Changing Birth in the Andes: Culture, Policy, and Safe Motherhood in Peru

CHANGING BIRTH IN THE ANDES

CHANGING BIRTH IN THE ANDES

Culture, Policy, and Safe Motherhood in Peru

Lucia Guerra-Reyes

VANDERBILT UNIVERSITY PRESS

NASHVILLE

© 2019 by Vanderbilt University Press

Nashville, Tennessee 37235

All rights reserved

First printing 2019

This book is printed on acid-free paper.

Manufactured in the United States of America

Library of Congress Cataloging-in-Publication Data

Names: Guerra-Reyes, Lucia, 1974-author.

Title: Changing birth in the Andes : culture, policy and safe motherhood in Peru / Lucia Guerra-Reyes.

Description: Nashville, Tennessee : Vanderbilt University Press, 2019. | Includes bibliographical references and index.

Identifiers: LCCN 2018039001| ISBN 9780826522368 (hardcover : alk. paper) | ISBN 9780826522375 (pbk. : alk. paper) | ISBN 9780826522382 (ebook)

Subjects: | MESH: Maternal Health Services—organization & administration | Parturition | Health Knowledge, Attitudes, Practice | Culture | Health Policy | Peru

Classification: LCC RG963.P4 | NLM WA 310 DP6 | DDC 362.198200985—dc23 LC record available at https://lccn.loc.gov/2018039001

ISBN 978-0-8265-2236-8 (hardcover)

ISBN 978-0-8265-2237-5 (paperback)

ISBN 978-0-8265-2238-2 (ebook)

To Mateo, Adrian, and Daniel with love.

CONTENTS

Figures

Acknowledgements

Glossary of Commonly Used Acronyms

Introduction

ONE: The Making of the Intercultural Birthing Policy in Peru

TWO: Higher Up and Farther Away: Implementing Intercultural Birth in Cusco and Cajamarca

THREE: Constructing Interculturality, Civilizing Birth

FOUR: Strategizing for a Good Birth: Women, Men, and Traditional Lay Midwives

FIVE: The Doctor Does Get Respect: Clinic Midwives’ Experiences of Intercultural Birthing

Conclusion

Notes

References

Index

FIGURES

Figure 1. Organization chart for the Peruvian public health system

Figure 2. A version of the traditional birth attendant referral sheet from a Ministry of Health Peru training manual

Figure 3. The cover of the Intercultural Birthing Policy (IBP) document from the Ministry of Health Peru and UNFPA

Figure 4. Quispicanchi Province, Cusco

Figure 5. San Marcos Province, Cajamarca

Figure 6. Kantu Labor Room

Figure 7. Birthing plan example: Esperando mi Parto

Figure 8. Poster: We want to treat you like in your home

Figure 9. Poster: We take care of your health and respect your customs

ACKNOWLEDGMENTS

I am immensely thankful for the many people and institutions that contributed to this project over the years. First, I am deeply indebted to the women and men in Lima, Cajamarca, and Cusco: the mothers, fathers, policy officials, health providers, and community leaders who took time to share their experiences and stories with me. These exchanges illuminated the intricacies of desires, effects, and expectations of intercultural birthing in Peru. My profound gratitude to Maria Layme, mother, anthropologist, and Kantu research assistant, for all her work, for supporting me in speaking Quechua, and for welcoming the wakcha-me warmly into her home. I dedicate this book in her memory and that of other indigenous women who seek equitable and respectful health care.

Several institutions in the United States and Peru have been instrumental in bringing this book to fruition. At the University of Pittsburgh my graduate colleagues and mentors read and commented on the early pieces of what would become this book. I am especially grateful to Kathleen Musante, Joe Alter, Martha Terry, Harry Sanabria, and Patricia Documet, Amalia Pesantes, and Tyra Hudgens. The University of Pittsburgh Center for Latin American Studies funded formative research for this project. The Cultural Anthropology Program at the National Science Foundation provided doctoral dissertation funding (DDIG #0918030) for the yearlong research study that made this book possible.

