Hannah Evans (left) with Miriam Elizabeth Santos (right), a student midwife at Manos Abiertas.
Written by Hannah Evans | Published: October 6, 2025
In March, I set out on a journey to visit Population Connection’s amazing Global Partners in Guatemala. The experience was both inspirational and transformative, and a powerful reminder of why their work is so important. I came back feeling deeply inspired, full of gratitude, and more connected than ever to the communities and people driving change in areas of reproductive health, family planning, sustainable development, and regenerative agriculture.
The purpose of my visit was to both gain a deeper understanding of how each organization operates day-to-day and to gather stories that highlight their impact in specific communities. It was also a chance to connect directly with the people they serve — whose voices, experiences, and insights are the heart of this work.
What struck me most was how multifaceted and deeply rooted our Global Partners’ work is. It’s not just about distributing resources or implementing programs — it’s about trust, relationships, and listening to the needs of the community. From clinics to remote community visits, every service is locally informed and shaped by people who truly understand the communities they serve. I had many wonderful conversations with staff and community members, and I’ll be sharing a few stories here.
This is part four in a four-part series. See Hannah’s earlier Guatemala field reports here, here and here.
I arrived at the Manos Abiertas headquarters in the morning and was warmly greeted by Astrid, the Administrative Assistant I had been coordinating with via email before my visit. She welcomed me inside and closed the large metal door behind me. Like many buildings in Guatemala, the center featured a spacious terrace filled with greenery, small trees, and a garden, while office and patient rooms lined the exterior. We walked across the terrace and up the stairs into a charmingly decorated room, where four female staff members were waiting to meet me. We sat together and enjoyed coffee, fresh fruit, and pan dulce—Guatemalan sweet bread—brought from a local panadería (bakery).
Manos Abiertas (Asociación Manos Abiertas, or AMA) is a women-led, culturally sensitive midwifery-based health center in Guatemala, founded in 2008 to serve marginalized communities. Based in Ciudad Vieja, Sacatepéquez, it provides comprehensive reproductive health care—including prenatal, birthing, postpartum, and pediatric care, family planning services, cervical cancer screening, and STI testing and treatment—to help empower women with dignity and informed decision-making. Guided today by Executive Director Diana S. Freiwald, AMA employs and trains local midwives and nurses (many of whom are first-generation professionals), operating on a hybrid funding model of grants, donations, and scalable service fees to ensure access regardless of ability to pay. Diana explained, “We offer the full spectrum of sexual and reproductive health care, so women can come to us from before their first menstruation, and then later with their partners when they’re exploring options for family planning. They can come to us once they’re pregnant; they can have a baby with us; and they can continue to come in for basic care, including pap smears, all the way to menopause.”
The women were open and eager to talk about their experience working as midwives in Guatemala and for Manos Abiertas, and all expressed a sincere and deep passion for this work. “I love everything about working here, especially the births,” Miriam, a student midwife, told me after I asked her what her favorite part of the job was. “When I heard a baby crying for the first time, it made me feel happy. That’s when I knew I wanted to be part of this.”
Miriam went on to talk about the need for this type of work in Guatemala. “I’ve seen a big difference between what women experience giving birth here versus at a hospital,” she said.
“My sister experienced obstetric violence[1] at a hospital when she was giving birth to her son. When she got to the hospital, she asked for a female doctor, but was ignored. The [male] doctor she was assigned told her to wait in the waiting room, even though she felt like she didn’t have time to wait. She ended up having her baby in the waiting room. Because she was a woman, no one believed her. No one helped her.”
– Miriam, student midwife, Manos Abiertas
In Guatemala, gender inequality is deeply rooted in patriarchal cultural norms that limit women’s access to education, employment, and decision-making, especially within rural and Indigenous communities. Childbearing practices also reflect deep gender inequalities, as women—especially Indigenous and rural women—often face limited autonomy over reproductive choices, while wealthier urban women experience pressure in the private health system, where Cesarean sections (C-sections) are disproportionately promoted and performed. The women I spoke with at Manos worry that the medical industry in Guatemala often prioritizes profit and convenience over women’s best interests.
“The health system in Guatemala is not great,” Diana explained to me during a conversation about the health-related challenges and opportunities Guatemala faces. “People have to wait a long time, or they have to walk several hours to a health center without any guarantee that the doctor will be in that day or that they’ll be seen.” She explained that, often, there just aren’t enough resources—staff, supplies, equipment, and funding are generally limited. “So the situation isn’t simple—the quality isn’t great—and that’s also why maternal mortality is twice as high among Indigenous women as among the Ladino population in Guatemala.”
I spent some time talking with the midwives about how patriarchy and machismo (a cultural norm present throughout Latin America that emphasizes male dominance and traditional gender roles, often marginalizing women in social, economic, and family spheres) affect women across the country, particularly regarding childbearing. Many were acutely aware of the double standards and contradictions embedded in the societal expectations placed on women and girls, and they expressed their frustration with striking honesty. “Men, just for being men, feel superior. That is worldwide,” Miriam told me after I asked her about the state of gender equality in Guatemala. “Women belong to men.”
Miriam went on to say that in her country and in many others, “The man can have total control over what she wears, what she does, where she goes.” She noted that “this may be getting better in some places, but in rural places, men still have the power.”
According to Evelyn, a junior midwife with Manos Abiertas, when it comes to childbearing, “The presence of men is very strong.” She explained, “[Men] are often against family planning and birth control because they want kids. They believe that we should have as many children as God wants.” In a later conversation, Diana highlighted the lack of information and social pressures that shape family planning decisions, noting, “A lot of people choose their family planning method according to what their friend, sister, or other family member tells them.”
