This and the money spent would perhaps in the end

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this, and the money spent would perhaps, in the end, have been better used to train professional midwives” – World Health Report 2005Guatemalan Health Care SystemoHealth care system distribution (PAHO 2001)65% of Guatemalan population is rural20% of health care facilities in rural areas80% of health care facilities in Guatemala CityBut only 25% of the population9 physicians per 10,000 peopleoMaternal Mortality in GuatemalaMaternal Mortality Rates (PAHO 2007)148.8/100,000 in 20051990-2005 ratesoIndigenous = 211/100,000oNon-Indigenous = 70/100,000Variation in birthing location and attendanceoComadronasRecruitment to the roleDivine selectionHeredityEmergencyGeneral Characteristics of comadronasMarried, elderly woman with children of her ownKnowledge of practice through personal experience, dreams, and apprenticeshipsoComadronas PracticesPrenatal careDeliveryPost-partum careMethod of paymentsoGuatemala Midwifery Training Programs1935 National mandate for training of comadronas1950’s national laws require participation in routine training programs1980’s WHO encourage incorporation and training of midwives in national health care systems to extend access in rural communitiesoEvaluations of Midwifery Training Courses in GuatemalaNon strong correlation between training courses and decrease in maternal and/or infant mortalityMay increase detection of complicationsIncrease in number and timeliness of referrals
Greater association with training of biomedical staff than midwives (O’Rourke 1995)Unclear if increase women’s utilization of biomedical servicesoMidwifery Training ProgramsRequired monthly training programsEmphasize identifying obstetric risks during the prenatal, delivery, post-partum, and neonatal periodsEmphasize referrals for complicationsTeach midwives to recognize their limitsoMethods of TeachingDidactic – formal teaching with textbook and lectureParticipatory – participation amongst physician, staff, and comadronas in discussion and comprehension of material (this model works better)oCritiques of Training ProgramsPedagogyLanguageDidacticTextbooksMale and young, unmarried and childless women as trainersoConstruction of Biomedicine as Authoritative KnowledgeConsensual construction of biomedicine as Authoritative Knowledge and denigration of experiential knowledge“Now we know more about these things. We know more about reproduction and women’s bodies. People don’t do this anymore”“Thank you for teaching us these things. Now we can leave behind our foolish practices (tonterias)”oContesting Authoritative KnowledgeIndividual interviews“Before I didn’t know that there were all these dangers during pregnancy or when I should send women to the hospital”“Training courses are good and I learn a lot when I go to them. But it is really the same work that Ido here. That’s why I don’t go to them anymore, because they only talk about the same things that I already do.”o

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