Bringing Light to Maternal Health: Solar Power for Casa Maternas
Kajal V. Parmar, Andrew Herrera, MPH, MBA
Executive Summary
In Guatemala, Indigenous women and their children face high risk of death and illness due to barriers in accessing community-oriented, culturally friendly, and logistically convenient options for care. Casa Maternas, which are community-built, -owned, and –operated birthing centers established to provide readily accessible delivery care to women living in remote areas of Guatemala and build trust between healthcare providers and their clients, have increased childbirth in a facility and decreased maternal deaths. However, a lack of reliable energy is a significant burden on the healthcare workers, their clients, and outreach programs. In Kenya, the solar microgrid implementation has been successful in equipping healthcare facilities with a constant source of power. In this policy brief, we demonstrate the positive impact of the Casa Maternas and the solar microgrid implementation in Kenya to propose replicating solar microgrid implementation for the Casa Maternas.
Introduction
On one side of the remote highlands of Guatemala, a young pregnant Mayan woman is in labor at home assisted by a comodrona, a traditional birth attendant. With no formal training, supplies, or equipment to support her client, she is unable to respond to this young women's seizures, indicative of pre-eclampsia, a dangerous birth condition that can cause death. As a result, both the mother and her baby die from eclampsia, which could have been prevented.
Despite progress in recent years, women in South America and Sub-Saharan Africa face deeply rooted obstacles accessing healthcare due to a paucity of basic infrastructure and reliable, community-oriented, maternity care. While maternity centers in Kisii County, Kenya, have been equipped with solar microgrid installations to support sustainable and reliable healthcare infrastructure, Casa Maternas located in the western highlands of Guatemala remain without such infrastructure, leaving the community-operated health care centers without a reliable source of electricity amid power outages. This lack of power at the facilities can deter patients from seeking care from the Casa Maternas and hampers the Casa Materna's ability to provide the fullest care possible.
Guatemala's indigenous population faces healthcare barriers due to their remote location and the high cost of government healthcare facilities. Further, language barriers, discrimination, and a lack of culturally appropriate care deter mothers from seeking care. Limited access leads many indigenous women to birth at home, which is a leading cause of death in the global south, with only 1 in 4 rural births occurring in hospitals, compared with over two-thirds of urban births. With this, there is an 8-fold greater risk of maternal mortality in a home birth compared to birth in a facility (mostly due to health facilities having access to trained health workers and supplies). As a result, the maternal mortality rate for indigenous women is 163 per 100,000 women – 3.7 times the rate in North Carolina in 2021, and as of 2016, twice the rate of non-indigenous women. Similarly, the indigenous population accounts for 71% of the country's maternal deaths while only 54% of the country's births.
Guatemala's Ministry of Health and Social Assistance trains and supports birth attendants to improve care in public facilities, but efforts remain fragmented. To resolve these disparities, Impact Global Health Alliance (IGHA) and its partner Curamericas Guatemala developed Casa Maternas. These birthing centers are strategically located, community-built, community-owned, and staffed with indigenous health professionals, offering effective and low-cost access to healthcare. However, these Casa Maternas face the effects of energy poverty due to underdeveloped infrastructure and high electricity prices causing frequent power outages. This scenario turns more patients away from accessing care in the Casa Maternas, exemplified in the case of Kisii County, Africa, where 1 in 3 women gave birth in their home in unsafe conditions.
Through supporting the installation of solar microgrids in the Casa Maternas, IGHA strives to address two issues: 1) existing, government-run and private healthcare facilities in the western highlands of Guatemala aiming to serve the indigenous population are inaccessible; 2) Casa Maternas do not have sufficient access to electricity to provide consistent maternal care services.
Methodology
IGHA implements the Community-Based, Impact-Oriented (CBIO) methodology to support marginalized communities to provide healthcare facilitated by providers that understand and treat common causes of unnecessary and readily preventable human suffering. After establishing a direct relationship with the community and engaging their participation, a community census is conducted to identify priorities. Thereafter, specific conditions are prioritized to create a comprehensive plan to address goals and assess improvements. Over time, the results are monitored and evaluated. The census is updated regularly through partnerships in the community and routine home visitation to reassess priorities based on progress and new foci.
