Twenty years ago, a colleague and I had the opportunity to listen to the birth stories of Guatemalan women living in small villages in the remote highlands of Sacatepequez. We sat on dirt floors in homes constructed of stick or cardboard, some with corrugated metal roofs, and recorded their voices. One woman said, "It is a miracle that one comes out alive. Only God can save your life at that time. It's hard. Many women die" (Callister & Vega, 1988, p. 292). We observed the incredible strength of these remarkable women, as well as the indigenous midwives who in many instances provided their healthcare. We met skilled traditional midwives with a deep commitment to women and their families.

Midwifery care has been provided in Guatemala for over 5,000 years, and these caregivers are often the most respected individual in their communities. They attend 80% of the births to indigenous women (Maya Midwifery International, 2016). It has been noted that "many traditional midwifery approaches are effective, readily available, and cost little." However, these midwives grapple with illiteracy, lack of written records, absence of standards of care, slight compensation for their services, sparse equipment, and little respect by professional providers. They deal with daunting challenges such as caring for women with malnutrition, grand multiparity, poverty, intimate partner violence, and lack of access to transportation and preventive care. Maternal and newborn mortality rates in Guatemala are among the highest in the Western Hemisphere, especially among indigenous populations (The World Bank, 2016).

Maya Midwifery International was born of grassroots efforts started in 1999 in which midwives from North America and charitable organizations partnered to help, and has resulted in educational and cultural exchanges and provision of birthing kits, equipment, and supplies. The goal is "to improve maternal child health outcomes by helping to prepare and sustain local midwives in their communities and helping them to have a voice in local and national policies which affect them" (Maya Midwifery International, 2016).

In 2000, the Association of Midwives of the Mam Area was established to address the issues of indigenous midwives and the communities of women they serve. In 2004, Casa Maternal de Nacimiento y la Comienza de Esperanza was opened in the Mam area, which includes a clinic and birthing center, educational facilities, and guest quarters. This is the only maternal/newborn health facility in the country that is owned and operated by indigenous midwives. Monthly meetings and training sessions are provided for midwives and apprentices, as well as birth supplies and equipment.

Simulation equipment and computers are used in training. Graduates of the programs receive a full midwifery kit (For contents see: /s/ACAMNoBleed.pdf). A donated van provides transport in emergencies and to facilitate mobile clinics in six isolated areas. Care is provided for modest fees, which are often waived. Two thirds of the operating costs of this center are generously provided by donors. Small salaries provided for the midwives are enabling them to educate their daughters, and some of these young women are becoming midwives. Besides a need for monetary donations and donated professional expertise, donations of hand knitted hats, sweaters, blankets, and socks are solicited as gifts for newborns born at the center or at home because the mountainous regions are very cold. These gifts serve as an incentive to childbearing women to seek care in the center. Due to lack of resources, without these donations many of the newborns are taken home wrapped in an old towel. It is tradition that mothers do not weave colorful ethnic clothing for their newborn until after they give birth to a healthy child.

This initiative is an example of working within the framework of available resources, addressing social determinants of health, using appropriate learning methods including verbal plus demonstration followed by practicing skills, and collaborating to enhance ability for indigenous providers to play a vital role in healthcare delivery that is safe, culturally appropriate, and cost effective.

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