Peru: Midwifery on High

by Ruth Madison

© 2002 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 61, Spring 2002.]

Machu Picchu. The imperial capital at Cuzco. The Incan Empire.

These are some of the images that come to mind when one mentions the country of Peru. I had the opportunity to work three years (1997-2000) in the department of Apurimac, Peru as director of a Child Survival Project. It was an incredible public health experience that deepened my nascent interest in midwifery.

A Child Survival Project works on public health interventions that have been proven to reduce infant mortality. These typically include vaccinations, access to care in cases of diarrhea and pneumonia, and may include growth monitoring, nutrition and other topics. Our project included diarrhea, pneumonia and growth monitoring/nutrition interventions, and we also worked on maternal health issues. The project was based in the approximately 140 communities in the province of Cotabambas, Apurimac, and focused on training community health workers (promotores), traditional birth attendants (parteras) and some traditional healers (hampiq runas in Quechua.) The project staff trained the promotores and hampiq runas in effective ways to treat diarrhea with and without signs of dehydration, and pneumonia, as these two diseases were the two primary killers of children under 5 in the zone and in most parts of the developing world. Project staff also trained promotores to refer mothers to the health posts for vaccines, growth monitoring checkups and enrollment in nutrition programs sponsored by the Fujimori government.

Our maternal health component included work with parteras, and was centered on teaching them the signos de alarma (danger signs) during pregnancy and how to refer those moms to the local health center for follow-up with the professional midwife on staff. The danger signs included swelling of hands and/or face, loss of blood, no movement of the fetus, headaches and attacks (signs of preeclampsia). Later on, the project was also able to give most parteras a kit de parto limpio (clean birth kit), which included soap, string to tie the umbilical cord, plastic for the delivery area and a razor. All health education was presented in Quechua, the language of the population.

It was a difficult assignment, to say the least. The project zone was in the Andes Mountains, with target communities located between 10,000 and 14,000 feet above sea level. Secondly, some of these communities had been hit by the terrorist group Sendero Luminoso and were reluctant to participate in a community health project sponsored by a non-governmental organization from overseas. Thirdly, the zone was characterized by the Ministry of Health and other government institutions as one of extrema pobreza, or extreme poverty. To say that help was needed in the zone was an understatement. To say the project would receive support from the community was another matter altogether.

Many individuals who have worked overseas can attest to the fact that health projects will not be productive if a working and productive relationship with the local Ministry of Health (MOH) does not exist. By this, I do not mean bribes or economic incentives. The people I worked with in the Ministry of Health in Abancay were professional in every way and helped me to understand the challenges public health professionals face in developing countries.

The MOH, as it is known by its initials in Spanish, is an entity similar to our Department of Health, but they work by departments (similar to our states). The MOH is responsible for hiring staff to work in the health posts (puestos), health centers (centros) and hospitals and convincing newly trained doctors, nurses and professional midwives to go to the rural posts to work. This convincing is facilitated by the existence of a directiva, or order known as SERUMS (Servicio Rural Urban Marginalizado en Salud) where all health professionals must spend a year in either an urban or rural underserved area. It is known that most people from the cities (Lima, Trujillo, Cusco, etc.) do not want to go to the rural areas, known in Spanish as el campo. That problem was exacerbated in the project zone because most health professionals do not speak Quechua, the language of the indigenous majority.

Our project was the first of its kind in the department of Apurimac. The catholic non-governmental organization Caritas was working in some of the communities in the project zone, but had limited staff and resources and focused primarily on nutrition. Convincing the MOH that promotores could improve the health of the populations was a hard sell, but other positive experiences with health promoters and parteras in other Peruvian departments such as Cajamarca and Trujillo, helped to convince them. But working with parteras was a whole other battle.

In Peru, a university-trained midwife is called an obstetriz (obsretra if male). A partera is the community midwife without formal university training. The relationship between obstetrics and parteras was nonexistent in most cases (when each acted as though the other didn't exist) or rocky when existence was acknowledged by both parties. Before exploring the problems in the relationship between obstetrices and parteras, let's take a brief look at the history of midwifery in Peru.

The midwifery profession was established in Peru on October 10, 1826* by a Supreme Decree and the first College of Births (Colegio de Partos) was formed. On January 9, 1895, the Colegio de Partos was incorporated into the medical school of the University of San Marcos, with university training the sole manner of becoming a midwife in Peru. In actuality, Peru has over 11,000 university-trained midwives. Training to become a midwife in Peru lasts 5 years and in the medical hierarchy, the midwife is usually in charge in the absence of the doctor.

By the second year of the project (1998), the province of Cotabambas, which had 21 health establishments, had the horrific distinction of being the province within Apurimac with the most maternal deaths. Of the 11 reported maternal deaths in Apurimac, eight took place in Cotabambas. With extreme pressure from the Central office of the Ministry of Health (MINSA Central) in Lima to do something, the MOH in Apurimac was struggling for solutions. One solution I suggested, to the anger of the Coordinator of the Maternal-Perinatal program, was for the obstetrices and parteras to start to work together. The number one reason that our moms were dying was from postpartum hemorrhage—some community midwives did not know how to perform a manual removal of the placenta or how to stop the bleeding. I had suggested to the Maternal-Child Health Coordinator for Apurimac that a working relationship with parteras be formed by the obstetrices in the health posts, but this idea was met with ridicule. I was reminded that the maternal deaths were the fault of the parteras and that parteras needed to be eliminated from Peru. Instead of looking for a solution, more drastic measures were proposed by the Health Ministry. Most of the "solutions" were punitive in nature and directed at the mother and the community midwife. One that was infamous in our zone was the multa, or fine.

