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Ms.
Magazine April/May 2001
CASAS
MATERNAS
In rural Nicaragua, a
grassroots network of maternity houses is saving women's
lives
By Ginger Otis
High in the hills
of Northern Nicaragua, in a small village named Jinotega,
26-year-old Victoria Rivera sits rubbing her stomach,
contemplating the arrival of her sixth child. "I
came to this village," she says, "because my
midwife (partera in Spanish) told me I would need
more medical help than she could give." Normally
Rivera would give birth the way campesinas in
Nicaragua I have done for centuries-propped up by female
friends and relatives while a partera oversees the
delivery. But somewhere along the line, this pregnancy
began to go wrong. "We think the due date was about
a month ago, Rivera explains, "but the baby won't
come out. I haven't felt it move in six weeks."
Rivera is staying
in Jinotega's casa materna, one of approximately
20 volunteer-run maternity houses in Nicaragua that
offer free shelter, medical counseling, and assistance
to high-risk pregnant women. The casa is a dilapidated
building, with flaking green paint on the walls and
chipped black and white tiles on the floor. But for the
women who come here, it is a vast improvement over the
conditions they face at home. Like other casas, the one
in Jinotega coordinates treatment for its clients with
hospital physicians. The women who leave their isolated
mountain homes for medical care come to the casas
because public hospitals are so underfunded they won't
see women until they're about to deliver.
Despite efforts
from international relief donors and the United Nations
Population Fund (UNFPA), Nicaragua is still struggling
to implement the most basic of social service systems.
The country is the second poorest in the Western
Hemisphere, with a per capita GNP of less than $500.
Health care is a luxury for most campesinas. That's
where the casas maternas come in. All are located in
remote places like Jinotega but are generally close to a
hospital. "Your average campesina can't come down
to the hospital and wait one or two weeks until she's
ready to deliver," explains Francisca Espinoza, a
licensed social worker and director of Jinotega's
maternity house. "And given the sometimes full
day's walk it takes to make it to the hospital, these
women can't wait for labor pains to begin before they
leave for the hospital." Without the casas, the
only choice for women diagnosed with a pregnancy-related
complication would be to take their chances with a
partera in the mountains.
Above Left: Francisca
Chavarrķa is partera who was trained by her
grandmother.
Above Right: Campesina relaxing in their room.
Middle left: Expectant mothers attend a seminar on
reproductive health
Bottom Left: Casa staff and patients make T-Shirts to
sell for fundraising.
Bottom Right: Outside casa Jinotega, a sign in Nahuati,
an indigenous, says,
"This is a place for women."
Casa staffers
estimate there was a much higher maternal mortality rate
in the country before their network started in the early
1980s. But reliable stats on the maternal death
rate are hard to come by. A 1998 government survey found
that approximately 133 women died for every 100,000 live
births, making Nicaragua's the third highest maternal
mortality rate in Central America. Unofficial estimates
put the number at 234 to 300 for every 100,000 live
births in the most impoverished rural areas. Women's
health advocates say even that number could be low.
Death rates in rural areas are not folded into
government numbers because they are not recorded by
hospitals or picked up by irregular census surveys.
Without the casas, the maternal death rate would be even
higher.
Unfonunately, a
number of maternty houses are barely scraping by and may
have to shut down. A few have been sponsored by foreign
donors. Jinotega's, for example, was initially funded by
an international aid organization from Spain. The group
provided money for raining and equipment for two years
only. The Nicaraguan government, already stretched thin
by the country's frail economic infrastructure and
endemic unemployment, has been able to provide little
support for the casas, which frequently open and then
close because of a lack of finances. Though four of the
20 casas currently in existence receive a stipend from a
government health care program, most struggle to survive
by selling crafrs or accepting small donations from the campesinas
who use their services.
Despite these
financial difficulties, says Espinoza, charging a fee to
stay at the maternity house is "out of the
question." Most families in the northern regions
make their living picking coffee. The majority earn less
than $360 per year and half the adult population is
unemployed. "We don't charge anything to the women
who come here," says Espinoza. "If we did,
they wouldn't come." The Jinotega casa does ask
guests for a one-time contribution of 20 cordobas (about
$1.50) to help defer electricity costs, but doesn't
insist. Espinoza is proud that Jinotega's casa has never
turned anyone away. Still, there are many services she
wishes she could provide. As it is, patients
bring and cook all their own food, and clean their own
rooms. The casa has frequent shortages of basic
necessities such as toilet paper, hot water, cleaning
materials, fresh linens, and even furniture. There are
currently enough beds to go around, but by the next
harvest season, a huge floating population will arrive
to work in the fields and the casa's 20 beds won't be
enough. To make ends meet the casa is selling
handicrafts, sweets, and silk-screened T-shirts to
locals. Espinoza also wishes she could pay something to
her staff of seven volunteers who take turns being on
call.
