STORY by KATIE SANDERS
ZACAPA, GUATEMALA — Luz Adela Lorenzo Agustin, 17, is handling almost every aspect of her pregnancy differently from her mother.
She takes vitamins to keep her baby healthy, sees a doctor for weekly checkups and has a pay-by-the-minute cell phone on hand to beckon an ambulance when she is ready for the delivery of her daughter.
She’s also defying Guatemalan custom: Her first baby could be her last.
Agustin will use birth control pills to avoid saddling herself with the eight children her Catholic mother bore in a nation that has the highest birthrate in Central America. The country’s society of large, impoverished families causes chronic food shortages and often leaves adults and their offspring malnourished.
But there are signs that Guatemala’s next generation, like Agustin, wants to challenge Catholic teaching on contraceptives and begin a new era of smaller, more manageable families.
The girl from El Modelo
Agustin lives with her family mother and seven younger siblings in a hot pink one-room house built by Hope of Life, a local Christian non-governmental organization, after her mother was widowed for a second time. Even though it lacks a door, the concrete home is considered the mansion of El Modelo, a rent-free village located a few miles from Zacapa City, and is envied by the family’s neighbors, most of whom live in homes walled with straw, dirt, bamboo and even plastic bags. Their dirt floors are violently flushed out during the rainy season, forcing parents to crouch in chairs with their young sharing the space until the storm passes.
Although she jokingly considers herself the millionaire of the neighborhood, Agustin’s mother, Elbaleticia Lopez Lorenzo, only makes about $40 a month by selling homemade tortillas, enchiladas and chile rejenos to neighbors. She wants a door to protect her children, but the $110 price tag forces her to settle for a piece of hanging cloth.
To make ends meet, Agustin and her sisters spend hours at a makeshift stove preparing food to sell to El Modelo citizens. Most of the time, her two young sisters turned saleswomen, return from trudging the grassy, rocky roads with baskets that weigh nearly the same as when they left. Given that the family’s wealthiest neighbors bring in about $70 a week from working odd construction jobs, most of their targeted audience has found that eating meals — even if they cost 50 cents — outside of rice and beans is an unaffordable luxury.
Agustin, who dropped out of school at third grade, used to support herself as a seamstress in Zacapa City. She taught herself to sew by making dresses for her sisters to wear for Christmas and Easter. In recent months, however, she has been unable to make the trip, which she usually made by squeezing on a bus, given her growing stomach and pains.
Making clothes in Zacapa was how she met Amilcar, the 23-year-old father of her unborn child. The couple lived together a month, but Amilcar left Agustin, three months pregnant at the time, to return to his old girlfriend, who also has a child by him.
Agustin doesn’t know the last name of her child’s father.
A Clinic’s Efforts
Just a few miles down the road from Agustin’s home is a modernized clinic in Zacapa that provides family-planning and contraceptive services at low costs for men and women.
The Association for the Well-Being of the Family, known as Aprofam, has 29 locations throughout Guatemala. The clinic’s mission has been the same for 44 years, but its work has become increasingly important as Guatemala grapples with issues of overpopulation, hunger and malnourishment.
The clinic offers birth control medication, injections, condoms, educational programs, hysterectomies and little-used vasectomies to its clients for about $1. USAid provides the center with birth control medication, Mycrogenon and Zofemenal, to distribute.
Andrea Lopez, an HIV counselor at the Zacapa clinic, said her location sees about 30 women from El Modelo alone, such as Agustin.
A vasectomy, a simple, reversible procedure for males, costs about $200, Lopez said. Because Zacapa is prime “machismo” country, however, Lopez said only about four men come for the procedure a year.
A hysterectomy costs about $215. In the United States, the surgery could cost about $3,000 to $6,000. Six times a year, however, the cost is lowered to $10 to accommodate the budgets of poor women who make the trip to the clinic by foot or bus.