The head male midwife in one of the health centers had devised a strategy to increase the number of deliveries in his health post. Any mother that did not deliver in his health post would be fined $25 nuevos soles, about $8 U.S. Furthermore, mothers would be unable to obtain the birth certificate for that child until this amount was paid. This was preposterous, because most of the population are subsistence farmers and don't have much cash, and it was also against established MOH norms and UNICEF's Rights of the Child, specifically the Right to a Name. As the child had no birth certificate, he had no name, and therefore, did not exist.

Not surprisingly, in the first few months, the strategy worked. More mothers were coming in to the health posts for their deliveries, at great financial cost to them. When mothers were forced to come to the health posts, upon returning home they were informed that some of their cattle had been stolen, or that they would have to reimburse the family or community members for taking care of the house in their absence. Mothers in the project zone were comfortable using community midwives because of the economic benefit they provided. Also, when a mother gives birth at home, she is able to make sure her animals are tended to, that her children are fed, and she can pay the midwife in kind with food, a sheep or a goat.

I had the opportunity to complain to one of the doctors who work for UNICEF about the policy of this midwife. During a local training where doctors and midwives from surrounding health posts were in attendance, the UNICEF representative confronted the midwife about the illegality of his strategy to fine mothers for not giving birth in the health centers. The policy was immediately dropped.

I had been in Peru long enough to realize that if used by the women in the area, the professional midwives in the health centers could prevent a lot of the maternal and infant mortality in the zone. Building on the working relationship I had with the zone's professional midwives, I created a monthly study circle for them, using CARE's manual, Promoviendo la Calidad del Cuidado Materno v del Recien Nacido (Promoting Quality Maternal and Newborn Care). Most of the mothers felt more confident with the female midwives (yes, there are many male midwives in Peru and other developing countries). The midwife could use this confidence to assure that the mother was taking care of herself and make sure the child was referred to the nurse for vaccines, growth monitoring or other services as needed.

UNICEF wanted to begin a small-scale intervention in the project area, called Adecuacion Cultural or Cultural Adaptation in Maternal Health. What a perfect compliment to the CARE manual! This program trained doctors and midwives in what many of the midwives in the United States and Europe already know: that mothers have fewer problems with delivery if they are at home; that the area needs to be warm and private, not like a normal health post where everyone is walking in and out of the delivery room and the lights are bright; that most women prefer female providers; and that most women want family members inside the delivery room. This program was directed to doctors and midwives in the zone with the intention of incorporating these "truths" into delivery practice.

Working with UNICEF, the project was able to help the Ministry of Health implement workshops to finally look at birth from the perspective of the mother. After constant discussion with the higher level doctors within the Ministry, the project revealed that nowhere in MINSA documents does it state that all births must take place in the health post. What they do stipulate is that health professionals should be attending the majority of births. That meant that it could be in the home, with the obstetriz!

Meanwhile, in the study circle, the professional midwives were receptive to the idea of parto supervisado or supervised birth. It is a practice that many midwives have used with great success.

In a supervised birth, both the partera and the obstetriz are present in the home or health center with the mother during delivery. In ideal circumstances, where there is sufficient trust between the partera and the obstetriz, the partera would actually attend the birth, with the obstetriz present. If any complications arose, the obstetriz would take over.

The obstetrices and most parteras liked this arrangement but in rural health there are many challenges that limit its full implementation. There aren't enough midwives in Peru (or the world) to fill the needs of all pregnant women. Secondly, most obstetrices are only in the rural areas a short time; most yearn to be in the cities where they are closer to their own families. Thirdly, it takes a lot of time to develop a trusting relationship between obstetriz and partera. Lastly, some in the Ministry of Health don't see supervised birth as a wise use of very limited health resources.

Experience has shown that most obstetrices who work with parteras are informed early on of pregnant woman in the community, thereby improving the chance for early and continued prenatal care. Parteras have much more respect and trust in the community and it would behoove obstetrices to try and work with them. Nothing will more quickly sabotage the career of an obstetriz than an angry partera!

By the third year of the project, the number of reported maternal deaths was down dramatically. Most mothers in the zone had been visited by project staff and the community health workers and now knew the warning signs during pregnancy. UNICEF as well as the European Community were building Maternal Waiting Homes (Casas de Espera) where women who were close to their delivery date could wait, to assure they would have access to care during delivery. The department of Apurimac is improving but more still needs to be done.

It is still an uphill battle in many parts of the world to deliver basic maternal-child health services—never mind the kind of health care that honors women during birth. I think it vitally important for midwives from all over the world to continue to share their wisdom with each other and to strive to keep birth sacred everywhere.

Ruth Madison, MPH, was project director in Apurimac, Peru for 3 years (1997-2000) and is planning to study midwifery in the near future.

*Source: Facultad de Medicina, Universidad Nacional de Medicina de San Marcos, Seminario Curricular: 13.

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