Guatemala has had a long and violent history of internal conflict(1). Complex social inequalities have been exacerbated by the effects of civil war. After peace accords were signed in Mexico in December 1996 Guatemalan refugees were repatriated to areas greatly lacking in health services and basic infrastructure. Refugee communities were repatriated to Guatemala but dispersed to places that were not their areas of origin. They therefore continued to be displaced within their own country, relabelled as IDPs and no longer cared for by the international community.
Over half of the population of Guatemala lives in extreme poverty; within the rural areas this rises to 91%. The population is very young with almost 40% aged below 18 years of age. Maternal mortality rates are among the highest in Latin America and highest amongst indigenous women. The maternal mortality ratio for indigenous women is three times higher (211 per 100,000 live births) than for the non indigenous group (70 per 100,000 live births), according to the Baseline Maternal Mortality study for 2000. More than half of maternal deaths are due to excessive bleeding. Others are due to infections, hypertension induced by pregnancy, and to unsafe abortion(2) . Among indigenous women, the contraceptive prevalence rate is 10% whereas the national figure is 27%. While 52% of urban women use a contraceptive method, only 27% of rural women and 10% of indigenous women do so(3) . Along with this, according to UNAIDS, Guatemala has the second highest prevalence of HIV/AIDS infections in Central America with a rate of 1% of the population aged 15 to 24(4).
In 1999 Marie Stopes Mexico initiated a project to ensure the provision and institutionalisation of quality, affordable reproductive health (RH) services for the displaced and static populations in Chiapas, Mexico. Populations include refugees from Guatemala, internally displaced Mexicans and local Mexican communities. The programme includes centres as well as outreach work providing extensive information, education and communication (IEC) initiatives.
In response to the situation in Guatemala, this successful and innovative programme expanded in 2001 to provide cross-border services to the returned communities in the state of Huehuetenango. Via a mobile unit, Marie Stopes Mexico is providing family planning (FP) and maternal child health services and IEC activities to raise awareness of sexual and RH in remote, under-served areas.
The objectives of the project are:
- improved access to high quality sexual and reproductive health (SRH) provided by a mobile outreach programme to rural communities
- increased awareness of SRH issues amongst rural communities and local organisations.
Project activities include non-surgical family planning, maternal and child health services and information, education and communication activities. This includes the training of health promoters and traditional midwives who can both improve the access to and raise awareness about SRH services. During the two-year project the mobile unit helped 2,786 women to access RH servies and trained over 28 health promoters and 45 traditional midwives in 22 rural communities.
To evaluate the project's success, surveys were carried out before and after the main intervention by the project teams. Each survey included 400 questionnaires to men and women aged 14 to 45 years old. Survey training was provided by the mobile team members and external consultants, and included reviews of the objectives and interactive methods such as role-plays to familiarise the team with the process. For cultural and linguistic reasons local health promoters and midwives undertook the bulk of the survey work.
There were limitations to carrying out the study, such as the time of year during which it was carried out (harvest time), the presence of males inhibiting women's responses, privacy issues and Mayan cultural constraints regarding speaking about family planning.
Results and analysis
The fact that literacy levels among women did not significantly improve in the two years of the project highlights the lack of government educational programmes. It was found that barely half of the women in the study could speak Spanish. These results indicate that returned populations have a significant disadvantage in terms of access to information. Illiteracy and monolinguism may have a direct impact on the health status of communities. Knowledge of problems during pregnancy was inversely related to literacy and knowledge of Spanish in the general population and specifically in women. Seventy per cent of women who cannot read were able to identify a problem in pregnancy compared to 50% of women who can read.
However, it is important to note that women who were not able to read have higher rates of fertility and generally tend to learn from other women who are close to them. These women may also have a higher percentage of problems during their pregnancies and births due to the fact that they are more isolated and less educated, an assertion supported by the results that women who are unable to read have almost twice as many miscarriages. This result requires further investigation as it signals important health disadvantages and risks related to literacy level.
Since the population's return to Guatemala, there has been no change or improvement in the services available to them. Marie Stopes Mexico's services are therefore extremely valuable as they are the only place people can get information and access to RH services. After two years of the project, 93% of the community cited Marie Stopes Mexico as important or very important, signalling the acceptance of and demand for services.
Results indicate that antenatal and childbirth care given by midwives increased significantly during the project. All the women interviewed stated they sought an attendant during birth. In the follow up survey, 89% of women had given birth with the assistance of a traditional midwife, as opposed to 71% at baseline.
