrating life.  Despite the work she had done, it was me Antonina called for to tend to the mom as childbirth was impending.  And so she proceeded to take off her gown, gowned me, helped me with the ties, and reminded me of what I needed to do.  In Mam, she then stated to Ofelia also gowned, ¨Dana is going to be the one to receive the baby.¨ For a second time, I was graced with the generosity of Antonina to share the experience – to allow me to be the one to lay my hands on the baby in the moment when he breathes his first breath – and to welcome him into the World.  With more assurance than the first birth, I severed the connection between Mom and baby which no longer pulsed, wiped him clean, measured him, then dressed him for mom to embrace.  She tenderly touched him fascinated by his small nose, small ears, small mouth, small hands; as did her husband, who hovered closely above the two, inhaling every moment.  Her mother and grandmother also stood by her side, hand in hand with Maria, praying thanks in Mam – expressing gratitude for her strength through labor and hoping for her healing in the coming days and weeks.  To experience this ceremonious moment and long standing Mayan tradition among these women -- those who cared for her day to day, and those with healing hands, I was humbled.  And in realizing this, I nearly cried.

Each midwife here has their own story of how they came to be chosen, by God, to pursue this profession.  They all concur that it is a calling.  I guess I´m partly here to understand if it is mine.

The Lovely Affectionate, Dona Margarita



Finally Among Mayan Midwives

Nuestra Madre Tierra - Mural in the center of town

I began planning my trip to Guatemala more than a year ago when I became restless with my job.  I contacted many organizations and clinics, including Primeros Pasos, Midwives for Midwives, and XelaAid.  In 2005 I met a Peace Corps volunteer who told me that he was working with midwives in San Martin.  He promised to tell them about my interest in working with them.  We kept in touch through email and I later received a message stating that they had extended an invitation for me to come work and stay with them.  Unfortunately, the email came just two days before I was leaving the country.  And that was that.

The day I met the ACAM midwives was a fortunate one.  My XelaAid contact, Luis Enrique de Leon, director of the clinic in San Martin, drove me to Concepcion Chiquirichapa.  He had given them no warning and when we arrived they were busy with a patient who needed an ultrasound, to confirm that one of her twins did not die in the womb.   The clinic only has bare minimum supplies.  After the business of getting her seen in San Martin, Luis and I sat down with Dona Azucena, President of ACAM and Dona Antonina, Vice President.  We talked for a while and I laid out my goals for working with them and offered them to come up with a list of projects they need assistance with.  So they agreed to have me and offered a place to stay and homecooked meals.  And on my first night here I assisted with my first birth, whose story I talk about at the end.

  

Where I live

La Iglesia Catolica - View from ACAM

Technicolor Cemetery

 I've been here now since the beginning of March and am just now blogging.  With my computer out of commission and their computer's internet very spotty, I'm typing this on Matt's Kindle.  Crazy.  I am living in Barrio Nuevo, Concepcion Chiquirichapa, a small pueblo about 30 minutes from the city.  This is where the clinic is located.  Here life is rich with culture, color, and  community and so has been my experience living in this traditional Mam Mayan town.

La Casa de Comadronas

Examination Room

ACAM is the Association of Comadronas in the Area Mam.  The clinic is a beautiful house that hosts Computer classes, English classes, community meetings, patient consults (prenatal, postnatal, and general) and of course, births.  I teach the comadronas English when there is a short moment to do so and even taught one girl Algebra since no one here was able to help. Teaching Algebra in Spanish isnt easy.  Two weeks ago we hosted a large meeting of women's groups from all over the region on el Dia de las Mujeres -- when three visiting American professors led a discussion about the problems the women see in the local environment and offered ideas on how to protect their precious Madre Tierra.    These groups are a means to empower women to effect change in their communities.  You can see how this place is special. 