At Indiana University I am lucky to work among inspiring colleagues who have supported and protected my time to allow me to finish this project. I owe special thanks to my chair, David Lohrmann, and to my senior colleagues in the Behavioral and Community Health curricular group. My special thanks to Virginia Vitzhun and Sara Phillips, who invited me to talk about this research in their anthropology classes, and to the students of Sara’s seminar class, who graciously provided comments on a very early version of the manuscript. Many thanks to the Office of the Vice-Provost for Research for providing grant-in-aid funding for the completion of this project.

I am immensely appreciative of the support of School of Public Health colleagues at the Universidad Peruana Cayetano Heredia. I would especially like to acknowledge Nancy Palomino, Ruth Iguiñiz, Alejandro Llanos, Patricia García, Victor Cuba, and Esperanza Reyes for generously sharing contacts that made research possible, and for their inspiring work on improving sexual and reproductive health for all in our country. I owe immense gratitude to Jeanine Anderson from the Pontificia Universidad Católica, who was instrumental in my education as a young field researcher and budding medical anthropologist.

I have been fortunate to benefit from various scholarly communities that have helped me think through the issues in this book. I was inspired by the work of senior researchers from the Council for Anthropology of Reproduction and by fellow panelists and discussants from the Society for Medical Anthropology, the American Anthropological Association, and the Society for Applied Anthropology. I am especially thankful to Trisha Netsch-López for the long hours of ongoing discussions about birthing, interculturality in health, life, and anthropology. Many thanks to Trisha, Eliza Williamson, and Mounia El Kotni for their willingness to read and comment on parts of this book. Many thanks also to Naomi Byerley, who battled with rogue citations and formatting. I am immensely grateful to the wonderful women of the Scholarly Writing Program at Indiana University, and Laura Plummer especially, who were an amazing source of practical advice, writing inspiration, and emotional support during this process. My heartfelt thanks to Emma Young, who worked independently with me on language and editing and made this process much easier. Many thanks to Michael Ames, Beth Kressel Itkin, and the editorial staff at Vanderbilt University Press for their work on the various stages of making this book a reality. I also want to acknowledge the anonymous reviewers for their gracious and detailed comments.

My family has been the most incredible source of support in this long process. Jaime and Esperanza, my parents, cared for my children in Lima while I was in the field and supported me financially and emotionally at very difficult stages of the research. I am in awe of their love and commitment. I am humbled by Daniel’s unwavering love and encouragement. His support for this project and for my career kept me going through the extended fieldwork, family separation, and long hours of work. This book would not have been possible without him. Finally, Adrian and Mateo, as infants, were immensely important to this study; being their mother made me acutely attuned to the multiple meanings and shared desires for a good birth. Now, as funny and joyful big kids, they keep me grounded and hopeful.

GLOSSARY OF COMMONLY USED ACRONYMS

DIRESA: Dirección Regional de Salud or Regional Health Direction

ESSALUD: Social Security Health Insurance

IBP: Intercultural Birthing Policy

MDG: Millennium Development Goal

MOH: Ministry of Health

PAHO: Pan American Health Organization

SERUMS: Servicio Rural y Urbano Marginal de Salud or Rural and Urban Medical Service

SRHS: Sexual and Reproductive Health Strategy

UNFPA: United Nations Fund for Population Activities

UNICEF: United Nations International Children’s Emergency Fund

Introduction

Peru embraces vertical births to save lives.

—Maria Luisa Palomino

The first time I heard about the Peruvian Intercultural Birthing Policy, I was floored. A policy that incorporated traditional Andean and Amazonian birth-care traditions into official clinical practices? This idea was groundbreaking and progressive. Implementing it would require a lot of effort—retraining staff, redesigning delivery rooms, updating the protocols for months of prenatal care. This was no minor tweak. The piece that really struck me, however, was that this new policy indicated a sea change in the way the Peruvian Ministry of Health (MOH) viewed indigenous peoples. The overarching policy goal was—as is pretty normal for any birth-care policy—to save lives by preventing death during delivery. Yet it encompassed so much more. In recognizing the desire for culturally respectful birth, the MOH was broadening its definition of success and thinking about indigenous women more holistically, as patients with rights. Indeed, the policy was officially touted as Peru’s great step forward to decreasing maternal deaths while providing culturally appropriate and compassionate birth for indigenous women (Andina 2008; Fraser 2008).

