By Kathleen Richter
In spite of the Millennium Development Goals and over fifteen years of foreign aid involvement in Bolivia, the maternal mortality rate (MMR) remains high. Unequal income distribution alone cannot account for this high rate, as neighboring countries with similar GINI coefficients have much lower MMRs. Understanding that poverty is not just about income, but about a variety of capability deprivations, EngenderHealth has been working with Bolivian communities to empower local communities with knowledge and availability of reproductive health services. This paper will examine contributors to the high MMR and the policies EngenderHealth has been doing to combat them. It will also offer criticism of current USAID strategies, as well as policy recommendations to improve them.
Statement of Issue:
The maternal mortality rate (MMR) in Bolivia is one of the higher rates in Latin America, at 229 per 100,000 live births1. Though this is already a high number, it becomes more shocking when disaggregated in terms of rural and urban MMR: According to Womankind Worldwide, the ratio for Rural Bolivia is 602 out of 100,0002. What makes this number more tragic is that it is unnecessarily high, as “most deaths related to pregnancy and childbirth in developing countries can be prevented through appropriate use of health services”3. An additional factor illustrating the avoidable nature of Bolivia’s high MMR is the apparent disconnect between a nation’s financial wellness and MMR: Paraguay4 , one of Bolivia’s neighbors with a comparable GINI coefficient and GDP per capita, has about half the value of Bolivia’s official MMR, at only 150 per 100,000 live births5. Thus, Bolivia’s high MMR must not be written off as an acceptable consequence of poverty, but must be alleviated through improved policy both at the national and international level. This paper will examine the historical and socio-political sources of Bolivia’s high MMR, examples of what EngenderHealth has been doing to alleviate the problem, an evaluation of USAID and EngenderHealth policies and practices in effect meant to challenge the MMR, and will recommend policy prescriptions to further abate the problem. This paper will make the observation that although the current policies have an emphasis on local empowerment, they only encourage it as much as it entails still receiving health care from others instead of being enabled to become health providers themselves, and conclude with policy recommendations advancing the case for empowering indigenous Bolivians by training some of them to be professional, monitored midwives.
History of Problem:
While various nations have demonstrated that material poverty and maternal mortality need not be connected, the capability deprivation associated with poverty does carry a substantial effect. One aspect of capability deprivation that plays a part in Bolivia’s high MMR is the deprivation of education: in 2003, the rural female illiteracy rate was 37.9 percent—while rural male illiteracy stood at 14.4 percent, and urban female illiteracy stood at 10.0%6. As much medical knowledge is conveyed to students through printed form, the high illiteracy of rural women presents a difficulty to transferring information about reproductive health. The problem of illiteracy is further compounded through the unavailability of medical or training texts published in either Quechua or Aymara7 , two prominent languages amongst rural Bolivians. In USAID reports, for example, training materials to improve equity between socio-cultural and gender groups are printed in Spanish and English, but not in Quechua8. This language barrier also makes communication difficult between doctors and patients, as most doctors are well-versed in Spanish, but may not speak Quechua or Aymara—and vice versa. This difference in literacy rates speaks to another issue: the urban-rural bias. Bolivia has had a long history of discrimination based on ethnic and class differences9; the prevalent assumption that rural, indigenous people are somehow less important and less deserving of respect than urban mestizos has had various effects.
Firstly, the urban-rural bias has meant that most hospitals with essential pre- and post-natal care units are located primarily in cities, far away from the rural poor making it difficult for them to get access to both skilled health attendants and the equipment necessary for skilled delivery, such as specific drugs and medical tools10. In spite of the lack of adequate health care services—or perhaps as part of a correlated relation—fertility rates in the rural poor is high, at 6.411. According to Paulson, the high fertility rate reflects the feeling of powerlessness amongst Bolivia’s rural women, who in light of their lack of opportunities in all other fields, “see sexual service and maternity as principal forms of social recognition and power,”12 and are thus inclined to have more children. Notwithstanding, the higher fertility rates compounded with less access to proper pre- and post-natal health care have led to higher mortality rates amongst Bolivia’s rural women. In addition to the geographical barrier, the urban-rural bias plays a part in the discrimination rural women face at the hands of doctors. Bolivia is 95 per cent Roman Catholic13, and with the prevalence of this religion “the idea that the pains of labour [sic] and birth are a form of retribution for women’s enjoyment or knowledge of sex”14 is widely believed and acted upon by doctors. During labor, doctors have been known to berate women who express pain during labor, and as a result, many women are afraid to visit doctors when they are pregnant or in labor15. Doctors’ abuse, already terrible for urban women, has often been worse for rural women. During her fieldwork in Bolivia, Bradby found out that at the time of birth, it was a fairly common practice in public hospitals to allow doctors and all their medical students to stare at the pregnant woman’s vagina, and for each of them to stick their hand in—not gently—to the point that many women could not walk afterwards on account of the pain, as well as had the distinct impression that they had been sexually taken advantage of16. On account of these stories, rural women have often avoided going to the hospital for fear of such treatment17.