La Hermosa Comadrona Santos

Comadrona Ofelia examines a patient

The consult room is very simple.  There is also a small closet full of donated medicines...our pharmacy, a waiting room, three birthing rooms, a kitchen, a medicinal herbs cabinet, the large salon where meetings are held, computer room, office, five bathrooms, the midwives bedroom (they rotate staying 24 hours, two at a time), and three more bedrooms for visiting guests like myself.  And even the traditional sauna called temazcal, or in Mam, chuj, in which some moms enter while in labor or after childbirth.

I began seeing consults immediately with Antonina who quickly became my favorite and to whom I refer now as my Mayan Mama.  She insisted immediately that I examine the prenatal patients and tell her my impression.  Since I have no experience in checking the baby's position, I mostly pretended and was self-assured with my touch, palpating the baby's head (I was at least able to do that...most of the time), checking the baby's heartrate with a fetoscope or doppler, then checking her blood pressure and her weight.  Antonina continues to offer tips on how to be more attuned to how the baby feels in utero but I continue to have trouble sensing where his or her arms and legs are.

Mi paseo

The pace is slow here and the days are tranquil.  Before my computer died I spent my nights 

watching an episode or two of Grey.s Anatomy (Yes. Greys Anatomy) or a bootlegged copy of American movies I bought at the market in Xela.  Now I am left with playing Scrabble on this Kindle.  And I just finished reading for the second time (Yes...I read something in its entirety) The Red Tent, which fictionalizes the biblical life of a midwife, Dinah, daughter of Jacob.  I loved it this time too.  I've also made it a routine of mine to go on walks-hikes around the community and up into the hills.  But when I'm really lucky, a birth keeps us occupied at night...and this was the case my first night living in Concepcion. 

Mercado en el Centro de Concepcion

Luisa's Childbirth

Dona Antonina looking at me plainly and sternly said "Come closer Dana.  You're going to catch the baby."  I sort of looked at her blankly and hesitated to step forward.  To this she challenged me with "What's wrong, are you scared?"  I stepped up to the woman's side and held the fleece blanket in my hands.  But even as the head of hair began bulging I wondered if maybe she misunderstood my birth assisting experience and I stood dumbfounded.  The baby's head came first.  Antonina had no time to entertain my awkwardness so she reached for the baby and with a swift lateral pass the baby was in my arms.  Receiving a newborn in this context, in the house of midwives, is unlike receiving a baby when I worked in the NICU --  where tension, anxiety, and fear hangs in the air.  Here the healthy newborn was wide-eyed and the thick ropy pulsing cord that sustained him in his mama's womb was still attached.  After a few moments I was instructed to care for the cord; tie it, clamp it, cut it, and then he was free and making his own way.  I wiped the baby, caked in vernix and blood, to encourage the familiar lusty cry that signals new life.  Antonina assumed reponsibility of caring for the baby while I was tasked with helping the mom birth the placenta.  I stood at the woman's side massaging her uterus with my left hand and holding the cut umbilical cord with my right.  The intact placenta didnt need a lot of coaxing and in seconds mom was free of it.  She sunk into the pillow in exhaustion.

It all happened quickly and it was incredibly exciting for me -- like an initiation into the world of babycatching.  I remember thinking- I think I'll like it here.

A large Batik that hangs in the Clinic

Vamos a divertirnos

While my first priority here certainly has been my work in a community clinic (with improving my Spanish conversational skills a close second), playful adventures have also been a must.  My Spanish Immersion school I.C.A. did an incredible job of planning daily activities Monday through Saturday.   Unfortunately, I was stubbornly anti-social during my 2 weeks of classes, after which I set aside my snobbery and went on the Saturday hike to Volcan Santa Maria.  

Volcan Santa Maria in the hazy distance

The summit, where Evangelists are holding a service

Praying for the Deceased

Volcan Santa Maria hovers peacefully over Xela (unlike it's volatile offspring nearby Volcan Santiaguito which erupts every 30 minutes or so).  After resuming a yoga practice upon arrival here and consequently overestimating my physical ability and endurance (Note to self: 12 sessions of yoga in 2 weeks after a several month sabbatical from exercise does not = being back in shape), I ignorantly committed to the climb.  Honestly the climb for me was a painful struggle of leg cramps and wheezing, as older women in flip flops carrying babies and anything else they could carry to make me look bad whizzed by.  Needless to say, the hike was well worth the following 2 days of debilitation.

