Elsevier

Midwifery

Volume 25, Issue 4, August 2009, Pages 411-421
Midwifery

Factors influencing health care-seeking behaviours among Mayan women in Guatemala

https://doi.org/10.1016/j.midw.2007.07.011Get rights and content

Abstract

Objective

to identify and better understand factors that influence care-seeking behaviour for women's health among indigenous Mayan populations in the highlands of Guatemala.

Design

adaptation of qualitative anthropological methods involving observations, key informant interviews and focus group discussions (FGDs).

Setting

Project Concern International's Casa Materna, Huehuetenango, Guatemala.

Participants

Interviews and FGDs were conducted among 21 clients (current or past) of the Casa Materna and traditional birth attendants; 17 female advocates/promoters of the Casa Materna and related services; and 12 male advocates, including spouses, non-government organisation staff and community health workers.

Findings

the following findings emerged from focus group data:

Women's support groups (WSGs) provided an enabling environment in which women could form friendships, bond, discuss concerns about their reproductive health, and identify concrete ways of addressing them; Supportive friends, family members and advocates influenced women's decisions to seek health care at the Casa Materna; Women's decisions to seek care were often associated with their sense of self-worth and self-esteem, and women's self-esteem was enhanced by their participation in the WSGs; Women's decisions to seek care were influenced by the perception that women would be able to access culturally appropriate, safe and secure health care services at the Casa Materna; The learned behaviour of negotiation with key decision-makers and/or opinion leaders was an effective tool for convincing such individuals of the value of accessing facility-based care; The proven track record, high quality of services and cultural competence offered at the Casa Materna increased the confidence and level of trust of clients and their family members about the care that would be received; Couple-based education and health promotion were effective techniques for achieving behaviour and attitude change among both men and women.

Key conclusions

the Casa Materna and its community outreach strategy serve an essential purpose in the provision of maternity care for the isolated and vulnerable families of the Guatemalan highlands, by bridging traditional and Western approaches to health care services. The Casa Materna service model plays a critical role in improving women's self-efficacy and ultimately strengthening the social fabric that characterises this high risk and vulnerable population.

Implications for practice

the Casa Materna model provides a foundation upon which to bridge and strengthen the relationship between community advocates, traditional community-based health care providers, and the government-funded system of health care. The findings of this study should be incorporated into future research to determine the potential for bringing the model to scale.

Introduction

The Central American (CA) country of Guatemala had a population of 12.7 million people in 2005. The country ranks 117th out of 177 countries on the Human Development Index and 44th out of 95 developing countries on the Human Poverty Index [United Nations Development Program (UNDP), 2005].

The Government of Guatemala does not have an explicit population policy. However, the reduction of maternal mortality has been an official target since the mid-1990s. The Law on Social Development, which covered reproductive health, family planning, sexual education, policy and development, was passed in 2001.

The country's population growth is estimated to be 16.3 million in 2015. Just over half (6.4 million) of the population are women [Population Reference Bureau (PRB), 2005a]. The proportion of women aged 15–49 years (48%) is lower than the average (54%) of eight CA countries (including Guatemala) (PRB, 2005b).

Guatemala's population growth is fuelled by a very high individual expected birth rate. Less than half (43%) of married women use some form of contraception and only one-third (34%) use modern methods, compared with respective figures of 70% and 62% for the CA comparison countries (PRB, 2005b). Guatemalan women are expected to have 4.4 births in their reproductive lifetime. This is the highest figure of the seven CA countries with which Guatemala is compared.

