Maternal health for all: indigenous communities in Colombia

María Cambar records in a pencil drawing the day she gave birth to her first son. Her contractions indicated that the birth was imminent and although, she needed urgent medical care, she refused to go to the nearby Dusakawi maternity clinic because she was ashamed to ask a 'alijunas' - a term used by the Wayúu to refer to white people - for help.

María's life and that of her son were in danger. Fortunately, a community worker from the Dusakawi clinic, Leyla Yadira González, was able to reassure her that her needs and indigenous traditions would be respected if she were to accept medical assistance. Maria felt she could trust Leyla because she was a woman and a member of her community. Also, though Leyla was trained as a nurse in western medicine, she had long been honoured by the elders of the Wayúu matriarchal society as a traditional practitioner. She not only spoke María's language but understood the cause of her concerns based on her intimate knowledge Wayúu belief systems and ways. Leyla knew Maria was apprehensive about having a caesarean section, being in unfamiliar surroundings and that she felt a sense of shame at having to be helped by someone from outside the community.

Maria's trust in the community worker was rewarded. When she arrived at the clinic, she had access to an interpreter and even slept in a bed similar to the hand-woven hammocks, 'chinchorros', she used in her home. Thankfully, she gave birth to a healthy, baby boy.

María's drawings show the ambulance that came to collect her to take her to Dusakawi maternity clinic.

A maternal healthcare system with an ethnic focus

María is one of the women from the Wayúu and Arhauco peoples in the north of Colombia, who voluntarily sought medical help during childbirth due to an interagency strategy to reduce maternal and neonatal mortality among indigenous peoples - up to five times higher than the national average. The initiative was launched in 2015 by the Pan American Health Organization (WHO/PAHO), the United Nations Population Fund (UNFPA), the United Nations Children's Fund (UNICEF) and the World Food Programme (WFP), in partnership with the Colombian Ministry of Health and Social Protection, the indigenous authorities and local government in the areas concerned.

UNICEF ensured that newborn babies are prioritized in regional health plans, helped raise standards of training in maternal nutrition for traditional practitioners and health teams and developed guidelines on adapting sociocultural services and maternal and perinatal care for the period of the pandemic. WFP focused its support on establishing food and nutritional security in Colombia - specifically, in remote, dispersed communities - broadening the expertise of midwives and raising awareness on the importance good nutrition in the first 1000 days of life. UNFPA trained community workers and traditional midwives in the Arhuaco and Wayúu communities, gathering evidence to inform new approaches to sexual and reproductive health. The agency was also involved in advocating for intercultural encounters and dialogue.

Nationally, the interagency strategy is seen as a good practice in maternal health for indigenous people and a model worth following, 'this analysis of health gaps and inequities, and of indigenous beliefs, were key in terms of setting priorities to develop emergency obstetric capacity and life-saving practices and adapting health services from a sociocultural perspective,' explains Dr Gina Tambini, WHO/PAHO representative in Colombia. The knowledge gained has enabled the state welfare institution, Our Lady of Perpetual Help in Uribia, to make cultural adjustments. According to its medical coordinator, Dr Sandra Díaz, applying the knowledge has reassured and calmed expectant mothers, 'thanks to the interagency project, health workers have been trained to respect the practices and customs of the Wayúu people, for example, allowing mothers to be accompanied during the birth, permitting them to wear the correct attire, use certain traditional medicines and returning the placenta to them afterwards. We even employ interpreters to overcome the language barriers.'

Information, Education and Communication (IEC) materials used to convey public health messaging to the Wayúu women.

Effective partnering to scale-up maternal health services to indigenous communities

There are 106 indigenous groups in Colombia and not all indigenous women have access to maternal health services. In 2020, for every 100 000 live births, there were 236.5 maternal deaths in indigenous communities. According to the National Health Institute, within the population as a whole, maternal mortality has gone down from 70.14 per 100 000 live births in 2005 to 50.73 in 2019. The COVID-19 pandemic would have affected these numbers, leaving more mothers vulnerable as well as their children. The problem is compounded because many indigenous people confront a devastating malnutrition crisis (Sustainable Development Goal 2), heightened now more than ever as the spread of COVID-19 threatens their livelihoods. The Wayúu people, in particular, are further affected because they live in a conflict zone on the Colombia-Venezuelan border, making it harder to access healthcare.

'Adequate nutrition is a basic human right and it is essential to prevent and reduce infant and maternal mortality and to foster healthy growth prospects and opportunities among children, ensuring that they can thrive and express their full cognitive and development potential. Ensuring an equitable access for all to adequate nutrition is key to the harmonious and just development of our societies,' affirms Carlo Scaramella, Country Director of WFP in Colombia.

Despite the pandemic, efforts are now being made to extend the interagency strategy to other indigenous peoples. It has been rolled out in Chocó, where there is an extensive network of midwives and encouraging results have been recorded in terms of access to healthcare and lower maternal mortality rates. A tool is currently being developed to present tracer indicators for health and maternal and perinatal care, disaggregated at the national and regional levels and prioritised at the municipality level. This will form part of the data repository and web platform hosted by WHO/PAHO to promote maternal health by addressing social determinants and improving equity in Colombia, to accelerate progress toward the Sustainable Development Goals 3 and 5.

The officer in charge of UNICEF Colombia, Victoria Colamarco, states, 'diminishing maternal and perinatal morbidity and mortality in indigenous communities is a priority for UNICEF. The Inter-agency project is a way to join forces between agencies and knowledge through collaborative work that allows for increasing access to prenatal care and childbirth services that are culturally appropriate with a view to reducing inequities in health and contributing to the fulfillment of the SDGs.'

María's drawing of herself smiling with her baby in her arms.

SDG3 Global Action Plan

The health partners involved in this project are signatory agencies to the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP). Under the Plan, 13 health and development partners have committed to working purposefully and evermore closely to support countries in achieving the health goals under the 2030 Agenda. Equity is at the front of the SDG3 GAP agenda and a strong resolve to leave no one behind. According to Veronica Siman, UNFPA Representative in Colombia, 'this is a very relevant and urgent project. On the one hand, it helps us contribute to leaving no one behind, as mandated by the 2030 Agenda, and at the same time, we are contributing to one of the UNFPA's transformative results of zero preventable maternal deaths. It is important to bring health services closer to indigenous communities, so they are able to exercise their rights, including their sexual and reproductive rights.'

A mother and newborn from the Wayúu indigenous community at Nazareth hospital.

Images and photos © WHO/Karen González Abril

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