Andrea Garcia, Meghna Nandi, Sandy Mux, Anita Chary and Kirsten Austad
Wuqu’ Kawoq | Maya Health Alliance
Rosa,[1] a 38-year-old Maya woman, receives a phone call from a nurse at the nongovernmental organization (NGO),Wuqu’ Kawoq, from which she has received injectable contraception for three years. This month’s shot is a couple of days late, and Rosa is worried about an undesired pregnancy. With public transportation suspended, the nurse cannot visit Rosa’s home as she usually does. Luckily, Rosa lives within walking distance of a government health post, a public clinic that is constitutionally mandated to provide her with free contraception. The nurse coaches Rosa to tell health center staff that she is currently on her period, as this is a requisite for first time use of contraception at the public clinics. The nurse calls back a couple of days later: Rosa finally got her Depo-Provera shot at the health post.
Rosa is one of many people, globally, facing heightened challenges to seeking contraception during the COVID-19 pandemic. Shelter at home orders, travel restrictions, supply chain disruptions, and over-stressed healthcare systems have decreased access to family planning services and will likely increase unintended pregnancy rates. Herein, we share perspectives on indigenous women’s access to contraception in rural Guatemala during the pandemic. Our writing is based on our clinical experiences with the NGO Wuqu’ Kawoq | Maya Health Alliance, which was founded to address the widespread language and cultural barriers to healthcare faced by indigenous Maya people.
Similar to racial and ethnic minorities in the United States who face higher infection rates and mortality due to systemic racism, indigenous Maya people may ultimately face the harshest consequences of the pandemic in Guatemala. Maya people have endured decades of physical and structural violence ignited by colonialism and exacerbated by civil war and genocide. Like many historically oppressed populations, the marginalization of their intersecting social, cultural, and political identities forces structural vulnerability upon the Maya people. Unsurprisingly, they face significant economic and health disparities, including over double the rates of extreme poverty and higher rates of childhood stunting, child mortality, and maternal mortality. These disparities persist in family planning; indigenous women have nearly double the rates of unmet need for modern contraception.
In our NGO’s women’s health program, we provide preventative sexual and reproductive health (SRH) services, including family planning, to mainly indigenous women living in rural Western Guatemala. Our providers are primarily female, indigenous nurses who speak local Mayan languages and conduct home visits and community-based clinics. We offer our patients hormonal and copper intrauterine devices, the progesterone implant, injectables, oral contraceptive pills, and condoms, as well as counseling around sterilization and natural methods.
When COVID-19 arrived in Guatemala in mid-March, the government swiftly responded by enacting strict lockdown measures. Within two weeks of the country’s first confirmed case, the government restricted international travel, enacted 4 p.m. curfews, closed many non-essential businesses, and suspended public transportation. Shortly after, the government limited inter-municipality travel.
As daily life dramatically changed, so did access to SRH services. Without public transportation, Wuqu’ Kawoq field nurses could no longer reach the majority of their patients requiring contraception. Like many providers, we turned to telemedicine. Field nurses make phone calls to patients, listen to their limitations, and counsel women on their options. Appreciation and desperation come across during these calls. Patients balance their anxiety around contracting the virus with their heightened fear of undesired pregnancy during a time of economic insecurity.
Often due to societal disapproval of contraception or familial pressures to have more children, many of our patients use contraception without their partners’ knowledge. They fear facing contraception sabotage or even violence if their partners find out. During the pandemic, they have expressed how much harder it is to hide contraception use. One patient lamented that her family members are now at home for most of the day, limiting her privacy and making it difficult for her to leave her home without her family’s knowledge to obtain her Depo shot. Our field nurse helped her think of an alternate reason to go to the health center that would not raise her mother-in-law’s suspicion, like a blood pressure check.
Our limited ability to reach our beneficiaries during the pandemic has required many women to find other supplies of contraception. We have helped many patients identify their local government health centers as potential sources. Unfortunately, patients have recounted challenges obtaining contraception at these centers, including unexpected closures, method shortages, and deprioritization of family planning visits. One patient hesitated to visit the government health center because she had been turned away before for previously using a family planning method administered by our NGO and not the health center. We soon realized patients would have to hide their history of family planning with our NGO in order to ultimately receive their method. With this information, we proactively counseled patients like Rosa.
For patients in especially remote communities, unable to reach a government health center without public transportation, nurses use personalized counseling to help find another option. For women with sufficient economic resources, private pharmacies, which outnumber health centers, have been a useful source of short-acting methods when paired with our tele-counseling. Our nurses explain which methods are available and help patients determine which is best for them prior to arriving at the pharmacy, where staff usually do not help with decision making. Our nurses have also helped patients identify natural methods that may work best for their personal circumstances. Patients left without alternatives are prioritized for the few days that nurses have private transportation. With limited funds, this service is reserved for only a handful of patients weekly.
