Everyone in Xela is getting geared up for Christmas and consequently the patient load throughout the clinic is winding down. This week marks the last week of women's group meetings for the year. They will start again in January. I lead the closing project with the Tierra Colorada Baja group today. We made fertility necklaces out of brown, black, cream and red wooden beads. The placement of the different colors on the necklace indicate when the woman is most fertile and can be used either for family planning or to help conceive. The project was a big hit, but most importantly it sparked some interesting conversation and important questions.

Women in this conservative, traditional, Mayan, catholic (or evangelical) region have been more open to methods of family planning than I had anticipated. This includes hormonal methods of contraception. You wouldn't think that at first, based on the typical family size; every family has 6-7 children. However, the patients never understand why anyone would only want to have only 2-3 children as is common practice in the US. The only disadvantage is after 5 pregnancies, the woman enters the category of grand-multiparous which puts her at risk for pregnancy and postpartum complications such as placenta previa (when the placenta lies over the opening of the uterus preventing the baby from delivering vaginally without hemorrhaging) and postpartum hemorrhage. I vividly remember when I was working in Nashville with a lot of Latina immigrants, specifically many Guatemalans, a patient recounting her labor story. She had no information to give us about the child's birth on the intake questionnaire. She gave birth at home in her small village. She bled a lot, causing her to go into shock and unconscious. She didn't wake up for over a week and when she finally woke up the baby had passed. Luckily, I have not heard of anything like this with my patients here in the Valley of Palajunoj. However, I will say that this story served as a large motivation to come to Guatemala.

So although many women are willing to use contraception, access to contraception is still controlled by the man. Most of my patients tell me that they have to discuss their treatment plan with their husbands and come back in for a second consult once they decide, even if the plan does not pertain to contraception. Unfortunately, this has hindered some women from getting the treatment that they need.

However, despite the women's reluctance to participate in family planning by themselves we were able to discuss some important points. There are many myths circulating in the community about miscarriages. I have devastated patients come to me after miscarrying stating my auntie told me it was because I ate X or my mother-in-law told me it was because I looked at Y while I was pregnant. Whatever the reason they give ends up being, it always puts full blame on the pregnant women. Ridden with guilt, the patient usually tries to get pregnant again immediately. However, it is advisable that after a miscarriage that the pregnant woman waits a few cycles to get pregnant allowing the endometrial lining (where the fertilized egg will implant) to replenish so it can sustain a healthy pregnancy. The reality is that 1 out of 4 pregnancies end in miscarriage. This is the body's way of preventing the birth of babies with genetic defects that are not compatible with life outside of the womb. I am trying to turn around some of these notions of guilt and blame as women in the community are always held accountable for the child's health even when the child contracts a simple cold virus.

Although my time with the women's group is coming to a close, this is not just a time to tie up loose ends. With a month remaining in my time in Xela there is still time for new beginnings. Today the new group of medical students from San Carlos University arrived and I led a two hour discussion on the basics of obstetrics and gynecology. It is amazing to me that the last group of med students have already come and gone. This new group is very tentative, as is only natural in the first few days. The last group of medical served as a good practice run. But with only 3 weeks until the clinic closes for Christmas, I will have to teach the new medical students in 3 weeks what I taught the last group of students in 2 months. These medical students will serve as the future of the women's clinic in the month of January at least until we figure out how to stabilize the women's health program after I leave at the end of December (too soon).

By far the most exciting new thing that has happened is my collaboration with one of the community midwives (comadronas). After knocking on a few doors we came upon her house. She is well respected in the community as a traditional healer. She is the president of the association of comadronas in the Valley. In addition to being a midwife she also treats children. She specializes in illnesses such as the evil and uses only herbal remedies. Despite the image that this may conjure, she is very well trained and I respect her work as a health practitioner. She received training at the local hospital and rotated on the labor and delivery floor for some time. She is also a certified provider of APROFAM, a great women's health organization in Guatemala with very progressive ideas and projects. Through APROFAM, she is provided with and certified to administer contraceptive injections.  However, she insists that her patients get a pap smear and bring her the results before she will administer the injection. Though she does not perform pap smears herself, it is her way of incentivizing the women to seek a women's health service that she knows to be important in the prevention of cervical cancer.

When the women's group meetings pick up again in January, she will be coming to speak to the women about her work during the segment on leadership, as she is a recognized leader in the community. The collaboration is very important as there are some things that she can't heal with traditional medicine and there are some things that we can't heal with western medicine. I have no idea what to do with a return patient who is not getting better because she is convinced that she must first be cured of the evil eye. I have really come to understand how much faith plays into the idea of wellness, or at least alleviation from pain and suffering.

The commadrona works with some western equipment. She showed me her fetoscope, blood pressure cuff, etc. She understands how important high blood pressure can be for a woman in labor (signs of pre-eclampsia/eclampsia) and knows that with high blood pressures she needs to bring her patients to the hospital in the city. At the end of last week I dropped off some few remaining supplies that she needed replaced including a stethoscope, sterile gloves and drapes and new scissors for the umbilical cord. She will be attending the birth of a patient that I have been providing prenatal care. I have been invited to come to the birth. Her due date is December 15th so hopefully she will give birth before I leave on the 18th. This partnership will hopefully allow us to perform better prenatal care in the valley with a more fluid transition to the birthing process which currently is very disjointed.