PERU - November 28 - Peru's persistently high maternal mortality ratio, the second highest in South America, dramatically illustrates systemic inequities that ravage the overall society and in turn reflect systematic violations of human rights and vast disparities in the health care system, according to a new report released today in Lima, by Physicians for Human Rights (PHR), in coordination with CARE-Peru. The bilingual PHR report Deadly Delays: Maternal Mortality in Peru, A Rights-Based Approach to Safe Motherhood states that deaths of largely rural and impoverished women are the result of a systematic policy, programming, and budgeting decisions as well as societal and cultural factors.
"Addressing maternal mortality requires increased funding to strengthen Peru's health system by both the Peruvian Government and international donors, with resources allocated equitably and without discrimination to poor women to access emergency obstetric care," said Alicia Ely Yamin, JD, MPH, the author and lead researcher of the PHR study. "Peru also needs a National Plan of Action to address human resources in health to ensure respect for both patients' and workers' rights and promote equitable allocation of services."
In Peru, over 1,200 women die in childbirth each year. Thousands of others come close to dying and are left with life-long debilitating complications The interventions needed to treat obstetric emergencies and therefore to prevent a great majority of deaths are well-known and readily available to women with economic means and to most living in urban areas in Peru. Behind each death and near miss there is a woman with a story. In this report, PHR puts faces to the numbers. In collaboration with CARE-Peru, PHR identified seven emblematic cases of women who died due to pregnancy-related complications (one woman who survived an obstetric emergency) in Puno and Huancavelica, two of the regions with the highest maternal mortality ratios in Peru (361 and 302 per 100,000 live births in 2000, respectively). This report tells their stories and gives voice to their families.
The leading causes of maternal mortality in Peru are the same obstetric complications responsible for the great majority of maternal deaths around the world. They are hemorrhage, toxemia (pre-eclampsia/eclampsia), abortion-related complications, and infection. Obstetric complications, including those stemming from incomplete abortions, require access to Emergency Obstetric Care (EmOC). In Peru, there are deep inequities in relation to having access to the programmatic interventions necessary to prevent the majority of maternal deaths, which include access to EmOC, skilled birth attendants and referral networks.
Under international human rights law, Peru is obligated to provide available, accessible, acceptable and quality EmOC for all pregnant women. According to the PHR report, true availability, accessibility and quality EmOC requires more than structures and equipment, it require trained personnel-- 24 hours a day-- and adequate communications and transportation, as well as the elimination of laws and policies that discriminate against women. Care also needs to be acceptable, which requires prioritization of programs and modifications in curricula to promote intercultural understanding and the rights of patients. Finally, accountability—financial, political and legal—needs to be improved for the right to safe motherhood to become a reality in Peru, PHR said.
The absence of available, accessible, acceptable and quality EmOC -- especially to rural, indigenous women-- leads to "three delays": delays in decisions to seek care (often ascribed to "cultural preference"), delays in arriving at care, and delays in receiving the appropriate treatment once at a health facility, which in turn leads to women dying.
"The failures to provide access to adequate EmOC and related reproductive and sexual health services is a powerful indicator of how rural campesinas are not treated as full citizens," said Yamin.
All of these deadly delays are related to systemic inequities in Peruvian society and in the Peruvian health care system. PHR found that delays in the decision to seek care can be attributable to the inequitable distribution of healthcare facilities, goods, and services that make EmOC both unavailable and physically inaccessible. It can also be attributable to economic barriers to access for these impoverished families that persist in spite of the comprehensive social insurance scheme—the Seguro Integral de Salud or SIS, including the cost of transportation. Lack of cultural sensitivity, including language barriers, and lack of respect for traditional birthing customs in health facilities all factor into delays seeking care, said PHR. Perceptions of poor quality care can also produce delays in deciding to seek EmOC at health establishments.
"The counter productive and punitive policies adopted by the health sector with respect to pregnant women and their families and front-line health personnel have produced perverse incentive, they undermine the possibility of sustained improvements in EmOC and violate the rights of both patients and health workers, " said Yamin.
Addressing these problems would also permit the health system to function in its capacity as a core social system to promote greater democracy and equality in the overall society and facilitate Peru's long-sought after national reconciliation after years of fragmentation during the brutal armed conflict with the Shining Path (Sendero Luminoso) between 1980 and 2000.
Putting a Face to the Numbers
Physicians for Human Rights conducted the investigation between January and June 2007 to analyze the systemic and social factors that perpetuate the injustice of maternal mortality in Peru.
In Puno, PHR encountered Antonia, who went into labor early on a rain-drenched Good Friday and seemingly every possible factor that could have delayed care did; Melania, who was nervous about having her first child but trusted the midwife and waited in vain for her to show up at her house as promised; Pabla, who did everything she could to follow the health post's recommendation to deliver at the hospital but was sent home and died in the room where her own mother had also died giving birth, and Carolina who, desperate not to have another child with her abusive husband, chose to induce abortion after her husband forbade her from using birth control.
