Saturday, May 10, 2014

Maternal Mortality in Bolivia

High maternal and child mortality have been two of the most persistent health problems confronting Bolivia over the past several decades.
Bolivia, with 65% of the population living below the poverty line, is the poorest country in Latin America.  It is characterised by a substantially rural population (41%) that is dispersed across three distinct ecological regions, some parts of which are extremely difficult to access.  The indigenous population, which represents around 32,7% of the Bolivian population, and the rural population, are farthest from reaching health goals due to historical gaps and lack of effective, equity-driven public policies. 
Maternal mortality in Bolivia is one of the highest in the world. According to the ENDSA 98 survey, the maternal mortality rate corresponds to 390 per 100,000 liveborn, which is higher than the average for low- and middle-income countries globally (238) and more than twice that found in an average Latin American country (162).
Mother and baby in Bolivia

There is a gap between departments with a greater indigenous population and those with a smaller indigenous population with respect to maternal health. All non-indigenous departments have already reached the MDG for institutional deliveries. On the contrary, La Paz, Oruro and Potosi, which are the departments with the highest rates of maternal mortality, are also the ones that have the lowest levels of institutional deliveries.
In certain rural areas of the highlands (altiplano) the maternal mortality rate reaches 887 per 100,000 liveborn (UNICEF november 2001).
Large inequities remain between deliveries in rural and urban areas. In 2008,only 43.7 per cent of deliveries in rural areas were done in health service facilities compared to 87.7 per cent in urban areas. This gap can be explained in two ways: first, better resourced health services are mainly located in urban areas; second, the generalized free health-care offer seems to have attracted in the cities people who previously had private health-care plans.
Infant mortality rates also depict a worrisome picture: 83 infants die per 1,000 live births in Bolivia while average rates in the region and for countries of similar income are around 45 per 1,000.  The state of health of a mother has a direct effect on her children, particularly on the youngest children. A mother with anemia suffers from exhaustion and does not have sufficient capacity to care for her children and look after their development. In the same way the deficient nutrition of a mother-to-be during pregnancy and after giving birth is the cause of a percentage of neonatal deaths, that is to say, those that occur during the first 28 days of life of the baby. Also, if the mother dies, the probability of survival for her child is reduced by half.
Among Bolivian women of child-bearing age, about 12 percent are so short (less than 145 cm) that they are at risk of having an underweight baby; and 27 percent of women of child-bearing age are so anaemic that they pass iron deficiency to the unborn child…lack of sanitation and inappropriate feeding of children under two are the principal causes of malnutrition in Bolivia. (World Bank, 2002).
Risks to women's health are related to reproduction and child care. The principal causes of maternal mortality are obstetrical complications: hemorrages, infections, complications related to childbirth and to abortion.
It is widely accepted that neonatal mortality is closely related to prenatal care and health care during delivery, while post-neonatal mortality (i.e. deaths between 28 days and 11 months after birth) is linked to living conditions and home care.
Mother and newborn baby in hospital

