A REVIEW OF MATERNAL MORTALITY AND MATERNAL HEALTH OUTCOMES IN
BOLIVIA AND CHILE
by
Melanie Nicole Grafals
BS Political Science, University of Central Florida, 2010
Submitted to the Graduate Faculty of
Behavioral and Community Health Sciences
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2014
i
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Melanie Nicole Grafals
on
April 25, 2014
and approved by
Essay Advisor:
Martha Ann Terry, PhD
_________________________________
Assistant Professor and Director, MPH Program
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Tammy M. Haley PhD, CRNP
_________________________________
Assistant Professor of Nursing, RN-BSN Program Coordinator
Division of Biological and Health Sciences
University of Pittsburgh at Bradford
ii
Copyright © by Melanie Nicole Grafals
2014
iii
Martha Ann Terry, PhD
A REVIEW OF MATERNAL MORTALITY AND MATERNAL HEALTH
OUTCOMES IN BOLIVIA AND CHILE
Melanie Nicole Grafals, MPH
University of Pittsburgh, 2014
ABSTRACT
Globally, 287,000 women die every year from pregnancy-related complications. In Latin
America, despite improvements in maternal health, not all countries have been successful in
reducing the rate of maternal mortality. This essay reviews existing literature regarding the
maternal health situations in Bolivia and in Chile. In Bolivia, the high rate of maternal mortality
is an issue of great public health significance. Chile, on the other hand, has been much more
effective in reducing maternal related deaths. By providing a context of the historical, social,
political, economic, and health care-related factors in these and other Latin American countries,
this essay discusses interventions that have been effective in morbidity and mortality reduction,
and interventions that have stalled or failed. Finally, the essay provides recommendations for
future maternal health interventions in both Bolivia and Chile. If culturally appropriate maternal
health and educational programs are implemented, the lives of countless women can be saved.
iv
TABLE OF CONTENTS
1.0
INTRODUCTION................................................................................................................ 1
2.0
BACKGROUND .................................................................................................................. 3
2.1 MATERNAL MORTALITY ...................................................................................... 3
2.2 LATIN AMERICA: SELECTED COUNTRY PROFILES .................................... 7
2.3 COUNTRY PROFILE: BOLIVIA .......................................................................... 14
2.4 COUNTRY PROFILE: CHILE ............................................................................... 22
3.0
METHODS ......................................................................................................................... 31
4.0
RESULTS ........................................................................................................................... 33
4.1 BOLIVIAN INTERVENTIONS .............................................................................. 33
4.2 CHILEAN INTERVENTIONS ................................................................................ 39
5.0
DISCUSSION ..................................................................................................................... 43
6.0
CONCLUSION .................................................................................................................. 48
BIBLIOGRAPHY ....................................................................................................................... 53
v
LIST OF FIGURES
Figure 1. Maternal Mortality Rate in Latin America ...................................................................... 8
Figure 2. GDP in Latin America ..................................................................................................... 9
Figure 3. Healthcare Expenditure (% of GDP) ............................................................................. 10
Figure 4. GDP Per Capita ............................................................................................................. 10
Figure 5. Map of Bolivia ............................................................................................................... 15
Figure 6. Map of Chile .................................................................................................................. 23
vi
PREFACE
I would like to thank my mother, father, and sister for loving and supporting me and for dealing
with cranky phone calls whenever I experienced writer’s block. I also thank my boyfriend
Bradley, for the encouragement, the countless pep talks and for keeping me company as I wrote.
I am thankful for my friends for their never-ending belief in me. I am grateful for the direction
and input from Dr. Tammy Haley, regardless of the distance between us from Bradford to
Pittsburgh. Lastly, I thank my advisor, Dr. Martha Terry, who from day one has been my fiercest
advocate. I am so grateful for her support, guidance, compassion, humor, and love.
vii
1.0
INTRODUCTION
Maternal mortality is an indicator for the overall health of a population [1]. Maternal
mortality rates vary around the world and are impacted by a many factors. Estonia has the lowest
maternal mortality rate globally, at two deaths per 100,000 live births. South Sudan has the
highest at 2,054 deaths per 100,000 live births [2]. In fact, Sub Saharan Africa has the highest
rates of maternal death in the world [1]. While Latin America is not experiencing levels
comparable to South Sudan, there is still great suffering occurring in the region as a result of
pregnancy and childbirth [3]. Bolivia is the Latin American country with the highest maternal
mortality, at number 58 of 184 countries ranked by the Central Intelligence Agency (CIA). Chile,
on the other hand, has some of the best maternal health outcomes in Latin America and ranks
131 out of 184 on the same scale of global maternal mortality rates [2].
This essay explores why such disparity exists between Bolivia and Chile. The
background puts these two countries in perspective by providing contextual material on other
Latin American countries that also share Spanish colonial histories and Christian traditions.
Economy, culture, government, history, health care, and the role of women will be explored in
depth in this section to better understand the current environment in Bolivia and Chile. This
essay also identifies which segments of the populations are experiencing the worst maternalhealth related problems.
1
The results section highlights maternal health interventions that have been implemented
in Bolivia and Chile and what the outcomes of each program are. The discussion section
analyzes what the results indicate for the future of maternal health in each country. Lastly, the
conclusion of the essay provides recommendations for future interventions to improve maternal
health.
2
2.0
2.1
BACKGROUND
MATERNAL MORTALITY
Maternal mortality is defined as “the death of women during pregnancy, childbirth, or in
the 42 days after delivery” [4, pg. 1609]. The maternal mortality ratio is the measure most
frequently used to define maternal mortality; it is the number of maternal deaths per live birth
that occur in the same time period [5]. Another commonly used measure is the maternal
mortality rate. It is the number of maternal deaths in a population divided by the number of
women of reproductive age (15-49 years old) that are alive during the specific period of interest
[6]. The main causes of maternal mortality worldwide are complications that arise during and
after pregnancy and delivery [7]. These complications include hemorrhaging (particularly after
childbirth), infection, pre-eclampsia, eclampsia, and abortion. Additionally, diseases such as HIV
or malaria cause maternal mortality [7].
Globally, 287,000 women die every year from pregnancy-related complications [8]. In
developing parts of the world, approximately 222 million women are not using modern
contraception, despite wanting to avoid pregnancy. If these women were able to access
contraceptives, an estimated 79,000 maternal deaths would be avoided [8]. Maternal mortality
impacts the global economy; annually, about $15 million in productivity is lost as a result of
slowed or stalled economic growth because of the death of women during pregnancy or shortly
3
after pregnancy. Health of a newborn is closely linked to that of the mother [8]. The death of a
mother can disrupt the functioning of the family unit. Oftentimes, if she leaves behind a newborn
or any other young children, they will be in a defenseless position without her [9].
The majority of maternal deaths are preventable. Increased access to antenatal care,
skilled birth attendants, and support following delivery are necessary to improve maternal health
[7]. Proper nutrition, adequate health care and family planning services can also prevent maternal
deaths [10].
The barriers that prohibit women from accessing the care that they need during
pregnancy and delivery can be the result of poverty, inadequate information, cultural practices,
and distance to health care facilities [7]. Even though achievements have been made worldwide
to reduce poverty, there are still 1.2 billion people living in extreme poverty [11]. According to a
Demographic and Health Survey (DHS) conducted in the 1990s, an analysis of 55 countries
showed that women in the poorest quintile were 5.2 times less likely to deliver with a doctor,
nurse, or skilled attendant present than women in the riches quintile. Women living in the
poorest regions of the world have the lowest maternal health care access and utilization [12].
Poverty is one of the main reasons why girls do not receive education [13]. Women who
are uneducated are 2.7 times at a greater risk of maternal mortality than those who receive
education. Even among women who are educated, those with one to six years of education have
twice the risk of maternal mortality than women with more than 12 years of education [10]. A
woman’s level of education is likely to be associated with marriage at an older age and
contraception use, which correlates to lower fertility [14]. More educated women are also less
likely to develop complications during pregnancy because they tend to be in better health prior to
4
becoming pregnant than less educated women. Education may also impact a woman’s decision to
seek care in the event of an obstetric complication [14].
Violence towards women and girls and practices like child marriage prevent girls from
receiving education and contribute to poor health outcomes [13]. Gender inequality affects
women through discrimination, infringement of autonomy, lack of income control, prohibiting
involvement in social networks, and perpetuating violence [12]. Together these factors impact a
woman’s ability and choice to seek and effectively utilize maternal health services. Cultural
practices and social norms may place young women at a great disadvantage because of
traditional marriage age. It is estimated that 17 million women globally are married before the
age of 20, primarily in low-income countries [12]. Marriage at a young age is often indicative of
young age at first child birth and high fertility, both of which are linked to maternal mortality and
maternal morbidity [12].
An important framework in maternal mortality is the three delays model [15, 16]. The
model defines three phases that explain the major delays in receiving emergency care from the
onset of pregnancy complications to the availability of treatment. The first phase is the delay in
the decision of the woman or her family to get care [15]. The second delay is in reaching the
health care facility. This could be a problem because of isolation or lack of transportation [16].
The third delay takes place at the health facility, where oftentimes women do not receive
adequate and/or necessary care [15, 16]. One or any combination of these delays can contribute
to a woman’s death [15].
