Factors influencing health care-seeking behaviours among Mayan women in Guatemala
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.
References (43)
- et al.
Monitoring utilization and need for obstetric care in the highlands of Guatemala
International Journal of Gynaecology and Obstetrics
(2005) - et al.
Husbands’ and wives’ reports of women's decision-making power in Western Guatemala and their effects on preventive health behaviours
Social Science & Medicine
(2006) - et al.
Safe motherhood: the FIGO initiative
International Journal of Gynaecology and Obstetetrics
(2003) Kaqchikel midwives, home births, and emergency obstetric referrals in Guatemala: contextualizing the choice to stay at home
Social Science & Medicine
(2006)Husbands and maternal health matters in rural Guatemala: wives’ reports on their spouses’ involvement in pregnancy and birth
Social Science & Medicine
(2002)- et al.
Effects of a maternity waiting home on adverse maternal outcomes and the validity of antenatal risk screening
International Journal of Gynaecology and Obstetetrics
(1994) Maternal mortality and the problem of accessibility to obstetric care: the strategy of maternity waiting homes
Social Science & Medicine
(1996)- et al.
A report of a midwifery model for training traditional midwives in Guatemala
Midwifery
(2004) - et al.
Evaluation of midwifery care: results from a survey in rural Guatemala
Social Science & Medicine
(2003) Vectors of contention in Highland Maya midwifery
Social Science & Medicine
(2004)
Migration and maternal health services utilization in rural Guatemala
Social Science & Medicine
Sex and the Catholic church in Guatemala
The Lancet
Too far to walk: maternal mortality in context
Social Science & Medicine
The maternity waiting home concept: the Nswan, Ghana, experience
International Journal of Gynaecology and Obstetrics
‘Because he loves me’: husband's involvement in maternal health in Guatemala
Culture, Health and Sexuality
Gender and community context: an analysis of husbands’ household authority in rural Guatemala
Sociological Forum
Diversity in the use of pregnancy-related care among ethnic groups in Guatemala
Journal of Family Planning and Reproductive Health
Writing ethnographic field notes
Rapid assessment procedures: ethnographic methods to investigate women's health
Cited by (38)
Networks and knowledge: Women's empowerment, networks, and health information-seeking behavior in rural Guatemala
2024, Journal of Rural StudiesEthnomedical research and review of Q'eqchi Maya women's reproductive health in the Lake Izabal region of Guatemala: Past, present and future prospects
2016, Journal of EthnopharmacologyCitation Excerpt :Higher birth rates are influenced by religious beliefs that do not support family planning, as well as sociopolitical concerns for the survival of the indigenous people (Schooley et al., 2009). Thus, most Maya births occur at home and attended are exclusively by a traditional birth midwife, and Maya women rely almost exclusively on herbal remedies for all stages of their pregnancy (Hughes, 2004; Orellana, 1987; Schooley et al., 2009). In terms of menopause, the first report from Guatemala was a qualitative exploration of attitudes and symptoms associated with menopause among 27 Quiché, Tzutujil, and Cakchiquel Maya women in the Guatemalan highlands (Stewart, 2003).
Transformation of potential medical demand in China: A system dynamics simulation model
2015, Journal of Biomedical InformaticsCitation Excerpt :One of the most important factors refers to the patients themselves. Various studies have focused on the universal factors influencing patients’ medical demand, such as health insurance (patients with health insurance were more likely to receive health care when it was needed) [10,52,21,72,48], economic status and monthly salary [30,60,73], health status [30,60,12], demographic factors (including gender, age, race, living settings, education level, and city size) [52,21,72,48,73], and patients’ perceptions on medical need and medical use [65], types of health profiles [59], and social relations [81]. Another important influencing factor is the health care providers themselves.
Treatment Preferences for Postpartum Depression Among New Israeli Mothers: The Contribution of Health Beliefs and Social Support
2023, Journal of the American Psychiatric Nurses Association