PERU

Denial of the right to maternal and child health

‘Why have children when you are so poor?’

María Luz lives with her mother and brothers in a one-room house in Huánuco Department. The family’s main source of income is from working on their smallholding. María Luz could not attend every prenatal check-up because she could not walk the 7km to the health facility in Huarichaca, especially in the later stages of pregnancy. On 20 December 2004, María Luz gave birth to a little girl. The baby was two months premature, which meant that María Luz was not able to make preparations to go to the health centre before the birth. Soon after she was born, the baby became ill and María Luz took her to the health centre, which promptly fined her 50 nuevos soles (US$15) for failing to attend prenatal check-ups and for giving birth at home. The doctor told María Luz that the baby would have to be transferred to hospital in Huánuco, the departmental capital, and asked the family to pay 17 nuevos soles (US$5) to travel with the baby to hospital. At the hospital the family was not allowed to see the baby. Staff told María Luz that the baby had an infection, but no one explained how serious the illness was or what treatment was being given. The hospital charged the family for saline solution and tablets and asked for 500 nuevos soles (US$150) for a transfusion. When María Luz insisted on knowing what was happening to her daughter, the doctor shouted at her: "why have children when you are so poor, stop bothering us… you should not have children if you are poor." The baby girl died 12 days after her birth. The family still does not know what she died of.

Amnesty International’s (AI’s) research revealed that, despite government initiatives to improve access to health services for poor and marginalized groups, women in Peru are still being denied access to medical care because they are poor.

"If you go badly dressed, they make you wait longer and the ones who arrive later but better dressed go first… and if you complain, they treat you worse."

Woman (identity withheld) in Nauta, Iquitos, July 2005

In many cases discrimination on the basis of a person’s economic status is reinforced by discrimination on the basis of cultural or ethnic identity. The first language of María Luz and her family is Quechua – an Indigenous language. Indigenous people face levels of extreme poverty almost three times higher than the rest of the population. They also face cultural barriers which prevent them from accessing appropriate health services. For example, few health professionals speak Indigenous languages.

"It is difficult to reach women in rural areas who are illiterate or have very little education, no more than primary level… we do not have sufficient personnel who speak the [indigenous] languages… they are shouted at… they are told they are dirty, that they

don’t wash…"

Obstetrician in Huánuco

The Ministry of Health has noted that among poor and marginalized communities there are signs of considerable mistrust of health professionals and the techniques used during childbirth in health facilities.This helps to explain the very low percentage of women in rural areas who give birth in health centres – just 21 per cent.The reluctance to go to health clinics for the birth can have fatal consequences. For example, according to the non-governmental organization Salud sin Límites, the majority of perinatal deaths in the Río Santiago district, Condorcanqui Province,Amazonas Department, are due to infections or asphyxia, which could have been avoided had the delivery taken place in a health centre.The Ministry of Health has issued guidelines and set standards for attending births which are in accordance with

Indigenous traditions.However, in many localities these measures, which were designed to reduce the barriers faced by excluded and remote communities in accessing health services, have not been implemented.

Legacy of armed conflict

Discrimination was one of the factors that fuelled the 20-year armed conflict in Peru and that today is reflected in the enormous inequalities which characterize Peruvian society. Women, and in particular Indigenous and peasant women in rural areas, suffered greatly during the conflict. Rape was used as a weapon of war and many women were targeted for other forms of torture and forcible recruitment for work or forced marriage. Years later, they continue to complain of mental and physical health problems, including reproductive health problems, caused by the violence to which they were subjected.

The Truth and Reconciliation Commission, set up after the end of the conflict in 2000, concluded in 2003 that persistent discrimination against poor, Indigenous and peasant communities was one of the factors which contributed to the cycle of violence during the armed conflict. The Commission observed that the veiled racism and contemptuous attitudes prevailing in Peruvian society meant that the deaths of thousands of Indigenous people in poor peasant communities went largely unnoticed and unremarked. In 2003 the Commission recommended that the authorities take urgent steps to address economic, social, ethnic and gender discrimination. While successive governments have made some positive steps in improving access to health care, much remains to be done.

‘Now they treat us the way we like’

Women interviewed by AI cited a number of factors which make it difficult for them to use state health facilities. These included the lack of women doctors and nurses, embarrassment over intimate examinations, the long distances which women have to travel to reach health facilities, and the dismissive attitudes of some health professionals. As long ago as 1998, a study by the Ministry of Health on childbirth in the Andes and Amazonia found that one of the main reasons why so few women from these areas gave birth in health centres was connected with the difference in cultural and obstetric systems. It went on to identify traditional practices which could be incorporated into state health provision.

Since then, some important steps have been taken to ensure that health provision is more culturally appropriate and that women are fully involved in deciding the conditions in which they give birth.

One initiative by Salud sin Límites, in the village of San José de Secce and the communities of Oqopeqa, Punkumarqiri, Sañuq and Laupay, in the district of San José de Santillana, in Huanta Province, Ayacucho Department, in the Andes, has seen the number of births which take place in health facilities rise from just 6 per cent in 1999 to 67 per cent in 2003.

"Before, they used to take them to a room, shut the door and not let their families in. They did not have the rope or the chair as they do today, but were made to lie on a bed with their legs open; they were shouted at and they did not like that, they were attended to in a noisy, laughing, manner and they did not like that either."

"Now they treat us in the way we like, whether in bed or sitting on the chair, holding onto the rope. Our husbands put their arms around our waist and we like that; because that’s what we are used to on the farm. We would like it to continue like this, boiling herbs, making household remedies just like at home."

Women interviewed by Salud sin Límites in San José de Santillana, July 2005

Consultation with women and local communities was key in building understanding and trust with health professionals and adopting culturally appropriate practices.These included ensuring greater availability of Quechua-speaking staff and women health professionals. Emphasis was also placed on the importance of making sure examinations and procedures were explained and that informed consent was given by the women.Workshops were held to tell communities about these new procedures and posters and radio programmes about these changes were produced in Quechua.

The experience of San José de Secce, Oqopeqa, Punkumarqiri, Sañuq and Laupay shows what can be achieved, and at relatively low cost, if there is the political will to remove some of the barriers which prevent poor and marginalized women from accessing health services.Overcoming discrimination and misunderstanding has improved the takeup of maternal and child health care services provided by health professionals and contributed to a reduction in maternal and child morbidity and mortality rates.

International human rights law

The Peruvian authorities have an obligation under international human rights law to safeguard maternal and child health. This includes ensuring that health services are equally distributed and that all women and children have equal access to them. The right to enjoy human rights without discrimination is a fundamental principle underlying international human rights law.

The right to health set out in the International Covenant on Economic, Social and Cultural Rights includes not only the right to timely and appropriate health care, but also to the underlying determinants of health, such as access to safe drinking water and adequate sanitation, food and housing, and access to information, including on sexual and reproductive health. According to the UN Committee on Economic, Social and Cultural Rights, this right to health also encompasses the right of peoples and communities to participate in making decisions about health provision.

Key recommendations

1. Health workers at all levels should receive training which enables them to meet the health needs of women and children from poor and marginalized communities.

2. The Peruvian authorities should promote the participation of communities in decisions about the kind of health services which they need and want and ensure that the services provided are appropriate to their cultural practices.

For more information, see Peru: Poor and excluded women – denial of the right to maternal and child health (AI Index: AMR46/004/2006) which was launched at the IIINational Conference on Health, Lima, Peru, in July 2006.

Amnesty International, International Secretariat,

Peter Benenson House, 1 Easton Street,

London WC1X 0DW, United Kingdom

www.amnesty.org

AI Index: AMR 46/006/2007

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