لخّصلي

As discussed earlier in the chapter, cultural values can have an immense bearing on where and how people give birth, who attends the delivery, and their willingness to address complications with emergency obstetric care should they arise. As noted, however, other factors, such as discrimination and a lack of empowerment, may also influence health-seeking behavior.
In the Andean region of Peru, both of these fac- tors have been at play. Some women in this area have traditionally given birth at home without the help of a skilled birth attendant. They have done this not only for cultural reasons but also because they did not always feel welcome in healthcare settings in which health providers may not speak their language, may not treat them respectfully, and may insist that they give birth in a manner different from their tra- ditional ways.
These factors, combined with poverty and low edu- cational levels, especially among women, contributed in the late 1990s to very high maternal mortality ratios in some places in the Peruvian Andes. In the region of Ayacucho, for example, maternal mortality ratios were six times the rates in Lima, the capital of Peru.
Courtesy of Mark Tuschman.
If women are not comfortable with available birth- ing services, they are less likely to use them. This is of critical concern when most obstetric complications occur during or immediately after delivery and can- not be predicted. It is therefore crucial that women, especially high-risk groups such as the indigenous women around Ayacucho, deliver with a skilled birth attendant.1 In an effort to address these concerns, the international nongovernmental organization Health Unlimited teamed up with Salud Sín Límites Perú (Health Without Limits Peru) to create a model for birthing services that is more responsive to the needs of indigenous communities in the Santillana district in Ayacucho.
The new model of care was planned in stages, with the participation of all key stakeholders.1
■ A survey was done to understand local birthing practices. Men and women in the community were surveyed, as well as traditional birth atten- dants and trained health professionals.
■ The stakeholders then designed the new model over a series of meetings. The aim of these meet- ings was to design a model that would respect local beliefs and practices as much as possible, but still ensure better outcomes for pregnant women.

• The model was rolled out over a nearly 2-year period and promoted through a variety of com- munication efforts in the local language, Quechua. 



• The new model was then evaluated, and refine- ments were made to the model based on what was learned in the evaluation. 



• A long-run evaluation of the model was set up on a continuous basis. 
During the planning stages of the program, a number of barriers were identified by women giving birth in government health centers: 



• Health professionals spoke only Spanish, although most indigenous women in this region speak Quechua. 



• The husband, family, and traditional birth atten- dant were not permitted in the delivery room, although the women prefer their participation in the delivery. 



• There was no option to use traditional medi- cines such as herbs and oils during the delivery process. 



• Women were required to deliver in a horizontal position on a gynecological bed, although they prefer a traditional, vertical, squatting position. 



• The umbilical cord could not be cut by a family member, following their tradition. 



• The placenta was thrown away, so it could not be buried according to tradition.