Changing Birth in the Andes: Culture, Policy, and Safe Motherhood in Peru
290
Changing Birth in the Andes: Culture, Policy, and Safe Motherhood in Peru
290eBook
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Overview
Peru's Intercultural Birthing Policy of 2005 was intended to solve these longstanding issues by recognizing indigenous cultural values and making biomedical care more accessible and desirable for indigenous women. Yet many difficulties remain.
Guerra-Reyes also gives ethnographic attention to health care workers. She explains the class and educational backgrounds of traditional birth attendants and midwives, interviews doctors and health care administrators, and describes their interactions with local families. Interviews with national policy makers put the program in context.
Product Details
| ISBN-13: | 9780826504166 |
|---|---|
| Publisher: | Vanderbilt University Press |
| Publication date: | 04/30/2021 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 290 |
| File size: | 9 MB |
About the Author
Read an Excerpt
CHAPTER 1
The Making of the Intercultural Birthing Policy in Peru
Graciela's Intercultural Birth
Graciela had arrived at the Kantu health center with contractions on a slow Monday afternoon. This was a great chance for me to observe a real intercultural birth in progress. The Kantu midwives had been open to sharing with me when I was there, but since they didn't notify me if a birth occurred outside of the times I spent in the clinic, I hadn't yet seen one, and I had already missed two. This was the first time I was in the right place at the right time.
After introducing myself and the study, I asked Graciela and her family for permission to observe. I then accompanied them and the attending midwife, Yuli, into the small labor room. Yuli closed the curtain on the large window, darkening the room while the family went about settling in. Graciela was accompanied by her mother and her husband. They looked serious and concerned, while she seemed to be in increasing discomfort. She sat on the low wooden bed with its blue plastic cover and dark linens. The bed was partially obscured by a pastel-green hospital-room divider covered in colorful local textiles woven by local women. As we entered, the room was decidedly medical looking: the tall, narrow, black-cushioned gynecological stretcher with stirrups attached; a pastel-green metal supply cabinet; a modern computerized warming crib (or Servo-Crib); and the shiny steel IV assembly loomed, reminders that this was not a home. But behind the colorful curtain sat the bed, with a low side table, a small heater, and a very low stool, comforts that made the room look cozy, if somewhat theatrical.
Like the setting, Yuli's care for Graciela was carefully choreographed, at least at first. She methodically set out an assortment of instruments and supplies on the side table, then sat next to Graciela and told her, in Quechua, that she needed to be "checked," the pared-down, almost euphemistic way that medical staff tell patients they will probe them to physically inspect the progress of dilation. With the husband's help, Yuli positioned Graciela on an absorbent pad, instructed her to lie down, lifted her skirt, and inserted a gloved hand to check for dilation. Graciela winced in pain but said nothing. "Only at four, maybe five, about 50 percent effaced. This is going to take a while," Yuli said to me in Spanish. Turning to the family and Graciela, she explained in Quechua that she needed to put an IV in Graciela's hand. Then, looking now only at the husband and mother, she explained that the IV was for fluid and that they would add medicine to it if needed. Her tone was imperative and matter-of-fact. No one said anything as she proceeded to prepare the fluid bottle, prepped the vein, inserted the needle, and regulated the flow. She left the room soon afterwards. Up to this point everything was going exactly like a normal clinic birth without cultural adaptation but for two key elements: Graciela remained in her own clothes, and she had two family members accompanying her in the room.
I tried to make myself comfortable sitting on the gynecological stretcher as we waited for Yuli to return. After a moment, I heard Graciela's voice for the first time since they had entered the room. Speaking to her family in Quechua, she said the IV made her arm feel cold and that her contractions had stopped. Her mother and husband looked concerned. This was not good. They discussed the possibility that the cold was stopping the contractions. They told me they had been in labor at home for a while, waiting for good strong pains before coming to the clinic; they had hoped this would shorten their time there. "Why?" I asked. "The señoritas (midwives) are sometimes impatient," Graciela's mother replied in a mixture of Spanish and Quechua. "They send women who take too long to the city (Cusco) to get cut," she said with a shiver and look of panic on her face. They needed to get her daughter hot again, she said. The husband turned on the heater, they wrapped Graciela with two thick wool blankets they had brought from home and started giving her sips of hot chocolate from a flask.