What made this even more surprising to me was that it felt almost as though the MOH was responding directly to what I had discovered in my own early research. I conducted my first field project in 1997; the objective was to understand birth-care decisions among rural women in an area of Peru called Cajamarca. That study was my inauguration as an anthropologist and researcher. It laid the groundwork for much of my successive work, including this book. I had been thinking about the issues I encountered in Cajamarca for nearly a decade—and now, it seemed, policy makers were thinking about them, too.

In the almost thirty interviews and birth stories I collected in 1997, I observed a profound disconnection between the ideals for birth care that mothers expressed and those that health personnel adhered to. By and large, a Cajamarca woman’s ideal birth began and ended at home: it involved family members, the local traditional birth attendant (partera), hot soups, herbal teas, massages, walking around, and ultimately delivering the baby from a squatting position, while cloaked in the privacy of traditional long skirts.¹ Health care providers were overly focused on the promise of Western medical protocols to manage risk in the process; to them a good birth was simply one in which the mother and infant survived with minimal complications. Women recognized that giving birth could be dangerous, and during their pregnancies, they would seek prenatal care from both the parteras and the clinic midwives with their modern medicine, hoping to avoid the most onerous risks.

But when labor began, consulting both caregivers was no longer an option. At this juncture, each family had to make the decision of whether to give up the other elements of a good birth in exchange for the expertise of the professional medical staff, whether to send the laboring mother to the health clinic to deliver. There were many factors weighing against the clinic: birth was expensive, the delivery rooms were cold and damp, every woman had personally endured or knew a woman who had endured physical and verbal mistreatment there, movement was restricted, and episiotomies (cutting the perineum to enlarge the vaginal opening) were routine. And the laboring woman knew she would have to face all this alone, because family would not be allowed in.

Listening to all this, it made perfect sense to me that most local people reserved the clinic-birth option for emergencies or for women who had no family support available. However, midwives and doctors in the local clinic bemoaned their patients’ preferences for a warm, supportive environment as detrimental entrenched traditions. They pleaded with me, the anthropologist, to help educate women about the dangers of these traditions. To the health professionals I was interviewing, the only thing that mattered was the physical risk of childbirth, and Andean culture was one of the barriers to their lifesaving work (Guerra-Reyes 2001).

Over the following few years, health care reform helped mitigate several of the structural issues that had been impeding access to biomedical care. New nationally funded insurance programs lowered costs; clinic expansions and improvements to health-center infrastructure reduced distance barriers. Community engagement policies also encouraged collaboration with local authorities to address specific community needs. When the Intercultural Birthing Policy (IBP) was proposed in 2005, it appeared designed to address the dissociation between family expectations and clinic realities that I had observed. The IBP gave explicit recognition to certain indigenous cultural birth-care values. It seemed like the crowning achievement of a movement toward equitable health care access for marginalized women. Culture remained a central issue in birth-care provision, but the value placed on it by doctors, nurses, clinic midwives, and health-policy officials appeared to have changed. It was now a key component of the Peruvian efforts to reduce maternal mortality and achieve the Millennium Development Goals (del Carpio Ancaya 2013). Through the lens of interculturalidad, culture had made the leap from barrier to possibility.

I had a flurry of questions: What did this new IBP actually look like on the ground? Did this new discourse indicate a true shift in how policy makers view the relationship between health and culture? How were the doctors and midwives in rural clinics like Cajamarca taking it? What did all this mean to parteras? How would this policy change the experience of indigenous women and their families?

The IBP is Peru’s part of a policy trend that has affected much of Latin America. There are now related intercultural sexual and reproductive health programs and policies in Ecuador (Laspina 2010), Bolivia (Ramirez Hita 2014), Guatemala (UNFPA 2010), Mexico (Secretaría de Salud de Mexico 2014), Panama (UNFPA 2010), Peru (Salaverry 2010a), and Chile (Sáez Salgado 2010), to name only a few. When I devised this study, I wanted to explore how the Peruvian case could illuminate the challenges and pitfalls of interculturalidad in health care in Latin America as whole.