In 2000, the international community and development institutions established the United
Nations Millennium Development Goals (MDGs). The MDGs were created as a roadmap to end
poverty and improve global health. There are eight MDGs; eradicate extreme poverty and
5
hunger, achieve universal primary education, promote gender equality and empower women,
reduce child mortality, improve maternal health, combat HIV/AIDS, malaria and other diseases,
ensure environmental sustainability, and global partnership for development. All of these goals
have measurable, time-specific targets to be accomplished by 2015 [17].
The fifth MDG is to improve maternal health. Its aim is to reduce the maternal mortality
ratio “by three quarters, between 1990 and 2015” and by 2015 to gain “universal access to
reproductive health” [10]. Despite having reduced maternal mortality by 47% worldwide in the
last 20 years, achieving the fifth MDG by 2015 is unlikely without more political will [10].
In developing areas, only half of pregnant women “receive the recommended minimum
of four antenatal care visits” [10]. In 2011, of the approximately 120 million babies born [18], 47
million were delivered without a skilled birth attendant present [10]. To combat global maternal
mortality, contraceptive use must increase, education for girls and women must become a top
priority, having a skilled birth attendant present at birth needs to expand to rural areas, and
“emergency obstetric care” must be made available to all pregnant women [10]. Increasing the
coverage of contraceptives and family planning services prevents unwanted pregnancies and
subsequent pregnancy complications. Providing universal access to maternal health services is
crucial throughout preconception, antenatal and post-partum periods. In addition to increasing
the presence of a skilled birth attendant during childbirth, it is critical that the availability of 24hour medical staff be increased to provide assistance during obstetric complications [19].
6
2.2
LATIN AMERICA: SELECTED COUNTRY PROFILES
While the main focus of this paper is to discuss maternal health and mortality in Bolivia
and Chile, selected Latin American countries are reviewed to put the Bolivian and Chilean
experiences in context. The countries discussed share a Spanish colonial past and have similar
cultural characteristics. Despite important improvements in maternal mortality reduction, not all
Latin American countries have been successful in reaching Millennium Development Goal 5
[20]. The Pan American Health Organization (PAHO) has identified some of the difficulties that
these countries are facing and how to overcome them, including reducing economic barriers,
providing universal access to health care and high quality health care from conception to birth,
improving the identification system for pregnancy complications and obstetric emergencies,
investing in infrastructure, improving drug distribution to mothers, and providing safe medical
care for abortions, among others [3].
Usually nutritional deficiencies, education, and socioeconomic conditions are at play
when a country has a maternal mortality rate of more than 20 per 100,000 live births [3]. All of
the Latin American countries discussed in this paper have a maternal mortality rate higher than
20 per 100,000 (see Figure 1). Bolivia and Chile have the highest and lowest rates of maternal
mortality in Latin America, respectfully. Both countries will be discussed in depth in the
following sections.
7
Maternal Mortality Rate Per 100,000
Chile
Uruguay
Peru
Argentina
Venezuela
Maternal Mortality Rate Per
100,000
Colombia
Paraguay
Ecuador
Bolivia
0
50
100
150
200
Information from CIA World Factbook
Figure 1. Maternal Mortality Rate in Latin America
Argentina is located between Chile and Uruguay and borders the South Atlantic Ocean.
The population of the country is estimated to be 43,024,374 as of July 2014 [21]. Argentina is
overwhelmingly Roman Catholic at 92%, although about 20% do not practice. Protestants make
up 2% of the population, as do people who practice Judaism. Argentinians are primarily
ethnically white (97%), being a mix of Spanish and Italian. The remainder of the population is
mestizo or Amerindian. The official language is Spanish, but Italian, French, German, English,
Quechua, and Mapudungun are also used [21].
The Argentinian maternal mortality rate between 2000-2008 was approximately 42 per
100,000. In 2009, it increased over 38.5% because of the H1N1 influenza epidemic that affected
all parts of the country, especially pregnant women who were particularly vulnerable [22]. In
2010, the maternal mortality ratio was 77 per 100,000 [21]. Despite progress made to reduce
maternal mortality by 2015, Argentina is not expected to reach MDG 5 [23]. Between 2004-
8
2005, the contraceptive prevalence rate was 78.9 [21]. A recent PAHO report found that 93% of
women had used contraception at some point and 78% used some form of contraception before
giving birth to their first child [22]. Between 2003 and 2008, pregnancy among adolescent girls
increased from 13.6% to 15.4% [22]. The total fertility rate in Argentina is 2.25 children per
woman. Of Argentina’s $771 billion GDP, 8.1$ is spent on health expenditures (Figure 2 and
Figure 3 for country comparisons). The GDP per capita in Argentina is $18,600 [21] (see Figure
4 for country comparisons).
GDP
$900.00
$800.00
$700.00
$600.00
$500.00
$400.00
GDP (Billions)
$300.00
$200.00
$100.00
$0.00
Information from CIA World Factbook
Figure 2. GDP in Latin America
9
Healthcare Expenditure (% of GDP)
12.00%
10.00%
8.00%
6.00%
4.00%
Healthcare Expenditure (%)
2.00%
0.00%
Information from CIA World Factbook
Figure 3. Healthcare Expenditure (% of GDP)
GDP Per Capita
$25,000
$20,000
$15,000
$10,000
GDP Per Capita
$5,000
$-
Information from CIA World Factbook
Figure 4. GDP Per Capita
Colombia is located in northern South America, with the Caribbean Sea to the north, the
North Pacific Ocean to the west, and is surrounded by Venezuela, Panama, and Ecuador. The
population of Colombia is estimated to reach 46,245,297 by July 2014 [24]. The official
10
language is Spanish and the population is 90% Catholic. Ethnically, Colombia is diversified;
58% of the population is mestizo, 20% is white, 14% is mulatto, 4% is black, 3% is Amerindianblack mixed, and 1% is Amerindian [24].
In 2010, the maternal mortality rate in Colombia was 92 deaths per 100,000 live births.
Colombia has not made enough progress to meet MDG 5 by 2015 [23]. The total fertility rate is
2.07 children per woman and the average age of the mother at first birth is 21.4 years old. In
2010, the contraceptive prevalence rate was 79.1% [24]. Fluctuations in maternal mortality and
total fertility rate in Colombia are found between rural/urban and developed/underdeveloped
regions [25]. The GDP of Colombia is $526.5 billion, of which, 6.1% is designated for health
expenditures. The GDP per capita of the country is $11,100 [24].
Ecuador is located between Peru and Colombia and the Pacific Ocean to the west [26].
The population is estimated to be about 15,654,411, 95% of which is Roman Catholic.
Ethnically, Ecuador is almost 72% mestizo, 7.4% Montubio, 7.2% Afroecuadorian, 7%
Amerindian, and about 6% white. Castilian Spanish is the official language, spoken by 93% of
the population. Additionally, indigenous languages like Quechua are also used [26].
In 2010, the Ecuadorian maternal mortality rate was 110 deaths per 100,000 live births
[26], making it one of the highest in the region, second only to Bolivia (see Table 1). Ecuador
has not made enough progress in maternal mortality reduction to meet the fifth MDG by 2015
[23]. Non-indigenous women are more likely to deliver in institutions while indigenous women
usually give birth at home [27]. As of 2004, the mean age at a woman’s first birth was 21.8 years
old. The total fertility rate in Ecuador is 2.29 per woman [26]. The contraceptive prevalence rate
in 2004 was 72.7%. Of Ecuador’s $157.6 billion GDP, 7.3% is used for health care expenditures.
The GDP per capita as of 2013 was $10,600 [26].
11
Paraguay is centrally located in South America, southwest of Brazil and northeast of
Argentina. The population of 6,703,860 speaks Spanish and Guarani, both of which are the
official languages. Ninety five percent of the population is mestizo. Religiously, 89.6% of the
country is Roman Catholic, and 6.2% is Protestant [28].
Paraguay is facing high maternal mortality; in 2010, the rate was 99 deaths per 100,000
live births [28]. In order for Paraguay to meet MDG 5 by 2015, it would need to reduce the
maternal mortality rate to 37.5 per 100,000 [29]. A PAHO report found that in 2008, over 90%
of maternal deaths happened in health care facilities. Of these deaths, 60% occurred when fewer
health care workers were present, in the early morning hours or late in the evening [29]. The
contraception prevalence rate as of 2008 was 79.4% and the mean age of the mother at first birth
was 22.9. The total fertility rate is estimated to be 1.96 children per woman. The GDP of
Paraguay is $45.9 billion, of which 9.7% is allocated for health expenditures. Per capita GDP is
$6,800 [28].
Peru is situated in western South America, bordered by the Pacific Ocean, between
Ecuador and Chile. Over 80% of the population of 30,147,935 is Roman Catholic and 12.5% of
the population is Evangelical [30]. Peru is an ethnically diverse country; 45% Amerindian, 37%
mestizo, 25% white, and 3% black, Chinese and Japanese. The official languages are Spanish,
Quechua, and Aymara [30].
The maternal mortality rate in Peru is 67/100,000 live births. The estimated total fertility
rate of the country is 2.22 children per woman and the mother’s mean age at her first birth is 22.3
years. Peru’s contraceptive prevalence is 68.9% [30]. Most maternal deaths in Peru are among
rural, poor, indigenous women. Since 2000, the country has made enormous progress in reducing
maternal mortality from 185 deaths/100,000 live births. These improvements can be attributed to
12
institutional birth increases, the implementation of culturally sensitive childbirth and pregnancy
care, and the proliferation of birthing homes for pregnant women [31]. Despite this impressive
progress, Peru is not likely to reach the fifth Millennium Development Goal [23]. Of the $344
billion GDP of Peru, 4.8% is spent on health expenditures. The GDP per capita is $11,100 [30].
