Global Health Travel Blog

UNC Gillings students share their global field experiences around the world.

Category: Guatemala

¡Adios, Guatemala!

“You just missed it, she gave birth while you were in the bathroom.” This is what one of the Casa Materna managers, Michelle, shared with me during one of my barrier analysis survey trainings in Tuzlaj, Guatemala. She assured me that I hadn’t actually been in the bathroom that long (which was a relief) and that the birth had happened a lot faster than anyone had expected. I was extremely lucky to share half of my experience in Guatemala this summer with fellow Gillings Student Emily Berns, who joined me moments later. Before we entered the room to visit the mother and newborn, Michelle told us that the girl who had given birth was thirteen years old. Having never seen a birth before, I began to feel fortunate for my poorly-timed bathroom break. This was one of many surprises that this summer held, including playing multiple games of dreidel with the staff and finding Philadelphia cream cheese in the rural highlands!

It rained most days in Calhuitz, but one day we were rewarded with a rainbow!

After completing a barrier analysis training at three different Casa Materna locations, I had some down time. I was able to observe the nurses at the Casa Materna as they did some routine prenatal consultations. Despite a slight miscommunication at first (the word for ultrasound in Spanish “ultrasonido” sounds a lot like the word for United States “estados uniods” when said quickly and made for some strange context clues), I was able to observe my first ultrasound. The nurse, Anne, told me to feel the woman’s stomach to see if I could tell what position the baby was in. I’m not a nurse, so touching this woman’s stomach felt strange and like I might offend her in some way, but she smiled at me and told me it was alright. I felt around blindly until I found a hard area, which Anne told me was the baby’s head. She then drew a small picture of the position of the baby on a form which she used for the rest of the consultation. Anne took out a small tablet-like laptop to begin the ultrasound and determined that the woman was 8 months pregnant.

In the United States, medicine is a very private matter. But in Guatemala, it’s a family affair. The exam room was only separated from the entrance to the Casa Materna by a curtain. In the sectioned off area for the exam room was the woman, the nurse, me, the woman’s three children, and her mother. “Look, that’s the baby’s leg” Anne said to the woman’s daughter who was watching the ultrasound intently, trying to decipher what was darkness and what was her future sibling. I was impressed how Anne had effortless made this a teachable moment and included this child in the experience. It was extremely powerful to see and I felt very lucky to have been there to experience this moment with this family.

Flore a “mujer de apoya” (helper woman, who is similar to a doula) at the Casa Materna getting a woman’s signature before beginning the barrier analysis questionnaire.

In addition to observing nurses in the clinic, I was able to go into the field with some of the community health educators to watch them survey women in the communities. Using records kept at the Casa Materna, the educators were able to identify women who reported using a method of family planning, so that’s where we started. This was an effective way to identify potential participants, but meant that women who may be using a modern method of family planning but did not already have children would probably be excluded from our sample size. As frustrating as this was, I understood that due to staff capacity, this was just a limitation that I would have to accept. Sometimes we would get to a house and a woman wouldn’t be home or it would turn out her child was too young to participate. Since exclusive breastfeeding for the first six months of life is a form a contraception, we decided to only include women who had children older than 6 months to ensure that she was she was using a modern method of family planning. Due to the size and close-knit nature of the community, we were also able to ask women if they knew of any other women who might be able to participate and use snowball sampling to find other participants. This allowed me to get a glimpse into the lives of the women who we were surveying and better understand what everyday life in Calhuitz was like. I also got to see a lot of kids chasing around chickens, pigs, and pigeons, which is always fun.

A goodbye photo with a few comadronas (midwives) from the surrounding communities and some of the Curamericas Guatemala staff who lent me a gorgeous huipil and corte for the picture. Can you spot me?

I am still in awe of the efforts by the staff to complete these surveys. It was a close call, but on my second to last day in Calhuitz, I received the last of the 96 surveys that we needed for the barrier analysis. Although the analysis and recommendations were supposed to be finished in Guatemala, as with most field work, we had a few setbacks that changed our timeline. Instead, I will be completing my analysis back in the US and will make a presentation to staff on the findings in order for us collaborate on recommendations in mid-August. I am deeply appreciative to the Curamericas Guatemala staff for their patience with this new type of study, their willingness to include me into their daily activities, and their politeness when eating my first attempt and making tortillas by hand.

¡Gracias y hasta pronto!

– Kay

Highlights from the Highlands in Guatemala

It’s hard to believe another month has gone by and that I am wrapping up my practicum very soon!  During the second half of my time with Curamericas in Calhuitz, Guatemala, I continued collecting and analyzing data on neonatal outcomes, modifying my interview guide, and then conducting and analyzing these group interviews with the nursing staff to collect their perspectives on managing and improving neonatal outcomes.

I am lucky to have shared most of my time in Calhuitz with another Gillings practicum student, Kay, and for both of our projects we needed to visit the neighboring Casas Maternas of Santo Domingo and Tuzlaj.  This was a great opportunity to learn first-hand about the different catchment areas covered by the organizations’ projects, meet more staff, and switch up the scenery.