Their focus on heating Graciela up was as normal here as a flurry of hand washing would be before entering a delivery room in America. In the Andean perception of birthing, heat is needed to coax the body open (Burgos Lingan 1995) and to ward off unwanted humoral imbalance: the correct temperature is a fundamental aspect of a good birth. So this episode was an encouraging sign that the intercultural birth-care protocol was making a difference. Providing an outlet for their anxiety, the new rules gave husband and mother space to manage a few aspects of Graciela's care — bringing their own blankets and beverages — which would never have been allowed in a non-adapted rural or urban public health clinic.
Afternoon turned into evening, and everyone agreed that Graciela was progressing well. Contractions had returned, she had shed the blankets, and she now seemed unaware of the IV. With her husband's help, she stood, squatted, and lay on the bed, repeating this cycle several times. Her two older children and three sisters arrived and took turns popping into the stifling hot room to find out how things were going. At around 6:00 p.m., some four hours after she had arrived, Graciela felt the urge to push. Yuli was expecting this. She had been sitting in the room with the four of us for almost an hour now, calmly monitoring the child's descent. The rest of the family were sitting outside in the corridor, waiting. Graciela had been sitting on the bed, her husband sitting behind her, supporting her weight. Yuli called in a nurse, Juana, to receive and manage the newborn. Juana brought in a nurse's aide to help her. When it was finally time to push, things got frantic. Yuli quickly prepared a plastic-covered mat, placed it on the floor, and covered it with a sterile sheet. She then covered Graciela's feet with sterile booties and had her raise her skirt and squat on the mat facing the bed, her arms around her husband's neck. "Chuqay (push), chuqay, mamita," Yuli urged repeatedly in Quechua, as she squatted low to the ground next to Graciela, her hand on the perineum to prevent, or guide, tears. In four pushes, a squiggly, long baby boy fell onto the sterile sheet. "It's a little boy," Yuli announced as she cleared the baby's airways. He gasped, and the tension in the room eased. Yuli clamped the umbilical cord and asked Graciela's husband if he wanted to cut it. He did so slowly and carefully using surgical scissors. Juana took the baby from the floor wrapped in the sheet for newborn care. She called out the Apgar score, weight, and length as the nurse's aide wrote them on a chart.
Graciela remained on her knees on the mat, the clamped umbilical cord dangling. But once the baby's stats were captured, it was time for the placenta to be delivered, and attention turned to her again. "Placental retention is very problematic," Yuli told me in Spanish. "We always use Pitocin to help birth it quickly," she said as she injected Graciela's IV with the drug. Graciela now lay on the bed; she had taken her soaked skirt off and was covered by a blanket. As she contracted, Yuli gently massaged her abdomen and, alternately, gently pulled on the umbilical cord. After a couple of minutes, Graciela sat up on the side of the bed and pushed the placenta out. Yuli examined where it fell on the mat. "It's complete. We are good," she announced in Spanish. Turning to Graciela's mother, she asked in Quechua, "Are you taking it?" The family did want it, so in another gesture that showed we were experiencing an intercultural birth here, Yuli put the placenta in a plastic bag, tied it with a knot, and handed it to Graciela's mother, who stowed it in one of the bags they had brought.
As Yuli checked and cleaned Graciela's vaginal area, she noted a small tear and instructed Graciela to wash herself as well. The family had brought warm chamomile water for this purpose, and it now made its way into the room for Graciela's mother to use. Once she was dressed and covered again, the children and other family members were finally allowed to stream in to see the new baby. He had been lying on a warming bed with the nurse by his side. Yuli now wrapped him in a shawl and set him beside Graciela, and after some more cleaning up, we all left the family alone.
