Registered Midwife Guatemala Interview

Hannah Friewald of Manos Abiertas

In a developed country, people have the luxury of forming a self-educated opinion on their preferred manner of giving birth. For most indigenous women in Guatemala, there is only one option. Indigenous women who live in the mountains or far from any type of hospital use traditional midwives who many times are not trained in modern life-saving techniques. When indigenous women do find a way to go to a hospital or clinic, they often face racial discrimination, lack of respect and have no control over their bodies.

Who are you?

I am Hannah Freiwald, a midwife born in Germany who visited the States when I was in my late teens. It was in the U.S. that I met a Guatemalan whom I married. I moved to Guatemala in about 1989. I have four children of my own and am passionate for natural childbirth. I studied midwifery at Maternidad La Luz in El Paso, Texas and am licensed in Guatemala. (Note: When it comes to international health insurance covering births attended by midwives, local licensing is important!)

How did you get interested in midwifery in Guatemala?

My first baby was born by c-section, since I was unaware that by being uninformed and naive I could be pushed into it. After that disempowering experience I was determined that I would not go through this ordeal again but heal from it. I had my second baby with a local midwife and that birth was all I had hoped it would be and more. A few years after, I applied to midwifery school, then became pregnant with my third and finally went to study at Maternidad La Luz when he was a year old.

Who is your "typical" patient?

I have no typical client (not patient, since they are not sick but pregnant). My clientele ranges from conservative indigenous people who live in the city but want a birth that is as close to indigenous customs as possible with the added security of my knowledge of western midwifery to VBAC mothers who, as I at some point, want to heal. I get highly educated women, both foreign and Guatemalan, who have informed themselves and know what they want for their birth.

Who benefits from your practice?

I attend a wide range of women and their families, women of all social classes, races and nationalities. It helps that I am trilingual, though I wish I spoke at least one of the Mayan languages. I am often consulted as a second opinion when a woman is told she needs an intervention, since everybody knows that while I agree completely with justified interventions, I do state openly when I feel a woman is being coaxed into a procedure because her doctor needs a new car, or wants to go on vacation on a certain date. I am the only English-speaking midwife in the capital and possibly the only midwife with a birthing clinic.

How has your practice developed over time?

Centro de Parto Natural has slowly and steadily claimed its place in Guatemala City and is known about by now all over the country. As the movement of natural birth has become a little more mainstream all over the world, and since the Discovery Channel is showing natural birth as an option, people are a little more relaxed around me. Ten years ago, I needed to do a lot more convincing when a couple first came to Centro de Parto Natural. Now people know what they want.

What birthing options are available for Guatemalans?

• For poor Guatemalans, there are the national hospitals: C-section rates are getting close to 50%, all kinds of other interventions are routine, and the woman is unaccompanied through her birth.


• The IGGS, the social security hospital, is very similar.


• Many people who can barely afford it therefore opt for one of the small private clinics, only to have the same experience but paying for it.


• Aprofam, an organization that started out subsidized but has to be sustainable at this point, has taken the same route in order to sustain itself.


• In the rural areas there are local midwives available, some of which are very experienced and well (mostly self-) trained, while others are not.


• The big hospitals in the city have a C-section rate of 70 to 80%, besides being very expensive.

In zone 11 we are facing the problem that people do not have a concept of a natural birth anymore - we have lost clients because they lost patience. People are so used to getting their babies cut out of them or pulled out of them or being hooked up to an IV that they do not believe in letting birth progressing normally. The urban clientele on one hand is used to getting things fixed "now" and on the other hand has no education to reason for themselves. The c-section rate in Guatemala is shocking, and seems to largely come from doctors being in a hurry (lots of patients!) and having inadequate training in obstetric techniques. They also get more money for performing a c-section than a vaginal delivery (as is the case in the US as well.)

How is what you offer with Manos Abiertas different?

It is unfortunate that respectful, empowering, and patient-based care is not the norm, but it is clear that when women find it they will not settle for anything less. Patients came to Manos Abiertas from across the country, taking 3 and 4 hour bus trips to seek care. Patients told stories of other clinics they had visited, where they never received results, where procedures and medications were not explained, where their birth control was unreliable and suddenly unavailable, and where they were c-sectioned unnecessarily. Low income Guatemalan women have not yet grasped that they deserve respect. Teaching them this fact is a big part of our work.

Manos Abiertas offers something different, and it is clear that it is needed. One of the most extraordinary things about Manos Abiertas is the home-birth atmosphere that they are able to offer to their clients. Women labor and birth in a quiet, comfortable, homey environment, surrounded by their family and friends (and sometimes half of the village.) They are able to deliver naturally, and usually go home to their family the next day. The new baby is celebrated and fussed over by the clinic staff, and the mom is at the center of all of the action.