I returned to Peru, and to the Andes, to trace the story of the IBP’s creation and to see firsthand how it was implemented. I chose two research sites and took a multilevel perspective, collecting the experiences of policy makers in Lima and of clinic midwives, other health care personnel, parteras, women, men, and community leaders in each area. My results paint a complex picture of policy implementation. Despite the hopes IBP created among scholars and activists, myself included, in the end I must argue that the actual practice of intercultural birth care in Peru continues the long history of government coercion of indigenous women and their reproduction. The fundamental agenda hasn’t changed: controlling reproduction is part of the broader modernizing enterprise that seeks to expand biomedical care not only because it saves lives but also because it is a marker of social development. The concept of interculturalidad has the potential to give rise to a radical shift toward a more inclusive agenda that still engages with the life and death statistics of childbirth. But in practice it is deployed as a temporary stopgap in an array of policy tools designed to stamp out home birth and steer all women to give birth in the clinic.

However, in this book I also explore many other layers: how indigenous men and women contest these homogenizing pressures, how parteras have cannily reworked their role in a new era of Andean birth care, and how clinic midwives struggle with their personal and professional roles in IBP implementation in the context of an unequal public health system. I was privileged to witness some cases where women achieved a good birth on terms that worked for them and for the health personnel, cases where interculturality seemed to make a difference. And I witnessed cases that were frightening and disturbing. I explore all these in the chapters to follow.

The Politics of Birth Care

This book is guided by anthropological perspectives on birth care and reproduction. Broadly speaking this study inserts itself amid anthropological research that describes the contentious relationships between non-Western cultural systems of birth care and technologically mediated obstetrical birth care. A central issue in the research is the increasing medicalization of birth, a process by which biomedicine has achieved the authority to redefine and treat birth as a medical problem (Georges 2008). Globally, anthropological research on reproduction has analyzed how the progressive medicalization of birth care is replacing all other forms of care (Bellón Sánchez 2014; Bohren et al. 2015; Brunson 2010; Cahill 2001; Cosminsky 2016; Georges 2008; Shaw 2013). This biomedical form of birth, also called technocratic, is an event mediated by the trappings of medical protocol, technology, and machinery, rather than a female-centered embodied experience (Davis-Floyd 2003). In a biomedical model of care, the locus of power and decision-making rests with the medical provider; medical knowledge is the only kind that counts, and, as such, it is constructed as authoritative (Davis-Floyd and Sargent 1997; Gaskin 1996; Jordan 1997; Sargent and Bascope 1996; Sesia 1996; Trevathan 1997). The embodied cultural knowledge that the mother brings, and her entire experience, can easily be squeezed out of the picture. Non-biomedical care is construed as constraints on the individual’s freedom to make rational choices from an ever-expanding field of options (Georges 2008, 158). Biomedical knowledge is constructed as not only rational but also morally superior; in contrast, indigenous women’s preferences, or traditions, are classed as irrational.

I argue that the intercultural birth-care policy in Peru expands the reach of a biomedical model of care, yet it does so by outwardly de-medicalizing the process though the incorporation of traditional Andean birth-care practices.² Nevertheless, these practices have been divorced from the cultural systems that engendered them and are recreated as tokens of culture in a biomedical space. I draw on the notion of authoritative knowledge to analyze the locus of power and decision-making in the implementation of intercultural birthing during patient–provider interactions, in describing the ways in which indigenous women engage strategically with the biomedical models of care, and in how traditional birth attendants subvert hierarchies of knowledge in their newfound roles.

This process of medicalization isn’t only about the relationship between individual patients and health care providers. The normalization of biomedical birth care on a global scale is, as Ginsburg and Rapp argue, profoundly political (Ginsburg and Rapp 1991, 1995). The control of female bodies and their capacity for reproduction is central to the creation of nations and citizens (Canessa 2005; Greenhalgh 1995). I draw on Foucault’s concept of biopower to tease out how techniques for the subjugation and control of bodies and populations (Foucault 1990) are enacted through implementation of intercultural birthing. I additionally argue that, in the case of Peru, accepted practices of pregnancy and birth similarly inscribe the impact of these controls on women’s bodies and color their claims to legitimate citizenship. I view the IBP through the lens of reproductive governance, a term proposed by Morgan and Roberts (2012), encompassing [a group of] mechanisms through which the different historical configurations of actors, such as state institutions, churches, donor agencies, non-governmental organizations—use legislative controls, economic inducements, moral injunctions, direct coercion, and ethical incitements to produce, monitor, and control reproductive behaviors and practices (243).

