Improving maternal and child health care in the mountains

By Ruth Ansah Ayisi

Resting on a wall in the hospital grounds overlooking the vast Andes mountain range in southeast Bolivia, Valerio Rodríguez Gómez, 23, tenderly holds his 20-month-old daughter, Yayita, while his wife, Elizia, who is 19, has an antenatal consultation.

Valerio says the trek to and from the remote valley town of Independencia, a 10-hour round trip which they do the same day, is worth it. “I always accompany my wife and baby to the hospital. I will bring my wife here to give birth too,” says Valerio. “Yayita would have been born in this hospital, but we didn’t have enough time as my wife went into labour. So we phoned for an ambulance. The doctors were with us in one and a half hours.”

Although it was a normal delivery, Yayita has not thrived. She is suffering from chronic malnutrition. “They told me she is too thin for her height,” says Valerio looking down at Yayita who shows no sign of tiredness. “The problem came when her mother went away for two months to work on a census project about agriculture,” says Gomez. Yayita, who was 6 months old at the time, abruptly stopped breastfeeding, and Gomez, a farmer, was left to take care of her.

The family exemplify some of the typical challenges that the government faces in its drive to improve maternal and child health care. Elizia is a teenage mother, with only primary school education, and Elizia’s husband only has a couple of years of secondary education. “Cultural barriers, lack of education of mothers, caretakers and families as well as remote distances are some of the main barriers,” says Dr Claudia Vivas, UNICEF Chief of Child Survival and Development in Bolivia. “However, the government has made significant progress in its implementation of the Sistema Único de Salud (Unified Health System), which is supported by UNICEF and other partners to provide quality health services to all population groups, including those who live in remote rural areas.” Most of UNICEF’s support is in capacity building, training of health personnel at all levels and technical advice.

Yet the statistics suggest there is still a long way to go. Between 2003 and 2008, neonatal mortality remained at the same high level with 27 babies out of every 1,000 live births dying within the first month. According to the National Demographic Health Survey 75 per cent of those deaths occur in the first week of life, mostly due to poor quality health care during pregnancy and childbirth. Also, between 2003-2008 the infant mortality rate only dropped from 54 to 50 per 1,000 , an annual reduction of just 1.9 per cent, far below the 3.9 per cent annual reduction needed to meet the target for the Millennium Development Goal (MDG) 4. The maternal mortality ratio stands at 229 per 100,000 live births, according to the latest data recognized by the government. This means Bolivia has the second highest maternal mortality ratio in Latin America after Haiti, a country that has suffered devastating national humanitarian emergencies in recent years.

Rural Independencia shows the typical geographical barriers. It takes seven hours to drive from Independencia to the capital of Cochabamba along the mountain range with its treacherous precipices and single winding mountain dirt tracks that rise and fall above the clouds. “Our roads are dangerous,” confirms Dr. Ángel Fernández, the director of the hospital. He adds that they had over 20 fatalities in one recent accident this year.

Despite these barriers, Dr. Fernandez says they have had two cases of neonatal deaths this year but no cases of maternal deaths in the past five years. The doctor credits the lack of maternal deaths to the significant improvements in the quality of maternal and childcare services at the hospital. These include their success in sensitizing communities about the importance of assisted deliveries, their well serviced ambulances and the fact that even in the most remote communities, people now have access to a mobile phone. “We are on call 24 hours, seven days a week,” he says.

However, messages about the importance of spacing pregnancies are still not making an impact. “While most women would like to use contraceptives, the men think that their use will encourage their wives to have a sexual relationship with other men.”

In addition, chronic malnutrition is still a challenge in the area due to poor infant feeding practices. The nutritionist at Independencia, Margot Tobar, explains that many mothers only breastfeed their infants for about three months; and then, besides bottle milk, they only introduce starch into the diet. “They produce greens, but they prefer to sell them,” she says. Moreover, a young mother often leaves her baby with someone else, like the grandmother. “When the grandmother attends the clinic with the baby, I encourage her to return again with the baby’s mother,” says Tobar.

Tobar welcomes the fact that she had the opportunity to talk to both of Yayita’s parents about how to provide better nourishment for their daughter. Fortunately, they have caught Yayita’s condition within the two-year window period; after that, evidence shows that chronic malnutrition can lead to irreversible cognitive impairment and physical stunting. Elizia’s pregnancy is also going well although she has not spaced her pregnancies.

Valerio says he too is happy that they explained to him about the health of his baby and his pregnant wife. “I want to better understand about their health,” he says as he prepares to carry Yayita on his back. Elizia carries a small bundle of blankets and food for the trek across the mountains in temperatures that will drop below zero before they reach home five hours later.