Hesperian Health Guides
Women organize for better health care
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In this chapter, we tell the story of a women’s group in Peru that organized for better women’s health services in their community. When they started organizing, many families in the town of Vilcashuamán, or Vilcas, had recently moved there from rural areas high in the Andes mountains. Armed conflict in the region had destroyed homes and crops, and forced people to migrate. Most of the refugees came from indigenous Quechua communities and were very poor. The community health center in Vilcas was also poor, but the nurses and doctors did the best they could. When one young mother died after a difficult birth, her midwife and a friend decided to take action so that no other woman in the community would die needlessly for lack of care.
How a needless death became a call for change
Like most girls in the indigenous community where she grew up, Sonia did not go to school. Her brothers went for a few years, and they learned to speak, read, and write in Spanish. At home, everyone spoke Quechua, the language of their ancestors. Sonia grew up learning to weave and to cook, to plant and harvest potatoes, take care of animals, and sing Quechua songs.
When Sonia was 16, she married José. Her 2 daughters were born at home with the help of a midwife. Sonia was 19 years old and 7 months pregnant with her third child when the military forced her and her family to move from the countryside to the town of Vilcashuamán, Peru. Soldiers had destroyed their farm and killed one of Sonia’s brothers.
In Vilcas, Sonia soon met Luz, a midwife who agreed to help with the new baby’s birth. José was far away working when Sonia’s labor began. His sister Tomasa came to take care of the children. Luz massaged Sonia and made her teas to ease the birth. But after many hours, Luz knew something was wrong. Sonia was very weak, and the baby was not moving. Luz knew she had to go to the health center to save Sonia’s life.
Sonia had never been to the health center. No one there spoke Quechua, and she did not speak Spanish. Luz did not like to go there, because the doctors and nurses often ignored or criticized her when she brought women to them needing help.
When Luz and Sonia arrived, the clinic was closed. After it opened, they had to wait a long time for a nurse to examine Sonia. The nurse accused Luz of waiting too long to bring Sonia for help. Luz did not say anything because she did not want to upset the nurse. She asked respectfully if she could stay with Sonia to explain what was happening and help her stay calm. But the nurse said no and reminded her of the health center rule that women were not allowed to have companions.
Sonia was terrified and did not understand what was happening. In a cold room with bright lights, a strange man speaking Spanish delivered her baby boy. Sonia never saw the baby, and no one told her that he was already dead. Afterward, the doctor came to the waiting room and asked for Sonia’s husband. Luz tried to explain that Sonia’s husband was away and that she was Sonia’s midwife, but the doctor did not pay attention to her until one of the nurses explained who she was. Then he told Luz that the baby had died and Sonia had lost a lot of blood. He said that the health center did not have blood to give her or transportation to take her to the regional hospital 4 hours away. Luz was telling the doctor she would find a way to transport Sonia when a nurse came and told the doctor that Sonia had died.
Luz was very sad but also very angry. She knew Peru was not a poor country, yet so many poor families had little access to health care or other services. She knew Sonia’s death could have been prevented and perhaps the baby’s death too. Luz left the health center thinking about all the things she wished she could change so that what happened to Sonia would never happen again.
Learning from each other
When Luz returned from the health center with the sad news, Tomasa was with her friend Paula. Paula had finished high school in Vilcas and had also participated in a young women’s leadership program. Now she and Tomasa were both training to be community health promoters in a project run by a non- profit organization. After listening to Luz’s story, Paula said she thought Sonia’s death was the result of a bigger problem. Tomasa suggested they talk about it more in a few days, after the funerals for Sonia and her baby.
Luz, Tomasa, and Paula knew that the government wanted women to give birth in health centers. They also believed that the nurses and doctors at the health center had a responsibility to treat all women equally and respectfully, even if they were poor and indigenous. And they knew that indigenous women living in poverty often had the least access to resources and basic human rights. Many of them were tired of suffering and ready to take action. Paula had learned that a key step towards taking action was to understand the problem more fully.
To learn more about women’s experiences at the health center, they decided to talk with other women in the community. Over the next few weeks, they visited friends and neighbors in their homes and listened to their stories.
The women named many problems that made it difficult for them to get care at the health center. Sonia was not the first woman to die for lack of blood or other supplies. And Luz was not the only woman who avoided the health center because she felt the nurses and doctors were disrespectful.
Tomasa and Paula had learned that to work for change, they needed to bring together people who shared similar problems and who would most benefit from finding solutions. Wealthy women did not depend on the government-run health center. They went to private clinics. So the women who would most benefit from an improved health center were poor, indigenous women of all ages. They decided to organize a meeting and invite the youth and women to share information and discuss changes that would help them get better health care.
Form a group to work together
Paula began the meeting by introducing herself and then asking each of the other women to do the same. At first, most of the women were shy and uncomfortable talking in front of the group, so Paula asked each woman to turn to the person next to her and tell her something about an experience with childbirth, either her own experience or something that happened to a friend or someone else in her family. Luz then told the group what had happened to Sonia.
