Teaching Guatemalan Lay Midwives Acupressure: Outcomes and Lessons Learned

Abstract

Purpose:

Lay midwives attend most births at home in Guatemala facing many challenges with limited resources. Current research demonstrates that acupressure can reduce preterm contractions and encourage post-term labor. Sharing acupressure techniques with lay midwives could improve birth outcomes in Guatemala. The purpose of this study was to deliver an educational session for lay midwives to assess their learning and satisfaction with acupressure, and its feasibility and usefulness in their work.

Methods:

Two acupressure protocols were designed based on the clinical expertise of University of Utah College of Nursing faculty and extant literature. Demographic data and a pretest were conducted, followed by a focus group and various educational activities. A post-test was administered, and participants were given Spanish-language, laminated Reminder Cards with acupressure point illustrations to reinforce knowledge retention as the group had a low literacy rate. This study was IRB approved.

Results:

Eleven lay midwives participated (all female, average age 52 with an average of 21 years of lay midwifery experience). Lay midwives lacked knowledge about acupressure before the educational session and were eager to learn. Afterward, most participants recalled six points to discourage preterm labor and six points to encourage post-term labor on a post-test, and expressed an intent to use their new acupressure knowledge with patients.

Discussion:

This sample of lay midwives eagerly embraced new acupressure information and demonstrated increased knowledge after this educational intervention. Next steps would be to continue to expand lay midwife knowledge and skills in response to their request for acupressure interventions for retained placenta.

INTRODUCTION

Guatemala is a Central America country with approximately 17,980,803 inhabitants. Although the economy is seen as growing, the country is still characterized by high poverty, unequal distribution of resources, and widespread malnutrition. Low government revenues adversely affect investment in education, sanitation, and health care.¹ Rural residents have limited access to hospitals, leading to 70% of people to birth at home with lay midwives.² In addition, the 36-year civil war, which was the longest civil war in Central American history, drained the country’s emotional and financial resources, rendering limiting government training, education programs, and hospital services. Subsequently, Guatemalans, particularly indigenous who suffered disproportionately during the civil war, distrust governmental programs.³ Most births occurring at home demonstrate the need for skilled birth attendants during labor and birth.⁴ Guatemalans’ continued use of lay midwives is rooted in trust.⁴ Lay midwives are traditionally respected community members, represent the indigenous culture, provide nondiscriminatory and nonabusive care, and minimize language barriers. These factors motivate pregnant people from rural communities to seek lay midwife care.^2,4

Guatemalans need culturally accepted and low-acuity interventions for pregnancy and birth. Acupressure has demonstrated efficacy in several areas related to birth. Acupressure positively impacts maternal bishop scores by ripening the cervix.⁵ The bishop score provides an indication of cervical readiness; a higher score indicates probability of vaginal birth with spontaneous or induced labor.⁶ Acupressure has demonstrated an ability to decrease pain and stress, which contribute to preterm birth.⁷ Acupressure diminishes levels of circulating prostaglandins,⁷ which can contribute to preterm labor by softening the cervix, collaborating with estrogen to trigger the oxytocin receptors in gap junctions, and directly stimulating the uterus.⁸ Maternal or fetal stress, from pain or psychological distress, can prematurely activate the fetal hypothalamic—pituitary—adrenal axis,⁹ raising corticotropin-releasing hormone levels, which increases prostaglandin production, directly stimulating the uterus and cervix in early labor.⁹ Acupressure can calm the stress pathway that triggers preterm labor by reducing pain.

The team’s hypothesis focuses specifically on the potential benefit of interventions to prevent preterm and post-term birth, thereby avoiding hospital transfers for pharmaceutical or invasive procedures from providers whom pregnant people distrust.^2,10 Multiple sources from the 1990s and earlier describe acupuncture and traditional Chinese medicine (TCM) as well received in Guatemala, perhaps due to resonances with traditional Mayan medicine, which included a form of therapeutic acupuncture and herbal medicine with some similarities in the theoretical framework to TCM.¹¹ Guatemalan lay midwives are not allowed to administer medication, which limits how they might intervene when facing preterm or post-term birth. Instead, lay midwives’ approach to birth complications commonly involves the traditional Mayan practice of abdominal massage, steam rooms, and plant-based treatments.¹² Thus, acupressure is a logical fit that culturally and legally falls within lay midwives’ scope of practice. Furthermore, acupressure has demonstrated efficacy for stemming preterm labor and encouraging post-term labor based on the pressure point location and the gestational age of the pregnancy.^2,5,7

The study aimed to provide lay midwives with accessible tools they could realistically implement for expanded labor care, and to assess their learning and satisfaction with acupressure and its feasibility in their practice. This article details the methods, procedures, and insights gained from this initial educational intervention to identify areas of future research and application.

