Deaths, Doctors, and Beliefs

The Informe Semanal in the June 24th, 2007 edition of La Razón was filled with depressing statistics about the maternal mortality rate in Bolivia. The Pan-American Health Organization had just released a report on the state of maternal health in the Americas, and Bolivia ranked near the bottom (235 women die for every 100,000 live births), edging out Haiti for the worst maternal mortality statistics in the hemisphere.

However, the report seems to place blame for these statistics on women themselves, and elides or downplays the role that the formal governmental health system has in contributing to Bolivia’s distressingly high rate of maternal death. One section of the report proclaims that “Creencias ponen al país en la cima de mortalidad materna. Un choque cultural. La atención médica que se presta en el país es distinta a la creencia que tiene la mujer en el momento del parto.”

But what are these “creencias”? The article mentions that women, especially women of indigenous background, believe that a woman’s body is like the earth, it prepares for growing life, and then it does – ok, but how does this lead to such mortality statistics, exactly? And sure, women might prefer to give birth in a warm environment, maybe squatting or sitting up at a nearly 90 degree angle, and that’s not available in hospitals, where women are expected to assume a “posición ginecológica.” Once again, how are these beliefs themselves necessarily detrimental to a woman’s health during childbirth, and why, in my reading, does the article seem to be implying that the beliefs of women need to change, not the practices of physicians in hospitals and health posts? In other words, how are these ideas different from many beliefs that the medical community have regarding what is an appropriate way for a woman to give birth?

The article continues to say that many “mujeres con raíces aymaras y quechuas” believe that birth is something “normal.” Well, isn’t it? Sure, can be risky, and there are medical issues and complications that arise, but isn’t childbirth a normal part of life? Here it seems to be painted as an abnormality, a disease, exactly the kind of conception that feminists have been working against for decades.

Perhaps even more worrisome, to me at least, is that the articles focus on only a few statistics, most notably that “53% de muertes maternas se dan por partos en domicilios.” There is no discussion whatsoever of the remaining 47% of deaths that occur in clinical settings. Let’s face it: 53% is not really that different from 47%. Furthermore, the Informe notes that 82% of “non-indigenous women” give birth in a hospital, while only 51% of indigenous women do. But how these two groups are defined is not mentioned. Still, considering these statistics and assuming that they are correct, that means that deaths within clinical settings are still inexcusably high, a fact that is not discussed in any great detail, instead the Informe focuses on rural women or women who give birth in their homes and their “creencias.”

Why not focus on the incredible systemic problems with the health care system in Bolivia? There are frequently unsanitary conditions in hospitals, lack of equipment, and lack of medicine. Furthermore, though doctors are frequently well-trained, there’s not much one can do in an old, run-down building with non-functioning equipment (and, no doubt, leads to many women avoiding hospitals where they will receive poor care and often be treated poorly themselves). Finally, the concept of childbirth as a disease, as I discussed above, is somewhat off-putting for many women, and with good reason, especially since it seems that elsewhere in the world the pendulum is swinging in the opposite direction. For instance, in the U.S. and Europe, more and more hospitals and obstetricians (though by no means all) are recognizing that having a woman in a “delivery room,” flat on her back, is not the best way to give birth for many psychological and physical reasons. These days, the norm seems to be that hospitals present their birthing suites as homey and welcoming, where women have some say in their childbirth process. In such birthing rooms, women often can labor, deliver, and recover all in one room, with their babies kept in with them. Often, women have the opportunity to use a whirlpool tub, walk around, use a birthing bar or a birthing bed (meaning she’s not flat on her back), or otherwise try to make themselves as comfortable as possible. Coaches, partners, doulas, and other support people are generally allowed into the room, if the woman requests. In other words, the trend in the U.S. and Europe seems to be (based on my own limited experience) back towards making the birth experience as personal as possible and less clinical. This new model sounds like the attitudes of many women in Bolivia surrounding childbirth, and it is worrisome to see such ideas painted as mere “beliefs,” while the accepted clinical model of childbirth is left unquestioned, despite evidence that the clinical model in Bolivia isn’t faring too well, either.

