Thanks for your response. That is interesting that the Guatemalan government explicitly applied the socioecological model to the process outcome of facility-based births - which I assume they knew was on the pathway to poor birth outcomes for indigenous communities? It sounds like their approach made efforts to be responsive to the context and needs of the population, which is clearly not always the case in interventions on women's reproductive health, where the outcome can take precedence over whether the process is respectful and grounded in human rights. I definitely agree with that thinking about how the dynamics of interpersonal care plays out on the ground is important, as the intentions of policy makers can sometimes be lost in translation on the ground (and vice versa). I am also wondering if they took into account issues such as transportation and child care for families when women were giving birth?
Your structural and intermediate factors are well described. I am also wondering about the role that the historical context has more broadly - e.g. not just about the history of mistreatment in health care system, but more broad based issues related to discrimination, gender-based violence, and violence targeting indigenous communities leading to mistrust of the government.