CHINAJAPEC, Guatemala (WOMENSENEWS)--The burning sun made it seem hotter than 90 degrees as the group toiled up the mountain for two hours, struggling with mixed results to keep their feet from being sucked into ankle-deep mud.

Stepping off the road into the jungle shade meant risking an encounter with a poisonous snake. Water was as frequently poured over their heads as it was dumped down their gullets.

The trek for journalists and health care workers in late September was guided by a United Nations agency actively trying to change the maternal mortality statistics in Guatemala, where 1 in every 71 women who becomes pregnant during her lifetime dies from causes associated with pregnancy, delivery and the postpartum period. In the Latin America-Caribbean region that's second only to Haiti, where the risk is 1 in 44.

When the group made it to the summit, it was hard to imagine the trip that local women make to get back down that hill when they are in labor and trying to get to a hospital.

Often women in difficult labor are carried down in a hammock by men from the 16-family community, a journey that takes about two hours. Once they reach the nearest passable road, they could try to flag down a ride. But more often they would still have to walk the rest of the way as well, taking at least another four hours.

As it was, Elviar Cuz didn't even get that chance.

Family members described how the 34-year-old, already a mother of seven, died in June while giving birth to twins, her husband in attendance, in this community too remote even for a midwife to live. It is one of hundreds scattered throughout the region of Guatemala known as Peten, which comprises almost the entire northern half of the country.

She had been to the doctor in Fray Bartolome de las Casas--a two-and-a-half hour drive by truck once you get to the road--and been told she had high blood pressure.

But her labor had started in the middle of the night, her family said, and they did not attempt the strenuous journey downhill in the dark.

One Twin Survives

One of the twins died with the mother. A surviving twin lives with her paternal grandmother in a more populated nearby area.

The father had agreed to speak with the observers but in the end sat among his fellow villagers with his chin resting on his hand, staring straight ahead.

Instead the others told the story for him through an interpreter of the Kekchi Mayan dialect, one of the most widely spoken among Guatemala's 20-plus indigenous groups, many of them scattered in remote settlements such as this one in the northern half of the country.

The U.N. Population Fund has worked with the Guatemalan Health Ministry to identify four major "demoras," or obstacles, that keep women separated from medical care, listed in the order in which they can present during labor.

First, the woman and her caregivers don't always recognize that there's a problem in time to act.

Second, once a problem is recognized, the woman often seeks the permission of her husband, mother-in-law or other family member to go to the doctor or hospital. If she doesn't get it, she doesn't go.

Third--and widely agreed to be the most difficult to change--are the logistics of lining up proper transport. Small communities often only have one vehicle.

The fourth demora is making sure that women receive proper attention once they reach the hospital. If a clinic does not deliver top-notch care, a woman's health may be endangered even if she makes it to the hospital.

Focus on Midwives

In order to overcome the first obstacle--failure to notice danger signs--the U.N. Population Fund recognized early on that the best way into the communities was through the "comadrones," or midwives, who deliver the babies. That's because a prime cause of death is "that they don't identify the danger signs," says Mario Aguilar, a coordinator of a council project that since 2003 has distributed "clean birthing kits" to thousands of comadrones and trained them to spot problems.

U.N. staff and Guatemalan health officials work together to teach midwives that a constant headache isn't normal, for instance; neither are abdominal pain or blurred vision.

Part of that process involves changing the minds of the rural poor, who often regard pregnancy as a sickness, Aguilar says.

Field workers say that when a pregnancy is over, indigenous groups often refer to it as being cured or taken care of. From that vantage point, death is not so far-fetched.

In response to demora No. 2--making the decision to seek medical attention--the health care providers are also educating male community leaders to encourage women to seek medical help, or at least to be aware of the need to give permission if she asks.

Once the decision is made to get to the doctor, however, transport--demora No. 3--emerges as one of the most difficult barriers.

Emergency Committees

Lining up a ride can take hours, as there are few if any vehicles in some remote communities, and the owner might not be available, or there might not be money on hand to pay for the ride. To address this, some communities are being advised to create emergency committees to coordinate an overall emergency-response plan and collect money for a fund to pay transport costs.

Guatemalan health officials said demora No. 4--lack of adequate care in clinics--can be traced partly to a scarcity of clinicians willing to work in remote districts.

The head of one health district said three positions are open.

The typical salary for rural doctors is about $1,000 a month, paid for by the Guatemalan Ministry of Health. But those funded positions often go unfilled.

Doctors from Cuba on two-year medical missions--part of that country's medical diplomacy program--fill some of the gap, but not all.

The Guatemalan Ministry of Health is also building more birthing centers. Several are already in operation throughout the countryside, and others are being built. A woman goes to the center before her due date so she won't have to travel while in labor.

Theresa Braine has been based in Mexico City for four years, writing for the Associated Press, People magazine and other media outlets.

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For more information:

United Nations Population Council (UNFPA) Guatemala:
http://www.unfpa.org/profile/guatemala.cfm

Women Deliver:
http://www.womendeliver.org/

"Major Health Data Hits U.S. Aid Politics":
http://www.womensenews.org/article.cfm/dyn/aid/3346/

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