Ann Davenport

Real Life Drama: The Economics of Birth

The Economics of Childbirth in Rural Bolivia Luisa, the nurse auxiliary at Licomas health post, and I were talking about things like

the price of eggs, while rolling chunks of course cotton into little balls to be soaked in alcohol for the next vaccination campaign. It was a warm summer day and the doors were wide open. Our friend and Save The Children co-worker, Macario, puttered up the little hill on his

motorcycle to the health post, dismounted without turning off the motor, and came in to see us. Macario has soft, caf latte colored skin, with strong forearms and big hands. He is not only the best nurse auxiliary Ive worked with, he is a kind man and a good farmer. This was one of the few times I saw a worried look on his otherwise placid Indian face. We were vaccinating over in Huaycana, and one of the little Mamani boys told us his

mother had fallen down and was bleeding he said, and she is expecting a baby. I went by to see her, and she is bleeding vaginally, but still talking. Maybe you should go see her. As the midwife-in-residence for Save the Children in this rural isolated province consisting of 57 villages spread out over 3 mountain ranges, I didnt really know all the pregnant women. Most had their babies at home by themselves, or maybe with the help of their husbands. On rare occasions, like having a footling breech or a retained placenta, they would call upon their own village midwife. And they would never purposefully ask to see me, the gringa foreigner. I represented the Intervention of Last Resort. It was significant, then, that this womans son had searched out Macario to ask for help for his mother. Most people in the isolated mountain villages are painfully shy and proud about their stony independence.

Ann Davenport

Real Life Drama: The Economics of Birth

Do you want to go with me, Luisa? I asked, It would be a good learning experience

for you. She was already getting the IV bags and tubing and needles ready, saying to me, Do you have your blood pressure cuff and stethoscope? Lets go then. By some fluke of fate, the truck was in Licoma that day the only truck Save the

Children had for all their agricultural and health programs in the entire province and it was the drivers day off. Of course, when some emergency happens, everybody wants to be involved and days off disappear. The driver was ready in ten minutes, the tank was filled from one of those big yellow 50-gallon drums in the storage garage next to the office, and we were off. Macario stayed at the health post in case any patient happened to wander in by mistake. Huaycana was only 30 kilometers from Licoma, but the roads in these steep tropical

mountains are not only hairpin-curved, they also traverse rushing rivers and the occasional mudslide. So, it took us almost an hour to arrive. As is the case in very small villages, most people knew what was going on, and some folks were gathered along the road to show us which one was Seora Mamanis adobe hut. It was dark and cool inside, and the smell of blood was as strong as the smell of vomit. A very tiny, pale woman was just wiping her mouth with the back of her apron when we ducked under the doorframe and came in. She reclined upon a straw mattress, which was covered with a faded wool blanket. Two small children were already indoors, and three more came inside while we began our examination. Luisa introduced us in Aymara, the native language, and asked the woman if she spoke

Spanish. Seora Mamani looked up at me as tears filled her eyes and nodded yes. I explained to Luisa and the woman everything I was doing, as I felt her pulse, which

was very rapid and thready, and started the IV. She was cold to the touch and shaking, but

Ann Davenport

Real Life Drama: The Economics of Birth

able to tell us she was seven months pregnant with her sixth baby. We infused the IV at a wide-open rate, put her feet up on some blankets, lay her head down on the bed and covered her with a soft sheepskin. I asked her to tell us when the bleeding had begun, as I listened for the fetal heart

tones and determined the fetal position. The babys heartbeat was also very rapid and thready, but present! The vaginal bleeding was not a hemorrhage, more like a trickle. We gave her some water and sat with her for a few minutes while the IV was infusing, just being a calming presence. I looked around the room, which was combination living room and bedroom. Kitchens are always in the back patio, with an open pit area for cooking. Lots of little kids clothes were draped over the wooden rail that was their closet. The dirt floor was swept smooth, and aluminum dishes were stacked neatly on the plain wood shelves. Four straight-backed unpainted wooden chairs surrounded a small wooden table. The woman was wearing a threadbare cotton skirt, no shoes on her mud-caked feet, and a worn out white T- shirt that said Reebok in English. I was gathering wood, and I fell down the hill in back of the house, she said to us

shyly, I am always so clumsy, but even more so when Im pregnant. Im sorry. We fussed over her and began the second bag of IV fluid. In order to listen to her lungs, I asked her to sit up if she could. Then I lifted her T-shirt to expose her back, and saw the real reason for the bleeding: old and new welts, some fresh with dried blood. I showed Luisa. The woman had difficulty breathing, so I lay her back down and asked, Was it wood or leather? She looked at Luisa, and her eyes filled up again. What does she mean? she asked

Luisa, in Aymara.