METHODS

Study Design

This study used a pre/post-test single design to evaluate the study’s feasibility and acceptability; baseline characteristics of participants were also collected. Although global health programs using acupuncture have been conducted in Guatemala since at least 1995,¹³ no studies of acupressure delivered in this context have been published to date. The present study provided acupressure education to lay midwives to determine the feasibility of the educational intervention and elicit feedback about acupuncture’s acceptability. We also gathered insights and familiarity for later investigation and to establish an understanding of the best designs for future global health studies.¹⁴

Expert faculty from the University of Utah (UU) College of Nursing (CON) designed the acupressure educational invention to support the goal of avoiding costly trips to hospitals and continuing the delivery of culturally competent care from lay midwives. The training utilized image-based teaching methods to reduce literacy barriers and was implemented by trusted community members.¹⁵ Lay midwives were invited to participate in an educational session on acupressure points to prevent preterm birth and to encourage postdate contractions. A presurvey was collected to establish a knowledge baseline, the educational session took place, and a postsurvey was administered to assess change in knowledge. Upon completing the training, lay midwives received laminated Reminder Cards (see Fig. 1 ). with illustrated diagrams demonstrating the recommended acupressure points and specific uses for labor intervention. The program aimed to provide a low-acuity tool participants could realistically use for expanded labor care and to assess their learning and satisfaction with acupressure and its feasibility in their practices.

FIG. 1.

Acupressure points for discouraging and encouraging labor.

Setting

This 4-hour educational intervention was delivered in person at a Refuge International Health Clinic in San Raymundo, a municipality in the highlands 60 km northwest of Guatemala City. Refuge International is a U.S.-based, nonprofit organization that has maintained three health care clinics in Guatemala for two decades. Refuge International partners with local, nonprofit, community development organizations and local committees to ensure that high quality health care is delivered in a culturally appropriate and responsive manner.

Acupressure education was provided to lay midwives in a large room in a two-story hospital in Llano de Virgen. Two translators met with each lay midwife and reviewed consent and questionnaire items. Some lay midwives filled out questionnaires themselves. Translators completed the questionnaires for those who were unable to read or write in Spanish.

Participants

The study sample consisted of lay midwives who spoke Spanish or Kaqchikel. Lay midwives are typically highly respected community members who are spiritually called to their vocation and provide care during pregnancy, labor, and the postpartum period.

Design of the Educational Intervention

Before the educational intervention, a team of experts (licensed acupuncturists and certified nurse midwives [CNMs]) from the United States discussed common acupoints for (1) encouraging labor, when a person is postdates, and (2) discouraging labor when a person has preterm contractions. Acupoints were chosen according to TCM theory, individual point indications and actions, and safety. We also included acupoints commonly used in labor that are easy to remember. Laminated Reminder Cards were designed with instructions and pictures of acupoints in English and then translated into Spanish (L.B., K.G.). Translation was verified by a native Spanish speaker in Guatemala (G.A.). We then printed and laminated a dozen Reminder Cards for participants.

Intervention Delivery and Data Collection

One of the primary investigators is a bilingual CNM who has had a program of study with Guatemalan lay midwives in partnership with Refuge International and the Guatemalan Ministry of Health (MOH) since 2009. Before the educational intervention, MOH representatives informed lay midwives about the study. Upon arrival at the educational session, lay midwives were informed about the study and provided verbal consent as the written literacy level among participants was low. Participant compensation consisted of herbs for perineal repair and health. Those who wished to do so filled out demographic and baseline questionnaires. Those who were not able to fill out questionnaires on their own were assisted by the translator, who completed the questionnaires by asking the questions to the lay midwives and recording their responses.

The other PI (L.T.S.) is a nurse researcher with 15 years of experience in acupuncture and Chinese Medicine. She trained the bilingual CNM (K.G.), who consistently uses acupuncture as a patient in the United States, about acupuncture points for encouraging or discouraging labor. Both the nurse researcher and bilingual CNM are faculty at the UUCON. The bilingual CNM (K.G.) taught lay midwives six points for encouraging labor, to address post-term pregnancy, and six points for discouraging labor, to address preterm labor. No contraindications were taught. The bilingual CNM provided a hands-on workshop with both demonstration and discussion. Participants received the laminated Reminder Card with pictures of all points to facilitate knowledge retention. All questions were answered, and participants practiced pressure points on each other.

