Addressing maternal mortality in Bolivia: women say 'respectful treatment is crucial': Ulrika Rehnstrom, a midwife with the United Nations Population Fund, describes the current situation in Bolivia where it is hoped to scale up midwifery education.

To go through childbearing without risking your life is a human fight, yet pregnancy and childbirth are still the leading causes of death and disability for women of reproductive age in Bolivia. Every year approximately 650 women die as a result of complications from pregnancy and childbirth; 47% of these women are aged less than 30 years. Most maternal death and disability could be avoided if births were attended by a qualified midwife with access to relevant equipment. Ensuring skilled care for all births is a prerequisite for making sure that those women who develop complications can get timely emergency obstetric care.

Millennium Development Goals 

Bolivia adopted the UN's Millennium Development Goals (MDGs) in September 2000, including the objective to reduce maternal mortality by three-quarters (Goal 5) before 2015 and ensure that at least 90% of women receive care from a skilled birth attendant during labour and birth.

The current maternal mortality ratio is 230 per 100,000 live births in Bolivia--one of the highest in Latin America. In rural areas where the population is mainly indigenous people, the rate is even higher. In some parts of the rural high plateau the ratio is 887 per 100,000 live births, which clearly shows the existing social and economic disparities.

Traditional methods of care

In Bolivia, pregnant women do not have access to professional midwives. Unfortunately the midwifery training that once existed was discontinued. At the present time, women in urban areas are attended by medical doctors, while in rural areas, auxiliary nurses take care of women in labour. Auxiliary nurses have a training of minimum six months, sometimes up to two years, in general health.

The traditional methods of care in the Bolivian rural areas are very different from the modern medical system. Traditional systems are highly valued within Bolivian communities. Many rural women are afraid to give birth within the health system, fearing that their culture and beliefs about childbirth will be ignored. Many women in Bolivia say that respectful treatment is crucial and that the disrespectful attitude of service providers is a major factor in their decision not to utilise maternal health services. Instead they choose to give birth at home assisted by their family. In a case when a complication arises, this may put at risk the women's life or her baby's.

Midwifery education

The Nursing College of Bolivia, selected universities from the Bolivian university system and the United Nations Population Fund (UNFPA) propose to implement midwifery education to degree level in Bolivia, with the mission to improve sexual and reproductive health for all, using a culturally sensitive and ethical approach. The professional education of midwives would concentrate on training them to care for the holistic needs of women in a competent manner, acting as women's advocate and working with them and their families to promote a sale and fulfilling childbirth experience.

The midwifery programme would promote:

* a philosophy of individualised, women-centred care

* equality for all women regardless of race, religion or age

* safe maternity care with an integrated reproductive health approach

* increased awareness of sensitive and compassionate care for family and sexual health problems both on an individual and wider level.

Initially this proposal was not well received by some in the country, who wanted to continue the training of auxiliary nurses. However, due to the positive approach by UNFPA, it was soon realised that such a programme would contribute to the improvement of sexual and reproductive health for the whole population--men, women and adolescents--with particular attention paid to socio-cultural aspects.

The government, in the middle of 2006, finally opened the discussion to start the pilot project 'To Institute the Career in Midwifery within the University System of Bolivia'.

The next step of this project is to prepare the curriculum for both midwifery students and midwifery teachers; after that will follow the training of teachers in midwifery. Authorities from the universities, nursing colleges and ministry of health, with assistance from UNFPA, PAHO/WHO and midwifery experts from Peru and Chile, will work together to develop a culturally sensitive programme for midwives.

UNFPA is convinced that scaling up midwifery is the strategy to reduce maternal morbidity and mortality; together with the public universities in Bolivia we will continue to advocate for the project proposal to implement full midwifery training in Bolivia.

For further information, please contact Ulrika Rehnstrom at [e-mail]