The data collected is used to implement community-specific and oriented programs and services. In the case of Guatemala and the Casa Maternas, the results of the census identified a lack of maternal care, which led to the implementation of the Care Group Approach. Complementing CBIO and through learning-empowered participation, female Care Group Volunteers visit and educate households with pregnant women or new mothers. The peer-to-peer education model empowers women and is a flexible system that focuses on monthly education topics based on community and data driven needs such as sanitation, nutrition, or establishing a birth plan. This tailored approach is personalized, cost-effective, and driven by data.
The Casa Materna ensures high-quality 24/7 respectful care is available, with the Care Group Approach peer-to-peer education encouraging Casa Materna facility births. The centers are staffed with auxiliary nurses with World Health Organization standard obstetric care training and are supervised by experienced obstetric graduate nurses. Indigenous communities build and manage the centers, integrating traditional birth attendants and culturally appropriate care in their local language. The culturally sensitive birthing centers are strategically located and physically accessible to partner communities. The centers remain free of charge or at low cost as the peer-to-peer education Care Group Approach trains mother peer educators to deliver life-saving health education based on the vital health data collected through the community census.
While not implemented yet in Guatemala, these installations follow three facilities in Kisii County, Kenya – including the Matongo Maternity Hospital – to address the lack of reliable energy. The solar microgrids have been built to last 20 years with modular parts that can be easily replaced or expanded alongside a two-week backup capacity. Including a remote monitoring system and training for staff, the microgrids can support additional power needs like incubators, vaccine refrigerators, and other critical equipment for mothers and babies. Furthermore, the grids are scalable and designed to grow over time, ensuring long-term sustainability. The money saved through using renewable energy is directed towards facility improvements, health supplies, drugs, and salaries for health workers. Such success with solar power demonstrates how renewable energy is a viable option to strengthen rural community birthing centers.
Analysis and Results of Current Projects, Policies, and Solutions
Patricia, a 29-year-old mother expecting her second child, was determined to obtain a birth experience different from when she endured an unnecessary C-section with her first child. The Casa Materna in Santo Domingo helped train her in breathing exercises and movement techniques to prepare her for delivery; as a result, when she arrived at the Casa Materna in active labor, the team supported her through the exercises and movements to progress her labor naturally. Patricia delivered a healthy baby boy in a natural, uncomplicated birth, and the team was able to discharge her later that evening – a testament to the power of respectful and informed care provided by the Casa Maternas.
The CBIO+ Approach has led to significant progress worldwide in supporting access to safe and culturally informed healthcare access for vulnerable populations. Since the beginning of the community birthing center models in Guatemala, four Casa Materna maternity clinics have been built to serve local communities. The Casa Materna partner communities have reduced maternal mortality in a 26-community catchment of 8,703 people where at least 1-2 maternal deaths occurred every year. Furthermore, 70% of women report delivering in a facility, compared to 20% of women in non-partner communities. Peer-to-peer educators increased antenatal care by 71%, pregnancy danger sign recognition by 74%, and immediate breastfeeding by 80%. The Casa Materna model costs $5.60 per capita year, with deliveries at one-tenth the cost of government facility births.
Figure 1. Maternal mortality in Guatemala from 2017-2024.
In the Matongo Birthing Hospital in Kisii County, Kenya, offering a similar community birthing model as Casa Maternas, in 2020, 8.7 KW of solar and storage microgrid was established. As a result, 95% of deliveries are conducted in the health facility with a skilled birth attendant, and the number of deliveries in the facility has increased from an average of five per month to an average of 20 per month, 60% of which occur at night. The implementation of solar power has transformed the quality of care, with a similar solar microgrid installation in Nyagoto allowing the hospital facility to support overnight stays and access to resources for patients. With 24/7 power regardless of peripheral power outages, the communities are assured that the healthcare facilities are open, with power, no matter the time of day. The communities gain confidence in the clinic, preferring to utilize the clinic's trusted resources and personnel rather than stay at home or visit a costly, distant health facility that is intended for higher-level medical care.
Figure 2. Maternal mortality decline at Kenya project site from 2019-2022.
Call to Action
Solar microgrid implementation in Kenya have improved the ability for rural healthcare facilities to deliver care through their backup batteries, maintenance program, and robust sustainable design. Similarly, the Casa Materna infrastructure in Guatemala has been a successful, community-centered approach to ensuring health care access.