Tomasa asked some of the women she and Paula had spoken with before to talk about difficulties they had receiving care at the health center. Others joined in to share their own stories and opinions.
The women decided that they wanted to form a group and work together to improve care for women at the health center. They talked about how much time they could give to the group, and they agreed to share childcare and cooking to make it easier for all the women to participate. Paula proposed a process for their meetings that would help make sure everyone had an equal voice and a role. For example, they agreed they would take turns leading discussions. They decided to call their group Vilcas Women’s Voices and to invite more women from the community to attend the next meeting.
While walking home, Luz said to Paula, "That meeting went really well. Everyone spoke and we got a lot done." Paula explained that meetings work best when they are well planned:
- Create an agenda in advance.
- Review the agenda with the group and change it if needed.
- Choose a person to lead the meeting and someone to keep time.
- Agree on the rules for the meeting.
- Evaluate the meeting afterwards.
For more ideas about how to plan successful meetings, see Appendix B: Good meetings from start to finish.
Discussion deepens understanding
Vilcas Women’s Voices held their second meeting several weeks after forming the group. Luz led this meeting and asked everyone to introduce themselves again, since there were many new women present. Then she asked for volunteers to summarize the discussions from the first meeting, and she invited the newcomers to share an experience receiving care at the health center if they had something different to add. The women were surprised at how many difficulties with the health center had been mentioned. They wondered how they could solve so many different problems!
Paula suggested an activity to group similar types of problems together. She wrote each problem on a card and posted it on the wall. Then she asked which other problems were most similar to it and why. Seeing how problems could be linked helped the women think about their experiences receiving care at the health center. Focusing on the patterns they observed then helped them look more deeply at the problems.
Identify problems to focus on
When they finished the activity, they looked at their work and noticed that many of the problems were related to the women not feeling comfortable seeking care in the health center because of the disrespectful treatment of indigenous women. Many of the other problems were about the lack of basic medical supplies. Everyone agreed that these were the things that they wanted to focus on and learn more about.
After the discussion, Tomasa asked the women how they felt about the meeting. The women all said that they enjoyed the activity and discussion. They felt that it helped them understand that the individual experiences of many different women are part of bigger problems. It also helped them realize that making the health center welcoming and comfortable for all women was important.
Next the group needed to decide what they could do to make changes, working together with others in the community. Paula knew this would take a lot of time, reflection, and discussion. So the women decided to gather more ideas by talking to health workers, family members, community leaders, teachers, and people organized in other community groups.
Gathering more information
Making an action plan
The group continued to meet regularly and discuss different points of view. They finally agreed to focus on improving care for all pregnant women and on more respectful care for indigenous women. They felt ready to decide which changes to advocate for and which actions to take. They were ready to make an action plan.
Choose what actions to take. The women made a list of all their ideas for improving women’s health care in the community. Then they considered how well each action would help make the health center welcoming and comfortable for all pregnant women, and respectful for indigenous women. They discussed which actions would be easiest to do with the resources they had. And they weighed which actions would improve health care for most women in the community and for the most vulnerable women.
With so many ideas and opinions, it can be challenging to make decisions. Even when you have built trust in the group, there can be disagreements. An activity such as Voting with dots can help build consensus.
Set short-term and long-term goals. Next the group thought about what they could accomplish in less time (short-term goals) and what might take years to accomplish (long-term goals). Then they imagined what kind of care women would receive if they were successful with each of these goals, or what a successful outcome would be.
Make detailed plans to achieve each goal. Having clear goals helped them decide on the strategies they would follow in their organizing work. A strategy is a series of steps carefully planned to reach a final goal. For example, if you are cooking for a big wedding, you will do a lot of planning, including thinking about who can help you, what foods will be available and affordable, and which jobs you can give to which people. With a good strategy, you can achieve your goal of having enough delicious food for everyone, and it will be ready on time!
The Vilcas Women’s Voices group also talked about the barriers they would face in working toward each goal. They discussed the human and material resources they would need, and the skills and knowledge that would help them.
Then they made a detailed plan by listing tasks and deadlines, and they divided responsibilities so that each woman in the group had a role. They agreed to review their progress each time the group met to see how well the plan was working.
Vilcas Women’s Voices decided their first step would be to meet with the health center director, Doctor Mora. They planned to present the information they had gathered and propose changes at the health center to meet their short-term goal of having the staff understand and respect their traditions. They expected that if they went as a group and were well prepared with a clear message, Doctor Mora would understand and accept their proposal.
The group decided to choose a small committee of 5 women to plan the meeting. They asked Paula to coordinate the committee, and Tomasa volunteered to help present the group’s proposals. They asked Yesenia to speak about the need for youth services, and they asked Alicia, a woman pregnant with her third child, to speak about problems women faced getting prenatal and emergency care at the health center.