Another barrier to the reduction of MMR is the inaccessibility of contraception and safe, legal abortions. While contraception is not illegal, only 31 percent18 of Bolivian women have access to it, leading both to higher fertility rates and higher unwanted pregnancies. Additionally, although abortions in the cases of rape, incest, danger to the woman’s health or life, and abduction without marriage have been legal since 1973, very few women—six—have been able to get a safe, legal abortion19. One needs a judicial order to end a pregnancy, but judges and other public officials strategically delay the processes and deny legal abortions20 —even when the rape victims are as young as ten years old, which, since “underage girls are the victims of over half of all cases of rape”21 in Bolivia, occurs with unsettling frequency. Even in the case that a woman received permission from the court, many doctors refuse to perform abortions on moral grounds22. This inaccessibility of abortion forces women to get illegal abortions, which are far more dangerous than legal ones. Post-abortion care is also difficult to obtain, since public hospitals have routinely interrogated women seeking post-abortion treatment23, and have charged higher prices to women who look as though they had an induced abortion rather than an accidental miscarriage24. The inaccessibility of post-abortion care has a high price: approximately 30 percent of maternal deaths result from complications from illegal abortions25.
In light of these obstacles, we at EngenderHealth have been working in Bolivia for over twenty years, instituting programs to improve the availability and quality of reproductive health services26. In light of the high rate of mothers dying from complications due to abortions, EngenderHealth has made it a priority to reduce the number of unplanned pregnancies, through improved access to and quality of contraceptive services27. In addition to expanding contraception, EngenderHealth has been working to improve maternal safety through ensuring availability of emergency obstetric care, making sure referral networks function, and training doctors and midwives to provide better-quality post-abortion care28. To combat the Bolivian “machismo” that places an unfair burden on women in the process of childbearing, EngenderHealth started the Men As Partners® (MAP) Program, which challenges gender norms through working “with men to play constructive roles in promoting gender equity and health29.” We achieve this goal through hosting interactive workshops that address the “masculine” and “feminine” stereotypes, and how holding these stereotypes can have a negative impact on the community, as well as reaching out to men to provide them with information and care in reproductive health30. In light of the fact that many women face discrimination, mistreatment and sometimes abuse from doctors, EngenderHealth has been promoting better quality health treatment through its COPE® program31, which stands for “client-oriented, provider-efficient” health care services. This program ensures high-quality services through requiring staff members to take a self-assessment guide, based on international health standards, to get a better idea of how the care they provide matches up with international standards; providing staff with client interviews, so that they are much better equipped to understand their client’s point of view; and committees that help assess the perceived gaps between international standards of health care and the quality of care provided by on-site staff, then develop an action plan to offset the differences32.
Critique of Existing Policies
Before criticizing the procedures already in effect to reduce Bolivia’s MMR, it is important to point note that they have met with a certain amount of success: In a span of 15 years, the MMR in Bolivia has reduced by 55.4 per cent, from 650 per 100,000 in 1990 to 290 per 100,000 in 200533. As this number is still too high and does not take into account differences amongst regions and socioeconomic groups, it is necessary to point a critical lens at the policies that are not working well enough.