Guatemala’s fertility rate is among the highest in Latin America, at an average of 2.3 lifetime births per woman. According to my conversations with the midwives, in rural, Indigenous communities, among women with lower education levels and from lower-income households, the average is often as high as five or six children. Early marriage is also a challenge. According to UNICEF, nearly 30% of Guatemalan girls are married before the age of 18, which often ends their education, increases their economic dependence, and raises their risk of early pregnancy and maternal health complications. Guatemala has one of the highest adolescent fertility rates in the region.
“There are different reasons why girls are getting pregnant—either because they’re being abused, or because they don’t have access to family planning, so they don’t know that they can prevent unwanted pregnancies,” María, a senior midwife, explained. “When they have access to family planning,” she said, “they are able to have better physical and mental health and can become more stable economically.”
A few days later, I met with Diana in the colonial town of Antigua, and our many conversations helped me gain a deeper understanding of the scope and severity of health care challenges in Guatemala. “If you have resources, quality care is widely available,” she told me, noting that most of the population does not have such resources. “Patient-centered care, however, is not widely available—it’s not really a concept that has arrived here yet. As midwives, though, patient-centered care is just how we do it.”
“With birth care, it’s also extremely challenging—it’s not getting better, it’s getting worse,” Diana told me. “We used to have lower C-section rates, but now they’re extremely high—in public hospitals, C-section rates are around 60%, and in private hospitals it’s much more.” She explained that even when women are not pressured into having C-sections, natural births are rare. “They’re being medicated and often have violent experiences.” When I asked her why she thought these percentages were so high, she responded without hesitation: “Because health care is a business.”
Diana emphasized that these issues are both complex and systemic, a point she reiterated throughout our talks. “Women have been conditioned and trained from very early on that they are not entitled to opinions about their bodies. They’re not allowed to ask questions about their health. They’re not encouraged to learn about their bodies. So, what we do is we give the power of our bodies and our health and our autonomy to whatever male seems like the current authority—in this case, the doctors.”
In response, Manos Abiertas works to expand access to natural birthing methods, offering an alternative approach to childbirth that is rooted in compassion and holistic care. They also hope to see these practices become more widely accepted throughout the country. “It’s not like we’re paving the way here or anything,” Diana clarified. “Midwifery has been around for ages—in fact, I dare to say it was the first profession ever.” She further noted that Guatemala has a long history of traditional midwifery, but that the midwives at Manos Abiertas are not traditional midwives—they are autonomous midwives—a term she used to describe practitioners who integrate some traditional practices while adhering to internationally recognized midwifery standards.
Diana explained that although there are over 29,000 midwives in Guatemala, there is “absolutely no support” for them, nor much interest in integrating their work into existing health care structures in ways that respect their practice. “The more work we do, the more care we can provide and the more awareness we can create,” she concluded.
“In midwifery, we say, What got the baby in is what’s going to get the baby out,” Diana told me as we discussed the differences between natural and hospital births. “And that’s oxytocin, that’s love, that’s intimacy, that’s comfortable spaces, that is being able to move, and so on.”
She explained that hospital conditions are often the opposite: harsh and impersonal. Women are frequently alone in sterile rooms with bright lights, instructed to lie on their backs, and guided by people they barely know—with little opportunity to voice their needs or preferences.
“I’m a firm believer that the way you birth directly impacts not only how you mother your children but also how you mother yourself in the process afterwards.”
– Diana Freiwald, Executive Director, Manos Abiertas
Manos Abiertas recognizes that there are many ways to give birth, and that hospitals and mainstream health systems have a very important role in Guatemalan society. “What we’re trying to do is to ensure women have the option to choose their health care provider. That is where autonomy around health care starts.”
Diana and I spoke at length about these issues, and she opened my eyes to perspectives I, as someone who has not yet given birth, hadn’t previously given much thought. How does the environment shape the birthing process—not only physically, but also psychologically and spiritually? How essential is it to feel safe and comfortable during childbirth, and in what ways might certain conditions or practices hinder that experience? And perhaps most importantly, do mainstream approaches to childbirth—so deeply ingrained as cultural norms—truly provide the best and safest option for everyone?
“It’s a huge conversation,” Diana remarked as we began to wrap up our hours-long deep dive. “But that’s really a great segue into what midwifery is. We really try to see the world as an ecosystem that works together and is completely connected. We understand that the way we birth affects the way we grow up and how we interact with our environment.”
“This is why I love working with Population Connection,” Diana said. “It just clearly speaks to me that we are doing the right work; that you cannot separate what is happening to our world from what is happening to the individual person—the individual woman, everywhere.” I nodded in agreement, having always been proud of Population Connection’s integrated approach to working at the intersection of population dynamics, reproductive rights, and environmental sustainability.
Population Connection joins Manos Abiertas in recognizing family planning as a human right and a cornerstone for sustainable development, empowering individuals to make informed reproductive choices, improving health outcomes, increasing economic opportunities, and strengthening communities.
[1] Obstetric violence refers to the mistreatment or abuse of women and birthing people during pregnancy, childbirth, or the postpartum period, often occurring in medical settings. The term originated in Latin America, where several countries—including Venezuela and Mexico—have legally recognized obstetric violence as a form of gender-based violence. It involves a wide range of practices, including unnecessary medical interventions, denial of informed consent, verbal shaming, and physical abuse.