Reproductive governance is a useful framework for understanding how international and national policies interact with each other and intersect with other kinds of governance, creating subjects of power, subjects of rights, and subjects of policy. Through this conceptual framing, we can understand the links between embodied moral regimes, national political strategies, and global economic logics, by situating the governance of bodies within world governance.

Public policies reinforce existing power relationships by which some categories of people are encouraged to reproduce and nurture, while others are disempowered (Rapp 2001). In other words, policies that control access to contraception, fertility care, and new reproductive technologies can be used to promote the creation of certain kinds of citizens and discourage others (Anagnost 1995; Greenhalgh 2008; Inhorn and Birenbaum-Carmeli 2008; Kanaaneh 2002; Morgan and Michaels 1999; Necochea-López 2014). Viewed from this perspective, even policies deployed with morally positive objectives, such as reducing maternal deaths, are so entwined in unequal power relationships that they have unfortunate consequences. Nicole Berry’s (2010) poignant study of the Safe Motherhood Initiative in Guatemala demonstrates this. She argues that, in application, the safe motherhood policies have created more barriers to reducing deaths and have endangered the very vulnerable community they sought to save.

Recent ethnographies of reproduction in Latin America have demonstrated other examples of these mechanisms of reproductive governance at work. Vania Smith-Oka (2013) provides a superb analysis of how Oportunidades, Mexico’s conditional cash-transfer program, creates new forms of neoliberal motherhood in the name of empowerment and development. Mounia El Kotni (2016) similarly describes how Prospera (a successor to Oportunidades) and the training of traditional parteras in Chiapas eat away at the important cultural relationships between parteras and women, erode la confianza (trust) by monetizing birthing in the clinic, and marginalize traditional parteras’ knowledge and community standing. El Kotni’s analysis also highlights how discourses of human rights and intercultural health foster further discrimination and marginalization of indigenous women and men in Mexico.

In each of these studies, the experiences of women, parteras, and anthropologists resonate with collected narratives and my own experiences of intercultural birthing in Peru. The similarities reflect the shared effects of neoliberal forms of nation building that have underpinned, and still guide, the Latin American political and policy climate of the last three decades.

In the Peruvian case, I will argue that the IBP uses an unconventional mechanism to pursue the conventional national goal of medicalization, in the process engendering creative resistance from the subjects of reproductive governance. Outwardly, by incorporating some practices from Andean traditions, the IBP reverses the trend of public-health policies that are committed to the absolute moral authority of a supposedly absolutely pure form of biomedical knowledge. However, these practices have been cherry-picked and divorced from the cultural systems in which they have meaning. Moreover, they are deployed by biomedical personnel who still see local knowledge as inherently inferior. In the journey from the policy page to the delivery room, these specific Andean practices are recreated as mere tokens of culture in a medicalization process whose basic power dynamics remain unchanged and as problematic as ever.

Peruvian Birth Care without Intercultural Adaptation

To understand what intercultural birthing changed, first we need an idea of what birth-care options were previously available to rural indigenous women. There is no one non-Western form or traditional birth-care system in Peru. Andean birth practices share some key elements with those of Amazonian regions, but there are many variations. Biomedical obstetrics are not homogeneous, either: the type of care a woman can expect at a biomedical facility in an urban setting is not the same as that available in similarly ranked rural clinics in the Andes. Both systems of care are constantly evolving. Nevertheless, throughout this book, community women, men, traditional birth attendants, clinic midwives, and other health personnel refer to both types of birth care as static categories, so I will take a moment to lay out what is broadly understood in Peru under these labels.