Uruguay is located in southern South America, between Argentina and Brazil and borders
the South Atlantic Ocean to the south. The population as of 2013 was 3,324,460, of which more
than half is Christian. Spanish is its official language. Ethnically, the country is primarily white
(88%), mestizo (8%), and black (4%). The entire nation has access to clean drinking water,
making it a rarity in the area [32].
In terms of maternal mortality, Uruguay has one of the lowest rates in the region, at 29
per 100,000 live births [32]. The contraceptive prevalence rate is 77% and the total fertility rate
is 1.86 children born per woman. The Uruguayan government has taken steps to ensure that the
country is on track to reach the 5th Millennium Development Goal by 2015. Among these are
policies to improve the quality of care that women receive during pregnancy and delivery and
free contraceptives [33]. Perhaps the factor most important in reducing maternal mortality in
Uruguay in recent years is the decriminalization of abortion. A bill was passed which allows for
elective abortion up until the third month of pregnancy, even for reasons such as extreme poverty
[34]. The country spends 8% of its $56.27 billion GDP on health expenditures and GDP per
capita is $16,600 [32].
Venezuela is located between Colombia and Guyana, bordering the Caribbean Sea to the
north [35]. Ethnically, the population of 28,868,486 is two-thirds mestizo, one-fifth European,
and one-tenth African [35, 36]. Roman Catholicism is practiced by 96% of Venezuela. Spanish is
the official language but various indigenous dialects are also spoken [35].
13
As of 2010, Venezuela’s maternal mortality rate was 92 per 100,000 [35]. Though
improvements have been made, it is unlikely that Venezuela will reach the fifth MDG target
[23]. A program called Proyecto Madre (Mother Project) was implemented in the country in
2006 with the goal of providing access to contraception, obstetric care, transportation services to
pregnant women, and prenatal care. The program was reintroduced in 2009 as Mision Nino Jesus
(Christ Child Project) [37]. The total fertility rate in Venezuela is 2.35 children per woman. In
1998, the contraception prevalence rate was 70.3%. 5.2% of the $407.4 billion GDP of the
country is designated for health expenditure. The GDP per capita is $13,600 [35].
2.3
COUNTRY PROFILE: BOLIVIA
The focus of this paper is on Bolivia and Chile. Their country profiles are presented here.
Bolivia is a landlocked country located in central South America, bordered by Chile to the
southwest, Paraguay and Argentina to the south, Peru to the west, and Brazil to the east and north
(see Figure 5). The Andes Mountains and the Amazon Basin are part of the unique terrain of the
1,098,581 square km region. The population is estimated to be about 10,461,053 [38]. The
country is divided into nine administrative departments including: La Paz, Santa Cruz,
Cochabamba, Potosí, Chuquisaca, Oruro, Tarija, Beni, and Pando [39]. Beni, Pando, Santa Cruz
and Tarija are non-indigenous departments while Chuquisaca, Cochabamba, La Paz, Potosí, and
Oruro are home to indigenous populations [40].
14
Reproduced from CIA World Factbook
Figure 5. Map of Bolivia
Prior to Spanish colonization in the 1500s, ancient Indian civilizations like the Tiwanaku,
Aymara, and the Inca covered the mountainous terrain of modern day Bolivia. These
civilizations utilized superior agriculture and mining practices. After the Spanish conquered the
land, they quickly exploited the rich mineral resources. In 1825, led by Simón Bolívar, Bolivia
gained its independence from Spanish domination. Since that time, Bolivia has endured many
boundary disputes with neighboring countries, the decline and rebirth of its silver industry, and
economic downturns [39].
The population of Bolivia is very diverse ethnically. There are a number of ethnic groups
in the country, including mestizo (30%), Quechua (28%), Aymara (19%), and European (12%)
[39]. The official languages are Spanish, Quechua, and Aymara [38].
15
Women in Bolivia are not treated as equals to their male counterparts. A “traditional
misogynist culture” exists and places women in roles pertaining to family care and reproduction
[41]. Violence against women and rape are widespread problems in Bolivia, and many cases go
underreported. Domestic abuse penalties are lax, oftentimes resulting in only a fine or up to four
days in jail. It is alleged by women’s rights groups in the country that authorities designated to
enforce domestic violence laws do so “irregularly” [42]. Conviction rates for rape charges are
low, although they have risen in the recent past [39]. Non-consensual sex in marriage is not
illegal [42].
Bolivia’s overall literacy rate is 91.2%, and the overall illiteracy rate is 8.8% [38]. The
illiteracy rate among women is 13.2% compared to 4.2% among men [38]. In rural areas, this
discrepancy is even greater: 37.9% for women and 14.42% for men. Males receive higher quality
education than women and are more educated than females in the country [39]. In fact, on
average, most males receive 1.5 more years of school than females [41]. The educational effect
for women can have major implications for their health, the health and well-being of their
children, and maternal mortality. Women who are educated are more likely to practice healthy
behaviors [43]. Because of the educational benefits they receive, men have better access to
higher quality health care than women. Additionally, women have less earning potential than
men, while at the same time, they take on greater responsibilities, including domestic tasks [41].
The dominant religion of Bolivia is Catholicism. Approximately 95% of the country is
Roman Catholic while the remaining 5% are Protestant and Evangelical Methodist [38]. Within
the Quechua and Aymara speaking groups, certain beliefs and rituals that stem from before
Spanish colonization are still held and practiced [44]. The Bolivian Constitution guarantees
16
religious freedom, although in many public schools Catholic direction is provided [39]. The
students, however, are not forced to attend these sessions.
Bolivia is defined as a constitutional multiparty republic. The government has three
branches: legislative, judicial, and executive. The Congress is composed of 27 Senate members
and a Chamber of Deputies with 130 members [39]. The primary function of the Congress is to
argue and approve legislation initiated by the president. Three senators are elected from every
administrative department [39].
The judicial system is comprised of the Supreme Court, and district, provincial and local
courts. The president nominates the 12 congressionally confirmed Supreme Court judges, who
serve ten-year, non-renewable terms. The Bolivian Supreme Court hears only cases of extreme
importance [39]. These cases pertain to the constitutionality of laws, decrees, and resolutions
approved by the legislative and executive branches. The Supreme Court also hears trials of
public officers, even the president, for crimes committed in office [45].
Evo Morales is the current president, having been elected from the Movement Towards
Socialism Party (Movimiento Al Socialismo- MAS) in December 2005. He is the nation’s first
ethnically indigenous leader. The president’s main responsibilities are diplomacy, control of the
armed forces, and the economic agenda [39].
There is a mandate in Bolivia to be sure that men and women are represented equally in
the selection process [42]. The mandate has worked to increase female involvement in key
governmental positions in the Senate, Congress, and Supreme Court. However, with these
positions come threats. Several women who won elections reported that they were threatened
with violence to give up their positions to men [42].
17
Bolivia is the poorest and one of the least developed countries in Latin America. In the
1980s, the country suffered massive economic turmoil. This led to the establishment of reforms
that encouraged economic growth and reduced poverty. The 2008 recession stalled growth for
the Bolivian economy, but in 2009, the Bolivian economy grew more than any other South
American country [38]. Despite this growth, there is currently a lack of foreign investment in
major economic sectors including hydrocarbons and mining [38].
Mining has been a long-established tradition in Bolivia since the time of Spanish
colonialism, when the mining capital was Potosí [44]. After the tin market crashed in the 1980s,
many miners began to grow coca leaves to sell in the cocaine trade to avoid starvation. In
Bolivian towns, many people work as street vendors, construction workers, or carpenters.
Increasingly there are more and more engineers and technicians [44].
Historically, the country tended to concentrate on production of single commodities, such
as tin and coca. In 1997, large natural gas reserves were discovered and became one of the
country’s most lucrative commodities. While Bolivia has experienced periods of economic
booms, instability in the political and agricultural sectors has stopped industry from thriving
[39]. Many Bolivian Indians living in the rural lowlands are completely excluded from the cash
economy [44].
As of 2013, Bolivia’s gross domestic product (GDP) was $58.34 billion with a real
growth rate of 6.5%. The Bolivian government spends 4.9% of its GDP on health expenditures
[38]. The gross national income (GNI) per capita in 2012 was $4,880 [46]. In 1985, Bolivia
suffered massive inflation of over 20,000%. By 1994, this rate dropped to 4.9%. However, in
that same year, the government experienced a $500 million budget deficit [39]. There are 4.724
18
million people in the labor force. The unemployment rate is 7.5%, and 49.6% of the population
lives below the poverty line [38].
While there have been increases in the number of children receiving vaccinations and
improvements in maternal mortality, there are still great inequities, especially between
indigenous and non-indigenous populations. The country is experiencing high fertility rates
while family planning services remain low. As of 2008, the contraceptive prevalence rate was
60.5%. The total fertility rate is 2.87 children per woman and the mother’s average age at first
birth is 21.2. Lack of clean water and sanitation exacerbates the already poor health of the
population [38].
