Conceiving Risk in K'iche' Maya Reproduction

Matthew R. Dudgeon

In the department of Quetzaltenango in Guatemala's western highlands, different meanings of risk attach to pregnancy and its management for three distinct groups of health care providers: local physicians, regional workers for an international NGO working to improve health quality in maternal and infant health services, and K'iche' Maya traditional birth attendants (TBAs)—midwives, or, in Spanish, comadronas. Moreover, theories of risk that focus on the state as a source of power and the administration of risk may be inadequate for conceptualizing local TBAs' meanings of reproductive risks. Many TBAs work with a multilayered discourse of risk within which they rate their clients' pregnancies, as well as evaluate each other's worthiness of the title comadrona. Indeed, midwives in rural Guatemala perceive their relationship to the supernatural as a mitigating force against the risks associated with pregnancy. Midwives who purportedly strike a pact with the devil may find themselves outside the parameters of local definitions of what makes a good midwife.

Background to Experiences of Reproduction in Cantel, Guatemala

For most of the twentieth century, the government of Guatemala interacted with its rural population as a sovereign power. State administration of that population was achieved primarily through force rather than infrastructure or social services, and it has differed according to locally recognized ethic distinctions between indigenous Maya and ladino groups of Spanish ancestry. Such regulation of the rural population has helped exclude indigenous groups from state politics, maintained a semi-feudal concentration of land and resources in the hands of a small minority, and supported some of the highest levels of inequality between the richest and poorest in the Latin American region (Suarez-Berenguela 2001). Throughout Guatemala's postcolonial history, national political debate has focused less on the inclusion of indigenous communities and more on the degree to which sovereign versus disciplinary and regulatory power should be exercised by elites in the administration of those communities; strategies have included privatization of land and indigence laws with forced labor directed at indigenous groups (Handy 1984).

While in the nineteenth and twentieth centuries Quetzaltenango's indigenous K'iche' elite class has wielded political power, much of its authority rested on administration of land and community relations of reciprocity, increasingly undermined as K'iche' elites depended more heavily on the state and its punitive powers. At the same time, a growing K'iche' middle class of merchants and artisans called for health and educational reforms and increasing integration of the Guatemalan state into local administration in the departmental capital (Grandin 2000). The prevalence of sovereign power has produced both fragmentation among indigenous communities and a limited degree of autonomy within them—an autonomy shattered for many communities as the state shifted from isolated massacres to total war, development poles (army-administered communities), and community policing during Guatemala's civil war in the 1980s. In the aftermath, and in parallel with the activities of international organizations such as the United Nations and bilateral and multilateral NGOs, Guatemala has seen increased administration of the biopolitical life of rural Maya, with a particular emphasis on reproduction and reproductive health. Most recently this shift has included the establishment of a Ministry of Reproductive Health and the pursuit of a plan for indigenous health, both implemented under Guatemala's Integrated National Health System (SIAS) and with the stated goals of reducing infant and maternal mortality (Cosminsky, this volume; Maupin 2008, 2009).

While conducting research on reproductive health in a K'iche' Maya community in the municipality of Cantel in Quetzaltenango, I encountered great variation among groups of health care providers in the meanings they attached to infant illness and death.2 Conducted from December 2001 until May 2003, my ethnographic and epidemiological fieldwork focused on Maya men's experiences of reproduction, as well as men's influences on maternal and infant health. The peri-urban municipality provided an ideal location to investigate reproductive health in a Maya community that had, relatively speaking, good access to the health facilities of the urban center of Quetzaltenango and yet, like many parts of Guatemala, still experienced relatively high rates of infant mortality. With a population of nearly 99 percent indigenous K'iche' Maya, the municipality of Cantel had 729 live births in 2001 and an infant mortality rate of 53.5 per thousand, higher than Guatemala's overall rate, estimated between 39 per thousand in 2000 and 45.8 in 2001 (CIA 2011).

I located my research in one aldea (hamlet) of Cantel, a community with a population of approximately 3,500, where I also conducted multisited ethnographic fieldwork with several groups of health professionals. These included physicians and epidemiologists working with the Ministry of Health, several local and regional health NGOs, and collective organizations of TBAs. I conducted semi-structured and open-ended interviews and attended planning and training meetings, gathering data via observation of physician training in reproductive health, interviews with traditional midwives, and verbal autopsies from families in the community after...