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Home births remain common among Indigenous women, who fear their cultural practices will not be honored in hospitals. Although the Morales administration ordered health care professionals to accommodate traditional births, they struggle to reconcile culture and safety.

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   As an Indigenous woman prepares for childbirth, she paces the width of her darkened bedroom. The light has been shut out, and she wears many layers of clothing. She is surrounded by family and friends who tend to her, bringing her warm foods and drinks. The warmth is important to her — it helps the blood flow when it should. She paces until she feels it is time and gives birth squatting or on her knees. If everything goes well, her baby enters the dimly lit world peacefully, gradually making the transition with loving family all around. The woman is tended to by her husband, mother and mother-in-law. Although the pain is great, she finds comfort in tradition.
   Most Indigenous women in Bolivia give birth at home, said Jaime Nadal Roig, Bolivia's representative for the Midwives Project for the United Nations Populations Fund, or UNFPA, its acronym in Spanish. Indigenous women often do not trust that their cultural practices will be respected in a hospital.
   "Women like that their cultural practices be respected," Lilian Calderón, coordinator of the UNFPA Midwives Project in Bolivia, said in Spanish.
   So they stay home.
   Calderón calls herself mestiza, of mixed races, but advocates widespread cultural sensitivity for Indigenous women, especially during pregnancy and childbirth. The UNFPA Midwives Project is a program coordinated with universities in Bolivia that recruits and trains men and women in rural Bolivia to become midwives and return to serve those rural areas. It is a program that gives knowledge to the people, empowering them to retain their culture while reducing infant and maternal mortality.
   Infant mortality rates include any infant who dies before reaching 1 year of age. Bolivia has the highest infant mortality rate in South America, and maternal mortality in Bolivia is also one of the highest in the world.
   Risks of complications during childbirth always exist, but when giving birth at home, those complications have greater consequences. A baby could be positioned incorrectly for birth, hemorrhaging could occur, or the umbilical cord could be wrapped around the baby's neck, Calderón noted. At home, family members or midwives might not know what to do in complicated situations. They might not know what a doctor would know.
   "Often times doctors do not reach these rural communities," Nadal said in Spanish. "The community needs someone who is skilled at delivering births."

Delia Cañari takes a break from selling nuts to talk to her son Cory. Cañari experienced traditional births for both her sons with the help of her husband and mother-in-law. [patrick breen]

Scope of tradition
   Indigenous women often choose to give birth at home without doctors because they fear their cultural practices related to giving birth will not be respected, such as keeping warm, drinking certain herbs and delivering in a squatting or kneeling position.
For safety and sanitation reasons, babies born in hospitals are exposed to bright lights, latex-laden hands and men and women in surgical masks. Usually, the woman is covered only with a hospital gown, and she is offered cold liquids in place of hot infusions of different plants. The doctor decides when the woman should begin pushing, even inducing contractions if necessary. The doctors make medical decisions quickly, especially if the baby or mother's life is in danger. After the baby is safely delivered, the umbilical cord is cut with metal scissors instead of ceramic; Indigenous women believe this destines the child to be wasteful and ungrateful. Finally, the baby is inspected, prodded and measured to ensure good health.
   Many Indigenous women want their babies to be part of Indigenous culture from birth, but sometimes these babies have complicated births and without help from professional healthcare workers, they die.
   "It is very painful to watch mothers and newborns die because of situations that are preventable and don't require much money," Roxana Silva Huanca, a student in the Midwives Project, said in Spanish. "But in the hospital as a patient they treat you badly, they don't dispel all your doubts, and above all you don't know what the end is like."
   But Silva said she believes the system will change for the better gradually with help from the government and the UNFPA Midwives Project. Zulma Chura, a Quechua woman, is also a student in the Midwives Project. She lived in Jaran, a community in rural Bolivia just outside of Pocoata, before attending the university. She too has seen mothers and babies die as the result of complications during childbirth.
   "One must protect life above all and not care about the region nor the culture and, above all, the social class to which a person belongs," Chura said in Spanish.

Seeking understanding
   Hugo Pérez García, director of the Women's Hospital, or Hospital de la Mujer, said each Indigenous region has a slightly varied version of "squatting labor."
   "For instance, for labor in the eastern region of the country, women are tied from their hands in a high place. She is lifted up, and in the moment of birth when the placenta is visible, they take the umbilical cord and it is wrapped around the thumb finger," Pérez said in Spanish. The placenta must be discharged after birth, and this helps encourage the process.
   Doctors can be reluctant to accept traditional ways of childbirth, not out of malice or prejudice, but because of a breach of comfort. They have been trained to deliver babies in a certain way to ensure safety, cleanliness and efficiency. Since the new constitution was written under Evo Morales' presidency, however, it has become law that women can give birth in traditional ways at hospitals. Pérez feels that although some doctors are still hesitant, hospitals are slowly becoming accustomed to allowing these traditional births.
   Morales' administration has implemented a motherchild subsidy program to try to convince women to seek professional prenatal and postnatal care. The Health Ministry's Universal Insurance for Mothers and Children, or SUMI, for its Spanish acronym, additionally ensures free care for mothers giving birth at any hospital in the country. Furthermore, hospitals are beginning to adopt "humanized" care plans that consider Indigenous people's culture and beliefs.

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  • Story by Ellen Hirst
  • Photos by Patrick Breen

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