Curious about the Gringos

Mensajes en las piedras

Hermosa sonrisa

Our descent through crops at the base of the volcano; in the distance a woman and child carrying firewood on their heads

Mateo arrived the first week of February.  The RSB graciously gave him permission to work in Guatemala for the month.  Lucky for me.  On weekdays, we were both managing busy schedules, but found ourselves on mini adventures on the weekends.  Through climbing blogs, Mateo discovered a local climbing spot just a short hike outside of Xela.  We opted to do some reconnaissance at Volcan Cerro Quemado.

Hike with Mateo to Volcan Cerro Quemado

Searching for rockclimbing spots

The base of the rock

The challenge

Along the hike to Volcan Cerro Quemado, is a side road which takes you to Los Vahos, thermal steam rooms fed by the vapors of this volcano.  The hike offers an incredible view of Xela and weaves past beautifully cultivated land.  Then at trail's end is your reward -- being enveloped by eucalyptus-infused steam.  Aaah!

A relaxation and changing room ajoins the steam room

Red in the face from 45 min of volcanic steam

No visit to Guatemala is complete without a visit to the popular and picturesque lake, Lago Atitlan.  For a pre-Dia de San Valentin weekend, Mateo and I made our way by chickenbus to Jaibalito, where we stayed at the luxurious hotel, Casa del Mundo.  The hotel is carved into a steep cliff, with accommodations on varying levels.  Making your way around the hotel grounds is better than any stair stepper.  We enjoyed an afternoon of napping in the sun and an evening of family style dining and cocktails with the other guests; then topped the night off in an outdoor wood-stove heated hot tub overlooking the lake.  Total relaxation!

Breakfast at Lago Atitlan

Panajachel's lake-side view

Catching a lancha to the town of Jaibalito

Casa del Mundo patio.  After arriving Matt dove off the higher ledge for a quick dip in the lake, which by the way was freezing.

My nap in the sun

Casa del Mundo's private dock

View of Volcan San Pedro from outside our room

Beautiful woodwork

View of Volcan Toliman and Volcan Atitlan

Hotel office and private room

On Sunday, I ventured off to the famously congested Chichicastenango market where I snapped some photos with my film camera (which is why they are not shown here), while Mateo joined a group of Guatemalan rockclimbers for a day of climbing in the nearby New-Age town of San Marcos.  After one more night at the lake in San Pedro la Laguna, we were hardly satisfied to return to urban living, but were summoned back to our work obligations -- Matt to Guatemala City for a couple days of meetings and me back to Xela for the week of Papanicolaous.

Mateo's view from the rockface during his climb

La Jornada de Papanicolaus

Our week of Papanicolaus was a success!  Forty women from the Palajunoj Valley came to receive checkups from Women's Health Nurse Practitioner Danielle Dittrich including our very own Primeros Pasos workers mother and daughter Florinda and Marta.  Solo practitioner Danielle had asked for my assistance in the one-on-one education of each women receiving a Pap smear.  This allowed for greater efficiency during the week and more importantly provided a private environment to address patient's questions.  During my time with them, I provided extensive education regarding the importance of Pap smear exams, what they tell us, how often they are required, and what occurs during the exam.  

Primeros Pasos Housekeeper Florinda y Dental Assistant Martita

Demonstrating how the Pap smear will be done

Many women with whom I spoke knew little, if any, information about Paps.  Those who had received a Pap smear in the past recounted their prior experiences.  Some stated that they had simply been told that getting the exam was an obligation; so they complied.  Some stated that previous practitioners did not explain what was being done to them during the exam; that they were simply told to undress, lie down, and spread their legs.  Those for whom this was their first experience, expressed being embarrassed or ashamed to get a pap smear because having a male practitioners was more common at the public hospital and other clinics where pap smears are more affordable.

