HEALTH -- February 15, 2011 at 10:58 AM ET
Reporter's Notebook: The Family Planning Frontier in Guatemala
A week of travel in Guatemala is a feast for the eyes: stunning volcanic peaks covered in a carpet of green -- cabbages, coffee, melons, bananas growing on impossibly steep hillsides -- and people working hard to wrestle a living out of the ground. After two years on the global health beat, I sometimes shake my head in wonder at how some of the most beautiful places on the planet can also be the hardest places to live.
Guatemala has one of the fastest population growth rates in the Western Hemisphere, about 2.4 percent a year. The population is pushing 14 million, and there is not enough arable land to support the rate of growth.
Our team from the NewsHour visited villages where it has long been common to have 8 to 10 children per family. Women made their way along rural roads or up hillside paths with one baby on their backs, a toddler in hand, and a four-year-old pulling up the rear.
Children are valued and loved here. At the same time, big families exact a tremendous toll. The maternal mortality rate - 240 deaths for every 100,000 live births, according to the World Health Organization-- is the highest in Latin America. Malnutrition is epidemic. In highland indigenous communities the tiny stature of children and adults is not solely hereditary. The short supply of food guarantees for now that Guatemala will not see the gains in height and weight, or the children towering over parents, seen in newly prosperous places like South Korea and China.
However, encouraging families to reconsider what the optimal number of children might be is more complicated than a quick lesson in microeconomics. To enter into the Guatemalan dialogue on family planning means taking history, gender relations, and religion seriously, and requires consideration of how each shapes the debate.
Guatemala is a deeply religious country. Even those who are not active church-goers grow up surrounded by Christian worldviews. No longer monolithically Catholic, the country has seen the grown of a vibrant, elbows-out Evangelical presence, which accounts for at least a quarter of the population. The Catholic Church, with its profound, 500-year old roots, and the energetic, emotional worship and deep cultural conservatism, make Guatemala's consideration of family planning a far different one from that of North America or Europe.
Abortion is viewed as a terrible sin. Birth control pills, intra-uterine devices and diaphragms are suspected of causing illnesses in the women who use them. Implanted, slow-release contraceptive chemicals are catching on, but they are expensive and provide only limited-duration protection. Condoms are unpopular among men, and discouraged by the Catholic Church, which only advocates natural methods for family planning.
Women often begin having children as teenagers in Guatemala, and continue with regular pregnancies into their 40s. At one mobile clinic I met a mother with eight children ranging in age from 28 years to 16 months. She said the last few births had taken an escalating toll on her body, and her husband agreed with her decision not to bear any more children.
Accompanying her that day at the clinic was her daughter-in-law with an 18-month-old. Both women had bandaged upper arms, where contraceptive implants were just inserted. The young mother wanted more children down the road, she explained, but thought it best to give her first child the best possible start in life by spacing her next pregnancy.
The mobile clinic was fascinating. A truck rolled up to a neighborhood clinic space. The team of doctors and nurses spilled out and began hustling green plastic crates inside. In less than an hour, what had been a series of bare rooms were now packed with the women of Jocotenango...giving histories, getting weighed, and scrubbed in for tubal ligations. Babies were handed from lap to lap as mothers passed through different stages of the clinic visit.
We were told across the week that the acceptance of men was a vital part of making this all work. Big families confer status on proud fathers. That sense of pride discourages birth control, but contraception also has a darker side in the relations between men and women: When women try to get men to agree to their use of birth control methods, the men often accuse them of infidelity or promiscuity.
We visited the grave of a woman who died at 43 giving birth to what would have been her ninth child. Accompanying us to the graveside was the dead woman's oldest daughter, Concepcion, and her husband, Diego. The couple said the death of the family matriarch did not cause them to reconsider their rejection of artificial birth control.
Concepcion, Deigo and their daughter Delores.
Concepcion said she wanted to space her children. As for limiting the number of children, Diego was adamant: However many children God sends, he said, is the number we will have. I asked Diego if it was also God's will that his mother-in-law was dead after trying to bring another child into the world. It was, he conceded, preferring to move on to list the many illnesses that can be brought on by birth control.
Evelyn Roquel is a young family planning educator with the Women's International Network for Guatemalan Solutions, or WINGS. She heads from town to town in the highlands region, extolling a woman's right to control her fertility. On the day we visited San Marcos on the banks of breathtaking Lake Atitlan, Evelyn had gathered more than a hundred indigenous women in a children's playground at the town's center. She stands about four-foot-ten, but her confident manner and down-to-earth straight talk about the difficult topic of birth control won over her audience.
When Evelyn unfolds a poster showing a pregnant woman with a child on her back and a toddler holding her hand you could feel a ripple of recognition move through the crowd. They all know a woman like that, Evelyn told me later, or they are in that position themselves. At this point, she has the crowd in the palm of her hand as she talks about the physical effects of back-to-back pregnancies and the financial toll of many children.
When Evelyn holds up a serious clinical map of what happens during vasectomy alongside a line drawing of an erect penis, the crowd bursts into laughter. The young birth control evangelist talks about how vasectomy has no ill effects for men, is quick and not very painful. She would tell me later that it is unlikely that any of the women will press vasectomy as a serious option in their own homes.
The programs we saw, the people we spoke to, the places we visited all confirmed that there is the beginning of a different idea about the role of birth control in society. It was easy to find people who acknowledged that the birth rate was creating problems. Many soberly expressed their hopes that their children could spend more years in school, and that the girls might have fewer pregnancies.
However many children God sends, He isn't creating any more Guatemala. Farms have been subdivided, and subdivided some more. Across the week we saw men, women, and children working tiny plots on shockingly steep land. The virtually vertical farmland could not be worked by machines. And the sloping triangular plot meant to be split among three children, will now be cut up for six, or seven or more.