Waiting for the promises to be fulfilled.

When 33 year-old Maria, an indigenous woman of Maya K’iche’ ethnicity from Santa Lucia la Reforma in Nicaragua, fell pregnant with her fourth child, her family refused to let her have antenatal care. Her husband claimed that traditional birthing attendants had little training and were too expensive.

The night Maria went into labour, her family called a neighbour who had no medical training to attend the birth and help with the delivery. After the baby was born, the neighbour cut the umbilical cord badly and Maria began to haemorrhage.

Worried that she would be accused of harming the mother and the baby, the neighbour fled the house, leaving Maria’s family to try to stop the bleeding. With the nearest hospital over two hours away and no money to hire a pick-up truck, there was nothing they could do. Maria was dead by the morning.

What do averages hide?

Maria’s story is far from unique. Across the developing world, maternal health tells a shocking tale of preventable deaths and complications. It is estimated that over 500,000 women die through pregnancy every year, 99 per cent of them in the developing world. At a UN Summit to review the progress of the Millennium Development Goals (MDGs) next week, reducing mother and infant mortality in developing countries will be on the priority list. It is also one of the most off-target goals. However, no mention has been made of the most vulnerable of these women: mothers from indigenous communities.

As data on maternal health is rarely broken down by ethnicity, the variations within countries are masked, making it impossible to see which communities are most at risk. Martin Drewry from Health Poverty Action, an international NGO at the forefront of the campaign to help indigenous mothers to assert their rights, says: ‘Maternal and child mortality rates are often twice as high in indigenous communities as the national averages. Averages hide gross inequalities and terrible suffering.’

Indigenous people’s lives, health and security are increasingly threatened by poverty, marginalization and social and political disempowerment. A recent UN report found that indigenous people’s life expectancy is up to 20 years lower than their non-indigenous counterparts. Many lost access to sources of traditional medicine and age-old livelihoods when private companies or government projects started to operate on their land. Logging, mining, or the building of dams can make land uninhabitable, depriving entire communities of crops, plants and traditional medicines and polluting their water sources.

Nowhere is this reality more starkly apparent than in the experiences of pregnant women and new mothers from indigenous communities where infant mortality can be up to ten times higher.

Multiple layers of discrimination

Economic and political marginalization has led to huge disparities between indigenous health and that of the mainstream society. Indigenous women bear the brunt, facing multiple layers of discrimination based on being poor, women and indigenous. The community as a whole is also largely excluded from political processes and has no voice to make their demands heard.

‘We are humble people. We can’t read or write, we’re shy and we don’t know how to demand our rights,’ says Maritza, a mother of Quechan ethnicity from Ayacucho in Peru.

There is also the fear that reporting abuses and poor treatment will lead to communities being targeted. ‘If we are treated badly we don’t tell anybody, we keep quiet,’ says Mara from Chihua in Ayacucho. ‘We don’t know where to go to complain, we just talk about it among ourselves. We’re scared that they’ll take revenge.’

As many people in remote indigenous communities in the Americas speak little or no Spanish, the language barrier is a major obstacle in communicating with medical staff in mainstream clinics. Coupled with this is the fear of the unknown and general mistrust of ‘Western’ clinics.

When Ana Luisa went to give birth at a clinic in Ayacucho, she found that the midwife she had seen before was away and that another member of staff, who didn’t speak her native Quechan, would be filling in. Feeling intimidated, Ana Luisa left the clinic to begin the long walk back to her village but gave birth on the way home.

‘It was a really bad experience. I thought I was going to die,’ she says. ‘The baby was on the ground covered in dirt and I was trembling, too weak to pick him up. Luckily, some people from a nearby village heard my screams and came to my rescue.’

For Dr Florence Levy, who runs an indigenous maternal health project in Nicaragua, mistrust of ‘Western’ medicine was to have fatal consequences one day when she was on call at a local hospital.

She says: ‘A woman who had given birth at home four days earlier was brought in by her family. She was bleeding heavily and had a raging fever. The placenta hadn’t been expelled and I told the family that she would need emergency surgery to save her life. But they wouldn’t listen to me. They claimed that a woman in the village had put a curse on the mother and that all they needed to do was find a witchdoctor to break the curse.’

‘I am half indigenous myself and I tried to convince them but they wouldn’t listen and took the poor girl back home. The next day, the family brought her back into hospital. She was in a state of shock and convulsing. I did everything I could to save her but she died right in front of me.’

Contradicting cultural practices

Indigenous women have very different cultural practices when it comes to giving birth. Mayan women in Guatemala and other indigenous women in Latin America usually give birth in a crouching position. The woman supports herself with a rope strung from the rafters or in the arms of her husband. Instead of painkillers, the woman usually puts her braided hair between her teeth and bites down on it. Traditional birthing attendants and other family members are also usually present.