Bolivia has several pressing public health concerns. Chagas disease, yellow fever,
malaria, tuberculosis, leishmaniasis and other communicable diseases are found in the country,
especially among the indigenous populations [47]. PAHO estimates that about 22% of the
population is infected with Chagas [48]. In 2010, the leading causes of mortality in Bolivia were
communicable, maternal, perinatal, and nutritional conditions (35%), cardiovascular disease
(22%), other noncommunicable diseases (19%), cancers (8%), injuries (8%), respiratory diseases
(5%), and diabetes (3%) [49] Within the Latin American/Caribbean region, Bolivia has one of
the highest rates of sexually transmitted diseases [48]. While the incidence of syphilis has
decreased from 4.2% to 1.1% and gonorrhea has dropped from 6.8% to 2.7%, chlamydia in
Bolivia has increased from 7.8% in 2001 to 13% in 2004 [50]. HIV prevalence is also on the rise,
especially among men who have sex with men [48]. In fact, Bolivia is classified as having a
“concentrated [HIV] epidemic” because high-risk groups have a prevalence rate higher than 5%
[50, pg. 120]. Infant mortality is ranked third highest in the region as a result of nutritional
deficiencies, lack of healthcare knowledge, and socioeconomic status [48, 51]. Proper sanitation
19
and access to medical services are lacking in rural Bolivia. Inhabitants of these areas are more
susceptible to illness because sanitation and safe drinking water are available to only 20% of the
rural populations [44].
Abortion is illegal in Bolivia. There are, however, instances when an abortion can be
performed under the law. In cases of rape or incest, to save the mother’s life, or to maintain
physical and mental health of the woman, an abortion can be performed by a doctor with judicial
permission [52]. In cases of incest or rape, an abortion can be obtained through legal action [52].
Abortion is not permitted on the grounds of fetal impairment, economic or social reasons or by
request [52].
The healthcare system in Bolivia is comprised of three components; the private sector,
the public sector and social security. The private sector is the smallest of the three and is made
up of private practitioners, clinics run by non-profit organizations, and traditional medicine. The
public sector focuses on the health of mothers, children, and the elderly. This sector is extremely
limited in capacity because of lack of resources. The social security sector is utilized by
Bolivians who are employed in the formal economy and offers coverage for diseases,
occupational risks, prenatal and neonatal care, and childhood care [40].
Health services in Bolivia are provided at three levels. At the first level are basic facilities
within which nursing assistants and doctors administer health promotion programs, preventative
services, basic health services, and outpatient care. These basic facilities are the most common in
Bolivia, particularly in rural areas. At the second level, hospitals provide general and trauma
care, general surgery, gynecologic services, and pediatric care. Most of this coverage is in urban
areas. The third level is located only in specialized hospitals in the capital of each department in
Bolivia that provide expertise in fields such as cardiology and psychiatry [40].
20
In order to improve the overall health of the population, the Bolivian government
established three insurance plans over the past 20 years. The goal of all of these plans was to
reduce economic barriers to health services by offering free care. The first plan implemented in
1996 was the National Maternal and Child Insurance (SNMN). The main focus of SNMN was to
reduce the number of maternal deaths by 50% and the deaths of children under five from
diarrhea and pneumonia. The services offered under SNMN included prenatal and postpartum
care, labor and delivery, obstetric emergencies, newborn care, neonatal asphyxia, and treatment
of diarrhea and pneumonia [40].
The second insurance plan was Basic Health Insurance (SBS), and it was implemented in
1998. The target population of this plan was women of reproductive age, children under the age
of five, and the general population suffering from endemic diseases. The goal of SBS was to
reduce the morbidity and mortality of the most vulnerable groups of society and improve care
quality while respecting cultural practices. The services offered in SBS covered the same
population as SNMS and added sexual and reproductive care, birth control, STDs care, endemic
disease services, and medical care to rural communities lacking health facilities.
The third and final insurance plan implemented in 2003 was the Universal Maternal and
Child Insurance (SUMI). The mission of the plan was to reduce maternal and child mortality,
and specifically emphasized neonatal mortality reduction. The plan offered more complex care
for children and mothers by expanding ambulatory care, diagnostics, and surgical treatments.
SUMI, unlike SNMN and SBS, provides services that are usually not available in primary care
facilities and as such, are not found in rural areas [40].
21
2.4
COUNTRY PROFILE: CHILE
Chile is located in the southern region of South America, bordered by Argentina to the
east, Bolivia to the northeast, Peru to the north, and the Pacific Ocean to the west [53] (see
Figure 6). The country is 756,950 square miles and about 177 kilometers wide, making it one of
the narrowest countries in the world [54]. The topography of Chile includes the Andes
Mountains, centrally located valleys, and the Atacama Desert in the north [53]. The Chilean
population was 17,216,945, as of 2013 [53]. The capital city is Santiago; and the country is
divided into 15 administrative departments: Antofagasta, Araucania, Arica y Parinacota, Aysen,
Biobio, Coquimbo, Libertador, General Bernardo O'Higgins, Los Lagos, Los Rios, Magallanes y
de la Antartica Chilena, Maule, Region Metropolitana (Santiago), Tarapaca, and Valparaiso [53].
More than 86% of the population lives in towns and cities and more than half lives in Santiago
and surrounding Metropolitan areas [55].
Before the Spanish arrived in Chile in the 1500s, Amerindians inhabited the land. The
Inca lived in the northern region of present-day Chile, but were unable to exert control over the
Amerindian groups to the south. Among these southern-dwelling groups were the Araucanians, a
disjointed association of people who farmed, hunted and gathered food [54]. The Mapuche tribe
was among them. The Mapuche provided the Spanish colonizers with the most resistance, but all
Araucanians were known for fierce resistance against the Spanish Empire. In the 1880s the
Spanish were finally able to conquer the Mapuche [53].
22
Reproduced from CIA World Factbook
Figure 6. Map of Chile
Ethnically, Chileans are 95.4% white or white-Amerindian, 4% Mapuche, and 0.6% other
indigenous group [53]. The official language is Spanish, and English, German, and Mapudungun
are also spoken. Chile is becoming an aging society, as it is has high life expectancy (75.25 years
for men and 81.42 years for women) and low fertility rates (1.85 children per woman) [53]. The
contraception prevalence rate was 64.2% as of 2006, and the mother’s mean age at first birth is
23.7, based on estimates from 2004 [53].
23
Chile declared its independence from Spain in 1810, but victory was not gained until
1818. Since that time, Chile has endured coups, Marxist governments, and finally a return to
democracy in 1990 [53]. Today, Chile is committed to a democratic political process, which
contributes to the country’s role as a regional and global leader [53].
The Chilean Constitution created three branches of government, the Executive, Judicial,
and Legislative. The Constitution was adopted in 1980 and since then has been amended
multiple times [53]. The current President is Michelle Bachelet, who served her first term in
2006. The president serves a four-year term and appoints his/her Cabinet [53].
The Legislative Branch of the Chilean government is the bicameral National Congress. It
is composed of a 38 member Senate who serve eight-year terms, and the 120 member Chamber
of Deputies, who serve four-year terms. Both the Senators and Deputies are elected by popular
vote [53]. The Judicial branch consists of the Supreme Court, the Constitutional Court and the
Electoral Court [53].
While today Chile enjoys a strong democracy, its political history is not a peaceful one.
Marxist president Salvador Allende was elected to office in 1970 from the Popular Front alliance
party. His presidential victory was an historic event, as it marked the first time a Marxist was
democratically elected in Chile [56]. During his three years as president, Allende set forth land
reforms and nationalized banking and copper mines that were owned by the United States in an
attempt to restructure Chilean society. As a result of these actions, the CIA defined Allende as a
communist. Because he was unable to effectively handle the economic problems facing the
country, the Chilean army, along with the CIA, orchestrated a coup in 1973 [56].
The coup ended in Allende’s death and the murder of his supporters. He was replaced by
General Augusto Pinochet in 1973 [56]. For 17 years, Pinochet led Chile under harsh,
24
authoritarian rule. His presidency ended in 1990, when democratic elections were held, even
though his military ranking was preserved until 1998 [57].
Michelle Bachelet won the presidential election in 2006 and while in office, pushed
through innovations in childcare and pensions for low-income mothers and advocated for labor
regulations to protect domestic workers [58]. Additionally, Bachelet was a proponent of
emergency contraception expansion. Despite these advancements and gender improvements, the
Bachelet administration is criticized for avoiding the issue of the illegality of abortion [58].
Under Allende’s presidency, copper mines were nationalized. Because of this, reforming
the banking system became challenging because the government did not have the capacity. Soon
after the nationalization, inflation skyrocketed above 200% and the national deficit surpassed
13% of the GDP. Despite efforts to stabilize the economy, the economic situation did not
improve. The financial situation spurred on the military coup of 1973 [54]. Pinochet’s
government was responsible for transforming Chile’s economy from isolation to a “world
integrated economy” [54]. Inflation rates were diminished, national debt was practically
eliminated, and a strong market was created [54].
Today, Chile is known for having powerful economic institutions. The copper industry
accounts for 19% of government revenue. Other main sources of industry are lithium, iron, steel,
and other minerals. There are approximately 8.234 million people in the labor force.
Unemployment is at 6.3% but 15.1% of the population lives below the poverty line [53]. Chile’s
GDP in 2013 was $335.4 billion, with a 4.4% annual growth rate. In 2011, 7.5% of the GDP was
spent on health expenditures [53]. The GNI per capita as of 2012 in Chile was $21,310 [59].