The fact that all women had been attended in their births is an important and significant success. However, this does not guarantee the level of training of the birth attendants. Costs and logistical difficulties of transport, reluctance of women to go to hospital and the importance of the husband's decision in where a woman will birth seriously affect whether a woman will be transported to a hospital in case of high risk or an emergency. Out of the population surveyed, 88% indicated that it was the husband's decision to approve of his wife's transport to a hospital in the event of a childbirth problem or emergency.
Identification of specific problems during pregnancy increased among the population, particularly in the case of haemorrhage, mal-positioning and frequent headache, recognition of which almost doubled. Knowledge of specific problems which can occur during childbirth also increased among men and women in the communities. Recognition that women can die at childbirth also improved significantly to almost 95% from 80% in the baseline survey.
Identification of problems which can emerge during childbirth rose from 53% to 67%, indicating an important programme success. However appropriate arrangements for transport need to be made possible as it remains a major obstacle to successful reduction of maternal mortality in rural areas, not just in terms of physical access to services but also in terms of the decision-making process. These results indicate that there is still important work to be done regarding gender equity, female empowerment and communication between men and women.
Knowledge of all modern family planning methods doubled and family planning use increased from 9% to 30%. Over 90% of the population surveyed in the follow up could identify where to purchase a family planning method, and 64% correctly said that family planning methods could be purchased through health promoters. It is significant that the presence of Marie Stopes Mexico brought local use of contraception into line with national rates. The fact that injectable contraceptives were the most popular and preferred method is in part due to women's need to use a more discreet family planning method without their husband knowing.
This signals the need to improve RH IEC directed at men. Despite increases in FP knowledge and use, there are still many ingrained fears and myths surrounding methods, reinforcing the need for IEC on RH to reach people at a much younger age.
Use of FP methods was associated with knowledge of Spanish among women and may reflect their improved access to education, resources and direct communication with all team members. In fact, women who speak Spanish were four times more likely to use an FP method then those who do not.
Regarding fertility preferences, more than half of all the respondents indicated that they would like another child. At the same time, demand for FP use almost doubled. Almost three quarters of women indicated they would like to use an FP method.
Although Marie Stopes Mexico has had an important impact on increasing FP method use, fertility rates remain high in the area. The results suggest that fertility is still highly valued and pregnancy is still considered a random, uncontrollable and/or pre-destined event by many. This has important implications for maternal mortality and morbidity, together with the fact that women are generally not considered as primary decision makers regarding their fertility or decisions affecting their health status.
Main lessons learned and recommendations
- To improve women's lives, decrease maternal mortality and morbidity, interventions need to also address male perceptions and knowledge of risk.
- Community involvement is crucial in affirming that maternal mortality is a collective issue which can be fought with the participation of all local actors.
- The establishment of a community fund to cover emergency transport costs of transport and improvement of roads could save lives.
- Emphasis must be placed on increasing gender equity and improving knowledge and application of reproductive rights.
- IEC activities should be expanded to include men and young people, particularly adolescent males who are less informed about reproductive risks and options. It is important that young people initiate their reproductive lives aware of SRH issues and the possibility of accessing appropriate services.
- Improved collaboration with the Guatemalan Ministry of Health is fundamental to address the comparative disadvantage of returned indigenous groups that remain isolated and ignored.
- Improved literacy provides a distinct advantage in terms of access to information; literacy programmes should be promoted and expanded.
Results show that provision of RH services and training for local health workers has a positive effect on knowledge and use of these services among returned indigenous Guatemalan communities. The success of the project indicates that this model would be replicable in other internally displaced or returnee settings where communities lack access and inclusion within the national health system and remain isolated in an unfamiliar land.
Cristina Alonso is an external consultant. Email: firstname.lastname@example.org.
Laura Miranda is programme director at Marie Stopes Mexico. Email: email@example.com.
Sally Hughes is programme support manager at Marie Stopes International. Email: firstname.lastname@example.org
Lucy Fauveau is assistant programme support manager at Marie Stopes International. Email: email@example.com
For further information on this programme contact Sally Hughes.
- See FMR 11, pp7-9 and FMR 7 pp16-19.
- MSPAS, Línea basal de mortalidad materna para el año 2000. Ministry of Public Health and Social Welfare Baseline Maternal Mortality Study, 2000
- The most common family planning methods are female sterilisation (14.5%), contraceptive pills (3.5%), intrauterine devices (2.4%), hormone injections (2.3%), condoms (2.2%), and male sterilisation (1.5%). Source: PAHO 1999.
- UNAIDS. Guatemala: Epidemiological Fact Sheets on HIV and Sexually Transmitted Infections', UNAIDS, UNICEF, PAHO, WHO, 2002 (www.unaids.org)