Instruments

A background and demographics data sheet, pre- and posteducational surveys were designed by our team and written in English. The data sheet and surveys were then translated by Spanish-speaking members of our team (L.B., K.G.). Translation was verified by a native Spanish speaker in Guatemala (G.A.). Upon return to the United States, deidentified data were entered into an Excel spreadsheet. Participants’ free-text answers written in Spanish were translated into English and then entered into an Excel spreadsheet.

Ethics

A UU Institutional Review Board deemed the study exempt. The study met all the following six principles of the Brocher Declaration: (1) mutual partnership with bidirectional input and learning; (2) empowered host country- and community-defined needs and activities; (3) sustainable programs and capacity building; (4) compliance with applicable laws, ethical standards, and code of conduct; (5) humility, cultural sensitivity, and respect for all involved; and (6) accountability for actions.¹⁶

Statistical Analysis

Analysis was performed using Microsoft Excel Office 2019 software.¹⁷ Descriptive statistics were calculated for demographics and pre/post surveys.

RESULTS

Demographics

Eleven, female lay midwives with an average age of 52 years (range, 31–72) and an average of 21 years (range, 1–52 years) of midwifery experience participated in the study. Lay midwives had an average of 3 years (range, 0–9) of education, and a majority were able to read, write, and count (see Table 1). The majority had neither received acupressure nor knew anyone who provided it but were very interested in learning about acupressure.

Table 1.

Demographics

	Mean (SD)	Range	Frequency (%)
Sex
Female	—	—	11 (100%)
Male	—	—	0 (0%)
Age (years)	52.0 (14.92)	31–72 years	—
Years as a lay midwife	21.0 (18.85)	1–52	—
Education (years)	3.3 (3.09)	0–9
Language(s) spoken
Spanish	—	—	5 (45%)
Not answered	—	—	6 (55%)
Able to read
Yes	—	—	9 (82%)
No	—	—	2 (18%)
Able to write
Yes	—	—	9 (82%)
No	—	—	2 (18%)
Able to count
Yes	—	—	8 (73%)
No	—	—	1 (9%)
Unanswered	—	—	2 (18%)
Received acupressure before	—	—	—
Yes	—	—	1 (9%)
No	—	—	10 (91%)
Interested in using acupressure
Very	—	—	10 (91%)
Somewhat	—	—	0 (0%)
Not interested	—	—	0 (0%)
Unanswered	—	—	1 (9%)
Know anyone who provides acupressure
Yes	—	—	1 (9%)
No	—	—	10 (91%)

Acupressure to Encourage Labor

We conducted a survey before and after the acupressure educational session. Education consisted of teaching lay midwives six acupoints to encourage labor. No participants knew any of the six acupoints before the educational session. Afterwards, all participants reported a correct or nearly correct location for five acupoints (LV 3, UB 20–24 area, GB 21, SP 6, UB 60), 1 person incorrectly identified the location of LI 4, and 10 people identified the location correctly or nearly correct location (see Table 2).

Table 2.

Participant Knowledge of Acupoint Location Before and After Acupressure to Encourage Labor Education

	BeforeN (%)	AfterN (%)
Acupoint		AfterN (%)
LI 4
Don’t know	11 (100%)	1 (9%)
Close to location	0 (0%)	3 (27%)
Correct	0 (0%)	7 (64%)
LV 3
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	6 (55%)
Correct	0 (0%)	5 (45%)
Lumbar massage (UB 20–24)
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	2 (18%)
Correct	0 (0%)	9 (82%)
GB 21
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	0 (0%)
Correct	0 (0%)	11 (100%)
SP6
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	3 (27%)
Correct	0 (0%)	8 (73%)
UB 60
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	3 (27%)
Correct	0 (0%)	8 (73%)

Acupressure to Discourage Labor

We conducted a survey before and after the acupressure educational session. Education consisted of teaching six acupoints to discourage labor. No participants knew any of the six acupoints before the education session. Afterwards, all participants reported a correct or nearly correct location for two acupoints (DU 20 and Yin Tang), 1 person incorrectly identified the locations of three acupoints (SP 4, CV 17, and CV 15), and 10 people identified the location correctly or nearly correct location. Six participants incorrectly identified one acupoint, KD 9, and five participants correctly identified this point.

