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HEALTH CARE IN CHILE by Ann Davenport (Published as "Maternal Health Care in Chile", Midwifery Today, Autumn 1999, No. 51) In most Latin American societies, sameness and conformity are much more comfortable, valued and promoted, than is individuality or non-conformity. The former brings social acceptance (very important to class-conscious people with rigid mores) and the latter anarchy and possible revolution (anyone with a different viewpoint is immediately labeled a "Communist", and is shunned, shot, or disappeared). As Jorge Castaeda said in a recent Newsweek editorial (Feb 22, 1999) "We Latin Americans are likely to fear any threat to the status-quo and oppose after- the-fact investigations" thus the seemingly benign acceptance of a culture of corruption in Mexico, of an endless cycle of poverty and NGO handouts in Bolivia and Peru, of street killings in Brazil, of torture and genocide in the Central American Highlands, of 75% cesarean operations by doctors, and of total white, middle class homogeny in Chile, Uruguay and Argentina. These last 3 countries, especially Chile, are looked upon by other Latin American countries as a role model: in spite of several years of military dictatorships, all 3 countries have had previous long histories of democratically elected governments, all have a strong healthy economic middle class, and all three have rid their nations of the burden of a pesky Indigenous population, as one Peruvian OB/GYN told me. According to this doctor, whom I met while in Peru, "the reason we all want to imitate Chilean health care is because it works so well for the

medical community. And the reason it works so well is because Chile doesn't have an Indian problem." A professor of military ethics and religions at Texas A&M University reminded me that good, fertile ground for sprouting any authoritarian dictatorships is when citizens prefer security to liberty. Authoritarian figures always give us the illusion of comfort and of security, which may be why 98% of Chilean pregnant women want a (hopefully male) doctor to attend their births, demand and receive ultrasound exams for every prenatal visit (and the average number of visits per pregnancy is 12), and why there is a 45% rate of cesarean operations in public hospitals and up to 75% in private hospitals (all statistics and health information is from the Ministerio de Salud de Chile, Programa de la Mujer, 1997). The culture inherited from the Spanish conquistadores along with the rigid mores and values of the Catholic Church here in Chile, insist upon and reward recognition of vertical authoritarian systems. For example, the "Patron" is the person who gives you a salary, guarantees you a place to live, sends your kids to schools that he constructed, and even arranges social events. The Priest is your intermediary with God and by rituals of baptism, blessings and burial ceremonies, assures you a good seat on the bus to the afterlife. The Politicians are the ones who certainly will rob you, but are the vertical authoritative representative between you and the Police, so that alone makes his presence worth the pain. The Doctor and his representatives, including midwives and other health care providers, is the authority figure with control over life and

health. The main idea here is CONTROL, and "the reassuring appearance of sameness and conformity to the socially dominant reality model" (Robbie Davis-Floyd in Birth as an American Rite of Passage, University of California Press, 1992). Brigitte Jordan pointed to this model of authority and conformity when she wrote, "In hospital deliveries, responsibility and credit are clearly the physician's. This becomes visible in the handshake and thank-you that resident and intern (or intern and medical student) exchange after birth. Good work is a compliment to a physician by somebody qualified to judge, namely another physician. Typically, nobody thanks the woman. In the common view, she has been delivered rather than given birth." (Birth in Four Cultures, Brigitte Jordan, Eden Press, Montreal, 1983) In order to give you a sense of just how strong and accepted this style of vertical authoritarianism is, you should know that in Chile there are almost no lawsuits filed against medical personnel or against hospitals, ever. The History of Chilean Health Care - Chile is a long, narrow South American country geographically isolated by the Andes on the east, the Pacific Ocean on the west, the driest desert on the planet to the north and Antarctica to the south. Chileans admittedly use these geographic phenomena for their collective mental

