Review of maternal mortality and maternal health outcomes in bolivia and chile

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The focus of this paper is on Bolivia and Chile. Their country profiles are presented here. Bolivia is a landlocked country located in central South America, bordered by Chile to the southwest, Paraguay and Argentina to the south, Peru to the west, and Brazil to the east and north (see Figure 5). The Andes Mountains and the Amazon Basin are part of the unique terrain of the 1,098,581 square km region. The population is estimated to be about 10,461,053 [38]. The country is divided into nine administrative departments including: La Paz, Santa Cruz, Cochabamba, Potosí, Chuquisaca, Oruro, Tarija, Beni, and Pando [39]. Beni, Pando, Santa Cruz and Tarija are non-indigenous departments while Chuquisaca, Cochabamba, La Paz, Potosí, and Oruro are home to indigenous populations [40].

Reproduced from CIA World Factbook

Figure 5. Map of Bolivia
Prior to Spanish colonization in the 1500s, ancient Indian civilizations like the Tiwanaku, Aymara, and the Inca covered the mountainous terrain of modern day Bolivia. These civilizations utilized superior agriculture and mining practices. After the Spanish conquered the land, they quickly exploited the rich mineral resources. In 1825, led by Simón Bolívar, Bolivia gained its independence from Spanish domination. Since that time, Bolivia has endured many boundary disputes with neighboring countries, the decline and rebirth of its silver industry, and economic downturns [39].

The population of Bolivia is very diverse ethnically. There are a number of ethnic groups in the country, including mestizo (30%), Quechua (28%), Aymara (19%), and European (12%) [39]. The official languages are Spanish, Quechua, and Aymara [38].

Women in Bolivia are not treated as equals to their male counterparts. A “traditional misogynist culture” exists and places women in roles pertaining to family care and reproduction [41]. Violence against women and rape are widespread problems in Bolivia, and many cases go underreported. Domestic abuse penalties are lax, oftentimes resulting in only a fine or up to four days in jail. It is alleged by women’s rights groups in the country that authorities designated to enforce domestic violence laws do so “irregularly” [42]. Conviction rates for rape charges are low, although they have risen in the recent past [39]. Non-consensual sex in marriage is not illegal [42].

Bolivia’s overall literacy rate is 91.2%, and the overall illiteracy rate is 8.8% [38]. The illiteracy rate among women is 13.2% compared to 4.2% among men [38]. In rural areas, this discrepancy is even greater: 37.9% for women and 14.42% for men. Males receive higher quality education than women and are more educated than females in the country [39]. In fact, on average, most males receive 1.5 more years of school than females [41]. The educational effect for women can have major implications for their health, the health and well-being of their children, and maternal mortality. Women who are educated are more likely to practice healthy behaviors [43]. Because of the educational benefits they receive, men have better access to higher quality health care than women. Additionally, women have less earning potential than men, while at the same time, they take on greater responsibilities, including domestic tasks [41].

The dominant religion of Bolivia is Catholicism. Approximately 95% of the country is Roman Catholic while the remaining 5% are Protestant and Evangelical Methodist [38]. Within the Quechua and Aymara speaking groups, certain beliefs and rituals that stem from before Spanish colonization are still held and practiced [44]. The Bolivian Constitution guarantees religious freedom, although in many public schools Catholic direction is provided [39]. The students, however, are not forced to attend these sessions.

Bolivia is defined as a constitutional multiparty republic. The government has three branches: legislative, judicial, and executive. The Congress is composed of 27 Senate members and a Chamber of Deputies with 130 members [39]. The primary function of the Congress is to argue and approve legislation initiated by the president. Three senators are elected from every administrative department [39].

The judicial system is comprised of the Supreme Court, and district, provincial and local courts. The president nominates the 12 congressionally confirmed Supreme Court judges, who serve ten-year, non-renewable terms. The Bolivian Supreme Court hears only cases of extreme importance [39]. These cases pertain to the constitutionality of laws, decrees, and resolutions approved by the legislative and executive branches. The Supreme Court also hears trials of public officers, even the president, for crimes committed in office [45].

Evo Morales is the current president, having been elected from the Movement Towards Socialism Party (Movimiento Al Socialismo- MAS) in December 2005. He is the nation’s first ethnically indigenous leader. The president’s main responsibilities are diplomacy, control of the armed forces, and the economic agenda [39].

There is a mandate in Bolivia to be sure that men and women are represented equally in the selection process [42]. The mandate has worked to increase female involvement in key governmental positions in the Senate, Congress, and Supreme Court. However, with these positions come threats. Several women who won elections reported that they were threatened with violence to give up their positions to men [42].

Bolivia is the poorest and one of the least developed countries in Latin America. In the 1980s, the country suffered massive economic turmoil. This led to the establishment of reforms that encouraged economic growth and reduced poverty. The 2008 recession stalled growth for the Bolivian economy, but in 2009, the Bolivian economy grew more than any other South American country [38]. Despite this growth, there is currently a lack of foreign investment in major economic sectors including hydrocarbons and mining [38].

Mining has been a long-established tradition in Bolivia since the time of Spanish colonialism, when the mining capital was Potosí [44]. After the tin market crashed in the 1980s, many miners began to grow coca leaves to sell in the cocaine trade to avoid starvation. In Bolivian towns, many people work as street vendors, construction workers, or carpenters. Increasingly there are more and more engineers and technicians [44].

