¡Back in Bolivia!

Dear Family, Friends, Professors, and Interested Strangers,

Welcome back to my blog! As many of you know, I have returned to Bolivia for a year to work on a maternal health care project with the support of a Compton Mentor Fellowship. I hope to keep you all updated on the progress of our project throughout the year, as well as my other adventures and musings on life in Bolivia. I hope you enjoy it and don't forget to leave comments! :)

So what exactly am I doing here? At its core, the goal of my project is to increase indigenous Quechua women's access to and satisfaction with maternal health care services in the Valle Alto of Cochabamba. We plan to do this by promoting an Intercultural model of hospital care that increases women's autonomy in the birthing process, valorizes traditional Quechua practices, and minimizes medical intervention in low-risk births.

Note: For those of you who want all the background info, read on. For those of you who've heard me talk about this a million times, feel free to skip to "Casa Materna Punata"

Background Info: Maternal Mortality and Sociocultural Barriers to Care:
So why is this necessary? Bolivia suffers from the highest rate of maternal mortality in Latin America: in the year 2000, an estimated 290 women died in childbirth for every 100,000 live births. There are a lot of reasons for this. For Bolivia's rural, indigenous majority, financial, geographic and sociocultural barriers restrict access to public health services. The health ministry has made many efforts to remedy this by building physical infrastructure to serve remote areas and providing free health insurance for pregnant women and children under age five. However, use of these services remains low. For example, in 2003, only 30% of births in the country’s rural areas took place in health care centers or hospitals.
While the geographic and financial barriers to maternal care have been addressed to an extent, cultural and social barriers remain a serious obstacle. Birth is a sacred event for the Quechua people of the Andean highlands, as evidenced by the wealth of rituals, beliefs, and customs that surround it. But for many Quechua women, giving birth in a hospital setting can be a traumatic and humiliating experience. Traditionally, women give birth in the home, surrounded by their family members. They often undergo labor fully clothed and in a squatting or kneeling position, which with gravity and the woman’s natural body movements, proves to be physiologically beneficial for both the mother and the infant. The husband may rub his wife's back, support her, and give her herbal teas to speed the labor. Dark colored blankets cover the floor and the room is dimly lit because strong light is believed to damage the baby's eyes. After the birth, the placenta is buried in the family’s patio with small gifts and food to ensure the future prosperity of the child. Family members perform a symbolic ritual burnt offering called the Q'oa, to give thanks for the new life, and prepare special foods so that the new mother can regain strength.
The contrast between these customs and the standard procedures of a modern hospital birth could not be starker. Many women are scared or ashamed to be attended by an unfamiliar male doctor. In addition, husbands are known to become jealous as a result of perceptions of the doctor’s central role. Women have also experienced discrimination or mistreatment by biomedical doctors who are often simply serving their obligatory six months of rural service before returning to a more lucrative practice in the cities. Regardless of their upbringing, university training tends to encourage doctors to exclude themselves from Quechua culture and to value Western knowledge over all others.
Bathing, shaving, and touching the woman's genital area is traumatic to many Quechua women, for whom modesty and privacy are very important and the chilly, sterile hospital environment can provoke anxiety over catching a cold, a common fear in the harsh Andean environment. Women may fear staining the white sheets with blood, bodily fluids, or dirt, as bathing is not always possible in their rural lifestyle. And the requirement that a woman undergo labor on her back on a gynecological table with her genitalia exposed is humiliating, as well as physiologically disadvantageous. Thus, it is not surprising that so few women are inclined to seek medical attention when they go into labor.
Many women believe that only complicated births require hospital delivery, but often problems aren’t apparent until labor has begun, so medical assistance does not arrive in time. Thus the cultural inaccessibility of hospital birth attention has serious and significant implications for women’s survival when problems arise during labor