We were told the Casa Materna in Tuzlaj had a different feel, that the area was more remote and unaccustomed to seeing foreign volunteers, and that it would be close quarters due to the Casa’s small size.  After a jostling two hours up and down rocky mountain roads, it’s true we found a cozy atmosphere, but with welcoming vibes.  We walked into what felt like a data-organizing party serenaded by Romeo Santos and reggaeton.  There was hot chocolate for breakfast and Philly cream cheese.  Dogs sprawled lazily on the grass rather than lurking fearfully for scraps.  A 13-year old was admitted to the Casa, and rather than experiencing a prolonged and difficult labor, delivered a healthy baby within a couple of hours.  Tuzlaj was full of surprises.

Entrance to the Calhuitz Casa Materna.

One of the main objectives for visiting Tuzlaj, and one of the most engaging parts of my practicum, was to conduct these group interviews with staff about their perspectives on neonatal complications and deaths.  I continue to admire these nurses and mujeres de apoyo for their hard work with limited resources.  These conversations convey a strong initiative and sense of responsibility to prepare and educate oneself due to their isolation and limited access to cell signal.  They share a holistic view of health and social determinants that’s at the heart of nursing, but which we hospital-based nurses can lose during hectic days.  As with many public health issues, it was clear these neonatal and maternal health challenges we were discussing had deep roots in longstanding gender and socioeconomic inequities, discrimination, and language barriers.  The staff knew the solutions still lie in preventive measures such as continuing to strengthen their health education outreach, community engagement, and garnering more support from civic and government partners.

View of Calhuitz and the Casa (tall green building) at dusk.

At the end of my time in Calhuitz, we were pleased to step fully back into tourists’ shoes for a couple days and visit Lake Atitlán on my way back to fly out of Guatemala City.  It’s one of those places that pictures don’t do justice and distance perception must be altered due to the enormity of the volcanoes and the beauty of the water.  We walked to a popular lookout and cliff-jumping site and after Kay confidently took a birthday jump, I of course had to follow. Only afterwards we learned that it was almost 40 feet—twice what it had looked to me.

Numbers that balance at Lake Atitlán, unlike in spreadsheets.

Back in NC I am continuing to work with both the quantitative and qualitative data in order to report back findings to staff and discuss next steps.  It is interesting to see how the data complement each other and also the amount of information available from a data set that was a bit confusing to piece together.  It’s been very meaningful having a practicum that places a foot both in global health and nursing, and hopefully this research work will offer the organization some insight into their outcomes and assist in determining next steps for reducing neonatal mortality.

– Emily

“Because sometimes it makes us fat”: Communication triumphs and challenges in Guatemala

I had a choice to make: to eat the unidentifiable cooked insect that was being offered to me or not. I had just arrived at Curamericas Guatemala’s project site in Calhuitz, Guatemala after being picked up at 4:30am and driven up countless mountain switchbacks by the project’s head doctor. Needless to say, charred mystery bug was not my first choice for breakfast. However, the staff had offered it to me and I wanted to make a good first impression, so I went for it. I still have no idea what I ate, but it wasn’t so bad!

This summer, I will be spending 8 weeks in Guatemala working with Curamericas Global and Curamericas Guatemala. In partnership with the Guatemalan Ministry of Health, Curamericas runs five community-operated Casa Maternas (or birthing homes) throughout the rural highlands of Northwestern Guatemala that are open 24-hours a day, seven days a week. Additionally, the Casa Maternas provide a host of maternal and child health services including antenatal care, postpartum visits up to 2 years after birth, adolescent health education groups, and maternal care groups. Curamericas has also developed relationships with comadronas (or midwives) in their partner communities, who often accompany women to the Casa Maternas to give birth. This community-based care model provides women with a space to receive care from skilled medical professionals in a culturally competent setting.

A painting outside of the Casa Materna in Calhuitz, Guatemala.

During my first few weeks in Calhuitz, I had the opportunity to go on a 6-month postpartum home visit with a community health educator. After verifying some demographic information with the new mother, Nancy, the community health educator, asked her if she could remember four warning signals for an at-risk pregnancy, postpartum complications, and if her child was sick. I was struck by the interactive and almost quiz-like nature of the home visit. I was reminded that these postpartum visits may be one of the few opportunities that this woman has to learn about her health for future pregnancies and her child’s health. With the nearest hospital almost 4 hours away and often only accessible by a costly ambulance ride, being able to identify when you need to seek care is of the utmost importance.

The birthing room at the Casa Materna in Calhuitz, Guatemala.