Chile is a primarily Christian nation. Seventy percent of the population is Roman
Catholic, 15.1% is Evangelical, 1.1% is Jehovah’s Witness, 1% is “other Christian,” 4.6% other,
25
and 8.3% of the population identifies as having no religion [53]. Since the days of Spanish
colonialism in Chile, the Catholic Church has played a major role in the political arena. In the
1800s, political conservatives strove to keep the social order of the colonial era intact. As such,
they defended the church’s position to control the educational system and oversee important,
traditional rites of passage. The conservatives also favored a close relationship between church
and state. To this day, the Church has great influence in the sphere of women’s health and
familial issues [54].
Men and women have equal educational opportunities in Chile because of access and
financial coverage [60]. In fact, according to the census statistics from 2002, women had a
literacy rate of 95.6%, compared to men’s 96.3%. Chilean women 15 years or older have about
nine years of education. Pregnant teens however, are excluded from attainting higher education
degrees [61].
In Chile, the family is of the utmost importance [62]. In fact, the family is a critical social
unit and a major influence on the nation’s political and economic development [63]. While there
is evidence that traditional family and marital roles are changing, the Chilean culture is still
dominated by men [64]. Women maintain influence in the domestic setting, while men remain
the principal gender in other spheres of influence [61].
Women today are still not completely equal to their husbands in marriage because of the
former gender order that existed prior to the democratization of the 1990s. This was based on
subordination, violence, exclusion and devaluation. Despite improvements, such as a recent law
criminalizing domestic violence in Chile, inequality persists today and has serious implications
for pregnancy and maternal health, even in cases of rape [64, 65]. Gender inequality is
exacerbated by barriers to reproductive rights [58]. In families of lower economic standing, men
26
tend to wield the decision-making powers. In rural traditional settings, women are expected to
follow restrictive social, traditional, and economic practices and usually do not have the
opportunities their urban counterparts do [61]. Infertile women often have to endure social
stigma and emotional turmoil because childbearing is held in high regard in the country [61].
The Chilean government first established health care for its citizens in 1924 with the
creation of the social security system. Initially, the system was funded through pension finances
but the argument was made that sectors of the population that did not have pension funds were
being excluded from health care coverage. As a result, The National Health Service (SNS) was
established in 1952 [54].
The SNS administered care to those covered by pensions in addition to the general
population, even if they could not pay. Women were provided with pre- and postpartum care and
birth control in the 1960s. Additionally, the population received inoculations under SNS, and
programs to improve hygiene and nutrition were initiated. After the financial crisis of the 1970s,
the state organized health programs were restructured [54].
The largest healthcare provider in Chile is the successor to the SNS, the National System
of Health Services (SNSS) [54]. Funding for SNSS comes from state revenue and seven percent
tax from the population. SNSS coverage is open to the entire population and for “indigents,”
coverage is free. SNSS is responsible for the major public health programs and implementations
in Chile. The program affords pregnant and nursing mothers and children supplemental
nutritional assistance. Because of this program, childhood malnutrition has drastically decreased
to insignificant levels, even though in 1989, childhood malnutrition was only at 8% [54].
SNSS is only one of the five components of the post SNS Chilean health system. The
others include the National Health Fund (FONASA), the Security Assistance Institutions,
27
Institute of Public and Preventative Medicine (ISAPRES), and private medicine [54]. FONASA
and ISAPRES make up the mixed insurance system of the state, allowing workers to choose
between the private and public sector. Typically, because of the high expenses of ISAPRES, only
the middle and upper classes are enrolled in it. Presently, about 16% of the Chilean population is
enrolled in ISAPRES and 73% of the population in FONASA. The remaining percent either
lacks coverage completely or is enrolled in other insurance plans [58].
The Chilean health insurance system developed out of traditional ideas about protective
men, dependent women and women’s nurturing role [58]. Evidence exists that Chile perpetuates
gender inequality by charging higher insurance rates for women of reproductive age. Income is
the determinant of entry to ISAPRES and women are most affected by this because often they
earn less than men. Pregnant women may have to pay four times as much for an insurance policy
than men [66].
Additionally, inequities exist in health care relative to access, region, ethnicity, and
income [58]. Research shows that indigenous populations in Chile are more likely to experience
poorer health than their non-indigenous counter-parts. In fact, infant mortality among indigenous
peoples is between 90%-250% higher than non-indigenous populations. While this is
discouraging, Chilean officials have launched several social protection programs specifically
targeted to those susceptible populations [67].
In the 1990s, the four leading causes of death in Chile were circulatory disease (27%),
cancer (18%), accidents (13%), and respiratory illness (11%) [54]. In 2006, the main causes of
death among young adults were external causes (44%), diseases of the circulatory and digestive
systems (16.5%), and tumors (17%). Among older adults (65 and above) in 2006, the leading
causes of death were tumors (31%), circulatory system diseases (30%), respiratory system
28
diseases (8.4%), and digestive system diseases (7.5%) [67]. Unlike Bolivia, communicable
diseases are not a major concern in Chile [67]. The leading causes for maternal mortality
between 2003-2007 were indirect, primarily as result of non-obstetric, pre-existing chronic
conditions [68]. Inoculations for tuberculosis, diphtheria, measles, tetanus, and pertussis are
standard for practically all babies and children. Pregnant women in rural areas who need to travel
long distances to deliver their babies can spend the last days of their pregnancy in temporary
residences for such purposes [54].
Chile can attribute its favorable health indicators to economic growth and poverty
reduction, improved access to sanitation and clean drinking water, and the high education
attainment of the population [66]. But despite major improvements to the overall health of the
country, inequities still remain in health care access, coverage, and opportunity. Low socioeconomic populations face higher mortality and morbidity [69].
Instead of protecting the life of the mother, the Chilean Constitution establishes that “the
law shall protect the life of the unborn” [70]. In addition to the Constitution, in 1989, a law was
passed in Chile that bans therapeutic abortion [68]. It is considered one of the strictest abortion
laws in the world [71]. Even if the life of the woman is in danger, abortion is not legal. As a
result, health complications from clandestine abortions are a huge public health concern [72]. It
is estimated that 120,000-16,000 abortions are conducted each year in Chile [58]. Exact figures
are not known because of the secretive nature of the procedure, but it is estimated that about 12%
of maternal deaths in Chile from 2000-2004 were from complications caused by illegal abortion
[71, 73]. Clandestine abortions are not often reported and therefore the data regarding maternal
deaths and health complications due to clandestine abortions may be skewed [73]. Higher-
29
income women are less likely than lower income women to suffer from complications as a result
of illegal abortions [58].
The Catholic Church plays a major role in the Chilean abortion ban. In Catholic
countries, such as Chile, debates about abortion are often ideological, but the policies have real
repercussions for women and families [72]. In countries that ban abortion (such as Bolivia and
Chile), rates of clandestine abortion are typically higher and contribute to hospitalization and
maternal mortality [72]. In Chile, the Church defines abortion as murder [72]. The strong
presence of the Catholic religion affects the cultural norms and attitudes about abortion. Women
are forbidden not only by law, but also morally, through religious constraints, to seek abortions
[72].
Health care institutions also impact abortions in Chile. Because abortion is illegal,
hospitals and health care institutions are required to report when abortions are encountered in the
clinical setting [73]. Fear of being reported to the authorities can be a barrier for women who are
in need of medical attention due to complications arising from clandestine abortions [64]. Only a
small number of Chilean doctors and nurses actually do report abortions however, citing medical
confidentiality as the primary reason [73].
30
3.0
METHODS
A literature search was conducted to identify articles related to maternal interventions in
Bolivia and Chile. The articles reviewed were chosen because they address maternal health,
maternal mortality, reproductive health, pregnancy, and maternal health interventions in Latin
America, specifically Bolivia and Chile.
PittCat was used to search “Bolivian Maternal Mortality” on January 17, 2014. The
criteria used limited the result dates from 1990-2014 and filtered for results only in English.
PittCat was also used to search for “Chilean Maternal Mortality” on January 23, 2014, with the
same search criteria and exclusions. PittCat was used to search for Bolivian culture and the role
of women on January 20, 2014. The search terms used were “Bolivia” and “Bolivian culture.”
The criteria were from 1990-2014 and English only. Google Scholar was used to research
“Chilean Maternal Mortality” and “Bolivian Maternal Mortality.”
PittCat was used to search “Maternal Health Interventions in Bolivia” and the criteria
used limited the results from 1990-2014 and filtered for results only in English. The same criteria
were used to search for “Maternal Health Interventions in Chile” on PittCat. Both searches were
conducted on March 26, 2014. On the same date, “Maternal Health Interventions in Bolivia” and
“Maternal Health in Chile” were searched for in PubMed. Google Scholar was used to find
results for “Maternal Health Interventions in Bolivia” and “Maternal Health Interventions in
Chile” on March 29, 2014.
31
On March 29, 2014, PittCat was used to search the terms “Maternal Health Chile” and
“Maternal Health Bolivia” with the search criteria limited to articles only in English and between
1900-2014. On April 1, “Chilean maternal health care” was searched for on PittCat and results
were filtered for articles only in English and from 1990-2014. The same search filters were also
used to search PittCat for “Bolivian Maternal Health Care” on April 1, 2014.
