Over 2 decades ago, I had the incredible opportunity to listen to the voices of indigenous women living in the rural Guatemalan highlands about their birth experiences (Callister & Vega, 1998). The vast majority of these Mayan women gave birth at home attended by traditional birth attendants (TBAs). I met some of these comadronas, dressed in brightly colored traditional clothing woven in the pattern of their villages, who were highly respected women in their communities. They often spoke of their role in caring for women and newborns as a divine calling.

I witnessed pioneering efforts to provide education for these TBAs. In the years since I was in Guatemala, 80% of Mayan women have continued to give birth at home, often without seeking prenatal care. The maternal mortality ratio for Mayan women is more than twice that of non-Mayan women. Contributing factors may include poor transportation and limited infrastructure, living in remote and isolated areas with limited access, continuing distrust between Mayan women and Ladinas, discrimination, limited maternal education among Mayan women, poverty, and disrespect of indigenous cultural beliefs and practices. Even though indigenous childbearing women continue to rely primarily on TBAs for care during pregnancy and birth, Guatemalan has not had an approved national comprehensive training program for TBAs in rural Guatemala.

But since 2011, consistent efforts have been made to strengthen educational initiatives for TBAs in rural areas of the country. One exemplary program, the School of POWHER (Providing Outreach in Women's Health and Educational Resources), was founded in Solola in the western highlands of Guatemala in 2011. In this region, 96% of women are indigenous, with only 2.7% of healthcare visits being made to clinics for prenatal care.

Hernandez, Oliveira, Jones, Chumil, and Shirazian (2018) have documented the impact of the provision of standardized prenatal clinical education for Guatemalan TBAs in the School of POWHER. The goal of POWHER is to educate TBAs on important aspects of maternal healthcare in the context of respecting local customs. Appropriate referral for maternity care is the key to decreasing maternal death and complications in the region.

This innovative immersion program is offered in both Spanish and the Tz'tujilan Mayan dialect and is supported by the Guatemalan Ministry of Health. The curriculum is based on World Health Organization standards, guidelines of the Health Professions Networks Nursing and Midwifery Human Resources for Health, and Guatemalan healthcare guidelines for TBAs. In addition to education, participants receive supplies including a stethoscope, blood pressure equipment, a fetal Doppler, prenatal vitamins, and safe birthing kits.

The program includes a 28-module lecture series and a 12-month clinical component with a preceptor. Skills development continues as graduates become preceptors and have continuing education. Respect is demonstrated for traditional Mayan cultural practices including the provision of spiritual guidance, abdominal massages, and traditional steam baths coupled with evidence-based care guidelines for the care of women and newborns. Through the end of 2018, over 60 TBAs have completed the program which is 100% sustainable through public and private grants (Hernandez et al., 2018).

It is projected that by 2025 this model of education for TBAs could potentially be integrated into the healthcare structure in Guatemala. According to Dr. Mariam Wallet of the United Nations Forum on Indigenous Issues, the 2030 Agenda for Sustained Development presents a unique opportunity to reduce health inequalities for indigenous women and mothers. Continuing outcomes evaluation is needed to document the effectiveness of these creative educational interventions designed to bridge the gap between the cultural beliefs and practices of indigenous people and healthcare systems in low- and middle-income countries.

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