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

• Published date: 01 March 2019
• Author: Dilys Walker,Sylvia Guendelman,Anna Summer
• Date: 01 March 2019
• DOI: http://doi.org/10.1002/wmh3.292

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

Introduction

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

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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,

2011).

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).

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