Traditional is often conflated with indigenous, and in Peru this could mean Amazonian or Andean ethnic groups. There are two large ethno-linguistic groups in the Peruvian Andes, Quechua and Aymara; however, a shared perspective of health and body encompasses the whole of the Andean region.³ One of the central tenets of an Andean worldview is that humans and their environment are inherently interconnected. A healthy body is one that achieves equilibrium between the human world, the spiritual world, and the environment that surrounds them (Cooley 2008). This form of conceptualizing health and the body is not exclusive to the Andes; it is regarded as one of the oldest forms of disease diagnosis and treatment (Foster 1987; Tedlock 1987). In practical terms, maintaining a healthy equilibrium is a result of careful daily practice of balancing hot and cold bodily humors (Bastien 1989).

Andean humoral theory extends to the whole environment. Food and drink are classified as hot or cold, regardless of their actual temperature. For example, rice, potatoes, eggs, and milk are considered cold, whereas beans, corn, and beef are considered hot. Balance is adjusted by combining hot and cold foods and also by adding medicinal herbs as needed (Finerman 1989). In the same manner, features of the landscape are considered hot or cold; for example, areas of pre-Hispanic ruins and burials are regarded as hot and dangerous (Larme and Leatherman 2003), as are certain areas near the peaks of well-known Apus or mountain deities. Thus, all daily activities of an Andean man and woman are seen as either contributing to humoral balance or endangering it.

A woman’s reproductive potential means that she is equal to the Pachamama (mother earth), something that both makes her dangerous and puts her in danger (Larme 1998). Openings in the body increase the threat of humoral imbalance, so a woman’s body is considered weaker than a man’s because of her extra orifice. Consequently, female reproductive processes—menstruation, pregnancy, birth, and postpartum—receive particular notice. For example, women pay close attention to the flow, consistency, and quantity of menstrual blood as an indicator of health. When the blood fails to show but there is no pregnancy, this is attributed to the action of cold elements (air, water, foods) causing the blood to harden in the abdomen. This hardened blood produces aches and lumps, which are considered very dangerous for the woman’s health (Hammer 2001); in some cases, they are equated to modern ideas about tumors and cancers. The condition is thought to lead to chronic weakness of the body and is treated using hot herbs, which are considered emmenagogues, or menstrual regulators (Hammer 2001).

Similarly, one of the main health concerns regarding childbirth is the effect of cold elements. Birth is considered a hot occurrence. In the same way in which a hot substance is needed to regulate the menstrual flow, a hot environment is needed to ensure a speedy and healthy birth outcome. Therefore, the preferred area for birth in an Andean adobe house is the kitchen, where the hearth is located, or the windowless main room. The woman is administered hot herbal beverages to aid dilation during labor; abdominal massages with herbs and warm animal fat or oil are also used to promote a quicker birth (Bradby 2002; Bradby and Murphy-Lawless 2002). Some parteras trained in biomedical forms of care have incorporated the use of Pitocin injections to increase uterine contraction and move along a slow birth.⁴ However, in general, herbal beverages are considered sufficient to aid the dilation period. The partera will ask the woman if she feels the urge to push and will ask her to wipe her genital area with a clean white cloth to check for signs of blood that may indicate the baby is almost ready to emerge (Guerra-Reyes 2001).

Women usually prefer birthing in a vertical position. The laboring woman squats on a shallow stool, bed, or chair supported by the husband, father, other family member, or partera. The woman is generally fully clothed, using several of her daily use wool or cotton underskirts so that her genitals remain covered from the dangerous air (Bradby and Murphy-Lawless 2002). The child is born onto a black sheep or llama hide (a dark-colored wool cloth is also used); this color is considered hot and will keep the child from harm while the placenta is tied off with a string and cut.

During the birth process, the main focus of the activity is the mother; thus, in many cases the child may remain on the mat or floor until all interventions on the mother’s behalf have ceased or until someone who is eligible can pick the baby up (Bradby and Murphy-Lawless 2002). It is generally supposed that someone other than direct family members should collect the child from where it lies after birth, wash, and clothe it. This is a ritual act that creates the fictive kin relationship of compadrazgo, a link similar to that established between a godparent and the family of a child, which strengthens internal community links and establishes a lifelong relationship of respect and responsibilities between families. There are mutual benefits to the creation of a compadrazgo through birth. For example, a birth attendant or partera serving a specific community can increase her standing and influence by being madrina, or godparent, to several generations of community members, and the child’s family benefits by being privy to the health-related advice of a knowledgeable person (Guerra-Reyes 2001).

