They are children too: Adolescent mothers and the “1,000 Days” nutrition movement in Guatemala

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David Flood
David Flood, MD, MSc, is a physician with the Guatemalan NGO Wuqu' Kawoq | Maya Health Alliance and resident in Medicine-Pediatrics at the University of Minnesota. He received his medical degree from Harvard Medical School and an MSc in international health policy from the London School of Economics.
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A young mother in rural Guatemala. (Photo from Watsi.org)

I first met Carolina on a crisp, sunny morning in April 2014. A young Maya indigenous mother, she had been referred to my organization’s clinic in rural Guatemala when her one-year-old infant son was found to be severely malnourished at a routine health center screening. At the time, I was coordinating a nutrition program in Carolina’s community that focused on improving child growth during the “1,000 days window” from an infant’s conception to his or her second birthday.

On this day, with a handful of other mothers, Carolina sat on a long red bench outside of the clinic room before her appointment with our nutrition team. Petite and dressed in a colorful Maya blouse and skirt, she carried her baby on her back in the traditional style tucked in a tightly wrapped bundle of weavings.

When it was Carolina’s turn for her appointment, one of my Maya colleagues who lives in the area and always has her finger on the pulse of the community, summoned me to a corner of the clinic room. “This mother,” she whispered into my ear, “gave birth because of a violación.” Carolina had been raped at age 13, and, now, two years later, she was pregnant for a second time.

We proceeded to enroll her son, Gonzalo, in our nutrition program. I referred Carolina to our women’s health coordinator, but, in the months that followed, I subsequently lost track of her.

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“When a fifteen-year-old [girl] comes to a health clinic with her infant… It is easy and comfortable for healthcare staff in attendance to pay attention to the infant without also recognizing that the mother herself is also a child worthy of special and individualized protection.” (Photo from Watsi.org)

Carolina’s story weighed heavily on my mind when I read Alejandra Colom’s recent analysis of adolescent reproductive rights and nutrition policy in Guatemala. Colom is an anthropologist, activist, and Senior Program Director for the Population Council, an NGO that operates programs promoting reproductive rights and leadership skills for rural adolescent girls in Guatemala. Her writing can be found in a recently released chapter in the edited book Privatization and the New Medical Pluralism: Shifting Healthcare Landscapes in Maya Guatemala.

“When a fifteen-year-old [girl] comes to a health clinic with her infant,” Colom writes, “It is easy and comfortable for healthcare staff in attendance to pay attention to the infant without also recognizing that the mother herself is also a child worthy of special and individualized protection… The current [“1,000 days” nutrition] framework… improves the health of children through the erasure of women. In the case of adolescent mothers, this means erasing one child in favor of another.”

I am a pediatrician-in-training at a large medical center in the United States. I have devoted my life to caring for children of all ages. However, reflecting on Colom’s analysis, I realize that, to a degree, I have also committed the error of muting the suffering of young adolescent girls like Carolina in my effort to build and sustain a high-quality nutrition program for young infants.

This same problem permeates nutrition policy in Guatemala where an enormous emphasis has been made been made in recent years by the government, NGOs, and civil society at large to reduce the country’s extremely high burden of chronic child malnutrition.

In 2010, Guatemala became the fourth nation to join the “Scaling Up Nutrition” (SUN) campaign, which is a global consortium aiming to reduce global child malnutrition and undernutrition by emphasizing evidence-based interventions during the “1,000 days” window between pregnancy and a child’s second birthday. The SUN platform, which was propelled forward by endorsements from Hillary Clinton and Ban Ki Moon, was heavily influenced by the first Lancet Series on Maternal and Child Undernutrition published in 2008.

From the beginning, the SUN and “1,000 Days” shared framework has advocated that countries take ownership of nutrition policy with the view that they are best suited to scale-up cost-effective interventions to their populations. In Guatemala, data has suggested that poor children have the very highest rate of chronic child malnutrition in the entire world, and much of the foundational scientific research supporting the “1,000 days” concept was derived from studies in Guatemala. In this manner, Guatemala was exactly the type of country it had been hoped would join the SUN movement.

