| | |  Health & Beauty | September 2008 
Peru: Birthing Houses Combine Native Traditions, Modern Medicine
 Milagros Salazar - Inter Press Service
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| | Native women prefer to give birth at home. (Milagros Salazar/IPS) | | |
Puerto Ocopa, Peru - "Ashaninka women give birth at home, in accordance with tradition," declares José Ponce, the head of the health committee in Puerto Ocopa, a village of 253 Ashaninka indigenous families deep in the central Peruvian jungle.
But the Peruvian government is trying to convince indigenous women to give birth in medical facilities, in order to cut maternal and infant mortality rates.
Since 2004, it has attempted to achieve this goal through intercultural health care initiatives, with sexual and reproductive health programmes developed as part of the public health system but based on respect for indigenous cultural practices and traditions. One of the cornerstones of this effort is the creation of birthing facilities in rural areas.
These are simply constructed houses where women can go through labour and delivery accompanied by their husbands and children. In most cases, they are also accompanied by the midwife from their community. As a result, women are attended during delivery by people they trust as well as medical personnel, which reduces the risk of fatal complications.
There are now 390 of these birthing houses throughout the country. The ultimate goal is for every rural health centre to have a similar facility, so that all women can give birth surrounded by their loved ones yet still have access to the advantages of modern medicine. But there are still many obstacles to overcome before this becomes a reality.
A PROGRAMME IN THE MAKING
"Sometimes in the health centres they don’t know how to do things properly, and they let the baby swallow the (amniotic) fluid, and it dies within a month. That’s why when a baby is born you have to turn it over so it doesn’t drink the fluid," stresses Ponce, who speaks from the experience of having assisted his wife, Marina, during the births of their six children.
Marina nods in agreement. All of the pregnant women in her community prefer to have their babies at home, she says. Most of them give birth in a squatting position while their husbands hold them up by the arms, while others drive stakes into the ground to hold onto while pushing, she explained.
And all of them drink tea made from a native herb known as piri piri to prepare for labour. "With piri piri you give birth more quickly," says Marina.
In Puerto Ocopa, located in the province of Satipo, most families have between five and seven children, although some have as many as a dozen, explained the village head, Sergio Pasos.
But the birthing house in Puerto Ocopa is still under construction, and in all of Satipo there are only two of these facilities to serve dozens of villages.
"We have to make them understand that more institutional deliveries mean a reduced likelihood of death for the mothers and babies," stressed Lucy del Carpio, coordinator of the Health Ministry’s Reproductive Health Care Strategy. "That’s why this programme was created. In the past, out of 50 women who gave birth in rural areas, only 10 gave birth in a health centre. That was very troubling.
"The leading cause of death during childbirth is haemorrhaging, and if there isn’t a medical facility close by, the woman dies," she added.
Fernando Carbone, a former health minister and the director of a rural reproductive health project in the neighbouring region of Huancavelica, said that this initiative is a medium-term effort, because it also needs to encompass prenatal care, the use of medical charts to monitor pregnancies, and the identification of pregnant women in rural communities in order to plan for when and how they will be taken to a health centre.
It also includes family planning information, accompaniment by family members, and the support of health workers from the community, said Carbone.
Between 2000 and 2007, institutional deliveries in rural areas increased from 24 percent to 48 percent of all deliveries, according to official statistics.
But the strategy implemented since 2004 has yet to bring about a significant decrease in maternal mortality in Peru, which is estimated at 185 deaths for every 100,000 live births.
There were 596 maternal deaths recorded in 2005 and 513 in 2007, but this rate of decline was no greater than in previous years. Between 1997 and 2001, for example, the number of maternal deaths recorded dropped from 764 to 612.
CULTURE CLASHES
Of the 390 birthing houses in the country, only 76 are in the primarily indigenous communities of the Amazon region, which make up just over two percent of the total population, according to 1993 figures.
