This research examines recent trends in Guatemala’s regional fertility. Guatemala is characterized by the highest total fertility rate (TFR) in Central America and the second highest rate in Latin America. The poorest quintile of the population has a TFR exceeding 7 births per woman as compared to 2.9 births per woman for the wealthiest. Moreover, Guatemala has one of the lowest contraceptive prevalence rates in Central America. However, recent country-level declines in fertility rates and rising contraceptive use have resulted in guarded optimism among policy and health professionals about the future of family planning in the country. These positive changes in overall TFR at the country-level, however, belie high and sometimes increasing regional TFRs. Using data from the 1987, 1995, and 1998/99 Demographic and Health Surveys (DHS) and data from the 2002 Reproductive Health Survey, this research aims to explore regional fertility differentials over time. The results of the analysis highlight the impact of social, political, and cultural differences on regional fertility levels. Also, by evaluating macro-level fertility trends within the context of regional attributes, this research provides information crucial for informing fertility and family planning policies at the regional level.