These patient narratives and provider testimonials may hold lessons for other NGOs. Telemedicine consults provided in native languages are a simple yet powerful way to support patients during the COVID-19 crisis. Our approach, informed by ethnographic methods, ensures that our personalized counseling recognizes local norms and imparts cultural capital, which can empower patients to navigate health systems, traverse difficult social situations, and identify the best options under current circumstances. Using expensive tools like private transportation only after exploring more cost-effective options allows NGOs to maximize resources. In these ways, NGOs can support their local communities during the pandemic.
Nonetheless, the challenges we have encountered during COVID-19 have made us acutely aware of our limitations as providers outside of the public sector during an international crisis. Despite increasing mobile technology in rural Guatemala, a substantial minority of our patients still do not have cell phones and are almost impossible to contact. Travel restrictions sometimes prevent even private cars from entering patients’ neighborhoods. Short-acting methods and those administered by providers, like the Depo-Provera shot, are most vulnerable. Thus, long-acting reversible contraceptives and self-administrable methods, like Sayana Press, may be more desirable during this pandemic. Accordingly, we recommend prioritizing these methods in global supply chains.
Our NGO cannot directly confront the barriers to contraception our patients report facing in government health centers, in spite of the public sector being the largest provider of family planning services in Guatemala and a free, geographically accessible option for indigenous women. During this lockdown, when rural communities are even more isolated and families find themselves in heightened economic precarity, this public safety net becomes even more important. Family planning, however, does not seem to be a priority for the public sector. The Guatemalan Ministry of Health has, to date, provided no guidance on maintaining SRH services during the pandemic. This lack of urgency may be because women, rather than government authorities, ultimately shoulder the consequences of unintended pregnancies. Access to contraception reduces unintended pregnancies and high-risk births, which leads to fewer maternal deaths and unsafe abortions, especially in countries with restrictive abortion laws, like Guatemala. Contraception use in Guatemala is also associated with better child growth. For these reasons, we, like other reproductive health providers and organizations, implore public officials everywhere to recognize contraception as the essential service it is.
Finally, we hope our perspectives spotlight the pandemic’s probable disproportionate effect on indigenous women’s access to contraception in Guatemala. Travel restrictions impart a greater hardship in rural areas, where most indigenous people live. Navigating obstacles at public health centers, where most providers are not indigenous and do not speak Mayan languages, is more challenging as a monolingual speaker of Mayan languages.
We must recognize that addressing these family planning disparities will require structural change within the larger healthcare system. Though the Guatemalan constitution guarantees healthcare to its citizens, the underfunded public system is unable to provide adequate care to rural, indigenous communities. Moreover, our patients and indigenous people across Guatemala report abuse and discrimination from nonindigenous providers in public facilities, including SRH services. Consequently, we urge healthcare and education programs to consider efforts to reduce racial and ethnic bias. As we rebuild in the aftermath of COVID-19, let us strive for a “new normal” that prioritizes the needs of indigenous people and others neglected by current systems.
Andrea del Rosario Garcia Quezada MD received her medical degree from the University of San Carlos in 2012. She then pursued a master’s in Nutrition and Food Security from the University of San Carlos and INCAP and a course in Health Administration from Loyola School of Business in Guatemala City. Andrea currently works with Maya Health Alliance as medical director of a preventive healthcare program for indigenous women in rural Guatemala.
Meghna Nandi graduated from Washington University in St. Louis in 2014 where she studied anthropology and psychology. She is currently a medical student at Brown University in the Primary Care-Population Medicine program. Here, she has explored her interests in immigrant health, trauma-informed care, and reproductive health advocacy. This past year, she worked with Wuqu’ Kawoq | Maya Health Alliance on family planning trainings and chronic disease research.
Sandy Marisol Mux is from San Juan Comalapa, Guatemala, a rural indigenous community. She earned her advanced nursing practice degree from Rafael Landívar University in 2014 and began working at Wuqu ’Kawoq | Maya Health Alliance in 2013. Here, she serves as the Women’s Health Program Manager. Her interests include intercultural care and reducing barriers to health facing Maya people. Her clinical work focuses on health promotion and patient selfcare.
Anita Chary MD PhD is an emergency physician at Massachusetts General Hospital and Brigham and Women’s Hospital. She is chief resident at the Harvard Affiliated Emergency Medicine Residency and a clinical fellow at Harvard Medical School. Dr. Chary is an anthropologist whose research focuses on health disparities and health systems development in low-resource settings. She has worked with Maya Health Alliance since 2008 on child nutrition, women’s health, and chronic disease programs.
Kirsten Austad MD MPH graduated from Harvard Medical School. She completed a residency in Family Medicine at Boston Medical Center and a Global Women’s Health Fellowship at Brigham and Women’s Hospital. Her research focuses on implementation science to improve reproductive health services globally. She is an Assistant Professor of Family Medicine at Boston University School of Medicine where she works as a hospitalist and family planning specialist.
[1] Pseudonym, composite case based on collective experiences of family planning patients