Guatemala is one of only a few Latin American countries still home to a large Indigenous population: nearly 50% of Guatemala’s total population is Indigenous Mayan.
Following Guatemala’s 36-year civil war (1960-1996), which resulted in the systematic massacre of Indigenous Mayans, Guatemala has struggled with the highest rates of social and economic inequality in Latin America, and of the highest in the world: 54% of the population lives in poverty, and 13% lives in extreme poverty.
The greatest health and social disparities persist between Indigenous and non-Indigenous Guatemalans. Often, these disparities are felt most strongly by Indigenous women of reproductive age.
In a country with one of the highest maternal mortality rates in its region, the country’s highest rates occur in rural regions, particularly where the majority of residents are impoverished Indigenous Mayans. Indigenous Mayan women are twice as likely to die from preventable pregnancy-related deaths than non-Indigenous women. Devastatingly, the national statistical averages of maternal mortality in Guatemala hide the disparities that exist between the wealthier urbanites and rural, marginalized populations.
Maternity and Birth in Guatemala
In Guatemala, the national maternal mortality rate is 73 per 100,000 live births. However, that rate can more than double among rural Indigenous women. This disparity is partly due to the lack of access to healthcare centers. For instance, while approximately 65% of all births in Guatemala occur in health facilities, the number is much lower among rural and poor communities, which are often located hours away from a facility.
Most maternal deaths caused by these factors are preventable if expectant mothers are given timely access to quality prenatal care and skilled attendance during labor and delivery.
WITH HOME BIRTHS, THE MAJOR CAUSES OF MATERNAL DEATHS ARE:
Hypertensive disorders of pregnancy including eclampsia and pre-eclampsia
Source: World Health Organization (WHO)
Major causes of maternal deaths are often exacerbated by systemic healthcare issues related to marginalization and inequity, including: chronic poor health, a lack of access to health services, a lack of autonomy enabling women to make decisions about their healthcare needs, discrimination in the formal healthcare system, and a lack of knowledge about warning signs in an obstetric emergency. Maternal deaths and complications are often due to a combination of factors listed above.
Alarmingly, most maternal deaths caused by these factors are preventable if expectant mothers are given timely access to quality prenatal care and skilled attendance during labor and delivery.
Barriers to Maternal Care and Drivers of Maternal Mortality Rates in Guatemala
Although most maternal deaths are preventable in Guatemala, there are several major barriers to healthcare that ultimately perpetuate the country’s high maternal mortality rates.
Language and Cultural Barriers to Maternal Care: Though many Indigenous Mayans do not speak Spanish, the majority of medical services in the country are only provided in Spanish. Additionally, the traditional use of comadronas by Indigenous mothers is often looked down upon by medical staff at healthcare facilities. The disparagement of cultural caregivers and the discrimination against non-Spanish speakers create powerful barriers, effectively driving away expectant mothers in need of care.
Systemic Oppression of Young Women Creates Pregnancy-Related Complications: A large percentage of maternal deaths in Guatemala are the result of the widespread practice of child marriage, resulting from the systemic oppression of young women. 30% of marriages in the country involve girls under the age of 18, one of the highest child marriage rates in Latin America. Very young girls are prone to complications during childbirth and pregnancy because they have not yet reached physical or psychological maturity. In fact, pregnancy-related complications are a leading cause of death for girls aged 15-19 globally.
Unsafe Abortions Lead to Complications and Maternal Deaths: Abortion was made legal in 1973 exclusively for cases in which a pregnant woman’s life is endangered. To be legal, the procedure must be performed by a physician and approved by a second doctor, although this process remains uncommon. Non-sanctioned abortions remain common and are often unsafe; in 2003, approximately 22,000 women were treated for complications from unsafe abortions. It is estimated that about 10% of maternal deaths are due to complications from unsafe abortions.
GUATEMALA KEY STATS
Indigenous women who give birth without a skilled attendant: 30%
Maternal mortality rate: 73 per 1,000 live births
Primary causes of maternal mortality: hemorrhage, hypertensive disorders of pregnancy including eclampsia and pre-eclampsia, infections, and complications due to unsafe abortions
The country’s traditional birth attendant: comadronas
Opportunities to Overcome Barriers and Solutions to Systemic Issues
Supporting Traditional Healthcare Givers: Comadronas are trusted members of local Indigenous communities. They are the keepers of valued customs and traditions around pregnancy and birth, such as knowledge about medicinal plants and, because they come from the same communities they serve, they speak the local language. For these reasons, comadronas play an important role in Indigenous women’s healthcare. Yet they are often ostracized from the formal health system.
In many formal healthcare environments, comadronas are often looked down upon by health facility medical staff, who ignore them when they have concerns and refuse to allow them into the hospital or clinic, and may also chastise them harshly for bringing women to the hospital too late. Often, comadronas are not allowed to stay with their patient and are forced to wait outside the hospital.
Recognizing and respecting the important role of comadronas and their traditions and knowledge is a critical component to reducing preventable maternal and newborn deaths in Guatemala. Like all providers, comadronas need training and resources to be able to recognize high-risk pregnancies and identify complications when they arise. They also require the ability to develop referral systems so comadronas can successfully refer and transfer women with high-risk pregnancies and remain with their patients in hospitals and clinics should patients’ request it. The Guatemalan government has recognized that comadronas have a role to play in the formal healthcare system and has worked to give them training; however, the training is often inadequate.
Investment in formal training and job placement of midwives (parteras) in the Guatemala health system offers a significant opportunity to reduce preventable deaths and complications, and offer women respectful, skilled care while incorporating Indigenous traditions around pregnancy and birth. When trained properly and provided with the necessary resources, midwives are able to provide 87% of the health care needs of women and newborns.
Providing Healthcare and Education to Adolescent Girls: As mentioned, the practice of child marriage is responsible for many maternal deaths in Guatemala. Forced marriages persist throughout the country, narrowing life plans for adolescent girls and putting their health at risk. Though a law was recently passed to elevate the age of marriage to 18 for both men and women, its impact has yet to be felt by many young girls.
Once married, girls often face pressure to prove themselves as wives and mothers. The rate of pregnancy in young girls and adolescents 10-19 years of age is high, and early sexual initiation is common. In rural and Indigenous populations, adolescent pregnancies are up to three times more common than in urban populations. Maternal deaths occur in adolescent girls under 20 years of age at a higher rate than in adults.
Women’s and girls’ access to family planning depends on a number of factors, including geography, poverty, and the consent of a woman’s male partner. Cultural barriers also limit access to reproductive healthcare, including concern about social or religious chastisement for using family planning and fear of side effects. Most Guatemalan women under 20 years of age who are in a relationship report needing to ask their male partner for permission to use contraception. 55% of sexually active, never-married women aged 15-19, and 26% of married women of the same age, report having an unmet need for contraception, meaning they wish to avoid pregnancy in the next two years but do not have access to contraception. Skepticism of family planning is widespread, including rumors that certain methods cause cancer or infertility. In many cases, this wariness stems from a long history of Guatemalan women being subjected to unethical sexual health experimentation and coerced or forced sterilization.
Culturally-appropriate education and outreach in local languages to both men and women is necessary to give women more choices and control over their bodies.