“Once a girl or woman enters a 1,000 days program in Guatemala—either by becoming pregnant or having a child—it doesn’t matter if she is fifteen or twenty-five,” Colom tells me in an interview. “They are treated as mothers or mothers-to-be. Their needs as adolescents, and their stories about how and why they became pregnant, are never asked.” (Photo from Katie Moore)

“Once a girl or woman enters a 1,000 days program in Guatemala—either by becoming pregnant or having a child—it doesn’t matter if she is fifteen or twenty-five. They are treated as mothers or mothers-to-be. Their needs as adolescents, and their stories about how and why they became pregnant, are never asked.” (Photo from Katie Moore)

In 2012, then-President Otto Pérez Molina further solidified young child nutrition as a national priority with the release of his Zero Hunger Plan (Pacto Hambre Zero), which was directly derived from the core principles advocated in the SUN global campaign. Persuaded in part by arguments that child stunting hinders economic growth, conservative business and corporate elites have also enthusiastically embraced “1,000 days” concepts. And the Zero Hunger Plan is here to stay; in recent days, President-elect Jimmy Morales has pledged to continue to fund “1,000 days” programs through his presidency from 2016-2020.

Despite the lofty language and stylish graphic design of its promotional materials, the Zero Hunger Plan as implemented on the ground in rural communities has consisted of the same interventions that previously have been utilized for years—distribution of micronutrient powders and tablets, deworming, provision of supplementary fortified flour blends, growth monitoring, and maternal “education” usually consisting of admonishments to extremely poor mothers that they breastfeed more and give children more expensive food. In addition, a cadre of rural nutrition workers has been retained to conduct case finding and collect data for severely malnourished children, but they have limited power, resources, and capacity to refer sick children to higher levels of care.

Colom understands the salience of addressing child stunting in her country, but she argues that the deployment of “1,000 days” concepts from the global discourse into local programs has had the destructive consequence of ignoring—and even worse, normalizing—the suffering of adolescent girls.

“Once a girl or woman enters a 1,000 days program in Guatemala—either by becoming pregnant or having a child—it doesn’t matter if she is fifteen or twenty-five,” Colom tells me in an interview. “They are treated as mothers or mothers-to-be. Their needs as adolescents, and their stories about how and why they became pregnant, are never asked.”

Colom continues, “Not only do we miss this opportunity to protect their rights, but we become accomplices in the perpetuation of constant violence against vulnerable young girls.”

The legal age of marriage in Guatemala has recently been raised from 14 to 18, but Colom doesn’t see this changing the practices she’s observed on the ground. “Although there is technically a legal mandate to investigate cases of adolescent pregnancies and rape, in practice, what happens?” Colom asks me. “Young rural girls as young thirteen or fourteen come to the public health center newly pregnant, are scolded and demeaned for ‘not taking care of themselves,’ and are sent back home with vitamins.”

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The same government that only thirty years ago explicitly targeted women in a campaign of genocide against Maya indigenous populations now, out of ostensible concern for Maya children, makes demands of Maya mothers and their bodies through the implementation of ‘1,000 days’ nutrition programs. (Photo via Watsi.org)

Worldwide, the gaze of the “1,000 days” initiative is fixed on the child. “Mothers… share a universal ambition: good education for their children,” writes a correspondent from The Atlantic in an article summarizing the historical trajectory and zeitgeist of the movement.

This child-centric view has the tendency to forget that women can have ambitions beyond their role as mothers. Moreover, as Colom shows in Guatemala, it omits the fact that mothers themselves can be children. Indeed, mothers are commonly children in Guatemala: A fifth of all children in Guatemala are born to mothers between 10-19 years of age; of the one million rural adolescent girls, one-third are pregnant or have a child; and the national fertility rate for teenage girls, already the highest in Latin America, actually has risen in recent years.

