By Susan Kolodin

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In rural Guatemala, most men say that pregnancy and birth are “women’s issues” and therefore not necessarily within their decision-making authority. On the other hand, most women declare that their husbands are the ones who decide about where to have the delivery because they are the ones who authorize a domestic expenditure.  Although this might seem like  a typical example of poor communication among spouses, understanding how these decisions in health are made is very important to be able to reduce maternal and child mortality.

Guatemala has seen important advances in this issue but there is still a gap between but rural and indigenous women are three times more likely to die during childbirth than their urban counterparts.  Studies of the barriers to service utilization point to socio-cultural barriers and fears of mistreatment, language barriers between Spanish speaking health providers and non-Spanish speaking patients, the high cost of transportation, geographical distance, and social pressure to maintain local traditions and customs.  It is crucial to better understand the decision-making process in order to design more effective communication and health promotion strategies targeted to specific actors who influence and make decisions about the use of health services.

In September of 2012, the Inter-American Development Bank, in support of the SM2015 Initiative, carried out a qualitative analysis of social networks among indigenous communities in Guatemala to understand how social networks influence decisions related to the utilization or no of health services for pre-natal care, delivery, and post-partum attention.  The study explores the inter-personal relationships that influence decision-making, to what extent the experience of a woman’s first pregnancy and delivery affects future decisions about subsequent pregnancies, and how decisions are made during obstetric emergencies.

Some of the most interesting findings include the location of family residence, either matrilocal or patrilocal, as an important determinant of who influences decisions.  When couples live with the husband’s parents, the pregnant woman’s mother-in-law has considerable influence, reinforcing the husband’s authority, and frequently reinforcing traditional roles and practices, often diminishing the importance of the pregnant woman’s own health and well-being.  When couples live in a matrilocal setting, the pregnant woman’s own mother has considerable influence.  As the new family consolidates, and gains more experience and independence, the influence of older women diminishes.

The size of the social network also influences how health decisions are made.  When the personal network is relatively large, implying strong intra-family support, deliveries are more likely to take place at home, with the assistance of a midwife, who is frequently also a family member.  In contrast, smaller personal networks often result in greater reliance on public services and the use of health centers for deliveries. Younger couples with some formal schooling prefer public health services, largely because the language barrier has been reduced. In the case of small personal networks that provide little or no family support, and who planned home deliveries, the woman’s and the newborn’s life were often in danger.

Situations that include asymmetrical intra-familiar power relations frequently result in the pregnant woman having little or no possibility to decide about her own health or that of her baby.  In these circumstances, the husband or other family member controls decision-making authority as well as resources, and often threatens or uses violence to restrict the woman’s access to other sources of support.  In cases of gender-based violence during pregnancy, maternal death is not uncommon.

In emergency situations, the main decision-makers are generally the husband, the midwife and/or a health worker from a nearby health post or center.  If it is a couple’s first child, men tend to rely on their own mothers and/or a trusted midwife for advice.  In subsequent pregnancies and deliveries, the nuclear family (pregnant woman and her husband), take on more of the decision-making authority, often with advice of a midwife.

In general, pregnancy and delivery in rural Guatemala is considered to be a private, intra-family affair.  Outside authorities or community leaders do not intervene, and couples generally do not seek advice outside a relatively closed network.   In this context, midwives who are trained in detecting and referring emergencies are an important link between the formal health system and families.

Finally, it is important to understand that decisions are not made at a single point in time, but rather are the result of continuous processes and influences.   This process demonstrates an intersection between the traditionally “masculine” domain of managing the family’s financial resources, and the traditionally “feminine domain” of pregnancy and birth.  Gaining a better understanding of the reasons behind decisions to use health services or to have a home delivery attended by a midwife will help us and the Government of Guatemala to design and develop better health services for the indigenous population.

Susan Kolodin is a Social Protection and Health Lead Specialist at the IDB.

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