DEADLY DELAYS Maternal Mortality in Peru A Rights-Based Approach to Safe Motherhood A Report by Physicians for Human Rights ©2007 Physicians for Human Rights All rights reserved. Printed in the United States of America ISBN: 1-879707-54-3 Library of Congress Control Number: 2007939731 Cover Photo: Christopher Drake Design: Glenn Ruga/Visual Communications, www.vizcom.org Physicians for huMan rights hysicians for Human Rights (PHR) mobilizes health As one of the original steering committee members professionals to advance the health and dignity of of the International Campaign to Ban Landmines, PHR Pall people through action that promotes respect shared the 1997 Nobel Peace Prize. for, protection of, and the fulfillment of human rights. Since 1986, PHR members have worked to stop torture, Physicians for Human Rights disappearances, and political killings by governments 2 Arrow Street, Suite 301 and opposition groups and to investigate and expose Cambridge, MA 02138 violations, including deaths, injuries, and trauma inflicted Tel. (617) 301.4200 on civilians during conflicts; suffering and deprivation, Fax. (617) 301.4250 including denial of access to healthcare caused by ethnic www.physiciansforhumanrights.org and racial discrimination; mental and physical anguish inflicted on women by abuse; exploitation of children Physicians for Human Rights in labor practices; loss of life or limb from landmines 1156 15th Street, NW, Suite 1001 and other indiscriminate weapons; harsh methods of Washington, DC 20005 incarceration in prisons and detention centers, and poor Tel. (202) 728.5335 health stemming from vast inequalities in societies. PHR Fax. (202) 728.3053 has undertaken significant work on health systems and www.physiciansforhumanrights.org on healthcare workforce issues in particular. i i i contents I. Acknowledgements .............................1 VII. Case Studies ......................................55 II. Map of Peru .........................................3 A. Puno ...............................................................55 “If only…”: Antonia ............................................57 III. Executive Summary .............................5 A Double Injustice: Melania ...............................64 IV. Approach to Investigation and Placing Blame Where it Belongs: Pabla............69 The Not-So-Secret Killer: Carolina ...................75 Methods ............................................23 B. Huancavelica .................................................79 V. Context: Peru and the Death Strikes Twice: Evarista ............................79 Peruvian Health Care System ...........25 A Precarious Success: Tomasa ..........................86 Socio-Demographic Overview............................25 Escaping Conflict to Face Economic Overview ............................................26 Tragedy and Injustice: Francisca .......................91 Gender Inequality ...............................................27 VIII. Applying a Rights-Based The Peruvian Health Care System .....................29 Approach to Address Maternal Mortality ........................................32 Most Recent Health Sector Reform Maternal Mortality in Peru .............. 103 and Maternal Mortality .................................34 Non-retrogression and Adequate Progress to the Maximum Extent of VI. Overview of Maternal Mortality Available Resources....................................103 as a Human Rights Issue ...................43 Non-discrimination and Equality .....................108 International Legal Framework; Meaningful Participation .................................113 Focus on the Right to Health .............................43 Accountability; Access to International Obligations to Respect, Effective Remedies ....................................117 Protect and Fulfill the Right to Health .........44 International Assistance Domestic Law.....................................................46 and Cooperation ...............................................119 “Progressive realization” to the “maximum IX. Conclusions ..................................... 127 extent of available resources”; Defining “appropriate” means and measures X. Recommendations ........................... 129 in light of best available evidence .................47 XI. Glossary of Terms and Acronyms .... 