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

Abstract

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.

How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous?

“…Guatemala is the country with the smaller coverage and the biggest gaps between indigenous and nonindigenous. In this country, the highest maternal mortality and the lower healthcare coverage have been related to socioeconomic factors and weakened national infrastructure derived from a 36-year civil war [27,34]. However, recently, it has been suggested that conflicting political agendas have contributed to a lack of progress in improving maternal health among indigenous women.…”

“…However, recently, it has been suggested that conflicting political agendas have contributed to a lack of progress in improving maternal health among indigenous women. The international policies have promoted skilled birth attendance while the domestic policies have sought to strengthen intercultural care provided by traditional birth attendants [34].…”

A critical interpretive synthesis of the roles of midwives in health systems

“…the medicalisation of the birth process and associated valuing of physician and hospital-based care) • Ideas relate to both political and health system factors by influencing the values of citizens and either valuing or devaluing gender and the medical model • Social construction of gender — the status of midwives in a given jurisdiction often reflected the value placed on women within the society (i.e. ‘gender penalty’) [ 8 , 11 , 41 , 43 , 46 , 48 , 61 , 71 ] • Some cultures did not allow women to receive care from men yet there were few health professionals that were women due to lack of educational opportunities [ 45 ] • Health system priorities as well as changing values were based on the medical model and normalisation of medical interventions, which favoured care by physicians and within hospital settings [ 41 , 48 – 50 , 75 , 78 , 99 – 101 ] • Incongruence between international recommendations for skilled birth attendants and needs of Mayan population in Guatemala for intercultural healthcare from traditional birth attendants [ 102 ] • Nordic maternity care systems’ non-medical models and women dominated professional groups [ 37 ]; respect of gender equality and informed choice [ 86 ] • Increasing consumer demand for midwifery-led care [ 77 ] • Reclaiming Indigenous midwifery and bringing birth back to the community (Canada and Guatemala) [ 35 , 103 ] [ 1 , 3 , 6 – 8 , 10 – 13 , 35 , 37 , 38 , 41 – 43 , 45 – 50 , 54 – 58 , 61 , ...…”

“…• Incongruence between international recommendations for skilled birth attendants and needs of Mayan population in Guatemala for intercultural healthcare from traditional birth attendants [ 102 ]…”