Haemorrhage during pregnancy, including abortion-related, is the primary cause of maternal mortality in Bolivia and abortion itself is the third cause. It can be speculated that the rise in mortality is due to a surge in abortions; however, further studies are needed to confirm this. Recent studies indicate that access to birth control services could prevent 75 per cent of maternal deaths and 50 per cent of neonatal deaths mainly by reducing abortions and unwanted pregnancies.
Abortion is illegal in Bolivia, except in cases of rape, incest, or when a woman’s life or health is endangered.  However, an international NGO called IPAS conducted a study in 2012 which found that judicial authority for therapeutic abortions is routinely denied, leaving even rape victims and women whose health is endangered at the mercy of clandestine and unsafe procedures. Reportedly, only six abortions have been approved in the more than 40 years since the penal code was enacted.  Decriminalization advocates have focused on the public health crisis surrounding illegal abortion, with the highest risks incurred by poor and indigenous women. Despite current restrictions, an estimated 60,000 to 80,000 abortions are performed annually in Bolivia, often using unsafe methods, and mostly in impoverished urban peripheries where indigenous populations are concentrated. In close to half the cases, post-abortion emergency hospital care is required.  Unsafe abortions account for one third of maternal deaths in Bolivia. The large volume of unwanted pregnancies is also closely tied to sexual violence, which victimizes seven out of ten Bolivian women (the second-highest rate in Latin America, after Haiti).
Data from a 2008 report was used to examine the link between birth control in women of childbearing age, and maternal and neonatal mortality. The analysis showed that neonatal mortality declined as birth control became prevalent. the departments with the highest percentage of women on birth control have the lowest neonatal mortality.
According to a Pan American Health Organization study, the rural Bolivian population is excluded from adequate services by factors that are both exogenous and endogenous to the health-care system. Exogenous factors, such as female illiteracy —a key factor—, poverty, geographic barriers, gender inequality, historic discrimination against the Indigenous People and inadequate housing, account for 60 per cent of the exclusion. Endogenous factors, which account for roughly 40 per cent, include systemic inadequacies such as the inability to solve health problems, limited coverage, frequent changes in health-care providers, or their non-responsiveness and incapacity, and differing cultural perceptions of the quality of care.
In an attempt to improve the health of the population, especially mothers and children, Bolivian governments have implemented three successive free health insurance plans since 1994, namely the National Maternal and Child Insurance (SNMN), Basic Health Insurance (SBS) and Universal Maternal and Child Insurance (SUMI).
By providing basic health services at first level facilities in rural areas, SBS was the only insurance plan that addressed geographic and economic barriers to health services.  In contrast, SUMI prioritized advanced therapeutic services for mothers and children that are mainly available in urban centres. In doing so, SUMI created a geographic barrier and failed to address the acute needs of the rural population. In effect, these needs were neglected, neonatal mortality rose and the general health situation of the rural and indigenous population worsened. In short, Bolivia reversed the gains made with the two previous insurance schemes.
In order to improve maternal and infant health and achieve the MDGs, Bolivia will have to redirect its strategies and interventions country-wide.   It is necessary to design and implement policies and interventions adapted to the needs of rural areas and the indigenous population and to focus on the reduction of the inequities affecting these groups.  When resources are scarce, priority could be given to interventions aimed at the indigenous departments such as Chuquisaca, Cochabamba, La Paz, Oruro and Potosi.   In designing and implementing maternal-child health policies, adequate sexual and reproductive health services —including access to modern birth control methods— should be made available to lower maternal and neonatal mortality.
Achtenburg, E. (2014)  For Abortion Rights in Bolivia, A Modest Gain.  [Online] 28th February 2014. Available from: nacla.org https://nacla.org/blog/2014/2/28/abortion-rights-bolivia-modest-gain [Accessed: 5th May 2014].

Batista, R. and Silva, E.  Policy Paper May 2010: Bolivian maternal and child health policies: Successes and failures.  FOCAL: Canadian Foundation for the Americas. Ottawa, Canada: May 2010. [Online] Available from:  http://www.offnews.info/downloads/Silva_EN.pdf [Accessed: 4th May 2014].

Dmytraczenko, T., Scribner, S., Leighton C., Novak K. (1999). Reducing Maternal and Child Mortality in Bolivia.  Partnerships for Health Reform, Resource Centre, Bethesda, Maryland, Abt Associates. [Online] 7, [1] Available from:  www.healthsystems2020.org/files/811_file_ess1.pdf  [Accessed: 6th May 2014].

UNICEF Bolivia. (2014)  The Children - The Situation of Women in Bolivia.  [Online] Available from: http://www.unicef.org/bolivia/children_1538.htm  [Accessed: 3rd May 2014].

Written by Eilidh Thomson.
Translated into Spanish by Eilidh Thomson and Maria Renee Trigo.
Edited by Kelly-Marie Roberts and Angie Lorini.

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