Overall, the articles reinforce the notion of rural or indigenous women as backward and driven by belief or culture, while doctors and hospitals are implied to be the paragons of modern, Western scientific rationality (assumptions that are not nearly as clear-cut in practice). This is despite the statistics presented in the Informe itself that contradicts, or at least troubles, these assumptions. It is this blindness that is deeply concerning to me, for it strips women of their ability to express their attitudes and desires towards their childbirth experience. Such opinions, clearly, are not being heard nor respected.

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3 Responses

  1. The statistic I would like to see is what percentage of women who give birth in the hospital die, as compared to the percentage who die at home.

    Kate, I think you make an excellent point that this is really about regulating women into fitting into a specific biomedical idea about how pregnancy and labor “should” be. Certainly infant mortality is a real problem in Bolivia, but simply giving birth in a hospital is not the whole solution.

  2. Having witnessed first-hand how pregnant women are treated in the Hospital de Clínicas, I have to agree with you, Kate, that it’s ridiculous for the article not to further question the role of the medical staff in the outcome of pregnancies and pregnancy-related decisions. I’ve been told women who are pregnant and 6-months post pregnancy are covered under the state, so what does it tell you that they are avoiding free care? It could be “creencias,” or it could be the system – either poor treatment or confusing care (there’s a lot of paperwork required).

    Most disconcerting to me has been the way the indigenous people (which is probably more than 90% of the patients) of the hospital, even by the most personable doctors, are treated more like animals than human beings. They never seem to be fully informed of their conditions, and when they are taken to consults (not to mention how complicated and disorganized the system is), they are never told what is going on, why they are being directed to a different location, how grave their condition is, etc. In addition, pregnant mothers are exposed to horrible conditions (walking everywhere, cold, bad food, lack of company) and a whole host of nasty illnesses while in the hospital, so it doesn’t surprise me in the least that they would avoid the place.

    I was present for one pregnancy consult: we took a woman to the Hospital de la Mujer, where we waited for 30 minutes for a vacant examination bed. The intern and I waited inside the ward, chatting with the doctors, while the patient stood in the hallway outside without anyone telling her what was going on. When we finally got her to a bed, she laid down while we used an audio ultrasound to try to locate her babby’s heart. This went on for about 20 minutes until we finally gave up and asked for an ultrasound for a monitor. Throughout this whole thing neither of the doctor’s assured her that what was happening was normal (aka that the lack of heartbeat wasn’t because her baby was sick, more because the technology is old and poor), nor did they tell her that the reason she needed an ultrasound was to make sure the anesthesia she had received for her wounds did not affect the baby.

    As far as reducing infant mortality in the country, I would argue that some key notions would be to improve doctor-patient relations, (obviously) to improve the services offered to pregnant women, and most importantly to work on a community level (since that’s the way everything seems to function in Bolivia) to improve awareness of patient’s options. Just my two-cents.

  3. I like the gist of the article. “Half of women go to hospitals to give birth, and half of women who die die in hospitals.” If your chances are the same in or out of the hospital, why squander money on getting to a hospital?

    The “hospital” in Tiwanaku was equipped about as well as a regular doctor’s office for giving birth. No surgical suite for doing c-sections. No fetal monitors. No ultrasound machine. No blood bank. No x-rays, no labs. They could get you to a high level of care hospital in about 90 minutes, IF the ambulance was working, and had gas in it, and didn’t have a flat tire, and if the driver could be located, etc. etc.

    I think it’s important that they’re looking at the cultural beliefs to identify things that women don’t like about the Bolivian medical system (such as giving the post-partum women cold water in hospitals, a definate no-no as that supposedly causes “rakira” [I’m not sure of the spelling]) but the sad fact is that identifying cultural factors is free, whereas health infrastructure costs lots of money.

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