Journal of Radiology Nursing 38 (2019) 123e130 Contents lists available at ScienceDirect Journal of Radiology Nursing journal homepage: www.sciencedirect.com/journal/ journal-of-radiology-nursing Building Capacity to Provide Maternal Health Care in an Indigenous Guatemalan Community Through Ultrasound and Skills Training * Mary F. Sousa, BSN, RN a, , Barbara Corning-Davis, MS, CPHQ b a MF Sousa Consulting, North Reading, MA b Waitemata District Health Board, Auckland, New Zealand abstract Keywords: Sustainable Healthcare in Underdeveloped Regions, SHURinc, is dedicated to improving health care Obstetrical ultrasound delivery in low-resource regions through use of technology and educational training, with the goal that Low-resource areas the improvements will be managed and sustained by the local group (www.shurinc.org). This article Midwives training programs outlines SHUR's involvement in a project to bring ultrasound technology and skills training to ACAM Guatemala women's health clinic located in Concepcion, Guatemala and describes strategies used to meet the learning needs of a Radiology nursing diverse audience caring for pregnant indigenous women in a rural low-resource area. This article offers experience in working collaboratively with the midwives and other groups to achieve the overarching goal of improving the health of the indigenous pregnant women in the region and their newborn babies. © 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved. Introduction: ultrasound in Guatemala Guatemala's indigenous population has some characteristics that make it especially vulnerable to maternal mortality. They tend Despite a recent destructive civil war, devastating natural di- to live in rural areas that are distant from medical services. Since the sasters, dangerous gangs, and extreme poverty, Guatemala remains women's first language is not Spanish, they experience language a beautiful and endearing country. It is rich in culture and barriers when visiting health professionals and facilities. geographic wonders and its pulsing energy is felt everywhere from Although some progress had been made through education and Guatemala City to the jungles and active volcanoes. Its people are nutrition, the greatest need was to have access to ultrasound for early warm, generous, and resilient. They are our neighbors. detection of at-risk pregnancies. Ultrasound was available in nearby When the SHURinc ultrasound project started in 2010, maternal cities but required traveling over roads, which if not pocked by mud- mortality in Guatemala was nine times higher than the United slides and disrepair were dangerous due to robberies. For pregnant States, even twice as high as Mexico, which has similar geographic women living in a remote village, the distance, danger, and cost are and demographic challenges (World Health Organization, 2010). barriers. Traveling to the hospital also meant having the examination in ACAM is the Asociacion de las Comadronas del Area Mam (translated Spanish, which was not the pregnant woman's first language. to Association of Midwives of the Area Mam). Serving the local Prenatal care reduces the risk of pregnancy complications. Early Mayan population, the clinic is operated by traditional Mayan health screening, providing advice on diet, exercise, and avoiding midwives and supported through assistance from various volunteer exposure to harmful substances (such as indoor pollution caused organizations. Approximately 100 women visit the clinic monthly. from poorly vented or nonvented stoves, and smoke from tobacco) Midwives perform 80% of the births in this region either at home or help prevent adverse outcomes for both mother and baby. Seventy in the clinic (Maya Midwifery International, n.d.). to eighty percent of indigenous Guatemalan women choose home What happens when a mother dies? Families shatter and the birth with an attending midwife (Maya Midwifery, n.d.; Safe disruption reinforces the cycle of poverty. Babies might be cared for Motherhood Project, 2003). This makes ultrasound an important by older siblings, often still children themselves, or other family tool as it can predict a complicated delivery and warn the mother members, or in orphanages. The societal loss cannot be measured who is planning a home birth. by a single statistic. Choosing local partners * Corresponding author: Mary F. Sousa, MF Sousa Consulting, North Reading, MA 01864. Sustainable change requires local people able and willing to E-mail address: [email protected] (M.F. Sousa). support the change being introduced. In this setting, skepticism and https://doi.org/10.1016/j.jradnu.2019.03.002 1546-0843/$36.00/© 2019 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved. 124 