However, an investigation by Health Poverty Action in the Ayacucho region revealed the often terrifying practices in ‘Western’ health clinics. Health workers treated women forcefully and prevented their husbands from entering the delivery room. They made women wear hospital gowns instead of their own clothes and made them give birth lying down on a table instead of in their normal standing or squatting position. They also discarded the placenta, when the traditional practice is for it to be given to the family to be buried.

It can be a very frightening and humiliating experience to be made to give birth lying down, unable to understand the language spoken by medical staff and with family kept waiting outside. In the worst cases this means women dying in childbirth at home rather than using a system that is completely foreign to them.

The clinics are not without faults, either. When Jesibel Serapio, a single mother from a Miskito community in Auhya Pihni, Nicaragua, went to a maternity clinic because her pregnancy was high-risk, she and other indigenous mothers were told that there was no food for them at the clinic. ‘Some of the other mothers went to complain to the management, who had no idea and were horrified at this. It turned out that there wasn’t any food for us because the nurses were stealing it to take home with them,’ she says.

Out of reach: left on their own

As many indigenous communities live in remote, sparsely populated areas with high levels of extreme poverty, health services are often physically and financially inaccessible. In the past, conditions and advice from bodies like the World Bank and International Monetary Fund have also encouraged governments to cut social spending and charge people for healthcare, making it extremely difficult for indigenous groups to access it.

Additionally, the cost of providing health services in areas where indigenous people live is often higher than in majority communities. Where finance is short, governments and donors emphasize the need for cost-effectiveness and tend to focus on areas where costs are lower, further marginalizing indigenous people.

While the MDGs represent a breakthrough in international collaboration to tackle extreme poverty, they fail to put the rights of the poorest and most vulnerable at their core.

Shortly after his appointment as the UK’s Secretary of State for International Development, Andrew Mitchell stated that the new coalition government’s policy would be to focus on results-based aid and ‘value for money’. But the emphasis on numerical targets to reduce poverty often leads governments and international donors to focus on reaching the largest numbers of people, and usually the most accessible people in urban areas.

In rushing to meet the targets, they throw money at the most easy-to-reach and neglect the most vulnerable. Local organizations are under pressure to get quick results to demonstrate to donors that the project is working in order to secure further funding. This made Martin Drewry ask: ‘Some communities are more expensive to reach than others. Does that make them poor value for money and their needs not worthy of aid?’

The solutions? Low-tech and inexpensive

Despite the woeful lack of provision, bringing effective healthcare to indigenous communities doesn’t have to be expensive or hi-tech. There are many simple, cost-effective solutions that would make a life-changing difference. For Dr Levy, the key is providing services in keeping with indigenous traditions of health and well-being, in their own languages and in a culturally appropriate setting.

‘We went to the people, we asked them how they wanted to be attended and prepared guidelines for antenatal care and birth attendance, guidelines for Traditional Birth Attendants and health committees,’ she said.

Guatemala is piloting an alternative method of maternal healthcare, run by the state authorities: Casas Maternas (‘maternal houses’). Women with high-risk pregnancies or those from remote areas can stay in these houses up to 48 hours ahead of the birth. Skilled medical staff are on hand and importantly, a woman’s spouse can stay with her, helping to reduce her anxiety at being away from familiar surroundings.

Having births attended by skilled health workers is vital in reducing the numbers of women who die in childbirth. Women in rural Ayacucho, Peru, face some of the country’s highest maternal death rates. Through a programme of introducing culturally appropriate facilities in the health clinic, like allowing women to squat rather than lie down, and having health staff speak the local language, the number of women using clinics soared from only 6 per cent in 1999 to 83 per cent in 2007.

Traditional birthing attendants also play a very important role. With the right training, they can advise women on whether they need to go to the health centre to have their baby. Attendants can also be trained to provide advice on topics like nutrition and breastfeeding.

Tackling the democratic deficit that many indigenous communities face is also key to improving health. In Guatemala, the Indigenous Parliamentary Forum provides a national voice for indigenous communities, representing their concerns in the Parliament and calling on the international community for a focus on development with (not for) indigenous people.

Solutions such as providing mobile health units to travel to remote areas, improving transport links, subsidizing travel costs and removing healthcare fees would also be a huge step forward.

The international community had a chance to address the plight of indigenous communities at the G20 summit in Toronto, Canada in June, but failed.

The next opportunity is this month’s UN Summit on the MDGs. Without the right investment and genuine political will, thousands more mothers will die from preventable illnesses and complications, proving that the MDG promise was only that – a promise.

For more information, please see Health Poverty Action

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