Gretchen Heinrichs, MD, teaching two traditional birth attendants in Guatemala. All photos courtesy of Michelle Shiver.
By Tonia Twichell
(May 2018) After the birth center at Trifinio Center for Human Development
opened in rural Guatemala in December 2016, Gretchen Heinrichs, MD and
the clinic staff realized that effort to lower the death rates for women
and newborns needed to extend into the homes of poor farmworkers and
Situated in southwest Guatemala along the border
with Mexico, the clinic provides health services in one of the country’s
most impoverished regions, where the neonatal mortality rate is among
the highest in Central America at 31 per 1,000 live births, and the
maternal death rates is one of the highest at 80 per 100,000 live
Half of the women in the area lack prenatal care and
one-third give birth at home assisted by traditional birth attendants,
who have little formal training.
Most local women are in good
health, said Heinrichs, CU associate professor of Obstetrics and
Gynecology and director of maternal health programs at the Colorado
School of Public Health Center for Global Health, so “we realized that
the best way to make a difference was to create a safety net around a
birth at home.”
CU physicians, nurses and midwives have helped
train birth clinic and birth center health professionals who in turn act
as preceptors to CU students from medicine, dentistry, pharmacy,
nursing and public health schools and colleges. The center is a
partnership of the University of Colorado, Children’s Hospital Colorado
and the Jose Fernando Bolaños Foundation.
The effort to improve the health of Guatemalan women and their babies faces significant obstacles:
- Families lack funds to pay for hospital births. “A lot of women
delivering at home would love to deliver in a clinic, but they can’t
afford it,” Heinrichs said. She recalled a couple so poor the husband
chose to deliver the couple’s child alone. Nurses from the center rushed
to the family’s home when neighbors reported the baby had breathing
problems. “The nurses’ relationship with the community provided a kind of safety net that day,” she said.
- Few physicians practice in remote areas. Before the clinic opened, the
closest doctor was at least an hour away. Those who were nearest were
often not trained in obstetrics so complications often went unnoticed or
unaddressed. Most developing countries rely on trained midwives, but
Guatemala only began its midwife training program in 2015.
- Traditions can stand in the way of basic services. Many women refuse to
leave home once labor begins based on a local belief that fresh air can
be dangerous to women for several weeks around childbirth. Plus “this
idea that birth needs to be monitored by someone who doesn’t know you is
a hard concept to accept,” Heinrichs said.
A nurse takes the temperature of a newborn.
To better understand
the health of the community, CU physicians and public health
practitioners have been working with residents to learn about social,
economic, health, cultural, geographic and genetic factors. Heinrichs
and her colleagues at the Center for Global Health joined with the
community to create Creciendo Sanos: Madres Sanas y Ninos Sanos, a
registry for pregnant women and their young children living in the
community with a population of about 25,000.
Birth center nurses
offer group and individual prenatal care, newborn and child home visits
and classes on nutrition and hygiene. Outcomes are tracked via a mobile
phone clinical data collection system to warn staff about problem
pregnancies or child health conditions.
Expecting many women to
continue home births, CU faculty and center staff offer training and
friendship to traditional birth attendants in hopes that these women
will become the first line of defense when facing problem deliveries.
birth attendants fulfill a role similar to doulas in the United States,
but have less education and limited knowledge of hygiene and
sanitation, though they recognize that complicated births can be
disastrous for newborns and mothers.
“Attendants are women of
respect in the community, and we really need to draw them in and not try
to exclude them. We want to be partnered with them and learn what their
practice is like,” Heinrichs said.
Amy Nacht, DNP, CNM, MPH, left, in a health class with two traditional
birth attendants, center, and a clinic nurse.
CU staff hold classes twice a
year for about 20 traditional birth attendants to teach basic emergency
obstetrics skills for the most common killers of women, such as
hemorrhage, long labor and hypertension and of infants including
shoulder dystocia, sepsis and respiratory infection.
nurses supply attendants with birth supplies and train them to recognize
complications before labor begins so attendants can encourage patients
to get medical attention. Unlike hospitals in the region, the center
welcomes traditional birth attendants and the mother’s family to support
“Traditional birth attendants are key players who
we want to enlist and act as informants in the community to ensure women
have safe pregnancies and births,” said Amy Nacht, DNP, CNM, MPH,
assistant professor and director of the University Nurse Midwives
Faculty Practice at the College of Nursing.
Some of the training has helped, Heinrichs said.
few have told us, ‘I used the shoulder (dystocia) maneuver and it
worked! It felt so great!’” Heinrichs said. “But our biggest success is
getting these women to bring in their patients. We do have a trusting
relationship and we’ve had a couple of big successes. And the families
know the birth center is clean and they will get a high level of care.
They don’t have to drive to the city and wait in long lines.”
But training traditional birth attendants has its limits.
found that some things are very difficult for them to learn,” Heinrichs
said. “That’s why we began focusing our efforts pretty quickly on
skilled birth attendants.”
A clinic nurse takes the blood pressure of a patient as her son watches.
CU faculty have
developed site-specific curriculum to increase the knowledge, skills
and attitudes of the nurses who work in the maternal health programs,
Teaching emergency obstetric care to center nurses,
faculty members use simulation models and e-learning, and rely on the
World Health Organization’s safe childbirth checklist to help nurses
recognize warning signs from admission to discharge. The center provides
obstetric ultrasounds performed by a local nurse who was trained at CU
Anschutz Medical Campus.
“WHO recommends eight prenatal visits
(for each pregnancy),” said Heinrichs, who travels to the center twice a
year. “We’re having trouble getting to four. Sixty percent have had
three prenatal visits and our goal has always been to get to four visits
with 75 percent. It’s hard to get out to rural communities and there
are a lot of transportation issues.”
CU faculty, students and
residents rotate through the clinic, but Nacht says the goal is to
support the local health care staff to become clinical leaders and
sustain the programs.
“We want the clinical staff to move forward
with as much independence as possible,” Nacht said. “This is truly an
interdisciplinary project, and I think it’s possible as long as all the
teams stay involved with ongoing educational support.”
have stepped up to take the lead in labor and delivery at the birth
center because funds for 24/7 physician coverage are unavailable.
are physicians (at the Center for Human Development) but most have
almost no training in birth,” Heinrichs said. “Our nurses started to
have more modern training in obstetrics than their physician supervisors
and that has created an interesting dynamic. In Guatemalan culture,
medicine is very paternalistic.
“Our job as trainers and partners
is to promote their growth and self-sufficiency. We have seen such
growth in our staff there. It has been an inspiring project to work