RIO DE JANEIRO, Jul 13, 2010 (IPS) - "You can only have one mother," as the saying goes, but in Brazil there are 215 ways of becoming a mother, one for each of the ethnic groups in this South American country. Promoting maternal health while respecting cultural traditions is a major health challenge.
Silvia Angelice de Almeida, who works at the state National Health Foundation's (FUNASA) Department of Indigenous Health, knows all about it from her nursing experience.
Some indigenous peoples believe the placenta must be returned to the community after birth. Others regard it as important that people should be born, and die, on their own land. In some native villages, special care is given to pregnant women, including particular haircuts and body painting.
"We have general guidelines for infant and maternal health, but we found we needed others, specifically for indigenous peoples," Almeida told IPS.
One of these, on "inter-cultural healthcare," includes respect for native healers or "pajés," shamans, traditional midwives and natural medicine.
"The concept of pregnancy is different among native peoples. Field staff have to undertake training in order to be able to address these issues," Almeida stressed.
According to the state National Indian Foundation (FUNAI), Brazil has 460,000 indigenous people divided into 215 ethnic groups, making up 0.25 percent of the national population of over 193 million.
There may be between 100,000 and 190,000 more native people living outside the indigenous territories, some of them in urban areas, and an unknown number have not yet been contacted, according to FUNAI.
The known native population is spread over 24 of the country's 26 states, 336 administrative centres, 4,413 villages and 615 indigenous territories comprising 107 million hectares, equivalent to 12.6 percent of the area of Brazil. Most live in small municipalities and in the northern Amazon jungle.
Geographical conditions in these areas mean that infrastructure is very poor, and access by healthcare personnel and by the state in general is difficult.
In Almeida's view, the goal is to guarantee "a high-quality healthcare system throughout the country," but that is not so easy in inaccessible regions like the Amazon.
Health workers can visit each village once a month, but it is traditional midwives or the woman's own relatives who look after mothers-to-be.
Differences in customs arise with issues like breast-feeding, which is encouraged by the state. In some ethnic groups, mothers are not supposed to give their first milk to their newborn babies; instead, breast-feeding is initially carried out by the baby's grandmother.
So the indigenous maternal health programme was designed by anthropologists, traditional healers, midwives and native spiritual leaders, said Almeida.
Each ethnic culture has a holistic understanding of health that includes the spiritual dimension.
For instance, when an indigenous woman had fever, doctors diagnosed an inflammation and prescribed a drug. But the village healers treated the patient by casting spells, because in their view healing is also a spiritual matter, she said.
"We have to work together. The pajé performs a spiritual cure, and we take care of the physical side," she said.
Indigenous people do not always accept Western medical methods.
If a health worker, even one trained within the community, finds a pregnant woman is at risk, he or she must take the woman to hospital. In some cases this may entail a journey by boat or by plane.
To avoid cultural conflict, birthing houses were set up near the villages to support mothers in labour. Sometimes the whole family comes to stay, so that they are not split up.
When a woman's pregnancy is low risk, natural childbirth is encouraged. Other health issues are also discussed, like prevention of uterine and breast cancer, HIV/AIDS and syphilis, as well as gender issues like domestic violence, which is sometimes linked to alcoholism problems.
Brazil's maternal mortality rate fell from 140 deaths per 100,000 live births in 1990, to 75 per 100,000 live births in 2007.
According to FUNASA, infant mortality decreased by 40 percent among indigenous people since 1999, as part of a long process of overcoming cultural barriers on either side. But infant deaths from digestive and respiratory tract infections are much higher among the native groups than in the rest of the population.
Because many indigenous women do not wish to be examined by a male doctor, the indigenous health department trained more women health workers, who now account for 30 percent of the total.
"There are certain very personal topics that a woman does not want to discuss with a man, or with a midwife in her own village who might be her mother- in-law," Almeida said.
Sometimes a health worker may have to remain isolated in a community for 30 days. Others feel insecure about having to attend a birth in a village, she said.
According to a survey by FUNASA, 46 percent of pregnant indigenous women are first seen by a doctor in the first trimester of pregnancy, 45 percent in the second trimester, and almost nine percent in the third trimester. Over 35 percent of indigenous women suffer from anaemia during pregnancy.
But there is a lack of specific data about the health of these women. The United Nations called for this information to be made available, on the eve of World Population Day, which was celebrated Jul. 11.
Grupo Curumim, a women's organisation in the northeastern state of Pernambuco, tries to fill what their director, Paula Viana, calls "gaps" in the indigenous health system.
It’s "Traditional Midwives" initiative promotes safe and humanised treatment with respect for diversity. Since 2000 it has trained 1,150 midwives and 892 health professionals in 14 states, with the help of the Health Ministry.
Viana criticised the hospital-centred approach and the failure to take cultural differences into account that have prevailed in indigenous health policies since 1940.
She said traditional midwives attend between 32,000 and 34,000 registered births a year, although the actual number could be twice as high. Even so, "there is still a lot of discrimination against traditional midwives."
The Curumim initiative also takes religious practices into account. "We make sure the wishes of the patient are followed," Viana said. "In some ethnic groups, when the placenta is delivered, all those present join in prayer. If this does not interfere with the care of the mother and baby and can be done without any harm to health, we respect the custom," she said.
In her view, the Health Ministry should establish "firmer guidelines" for the indigenous health system. Some medical and nursing staff do not respect local cultures, in spite of the general training they receive.
In March, Brazilian President Luiz Inácio Lula da Silva created the Special Secretariat of Indigenous Health within the Health Ministry, to prioritise the functions previously carried out by FUNASA.
The Conference of Brazilian Catholic Bishops' Indigenist Missionary Council (CIMI) said it doubts whether the new proposal will improve health conditions for these peoples, partly because they "were excluded from the process of taking the most important decisions."