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A long way from home birth understanding birth practices and politics in the Peruvian Andes.

"Uno, dos, tres, empujemos... one, two, three, push!" Lying with my back to the floor cushion and a hand cupped under each knee, I took a deep breath in, lifted my head and contracted my non-pregnant belly. I was rehearsing bearing down with six other very pregnant Peruvian women. All of us were sprawled out on the floor of the health post waiting area, due to a lack of better space. The other patients looked on amusedly from the benches pushed against the side walls, and at any given moment at least a half dozen toddlers wandered between and scrambled over the rows of pregnant bellies. We were all here for Friday afternoon psicoprofilaxis childbirth education classes at the Juan Parra de Riego government health post in Huancayo, Peru. A few hours later, I would find myself in the same position, this time with my legs flung precariously over a big blue birth ball with another group of pregnant ladies scheduled to give birth at one of the private clinics nearby. The facilities were much nicer; we spread out in a spacious room dedicated solely to childbirth education equipped with yoga mats, birth balls, and soothing music playing over the sound system. Instead of using these birth balls to help women practice positions to ease labor, their primary use was to simulate the on-the-back, feet-in-stirrups position in which all of these women would soon be giving birth. This was not the case twenty years ago in Peru, when most women, particularly those in rural areas, gave birth at home. Yet now, due to a strategy to combat high levels of maternal mortality in the Andean regions of Peru over recent decades, the birth demographic is shifting. Government or private, urban or rural, childbirth in Peru is moving in a more medicalized and institutionalized direction.

I am studying childbirth perceptions in Huancayo, Peru, an urban center about 10,000 feet in elevation above sea level and seven hours inland from coastal Lima. I received a Fulbright grant to spend ten months researching reproductive and maternal health in Peru. There has been a pendulum shift from a majority of births attended in homes by traditional parteras (midwives with no formal training, but ample apprenticeship experience), to nearly exclusively medically managed birth, centralized in government clinics in some areas (Grady, 2009). Different regions of the country have applied different tactics to compel women to come to the clinics for their births and prenatal appointments. The Juntos program, active in some rural areas, creates a 100 Peruvian nuevo sol/month incentive (about $30) for women to come to their appointments, while clinics in other areas lure women with government provisions of sardines, rice and corn oil for each month they attend (Perova & Vakis, 2009).

According to the clinic nurses, other regions have tried the opposite approach; women are threatened with unregulated fines determined by the individual clinics if they miss their prenatal appointments or give birth at home. In some cases, those who opt for a home birth or birth with a traditional partera have a difficult time obtaining a birth certificate for their newborns.

Despite these positive and negative reinforcement tactics, some women from traditional backgrounds and rural areas still resist the clinics. Peru's wide array of indigenous dialects and customs creates a stark language and cultural barrier between the care provider and the pregnant woman, making it difficult to obtain competent and empathetic care (Tarqui-Mamani & Barreda-Gallegos, 2006; Amnesty International, 2009). In some communities, standards of modesty prohibit women from traditional societies from disrobing in front of anyone but their husbands. A story I frequently heard by women at one clinic spoke of the parteras who have been known to determine when a woman is fully dilated just by feeling her pulse, something not exactly taught in standard obstetrics classes. So even after explaining the vaginal exam to a woman in labor, tension still arises when health providers try to check the labor's progress on women who resist the exams. This endangers the mother and baby as the health providers cannot care for them in the way they have been trained.

In parts of the rural Andes in Peru, mamawasis, or maternal waiting houses, provide a place near the clinic for women who travel long distances to stay when they are close to their due dates. Mamawasis were designed with a culturally-sensitive approach toward childbirth in mind, and clinicians more commonly accommodate traditional practices such as giving vertical birth (Callister, 2009; Nurena, 2009). However, from my experience in urban Huancayo, working both with local women and women who have recently migrated from rural communities hours from the city, the medicalization of childbirth is overwhelmingly prevalent. I have spent the past two months getting to know some of the government health posts and health centers which oversee most births, as well as a few private birth clinics. In the government health centers, all pregnant women receive a "birth plan" on their first visit. This is a regionally pre-drafted contract that commits women to giving birth at the government facility in the position most convenient for the health provider. There is no real space to voice desires about specific interventions or preferences during birth, and women are assumed not to know much about the institutional process of childbirth to voice opinions anyway. While en culclillas (squatting) and parto en domicilio (home birth) are listed on the sheet, they seem to appear just so the health providers can emphasize what poor choices these could be, and eliminate them as options without further discussion.

From the perspective of valuing informed choice among birth alternatives, these strict parameters seem oppressive. However, it is important keep in mind that the threat of maternal death here is very real. Estimates vary as to the numerical data; according to a 2008 report by the United Nations Population Fund, Peru's maternal mortality rate is second highest in South America, at 240 for every 100,000 live births (United Nations, 2008). The Peruvian government reports 185 women die for every 100,000 babies born (Ministerio de Economia y Fiananzas, 2008). Either way, the possibility of maternal death is a very present concern for all health workers. The consultation rooms in the government clinic are far from warm and fuzzy; on entering the Juan Parra de Riego health post office, instead of smiling baby pictures or pastel cartoon animals, one is met with six poster-board cutouts of cartoon Andean women graphically displaying danger signs in pregnancy. Similar displays were present in every government clinic I entered.