Casas maternas also
function as information and training centers for the
country's 5,000 midwives. Foreign health workers have
long recognized the important role midwives play in
indigenous and rural communities. "Women generally
prefer parteras," says Ruth Largaespada of UNFPA in
Nicaragua. "In places where there is no other
medical access, a partera is the only one responsible
for diagnosing complications and sending high-risk
pregnancies to the nearest casa."
The idea for
maternity houses developed through a grassroots network
of women and parteras in the '80s. The Sandinista
government, which had a progressive, socialist agenda at
the time, recognized the importance of the parteras and
used them to disseminate reproductive health information
and birth control to rural women. Through the casas
maternas, UNFPA workers have conducted family planning
and reproductive health workshops with more than 200
parteras in Jinotega and the nearby municipality of
Matagalpa-the two regions with the highest maternal and
perinatal death rates in the entire country. In addition
to brochures advocating safe sex and reproductive
health, each partera left the workshop with a maletin
de partera, a small suitcase filled with medical
instruments to aid with deliveries and improve sanitary
conditions.
The importance of
the maternity houses becomes alarmingly clear in a
situation like Rivera's. "She should have come here
six weeks ago, immediately after the partera told her
something was wrong, but the distance and poverty make
it impossible," says Espinoza. Despite the worried
faces of Espinoza and a midwife volunteer, Rivera
doesn't seem unduly concerned about the fate of her
child-partially because she is still recovering from her
journey. She is from Matagalpa, some 20 miles away.
After waiting by the side of the road for several hours,
Rivera was finally able to hitch a ride to Jinotega. She
says she was "lucky this time" because she
didn't have to wait days for a ride. Espinoza feels that
in all likelihood Rivera's child has already died. Now
Rivera faces the possibility of a drawn-out delivery.
Hospitals ofren lack labor-inducing drugs and won't
perform a cesarean for a stillborn child unless there is
absolutely no other choice. When Rivera is eventually
discharged from the hospital-regardless of whether her
pregnancy is successful-the casa will welcome her back
until she feels healthy enough to begin her trek home.
The Nicaraguan
government's inability, or some say unwillingness, to
support networks such as these isn't solely due to the
country's disastrous economic situation. Much of it has
to do with long-held macho beliefs regarding
childbearing and women's issues. In Nicaragua, which has
one of the highest fertility rates in all of Central
America, women are referred to as hembras-a word
that connotes an animal created for breeding. Men are
referred to as varones-something akin to
"studs." In a country where the average family
has 3.9 children-2 or 3 in urban families and 7 or 8 in
rural areas- (these outdated social norms cause real
problems for health activists. According to Dr. Alba
Alvarado, a pediatrician who oversees a network of
health services for women and children throughout the
country, men view the use of contraception as women's
way of sleeping around without getting pregnant.
"Nicaragua is
still Catholic," Alvarado says, "so there is a
religious component against birth control. Men also
object to their wives using contraceptives because they
think a small family means a lack of virility."
According to the latest Demographic and Health Survey,
conducted in 1998, one third of all women with partners
were at risk of having an unwanted pregnancy because
they did not use any means of contraception. And young
women, especially in rural areas, are often pressured by
men to start families very young. By 19, almost half of
Nicaraguan women have been pregnant. Nicaragua has the
highest adolescent fertility rate in all of Latin
America.
In this climate,
long-term family planning is a distant dream. A prime
example of the impact of machismo,
says Espinoza, is
the attitude Nicaraguan doctors have toward tubal
ligation. Although it is illegal to deny a woman over 21
a sterilization procedure, most doctors will not perform
it unless the patient brings a note of consent from her
husband or an adult male guardian. "Doctors are men
first and foremost," says Espinoza. "They
don't see how this hurts women."
Marta Villalobos,
ashy, soft-spoken woman in her mid-30s, is currendy
staying in Jinotega's maternity house.
After the birth of
her fifth child, Villalobos asked her husband if she
could have a tubal ligation; he said no. He also said no
after the birth of their sixth child. As her seventh
pregnancy advanced, Villalobos and her partera cooked up
a scheme to get her to Jinotega's casa for the delivery.
Espinoza has a cadre of sympathetic friends willing to
forge tubal ligation notes for desperate mothers.
Whether her husband likes it or not, Villalobos is going
to undergo the procedure this time. "To send a
38-year-old malnourished woman with seven kids back into
those mountains without giving her a simple procedure
which could save her life and that she has asked for, is
criminal," insists Espinoza. "I won't do
it." As Espinoza and others in the casa
materna network continue their struggle, they are hoping
to organize a national union of parteras, which would be
a first for Latin America. The network is also working
with parteras to research and disseminate information
about natural roots and herbs to treat complications
relating to pregnancy. All they are waiting for is
financing. But for now, the very existence of the
maternity houses is a miracle for rural women. "In
the Jinotega casa," says Espinoza, "our sign
is in Nahuad, an indigenous language. It says this is a cihuatlampa,
a place for women. And that will always be true."
ACTION ALERT:
To support the CASAS, contact the
U.S. Committee for
UNFPA
220 east 42nd Street
New York, NY 10017
www.uscommitte.org
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