M.F. Sousa, B. Corning-Davis / Journal of Radiology Nursing 38 (2019) 123e130 distrust still lingered from the brutal 36-year-long civil war and Equipment acquisition violence (1960-1996), as well as fear of strangers around babies. In recent years, at least 500 cases have been documented (Brandies After 2 years of grass-roots fundraising, asking friends and University, 2007) of Guatemalan children kidnapped and subse- family for donations, gift basket raffles, fund raising at local res- quently exported abroad for profit. For these reasons, a local partner taurants, we were able to purchase an older ultrasound machine. who was trusted by the community was especially important. Volunteer team members paid their own travel expenses. Some of Connecting with the ACAM clinic was somewhat serendipitous, the team's lodging costs were offset by accumulated hotel points. though the midwives claim their prayers were answered. In Mayan culture, the midwives are highly trusted and respected. They are The vision fluent in the indigenous Mam language and understand the daily struggles of life, customs, and traditions. With the proper training, The initial vision was to provide ultrasound services that could equipment, and support, these midwives are an obvious choice to send images for remote reading. There were obstetrical and gyne- advance the care of pregnant women. cology (OB-GYN) physicians in Quetzaltenango, Guatemala who The ACAM Clinic serves a Mam-speaking population of were willing to help, but unable to travel 10 miles (about 45 mi- approximately 50,000 located in the western highlands of nutes) to the clinic to read examinations. Unfortunately, the age of Guatemala not far from Quetzaltenango, Guatemala's second the initial ultrasound was predigital. However, the clinic had been largest city, also known by its Mayan name, Xelajú. Spanish is the given a grant to hire a physician part-time, so they had someone official language of Guatemala, but the linguistic landscape is who could read the scans. The midwives would, however, need complex with a total of 24 languages spoken. Of these, 21 are some training to perform the scans. Mayan, one indigenous, and one Arawakan (World Atlas, 2017). The country is divided into 22 regions called departments First year: obtain and deliver an ultrasound machine thus (Central Intelligence Agency (US)). The Mayan language of Mam escalating the standard of health care provided was spoken by the ACAM midwives and the Mam people living in the department of Quetzaltenango and surrounding de- Our initial team was three. The person who initially met with the partments of Huehuetenango, Retalhuleu, San Marcos (World ACAM midwives recruited a radiology nurse who could answer Atlas) Figure 1. clinical questions about the ultrasound. A Guatemalan-born cul- Well-established and accepted in the community, the ACAM tural specialist with experience working with various volunteer midwives proved a perfect partner. In the early exploratory phase of groups in Central America was also asked to join the campaign. Her our project, the ACAM midwives were asked what would help with connections and cultural understanding proved extremely valuable the problem of maternal mortality. They said another organization as she not only translated, but she also made outstanding ground had recently funded construction of their clinic, which gave them a transportation arrangements and helped us achieve a solid rela- solid building and was providing some midwifery skills training. tionship with the midwives and other partners. What they needed now was technology (ultrasound) and training With the aim of creating sustainable and ethical improvements, for the technology. They had Internet and mobile phones, ample our process was directed by the needs identified by the classroom space, and a lot of heart and enthusiasm. midwives and their supporters. Meetings conducted in advance Figure 1. Linguist Map based on Guatemalan Population Census (Guatemalan Ministry of Education). M.F. Sousa, B. Corning-Davis / Journal of Radiology Nursing 38 (2019) 123e130 125 were respectful of local culture and care standards, and extreme misconceptions, we spent time explaining ultrasound scanning and care was taken to avoid imposing personal or religious beliefs. The its usefulness in helping to identify perilous conditions. goal was to empower the midwives through education and provide The preprocedure education and allowing the woman to see and them with the tools they identified as necessary to improving the touch the equipment before scanning was helpful in decreasing fear health care for pregnant women in this rural region. of the unknown. The smile on the faces of women who had already Developing