Once the child is born, the placenta becomes the focus. Considered to be linked to the health of the mother and child, the placenta is sometimes called the madri, or mother, and is said to sleep next to the child during the pregnancy (Davidson 1983). In its role of mother, the placenta provides teats for the child to suckle and feed on while in the womb (Bradby and Murphy-Lawless 2002). Because of the strong link between child and placenta, it is important to dispose of it correctly so as to prevent cold–hot imbalance in the child’s body; this is generally achieved by burying the placenta deep in a field or under the family cooking hearth. Within Andean belief systems, this mode of disposal allows the womb mother to return to the earth mother (pachamama) and nourishes the family field or family house (Bradby and Murphy-Lawless 2002; Guerra-Reyes 2001).

After birth the woman’s body is considered to be dangerously open and liable to suffer humoral imbalance. Immediately after birth her hips are bound with a strong broad cotton or wool cinch to help close the body. Additionally, women are encouraged to rest from their usual duties for thirty or forty days. During this time, a recently birthed woman should avoid cold-air drafts, coming out of the house only when it is sunny and she is protected; she should eat only warm food and should not do any washing or cooking. The effect of a humoral imbalance during this period can lead to sobreparto, owing to the coagulation of birth blood inside the abdomen caused by cold air (Larme and Leatherman 2003). Sobreparto is a sometimes-fatal illness that presents as fever and abdominal pain; some scholars have associated it with puerperal fever (Bradby and Murphy-Lawless 2002; Hammer 2001; Larme and Leatherman 2003). However, it can also occur months and years after the birth (Larme and Leatherman 2003) and is also associated with a specifically female illness called debilidad, or weakness (Oths 1999). Scholars have proposed that these ailments are embodied cultural responses to years of productive and reproductive labor in a male-dominated hierarchical society (Cooley 2008; Larme and Leatherman 2003). While they are feared, they may bring a culturally acceptable respite from female responsibilities in the home and fields when a woman cannot maintain the same pace of labor anymore. The work of women in the Andes extends from all home and child care to small-animal husbandry and vegetable production to seeding, weeding, and reaping crops alongside their male counterparts (Bourque and Warren 1981). When a woman is diagnosed with sobreparto, other female members of the family, generally daughters, may then undertake her work. A woman who has no daughters is pitied, as she has no one to alleviate this burden and is then more prone to illness (Crandon-Malamud 1991).

Given the woman’s pivotal role in the wellbeing of the family, and the intrinsically dangerous nature of the reproductive process, the type of care sought during pregnancy and birth is subject to much thought and discussion. Particular circumstances, like number of pregnancies, previous personal experiences, experiences related by other people, family input, the types of care available and the barriers to access, the woman’s age, and the nature of the family’s livelihood, all play into the final decision, augmenting or reducing the focus on humoral balance. In practice preferred care may mix elements of both traditional and biomedical practice (Guerra-Reyes 2001).

The other option for birth care for rural women in the Peruvian Andes is the public health system. The following description of a typical birth in a rural health clinic is based on my own experiences and observations in the Andes and on descriptions in Reyes (2007) in the coastal and highland facilities of a rural micro-network.

Although officially birth-care practice in a public health center follows the same directives of care as anywhere in the country, the particulars of the Andean rural environment and the rarity of access to other biomedical infrastructure make providing birth care particularly challenging. Structural constraints of the health system itself can influence care: the type, experience, and readiness of attending personnel; the availability of needed supplies; and the possibility of evacuation to a higher-ranked facility in case of emergency. Rural clinics contend with undependable electricity, water, and sewage services; incomplete or non-existent access roads; and the highland weather, which alternates drastically between hot and cold temperatures. Staffing levels, staff expertise, and availability of supplies can also pose structural limits to the services that rural clinics can offer.

Most public health clinics are constructed using a similar pattern, favoring cement walls and floors