32
4.0
RESULTS
The results of the literature search discuss existing maternal health interventions in
Bolivia and Chile and whether or not they have been successful in reducing maternal mortality
and improving maternal health. Barriers to maternal health care and services are also reviewed in
this section.
4.1
BOLIVIAN INTERVENTIONS
Bolivia has the highest rate of maternal mortality in Latin America and the Caribbean,
second only to Haiti [40]. Current estimates of the maternal mortality ratio in Bolivia are
180/100,000 live births. About three women die each day as a result of pregnancy or delivery
complications [74]. The main causes of maternal mortality in Bolivia are hemorrhage (39%),
eclampsia (39%) and abortion (10%) [50]. The risk of maternal mortality is higher in rural areas
[50]. According to recent PAHO studies regarding Bolivia, rural and indigenous populations are
excluded from adequate health services because of the lack of literacy among females, rampant
“poverty, geographic barriers, gender inequality, historic discrimination against the Indigenous
People and inadequate housing” [40, pg. 1]. Poverty and economic hardships cause great
emotional stress that manifests physically and affects overall health. Stress can make the body
more susceptible to illness, which is especially dangerous for pregnant women [75].
33
Research indicates that there is a correlation between the use of skilled birth attendants
(SBA) in delivery and the maternal mortality ratio. Maternal mortality ratios are drastically
reduced when a trained person attends the birth [5]. Oftentimes, home births occur without
attendants and most births in rural Bolivia occur in the home [76]. In fact, more than half of all
maternal deaths in Bolivia happen at home (53.5%) [50].
The maternal-child health insurance models discussed (SNMN, SBS, and SUMI) have had
success in reducing maternal mortality early on in their implementation, but have stalled and even
partly contributed to maternal deaths. Between 1994-2003, when SNMN and SBS were
implemented, maternal mortality dropped 41%, from 390 to 230 deaths per 100,000 live births.
Most of these reductions were made under SBS. Unfortunately, during the SUMI implementation,
maternal mortality rose to 310 deaths per 100,000 live births [40]. The reason for this is because
under SUMI, coverage for women of reproductive age was dropped, as was birth control access,
and easily obtainable information on reproduction was no longer provided. Additionally, SUMI
failed to ensure that health access and quality health care was provided to the population, nor did
it guarantee the adequacy of mothers’ nutritional status before conception or during pregnancy
[40].
Under SNMN and SBS, institutional deliveries increased, especially from 1994-1998. In fact,
all Bolivian departments considered non-indigenous have reached the MDG for deliveries in a
health care institution or facility. In contrast, indigenous departments, particularly Potosí, Oruro,
and La Paz, have the lowest rates of institutional deliveries and not surprisingly, the highest rates
of maternal mortality. SUMI has been unsuccessful in reaching rural, remote communities in
Bolivia, and it is apparent that health in these areas is waning [40].
34
Barriers are established when birth attendants in hospitals do not respect the cultural
practices of the woman during childbirth [40]. A study conducted among rural women in Bolivia
indicated that fear of “sexualization” in hospitals during delivery was a main factor in the
decision to give birth at home. Traditionally, rural women deliver at home where they remain
fully dressed and privacy is respected. This sharply contrasts with the birthing process in
hospitals where “women [lie] with their legs open in front of a crowd of younger men” [76, pg.
51]. The women expressed fear of being seen in this position and explained that this is why they
usually prefer to deliver at home rather than in the hospital [76]. Additionally, many rural
Bolivian women do not understand what is involved in a hospital delivery [76]. Women also
reported fear of being mistreated by hospital staff [77]. For example, some medical staff in this
study alluded to the sexual act as the reason for her pain during delivery. In several instances, if a
woman cried out during delivery, nurses would tell her, “You’re screaming now, but why didn’t
you scream like that when you were with your husband?” [76, pg. 54].
Bolivia’s lack of, or inadequate transportation to hospitals in rural regions is a major
obstacle to accessing obstetric help [78]. This is problematic, especially in cases of severe
hemorrhaging. Also, as mentioned above, the preference to deliver at home presents another
barrier to getting emergency care for a hemorrhage.
The Bolivian government has implemented interventions to reduce the high levels of
maternal mortality within the country. Special health vouchers have been given to pregnant
women who lack health care coverage; this voucher entitles them to stipends as an incentive to
give birth in a hospital. The purpose of the program is to change women’s minds about giving
birth at home and encourage those living in rural areas to visit health clinics and doctors
frequently [74].
35
The Bolivian government and the World Bank have designated $25 million to incentivize
women to utilize prenatal care and deliver in a hospital [79]. The initiative is called the Juana
Azurduy Mother Child Subsidy, named after an indigenous woman who led an uprising against
the Spanish. Additional financial incentives are offered to women for the first two years of their
child’s life if they access well-child health and maternal health visits [79]. This averages out to
approximately $258 per woman. Considering that the average monthly salary in Bolivia is $90,
this incentive is worthwhile [79]. Critics claim that interventions like these are flawed, however,
because they do not consider the shortage of rural clinics, and question if available existing
clinics are prepared to handle the increase in patients [74].
UNICEF has a program in Bolivia called Renacer (New Start) specifically targeted for
the Ayamaras in the central Andes region [79]. Weekly meetings are held among childbearing
women in the community to share their experiences and support one another. Another project to
increase maternal health in Bolivia was launched in 2007 called the Zero Malnutrition National
Program. Its mission is to improve nutrition among pregnant and breastfeeding women and
young children [79]. As part of the program, indigenous women living in the highlands regions
of Bolivia are trained to teach mothers about balanced diets and to monitor the nutritional intake
of the children living in their communities [79].
The Warmi Project was an intervention in Inquisivi, Bolivia, from 1990-1993 developed
by Save the Children Bolivia and MotherCare. Inquisivi is resource-poor, rural and “remote from
any service infrastructure...or hospital for emergency obstetric care” [80, pg. 49]. Additionally,
women have few interactions with other females and do not have access to information, and
SBAs are usually not present during delivery [80]. After conducting a needs assessment of the
village to prioritize problems, birth attendants, women, and husbands were trained on safe birth
36
practices. Additionally, ties to hospitals were strengthened because of the referrals provided and
there was a reduction of costs for emergency admissions [80]. Family planning education was
also provided for communities in Inquisivi. The results of the Warmi Project showed that by
empowering “women to acknowledge the importance of their own reproductive, maternal, and
neonatal health problems, the psychological, geographical and financial gap was reduced and
access in the delivery department improved” [80, pg. 49].
In Cochabamba, Bolivia, in 1992, the Ministry of Health, the University of San Simon
Faculty of Medicine in Cochabamba, the Institute for Research in Biomedicine, and the
University of North Carolina School of Public Health initiated a community-based intervention
called Proyecto MADRE. The goal of Proyecto MADRE was to “promote improved decisionmaking and appropriate utilization of reproductive health services,” [81, pg. 53] thereby reducing
maternal mortality. To meet this goal, two measurable objectives were identified: to improve the
knowledge about reproductive health among women and to increase the use of health services by
pregnant women. The program was evaluated by monitoring visit uptakes in family planning and
gynecological care services and examining changes in practices and feelings of healthcare
providers. Educational sessions between reproductive age women and service providers were
held in community centers, which enhanced trust. The health topics discussed encouraged the
women to gain more information about reproductive health that had previously not been
provided to them. Women who attended these educational sessions gained greater self-efficacy
by feeling as though “they could exercise some control and make changes in their lives, e.g.
preventing unwanted pregnancies…”[81, pg. 53].
The Bolivian president implemented a structural adjustment policy (SAP) called La
Nueva Politica Economica in 1986 [82]. The policy called for a reduction in state spending in the
37
health sector. International financial institutions and world leaders considered the SAP to be a
success because it reduced the role of the government and stabilized the economy.
Unfortunately, the “success” came at the disadvantage of most Bolivians because the health and
well-being of the population diminished and poverty increased [82]. During this time, NGOs
became an alternative to state-run programs to provide for the social, economic, and health needs
of the public. In 2000, Bolivia had over 600 NGOs, compared to the 39 NGOs working in the
country in 1880 [82]. With increased funding from the World Bank, NGOs proliferated in
Bolivia [82].
A recent study concluded that the majority of NGO projects in Bolivia are in the health
and agricultural sectors. Most of these NGOs are distributed unevenly across all municipalities,
specifically concentrated in the central highland regions, while very few are located in the north
eastern lowlands [82]. The study also found that NGO activity tends to be greater in areas with
large, usually indigenous populations. Health related NGOs are usually concentrated in rural as
opposed to urban regions. The study found that NGOs are not located in the poorest regions,
where one would expect to find the most vulnerable populations [82]. NGOs may be hesitant to
work in poor regions because of the difficultly they present to providing measurable, specific
successes donors to maintain funding. This could negatively impact the most at-risk populations
by creating a bias to work in areas where measuring successes are easier [82]. The study also
concluded that NGO activity tends to be concentrated in areas where there is already existing
health system coverage.
38
4.2
CHILEAN INTERVENTIONS
In sharp contrast to Bolivia, Chile’s maternal mortality rate is 25 per 100,000 [53]. This is one of
the lowest rates of maternal mortality on the continent [65]. Several factors contribute to the low
incidence of maternal deaths in Chile. Since the 1990s, the government has been working to
improve women’s lives and health by cutting poverty rates, improving gender equality, reducing
domestic violence, and pushing for education. In fact, women in Chile attend more years of
school than men today. Additionally, day care centers for children of women in the lowest
income bracket have been created and other social programs specifically tailored to suit women
and mothers have been implemented [65].
