UC Berkeley

Guatemala has an unacceptably high maternal mortality ratio (MMR) of 140, and

improvements in this area have been slow. Furthermore, gross inequalities in health

outcomes exist within its population, with over 70% of maternal deaths in Guatemala

occurring among indigenous Mayan women. Mayan communities have been historically

marginalized, and most Mayan women prefer the services of traditional birth attendants

(TBA). As such, a disconnect exists between the formal and traditional health sectors in

Guatemala, contributing to poor maternal health outcomes. It is widely agreed that

professional midwifery is an important component of safe motherhood strategies that can

reduce maternal morbidity and mortality. Today the Guatemalan Ministry of Health is

reintroducing midwifery for the first time since 1960. Given the potential professional

midwifery has to address the obstetric care needs of Mayan women and bridge the gap

between the health sectors in Guatemala, formative research is needed at the outset to

inform the design and implementation of this program.

This dissertation aims to inform future directions for professional midwifery in Guatemala

by assessing and analyzing historical policies and current perspectives and presenting

context-specific recommendations for the future. The first paper looks to the past to

consider how international and society-centered forces influenced the creation of policies in

Guatemala regarding birth attendance since the signing of the Peace Accords in 1996 up to

the reintroduction of midwifery. Next, the second paper elucidates the misperceptions,

attitudes and expectations about the addition of midwifery to the healthcare system by

Guatemalan physicians, nurses, midwives and TBAs today, identifying potential threats and

facilitators to this strategy’s success in Guatemala. Finally, the third paper proposes

recommendations for the future, considering identified impediments to midwifery’s capacity

for sustainability. This dissertation provides findings that can improve the design,

implementation, monitoring and evaluation of the professional midwifery strategy in

Guatemala, and can inform program and policy decisions to implement this strategy in

Guatemala, Latin America and beyond.