Case Study of Integration: Maternal Health Care
Andean woman with infant (photo by Jack Lazar)
The world has had no shortage of inequality and oppression. Often on the receiving end of these inequalities are the marginalized and oppressed. Indigenous women have multiple strikes against them, as they are not only usually poor, less educated, and socially devalued, but also women. One form that this oppression has taken in Peru is in the way that the importance of traditional forms of medicine and birth have been lessened in the face of “development” and “modernization” of the nation. Though women have been practicing birth and healthcare in much the same way for centuries, more and more they are forced to hospitals and clinical births (for additional information on birthing practices, click here). Often these women cannot speak Spanish and are fearful for the health of themselves and their babies. I encountered this problem in a few capacities while in Peru: meeting a midwife, talking to community healthcare workers, and hearing stories from women. In this case study I would like to look deeper into the issue and expand upon possible solutions that ensure mother/infant safety while preserving cultural practices and identity. I would also like to extrapolate from this solution to understand similar situations featuring a disconnect between cultural groups in other ways.
Paul Farmer describes structural violence as “social structures—economic, political, legal, religious, and cultural—that stop individuals, groups, and societies from meeting their full potential” (15, p. 1686). In this case, the social structures of the Peruvian government—fairly removed from the lives of indigenous people—have interfered in the lives of these women. In many places, like the far-flung hamlets I visited, women are often not given the choice to have home births surrounded by their family and helped by a midwife knowledgeable in traditional birthing practices. Instead, pregnant women are closely monitored; when they begin labor a call is sent down to a larger city and a truck comes to take the woman down to a hospital.
It is true that the government does not always have bad intentions when creating laws like those that force women to hospitals to give birth. Sometimes they are trying to legitimately create better health for their citizens; other times they are trying to boost the success of their healthcare systems in the eyes of international organizations. And in many cases, designing such laws has drastically improved maternal mortality rates. As one of the Millennium Development Goals, decreasing maternal mortality rates has become a major focus of many institutions and governments. However, distrust takes root when women are forced into an unfamiliar setting and their needs—as they understand them—are not met.
One fitting and horrifying example of understandable distrust is that of the Peruvian government under Fujimori in the 1990s. He introduced a “family planning” program that actually only targeted poor women who were usually indigenous. Thousands of women were sterilized against their wishes (by either being bullied into it or completely without consent) in order to meet quotas of “poverty control.” Because the poorer, rural women tended to have over double the number of children and live with more limited access to healthcare than wealthier women in the major cities, they were targeted as part of the reason for the continuation of poverty. This “program” has been identified as a human rights abuse and has also been under investigation. Through the structurally violent actions of the Peruvian government, indigenous women were essentially sent the message that they are worth less than others and that they could not make good choices about their sexuality and families (3). Is it any wonder that Quechua-speaking women feel powerless when forced to Western hospitals to give birth?
Paul Farmer describes structural violence as “social structures—economic, political, legal, religious, and cultural—that stop individuals, groups, and societies from meeting their full potential” (15, p. 1686). In this case, the social structures of the Peruvian government—fairly removed from the lives of indigenous people—have interfered in the lives of these women. In many places, like the far-flung hamlets I visited, women are often not given the choice to have home births surrounded by their family and helped by a midwife knowledgeable in traditional birthing practices. Instead, pregnant women are closely monitored; when they begin labor a call is sent down to a larger city and a truck comes to take the woman down to a hospital.
It is true that the government does not always have bad intentions when creating laws like those that force women to hospitals to give birth. Sometimes they are trying to legitimately create better health for their citizens; other times they are trying to boost the success of their healthcare systems in the eyes of international organizations. And in many cases, designing such laws has drastically improved maternal mortality rates. As one of the Millennium Development Goals, decreasing maternal mortality rates has become a major focus of many institutions and governments. However, distrust takes root when women are forced into an unfamiliar setting and their needs—as they understand them—are not met.