Shy of pictures

Danielle Dittrich, Women's Health Nurse Practitioner Extraordinaire

My basic education materials

When asked what a pap smear was, the majority of women explained that it was an opportunity for providers to clean their uterus.  These were their words not mine.  Though I was dumbfounded at this response, I understood.  With some rudimentary educational materials, we worked to untangle the misinformation and replaced it with a comprehensive explanation of Papanicolaus, for which the women were very appreciative.  All in all the "jornada" was successful -- a testament to the trust and confidence the communities have in us.  Danielle plans to come back in a year and the hope is that a greater number of women turn out than this year.  In the meantime, I can only hope that the clinic's next medical director is female.

I've since moved to another clinical location -- ACAM -- Asociacion de Comadronas del Area Mam and have been living with the midwives of Concepcion Chiquirichapa for a few days now.  Which as some of you know is an incredible opportunity for me.  Matt has come and gone after a month stay here with me in Xela, but not before a few mini-adventures.  I do miss him dearly.

The Waiting Room

Primeros Pasos Staff members with volunteer Cather: Mynor, Miriam, Marloes, Marta

Escalera a Una Buena Salud

The women we serve at Primeros Pasos

Prevention, prevention, prevention.  It's what nurses try to teach their patients, when doctors overlook the opportunity or are just too swamped to do so.  While working with school children has been wonderful, for me, going out into the communities of Bella Vista and Llano del Pinal to talk about Pap smears and cervical cancer was more in line with what I wanted out of my volunteer experience.  Miriam y Marloes, the only 2 staff members of Escalera a Una Buena Salud (EBS)--the women's health education program at Primeros Pasos, graciously invited me.

My talks in the community became an important component of the women's health education program.  A few years ago, Danielle Dittrich, an American Women's Health Nurse Practitioner, began a Women's Health Clinic at Primeros Pasos.  With a gynecological exam table in tow as well as other supplies, she came to Xela to jumpstart Primeros Pasos' cervical cancer prevention initiative.  These scheduled talks preceded Danielle Dittrich's return to perform a week of Papanicolaus.  The goal was to inform EBS participants of the importance of a yearly well-woman exam and Pap smear and to strongly encourage their attendance.

A few summers ago, my old roommate Veronica worked in Antigua, Guatemala with a reproductive healthcare clinic called Wings.  They provide medical care to women, train men about reproductive health and family planning, train youth peer educators, and provide pap smears and treatment to those who need it.  Since the program, which has been in existence for a while now, is a perfect model of what Primeros Pasos could be for the highland communities, Vero kindly guided me to their website as a resource.  (Interested in learning more go to: http://wingsguate.org/)

Vero at Wings, Antigua, Guatemala

Why are reproductive health services important for our patient population in the Palajunoj Valley?  Here are some facts that are important to know in this context: 

"Cervical cancer is the number one cause of cancer-related deaths among women of reproductive age in Guatemala. Worldwide, 470,000 new cases of cervical cancer are detected each year and more than 200,000 women die annually of this preventable illness. The vast majority of deaths occur in developing countries, where comprehensive screening programs, which have been shown to reduce mortality by up to 90%, simply do not exist.

Many Guatemalan women have increased risk for cervical cancer due to factors such as limited and irregular screening, multiple pregnancies, early initiation of sexual relationships, poor nutrition, and unfaithful partners who are more likely to transmit HPV."         

                    ~ Wings, non-profit organization, Antigua, Guatemala

EBS participants in Tierra Colorada, where the clinic is located

The women we serve in the Palajunoj Valley are sexually active teens interested in family planning, teen moms, veteran mothers with extensive pregnancy histories, and older women in their menopausal years.