The statistics are sobering, but I wanted to gain a personal understanding of Andean childbirth by talking to women about their own experiences. I organized a childbirth education series in a small rural health post called Huari, and spent the remainder of my time either participating in childbirth education classes or shadowing the obstetrices, obstetric nurses who oversee most vaginal childbirths in the government clinics. Teaching classes in the health posts and clinics has been a real learning experience for me on several levels. At first, the logistics of gathering several mothersto-be together to discuss childbirth preparation seemed an insurmountable task in the chaotic clinic environment. An ii:00 class would often not begin until over an hour later and then end abruptly when the older toddlers began wreaking havoc. I had to rescue more than a few children from waddling, arms outstretched, toward the shiny, red, biohazard sharp boxes while their mothers were in their consultations. The overburdened government clinics are always very crowded. This is largely due to the rapid rate of urbanization Peru has experienced the last few decades, bringing more young, underemployed and undereducated people to the cities (Alcalde-Rabanal, Lazo-Gonzalez, & Nigenda, 2011). The facilities are short on space, so for our first few classes, we sat together on the grass behind the clinic. Even when there was space to hold class inside, no one even leaves their home when it's raining, which in February in Huancayo is about every afternoon.

But we worked out a class schedule, and over the next six weeks, I really enjoyed getting to know the pregnant women at the Huari Health Post. Sometimes the women would come in traditional Andean dress, with their long black braids meticulously fastened under their bowler hats, and their bright colored skirts splayed out like tents as their toddlers played underneath. They would teach me Spanish and Quechua pregnancy vocabulary and giggle at me as I tried to explain Kegel exercises and demonstrated positions to alleviate back and leg pain, with my feet up against wall, or on my back in a pelvic tilt. Nearly every Peruvian woman carries her infant in a colorful rebozo slung over her back. The women move so naturally with their infants secure in the rebozos that the sling seems part of their everyday dress.

My knowledge of nutrition during pregnancy was supplemented by rich Peruvian additions. A common ingredient of traditional Peruvian dishes is sangrecita, or chicken blood, mixed often as a sauce with rice or potatoes and providing a superb source of iron. Anticucho, or beef heart, a Peruvian delicacy often served on the street, is also packed with iron and protein. Another good source is cuy, or guinea pig, but it is more expensive (and perhaps less palatable to those who grew up with them as pets). High protein grains like quinoa, maca and kiwicha are staples in Peruvian kitchens. Peru is geographically renowned for its microclimates, meaning that the rainforest, with all of the eclectic and nutritious fruits found therein, is never too far away even up here in the Andean Mountains. Fruits like pomegranate, cherimoya, maracuya, lucuma, papaya, mango, and star fruit are fresh daily, and countless juice vendors line the streets waiting to prepare blenders of fresh fruit smoothies for the equivalent of about 80 cents.

Artichoke and asparagus are packed with the important prenatal vitamin folic acid, among many others, and are also two of Peru's chief agricultural exports (Meade, Baldwin & Calvin, 2010; USDA, 2012). Very little artichoke or asparagus seems to be consumed domestically, and the women I spoke to strongly dislike the nutritious vegetables, preferring their potatoes (of which more than 30 varieties are sold in the market) (Meade, Baldwin & Calvin, 2010).

The epidural anesthetic portion of my childbirth education course I had been accustomed to giving back home turned out to be superfluous; all women give birth without pain medications in the government health clinics. Anesthesiologists are only present in the larger hospitals, and even then are only called in for help with pain management during cesarean sections. The cesarean rate at the government clinic I visited is consistently only about 3% of births, while in the private clinics the rate reaches up to 20 or 30%. Several obstetrices assured me that any woman in the cities who can afford to pay for a cesarean would choose to give birth this way. The whole procedure costs about 1750 sols or $650 in Huancayo's private clinics. Another obstetriz explained to me that many women feel paying for an elective cesarean demonstrates that their husbands can take care of them, even going so far as to say some believe it is a more "civilized" birth.

Machismo is very much alive throughout the world, and Peru is unfortunately no exception (Martinez, 2010). I have yet to come across a female obstetric doctor, and women do not seem to have much autonomy in childbirth. At the private clinics where I worked, every first-time mother receives an episiotomy, and gives birth on her back with the help of Pitocin with few, if any, exceptions. At a few of the government clinics in Huancayo that serve primarily migrant populations from more rural areas, ropes are suspended from the ceilings of the labor rooms to allow the women to give birth vertically. Whether or not they are used is another matter; the obstetrices said they worry they cannot catch the baby in this position, and that the dirty floor will cause contamination, so they try to avoid vertical births if possible. At the private clinic I asked if women ever ask to birth in an upright position, or request to not receive Pitocin or episiotomies. The physician was puzzled by my question, but assured me that this never occurs; these women are educated and they know how birth must proceed.

In terms of institutionalizing birth to combat a high level of maternal mortality, it is understandable that Peru is covering its bases. One can only hope that in the future, birth as a natural process and life experience where these women can give birth confidently and safely will become the norm. Maybe then, health providers will aim to holistically respect, support and care for women in birth instead of medically micromanaging every step of the process.

Keri Zug graduated with a BA from Scripps College in 2009 with a degree in Humanities and Politics. She wrote her Honors Thesis on the Medicalization of Childbirth in the United States and received a Fulbright grant to study reproductive and maternal health in Peru. After completing her work abroad, she began the Accelerated BSN/Nurse Midwifery Program at the University of Pennsylvania.


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Author:Zug, Keri
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:3PERU
Date:Jan 1, 2013
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