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An Integrated Approach to Improving Maternal Health Care in the Ixil Triangle, Quiche, Guatemala. Christina Biller Fiona Clement Gia-Thanh Le Jennifer Kasper Sebalda Leshabari Kimberly A. Thiede. Enchantment of the World: Guatemala. http://tamasi.com/history/guatemala.html.

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an integrated approach to improving maternal health care in the ixil triangle quiche guatemala

An Integrated Approach to Improving Maternal Health Care in the Ixil Triangle, Quiche, Guatemala

Christina Biller

Fiona Clement

Gia-Thanh Le

Jennifer Kasper

Sebalda Leshabari

Kimberly A. Thiede

history of the armed conflict
History of the Armed Conflict
  • 36 Years: longest, bloodiest insurgency in Latin America
  • Human Toll
    • 140,000 killed (including 40,000 “disappeared”)
    • 200,000 children orphaned
    • 80,000 widowed
    • 1.5 million displaced (internally and in refugee camps in Mexico)

*EVERY SINGLE VILLAGE IN THE IXIL TRIANGLE WAS DESTROYED!

history of the armed conflict12
History of the Armed Conflict
  • October 8, 1992: Repatriation of Refugees in Mexico
  • Peace Accords signed December 29, 1996
    • Two Critical elements:
      • Government committed to increase spending for health and education by 50%
      • Accord on Identity and Rights of Indigenous Peoples
        • Indigenous practices respected
        • Guatemala “multiethnic, multilingual, pluricultural”
health indicators
Guatemala

Fertility Rate 5.1

Maternal Mortality 200/100,000 births

IMR 51/1000 live births

Quiche

Fertility Rate 6.7

Maternal Mortality 284/100,000 births

IMR 69/1000 live births

56% Women have not received tetanus vaccine

Health Indicators
project goals
Project Goals
  • Reduce maternal mortality
  • Reduce neonatal mortality
  • Improve women’s health, including their mental health
strategy
Strategy
  • Improve quality of TBA services
  • Strengthen obstetric referral services
  • Improve access to emergency services
  • Women’s Community Health Center as forum for women to meet
why the ixil triangle
Why the Ixil Triangle?
  • MMR and IMR higher than national average
  • Most maternal deaths could be prevented with better prenatal and delivery care
  • 30-40% IMR attributed to inadequate care during pregnancy and childbirth
  • If mother dies, infant has only 10% chance of survival to 1st birthday
  • Psychiatric morbidity may be >35%
why selected strategy
Why Selected Strategy?
  • 80% indigenous women deliver at home with TBA
  • Improved TBA training can decrease MMR
  • Some women will need emergency services
  • No rural services for mental health
tba training
TBA Training
  • Culturally sensitive, linguistically appropriate course
  • Two 1-week intensive training courses
  • Apply principles from “Training Manual for Traditional Birth Attendants”, “Where Women Have No Doctor”, and other WHO materials
  • Monthly refresher courses
training course topics
Training Course Topics
  • Antenatal care/risk assessment
  • Safe, sanitary labor and delivery
  • Emergency situations and referral
  • Care of the newborn
  • Postnatal care
  • Family planning
methods of teaching tbas
Methods of Teaching TBAs
  • Demonstration
  • Role-Playing
  • Group Discussion
  • Case-Presentation
  • Visual Aids: diagrams, posters, models, flip charts
  • Incorporate Mayan health beliefs wherever possible
map of ixil triangle
Map of Ixil Triangle

Chajul

7 km

Pulay

(site of WCHC)

S. Juan Cotzal

6 km

7 km

Uspantan

(site of Health Center)

45 km

Nebaj

women s community health center wchc
Women’s Community Health Center (WCHC)

Activities

  • Prenatal Care/Risk Assessment
  • Delivery Facility/Emergency Services including transportation
  • Postpartum Family Planning
  • Newborn Exam
  • Mental Health
intervention capabilities at wchc
Intervention Capabilities at WCHC
  • Vacuum Extraction
  • IV Fluids/Oxytocics
  • Manual Removal of Placenta
  • Oral/Parenteral antibiotics
  • Anti-Hypertensives/Sedatives
  • Repair of Obstetrical Lacerations
emergency services
Emergency Services
  • Communication and Transport
    • Two-way radios in specified villages, WCHC, and transport vehicle
    • Four-wheel drive vehicle

Uspantan

Village TBA

WCHC

network of women in ixil
Network of Women in Ixil
  • Holistic approach to address maternal health, home life, after-effects of war
  • Centered at WCHC
  • Mental health seminars (formal and informal) in conjunction with CONAVIGUA
  • Weaving club/market day
conavigua human rights
CONAVIGUA/Human Rights
  • Women empowered to organize for human rights
  • CONAVIGUA (National Coordinator of Guatemalan Widows) established in 1988
  • More than 11,000 women, primarily poor indigenous women
weaving club market day
Weaving Club/Market Day
  • Weaving plays integral role in Mayan women’s culture
  • Women taught skill at early age
  • Guatemala one of the only countries in world where women wear decorative woven dress on daily basis
  • Primero coordinating market day at WCHC once a month
evaluation of tba training
Evaluation of TBA Training

Test of Knowledge

  • Content driven oral exam measured against supervisory guides
  • Demonstration of proficiency
    • Simulated deliveries
    • Observation of TBAs on home visits and deliveries
evaluation of referral system
Evaluation of Referral System
  • Number of appropriate referrals to WCHC
  • Number of appropriate referrals to Type A

Facility in Uspantan.

    • Measured by chart reviews
    • Case review and discussion of referrals in monthly TBA refresher course
evaluation of monthly gatherings and weaving club
Evaluation of Monthly Gatherings and Weaving Club
  • Personal satisfaction survey
  • Number of women per village at monthly meetings
  • Number of referrals to CONAVIGUA
project sustainability
Project Sustainability
  • Partnership with MSPAS for TBA training and obstetric/prenatal care aspects
  • Collaboration with CONAVIGUA to empower women to actively participate in health and human rights
  • Weaving club/Market Day as incentive for women to gather and share/sell woven goods
cost analysis
Cost Analysis
  • 31,000 females & 15,000 Women of Reproductive Age (15-49) in Ixil Triangle
  • Primero CBR per Year = $6.86/WRA $3.32/female
  • MSPAS CBR per Year = $1.56/WRA

$0.76/female

  • Yearly on-going CBR = $2.02/WRA

$0.97/female

*CBR=Cost-Benefit Ratio