By: Marcela Gómez
Photos: Javier Pinzón
Western Panama is the breadbasket of a country that derives most of its income from trade and services. While the trans-isthmian zone generates much of the national income, the western mountains grow the food the country needs. But these mountains are also home to a significant segment of the Panamanian population that lives in extreme poverty, many of whom belong to the Ngäbe Buglé people: 154,355 individuals scattered over 2,690 square miles of steep mountains and deep canyons with no highways or bridges, much less basic services like electricity, potable water, or sewers. This helps explain why women from this ethnic group are four times more likely to suffer pregnancy-related deaths than other Panamanian women.
Now, however, we are witnessing the development of a collective effort in which various community agents help save the lives of mothers and children in a program that could become a model for other deprived and isolated areas of the Americas. Ana de Obaldía, coordinator of the United Nations Population Fund project, comments: “When we came here to try to reduce maternal mortality, we found a void. We hoped to bring together government institutions and community leaders, but they were the ones to seek us out.”
The story is confirmed by four leaders of the Association of Ngäbe Women we met in San Félix. They tell us how the Association was formed fifteen years ago to sell handicrafts, as a way for women to pull themselves out of poverty. They soon noted that a number of the members stopped coming to the meetings; when it turned out these absences were due to pregnancy-related deaths, the leaders decided to act. Women could not continue to die while giving life, leaving behind many motherless children.
The Virtuous Circle
The collective life saving efforts begin with these mothers who have become community multipliers; they donate their time and go door to door, looking for pregnant women and convincing them to go to health centers and have at least four check-ups during pregnancy. This is no easy task, given the area’s geography and the distances between districts and towns; the need to organize childcare; the steep, muddy roads; and the danger of crossing rivers that can suddenly rise.
We met two health promoters at the Hato Chamí health center in the Nole Duima district, some two hours from David, the provincial capital of Chiriquí. Forty-year-old Chella Montezuma has always possessed the spirit of leadership. Once her children were grown, she attended seminars in domestic violence, family planning, and women’s rights, and then headed out on those difficult roads in search of women who needed her help.
“I am both mother and father to my children,” says another woman. “And my mother is 89, so I have to be at home, but I really enjoy this work. Once a month I leave at six in the morning and get home around six in the evening. I bought a horse and I ask my neighbors for help when we need to transport people down the mountain.”
The next link in this community effort consists of hostels near the health centers where women who live far away can come before they go into labor and wait for birth.
“In order to understand the causes of maternal death, we need to follow the roadmap of a birth,” explains Ana. “Distance, impassable roads, and a lack of information all complicate matters. It is different when there is an infrastructure with all the facilities and personnel for attending a birth. That is why the hostel is so important: women can leave their homes in plenty of time, knowing they have somewhere to go where they will be provided meals.”
We visited the Hato Chamí health center’s hostel, which offers patients and their companions the use of bathrooms and a kitchen. There is another hostel attached to the José Domingo de Obaldía Hospital, two more on opposite sides of the indigenous region, and the premium hostel, La Virgen del Camino, located in San Félix.
Another arc of the virtuous circle covers training regional medical personnel and raising awareness of interculturality. The Autonomous University of Chiriquí plays an important part in this effort with its Masters Degree in Intercultural Public Health, with an emphasis on attention to women and children. But the intercultural sensitivity of each health professional is also crucial. Young doctor Erik Reyes, who is in charge of the health center in the Ngäbe Duima district, studied at a private university and could have set up a practice in the capital, but he chose to work in the indigenous region: “The work is much harder, but little by little you begin to appreciate it and you know that, in the future, you will be proud of having been part of a process that furthered development.”
In his opinion, “One of the most important factors affecting maternal death rates is training for traditional midwives. As part of the community, they can recognize warning signs and save a woman from certain death. Here, we are reinventing the Republic of Panama from the ground up, trying to do things right and including all population groups and institutions,” says Reyes, although the facilities have no electricity or infrastructure for emergency surgery.
The doctor is assisted by Yenitza Barrios, an intensive care nurse who worked in private hospitals in the United States, but chose to return to the indigenous region. “I have been here for eleven years and I can attest to the changes. Before, people did not come for check-ups or vaccinations. Today there is more awareness in the community. We hope that those of us who decide to stay here can effect more changes over the next eleven years.”
José Domingo de Obaldía Hospital
One of the most important components of the process may well be the José Domingo de Obaldía tertiary hospital, the largest maternity hospital in western Panama. The management style and the cultural sensitivity of the professionals who run the hospital have given the institution a leading role.
Hospital director Edgardo de La Sera notes that the institution “has tried to adapt to the reality of its target population: a community living in extreme poverty and scattered around a vast area with few passable roads.” He summarizes the problems as follows: “poverty translates into malnutrition, which makes people more susceptible to illness and more serious complications. The distances and the difficulty of reaching the hospital make emergencies more critical, and language barriers hinder the taking of medical histories, which are essential in handling an illness.”
De la Sera lists the solutions developed by the hospital to serve its community: it designed and opened a hostel where women can come in before their due date and await the birth; it created the Intercultural Ward, where indigenous women are served in their own language and receive information on maternal and neonatal health; and it hired two Ngäbe women as interpreters, not only to interpret for the doctors, but to facilitate understanding of customs, traditions, and needs.”
Alcibíades Batista González, head of the institution’s teaching and research department, explains that this is a teaching hospital that must provide a comprehensive education. “It is not only a matter of acquiring knowledge, abilities, and skills, but of having our students likewise acquire cultural aptitudes.” Xxxxx Xxxxx clarifies that in terms of understanding the factors influencing health or illness, one of the barriers is culture itself, not understanding that other people may have different perspectives and not realizing that others have a different world view and another way of seeing health and illness. “These cultural aptitudes are not learned from books; while parts of this knowledge can be incorporated into textbooks, it is essentially acquired through work and learning to see through another’s eyes.”
The contributions of Dr. Mariela de González, director of the hospital’s OB-GYN ward, have been vital to the effort. This young professional sees a need to modify the hospital’s processes. She would like to introduce the option of upright birthing positions and send the hospital’s doctors to train in places like Otavalo or Cusco, where this is more common. She believes that the hospital can incorporate indigenous traditions, which could also benefit non-indigenous women.
Lastly, in the Intercultural Ward we meet Eira Carrera, whose name tag ―pinned to a typical folk dress― identifies her as a member of the hospital staff. She sports a wide smile and has such a melodious voice that she was encouraged to study communication. Eira began working in 2011, but at the age of fifteen she joined a Ngäbe women’s organization, sitting on the board of directors until she reached management level at the age of 27.
The ward houses nearly a dozen mothers with their newborns; the women will head back into the mountains today, carrying their babies along the muddy, rocky roads. Here in the ward they are given final instructions before they leave the hospital. First, the nurse speaks in Spanish for the non-indigenous patients, and then Eira takes over. It is easy to see the connection she has with these mothers. She speaks about the importance of breast-feeding, vaccinations, check-ups for both mother and baby, and planning their next pregnancies so they have time to recover and feed this baby well before starting the cycle again.
The United Nations Population Fund paid Eira’s fees for a year, and her positive results encouraged the hospital to offer her a permanent position. She was joined by Helena Pinto, who was assigned to the neonatal ward, where premature or very small Ngäbe babies requiring special care are treated.