Mixed-methods study identifies key strategies for improving infant and young child feeding practices in a highly stunted rural indigenous population in Guatemala.

Guatemala's rural indigenous population suffers from one of the highest rates of chronic child malnutrition (stunting) in the world. Successfully addressing stunting requires defining the barriers to and opportunities for new behaviour-change initiatives. We undertook a mixed-methods assessment of feeding practices and food purchasing behaviours around infants and young children aged 6-36 months in two rural indigenous Guatemalan communities. We found that most caregivers were aware only of acute forms of child malnutrition and that they greatly underestimated the local prevalence of malnutrition. Despite moderate adherence to exclusive breastfeeding and timing of complementary food introduction, diets had poor diversity and inadequate meal frequency. Furthermore, perceptions of food insecurity were high even in the presence of land ownership and agricultural production. Although fortified foods were highly valued, they were considered expensive. At the same time, proportionally equivalent amounts of money were spent on junk foods or other processed foods by most participants. Biological mothers often lacked autonomy for food purchasing and nutritional decisions because of the power exerted by husbands and paternal grandmothers. Our findings suggest several creative and community-based programming initiatives including education about the acute vs. chronic malnutrition distinction, engaging landowners in discussions about domestic food consumption, engaging with caregivers to redirect funds towards fortified foods rather than junk food purchases and directing behaviour-change initiatives towards all household stakeholders.

Insights into Global Health Practice from the Agile Software Development Movement.

Global health practitioners may feel frustration that current models of global health research, delivery, and implementation are overly focused on specific interventions, slow to provide health services in the field, and relatively ill-equipped to adapt to local contexts. Adapting design principles from the agile software development movement, we propose an analogous approach to designing global health programs that emphasizes tight integration between research and implementation, early involvement of ground-level health workers and program beneficiaries, and rapid cycles of iterative program improvement. Using examples from our own fieldwork, we illustrate the potential of 'agile global health' and reflect on the limitations, trade-offs, and implications of this approach.

The changing role of indigenous lay midwives in Guatemala: new frameworks for analysis.

OBJECTIVES: to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking midwives, with special attention to their interactions with the Guatemalan medical community, training models, and allopathic knowledge in general. DESIGN/PARTICIPANTS: a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives of a local non-governmental organization. SETTING: Kaqchikel Maya-speaking communities in the Guatemalan highlands. FINDINGS: the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to improve maternal-child health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel Maya midwives integrate allopathic obstetrical knowledge into their practice at a high level. CONCLUSIONS AND IMPLICATIONS: as indigenous midwives in Guatemala will continue to provide a large fraction of the obstetrical services among rural populations for many years to come, maternal-child policy initiatives must take into account that: (1)Guatemalan midwife training programs can be significantly improved when instruction occurs in local languages, such as Kaqchikel, and (2)indigenous midwives' increasing allopathic repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the allopathic medical community.