Mothers of the River: raising the ceiling for maternal care in the Amazon

Programme at work

As Blas explains, CHWs, who are volunteers and not paid, provide pregnancy tests and make six visits—three during pregnancy and three postnatally. CHWs provide families with posters illustrating warning signs like fever, unbearable pain, difficulty breathing, blurry vision, and other symptoms of distress, as well as what to look for during pregnancy, delivery, postpartum, and in the newborn.

To facilitate access to emergency care, if needed, and for those who elect to give birth in a health facility, the CHW and family develop an emergency transportation plan together, deciding in advance “who will drive you or take you in your peke peke or in your canoe, who will take care of your kids, and how much gasoline you need,” says Blas. Early CHW prenatal visits also include an explanation of nine elements of essential newborn care, including early skin-to-skin contact, early breastfeeding, colostrum feeding, and cutting and clamping the umbilical cord with a sterile blade.

In a second year follow-up study recently submitted for publication, Blas and colleagues report that most women in their programme area received a CHW visit during pregnancy, with improvements to care seen in seven out of nine early neonatal care indicators among home births. These include improvements in immediate skin-to-skin contact, colostrum feeding, and avoiding non-sterile substances being applied to the cord.

Challenges

Maria Juana Pacaya, a CHW from the Esparta community along the Marañon river, has been with Mamás del Río for four years, and is hopeful the programme will continue.

“When the programme started,” says Pacaya, “they sent an official letter to the community, asking for a representative for Mamás del Río, but it’s a voluntary job. There is no payment. It consists of bringing information and providing it to pregnant mothers.”

Luis Huicho, a professor of medicine at the research centre for maternal and child health at the Universidad Peruana Cayetano Heredia and an adviser to Mamás del Río, says that sustainability is a major problem. “CHWs are not fully incorporated into the formal health system and so they lack formal mechanisms of incentives, including salary, and a clear pathway of professional development.”

Blas says they are working to change that, opening discussions with policymakers at the regional government of Loreto, as well as at national government levels in Peru and Colombia, “advocating for the inclusion of CHWs officially in the health system—not as volunteers.” The programme has been well received, says Blas, though one of the challenges has been the rapid turnover of Peru’s health ministers—the country is currently on its fifth minister in just over two years and tenth since the beginning of the covid-19 pandemic.

To fight for their rights with a bottom-up approach, explains Blas, CHWs have also recently organised into an association of Indigenous health workers in Loreto.

A 2016 study by Huicho and colleagues4 suggested that between 1999 and 2013, the Peruvian urban-rural inequality gap had been closing. More recently, however, gains have been set back by pandemic related challenges. A 2021 report by Camila Gianella and colleagues at the Chr Michelsen Institute suggests that Peru has backtracked at least five years on its path to reducing maternal mortality because of the impact covid-19 had on health services capacity.

Ripple effects

Based on World Health Organization data5 from 2000 to 2020, neonatal mortality in Peru has decreased by more than 50% from 16 per 1000 live births to 7, attributed to expanded health insurance and services. But this progress at a national level masks regional inequalities, say researchers.

More programmes like Mamás del Río could help. Blas’s programme has funding from the ministries of foreign affairs of Peru and Colombia. That will allow it to run for another two years—spending goes on training, administration and travel, and subsistence for the CHWs, though they remain unpaid.

Mamás del Río is also expanding to more communities along the Amazon and its tributaries, like the Putumayo river in the Peru-Colombia border region. The aim is to have CHWs take on other tasks like following children through their first year, and detecting and trying to tackle violence against women—something Blas sees as an urgent long term priority, along with providing access to contraceptives.

Melissa Mugambi, assistant professor in the Department of Global Health at the University of Washington, who is not connected to the programme, says that projects such as Mamás del Río are vital for reasons beyond maternal health. With greater access to antenatal care, women can benefit from other services such as HIV prevention early in pregnancy. And by providing care early “you’re more likely to identify mothers who are at risk for certain problems,” like high blood pressure or diabetes.

“Early screening enables, at least in theory, earlier access to interventions,” Mugambi says.