Life expectancy at birth for Guatemalan women is 65.8 years. This is less than the life expectancy in 13 CA and Caribbean countries (71.5 years) [World Health Organization (WHO), 2005]. However, a woman's lifetime chance of dying from maternal causes is one in 74, which is far less favourable compared with one in 239 for Latin American countries (PRB, 2005b). The maternal mortality ratio ranges from 156.2 (Kestler and Ramírez, 2000) to 240 per 100,000 births [United Nations Population Fund (UNFPA), 2005a, United Nations Population Fund (UNFPA), 2005b] (sources vary, depending on method of assessment). It is estimated that only 41% of deliveries are attended by skilled personnel, compared with 77% for the seven comparison countries (PRB, 2005b). The infant mortality rate, variously estimated at a range of 41 (UNDP, 2005) to 45 (Demographic and Health Survey Guatemala, 1998/99) to 49 (PRB, 2005b) per 1000 births, is far less favourable when compared with a rate of 30 per 1000 births for the seven comparison countries (PRB, 2005b). The urban or rural residence of Mayan women adds an additional dimension.

These population-based statistics do not reflect the specific experiences of indigenous Mayan women. Maternal and infant health statistics for Mayan women are less favourable overall. Maternal mortality among indigenous Mayan women in certain rural areas has been estimated to be almost twice as high (446 per 100,000) as the national statistic. It is estimated that 75–85% of births in rural areas occur in the home, and are attended by a traditional midwife or family member [Pan American Health Organization (PAHO), 1998]. Life expectancy at birth for Mayan women is 3 years lower than that for their country counterparts.

Mayan women have an average of 6.8 children. This higher fertility rate is thought to be influenced by religious beliefs that do not support the use of family planning methods, as well as by deeply rooted sociopolitical concerns for the survival of the indigenous people (Center for Reproductive Law and Policy, 2000; Hughes, 2004; Replogle, 2005). Residents of agrarian communities that rely heavily on subsistence family farming may hold a perception that having larger families, and therefore more family members contributing to the work effort, yields certain economic benefits.

The diversity of languages among the Mayans may lead to a lack of accurate, unbiased information about the benefits of child spacing. The indigenous population in Guatemala speaks over 20 mutually distinct languages, and many indigenous women do not speak Spanish (Glei and Goldman, 2000). Knowledge of modern contraceptives is more common among women who have family who have migrated to urban areas or international settings, and who have returned to their communities (Lindstrom and Muñoz-Franco, 2005).

Access to health-care services is limited in general, and particularly so for Mayan residents of the rural highlands. There are many fewer physician providers compared with urban settings, and there is no effective system in place for referrals (PAHO, 1998).

The social and cultural context in which sexual and reproductive health-care decision-making occurs also contributes to a higher health risk status for Mayan women. There is a historical context of political, racial and ethnic oppression of the Mayan people (Quintana and Segura-Herrera, 2003). There is substantial imbalance in power relationships between genders, often characterised by verbal and physical violence. The phrase ‘me pega lo normal’ (‘He beats me about the normal amount’) is not an uncommon statement by women. Power imbalances are particularly notable with respect to the authority for management of household money, including decisions about spending household income on food, medicine or health-care services (Carter, 2004).

The administrative district of Huehuetenango, located in the country's western highlands, is predominantly inhabited by the Mayan population. In 2000, in partnership with the Ministry of Health (MoH), UNICEF and a local association of midwives in Huehuetenango, Project Concern International (PCI)/Guatemala began implementation of an integrated health programme designed specifically to reduce the incidence of maternal mortality during pregnancy, childbirth and the postpartum period. The maternal mortality rate in Huehuetenango was, at that time, the highest in all of CA.

A critical component of the PCI/Guatemala programme is the Casa Materna (‘mother's house’). This maternity waiting home operates in an MoH property located immediately adjacent to the MoH hospital. The Casa Materna provides prenatal, postnatal and infant health-care services, in addition to family planning and well-woman health screening (Pap smears). Its primary function is, however, care and monitoring during the final weeks of pregnancy for women who present signs of obstetric risk, who then deliver at the MoH hospital. The collaborative relationships established between Casa Materna staff and clients, and the staff at the referral facility, have served to facilitate continuity of the high quality and respectful style of care as clients are transferred between facilities to receive services.

