Examining the Cultural Appropriateness and Acceptability of a Traditional Birth Attendants' Training Program in Rural Guatemala.

Introduction: While there has been notable global advancement in reducing maternal mortality rates (MMRs) in Latin America, the rates among indigenous women remain alarmingly high. This disparity persists in Guatemala, where indigenous women face a two-fold higher MMR compared to their non-indigenous counterparts. Most of the obstetrical care is performed by traditional Mayan birth attendants (TBAs), also known as comadronas, who have minimal formalized clinical training in obstetrical care. Considering there was no national comprehensive training program for TBAs, a unique training program was established in 2014. This program, the School of PowHER (Providing Outreach in Women's Health and Educational Resources), aims to ensure sustainable education led by TBAs for TBAs in rural Guatemala with the ultimate goal of helping TBAs provide basic antenatal care and learn how to identify and refer high-risk pregnancies. The aim of this proposed study is to examine the cultural appropriateness and sensitivity of the training program through a mixed-methods approach.

Methods:  We utilized a mixed-methods strategy, combining quantitative and qualitative methodologies. The quantitative aspect involved a 14-item written survey using a three-point Likert scale for responses, while the qualitative part utilized a semi-structured interview guide to conduct a focus group discussion.

Results:  The survey (n=33) showed that 32 comadronas found the curriculum applicable (97%) and comprehensible (97%). However, only 26 comadronas (79%) were comfortable with anatomy terminology. Opinions on teaching tools varied: 13 comadronas (39%) felt they were always representative, 13 comadronas (39%) sometimes, and seven comadronas (21%) never. Group discussions echoed this lack of representation. In the learning environment, 32 comadronas felt welcomed (97%) and 31 felt understood (94%), but five comadronas (15%) were not comfortable asking questions. Thirty-one comadronas (94%) believed training made pregnant women trust comadronas more. Group interviews highlighted increased confidence, better care, and perceived lower maternal mortality.

Conclusion: This study found the program to be culturally sensitive and effective. Group interviews highlighted increased confidence, improved patient care, and perceived reductions in maternal mortality. Feedback emphasized the need for more culturally relevant materials, resources, and collaboration with the Ministry of Health. This program's community-centered approach could serve as a model for similar initiatives in low- and middle-income countries addressing high maternal mortality rates, despite language and access challenges.