Historically, the country tended to concentrate on production of single commodities, such as tin and coca. In 1997, large natural gas reserves were discovered and became one of the country’s most lucrative commodities. While Bolivia has experienced periods of economic booms, instability in the political and agricultural sectors has stopped industry from thriving [39]. Many Bolivian Indians living in the rural lowlands are completely excluded from the cash economy [44].

As of 2013, Bolivia’s gross domestic product (GDP) was $58.34 billion with a real growth rate of 6.5%. The Bolivian government spends 4.9% of its GDP on health expenditures [38]. The gross national income (GNI) per capita in 2012 was $4,880 [46]. In 1985, Bolivia suffered massive inflation of over 20,000%. By 1994, this rate dropped to 4.9%. However, in that same year, the government experienced a $500 million budget deficit [39]. There are 4.724 million people in the labor force. The unemployment rate is 7.5%, and 49.6% of the population lives below the poverty line [38].

While there have been increases in the number of children receiving vaccinations and improvements in maternal mortality, there are still great inequities, especially between indigenous and non-indigenous populations. The country is experiencing high fertility rates while family planning services remain low. As of 2008, the contraceptive prevalence rate was 60.5%. The total fertility rate is 2.87 children per woman and the mother’s average age at first birth is 21.2. Lack of clean water and sanitation exacerbates the already poor health of the population [38].

Bolivia has several pressing public health concerns. Chagas disease, yellow fever, malaria, tuberculosis, leishmaniasis and other communicable diseases are found in the country, especially among the indigenous populations [47]. PAHO estimates that about 22% of the population is infected with Chagas [48]. In 2010, the leading causes of mortality in Bolivia were communicable, maternal, perinatal, and nutritional conditions (35%), cardiovascular disease (22%), other noncommunicable diseases (19%), cancers (8%), injuries (8%), respiratory diseases (5%), and diabetes (3%) [49] Within the Latin American/Caribbean region, Bolivia has one of the highest rates of sexually transmitted diseases [48]. While the incidence of syphilis has decreased from 4.2% to 1.1% and gonorrhea has dropped from 6.8% to 2.7%, chlamydia in Bolivia has increased from 7.8% in 2001 to 13% in 2004 [50]. HIV prevalence is also on the rise, especially among men who have sex with men [48]. In fact, Bolivia is classified as having a “concentrated [HIV] epidemic” because high-risk groups have a prevalence rate higher than 5% [50, pg. 120]. Infant mortality is ranked third highest in the region as a result of nutritional deficiencies, lack of healthcare knowledge, and socioeconomic status [48, 51]. Proper sanitation and access to medical services are lacking in rural Bolivia. Inhabitants of these areas are more susceptible to illness because sanitation and safe drinking water are available to only 20% of the rural populations [44].

Abortion is illegal in Bolivia. There are, however, instances when an abortion can be performed under the law. In cases of rape or incest, to save the mother’s life, or to maintain physical and mental health of the woman, an abortion can be performed by a doctor with judicial permission [52]. In cases of incest or rape, an abortion can be obtained through legal action [52]. Abortion is not permitted on the grounds of fetal impairment, economic or social reasons or by request [52].

The healthcare system in Bolivia is comprised of three components; the private sector, the public sector and social security. The private sector is the smallest of the three and is made up of private practitioners, clinics run by non-profit organizations, and traditional medicine. The public sector focuses on the health of mothers, children, and the elderly. This sector is extremely limited in capacity because of lack of resources. The social security sector is utilized by Bolivians who are employed in the formal economy and offers coverage for diseases, occupational risks, prenatal and neonatal care, and childhood care [40].

Health services in Bolivia are provided at three levels. At the first level are basic facilities within which nursing assistants and doctors administer health promotion programs, preventative services, basic health services, and outpatient care. These basic facilities are the most common in Bolivia, particularly in rural areas. At the second level, hospitals provide general and trauma care, general surgery, gynecologic services, and pediatric care. Most of this coverage is in urban areas. The third level is located only in specialized hospitals in the capital of each department in Bolivia that provide expertise in fields such as cardiology and psychiatry [40].

In order to improve the overall health of the population, the Bolivian government established three insurance plans over the past 20 years. The goal of all of these plans was to reduce economic barriers to health services by offering free care. The first plan implemented in 1996 was the National Maternal and Child Insurance (SNMN). The main focus of SNMN was to reduce the number of maternal deaths by 50% and the deaths of children under five from diarrhea and pneumonia. The services offered under SNMN included prenatal and postpartum care, labor and delivery, obstetric emergencies, newborn care, neonatal asphyxia, and treatment of diarrhea and pneumonia [40].

The second insurance plan was Basic Health Insurance (SBS), and it was implemented in 1998. The target population of this plan was women of reproductive age, children under the age of five, and the general population suffering from endemic diseases. The goal of SBS was to reduce the morbidity and mortality of the most vulnerable groups of society and improve care quality while respecting cultural practices. The services offered in SBS covered the same population as SNMS and added sexual and reproductive care, birth control, STDs care, endemic disease services, and medical care to rural communities lacking health facilities.

The third and final insurance plan implemented in 2003 was the Universal Maternal and Child Insurance (SUMI). The mission of the plan was to reduce maternal and child mortality, and specifically emphasized neonatal mortality reduction. The plan offered more complex care for children and mothers by expanding ambulatory care, diagnostics, and surgical treatments. SUMI, unlike SNMN and SBS, provides services that are usually not available in primary care facilities and as such, are not found in rural areas [40].

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