Women staying at the Casa Materna can be evaluated by an obstetrician based at the MoH hospital prior to transfer for delivery. The Medical Cuban Co-operation team in Guatemala, through a co-operative agreement between the MoH, the Cuban Co-operation and PCI, assigns one of their female doctors to be based at the Casa Materna to provide clinical services. This doctor often accompanies women who are scheduled for delivery by caesarean section to a meeting with the hospital-based obstetrician who will perform the surgery, so that all parties are familiar with the unique circumstances of each individual.

Most nurses at the Casa Materna have worked at the MoH hospital or are current part-time employees of the facility, and maintain an excellent relationship with the staff there. The Casa Materna nurses accompany Casa Materna clients to the hospital at the time of transfer in the role of supportive companion, and follow through the case until its complete resolution. Deliveries at the MoH hospital are performed by doctors or nurses who have received training in birth attendance (International Confederation of Midwives, World Health Organization, International Federation of Obstetricians and Gynecologists, 2004). Women who need special care after vaginal or caesarean delivery can return to the Casa Materna to recover after their surgery. Women whose babies have had to stay in the hospital are also welcome to stay at the Casa Materna, which allows them to visit and breastfeed the baby on a regular basis.

Casa Materna care providers also work in close collaboration with a cadre of volunteer workers who work in the very remote communities of Huehuetenango, serving as peer educators and health-care advocates. The involvement of community-based traditional birth attendants (TBAs) is also encouraged, as these providers are very important links in the chain of referral for clients who need higher levels of care.

PCI had noted the favourable trends that were occurring in the years following the inauguration of the Casa Materna; notably, a consistent increase in enrolment for prenatal and postpartum services (Table 1), a downward trend in number of pregnancies and a three-fold increase in acceptance of Pap smear services. The Casa Materna staff were of the opinion that these favourable trends were being influenced, at least in part, by the positive health-care messages that were being conveyed within communities by the volunteers, peer educators, clients and their families. These messages addressed both the importance of engaging in health-care services, and the quality of care offered at the Casa Materna. PCI designed a qualitative inquiry and case study to document the validity of this anecdotal evidence.

Section snippets

Methods

Recruitment for participation in the study included an invitation to women and men in the service area of the Casa Materna and the MoH hospital who met the established criteria for the target groups. The invitation informed potential participants that they had an opportunity to meet with foreign visitors interested in hearing their opinions on the Casa Materna and maternity care in Guatemala. Some of the participants had travelled great distances, literally all night, to be there, and therefore

Sample

Observations and FGDs were held with all staff of the Casa Materna, as well as with three groups, each composed of a convenience sample recruited via word of mouth initiated by the Casa Materna staff. The invitation was made by telephone and telegrams, asking people to participate in an activity at the Casa Materna during which they would be able to share their opinions about the Casa Materna in any capacity (e.g. as a patient, family member, training beneficiary, or referral source).

Discussion

Maternity waiting homes have a long history of use as a strategy to increase access to maternity care for women at risk of obstetric complications (Figa-Talamanca, 1996; van Lonkhuijzen et al., 2003). Women who live far away from a source of health care services have been well served by these facilities that offer free or low-cost accommodation to women as they await the onset of labour. This strategy targets the delay in reaching an appropriate service source; one of the three delays that have

Key conclusion

The Casa Materna and its community outreach strategy serve an essential purpose in the provision of maternity care for the isolated and vulnerable families of the Guatemalan highlands, by bridging traditional and Western approaches to health-care services. The Casa Materna service model plays a critical role in improving women's self-efficacy and ultimately strengthening the ‘social fabric’ that characterises this high-risk, vulnerable population.

This study generated both internal and external

Acknowledgements

This study was conducted with the assistance of the staff at PCI/Guatemala and the Casa Materna. The authors would especially like to thank the tireless health workers at the Casa Materna and the women and families they serve.

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