Ann Davenport

Real Life Drama: The Economics of Birth

La doctorcita wants to know if you were beaten with wood or with leather, because to me it looks like wood. Tell us now, when did it happen, asked Luisa, as she held the womans dry, wispy hand in hers. Seora Mamani looked intently at the pattern on the hand-loomed wool blanket for a while, and then whispered, This morning. I was arguing with my husband. He beats me sometimes. I explained to Luisa and the woman about how a placenta can detach from the womb, the signs and symptoms, the causes (severe trauma), what could happen (death) and the treatment possibilities. The baby is still alive, I said, but I dont know for how long or when the bleeding will stop. We need to transport you to the hospital, I explained to her. But, who will take care of my children, she said, as a few little ones got up onto the bed with their mother, Who will feed the chickens and the cow and who will cook supper? Then she began to weep silently again. And who will do this if you are dead, Seora? asked Luisa, bluntly. I asked the oldest boy, who seemed to be about eight or nine years old, to go find his father. We discussed the pros and cons of staying home and the importance of counting on friends and neighbors to help out. The two of them rolled their eyes in disbelief at this last suggestion. I was still learning the social code of extremely self-reliant mountain people. Seora Mamani answered, It all depends on my husband. Then a flash of light entered the room as the door opened and her husband came in. He stood up as tall as his 54 frame could manage, crossed his arms over his barrel chest,

Ann Davenport

Real Life Drama: The Economics of Birth

spread apart his legs to put himself in an alpha-male pose, and hovered over us three women who were all sitting on the bed. Whats going on here? he demanded. I explained that his wife was bleeding from the vagina, that her life as well as the life of his child was at risk, that we had stabilized her with two bags of IV fluids (at no cost to him) and we needed to transport her to the hospital right away (also, no cost) because it takes almost four hours to get there and she is in critical condition. What about the cost of the hospital? Who pays for that? What if she needs treatment? Will Save the Children pay for that? he said. Luisa explained that it was a public hospital, pregnant women are treated free - except for any cost of blood transfusion or medications - and he would need to pay for that. It would be around 25 Bs. (about US$5) depending on what was needed to save her life. No, said, then added, now get out of my house. I stood up to my entire height of 5 10, crossed my arms over my chest, hovered over him, and said in my ice-bitch tone of voice, She is bleeding because you beat her with wood. You could have killed her and the baby. If you dont allow her to go with us, right now, she will die, right here, right now, in front of your children. No! he said, puffing himself up, not unless you pay all the expenses. I would have to sell my cow to pay for this. And its easier for me to find a new wife than to find a new cow. That shut me up for a good few seconds. I pointed to the kids on the bed, as they looked up at us with their little open-bird-mouths, and I continued in a loud voice, knowing the neighbors were outside the door.

Ann Davenport

Real Life Drama: The Economics of Birth

Who will take care of these children when she dies? I said, Do you think you are capable of feeding them every day, of washing their clothes, of helping them with their schoolwork? Who would marry you, knowing you beat your pregnant wife with wood until she bleeds? By then, the driver of the Save the Children truck was also inside the house, standing next to me. Annie, can I have a word with you outside please? he said. We went into the sun, and the driver said, There are some water engineers here putting in a sewer pipeline, and they want to know if they can use the truck for a few hours while were here. Carlos, I said, with all the patience I could find in me at that moment, did you hear what was going on in there? Do you want to get this woman to the hospital or not? Do you understand that she could DIE? Does putting in a pipeline have more value than the life of a woman? What kind of priorities do these men have? He caught on right away, and with palms up, he sheepishly capitulated, saying he would talk to the engineers and be right back. By now, I heard the children in the house crying loudly and their father yelling at them to be quiet. I walked back in, stood over the husband once again, and said We are taking your wife to the hospital. You can come or not, I dont care. Luisa, I said, as I turned to the two women still sitting on the bed, does she want to save her life and prevent her children from becoming orphans, or not? I glared at this woman, too. She immediately began to get up off the bed and gather a toothbrush and paste into her aguayo (the Bolivian cloth that serves as baby carrier, overnight bag, produce container or wood hauler).

Ann Davenport

Real Life Drama: The Economics of Birth

The husband walked out the door and we heard hissing and cursing from several of the neighbors who had gathered around. Baby-killer, one woman cried. Worthless old man, grumbled another, and they publicly humiliated him all the way to the truck, where he climbed into the back and looked away from them, as we drove down the hill toward the hospital.