Ethnic Inequality in Guatemalan Reproductive Health Care Use International Perspectives on Sexual and Reproductive Health

International Perspectives on Sexual and Reproductive Health 106 en, compared with 4% of ladinas, considered the ideal number of children to be “as many as God wants.” The tendency of indigenous Guatemalan women to avoid modern medical care has been reinforced by ladinos’ ongoing discrimination against indigenous people. Such discrimination was manifested in the often brutal treatment that indigenous people received at the hands of government troops, who annihilated 440 indigenous villages during the 30-year Guatemalan civil war from 1960 to 1996. The disproportionately large number of indigenous casualties reflects deep-rooted ethnic discrimination in Guatemala. Although the civil war ended in 1996, indigenous people’s ongoing distrust of the ladino government may make them hesitant to seek health care services at government-run facilities, whose personnel are predominantly ladino.25,26 Indigenous people are particularly suspicious of government-run family planning programs, which many perceive as part of a ladino “plot” to diminish the indigenous population.24 Our study has at least two important implications. First, our finding that a large portion of ethnic differences in the use of institutional delivery services and modern contraceptives was attributable to indigenous women not speaking Spanish suggests that increasing the number of health care personnel who speak the local Mayan language may raise the use of institutional health care services among indigenous people. Improved communication should facilitate the provision of unbiased information about the benefits of using modern care, including treatment for adverse consequences of pregnancy and delivery complications, and the benefits of child spacing.27 residence. In qualitative studies, social and cultural contexts are important factors in the persistent differences between indigenous and ladino Guatemalan women’s use of modern medical services. Traditional midwifery and modern pregnancy-related care are often seen as complementary in Guatemala:11,19 As a result of the government’s efforts to integrate traditional midwives into the formal health care system,12 many indigenous women who see traditional midwives also receive institutional prenatal care, often on their midwives’ referral. Approximately 40% of pregnancies among indigenous women who received institutional prenatal care also received care from a traditional midwife. However, childbearing is highly ritualized in indigenous communities, where traditional midwives often assume symbolic and mystical roles and provide not only physical but also social and spiritual care.20,21 Furthermore, indigenous women continue to prefer traditional midwives for assistance at delivery.12,22–23 Unfortunately, even trained midwives often lack knowledge of basic aseptic techniques, fail to recognize danger signs quickly and are not prepared to handle delivery complications. These shortcomings are considered contributing factors to the relatively high maternal and infant morbidity and mortality in rural and indigenous areas of Guatemala.21 The mystical meaning attached to women’s reproduction also contradicts the idea that fertility can be calculated or controlled. Rather than considering pregnancy and childbearing to be health concerns or biomedical issues, indigenous people tend to think that fertility is predetermined by God10 and associate contraceptive use with “killing.”24 In an auxilliary analysis, 13% of indigenous womFIGURE 1. Predicted probabilities of use of institutional prenatal care, having an institutional delivery and having a met demand for modern contraceptives, according to ethnicity