In Huancavelica, PHR encountered Evarista, the playful young woman who loved to watch videos in Quechua, who had married Alejandro to raise the children left motherless when his first wife died due to pregnancy –related complications; Tomasa, who watched her children's faces in terror and thought about her hopes for their future as she felt the blood seeping out of her, and Francisca, who dreamed of returning to Ayacucho, from where the family had fled during the civil conflict only to die of neglect and poor care at the health center. The PHR report also chronicles the families and the health professionals who were involved in each case—both the dedicated ones, from Dr. Tayasco in Huancavelica to the midwife Hermelinda Abado Sucapuca in Puno and the callously indifferent and negligent ones.
"Maternal mortality provides a social X- Ray of Peruvian society, illuminating interactions of rural poverty and gender inequality, which disproportionately affect indigenous women and those who are illiterate and otherwise marginalized as well as the way in which the health system exacerbates those patterns of exclusion," said Yamin.
The report traces back the paths that led to these women's deaths (and in one case, the saving of a woman's life) and analyzes the structural obstacles to reducing maternal mortality at the level of household and community, the health center, the regional government, the national government, and ultimately international actors such as the World Bank, and the Inter-American Development Bank which are playing fundamental roles in the restructuring of Peru's health sector through PARSalud (Proyecto de Apoyo a la Reforma del Sector Salud).
In each case, the factors leading to the deadly delays that cause the women's deaths, as well as the factors that mitigated the delays in the case of the woman who survived, are analyzed explicitly in terms of Peru's human rights obligations related to the right to health under international law, including the obligation to provide EmOC.
Selected and Summarized Recommendations
To the Peruvian Government
- Increase the percentage of the national budget devoted to healthcare spending, including spending on maternal mortality, to bring Peru in line with other middle-income countries in the region.
- Adopt by National Decree and implement a National Concerted Plan of Action to Reduce Maternal Mortality, paying specific attention to the needs of marginalized groups, including indigenous populations and for Peru to adopt and implement a National Plan of Action to Address Human Resources in Health to ensure respect for both patients' and workers' rights and promote equitable allocation of services.
- Promote meaningful popular participation so that rural women can participate in the political process and gain access to government benefits programs.
- Promote accountability and effective remedies by creating programs to educate judges and lawyers about women's rights to health and life.
To the Peruvian Ministry of Health
- Ensure that under the re-designed social insurance scheme benefits are correlated with need so that women from the poorest quintiles and historically marginalized populations are adequately covered.
- Reinvigorate reproductive health and family planning services, including more funding, training and staffing and ensure the availability of full range of contraceptive options, especially to rural indigenous women and adolescents.
- Revitalize the CLAS (Comités Locales de Administración en Salud/Local Health Administration Committees) system through increased funding and modified contracts for salaries of health professionals working at CLAS facilities and ensure that CLAS councils always included women.
- Improve monitoring and accountability systems for the purchase of medicines and implement an automated system for purchases of medical equipment by requiring use of SIGA (Sistema de Información de Gestión Administrativa) and integration with SIAF (Sistema Integral de Administración Financeria).
To the Regional Governments of Huancavelica and Puno
- Promote available, accessible, acceptable quality EmOC, including transportation and communications-ensure that health care spending adequately reflects the needs and rights of rural populations, in particular indigenous women.
- Prioritize purchases of radios and/or cell phones where appropriate for health posts and communities and consider credit schemes that enable women in communities to control cell phone and charge small fees for their usage
- Budget monies which are strictly dedicated for regular maintenance and fuel for ambulances, and require logs be kept for mileage, to facilitate calculations of when and how many emergencies are attended.
To The World Bank and Inter-American Bank
- Insist upon technical and not political criteria in the design of PARSalud II and include funds in PARSalud II for the distribution, especially in rural areas, of national identity cards as a heath promoting measure.
- Use outcome measures such as magnesium sulfate usage, C-Section rates, oxytocin usage, rather than spending indicators as indicators of progress
To the US Government and USAID
- Participate in a debt-for-health conversion program in alliance with the Global Fund to Fight AIDS, TB, and Malaria in order to expand resources available for health system, and for maternal health in particular.
- Repeal the global Gag Rule so that aid recipients can provide information and education with regard to the signs and treatment for complications arising from abortions, which is leading cause of maternal death in Peru
- Stop interference with provision of public information about emergency oral contraception by grantees in Peru.
Alicia Ely Yamin, JD, MPH, consultant and former Director of Research and Investigations for PHR, wrote the report. Tiffany Moore, MD, assistant professor of Obstetrics and Gynecology at the University of Massachusetts-Worcester and PHR consultant and Marion Brown, MD, PHR consultant, participated in the field work in Huancavelica and Puno, respectively, and contributed clinical analysis to the report. Stephanie Swanson and Christopher Drake, Harvard Law School students, also participated in the investigation and research. CARE-Peru, in particular Luz Estrada and Ariel Frisancho, MD, were pivotal consultants for this investigation. Dr. Frisancho served as main coordinator of CARE-Peru's participation in the research upon which the report is based.
The report will also be released in Puno, Peru on November 30.
International Initiative on Maternal Mortality and Human Rights Unveiled
Physicians for Human Rights (PHR) mobilizes the health professions to advance the health and dignity of all people by protecting human rights. As a founding member of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace Prize.