"This was a good birth," Yuli told me. "It is easier with the multiparas. They know what to do! So much easier." Multiparas are women who have given birth vaginally at least twice before. Indeed, it had been a calm birth overall. Yuli had managed the process with ease, stopping in and chatting with the family, responding to their early concerns, letting Graciela take her time. This was a good birth compared to other births I had experienced or heard about so far from peasant women, urban women, and my own friends and colleagues. It was thrilling to see a midwife and family working together.
I would learn later that this positive dynamic very much depended on who was on call. Yuli, the only Quechua descendant in the midwife group, was particularly calm and less anxious to assert her medical dominance over the situation than her other colleagues would have been. The only fluent Quechua speaker among them, she communicated more, and more easily, with the families than did other staff. Graciela's family seemed to feel positive about their experience. They were able to designate members to be with Graciela and to make some decisions that were important to them: the heat, the beverages, the warm water, the positions, and the treatment of the placenta, and ultimately they seemed to leave satisfied with the care they had received. This was by no means always the case. In the following months, I witnessed several birthing processes in the Kantu and Flores clinics that ranged from mostly positive, like this one, to truly heartbreaking in their othering and violence. What made the difference?
Culture, Policy, and Reproduction in Peru
In Peru, as in other countries in Latin America, the post-independence creation of a unified national identity rested on solving the "Indian question." Specifically, it asked if, and how, to incorporate the native populations into the imagined communities of the state (Canessa 2005). Indigenous descendants were viewed as degraded versions of a prior glorious civilization, inherently inferior to those of European descent, and a serious impediment to modernity and development. While in other former colonial states these views meant that indigenous communities were geographically and administratively separated from national society, the widespread mixed-"caste" marriages of Andean Latin America meant that shared indigenous ancestry could not be denied (Canessa 2005). In Ecuador, Bolivia, Venezuela, Peru, Colombia, and others, the rise of eugenics inspired health and educational interventions that sought to assimilate the embattled bodies and intellects of indigenous peoples into modern society, by remaking them under the so-called morally superior values of whiteness (Mannarelli 1999; Pasco, Cueto, and Lossio 2009; Zulawski 2000, 2007).
Twentieth-century Peru was shaped by the aftermath of the War of the Pacific, a struggle between Bolivia and Peru on the one hand and Chile on the other, which ended in 1883 after four years and a brief but devastating occupation. For educated elites caught up in the postwar soul-searching, reproducing the right kind of Peruvians became a centerpiece of their effort to rebuild Peru as a modern nation (Mannarelli 1999). The state responded to high levels of maternal and infant death with state-sponsored public health programs that would one day coalesce into the national public health system. Early public health clinics and interventions were created by social hygienists who focused on the regulation of poor, indigenous, and black female bodies as the main site for betterment of the national race (De la Cadena 1991, 2000; Mannarelli 1999).
These early modernizing hygiene campaigns made public the private domains of women's sexual health, pregnancy care, birth care, and mothering behaviors. Improving the so-called "Indian stock" was the focus of "good mothering" interventions, which promoted European ideals and moral dictates (Mannarelli 1999). Women were responsible for reducing child mortality and nurturing a new type of citizen for the nation's development (Ewig 2010; Roberts 2012). This public health system reinforced class, gender, and racial inequalities (Ewig 2010). In this hierarchy of care, rural indigenous female bodies were seen as more indigenous, out of control, entrenched in tradition, and difficult to govern (De la Cadena 1991; Weismantel 2001).