Feasibility and Acceptability

We asked participants questions about the acceptability of the educational session. Ninety-one percent (n = 10) indicated that acupressure was easy to learn, and all participants endorsed liking acupressure and an intention to use acupressure with their patients (see Table 3). When asked about what might inhibit them from using acupressure, respondents indicated if a patient was at risk or faced an emergency (n = 3), patient preference (n = 5), depended on the case (n = 3), threat of labor (n = 3), or birth of baby (n = 1). When asked, “What would help you use acupressure with your patients?” participants indicated the handouts were helpful (n = 1), to help the patient (n = 4), they would put it into practice (n = 2), if the patient has need (n = 1), and to discourage birth (n = 1).

Table 3.

Participant Knowledge of Acupoint Location Before and After Acupressure to Discourage Labor

	BeforeN (%)	AfterN (%)
Acupoint
DU 20
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	3 (27%)
Correct	0 (0%)	8 (73%)
Yin Tang
Don’t know	11 (100%)	0 (0%)
Close to location	0 (0%)	2 (18%)
Correct	0 (0%)	9 (82%)
SP 4
Don’t know	11 (100%)	1 (9%)
Close to location	0 (0%)	3 (27%)
Correct	0 (0%)	7 (64%)
KD9
Don’t know	11 (100%)	6 (55%)
Close to location	0 (0%)	0 (0%)
Correct	0 (0%)	5 (45%)
CV 17
Don’t know	11 (100%)	1 (9%)
Close to location	0 (0%)	0 (0%)
Correct	0 (0%)	10 (91%)
CV 15
Don’t know	11 (100%)	1 (9%)
Close to location	0 (0%)	6 (55%)
Correct	0 (0%)	4 (36%)

DISCUSSION

Most indigenous Guatemalans face resource constraints and experience poor health outcomes,¹⁸ often choosing to birth at home.¹⁹ Due to their distrust in institutions and long distance from hospitals, lay midwives assume a vital role in safeguarding the health of pregnant people and infants.⁴ Hence, providing lay midwives training is crucial in alternative techniques for laboring, such as acupressure, which offers a noninvasive and cost-effective approach to treatment. By equipping lay midwives with additional skills, we enhance their capacity to effectively address health care needs in the communities they serve.

The findings suggest that the average age of lay midwives is 52 years, and they possess more than 20 years of professional experience. However, their years of formal education is relatively few. This finding underscores that the expertise of lay midwives lies in their hands-on experience with labor and birth. In addition, lay midwives have no prior experience with acupressure, and no individuals in their community provide acupressure, highlighting a need for targeted education and training programs. Despite these challenges, the study revealed that lay midwives have a strong interest in using acupressure, demonstrating a willingness to learn new and cost-effective methods that align with their professional ethics and desire to improve care for pregnant people. The finding aligns with the study’s indication that Guatemalan lay midwives have a strong desire for enhanced training opportunities and access to essential supplies to practice their trade.²⁰ Addressing the educational needs of Guatemalan lay midwives supports better maternal and child health outcomes and contributes to building a stronger health care workforce.

The pre- and postsurveys revealed a significant improvement in knowledge regarding the identification of acupoints for labor encouragement and inhibition. These findings highlight lay midwives’ learning abilities and potential for acquiring additional professional knowledge to assist pregnant people, as demonstrated in other studies.^15,21–23 Although the results indicate that lay midwives are generally adept at locating commonly recognized acupressure points, such as DU (20) on the head, and Yin Tang between two eyebrows, they may face challenges identifying less conspicuous acupoints that require the use of cun units for measurement, such as KD (9) on the medial aspect of the lower leg. Lay midwives who are unfamiliar with these may encounter difficulties in providing optimal care. Therefore, lay midwives should receive comprehensive training and education on the precise location and calculation of acupoints to ensure the provision of effective patient care.

The after-education questionnaire revealed that all lay midwives, except one with missing data, found learning acupressure easy, and they intended to use it with their patients. This finding indicates that lay midwives recognize the benefits of acupressure and are accepting of it. Furthermore, all lay midwives expressed genuine interest and favor toward acupressure, demonstrating a willingness to integrate it into their practices. Thus, promoting acupressure education among lay midwives is a feasible approach to enhancing effective, accessible, and cost-effective labor care.