Coupling the success of the solar microgrid implementation in Kenya with the success of the Casa Maternas in Guatemala, we propose implementing solar microgrid infrastructure at the Casa Maternas. Doing so would further support the community-friendly healthcare facilities through providing a sustainable and reliable system of power. However, the microgrid is not the only part of the system. The system equally relies on infrastructure, personnel, financing, and other factors contributing to delivering community-oriented care.
Financing the project's upfront and ongoing costs can come from a multi-faceted approach with the support of the community, government, and outside supporters. Communities can invest in low-cost loans via Digital Financial Services (DFS). In Guatemala, DFS is an efficient way to support low-income communities. The government of Guatemala must aid the Casa Materna with funding, staff, and critical resources. The local community runs the Casa Materna; thus, their contributions in paying for their own Casa Materna alleviates additional cost burdens. Further, the Casa Materna utilizes earned income to partially fund the continuing facility costs.
To maintain the facility, the Casa Materna must address additional barriers such as a lack of internet. Internet supports both the Casa Materna staff and general operations, allowing for training and access to outside support such as telemedicine or phone calls. To add, internet is critical for engineers to monitor microgrids and ensure the health of the system. Despite investments from the U.S. Trade and Development Agency, more funding is needed for rural internet access, connectivity, and digital literacy. Thus, funds from international partners and non-governmental organizations to bolster internet education and access are critical. Doing so would empower the community to learn the operational matters of internet maintenance and become resilient in meeting their own needs. In the process, remote internet monitoring can support the Casa Maternas, where internet experts from countries such as the United States oversee and manage network devices, internet traffic, and respond to issues such as a cut in internet access or a security threat.
To measure the impact of solar microgrids on the rural Guatemalan communities, data collection tools must be leveraged. Numerically analyzing the number of women delivering at the Casa Maternas, the infant and maternal mortality rates, and the staff retention rates can showcase the direct impact of the microgrids. Furthermore, through ethically responsible interviews, the reasoning behind mothers choosing to deliver at the Casa Materna and the way staff perceive the microgrid can be documented. Other methods include comparing partner and non-partner communities based on the number of patients the facilities are able to see and treat, and long-term surveys of patients post treatment in the hospital.
Impact & Conclusion
For Job Atai, the nursing officer in charge at the Nyagoto Community Birthing Center, solar microgrids have been a "game changer" and "small effort making life easier". He explains that, initially, the facility "would never perform deliveries during the night" because "most often, we would do it in darkness". However, he continues, "since the inception of the solar microgrids, we have enough light such that we are able to conduct our deliveries with more caution" and "improve the outcome of the mothers".
Establishing solar microgrids as a more sustainable and long-term source of energy allows the healthcare facility to be able to run on its own. Clinics with 24/7 electricity boosts staff morale, increases patient visits and revenue. The money can be harnessed to run the facility without governmental reliance and equally invest into new initiatives such better water purification, the education of aspiring healthcare professionals, and supporting women's health initiatives – all areas of public health and safety often neglected in the rural towns of Guatemala due to distance from modern institutions.
A stronger and more energized healthcare facility is crucial towards successful patient outcomes. In a study examining the impact of safe and sufficient water, sanitation, and hygiene (WaSH) on the spread of disease in healthcare facilities. Access to 24/7 clean water also alleviated operational inefficiencies. With the implementation of on-premises water sources, health workers didn't need to travel extensively to collect and carry the water; consequentially, on-site and more hygienic water infrastructure improved patient outcomes. In the case of the solar installations in the Casa Maternas, this infrastructure provides a more reliable source of electricity, which can avoid time lost with patients due to power outages, circumvent time-intensive facility operations, and increase satisfaction in staff work environment.
Dark facilities turn patients away, reducing access to care. 24/7 clinic with light, such as the Casa Maternas in Guatemala, will ensure that individuals can receive access to care at night with the knowledge of the Casa Materna serving as a safe and secure facility. Similarly, the Casa Materna will be able to receive more patients that don't require hospital level care, ensuring that they stay at a strongly resourced clinic instead, and that the larger hospitals can focus on higher level emergencies.
To ensure equitable access to healthcare, particularly for historically under-represented communities, community healthcare centers must be equipped with the resources needed to support the needs of the population in a culturally friendly and trust-bearing way. Supporting the Casa Maternas, trusted and low-cost birthing centers, with solar microgrid infrastructure does exactly so.
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