Toward the middle of the twentieth century, the global spotlight swung to the relationship between population control, social development, and economic growth. In Latin America, this inspired more interest in reproductive patterns and practices (Necochea-López 2014). Between the late 1960s and the early 1980s, policy focus was on implementing and expanding health care access under the framework of the Alma Ata declaration (1978), which prioritized primary health care for all (Ministerio de Salud Perú 2009a). Traditional birth attendants (TBAs) and other community health workers (CHWs) were trained to become liaisons with the health system and were given central roles in identifying high-risk pregnancies and promoting family planning (Leedam 1985; Simons and Maglacas 1986; Verderese and Turnbull 1975).
As a result, child-rearing practices, family planning, and pregnancy-care customs of rural and indigenous women came under extra scrutiny. Research focused on identifying "approved" behaviors and changing others considered detrimental to infant health (Atucha and Crone 1979; Bourque and Warren 1981; Brown 1976; Browner 1980; Mead and Newton 1967; Oyeka 1981; Scrimshaw 1978; Verderese and Turnbull 1975). Certainly, common to all was the focus on controlling reproduction, including birth care, and the disavowal of all non-biomedical practices. Physicians denounced traditional healing systems, labeling them "backward." They argued that deeply entrenched health beliefs were the main cause of poor health and poverty, and it was the role of public health to foster assimilation into Western medical paradigms.
The particular focus on indigenous women's reproduction made pregnancy and birth a central battleground for behavior change in the Andes. Anthropologists of reproduction have previously argued that birth rituals and processes are symbolic sites of cultural reproduction: a biological universal that is patterned by humans in response to their societies' most important values (Browner 1982; Cosminsky 1982; Homans 1982; Jordan 1978; Kay 1982; MacCormack 1982; McClain 1982). A modernization of this value system was viewed as fundamental to changing birth-care practices in Peru.
The specific scope of these efforts varied as different development agencies (e.g., UNICEF, CARE, USAID, Population Council) funded, and sometimes performed, interventions in diverse geographical areas in coordination with the MOH, beginning in the 1960s and extending well into the early 2000s. The results varied, and data was difficult to collect (Gomez 1988; Iguiñiz and Palomino 2012). Public health facilities were scarce, existing ones were understaffed and underequipped, and professionals at all levels of care were chronically undertrained in responding to obstetrical emergencies. These issues, coupled with the international focus on population reduction (Stycos 1965; Verderese and Turnbull 1975), meant that health policy and practice in this era focused more on family planning and child survival than on preventing death in childbirth.
Safe Motherhood: From Traditional Birth Attendant (TBA) to Skilled Birth Attendant (SBA)
When the Safe Motherhood Initiative emerged from the Nairobi Conference (1987), Peru was in the midst of an internal armed conflict and a severe economic crisis (Boesten 2010; Ewig 2010) that had undone much of the earlier policy effort. Government infrastructure, including health care facilities and personnel, suffered losses; in many hard-hit rural areas and even in urban centers, health clinics were abandoned. The convergence of both crises drove the health system close to collapse. In rural outposts the spaces left vacant by the government were filled by non-profit and development agencies, which largely managed emergency food aid and primary health projects, working closely with "lay agents" (Davison and Stein 1988) — the CHWs and TBAs, who increased their activity. Through the early 1990s, Peruvian maternal-health policies in rural areas focused mostly on improving health care provider responses and training for TBAs (Iguiñiz and Palomino 2012).
(Continues…)
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Table of Contents
Figures, vii,
Acknowledgements, xi,
Glossary of Commonly Used Acronyms, xiii,
Introduction, 1,
ONE The Making of the Intercultural Birthing Policy in Peru, 25,
TWO Higher Up and Farther Away: Implementing Intercultural Birth in Cusco and Cajamarca, 48,
THREE Constructing Interculturality, Civilizing Birth, 86,
FOUR Strategizing for a Good Birth: Women, Men, and Traditional Lay Midwives, 139,
FIVE "The Doctor Does Get Respect": Clinic Midwives' Experiences of Intercultural Birthing, 186,
Conclusion, 211,
Notes, 232,
References, 240,
Index, 267,