Guatemala is marketed across the globe as the "Heart of the Mayan World". Photographs of spectacular jungle pyramids and smiling indigenous women, carried on Piccadilly buses in London and splashed across screens in new York's Times Square, promote a tourism industry worth almost $3.4 billion (€3 billion) a year.
On arriving in Guatemala, it is easy to recognise the vivid colours of Mayan traditional clothing and the dramatic scenery of imposing volcanoes, shimmering lakes and dense forests sliced into steep hills and sharp ravines.
The tourism posters and picture postcard scenes, however, conceal a reality in which indigenous peoples, particularly women, are pushed to the margins of society.
The smiling Mayan women whose images are used to drive tourist dollars to Guatemala are the least likely to benefit from the economic gains made by tourist boards cashing in on their culture.
Instead, they routinely experience violence and discrimination, the legacy of a 500-year colonial regime, and more recently the 36-year internal armed conflict that ended in 1996, resulting in an estimated 200,000 people dead or disappeared, 83 per cent of whom were Mayan indigenous people.
Guatemala’s healthcare spend, at 3.5 per cent of GDP, is the lowest in Latin America, which is reflected in the national maternal mortality rate in 2018 of 105 per 100,000 live births. Ireland had a maternal death rate of 10 per 100,000 in the same year, an unusually high figure and three times the rate for 2017.
The rate in Guatemala doubles in rural and indigenous regions, with Mayan women accounting for 64 per cent of all maternal deaths.
Nevertheless, the women of Guatemala are resilient and creative in their daily struggle for survival and against oblivion.
“There was a woman who was experiencing difficulty in labour, she was carried on a chair over hills for hours to get to a pick-up truck,” says María José Aldana, an independent researcher on women’s health. “When she arrived at the hospital hours later, she was covered in mud and the staff wouldn’t let her in. They hosed her down outside with cold water. She was so traumatised she refused to return to hospital for her second pregnancy and died at home.”
Women in Guatemala die in pregnancy and childbirth from largely preventable causes: haemorrhage, infection, high blood pressure and unsafe abortions. Experts in public health have identified three crucial delays that can determine whether a woman lives or dies: the decision to seek care, arriving to a healthcare facility, and finally, in receiving adequate care.
The majority of Guatemala’s 16 million people live in rural and often isolated mountainous communities, and many indigenous women give birth at home, accompanied by a traditional midwife, or comadrona.
In some cases the belief that home is better than hospital, and a culture that doesn’t prioritise women’s health, means that families or husbands decide to seek care too late, or not at all. They may not have the means to pay for private transport, and the nearest health facility could be up to 12 hours away, over dirt roads. With many public health centres understaffed and sometimes even lacking basics such as latex gloves and running water, getting there is no guarantee of prompt, quality care.
When a woman is experiencing heavy bleeding during or following birth – the number one cause of maternal death in Guatemala – these delays can be lethal. Comadronas refer the women in their care to hospital when they suspect an emergency, but they might not arrive in time.
Few comadronas have access to the standard treatment for haemorrhage, oxytocin, which is expensive and administered via saline drip. Although commonly known as the abortion drug, misoprostolis is a safe and cheap alternative for treating and preventing haemorrhage, and is legally available in Guatemala, unlike much of Latin America.
Dr Linda Valencia, a former president of the Association for Gynaecologists and Obstetricians in Guatemala, believes that training all comadronas in the use of misoprostol would make a huge impact on the numbers of maternal deaths in rural communities: "It's a key medicine for saving women's lives."
It’s a frightening statistic, but 20 per cent of maternal deaths in Guatemala are of girls aged between 10 and 19. In 2018, 66 girls died, four of whom were under 14.
Guatemala’s public hospital of San Juan de Dios is a tense, high-security place, complete with high walls, reinforced gates, and security guards who won’t let you in without an official letter and ID.
Dr Maryola Martínez, a gynaecologist at its unit for adolescent pregnancies, sees one to two pregnant teenagers a day. Her youngest patient was nine, and got her first period after she had given birth to her first child.
“I had to explain everything that was going on in her body, that there was new life there,” she says. It often falls to her team to tell girls about periods, contraception, or pregnancy. Sexual education in schools is patchy at best and these subjects are taboo in many families. This, coupled with increasing levels of sexual violence against young girls, contributes to Guatemala having one of the highest rates of child pregnancy in the region.
Terminating the pregnancy is rarely an option: abortion in Guatemala is criminalised under all circumstances, except when the life of the mother is in danger.
“A risk to the life of the mother is understood in its narrowest sense,” says Valencia. “They don’t take into account the social and mental health risks. Many adolescent girls take their own lives because of unwanted pregnancies, often the result of rape or sexual exploitation.”
Few in Guatemala are willing to speak openly about abortion: many of the activists we interviewed asked to remain anonymous or off the record. This silence belies the reality that one in every six pregnancies ends in abortion and unsafe abortion is the fourth leading cause of maternal mortality in Guatemala.
Valencia first became aware of the devastating consequences of “backstreet” abortions while she was a resident at the San Juan de Dios hospital. She often treated women with severe infections or injuries to their wombs, many of whom could not be saved. She now advocates for improved maternal healthcare, access to family planning and the legalisation of abortion in the cases of rape, incest and a risk to the health of the mother.
Recent evidence suggests that the increasing availability of misoprostol to induce abortion has increased the safety of clandestine abortions across Latin America, with fewer cases of women arriving to hospital with life-threatening injuries and infections.
Informal networks of Guatemalan feminists have begun to distribute abortion pills to women, risking prison if they are found out. One lawyer advising the activists says “there is a fear that things could go the way of El Salvador”. Guatemala’s nearest neighbour is notorious for imprisoning women suspected of having aborted.
Reducing the maternal mortality ratio worldwide to 70 is one of the principal aims of the 17 United Nations Sustainable Development Goals. For Guatemala, meeting this goal by 2030 will be a challenge. Increased public spending on health would be a start but as congresswoman Sandra Morán says, "It's not only a lack of money, it is a lack of political will."
While laws have changed to increase the minimum legal age for marriage, provide universal access to family planning and a robust legal framework to protect women from violence, activists on the ground say the necessary social changes haven’t followed. Religious fundamentalisms are increasing across the region, meaning the immediate possibilities for more liberal laws around abortion and reproductive rights are slim.
But there are reasons to be optimistic. “Hope is to be found in women’s resistance,” says Morán. “Their strength, their fight and their creativity.”
Many doctors, nurses, midwives and comadronas are committed to improving outcomes for Guatemala's women. For example, the use of misoprostol to treat haemorrhage by Acam (Association of Comadronas from the Mam indigenous region of the western highlands), in its clinic and rural communities around Quetzaltenango has resulted, it said, in only one maternal death in the last four years across all the communities it works in. Sixty miles (96km) away, the nonprofit Hospitalito Atitlan is developing its own blood bank to meet an essential need not met by the state.
“The solutions are not going to come from just one source, we can learn from international strategies and best practices but we can also look for internal solutions,” Valencia said. “All that is required is to be more open minded to innovative approaches.”
* This article was supported by a grant from the Simon Cumbers Media Fund.