According to the Baseline Maternal Mortality study for 2000, the maternal mortality ratio for indigenous women living in Guatemala is three times higher (211 per 100,000 live births) than for the non-indigenous group (70 per 100,000 live births). In response to this situation, Marie Stopes (MS) Mexico engaged in a project with the aim of raising awareness of, and improving access to, sexual and reproductive health (SRH) services among indigenous returned refugees in Huehuetenango, Guatemala. From June 2001 to October 2003 a mobile team from MS Mexico provided cross-border services to the returned communities, including family planning (FP) and maternal child health services. They also carried out information, education and communication (IEC) activities to raise awareness about SRH in remote, under-served border areas.

Surveys were carried out before (baseline: June 2001) and after (endline: June 2003) the main intervention by the project teams. Some 388 baseline and 400 endline surveys and interviews were conducted with men and women aged 14 to 49 years old in 12 communities. Survey training was provided by the mobile team members and external consultants, and included reviews of the objectives and interactive methods such as role-plays to familiarise the team with the process. For cultural and linguistic reasons, local health promoters and midwives undertook the bulk of the survey work.

There were limitations to carrying out the study, such as the time of year during which it was carried out (harvest time), the presence of males inhibiting women's responses, privacy issues, and Mayan cultural constraints regarding speaking about FP.

During the two-year project the mobile unit helped 2,786 women access SRH services and trained over 28 health promoters and 45 traditional midwives in 22 rural communities.

Identification of specific problems during pregnancy increased among the population, particularly in the case of haemorrhage, mal-positioning, and frequent headache, recognition of which almost doubled.
Specifically, knowledge of specific problems which can occur during childbirth rose from 53% to 67% among both men and women. Recognition that women can die at childbirth increased to almost 95% from 80% in the baseline survey.

However, organisers stress that "appropriate arrangements for transport need to be made possible as it remains a major obstacle to successful reduction of maternal mortality in rural areas, not just in terms of physical access to services but also in terms of the decision-making process. These results indicate that there is still important work to be done regarding gender equity, female empowerment and communication between men and women." Out of the population surveyed, 88% indicated that it was the husband's decision to approve of his wife's transport to a hospital in the event of a childbirth problem or emergency.

Knowledge of all modern family planning (FP) methods doubled. Knowledge of injectables, for instance, increased from 41% to 89% ("The fact that injectable contraceptives were the most popular and preferred method is in part due to women's need to use a more discreet family planning method without their husband knowing".) Over 90% of the population surveyed in the follow-up could identify where to purchase a FP method, and 64% correctly said that FP methods could be purchased through health promoters.

Only half of the women interviewed in the study could speak Spanish; the literacy rate was 37%. Knowledge of problems during pregnancy was inversely related to literacy and knowledge of Spanish in the general population and specifically in women. 70% of women who cannot read were able to identify a problem in pregnancy compared to 50% of women who can read. However, illiterate women or those without knowledge of Spanish were less likely to know about FP methods.

Intention to use FP methods increased from 36% to 68%, with almost three-quarters of women indicating they would like to use an FP method.

More than half of all respondents indicated that they would like another child.

FP use increased from 9% to 30%. Use of FP methods was associated with knowledge of Spanish among women and may reflect their improved access to education, resources, and direct communication with all team members. In fact, women who speak Spanish were 4 times more likely to use an FP method then those who do not.

Results indicate that antenatal and childbirth care given by midwives increased significantly during the project. All the women interviewed stated they sought an attendant during birth. In the follow-up survey, 89% of women had given birth with the assistance of a traditional midwife, as opposed to 71% at baseline.

After two years of the project, 93% of the community called MS Mexico's work in Huehuetenango, Guatemala "important" or "very important", signalling acceptance of and demand for services.

"Despite increases in FP knowledge and use, there are still many ingrained fears and myths surrounding methods, reinforcing the need for IEC on RH to reach people at a much younger age."