One fitting and horrifying example of understandable distrust is that of the Peruvian government under Fujimori in the 1990s. He introduced a “family planning” program that actually only targeted poor women who were usually indigenous. Thousands of women were sterilized against their wishes (by either being bullied into it or completely without consent) in order to meet quotas of “poverty control.” Because the poorer, rural women tended to have over double the number of children and live with more limited access to healthcare than wealthier women in the major cities, they were targeted as part of the reason for the continuation of poverty. This “program” has been identified as a human rights abuse and has also been under investigation. Through the structurally violent actions of the Peruvian government, indigenous women were essentially sent the message that they are worth less than others and that they could not make good choices about their sexuality and families (3). Is it any wonder that Quechua-speaking women feel powerless when forced to Western hospitals to give birth?
Moving Forward...
My friend Jack with community health promoters and children
How do we negotiate between reducing maternal mortality and respecting cultural traditions? This is a problem that I struggled with while in Peru while speaking with Don Pancho, a traditional midwife, and also throughout my entire project this semester. We should not try to “preserve” cultural practices because they are interesting if they are in fact harmful to the participants, right? If women are more likely to survive childbirth at a Western hospital, should we not want them to utilize these facilities? During my reflections, however, I have begun to wonder why they have to be such separate entities. One solution that has taken root in a community I visited in Peru does seem to integrate the “traditional” with the “modern.” This solution involves community health workers as mediators between the indigenous women and the clinical side of maternal healthcare. Brown et al. describe these health workers as working in any of the following positions: health promoters, traditional birth attendants, and traditional healers. They find that oftentimes these workers, who are in tune with indigenous concerns and able to speak Quechua, are more able to serve the women in helpful and calming ways. They also emphasize a need for the Ministry of Health to utilize community health workers as a valuable tool to bridge the gap between the government and indigenous women’s concerns (4).
Similarly, in an article by Oana M.R. Campbell and Wendy J. Graham, they find that the “best intrapartum-care strategy is likely to be one in which women routinely choose to deliver in a health center, with midwives as the main providers, but with other attendants working with them in a team” (8, p. 1291). In other words, one of the best approaches is to integrate the traditional practices with the modern facilities, in which women can feel comfortable and safe.
Understanding this divide in traditional versus modern has helped me to better understand and focus on what is important in the preservation of traditional medicine in general. This problem, the disconnect between governmental programs (such as healthcare) and the common people, is one that many countries face in one way or another. It goes way beyond just maternal healthcare in Peru, reaching all parts of the world. To me it seems that small Peruvian communities and their health workers could serve as a useful model for approaches to healthcare (and other issues) anywhere. One of the most important things I have learned throughout this research is that often the best method in terms of cultural disconnects does not necessarily mean choosing one way over another, but rather incorporation and integration. Understanding that change is inevitable but not inevitably painful is not just an important life lesson; I believe it is also a vital concept in creating programs that seek to facilitate an improved quality of life while simultaneously legitimizing and maintaining cultural traditions.
Similarly, in an article by Oana M.R. Campbell and Wendy J. Graham, they find that the “best intrapartum-care strategy is likely to be one in which women routinely choose to deliver in a health center, with midwives as the main providers, but with other attendants working with them in a team” (8, p. 1291). In other words, one of the best approaches is to integrate the traditional practices with the modern facilities, in which women can feel comfortable and safe.
Understanding this divide in traditional versus modern has helped me to better understand and focus on what is important in the preservation of traditional medicine in general. This problem, the disconnect between governmental programs (such as healthcare) and the common people, is one that many countries face in one way or another. It goes way beyond just maternal healthcare in Peru, reaching all parts of the world. To me it seems that small Peruvian communities and their health workers could serve as a useful model for approaches to healthcare (and other issues) anywhere. One of the most important things I have learned throughout this research is that often the best method in terms of cultural disconnects does not necessarily mean choosing one way over another, but rather incorporation and integration. Understanding that change is inevitable but not inevitably painful is not just an important life lesson; I believe it is also a vital concept in creating programs that seek to facilitate an improved quality of life while simultaneously legitimizing and maintaining cultural traditions.