For my practicum this summer, I am working with Curamericas on a barrier analysis to help the organization better understand what is preventing women in the communities that they serve from using a modern method of family planning. This analysis is designed to assess behavioral determinants within communities in order to create more effective programming to promote behavior change. I have been working with staff to develop a questionnaire for community health educators to take into the field during their postpartum home visits. Part of my job has been to go to each Casa Materna and train the health educators on how to administer the barrier analysis survey. Working with these educators has re-emphasized how difficult and important their work is for the communities they serve. With over 25 different indigenous languages spoken throughout Guatemala, most educators spoke at least three languages and will have to translate the survey into Chuj or Akoteko for the women while recording their responses in Spanish for me to analyze. I was humbled by their willingness to participate in this labor-intensive process on top of their already mountainous workload and their graciousness towards my sometimes clunky Spanish during our training. I was also impressed by their positive attitudes and willingness to let me, a stranger, come and teach them something new.

My favorite moment so far happened during my training last week at the Casa Materna in Santo Domingo. The training had started off a little rocky because the staff had some difficulty understanding my Spanish. Part of the training involved practicing the barrier analysis interview in pairs, with one health educator pretending to be the woman being interviewed and the other conducting the interview. When one of the male health educators pretending to be a woman who wanted to use a modern method of family planning was asked what he thought some disadvantages of using birth control might be, he replied “because sometimes it makes us fat.” We all laughed really hard and the group was more relaxed for the rest of the training.

Need internet access? Step into our office on the roof!

In the coming weeks, I’m looking forward to more creative responses during our trainings, the data collection process, getting to spend more time with incredible Curamericas Guatemala staff, and eating more delicious tortillas than I thought possible.

– Kay

Saludos desde Guatemala!

Saludos desde Calhuitz, Guatemala!  It’s nearing the end of a second week in the rural highlands of Huehuetenango.  For my practicum I am working with Curamericas Global and Curamericas Guatemala, who partner with the Guatemalan Ministry of Health to provide community-based maternal and child healthcare services, as well as basic health education, to remote areas which historically experienced high maternal mortality.  Over the years the project has constructed Casas Maternas, or birthing homes, which serve as clean, safe settings where women can elect to deliver according to cultural traditions, but with nursing supervision and referral to higher level care if needed.  The project also includes post-partum home visits for mother and child health, and community-run Care Groups focusing on women’s and adolescent health topics.

View from the walk to San Juan market.

The first week here turned out to be a more collaborative learning environment than anticipated, with the staff from the project’s three territories all coming together in Calhuitz for meetings and trainings.  A Haitian doctor from a potential partner organization presented on refining ultrasound interpretation skills for assessing potential pregnancy complications such as hydrocephalus, placenta previa, and placental abruption.  It was exciting to learn so much from his expertise in a health area unfamiliar to me, and then to immediately see these skills demonstrated during prenatal visits at the Casa’s clinic.  Another day focused on the project’s data management systems and future changes in reporting required indicators.  This presentation turned into an important opportunity for staff to share their perspectives on current challenges in their monitoring and evaluation systems, and to discuss their preferred strategies to improve the organization’s data and M&E capacities.

The following weekend, when most staff leave the Casa for their own homes, turned out to be a busy one for the Calhuitz Casa Materna with three births occurring.  It was remarkable to be in a setting where multiple new lives were beginning while simultaneously feeling so far removed from the rest of the world, and to witness a tiny newborn’s first cries while helping to dry and swaddle them.  As a nurse myself, it was humbling to recognize the variety of responsibilities and breadth of knowledge the staff here have in order to successfully run the Casas and programs.  The nurses are the primary providers and decision-makers during deliveries, with a doctor available via phone if necessary.  Role-shifting is clearly also an important strength, as the data manager and community educators have been quick to assist nurses with births or consults for pregnancy complications in the Casa.

As I focus on practicum-specific tasks centered around analyzing neonatal outcome data and staff focus groups on managing neonatal complications, I’ve been reminded of key lessons applicable to public health work in general and perhaps particularly to global work.  Challenges in locating and accessing data needed—not to mention understanding the organization of a new data system as a whole—have made me check my own assumptions about how much time certain work “should” take and the ease with which information “should” be available.  Being so used to having information at my fingertips via the internet and digitalized charting systems, I forget that that is a luxury.

Got internet? For internet, the prime office space is the roof.

The importance of understanding the perspectives of local health workers and their work-loads has also been re-emphasized.  Gaining more background knowledge of prior project changes, expansions, and funding has allowed me to better comprehend the work and program goals through staff’s eyes.  These conversations lead to a greater understanding of the challenges and power dynamics in global health work and the importance of maintaining a decision-making process based upon beneficiary impact.

I look forward to further learning and collaboration as my practicum continues, and am grateful that the staff here have been patient, open, and welcoming.  In the next couple weeks we will be traveling to other Casas in the region for data collection, focus groups, and home visits.  I am sure to continue enjoying the simple pleasures of life here—such as the staff’s sense of humor, fire-fueled hot showers, and the best homemade salsa I’ve ever had—and will be curious to see how the terms “communication” and “planning” continue to take on new meanings in new contexts.

– Emily