“Being an indigenous girl in Guatemala is not an easy task,” relays Gilda, a fourteen year-old Maya girl, in an interview with the BBC. “The fact that we are discriminated [against], the fact we do not have education, we do not have health[care], opportunities, really makes us fight every single day of our lives to get respected.”

Colom compares the progress made in favor of infant and child health in Guatemala—as exemplified by broad investments in “1,000 days” nutrition programs—with the minimal advances made in the area of adolescent rights.

“Some progressive peers in Guatemala don’t understand my view,” Colom tells me. “They say, ‘There’s nothing wrong with making sure that girls and young women look after their children so that they’re not malnourished.’ I agree; there isn’t anything intrinsically wrong with that. But every single message in ‘1,000 days’ programs  tells these girls, many of whom have been assaulted and raped: ‘The only thing valuable about you is your pregnancy and your baby.”

The stakes are particularly high in Guatemala that health programs—especially programs implemented by the government—protect girls and women. During Guatemala’s 36-year civil war (1960-1996), which peaked in the early 1980s, rape, torture, and indescribable violence directed at Maya girls and women was an institutionalized war strategy of the army. And violence against women has remained at “epidemic levels” even after the war formally ended. “Femicide as the socially tolerated murder of women in Guatemala relies on the presence of systemic impunity, historically rooted gender inequalities, and the pervasive normalization of violence as a social relation,” write one pair of scholars.

Colom tells me of her experiences discussing with Maya adolescents the history of violence against Guatemalan women in workshops. She says, “I was expecting that some of the most vicious crimes from the 1980s—taking babies out of wombs, for example—would be on the list of things that don’t happen anymore. But these girls and young women conclude that every single form of violence against women is still replicated today in Guatemala in one way or another. There may not be a soldier pulling a baby out of your womb, but if your husband comes back drunk, beats you, and provokes a miscarriage, it’s exactly the same because no one will protect you.”

In short, the Zero Hunger Plan is being deployed in an extremely fraught cultural and historical context in Guatemala. The same government that only thirty years ago explicitly targeted women in a campaign of genocide against Maya indigenous populations now, out of ostensible concern for Maya children, makes demands of Maya mothers and their bodies through the implementation of “1,000 days” nutrition programs.

“Child malnutrition is a worthy cause,” Colom concludes. “I just think that the framing of the ‘1,000 Days’ needs to change in Guatemala. If you focus only on children under two years of age, you are condoning the fact that many of the young mothers girls who arrive to your clinic are themselves children. We must consider the rights of these vulnerable girls and not only the rights of their infants.”

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“Child malnutrition is a worthy cause,” Colom concludes. “I just think that the framing of the ‘1,000 Days’ needs to change in Guatemala.” (Photo via Watsi.org)

Thinking of Carolina, I ask my Guatemalan friends who work in in her rural village what her life is like these days. They report that she is now 17 years old and married. Her husband, Juan, is a young man who is also the father of her second child, a beautiful baby boy.

I think about how, before her 18th birthday, Carolina has been raped, has married, and now has given birth to two children. Viewed by her government and civil society primarily as a tool to deliver nutrition interventions to her children, Carolina is still a child herself.

Carolina and Juan live together with his parents in a cinderblock home with a tin roof on the edge of town. By all accounts, they get along well. Carolina spends her days taking care of her baby boys, helping Juan’s mother around the house, and weaving Maya textiles to sell at local markets. Juan is not the person who raped and impregnated her; indeed, Carolina’s family has never revealed the identity of this man, and no public charges or denunciations were ever made.

My community contacts tell me that they see Carolina in the clinic and around town. “She looks tranquil,” they tell me. “We think things have gotten better for her.”

Perhaps this is true. I hope it is.

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