As part of its 2008 response to maternal mortality goals and fiscal appropriations, USAID reported that it was “helping to improve the institutional capacity of two private sector institutions: PROSALUD, the largest network of private health service providers in the country, which provides over 500,000 consultations nationwide per year; and CIES, with nine centers across the country, which specializes in reproductive and maternal and child health34.” Because private hospitals have historically shown better care, both in terms of medical skill and respect towards their patients35, aiding these private hospitals represents a much better choice than aiding the public ones. However, with provision of aid to these private hospitals, two blockades arise towards the improvement of maternal survival: cost and accessibility. Because the institutions carry the “private” label, patients still have to pay in order to use the facilities, a cost which may be too expensive for Bolivian rural poor. Even if there were mechanisms to grant poor Bolivians discounts or subsidies on health care, 32.7 percent36 of Bolivian women do not have official documents—a fact which could seriously hamper their ability to collect government payoffs. In addition to the cost factor, there is also the accessibility problem: most of the private hospitals are still located in urban settings37, which are difficult for rural Bolivians to reach both in emergency situations and for routine check-ups—even in the USAID report it is mentioned that its “Programs reach people in peri-urban or urban areas in all nine of Bolivia’s departments and in the rural areas of four departments38.” Thus, while investing in private medical institutions has helped reduce the maternal mortality rate to a certain extent, it has largely done so without targeting the group that is most in need of attention: Bolivian rural women. Although USAID has proclaimed an interest in promoting decentralized, socially inclusive, community-based health programs that address the needs of the poor through empowering them and providing them with services, current policies seem to fall short of these claims in one respect: none of the policies in place allow for including rural Bolivian women into taking maternal health into their own hands through a medical profession. In Bolivia there already exists a culture of rural midwifery—known as partera39—which USAID should tap into to reach the Millennium Development goals. Because rural midwives already come from the rural area, they will not form part of the group of health professionals that discriminate and use harsh or unfair treatment against rural Bolivians. In addition, rural midwives already speak the local language, so communication between health provider and client would become much easier and smoother. Because the midwives would come from the culture of the rural poor, they would have a higher sensitivity to the cultural taboos and norms than urban-dwelling doctors might, and therefore practice giving birth in a more culturally sensitive way. Encouraging midwives, as they are, to continue doing their work is not enough, however, as Liljestrand notes that “There is no evidence that minimally trained community workers or traditional birth attendants can reduce MMR to below 100.40” What is needed in order to help this group become more efficient in helping their communities is a government-assisted intensive training program. Similar programs have been implemented elsewhere, such as in Sri Lanka and Malaysia41, and have met with great success. The training program to professionalize midwives should last 18-24 months, should focus on clinical skills, such as suturing, stopping bleeding, diagnosing, and treating infections42. Especially in the case of Bolivia, this training should also include obtaining the skills to administer Emergency Obstetric Care, which includes training with “parenteral antibiotics, uterotonics, and anticonvulsants; assisted vaginal delivery (vacuum extraction e.g.); treatment of incomplete abortion; and manual removal of retained placenta” 43. In addition to training midwives in these capacities, there should also be structures set in place to do the following: create regulations to control practices of midwives, as well as grant certified midwives the so-called “stamp-of-approval” which can be useful for asserting qualification to obstetricians and referral hospitals; ensure that systems to provide supervision to midwives function in the best interest of the clients; and provide support to midwives in emergencies and referrals44.
Because Bolivia’s MMR is still so high, even after over 15 years of foreign involvement, because the blockages to improving maternal survival reflect a larger system of discrimination and subjugation, and because there are simple ways to improve maternal survival, it is crucial that more attention and effort be allocated to reduce Bolivia’s MMR. The policy recommendation of bringing local, rural women into the practice of professionalized midwifery is not a far call from current USAID strategies—since USAID claims to “support the Bolivian government’s efforts to decentralize health services to reach underserved populations and promote a public health model based on community, family, and intercultural health”45, one may see the inclusion of rural midwives into the health care apparatus as an extension of USAID policies. In a larger framework, USAID policies, EngenderHealth policies, and the policy prescription recommended in this paper have largely been informed by Amartya Sen’s conception of development as freedom. In allowing rural Bolivians freedoms in their own health care decisions—whether this be through providing information on proper nutrition during pregnancy, releasing pressure on mothers through training men to cast away misogynist preconceptions, encouraging dialogue between client and patient, or encouraging them to become trained in skilled birth attendance—MMR reduction programs in Bolivia allow rural Bolivians to help themselves be active participants in the reduction of the high MMR in their country. Thus, because the policy recommended in this paper builds upon the same principles as the USAID policies, USAID should work to address the problem of Bolivia’s high MMR through the lens of encouraging the training of professionalized, methodological midwives.
Photo courtesy of Dennis Jarvis