Understanding Peruvian Progress Fighting Maternal Mortality

Co-authored with Gustav Cappaert at Latin Correspondent.

Even though most maternal deaths are preventable, every day 800 women across the globe die due to complications during pregnancy and childbirth.

Peru is one of only two South American countries expected to hit its maternal mortality Millennium Development Goal, one of a set of UN-backed global poverty reduction targets that culminate in 2015. Peru today has a ratio of 67 maternal deaths per 100,000 live births, down from 265 in 1990.

The Andean nation remains behind industrialized countries like Japan (with a rate of six) but way ahead of the world’s least developed nations: in Sierra Leone, which has a maternal mortality rate of 1,100.

Help for expectant mothers

“The principal problem Peru has had is access to maternal health services,” said Mario Tavera, Health Specialist for UNICEF Peru. “Global evidence demonstrates that the reduction of maternal mortality is associated with medically-attended birth in health care centers,” he said.

Peru has made strides on this front, 80 percent of women now give birth at a medical facility, compared to just one quarter in the early 1990s. Over 90 percent attend prenatal care visits.

According to Tavera, Peru has more than doubled the number of state-run health facilities in operation, greatly increasing access to care. Some clinics operate associated casas maternas which allow women who live in remote areas to stay for up to a week as they wait to give birth.

But perhaps the most important change has taken place inside of clinics. “There’s a set of very distinct customs” in rural Peruvian communities, Tavera said. “The people were permitted to bring into the clinic customs from giving birth in their homes.” Family members were allowed into the birthing room for the first time; women were allowed to give birth sitting or on their knees; they could bring a rope to hold onto — another traditional custom.

There are wrinkles in this success story, though.

One-size-fits all?

Creating a one-size-fits-all policy is uniquely difficult in Peru. Its three major regions: coastal desert, mountainous center, and Amazon jungle each demand a different approach dictated by culture and geography.

On the traditionally wealthy coast, the average maternal mortality ratio was 56.4 between 2007 and 2011. In the poorer highland and jungle regions it was considerably higher, at 152 and 137 respectively.

“Peru is one of the most unequal countries in Latin America…Parts of Peru have European levels of mortality, other parts have African levels,” said Tavera.

In the mountains, a long history of discrimination against the majority indigenous population makes some women reluctant to visit government health posts. For one, health care providers rarely speak Quechua, the native language in most of highland Peru.

“Those that speak Spanish ignore us, those of us from the town, from the communities that come down. They humiliate us sometimes or don’t treat us well,” said Teresa Echame Vargas, a health promoter in the rural community of Huilloc.

Home births

Perhaps not surprisingly, home birth is more common in rural areas. Although official policy is to support traditional birthing methods and attend home births if possible – a practice supported by medical evidence – in reality it depends on the clinic. “We would like the health posts to attend at home, but they say they can’t,” said Vargas.

Fueling claims of discrimination is the illegal but common practice of imposing fines on women who chose to give birth at home.

Keri Baker, the executive director of the health promotion organization Ayni Wasi, recalled a patient who suffered complications during a home birth, “She hadn’t expelled her placenta all the way which can cause hemorrhaging. We saw her at that point, and she hadn’t sought medical care because of the fact that she had given birth in her home.”

A 2009 survey of women in the coastal community of Huaycan – the majority of whom had migrated from the highlands – found that 46.5 percent of women who elected home birth did so because they’d had a bad experience on a previous hospital visit or knew someone who had. A majority of women in a similar study in 2005 cited discrimination and a feeling of violation by health care providers as reasons to give birth at home.

In a jungle region like Madre de Dios, in Peru’s southeast, communities’ distance to health facilities makes professional attention a challenge. The Spanish-speaking population is transient – attracted by the lucrative business of illegal mining. Women that live in mining camps rarely make the river trip to attend prenatal visits, said Nelva Miraya, the government’s Coordinator for Community Strategy and Reproductive Health for the region.

Indigenous challenge

The area’s far-flung indigenous population of 60,000 is another challenge. Communities in Madre de Dios speak 12 different languages, and live in settlements up to three days away from the nearest hospital. The lack of government presence in these areas raises the possibility that deaths go unreported.

“(Until recently), in the entire region of La Salvación, there was only one obstetrician. She was the only one to intervene in native communities that are two, three, four days away by boat,” said a nurse in Madre de Dios’ capital of Puerto Maldonado.

Although recent progress on maternal mortality is encouraging, Mario Tavera of UNICEF warned about diminishing returns. “(Peru is) starting from a very high rate,” he said. “A country like Chile had 30 (maternal deaths per 100,000 live births). Getting to seven is more difficult.”

China Figures Out Cultural Hegemony

From Slavoj Žižek’s Living in the End Times:

Over the last few years, the Chinese have changed their strategy in Tibet, increasingly relying more on ethnic and economic colonization than on military coercion, rapidly transforming Lhasa into a Chinese version of the capitalist Wild West with karaoke bars and Disney-like “Buddhist theme parks” for Western tourists. In short, what the media image of brutal Chinese soldiers terrorizing Buddhist monks conceals is the much more effective American-style socio-economic transformation: within a decade or two, Tibetans will be reduced to the same status as that of Native Americans in the United States. It seems that the Chinese Communists have finally learnt the lesson: what is the oppressive power of secret police, prison camps, and Red Guards destroying ancient monuments, compared to the power of unbridled capitalism to undermine all traditional social relations?

This is super related to my earlier point about language regulation in Québec, though at the moment I’m not sure exactly how.

En Français, S’il Vous Plait

I spent this weekend in Montréal, where the provincial government mandates—with some exceptions—that all signage be primarily in French. English or other translations are allowed, but must be in a smaller font than the French text.

On the face of it, the law seems to dramatically limit how people and businesses can publicly express themselves. I imagine that many in the United States would consider the rule an unacceptable violation of free speech rights.

But there are pitfalls to evaluating cultural and language policy solely on whether citizens are free from restriction.

I think back to my time in Cuba, where the government has wide-ranging control over most forms of mass media. When asked why, I heard one former government official answer: “If we didn’t, then the largest newspaper in the country would be the one that is funded by the United States.” Similarly, Québec’s rules are meant to protect the province’s French culture and identity in an overwhelmingly anglophone country.

The lesson is that speech reflects not just freedom but also power. In the same way that an unregulated market is advantageous to those with the most economic power (who are the ones always pushing for less regulation?), a totally unregulated cultural scene benefits the most culturally powerful.

That’s not to say that Québec’s way is necessarily the best way, but we should be careful about dismissing the policy simply because it attempts to regulate expression.

Photo: Montréal metro.