An Intercultural Model of Care
For many years, Bolivian organizations like Acción en Salud Integral (ASI) and Causananchispaj have been working to address this issue and develop new models of care that better respond to the cultural practices of indigenous populations. ASI has helped various clinics in the rural provinces of Cochabamba and Northern Potosi implement a new model called "El Parto Intercultural." The model emphasizes communication and collaboration between the family, healthcare staff, and traditional birth attendants. Modern medical techniques are available should the need arise, but primarily the woman is allowed to give birth naturally with the support of her partner and family members. Intercultural birth rooms are designed to feel more similar to the homes where women would traditionally give birth. The sheets and bedding are dark-colored and the room is kept at a warm temperature by boiling water on a gas stove. Family members may feed the mother familiar foods or teas and the mother is supplied with a hospital gown that is similar to her usual dress. Unnecessary procedures such as shaving the mother's pubic hair, enemas, and routine episiotomies are eliminated.
Most importantly, the mother is allowed to labor in the position she prefers, whether walking, standing, sitting, kneeling or squatting on a specially designed mattress, while supporting her weight on a shoulder-height bar. This practice not only is more culturally acceptable, but also healthier, as it dilates the blood vessels, improving oxygenation to the mother and child, and decreases pressure on the uterus, reducing the effort and duration of labor.

The need to adapt birthing protocols to indigenous cultural practices has been recognized in other Andean countries as well. In Peru, after the implementation of such changes, health ministry studies found that in the rural areas, the proportion of births that took place in public health centers increased from 22% in 2000 to 40% in 2004. A similar project in Chile found that the Intercultural attention and vertical birthing position actually diminished the risk of cesarean section.
Various hospitals that have implemented the new model have already demonstrated the potential to greatly increase use of maternal health services and thus reduce maternal mortality. For example, in Torotoro, Potosí, in the year after the Intercultural Model’s implementation, deaths due to complications of childbirth were reduced from twelve in 2005 to only one in 2006.
Yet, there is still much resistance to these changes on the part of biomedical practitioners. The supine gynecological position is more convenient for the delivering nurse or physician to be able to medically intervene, especially if complications arise in during labor. The herbal medicines, vertical birthing position, and other traditional practices are often misunderstood and viewed as evidence of rural peoples’ “backwardness” rather than appreciated for their cultural and physiological merits.

Casa Materna Punata
So back to the original question: What am I doing here? Well the truth is a lot of that I am figuring out day by day. My project revolves around a Casa Materna, or intercultural birthing center, that was recently built by Japanese foreign aid in Punata, a mid-sized town 45 minutes from Cochabamba. It is the first center of its kind in the area, and the first in the country to be built next to a higher level hospital, where medical specialties like gyneco-obstetrics are available. While the physical infrastructure is there, the Casa Materna has yet to begin functioning, primarily for lack of human resources and resistance on the part of those specialist doctors, who dont see the necessity or importance of the intercultural model.
So our project is filling in that niche. We're hiring two doctors who will be trained to attend births in the center, in collaboration with the husband, midwife, and/or family members that the mother chooses to accompany her. The part I'm the most excited about will be working with a promotion/ investigation of team of 3 women from the community to spread the word about the new model through workshops, sociodrama skits in the marketplace, and home visits with families in the rural communities surrounding Punata, as well as interviewing women about their experiences. Once things are really working well, the plan is for the doctors to train each of their colleagues, one by one, in the new model. Because honestly, it seems that most of their resistance stems from an inability to imagine how one might attend birth in a vertical position and what it would be like to actually collaborate with family members and midwives, and that witnessing a colleague attending in this way might reassure them. I guess we'll see!
The second half of the year will be devoted to diffusing the results of the investigation and spreading the intercultural model throughout the region.... but I’ll have to tell you more about that when we get to it!
So thats the scoop for now, things have been going really well, the local government approved the project, I’ve been making friends in Punata, and we’re hiring doctors next week! Hope you all are well, take care, and I hope to write more soon!



New Friends on a Weekend Trip to Chapare!