Original Research

Pretest–post-test evaluation with lay midwives in remote Guatemala after educational activities about COVID-19


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Kimberly S Garcia
1 (Hispanic) DNP, CNM, FACNM, WHNP, Associate Professor *

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Argelia Rodriguez
2 (Guatemalan) RN, Director

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Zoila Gonzalez
3 (Guatemalan) RN, RN

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Cheryl Armstrong
1 (Caucasian) DNP, RN, Associate Professor

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Eli Iacob
1 PhD, Statistician

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Emily E Flynn
1 RN Student

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Molly Simmons
4 Birth and Postpartum Doula, and Health Educator


1 College of Nursing, University of Utah, 866 East Red Sage Lane, Millcreek, Utah 84107, USA

2 Guatemalan Ministry of Health, Northern Peten, Guatemala

3 Refuge International Clinic, Sarstun, Izabal, Guatemala

4 Hospital Doula Program, Swedish Hospital Seattle, Washington, USA

ACCEPTED: 5 March 2024

early abstract:

Introduction: Guatemalan lay midwives are well-respected community leaders in a country that lacks the institutional capacity to meet health care needs related to pregnancy, newborns, and COVID-19. Thus, Guatemalan lay midwives, who attend the majority of births in their country and who attend most births at home, are in an optimal position to offer front-line to support to pregnant women and newborns regarding the global pandemic.
Purpose: The primary objective of this program of study was to dispel myths about COVID-19 and to provide culturally relevant educational activities to low-literacy Guatemalan lay midwives about issues related to the virus, such as signs and symptoms, risks to the mother and fetus, which patients are most vulnerable, appropriate responses, benefits and side effects of the vaccine, timing of the vaccine, how the virus interacts with breast feeding and breastfeeding recommendations.
Methods: In a partnership among the Guatemalan Ministry of Health, expert faculty at the University of Utah College of Nursing, and Madre y Nino, a non-profit organization from the U.S., evidence-based educational activities about COVID-19 were offered orally in the native language of participants. Two hundred and ten lay midwives attended educational sessions at 11 different locations throughout the remote Peten department. Educational activities included repetition, storytelling, and role plays. A pretest posttest evaluation with 24 correct answers was used to determine if the educational activities changed lay midwife knowledge about COVID-19. Participants were given essential birth supplies and laminated COVID Reminder Cards, which were designed to increase visual literacy, to encourage knowledge retention after the educational sessions.
Findings: Participants showed a significant increase in knowledge scores (possible 0 - 24) from pre scores 7.09 (SD=3.06) to 15.20 (SD=4.61), student’s T-test p<0.001. In addition, a significantly higher proportion of participants mistakenly thought COVID-19 passed through breast milk on the pretest (70.1%) compared to posttest (8.4%) (McNemar test, p<0.001). Regarding breast feeding, 12.6% of participants knew on the pretest that women with COVID-19 who breast feed should wear a mask and wash their hands compared to 74.3% of participants who knew these recommendations on the posttest (Wilcoxon sign test, p < 0.001). Finally, two percent of participants knew on the pretest that pregnant women with COVID-19 should take a baby aspirin compared to 67% of participants on the posttest. X2 (1) = 194.7, p < 001.
Conclusions: These essential primary care providers misunderstood many critical issues related to COVID-19, pregnancy, and newborns. Culturally relevant educational activities provided orally in the native language of participants dispelled myths about the virus and significantly improved lay midwife knowledge. Providing evidence-based educational activities in a culturally relevant format is critical to protecting remote, vulnerable populations, such as pregnant Guatemalan women and newborns, during a global pandemic.
Keywords: Guatemala, lay midwives, COVID-19, educational activities