Lopez said doctors from USAid usually perform about 50 hysterectomies on the promotion days. If a poor woman comes to the clinic when the surgeries are sold for regular price, Lopez said clinic employees will tell her to come back on the sale day and supply her with birth control medication to keep her infertile before her appointment.
“Nobody is brought here by force,” she said. “You come here of your own will, on your feet, happily.”
Lopez said a woman’s wealth and education are two factors that determine how, or if, she will plan her family. For instance, nurses, consultants and physicians at the clinic typically don’t have more than two children. Women from areas such as El Modelo, on the other hand, don’t know when or why they should stop having children, she said.
“These people aren’t conscious of the situation that is happening in Guatemala,” she said, speaking of Guatemala’s overpopulation woes.
For young, rural women like Agustin, however, the realization that fewer mouths could mean a greater abundance of food is starting to sink in.
Figures from USAid show that between 1998 and 2002, the country’s fertility rate declined from 5 to 4.4 births per mother. The CIA estimates the rate to be 3.59 for 2008.
With eight of her nine children still alive, Agustin’s mother, Elbaleticia Lorenzo, 37, has already beaten the odds. Her country has the highest infant mortality rate in Central America, six times that of the United States, according to USAid.
Lorenzo, who has 12 brothers and sisters, said despite what she thinks Luz Adela’s family will lose by her going on birth control medication — ready-made playmates and help around the house — she is proud of her daughter for making the choice to plan her family.
“I told her, ‘Don’t have more family,’” Lorenzo said. “Instead of doing better, you’ll be doing worse.”
Delmy Franco, 30, the director of the family-planning clinic in Zacapa, said children are inevitably malnourished when rural families living in poverty become too large. Even four, the average number of children per mother, is too many for struggling mothers, she said. There just isn’t enough money to keep them all healthy.
Guatemala has the highest rate of chronic malnutrition, 49 percent, in the American hemisphere, according to USAid.
Agustin’s younger brothers and sisters, all of whom have stunted growth, are indicative of the country’s malnutrition aches. Agustin, who takes vitamins to keep her and her baby healthy, is the only one who resembles her age — the rest look about two years younger. Her youngest sister, Belsi Anali, 3, has thinning black hair and a persistent cough, and like her 6-year-old brother Donis, a distended stomach. Sisters Rayna, 14, Blanca, 12, Elbamabilia, 10, and Marlene, 9, have stick-thin frames, but they still manage to heave heavy loads of wood and wet clothes atop their heads from the creek to their home, a half-mile, mountainous journey.
Their bodies serve as a warning sign for Agustin, reminding her of what can become of families who take on too many children. None of Agustin’s siblings go to school.
Franco said educating mothers in rural villages about the affordability of contraceptive measures is essential to her clinic’s purpose and its goal of improving Guatemala’s quality of life for its residents.
In the past, however, even rural women who were aware of what’s available were blocked from a hysterectomy because of the country’s government.
Some women, including Elvia Suchite, a 21-year-old mother living in Agustin’s village of El Modelo, remember when restrictions were imposed on who could get a hysterectomy.
When she was 16 and already a mother of two, Suchite wanted a hysterectomy to bring an end to her family’s economic woes. Two children were all Suchite and her partner, whom she calls her husband, felt they could clothe, feed and support given their income of about $42 a week.
However, her bleak situation wasn’t dire enough to qualify for a procedure.
A policy mandated that a woman be at least 25 years old or have three children before getting the surgery. Suchite’s situation satisfied neither stipulation until she had her third child a few years later.
With women like Suchite perpetuating the number of hungry mouths by skirting the law, Lopez, the HIV counselor, said the policy was abolished because it only seemed to worsen the overpopulation problem. Now, there are no obstacles blocking a woman to the procedure.
“We can operate on any woman as long as she wants to be,” she said.
Increased eligibility for hysterectomies may satisfy residents, clinics and distributors at Zacapa’s family planning clinic, but one institution continues to disapprove of the country’s eagerness to control births.
The Catholic Church has long held that contraception goes against the will of God.