In the 1980s, Chile reached almost complete coverage for prenatal and delivery care. This
was due in part to the creation of the National Health Service (NHSer). NHSer reforms began in
1952, and it was the start of a series of reforms that continued through 2000 to expand maternal
health coverage. As discussed above, expansion of maternal health care services is associated
with maternal mortality reduction, especially emergency obstetrics [83]. Chile has successfully
increased access and quality of health services, which contributes to its low maternal mortality
[83]. In order to do this, Chile utilized a market-focused approach to service delivery and
implemented an efficient, unified system, aided by satellite assistance organizations [83].
The World Health Organization influenced the maternal health policy during the
formation of the NHSer. Chile’s goal was to formulate policies aimed at reducing maternal
deaths and illness by increasing coverage for prenatal and institutional deliveries. While using
primary health care as a means of service provision, the NHSer implemented a program that
integrated health promotion, prevention, care and treatment [83].
39
Prior to the implementation of NHSer in the 1980s, maternal health care was vertically
structured, meaning that hospital was the primary center for health services and rural health posts
were the focus for rural areas [83]. In other words, geography was the principal determinant of
access to health services [83].
The Chilean government implemented the SNSS after the NHSer with the priority being
the modification of delivery services as a result of public and private insurance entries
(FONASA and ISAPRE, respectively). Between 1990-2000, Chilean municipalities were
required to give a financial contribution to public primary care clinics based on the number of
individuals enrolled in the clinics. This allowed patients to pick a health service close to their
homes or place of business [83].
Until 2000, primary maternal care was provided by midwifes, referred to as a matronas.
These women earned four year degrees and provided care in the areas of health education, preand post-partum care, labor, delivery, family planning, and gynecologic and obstetric morbidity
[83]. Distribution of matronas was linked to the geographic dispersion of the local population
[83].
ISAPRE was designed to provide only prenatal, postnatal, labor and delivery services.
Multiple plans were offered to the population at various rates. As a consequence of this, certain
plans restricted coverage of labor and delivery and newborn coverage. To reduce this inequity,
the Ministry of Health interjected to change this policy and live up to the government’s goal of
equitable maternal care that was established after Pinochet left office [83].
In the 14 years from 1990 to 2004, the number of women recorded who died as a result of
pregnancy in Chile dropped from 123 per 100,000 to 42 per 100,000. The decreases in the
reported deaths were due to reductions in obstructed labor (decreased 13% from 18% to 5%),
40
infection (decreased 9% from 11% to 2%) and illegal abortion (decreased 13% from 20% to 7%).
Deaths attributable to hypertension stayed at the same rate of 20% [84].
Research indicates that when the economic situation improves, the maternal and infant
mortality rates decrease. This is true in the case of Chile. As the number of people living in
poverty decreased from 1990 to 2004, so too did the maternal mortality rate (from 123/100,000
to 42/100,000) [84].
In an effort to reduce health disparities between the lowest and highest socioeconomic
regions in Chile, the government implemented several interventions. Among these was the Chile
Solidario System introduced in 2002. This plan aimed to provide free primary health care,
including antenatal care [84]. The program was designed to benefit families living in extreme
poverty. In the 1990s, a supplementary food program called National Supplementary Feeding
Programme (NSFP) was introduced and specifically targeted to children six years or younger and
pregnant women. The program is regarded as a success because it lowered the incidence of
malnutrition in children from 10% to less than 3% [84]. Additionally, in an evaluation of NSFP,
pregnant women who participated had better weight gain during pregnancy and less frequency of
low birth weight compared to women who did not participate [85].
In 1994, the government introduced the Women’s Health Program. This intervention’s
aim was to further improve reproductive health by strengthening sexual education campaigns,
STD prevention and treatment programs, family planning, and antenatal and delivery services
[84]. The program also granted more extensive coverage to adolescent girls regarding
reproductive health counseling and antenatal services. The distribution of free contraception
continued and guidelines for the medical management of pregnancy and delivery were
implemented under the Women’s Health Program [84]. The Women’s Health Program has not
41
benefited the targeted four million women it was intended to reach, however, because the only
aspects implemented thus far have been geared toward prenatal care, depression treatment, and
women experiencing menopause. Program coverage is limited [86].
Chile has one of the highest rates of cesarean births in the world. Recently, a law was
passed under FONASA stating that vaginal births and cesarean births will be reimbursed for the
same cost [87]. This was done in an attempt to discourage C-sections. The explanation for the
high prevalence of cesarean sections is not purely financial, however. If there are no
complications, a C-section takes about an hour as opposed to a vaginal birth that could take
much longer, which is why some doctors prefer it. Additionally, over the last 50 years, women in
Chile have been told that cesareans are the safest method for delivery [87]. Obstetricians and
pediatricians condone cesareans and women are eager to receive them because the culture in
Chile places great importance on authority figures. In Latin American countries, doctors are seen
as the ultimate power over all things health. This culture and reverence for authority have been in
existence since the Spanish colonizers and are also attributed to the rigidity of the Catholic
Church in Chile [87].
Chile serves as a role model for the other Latin American countries because of its
democracy, strong middle class and healthcare system [87]. According to one journal article, an
ob/gyn practicing in Peru said that the reason Chile’s healthcare system is successful is because
“Chile doesn’t have an Indian problem.” [87, pg. 1]. As stated above, most of the Chilean
population is white and very few live in rural, isolated areas. There is less discrimination based
on the fact that there is less ethnic diversity.
42
5.0
DISCUSSION
Based on the results, it is apparent that a number of factors inherent in both the Bolivian
and Chilean populations impact whether or not specific maternal health interventions will be
successful. In the case of Bolivia, while there has been country-wide improvement over the last
several years thanks to strong government commitment [88], maternal mortality is still a serious
public health concern. Governmental interventions involving vouchers or financial incentives
seem logical to encourage women to deliver in hospitals and health care facilities, but if there are
no clinics in rural, isolated areas where unattended home births are common, this type of
intervention is useless. The same is true of interventions that work to reduce the cost of
emergency services. And if existing health services cannot accommodate patient uptake as a
result of the vouchers, there is no improvement made, as resources are too limited.
The entire infrastructure of the country needs to be built up so that rural and indigenous
communities are able to access high quality maternal care without having to travel long distances
in dangerous conditions. This does not seem likely, however, considering how poorly the
Bolivian economy is performing and the extreme poverty in which most of the population is
living. Bolivia ranks very low in relation to other Latin American countries with regard to the
percent of GDP designated for healthcare expenditure.
In the event that indigenous women choose to and are able to deliver in institutions, they
fear how hospital staff will treat them. The birthing process in the hospital is vastly different
43
from the traditional practices they are accustomed to. Hospital staff are not trained to treat
indigenous populations respectfully, in accordance with cultural norms and values. In order to
combat this barrier to care, staff should be required to attend cultural sensitivity trainings. There
should also be individuals working at the hospital who speak Quechua and Aymara available at
all times. This will help ease some of the fear and make the women comfortable and more
willing to deliver in institutions.
The maternal health interventions in Bolivia that have been successful are those that
focus on self-efficacy and education, like the Warmi Project and Proyecto MADRE. It is
important to provide education about contraception, healthy pregnancies, and early detection of
obstetric complications in order to reduce maternal mortality. Rural Indian populations are less
likely to have access to this information so there must be greater effort on the part of the
government and NGOs to extend education to isolated populations. Also, including fathers and
men in these educational sessions is valuable if the importance of women is to be elevated and
men are to be positive, constant forces in the lives of their children. This may also help to reduce
abuse against women, which is a huge problem in Bolivia.
NGOs in Bolivia are not using their resources to provide for the poorest and neediest
population segments [82], which is problematic for maternal health. If NGOs are hesitant to
establish projects in areas where there are not already existing health systems, isolated
populations that need the most help will not benefit. This is another reason for the Bolivian
government to build up the infrastructure of the country and establish health systems in areas that
are currently lacking them. NGOs also need to rethink how success is measured. New indicators
and guidelines for project success measurement need to be made to satisfy funders.
44
NGOs also need to establish sustainability plans so that when they leave at the end of the
project date, they do not leave a void. The local population needs to be involved in the
implementation and maintenance of health projects so that they are invested in the project and
have a commitment to its cause. It is important to involve community stakeholders and the local
(and national) governments from the onset of the program.
The results indicate that there should be greater emphasis on getting contraception to the
women who need it. There must also be a greater push for reproductive health education in order
to avoid unintended pregnancies, clandestine abortions and the resulting health complications
from them, thereby reducing maternal mortality.
The look at Chilean maternal health interventions illustrates that governmental policies
enacted to protect mothers have been quite successful. Implementing insurance plans to provide
universal maternal health coverage allows women to receive prenatal, natal, antenatal care, and
emergency obstetric services. Strong government involvement and intervention have helped to
lower the maternal mortality rate consistently since the 1990s. It is clear that the Chilean
government made maternal health a top priority for the country and has taken the necessary steps
to ensure that pregnancy and childbirth are safer for all women.
