Juana Cac Perpuac sits on the grass outside the health centre in her town with a look of desperation and disbelief in her eyes. She whispers: “I’m attending to one woman who is eight months pregnant and very thin. I told her to come here to get help, but the staff wouldn’t see her. She’s due soon and I think she’s going to have problems.” Cac Perpuac adds that doctors and nurses often don’t take women like her seriously. She fears the worst for the woman she is looking after.

Cac Perpuac, 78, works as a comadrona in a rural area of Totonicapán, a region in the highlands of Guatemala. Comadronas are hired by families, especially indigenous ones – 41% of the population of Guatemala identifies as indigenous – to guide a woman through pregnancy, labour and the weeks after childbirth. They fulfil a role similar to that of a doula: they help deliver babies, perform massages before and after birth, and use medicinal plants to ease pain and stimulate breast milk.

There are 23,320 comadronas registered with the Guatemalan Ministry of Health and they are often older women. They perform a vital role in hard-to-reach areas, where it can take hours to get to the nearest hospital by truck or foot along dirt tracks – which often comes at great expense – and in communities where Mayan beliefs and practices still play a part in everyday life.

Juana Cac Perpuac (left) and Margarita de León Tamup sit outside a health centre. Photograph: Sarah Johnson

In the past they would be the closest person to a doctor women would see during childbirth. Now the situation is changing. In an effort to reduce maternal mortality rates in the country, the Ministry of Health has been working with comadronas to ensure more births happen in designated centres – including hospitals and smaller clinics in the community – with trained healthcare professionals present. But the work of women like Cac Perpuac is still necessary.

The national maternal mortality rate in Guatemala [pdf] is 140 per 100,000 births, compared to nine in the UK. In the departments of Totonicapán and Quetzaltenango, where the Guardian visited, maternal mortality continues to be an issue. According to provisional Ministry of Health figures, in Totonicapán there were 21 maternal deaths in 2017, up from 16 the year before. In Quetzaltenango, there were more in 2017 than two years previously.

Comadronas are now required to register with the Ministry of Health and attend monthly training, where they learn to detect danger signs like whether the baby is in breach position, or if the woman has a fever and abdominal pain. In such cases, they are encouraged to take their patients to the nearest health centre.



Comadronas attend a monthly meeting with Ministry of Health officials. Photograph: Sarah Johnson

Stories like Cac Perpuac’s are still common, however. Comadronas are looked down upon by medical staff, who ignore them when they have concerns and yet tell them off for bringing women to hospital too late. In some cases, they are not allowed to stay with their patient and are forced to wait outside the hospital.

Indigenous women also face discrimination – they are patronised and berated for turning up with dirty feet after walking to hospital and for screaming in pain during childbirth. There have been stories of them being sterilised without informed consent. Dr Juan Efraín Nájera, director of the Quetzaltenango health area, where about 61% of the population is indigenous, says: “The Ministry of Health insists that health services do not discriminate against indigenous people. It is absolutely not allowed.” He admits that it continues, however. “There are still traces, but it doesn’t happen as much.”

Cac Perpuac and other comadronas’ experiences don’t seem to tally with the official line. She says: “It really hurts when we tell our patients they have to come to the health centre, saying that they will receive good care – and when they do come, they are not treated well. They tell us we’re liars.”

In rural Totonicapán, it can take women hours to get to the nearest hospital. Photograph: Sarah Johnson

Her companion, Margarita de León Tamup, adds: “Most of my patients give birth at home. Once I brought a pregnant girl here. I don’t speak Spanish. When we arrived, staff got angry and didn’t speak to us. Things are a bit better these days, but patients are still ashamed and embarrassed to come here. I would only bring a patient when absolutely necessary – if I can’t do any more, I bring them in order to save their life.”

Hearing these experiences comes as no surprise to Thomas Hart, country director for Health Poverty Action in Guatemala, which works to improve awareness of issues facing indigenous people in health services. He admits: “Three quarters of the people we work with will improve their cultural awareness and change their practice as a result. There will always be a significant minority who won’t.”

Progress on fostering closer working relationships between comadronas and healthcare services may be slow, but there are pockets of hope. In San Carlos Sija, a municipality in Quetzaltenango, Dr Samy Juarez and his psychologist colleague, Ligia Gomez, recognise the benefits that comadronas can bring. Figures for births that happen in the health centre there have increased year on year: in 2015 there were 93, in 2016 that figure rose to 138, and there were 151 in 2017.

Adela Ixcotoyac has worked as a comadrona for 40 years. Photograph: Sarah Johnson

“We work hand in hand with comadronas and we trust them,” says Juarez. “They have a deep knowledge of the patient. They make referrals to us. We ask that they tell us if a doctor or nurse doesn’t tend to them in a culturally appropriate way. We want them to point things out so we can improve the service.”

At the health centre, beds are lined with traditional material, there are special gowns, women have the option of giving birth standing up, common in indigenous communities – and comadronas can be present during labour, important when the mother-to-be speaks K’iche’ for example, and not Spanish.



Meanwhile, in Santa Maria Chiquimula in Totonicapán, Adela Ixcotoyac, 67, a comadrona, acknowledges that the situation has improved. She remembers one occasion five years ago when she attended a patient who lived far away from the health centre. She delivered the baby but it was green and vomiting. The mother was on the verge of losing consciousness. Ixcotoyac knew that both would die without medical attention. She ran to find a doctor but the health centre was closed. The mother’s husband didn’t want his wife and baby to leave the house. Ixcotoyac managed to call the doctor, who came at her request and insisted that mother and baby go to hospital, where both received treatment and survived.

It’s stories like this that have earned Ixcotoyac and her peers hard-won trust and respect. She says: “Forty years ago when I started, it was really hard. They [healthcare professionals and the Ministry of Health] saw us as being useless. It’s changed – but with such struggle.”