139 The Three Delays Model; Available, Accessible, Acceptable, and Quality Care ........................49 Availability ..........................................................49 Accessibility .......................................................50 Acceptability .......................................................51 Quality ................................................................51 v i. ACKNOWLeDGEMENTS his report was principally written and edited by access to health facilities. Inocencio Turpo Quispe and Alicia Ely Yamin, JD, MPH, consultant, and former Edmundo Tapia assisted with the logistics in Puno. TDirector of Research and Investigations, Physicians Elena Esquiche, National Associate on Maternal for Human Rights (PHR). Jessica Cole, Research Health, and Fernanda Loayza, Huancavelica Regional Assistant, PHR, contributed research to multiple chap- Representative for CARE Peru’s Right to Health ters of the report and participated in the fieldwork in Program helped to identify cases for the fieldwork in Lima and Carabayllo. Ms. Cole also played an integral Huancavelica and Ms. Esquiche participated in the field- role in the coordination of the investigation. work there. Jorge Gonzales Ccanto, of CARE Peru, and Tiffany Moore, MD, assistant professor of Obstetrics Walter Mendoza Huaman assisted with the logistics in and Gynecology at the University of Massachusetts- Huancavelica and Mr. Ccanto also translated between Worcester and PHR consultant, and Marion Brown, Quechua and Spanish. MD, PHR consultant, participated in the fieldwork in Dr. Ariel Frisancho, MD, National Coordinator for the Huancavelica and Puno, respectively, and contributed Program on the Right to Health at CARE-Peru, played a clinical analysis to the report. pivotal role in this investigation from beginning to end. Alicia Yamin supervised several Harvard Law School Dr. Frisancho participated in part of the fieldwork in both students who participated in the investigation and Huancavelica and Puno and was essential to ensuring that contributed to the report as part of clinical work done both trips were carried out successfully. Dr. Frisancho in conjunction with the Harvard Law School Human also provided enormous assistance in obtaining written Rights Program: Stephanie Swanson contributed legal information and making contact with key informants and other research and drafted portions of the report; in Lima. In addition, Dr. Frisancho’s knowledge of the Christopher Drake contributed background research and Peruvian health sector was critical to the investigation. both he and Ms. Swanson participated in the fieldwork We are deeply grateful to Dr. Frisancho, as well as to Jay in Huancavelica; and Margaux Hall contributed research Goulden, Director of Programs at CARE Peru, for their relating to user fees and debt relief to the report. support for the project from the outset. PHR is deeply indebted to CARE-Peru, without which Additional field research was conducted by Dr. Eloy this investigation simply would not have been possible. Neira and Lic. Eliana Elías of MINGAPeru in Loreto. Luz Estrada, a consultant to CARE-Peru and a member of An accompanying video was filmed and produced by Foro Salud-Puno, identified cases, conducted preliminary Carlos Cárdenas Tovar, Director of the independent docu- interviews and coordinated all of the logistical prepara- mentary film production company, TV Cultura, together tion for the fieldwork in Puno. Ms. Estrada also provided with Héctor Gálvez Campos. Mr. Cárdenas and Mr. Gálvez important insights regarding the obstacles to reducing accompanied the PHR team to Huancavelica and Puno. maternal mortality in Puno. Elizabeth Magna Guerra Diaz Lic. Emma L. Rubín de Celis T., Director of Projects assisted Ms. Estrada in the identification of cases and of Socios en Salud Sucursal Perú, arranged for PHR’s interviews of informants in the Quechua zone of Puno; focus group in Carabayllo, Peru. The nine women who Alicia Diaz Ticona assisted Ms. Estrada in the identifi- participated in the focus group generously shared their cation of cases and the interviews of informants in the experiences and their views with PHR. Aymara zone of Puno. Ms. Estrada and both Ms. Guerra The report was reviewed in whole or part by Dr. Deborah and Ms. Ticona participated in the fieldwork during PHR’s Maine, Professor of International Health at the Boston visit to Puno. Ms. Estrada, Ms. Guerra and Ms. Ticona University School of Public Health; Dr. Ariel Frisancho, translated between Quechua and Spanish and Ms. Ticona National Coordinator for the Program on the Right to translated between Aymara and Spanish. Woodro Andia Health at CARE-Peru; Frank Davidoff, MD, Editor Emeritus Castelo, Director of CARE’s regional office in Puno, greatly of Annals of Internal Medicine and Board member, PHR; facilitated the team’s interviews with health officials and Justice Richard Goldstone, former justice of the South 1 African Constitutional Court and Board member, PHR; Dr. The 32 key informants provided invaluable insights Claudia Lema, Director, Salud sin Límites-Perú; Jaime and information that greatly enriched this report, as did Miranda, MD, founding member of EDHUCASalud;