Additionally, there has been a great push for gender equality and in Chile. The country is
not experiencing the high rates of violence against women that are occurring in Bolivia. This
coupled with excellent educational opportunities allows women to chose when to become
pregnant and decide for themselves how many children they want to have. Also, women hold
higher political offices in Chile and have more career opportunities and earning potential.
In contrast to the current system in Bolivia, maternal health care in Chile is less based on
geography. Women in Chile can pick health services close to their home because isolation is not
45
a problem for the population the way that it is in Bolivia. The infrastructure of the country is
sophisticated and most Chileans have easy access to necessary health services because over 80%
of the population lives in cities or metropolitan areas [55]. When obstetric emergencies occur in
Chile, it can be assumed based on the literature, that geography is not a barrier to care. Not only
is there ease of access to maternal health services in Chile, they are of higher quality than those
in Bolivia.
Chile has made enormous strides to reduce poverty. The health of the economy leads to
better overall health of the population. This is especially true in Chile. Almost half of Bolivia’s
population is living in poverty while about 15% of Bolivia’s population lives below the poverty
line.
As discussed in the background, ethnically Chile’s population is almost completely
white. Indian and indigenous populations are considered vulnerable in other Latin American
countries (like Bolivia). Because Chile does not have a large Indian population, the maternal
mortality for that group is not as high, comparatively speaking. It is interesting to note that three
of the four countries in Latin America with the lowest rates of maternal mortality (Chile,
Uruguay, Peru, and Argentina), are all primarily ethnically white. This demonstrates a serious
disparity between white, European descent Latin Americans and indigenous, Indian, and mestizo
Latin Americans.
The high rate of cesarean sections performed in Chile is troubling. As the literature
indicates, Chilean women have been subjected to propaganda about how C-section deliveries are
safer than natural deliveries. The findings also suggest that Chilean women are so stuck in the
traditional authoritarian mindset established long ago, that they will always defer to the doctor on
46
health issues. This could also be related to the teachings of the Catholic Church. Further research
should be conducted to find out how much of a role authority figures impact society in Chile.
While there is information regarding the program planning, implementation, and
evaluation for government-initiated maternal health interventions in Bolivia and Chile, there is a
striking shortage of information about interventions carried out by NGOs. The literature suggests
that more than 600 NGOs are operating in Bolivia (many of which are health-based) [82], yet the
results of these interventions are not available. Program evaluations for these maternal health
interventions are important so that successful projects can be scaled up. Similarly, if the
programs are ineffective or harmful, results must still be disseminated so that program planners
can revise or alter the project to achieve desirable results.
In Chile, maternal health interventions initiated by the government are well-documented
and evaluated. But like Bolivia, evaluations of NGO interventions in Chile are missing from the
literature. Chile has done an excellent job of reducing maternal mortality, so it can be assumed
that the successful NGO interventions in that country can be tailored to work for the Bolivian
population. This is not possible without proper documentation of the planning, implementation,
and results of all interventions carried out.
47
6.0
CONCLUSION
Maternal mortality continues to impact populations around the world. Unfortunately,
ending maternal mortality is not a simple task. There are a variety of factors that contribute to
maternal mortality and as such, there is not one single magical solution to reverse it. In the case
of Latin America, it will take integrated approaches, substantial financial backing, strong
political and governmental will, dedicated human resources, and time commitment.
Based on the literature, it is clear that the biggest factors affecting maternal mortality in
the cases of Bolivia and Chile are economic. Because Bolivia is one of the most impoverished
countries in Latin America, women are not able to access high quality maternal care,
contraception or education. This cycle of poverty is not easy to break. Without addressing the
income inequities in the country, it will be difficult to educate women, and in turn prevent
unwanted pregnancies and resulting complications. While income inequalities exist in Chile, the
overall financial situation of the country is good. Poverty is not necessarily a health determinant
for most of the Chilean population, as it is in Bolivia. In Chile, there is complete maternal health
coverage for all women; contraceptives and reproductive health education are not out of reach.
This is one of the many reasons why the maternal mortality rate in Chile is so much lower than
that of Bolivia.
Location is also an important consideration in maternal health and mortality. Most
Bolivians live in rural areas, isolated from life-saving emergency obstetric care. Chileans do not
48
have this issue, as only a small proportion of the population lives in rural areas. Even if quality
health services are established in rural areas, it is crucial that staff be of the same ethnicity or at
least be sensitive to the cultural and ethnic background of the populations they are serving.
A major theme that emerged in the literature was discrimination against indigenous and
Indian populations, not only in Bolivia and Chile, but also in all Latin American counties. The
countries with the highest rates of maternal mortality in the region are all ethnically diverse and
composed of large indigenous communities. Conversely, the countries experiencing the lowest
rates of maternal death are primarily white and ethnically homogeneous. This may indicate that
racism and discrimination are widespread and are very seriously affecting maternal health. There
must be anti-discrimination policies enacted to protect these vulnerable populations and improve
their health.
Historically, Latin American countries are patriarchal and women are not valued as
highly as men. Men tend to hold the decision-making powers of the family, which places women
at a disadvantage. If maternal health is to improve, the value of women must be elevated.
Insurance plans and health coverage plans that charge more for pregnant women or women of
childbearing age must be eliminated to safeguard health of mothers and their children. Female
empowerment is critical if gender equality is to be achieved.
The countries explored in this essay share similar histories. Spanish colonizers brought
along with them Roman Catholicism which is still a dominating force in Latin America today.
The Church’s stance on abortion plays a major role in maternal mortality. Both Bolivia and Chile
are overwhelmingly Catholic nations and the anti-abortion beliefs of the Church impact legal
policies. It should not be the decision of the Church to influence abortion policy to “save” the
49
unborn child at the expense of the mother. There needs to be a way to accommodate family
planning that the church will accept.
In Latin America, policy makers and the religious community need to seriously
reconsider the illegality of abortion. Regardless of whether or not it is illegal, abortions will
continue because there is a great unmet need for family planning services and poverty is
rampant, especially in the case of Bolivia. If abortions are legalized, they are more likely to be
performed under safe conditions. Abortion complications are a huge contributing factor in the
maternal mortality rate, and much of the data about the rates of abortion injuries and death are
skewed because of the clandestine nature of the procedure.
This essay has a few important limitations. First, only existing data was reviewed and no
new research was contributed to this area of study. Secondly, only articles in English were
reviewed and only those that were available through the University of Pittsburgh’s library
databases and in the public domain.
Based on the literature, several recommendations can be made to improve Bolivia’s
maternal mortality by incorporating some of the maternal health successes from Chile.
Populations are not as isolated in Chile as they are in Bolivia. Because women do not have to
travel far, help is close by in the event of obstetric complications. As mentioned above, to
combat this problem, the Bolivian government must make a commitment to build infrastructure
in remote areas by making better roads, and building hospitals and health centers in hard-to reach
areas where indigenous and rural populations reside.
It is simply not enough to build health facilities in rural areas for women to access
maternal health services; there must be adequate human resources for staffing purposes. As
mentioned earlier, most maternal deaths in Paraguay occurred in hospitals and health care
50
institutions when fewer staff were present. That is unacceptable. Staff must always be available,
day or night, to treat obstetric emergencies. In the case of Bolivia, staff should be sensitive to the
unique needs, cultures, and customs of the indigenous populations.
Considering that hemorrhaging is the main cause of maternal mortality in Bolivia,
evidence based interventions to stop this must be implemented immediately. If women must
deliver at home, a skilled birth attendant or trained community health worker should be present
to assist with delivery and initiate active management of third stage labor (AMTSL) [89].
AMTSL involves the administration of a uterotonic like oxytocin or misoprostol, which
stimulates the uterus to contract and reduce blood loss. AMTSL also involves placental delivery
and massage of the uterus [89]. Skilled birth attendants and trained community health workers
from the indigenous communities are ideal to do this because of cultural and linguistic reasons.
If AMTSL is not possible because a woman delivers alone, the use of oxytocin and
misoprostol pills greatly reduces the risk of bleeding if taken immediately after childbirth [89].
Interventions in other parts of the world have proven successful in reducing maternal mortality
by training women who do not have access to health care providers to take the pills on their own.
Misoprostol administration is supported by the WHO because it is effective in reducing PPH and
does not need to be refrigerated [89]. As such, it is ideal for remote, rural areas, like those in
Bolivia.
Program evaluations of nongovernmental interventions to reduce maternal mortality in
Bolivia and Chile are critical. Currently, there is a lack of evaluation research on this topic in
these countries. Results also need to be disseminated in academic journals and scientific
publications so that successes can be duplicated and program planners can learn from the failures
51
and shortcomings of other projects. As such, NGOs and program evaluators may find this paper
useful.
Each day, thousands of women die as a result of pregnancy and delivery complications.
Interventions to stop these unnecessary deaths exist. To implement them, the international
community, governments, and religious institutions must work together to provide education and
contraception for all women. Without the cooperation of these entities, maternal mortality will
not decline. Poor, indigenous, uneducated women are most at risk of maternal mortality in Latin
America. The amount of money a woman has, the color of her skin, her ethnicity, and cultural or
religious practices should not be the determining factor of whether or not she is worthy of
surviving pregnancy. Health is a basic human right, not just a privilege for the few. Our
generation has the capacity to change the trend in maternal health worldwide now. We cannot
continue to turn a blind eye to this tragedy.
52
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