One mother, a 32 year-old woman, has been pregnant 11 times with only 5 children living.  Four were miscarriages; 2 died soon after birth.  Another woman, 23 years-old, was married a little over a year ago and has been trying to get pregnant since.  She thought she was infertile until she discovered that she was pregnant.  Four months later, she had a miscarriage, and immediately after, when she chose to get contraceptives to give her some time to heal both physically and mentally, her husband's family insisted that she stop taking them so they could try again.  Another mother of a 3 month-old newborn, is 16 years old.  She is planning to have another child soon.  She has a low level of education and has difficulty maintain her own good health, that of her newborn, and potentially that of her future child.

While this is not representative of all the women in the Palajunoj Valley, it is illustrative of some of the reasons why many Guatemalans are at higher risk for poor reproductive health outcomes including cervical cancer.  A lack of education about HPV and pap smears, inaccessibility to cervical cancer prevention services, multiple pregnancies in a short period of time, and a lack of control over health decisions concerning their own bodies, compromise the reproductive health of these women.

Miriam, Director of the EBS program, with her sweet son Tony demonstrating good dental hygiene

The morning of my talk in Bella Vista, I met Miriam at the main bus terminal in Xela: Terminal Minerva, where the bustling market is located and where pick-pocketers prey on shoppers.  We in turn, met up with Marloes on the way.  On a dusty road past Tierra Colorada (where the clinic is located) we traveled to Llano del Pinal by chickenbus.  From there no chickenbuses travel further to Bella Vista so we began our climb by foot.  With some luck, we were offered a ride on the back of a pic-up, though the type not outfitted for public transport.

I sat in the back as we navigated through some rough terrain -- the rocky, dusty road up the mountain.  I felt each and every rock, as I was jostled around; once catapulted in the air nearly 2 feet until my sacrum met the truck bed with a loud thump.  My bony butt did not see the humor in this.  Unprotected in the back from the elements, our vision was also obscured with waves of dustclouds.  If I protected my face and lungs, this meant not having hands or arms free to brace the sides of the truck.   It was a relief to finally arrive at our destination.

EBS group with former staff assistant, Elizabeth

Bella Vista is one of the smallest communities we serve and the second furthest from the clinic.  Nervous about doing a talk in Spanish in front of a group of adults, I had come prepared with a Power Point presentation (on paper), images of cervixes (cervices?), specula, and the female's reproductive organs.  I imagined myself speaking to a group of about 20 or so.

After being confronted in the street by one of the women, who stated that she was unable to attend because she had some last minute business in the big city, then minutes later meeting another woman who stated that she and her sister (who had just given birth the previous day) would also not be attending, the group of "20 or so" was quickly dwindling.  I realized quickly that the group of 20 or so that I anticipated was actually a group of 8 women in total.  Three of whom were already not attending.  We sat patiently for several more minutes, when one EBS participant, Ofelia arrived.  After several more minutes 3 more women arrived.  My audience of 20 was now an audience of four.

Marloes, current EBS staff assistant from Holland

I had been informed by Marloes of the difficulty in building rapport with these women in such a short time.  With this in mind, Miriam introduced me as a nurse who specialized in women's health, there to educate them about Pap smears, to address their questions and to invite them to our upcoming week of Papanicolau exams.  Minutes into my presentation, I realized the irony in the words on my sheets of paper.  Less than 5% of Guatemalan women have more than a 6th grade education, and only a slightly higher percentage of them are literate.  It was silly really.  The sheets of paper served me more than they did the women.  They were my crutch.  My presentation was received with some yawning, a few melodic cellphone ringtones, and some street noise.  Sadly, my talk had been more glamorous in my imagination.

My talk at Llano del Pinal two days later was better received.  Seven women from the group attended the talk.  They were genuinely interested in who I am, my work, my family, my age, and my life.  The environment was significantly warmer and by presentation's end, the women were offering hugs and cheek kisses to send us on our way.  Excited to hear that I would be assisting the "doctora" (aka Women's health nurse practitioner Danielle) coming the following week, the women stated that they looked forward to seeing a familiar face at the clinic.  The response was reassuring and validating and the following week I greeted them with a warm smile and an earnest desire to educate them about their health -- to offer an opportunity for them to regain their power over their health decisions.

Sweet little niñita