With about 60 percent of the country identifying with the Catholic faith, some rural women find the idea of regulating their ability to conceive comparable to denying God control.
Emilio Morales Jordán, a deacon at St. Peter’s Catholic Church in Zacapa, said he can agree with the employees of Aprofam on at least one idea: Poor women will not learn the importance of adjusting from traditional big-family practices to a small-family culture on their own.
However, he said, Aprofam sends the wrong message to rural residents about contraception.
He said they are wrong to teach rural residents about birth control medication, injections and surgeries instead of promoting the natural planning methods the church allows.
He said the preferred family-planning method of Catholics is reserving sex for the days of the month when women are not fertile, known as the rhythm method.
Although the children objects to contraception and birth control, Jordán said it also discourages families from having more children than they can afford.
“If you have the capacity to educate three, well, have three. If you have the capacity to educate five, then five,” Jordán said. “But if you don’t have the capacity to educate 10, and you’re going to open a situation of poverty, of misery, then it’s better to have less.”
He said the church objects to hysterectomies because they encourage women to be promiscuous and are unnecessary for married women.
He said women in rural villages are told by the clinic’s representatives that the surgery is in their best interest, but health and personal complications often ensue when the woman submits to having her tubes tied.
Jordán said the surgery takes away a woman’s ability to change her mind: If she decides that she is ready to have a baby, there is no way to undo the procedure. His church sends counselors to educate the people about natural birth control methods and the hazards of hysterectomies, he said.
However, clinic officials contend that the Catholic missionaries are spreading a different message.
Franco, the director of the clinic, asserts that the Catholic workers tell uneducated people that birth control medication will cause cancerous side effects. It’s not unusual for medications and surgeries to have side effects depending on the user, Lopez said, but cancer is not one of the results for the medication her clinic distributes.
Lopez said the clinics don’t exert much effort to disprove the rumors left lurking in the villages. If they want the information, they know where to look, she said.
“We don’t make things up to bring in more patients,” she said.
Despite their differences, Jordán said there is no war with the family planning clinic.
That, too, goes against the Catholic mission.
“Does the Church like their point of view? No, because (the Church) is always in favor of life,” he said. “Any question against life is against the plan of God.”
‘It has to stop’
Guatemala’s population problem has provoked some community leaders to question if implementing a family cap similar to China’s “one child” policy would solve the country’s economic woes.
Since 1979, the Chinese government has practiced a restriction on urban and rural families to keep its population, the largest in the world, from growing out of control. For the strategy to be effective, the country depends on almost universal access to contraception and abortion, according to a 2005 report from the New England Journal of Medicine.
Local specialists in medicine and theology disagree on the measure’s potential for change in Guatemala, which has the second lowest contraceptive use rate in Central America, according to USAid figures.
Jordán dismissed the policy, saying it would grant the Guatemalan government the authority to interfere with a family decision. Although he has no wife or offspring because of his commitment to Catholicism, he grew up in a family of twelve.
“A regulation cannot be imposed,” Jordán said. “Families would not agree with that.”
He said the government should focus instead on educating young girls about the benefits of having a small family, not intimidating them into the culture like the Chinese.
Dr. Ennio Hector Lava Castaneda, a gynecologist at Zacapa General Hospital for 15 years, said education is not enough. Castaneda thinks such a restriction is overdue in Guatemala.
In September, the hospital oversaw the birth of 313 children. About 10 percent of the mothers were under 16, and a good portion of the children were delivered underweight, Castaneda said.
He said a family cap could solve some of the country’s ill statistics: Guatemala has Central America’s highest infant mortality rate and one of its highest maternal fatality rates.
A snare to the plan’s success is that the country’s government and its official religious body, the Catholic Church, will never come to agreement on how to deal with the population problems, he said.
“It has to stop,” Castaneda said. “Somebody has to stop it.”
Planning against tradition
For some of the indigenous Catholics living in El Modelo, the taboo of contraception becomes easier to forget when God’s gifts become financial burdens.