Despite the benefits of our educational intervention, lay midwives identified barriers to providing acupressure. One barrier is patient preference. Some patients may reject the use of acupressure. While a paucity of data is evident in the literature regarding Guatemalans’ acceptance of acupuncture, one pilot study revealed that they were receptive to an ear seed protocol for management of diabetes symptoms.²⁴ Another barrier is potential risks that pregnant people or infants may experience during acupressure. In addition, the decision to use acupressure may depend on the specific case, and lay midwives may use their clinical judgment to decide against it. Despite these barriers, the study highlights the potential of acupressure as a valuable tool in labor care and lay midwives’ learning ability and interest regarding acupuncture. Further research is needed to address these concerns and to explore ways to overcome the stated barriers.

Strengths

Our study had several distinctive strengths. First, our study allowed us to gain valuable input from lay midwives and gauge their interest in learning about acupressure. Another strength is that acupuncture is a culturally sensitive method of alternative medicine. Lay midwives were eager to learn about it and to integrate it into their practice. Finally, and in a timely manner, our study showed the strength of the transfer of ability for those leading the research. One of the PIs, an expert acupuncturist and Chinese medicine herbalist (LTS), contracted COVID-19 halfway through the experience and was not able to teach acupressure as originally planned. However, the bilingual CNM (KG) was able to quickly learn the techniques and teach them to participants.

Limitations

We acknowledge our study’s limitations, namely, a lack of time to teach acupressure due to the worldwide pandemic. We only tested the midwives’ knowledge of acupressure but not how they applied it in practice; doing so would have enabled more insights to the use and benefits of acupressure for patients. A general limitation, not with respect to this study, but rather a general challenge in Guatemala is that health care services are underfunded, and sometimes lay midwives do not receive payment for their work. In addition, some Guatemalans lack resources for cell service, thus complicating follow-up. Finally, some participants may not work full-time as lay midwives, thus coordination and follow-up become difficult when participants may have other jobs and are not compensated for their time learning about acupuncture.

Lesson Learned and Future Recommendations

Through this study, we learned that more time to reinforce teaching and follow-up regarding patient care would have provided greater insights about the benefits of acupressure for pregnant people. Lay midwives were eager to learn, but we lacked the time to teach them additional acupressure methods. We also learned the crucial role of international cooperation and training. With more international cooperation and training, lay midwives in Guatemala and around the world could learn about and utilize acupressure to help manage symptoms of pregnant patients. Future studies should aim to establish a long-term internet-based acupressure training that would be widely accessible and a trusted source for acupressure treatments for patients around the world. Moreover, studying barriers is imperative regarding obstruction of the clinical application of acupressure, including consideration of patients’ inclinations and unique cases.

CONCLUSIONS

Guatemalan lay midwives, who attend the majority of births in their country at home with limited resources, were enthusiastically receptive to learning about acupuncture points to encourage and discourage labor. Lay midwives from San Raymundo who attended the educational intervention about acupuncture showed a significant change in knowledge and voiced an intention to use their new knowledge in their practices. Future studies should provide follow-up to reinforce and expand acupuncture education and to access if lay midwives are using acupuncture correctly in their practices and if acupuncture therapy is ultimately improving birth care in their country.

Footnotes

Acknowledgements

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

This study was funded by the UUCON Global Health Intramural Grant (K.G.).

References

CIA. The world factbook. Country Summary: Guatemala May 30, 2024. Available from: https://www.cia.gov/the-world-factbook/countries/guatemala/summaries

Juarez

, Austad

, Rohloff

. Lay midwives: On the front lines of the fight against maternal mortality in rural Guatemala. Am J Trop Med Hyg, 2019; 100(2):237–238; doi: 10.4269/ajtmh.18-0518

Stanaway

, Afshin

, Gakidou

, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet, 2018; 392(10159):1923–1994; doi: 10.1016/s0140-6736(18)32225-6

The World Bank. Improving maternal and neonatal health in the department of Sololá, Guatemala. May 23, 2017. Available from: https://www.worldbank.org/en/results/2017/03/23/improving-maternal-neonatal-health-solola#:∼:text=Guatemala%20has%20the%20highest%20rate [Last accessed: June 5, 2024].

