In Guatemala, the most common form of family planning is voluntary female sterilization. According to the most recent Demographic and Health Survey, 21 percent of married Guatemalan women have elected to undergo this operation, usually after five or six children.[i] Working as a Research Assistant at the Berkley Center for Peace, Religion, and World Affairs on a Guatemalan mapping project during my first year with GHD, I was struck by this statistic. Why were so many women in Guatemala choosing such a permanent, invasive method of birth control, when others like the IUD, the birth control shot, or the pill were all widely available and more flexible?
To answer this question and gain more experience working abroad, this summer I joined WINGS, a non-profit organization based in Antigua, Guatemala, as a Monitoring and Evaluation Intern. Founded by American Sue Patterson, a former U.S. Foreign Service Officer in Guatemala, WINGS has provided quality reproductive health education and services to rural Guatemalans for over fifteen years. During this time, the average fertility rate dropped from five to just above three children per 1,000 women, and the percentage of married women using at least one form of family planning nearly doubled from 38 percent to 60 percent.[ii] Yet, rates of family planning use remain low within rural and indigenous communities, which subsequently have alarmingly high rates of maternal mortality and malnutrition.
Banner outside of WINGS office in Antigua celebrating fifteen years and thousands of women served.
As my second semester of graduate school wrapped up, I began working with my supervisor at WINGS to design an interview guide and plan for a series of focus groups with women to better understand their thoughts about family planning. These responses would allow the WINGS health promotion team to adapt their educational chats to the needs of each community and also could serve as a baseline study for comparison against any changing attitudes and beliefs down the road.
View of the Agua Volcano from Antigua, Guatemala.
I arrived in the beautiful colonial city of Antigua at the end of May and immediately got to work with WINGS. Together with a health promoter, my supervisor and I visited communities in six departments in western Guatemala over the course of a month. Since we would be asking sensitive questions as part of the focus groups, we chose communities in which WINGS already had a counterpart in order to remove some of the fear of the unknown. Even with this connection, I expected that we would face some resistance – or at the very least, silence – in response to our questions. Instead, we were welcomed graciously and received thoughtful and honest responses by the participants, many of whom openly discussed the challenges of childbearing while breastfeeding a newborn and watching over a toddler.
Many of the responses we heard in our focus groups echoed the findings of similar studies conducted in Guatemala. For example, interviews with young women in 2013 in Chimaltenango identified three interrelated barriers to family planning uptake: concern about social chastisement for using family planning, one’s husband being against family planning, and fear or experience of side effects, including cancer, infertility, or infection.[iii] Similarly, in our focus groups we consistently heard women say that the shot will give you cancer; that birth control pills will clump together in your stomach and require operation to avoid infertility or cancer; and that a baby could be born with an IUD implanted in its skull. Likewise, women mentioned the pressure that female relatives, particularly in-laws, and husbands placed on women to avoid family planning and continue to give birth. However, this social pressure seems to be lessening over time, particularly as more men have come to understand the costs (both physical and financial) of each additional child.
One of WINGS health promoters gives an educational talk about family planning following a focus group discussion.
In fact, for many Guatemalan women this cost consideration has prevailed over an even more powerful social pressure: the Church. In nearly every focus group, at least one participant asserted passionately that while Catholic and Evangelical leaders liken family planning to murder, it is in fact more sinful to continue having children that one cannot afford. At the heart of this comment is a complex truth: while many women in Guatemala are using or wish to use family planning, this is not necessarily because small families are valued. Rather, every focus group offered up the same sentiment again and again: “Es bonito tener todos los hijos que Dios le mande, pero no es posible con la economía.” There was a general feeling that in an ideal world, family planning would not be necessary, as families would be able to afford to raise all the children that God sent their way. Many women mentioned growing up in households with at least ten brothers and sisters, but life is too expensive now. Employers today expect children to be fully educated, holding diplomas and trained in a skilled craft. In order for parents today to give their children the resources needed to succeed and avoid suffering as they have, parents need to limit the number of children they bring into the world. Thus, women elect to undergo operations after several children upon realizing they can no longer afford to care for another.
WINGS staffers walk through a village following a focus group.
At a recent talk in Antigua, Sue, the founder of WINGS, mentioned that people were not migrating to the U.S. from Guatemala due to gangs or violence, as they have been in neighboring El Salvador and Honduras- they were moving out of economic necessity. This is because despite having the biggest GDP in Central America, nearly half of Guatemala’s population lives below the poverty line. This poverty is heavily concentrated within rural and indigenous communities.[iv] One study found that the effect of being rural and/or indigenous in Guatemala nearly doubles the likelihood of being stunted, a measure of chronic malnutrition that results in lower cognitive and physical abilities over the course of a lifetime, limiting an individual’s earning potential and perpetuating an intergenerational poverty trap.[v]
Clearly, this inequality is not a problem that WINGS alone can tackle. While increased access to family planning has been proven to increase women’s earnings and children’s schooling and body-mass index, there remain greater issues such as job creation and social inclusion that require outside collaboration.[vi] During its history, WINGS has demonstrated the power and potential of these partnerships. In 2007, WINGS began working with the Ministries of Health and Education in Chimaltenango to improve sexual health education and services in schools. In 2011, WINGS for Men began working with sugar cane plantations to target male workers, a group that has a high-risk for contracting HIV and other sexually transmitted infections.
I am now at the halfway point of my summer internship and am working on compiling and analyzing the results of our focus groups. I have had incredible opportunities to travel around this beautiful country and learn about the enormous cultural diversity that shapes these important beliefs. As a result, I believe that WINGS, through their dedicated staff and focused mission, can bring about real change by increasing opportunities for women and families to increase their agency through education and health services, and am grateful for the opportunity to participate in this inspiring project.
[i] Ministerio de Salud Pública y Asistencia Social (MSPAS), Instituto Nacional de Estadística (INE) and ICF International, “Encuesta Nacional de Salud Materno Infantil. (ENSMI). 2014-2015. Informe de Indicadores Basicos.” (Guatemala, November 2015).
[iii] Emma Richardson et al., “Barriers to Accessing and Using Contraception in Highland Guatemala: The Development of a Family Planning Self-Efficacy Scale,” Open Access Journal of Contraception, April 2016, 77, doi:10.2147/OAJC.S95674.
[iv] World Bank, “World Bank Country Partnership for the Period FY 2013-2016 Strategy for the Republic of Guatemala” (World Bank, August 17, 2012).
[v] Thomas G. Poder and Jie He, “The Role of Ethnic and Rural Discrimination in the Relationship Between Income Inequality and Health in Guatemala,” International Journal of Health Services 45, no. 2 (April 1, 2015): 285–305, doi:10.1177/0020731414568509.
[vi] David Canning and T Paul Schultz, “The Economic Consequences of Reproductive Health and Family Planning,” The Lancet 380, no. 9837 (July 2012): 165–71, doi:10.1016/S0140-6736(12)60827-7.