LA PAZ, Bolivia (WOMENSENEWS)--At the entrance to the delivery wing of the Women's Hospital of La Paz, there is a thick yellow line on the floor and red "Do Not Enter" sign stuck to the wooden swinging doors.
On the other side, dozens of women are in labor, lying on single rolling beds feet apart from one another in a long drafty room while their husbands, mothers, sisters and friends wait behind the wall.
"We can't have families traipsing in and out of here," a hospital staffer said when questioned about the no-entry rule. "It's unsanitary. And what if the husband of one woman sees another woman's private parts?"
This entry ban violates Ministry of Health policy, according to officials. But it's still commonplace and, for women like Gloria Mamani, it's seen as just one of the sacrifices women in labor are asked to make in exchange for free medical care during childbirth.
"Giving birth here in the hospital seemed like the best option, in case something happened," Mamani said last December after spending 16 hours in labor in the hospital while her husband Jose and his mother waited behind the yellow line. "But it would have been much easier if I had had someone with me."
These sacrifices are making for a complex debate on what the best practices for childbirth are here in South America's poorest country.
Expanded Medical Reach
Seventy percent of maternal deaths worldwide are caused by problems such as hemorrhaging, infection and obstructed labor, according to the World Health Organization's 2005 "Make Every Mother and Child Count" report. Since those are remedied with timely medical care, the global women's health movement has for decades focused on increasing women's access to health care, particularly in poor countries.
Bolivia has done well in this regard.
Since 2003, pregnant women and children under 5 have been guaranteed free medical services under the government's Universal Maternal and Infant Insurance program. Currently over 2,000 clinics, in every municipality of the country, offer care and more than 1.5 million women and children have taken advantage of free vaccinations, prenatal care and reproductive health services over the past five years.
The system is not perfect. According to Health Ministry officials, doctors often see over 100 patients a day, medical supplies are limited and clinics are still few and far between in rural areas. But statistics have improved dramatically.
By 2004, Bolivia's national infant mortality rate had dropped from 116 deaths per 100,000 births in 1994 to 75 deaths for every 100,000 births. The maternal death rate dropped from 390 deaths per 100,000 in 1998 to 230 deaths in 2005.
For rural women who can't reach hospitals, though, the situation remains dire. In 2006, up to 600 out of every 100,000 women in rural regions were dying during labor, according to the National Institute of Statistics.
That's why women like Mamani come to hospitals, despite giving up certain comforts. There were no complications with 7-pound, 2-ounce Lucero, her firstborn, and she says she doesn't regret the decision despite being alone during labor.
Many Stay Away
Many, however, do, or have heard enough hospital horror stories to refuse to enter.
"Women often have bad experiences in hospitals," says Dr. Carmen Cornejo, director of SEDES La Paz, an agency of Bolivia's Ministry of Health. In addition to isolation during labor, mothers complain of frigid rooms, unfamiliar food and being forced onto delivery beds that Cornejo says "resemble torture devices, with all their straps and buckles and stirrups."
In 2004 the Ministry of Health released a prenatal and maternal health guide for medical providers which noted that when a woman has emotional support during labor, her chances of having a Caesarean section drop 32 percent; the rates of episiotomy, the cut made to enlarge the vaginal opening, decrease 34 percent; and the chance of natural childbirth increases by 16 percent.
But Cornejo says there's often a fundamental communication gap between doctors and their patients, especially indigenous women.
Stories told to Women's eNews range from the doctor who chided his patient for her "dirty rituals" (burying the placenta after childbirth) to the hospital that turned away a laboring woman who arrived with serious complications after she first tried to give birth at home.
This, says Ineke Dibbits, coordinator of the Bolivian Network for Humanizing Births, or Rebohupan, helps explain the high rates of home births in cities such as El Alto, the impoverished sister city of La Paz. Among El Alto's population of just under 1 million--95 percent of whom are indigenous--over half the women choose to give birth at home, despite free public maternity centers throughout the city.
Dr. Victor Conde, who works in the Women's Hospital, is involved in an effort, led by SEDES La Paz, to provide cultural sensitivity workshops for doctors and reform medical school curricula. "We get to a point where we depersonalize our work," he says. "We get overwhelmed by the number of patients and we don't treat each woman like an individual, like a human being."
Hanging on to Power
Rebohupan's Dibbits says that for many indigenous women, particularly Aymara--Bolivia's second largest ethnic group who live primarily in the highlands--traditional childbirth is one of the most empowering moments of their lives.
In a male-dominated society, she says, labor is a rare occasion when women are in total control. The husband is expected to fetch water, make food, give massages, tend to his wife's needs and look after the other children. Also, the woman has control over her body, deciding on her movement and position depending on her own comfort.
"It's that empowerment that's lost in hospitals," says Dibbits. "Here, once you are inside a medical clinic, the doctor is in control. He or she makes all the decisions concerning a woman's body, rather than the woman in labor. This, of course, is the great paradox. The Western world is supposed to represent advanced feminism, yet here Western medicine ends up disempowering women at the exact moment when their own culture empowers."
Those working to improve women's childbirth experience have coalesced around the "humanized birth," a holistic approach that aims to combine medical safety with emotional and spiritual wellbeing.
The humanized birth campaign includes doctors' sensitivity trainings, providing medical equipment to public birthing centers, advocating for midwives' assistance in hospitals and persuading hospitals to end problematic practices, such as banning family from the laboring women's bedside or forcing them to use stirrups.
But Cornejo says that progress under the administration of the country's first indigenous president, Evo Morales, has been slow at best.
Grassroots movements, like Dibbits' network, encourage solutions from the ground up and she sees hope in the rural areas. "Doctors in the countryside are the vanguard because they have learned--out of necessity--that things must be done differently."
In many countryside communities, for example, doctors come to the house when labor begins but only to observe, interfering or transferring the women to a hospital only if necessary.
"Essentially, we need to move beyond the dichotomy of home or hospital birth," Dibbits concludes. "We've got to keep bridging that divide."
Jean Friedman-Rudovsky is a freelance journalist in La Paz, Bolivia, where she reports for Time, ABC News, Radio Netherlands and others. She is the co-founder of Ukhampacha Bolivia, an online journal covering political and social movements in Latin America.
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