In the Andean highlands, greater progress has been made, particularly in the southern region of Cuzco. The 140 houses in this part of the country follow the traditional practice of "vertical delivery": the women give birth standing up, usually over animal skins to keep warm.
"The Amazon is the most difficult region, because the people there want something more outdoors, they don’t like to be shut inside," commented del Carpio.
The problem is "basically cultural," said Alfonso Nino Guerrero, a public health professor at Cayetano Heredia University. "You can’t simply replicate in the Amazon the same health care models used on the coast or in the highlands," he told IPS.
For the indigenous peoples of the Amazon, childbirth is an intimate, family-centred experience, "and not something that should be watched by strangers," he explained.
The "intercultural approach" adopted by the public health authorities is essentially geared to persuading communities to change their way of thinking, when in fact it is the services that should be adapted to the communities, he stressed.
Elisa Terreros, who heads up a programme on health care in the central Peruvian jungle at the non-governmental Amazon Centre of Anthropology and Practical Application, told IPS that "you get the feeling that the authorities are only providing this service to say they have done something, because in the majority of cases the population has not been consulted, and they don’t feel like these facilities are a part of their world."
For Terreros, who has visited almost all of the communities in the region as a nurse, "it’s important to strengthen the ties between the community and the state so that there can be a dialogue between Western and indigenous viewpoints."
DISTANT TOWNS
To break the ice, health care professionals visit villages to explain the benefits of the birthing houses with pamphlets written in indigenous languages, said del Carpio.
But the programme’s reach is still very limited. The region’s health centres do not have adequate transportation to or from isolated villages in the dense Amazon jungle. Travel is almost always by river, and boat trips can be costly.
In the attempt to establish the kind of dialogue recommended by Terreros, the most effective allies are health workers from the communities themselves, including midwives.
Luzmila Chirisente, president of the Regional Federation of Ashaninka, Nomatsiguenga and Caquinte Women, believes that "indigenous people face discrimination in health care services because the doctors don’t value them as people, and that is something they have to learn to do."
In all of Satipo, only the head doctor for the entire province has been trained in intercultural health care.
Giovanna Sandoval, the young doctor who heads up the health centre in Puerto Ocopa, told IPS about some of the difficulties she has faced in working with indigenous communities. "They only come when they’re in really serious condition. You have to go out and look for them, and they get mad when you give them some sort of treatment. They also don’t like you to touch them."
Was she adequately prepared for the challenge? "Before you come to a place like this, they give you some prior training through seminars. They talk to you about the native population, but the people who give the training hardly know anything about the communities, and they just speak in general terms and about tropical diseases that are common in the jungle. So when you get here, you come up against things that can seem kind of shocking," said Sandoval.
"But things are moving ahead. They are learning a lot from us about nutrition, and are starting to eat vegetables and legumes. They’ve learned how to make bean puree, which is really good for children," she said.
LIMITED RESOURCES
Professor Nino Guerrero noted that most health centres in rural areas are run by poorly qualified technical staff due to scant resources and incentives. "The project has helped draw people into the public health system, but it isn’t a formal strategy because it isn’t backed by state health spending and doesn’t form part of the health care system," he added.
Del Carpio acknowledges this shortcoming. This year for the first time ever the central government allocated 218 million soles (around 73 million dollars) to her sector. Until now it was fully funded by international donors and provincial and local governments.
The real challenge is to make this system "a genuine priority for the government," with a fixed budgetary allocation and more staff, she stressed. The sector she directs has dropped from a staff of 45 to just four, who are responsible for supervising five national programmes, including the intercultural maternal care programme.
"Sometimes they tell me you can’t cut the number of maternal deaths without understanding that when cultural reasons are involved, this is a process that takes time," she noted.
For Guerrero, the key is to promote trust, for example, by striving to ensure that pregnant women are treated by female doctors, and that health care professionals working in the region remain for a long enough time to forge social and personal ties with the local communities. |
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