A Review of the Forces Influencing Maternal Health Policies in Post‐War Guatemala

Published date01 March 2019
AuthorDilys Walker,Sylvia Guendelman,Anna Summer
Date01 March 2019
A Review of the Forces Inf‌luencing Maternal Health
Policies in Post-War Guatemala
Anna Summer, Dilys Walker, and Sylvia Guendelman
Guatemala’s 1996 Peace Accord ending the 36-year civil war included the goal to lower its
maternal mortality ratio (MMR). Yet, Guatemala still has one of Latin America’s highest MMRs,
especially among Mayan women. To improve maternal health, the professional midwife is being
reintroduced in Guatemala. Meier’s Linear Model of the Public Policy Process states that
policymakers respond to international and society-centered forces when making policy decisions.
How have such forces inf‌luenced the creation of birth attendance policies in Guatemala from 1996 to
today? Using a process tracing approach, we analyzed 132 policy documents, peer-reviewed journal
articles, and gray literature noting international and national maternal health recommendations
and all birth attendance legislation passed in Guatemala from 1996 to present. International forces
advocated for skilled birth attendance (SBA) to address maternal mortality. Society-centered forces
promoted intercultural care with traditional birth attendants (TBAs). Both—sometimes conf‌licting
—forces have inf‌luenced policymakers in the creation of maternal health policies in post-war
Guatemala. Policymakers must constantly reconcile tensions between society-centered realities and
international agendas when making policies. The reintroduction of professional midwifery in
Guatemala presents a means of addressing both agendas: Increasing SBA and improving
intercultural care.
KEY WORDS: maternal health, midwifery, reproductive health
Guatemala continually ranks among the countries with the highest maternal
mortality in Latin America and has been slow to improve in this area (Schieber &
Stanton, 2000). Guatemala also endured a 36-year civil war targeting the
indigenous Mayan population that ended with the Peace Accords in 1996. The
war weakened national infrastructure and resulted in the deaths or disappear-
ances of over 200,000 Guatemalans, the majority of whom were indigenous
Mayans (Schlesinger, Kinzer, & Coatsworth, 2005).
Guatemala is an ethnically diverse country; approximately 38 percent of the
population identif‌ies as Mayan. The indigenous communities often experience
severe discrimination which can be traced back to the Spanish colonization in
World Medical & Health Policy, Vol. 11, No. 1, 2019
doi: 10.1002/wmh3.292
#2019 Policy Studies Organization
1523 (Ashdown, Gibbons, &
U de Baessa, 2015; Chary, Dı
´az, Henderson, &
Rohloff, 2013; Gibbons & Ashdown, 2010). The signing of the Peace Accords
promised to recognize the rights of indigenous people and shed light on
numerous disparities—including the high maternal mortality—among indigenous
Mayan populations. Specif‌ically, the Accords agreed on a national goal to reduce
maternal deaths by 50 percent by the year 2000 (Rodrı́guez et al., 2011). This goal,
however, was not met. Government data estimated that, at the most, maternal
mortality decreased by 30 percent between 1989 and 2000 (Segeplan/MSPAS,
Given the unreliable nature of the data, a collaboration of international
organizations, such as UNFPA, USAID, and UNICEF, together with the
Guatemalan Ministry of Health (MOH) conducted a maternal mortality baseline
study in 2000. This survey found a national maternal mortality ratio (MMR) of
153 deaths per 100,000 live births that was adjusted to an MMR of 290 when
factoring in unreported deaths (Ministerio de Salud Publica y Asistencia Social,
2003). Disparities among different populations within Guatemala were startling.
While the MMR was 70 among non-indigenous Ladina women, it was 211 among
indigenous women, not accounting for underreporting (Ministerio de Salud
Publica y Asistencia Social, 2003). In 2007, the national MMR was 139, and the
MMR among indigenous women was still twice that of non-indigenous women
(163 vs. 77). Over 70 percent of maternal deaths in Guatemala were still occurring
among indigenous women (Segeplan/MSPAS, 2011).
Given that maternal mortality was named a national priority in 1996 leading
to subsequent legislation to improve maternal health, why has it remained
unacceptably high among Mayan women? What inf‌luenced the maternal health
policies created during this time?
At the time of the Peace Accords, international agencies were promoting
delivery with skilled birth attendants (SBA) def‌ined as a professional midwives,
physicians, and nurses that are trained to provide basic emergency and
comprehensive obstetric care during pregnancy, normal childbirth, and the
postpartum period (WHO, n.d.). However, childbirth in Guatemala has long
included birth attendants who fall outside this def‌inition of SBA. As of 2007,
SBAs—per the def‌inition above—attended only 51 percent of births in Guatemala,
with that rate signif‌icantly lower among indigenous women (Segeplan, 2010).
When considering maternal mortality in Guatemala, it is important to also
examine the role of birth attendants and the cultural context within which women
give birth. Approximately 70 percent of births in rural indigenous Guatemala still
take place outside the formal health-care sector with the assistance of traditional
birth attendants (TBAs) or comadronas (Chary et al., 2013). TBAs are trusted
members of Mayan communities who have not been formally trained; rather they
acquire their skills through apprenticeships with other TBAs (Sibley, Sipe, &
Barry, 1996). They allow women to give birth in keeping with traditional birthing
practices, and Mayan women continue to demonstrate their preference for their
services (Chomat, Solomons, Montenegro, Crowley, & Bermudez, 2014; Foster
et al., 2012; Hitziger et al., 2017).
60 World Medical & Health Policy, 11:1

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