Torkzahrani

, Ghobadi

, Heshmat

, et al. Effect of acupressure on cervical ripening. Iran Red Crescent Med J, 2015; 17(8):e28691; doi: 10.5812/ircmj.28691

Marowitz

. Complications during labor and birth. In: Varney’s Midwifery. ( King

, Brucker

, Osborne

, Jevitt

. Eds.) 6th ed. Jones & Bartlett Learning: Burlington, Massachusetts; 2018:548-552.

Sharghi

, Mansurkhani

, Ashtary-Larky

, et al. An update and systematic review on the treatment of primary dysmenorrhea. JBRA Assist Reprod, 2019; 23(1):51–57; doi: 10.5935/1518-0557.20180083

Anderson

, Avery

. Anatomy and physiology during labor and birth. In: Varney’s Midwifery. ( King

, Brunker

, Osborne

, Jevitt

. Eds.), 6th ed. Jones & Bartlett Learning; Burlington, Massachusetts, 2018:861.

Reedy

, Bowers

, King

, et al. Pregnancy-related conditions. In: Varney’s Midwifery. 6th ed. Jones & Bartlett Learning: Burlington, Massachusetts; 2018:775-818.

10.

Smith

, Armour

, Dahlen

. Acupuncture or acupressure for induction of labour. Cochrane Database Syst Rev, 2017; 10(10):CD002962; doi: 10.1002/14651858.cd002962.pub4

11.

Petrucci

, Papalia

, Russo

, et al. Psychological approaches for the integrative care of chronic low back pain: A systematic review and metanalysis. Int J Environ Res Public Health, 2022; 19(1):60; doi: 10.3390/ijerph19010060

12.

Hernandez

, Oliveira

, Shirazian

. How a training program is transforming the role of traditional birth attendants from cultural practitioners to unique health-care providers: A community case study in rural Guatemala. Front Public Health, 2017; 5:111; doi: 10.3389/fpubh.2017.00111

13.

Melrood

. Guatemala Acupuncture and Medical Aid Project (GUAMAP). Tuscon, AZ; 2006. Available from: https://cdc.thehcn.net/prommisepractice/inded/view?pid=480 [Last accessed: June 5, 2024].

14.

Cuthill

. Exploratory research: Citizen participation, local government and sustainable development in Australia. J Sus Dev, 2002; 10(2):79–89; doi: 10.1002/sd.185

15.

Garcia

, Dowling

, Mettler

. Teaching Guatemalan traditional birth attendants about obstetrical emergencies. Midwifery, 2018; 61:36–38; doi: 10.1016/j.midw.2018.02.012

16.

Prasad

, Aldrink

, Compton

, et al. Global health partnerships and the Brocher declaration: Principles for ethical short-term engagements in global health. Ann Glob Health, 2022; 88(1):31; doi: 10.5334/aogh.3577

17.

Microsoft Excel. 2018. Available from: https://office.microsoft.com/excel

18.

Rogg

, Pezzia

. Victimization and distress in indigenous Maya women: A qualitative investigation of gender-based violence and mental health outcomes in rural Guatemala. J Fam Violence, 2023:1–15; doi: 10.1007/s10896-023-00500-2

19.

Stollak

, Valdez

, Rivas

, et al. Casas Maternas in the rural highlands of Guatemala: A mixed-methods case study of the introduction and utilization of birthing facilities by an indigenous population. Glob Health Sci Pract, 2016; 4(1):114–131; doi: 10.9745/ghsp-d-15-00266

20.

Garcia

, Kilanowski

. Senales de Peligo: Guatemalan lay midwives’ perceptions of responding to obstetrical complications. J Transcult Nurs, 2019; 31(6):547–553; doi: 10.1177/1043659619889114

21.

Garcia

, Morrison

, Savrin

. Teaching Guatemalan midwives about postpartum hemorrhage. MCN Am J Matern Child Nurs, 2012; 37(1):42–47.

22.

Garcia

, Gee

. Pretest-Posttest evaluation of change in knowledge and knowledge retention after educational activities with low-literacy lay midwives in Urban Guatemala. Journal of Academy of Health Sciences, 2023; 24(3):8387.

23.

Garcia

. An observational study of teaching methods with low-literacy comadronas in urban Guatemala. Canadian Journal of Midwifery Research and Practice, 2022; 21(3).

24.

Taylor-Swanson

, Tu

, Howell

, et al. Delivering acupuncture therapy in an interdisciplinary global health setting in Guatemala: Pilot study and lessons learned. Med Acupunct, 2023; 35(4):163–169; doi: 10.1089/acu.2023.0023