The image of Suchite’s two weather-beaten and bare mattresses, which serve as dining room chairs, living room couches and cribs for her newborns, begins to illustrate her dire situation.
Her three children, ages 2, 5 and 6, run with friends about the single-room house, which is supported by sheet metal, bamboo, mud and plastic bags, and almost knock over the day’s bowl of rice with their frenzied play.
Suchite’s mother, Maria Mercedez, 62, is a devout Catholic, but the constant chaos of Suchite’s life helps her to understand why she and her sister decided to have hysterectomies.
Sometimes there just isn’t enough money to support the will of God.
Mercedez said she never tried to convince her daughters that the surgery would be in their best interest, and she isn’t disappointed in them for going against their religion.
“Those are their decisions,” she said.
Agustin’s mother, also a Catholic, attends church on Sunday nights when she can. Her walk is deterred only when it’s raining, when her 7-month-old son is sick or when she feels uneasy about leaving her children unattended in the house, which has no door.
Lorenzo said her mother, who had 13 children, warned her that taking care of many children would be difficult and that she should try not to have a lot of children.
“I never listen,” she said. “It’s normal to have a lot of babies.”
She said with God’s help, she is able to provide food for her children on most days. It gets complicated when her babies become sick and need expensive medical care.
She was well aware that getting a hysterectomy was against the rules of her faith from her preacher’s messages, but she said the surgery was her choice. Even if she does find love again, she will not have any more babies because, well, eight is enough.
She said sometimes she feels regret that she didn’t know about the birth control methods her daughter will soon begin, but she is pleased with her family.
“I don’t think or stop to think that if I had less children, I’d have a better life,” she said.
Jordán said there is still hope in eternity for women who were tricked into the surgery and even those who understood the spiritual consequences before going on the table.
“If the woman thinks what she did was really bad, God can forgive her because she did it to give her family a better life,” Jordán said.
He said the Catholic Church doesn’t reject women who have had the surgery — just the people who inform, encourage and trick them to do it.
“What the Church does is continue Christ’s mission in favor of life and will always be in support of families, of children, of couples, of grandparents,” he said.
Beliefs about contraception are not universal among Zacapa’s Christian leaders.
Christian Archioa, 30, is the minister of an evangelical Protestant church in Jesus Maria, a small village near Zacapa. He has three children, ages 1, 4 and 8.
Guatemala’s overpopulation woes stem from antiquated ideas about family planning prevailing in the rural villages, Archioa said.
Many don’t consider using birth control methods because as residents in a traditionally Catholic nation, they are told to believe that God will provide for the family, no matter the size.
The country’s upper and middle classes, meanwhile, have shifted to a North American mentality: Wealthy families use artificial methods of birth control — even if they don’t admit it — because they know what is available and why they can’t provide for all the children they could bring into the world, he said.
“Somebody showed it to us, but who is going to show that to the people in the mountains?” Archioa said. “That’s the work that I want to do.”
Guatemala’s next generation of mothers
Thoughts of single-parenting, in the new sense of the word, have trickled into the thoughts of Agustin’s five younger sisters, though most of them giggle when asked about their far-off futures with husbands and babies.
After watching her sister and mother go through a combined seven pregnancies since she was born, Rayna Lorenzo Lopez, 14, said she has no desire to fill her home with lots of sons and daughters. Rayna has shared much of the responsibility for her own siblings for years, but now that her mother has to care for the newborn, she does most of the cooking and cleaning.
“A small family is more beautiful,” she said.
Only time will tell if Agustin will hold true to the same philosophy.
After being abandoned by her first love, whom she knew a month before moving in and getting pregnant, she said she knows it will be a long time before she can trust men again.
If she meets a new suitor down the road, she said she plans to make him wait a year until she considers going off of her birth control pills.
She, like other Guatemalans in her generation, has learned that bringing children into her world of scarcity and strife is a decision worth thinking about.
“Maybe in a few years, I will think differently,” she said.