What goals has Manos Abiertas already reached?

In our first clinic in Ciudad Vieja, we have attended over 1,700 clients so far. These are not people who come once out of curiosity, but women who decided that we will be their caregivers. Most of our propaganda is mouth to mouth.

The offer to run a second clinic in Guatemala City was unexpected and quite a challenge. The clientele is very different but we are getting that clinic off the ground as well. There, we have made agreements to work in strategic alliance with other organizations, for example ICOS, an educational NGO that has been working in the country for 20 years and is supported by the USAID, and with the municipality of Guatemala City. Now we are looking into an alliance with the veteran's organization in order to educate families of former soldiers as well as soldiers' widows. All these organizations approached us about midwifery and health promoters' training as well as about sex education for adolescents, a program that should be taught by the government but is not.

What sort of goals/vision do you have for the future?

It looks as if Manos Abiertas has more of a future in education than in the provision of services, which makes me sad, since I believe in changing peoples' lives through their individual experiences in key situations like pregnancy, birth etc.

We urgently need to implement a tubal ligation program. We have run a vasectomy program successfully for the last two years - which means we have had about 30 men actually getting a vasectomy. In other countries one would laugh at this number, but for Guatemala, this is a big success. Now, we know that for each vasectomy we could have 30 women get a tubal ligation...

On the other hand, my dream has been to open a midwifery school for rural women, so midwifery will become more professional without losing its essential traditional knowledge, of which the Maya people possess a lot. Lately the worldwide climate for midwifery has become a lot more favorable, so I believe that now is the moment and we are working on it!

To find other midwives in Guatemala and beyond, check out this Midwife Directory.

How do you see a program like Manos Abiertas benefiting Guatemala long-term?

Our example will hopefully set new standards for women's health care in the country. Hopefully women will demand respect and personalized care. The midwifery school, once it is in place, can make a huge difference regarding maternal and infant mortality and morbidity, as well as give rural women an opportunity for a career.

What does a program like Manos Abiertas need the most?

We need financing for our many projects, but mostly for the school. We have the potential students, have the potential location, have the curriculum - now we need to be able to give stipends to these students and make sure they will be paid a salary at least for three years once they get back to work in their communities. We need to be able to cover teachers' salaries, to pay for overhead... the challenge is huge.

The Manos Abiertas Clinics themselves need unspecified donations, so we do not get stuck when something unexpected arises. Last year, for example, we had to replace two employees because they did not work out and we had to pay their worker's compensation, which brought us to the verge of bankruptcy. Our organization needs a cushion and it will not come from the services provided, since what we charge barely covers our direct costs (for example 35 Q per visit that usually lasts half an hour or longer)

How could an ordinary person help?

An ordinary person could donate to us. If there is a specific interest you have - like sponsoring a birth for a person that can not afford our lowest price or family planning for a woman - you can make that known and you will know what happened to your money, since we will keep you informed. If not, a general donation will be most appreciated.

We love visitors, so if anybody would like to come by, just give us a call and somebody will be available to show you around.

What are some immediate needs you have?

• We do need at least two more professional grade, waterproof fetal dopplers with the appropriate batteries. We use cheap ones which means they stop working after about two and a half years.


• We urgently need educational material in Spanish, which probably means the money to buy it, since these materials are hard to come by around here and we would need to get them over the internet.


• We always appreciate donations of used (not worn out) toys and baby clothes.


• Medical disposables like syringes, chux, (disposable layers for a bed, to put under the woman) gloves etc. are always appreciated as well.

Where are your offices located, and how can potential patients contact you?

The clinic called Centro De Parto Natural is in the capital, not far from the airport and near the best NICU in the nation at Roosevelt Hospital. It is also close to the major hospitals. Centro de Parto Natural has backup; both obstetric and pediatric in those.

Manos Abiertas, because of its clientele, uses the public hospitals for referrals in emergencies. Manos Abiertas in Ciudad Vieja, Sacatepequez, has its own neonatal and pediatric program in conjunction with an Italian NGO.

Hannah Freiwald

Regardless of how you feel about the midwife vs. hospital birth issue, if nothing else let's agree that no matter one's social status, they should have an option. The ability to have control over one's own body is a basic right. If that right is given away freely, that's one thing, but the ability to have a choice is necessary. Without funding, Centro de Parto Natural and Manos Abiertas wouldn't be able to offer the Guatemalan indigenous women, the ones who are constantly refused the rights to their own bodies on a daily basis, the ability to choose their own manner of birth. Please consider donating (see full wish list).