Below the tip of the iceberg: the problem of adolescent pregnancy, early motherhood, fatherhood, and reproductive health practices in Alta Verapaz, Guatemala

Abstract

Guatemala signed the peace accords in 1996, ending a 36-year civil war marked by Mayan Indigenous genocide. Underinvestment in the public health system has resulted in inequalities in accessing healthcare, particularly sexual and reproductive health (SRH), for Indigenous adolescents. Alta Verapaz is the most affected department, reporting the second-highest number of adolescent pregnancies and gender-based violence nationwide. The Guatemalan government implemented the National Plan for the Prevention of Adolescent Pregnancy (PLANEA) 2018-2022; however, it falls short of addressing the situation and reaching the target population. This doctoral dissertation explores the perceptions of adolescent pregnancy, early motherhood, fatherhood, and reproductive health practices, as well as the perceptions of implementing the national action plan. An exploratory descriptive methodology and reflexive thematic approach were employed to collect and analyze the perspectives among adolescents, community members, and stakeholders. This involved four focus group discussions with Indigenous adolescents (n=30), 18 semi-structured interviews with community members, and 20 interviews with stakeholders. Findings revealed that underlying factors, such as poverty, discrimination, deep-rooted family and community values, harmful gender stereotypes, stigma, fear, cultural, moral, and religious norms, and communication challenges hinder adolescent access to SRH information and services. Additionally, limited access to maternal, neonatal, and mental health services often leads to forced marriages, unsafe abortions, higher risk of maternal and neonatal mortality, and mental health problems, including suicide. These factors contribute to a heightened risk for sexual violence and pregnancy, especially among adolescents under 14 and during the COVID-19 pandemic. Moreover, budget constraints, government shifts, limited multisectoral and interinstitutional coordination, and insufficient monitoring and evaluation capacity threaten initiatives’ continuity and long-term sustainability. However, opportunities exist to enhance adolescent SRH interventions through stronger partnerships, community participation, youth leadership, demographic changes, technology use, and mental health integration. The dissertation concludes with reflections on the implications and recommendations for designing and implementing equitable adolescent SRH programs and policies.