and spiritual isolation as well. A typical Chilean will ask me "why have you come here, to the tail end of the world, when you could have gone anywhere?" This sense of geographic and collective-consciousness isolationism is very important when understanding the recent changes in health care and the optimism (or pessimism) by health care providers when the system is confronted by a large population of native sons and daughters who have returned to their homeland after being exiled in various countries around the globe (one Chilean midwife, tortured while in prison during the 1970s then sent to England, refers to this government imposed exile as "my Pinochet scholarship"). Health care in Chile is governed by the National System of Health Services (whose Spanish initials are SNSS) and all public or private care givers or institutions must comply by the norms and standards of the Ministry of Health. This system was formally restructured in 1983 during the military government, and was implemented by Pinochet when the military junta began imposing neo-liberal capitalism reforms in the economic sector. The idea was to rescue those sectors with more potential earnings, such as mining, manufacturing and agriculture, redistributing funds from education and health. This institutionalized the system of co- payment, which still exists today. The federal government pays the municipalities a fee-per- patient, and with this income the municipalities pay salaries, utilities, maintenance and obtain medical supplies. As with any federally based law, it takes an act of Congress to change anything about the public health or education systems.

Before this military economic intervention and restructuring, a National Health Service existed (from 1952 to 1983), which coordinated standards of care, professional educational requirements, payment systems reimbursement (a form of socialized medicine) and division of public and private health care responsibilities. Before 1952 there were simply a hodge-podge of diverse and independent systems in place, from milk give-away programs for pregnant women, to the Red Cross, and of course private doctors and health care providers have always existed. Before the 1952 restructuring, anyone who needed primary attention went to a hospital (public or private) or paid for private home visits. Midwives up until then did mostly home births. After 1952, the National Health Service began a vigorous and loud campaign to encourage all women to have their babies in a hospital, as well as began training professional midwives to attend hospital births (training was done by physicians, with a medicalized focus). Also, during this time, in response to the poliomyelitis endemic, the system created what are called "Consultorios" (in the US we would call them "public health clinics" but in Latin America the word "Clinic" signifies private and costly small health care facilities private hospitals are still called "Clinics" today, in order to distinguish them from public hospitals). These public health care Consultorios were called "poli-consultorios" not because of their multiplicity of coverage (which they do have, ranging from tuberculosis to tetanus shots) but because of their focus on the early detection, vaccination campaigns and later treatment of polio. It was in these Consultorios that midwives first began to have their own space outside

the hospital setting, but more importantly, outside the home setting as well. While doctors were still making private house calls (mostly for the rich), midwives were encouraged to see "their patients" within the Consultorio setting, and began to be paid a salary by the state (not her client). This was ONLY for prenatal and postnatal care, however, thus beginning the separation between prenatal and labor/delivery (which was to be done in the hospital, by ANOTHER midwife), that was to become the hallmark of the Chilean model of midwifery care: separation of care and promotion of medical attention within the hospital setting, and payment reimbursement by the institution and not the client. Current Health Care System - In 1983 (during the Pinochet government) all primary health and educational systems were transferred from the central government in Santiago (the capital of Chile) to the 13 Regions (like States in the U.S. or Provinces in Canada). In fact, there were no Regions or general divisions within the country until that time (the current population of Chile is almost 14 million people, in 1983 it was almost 11 million). The Regions, and their county and municipal governing bodies, suddenly became fiscally and operationally responsible for managing health and education, with no training or experience. Nevertheless, some systems continued to be under the jurisdiction of the central government, such as public hospitals and higher centers of education past high school.

The disastrous implications of this separation continue to be evident and are still being sorted out today. A pregnant woman (seeking public, not private, health services) gets her prenatal care at the public Consultorio, whose personnel, infrastructure and supply management (such as how many birth control pills, condoms or Pap kits are available) come under the jurisdiction and budget of the local Municipality. She gets her STD or AIDS exam (or her high risk OB care if that exists) at still another Consultorio that has it's own personnel, budget and supplies under the jurisdiction of the Regional (State) government. She goes to the public hospital for labor and delivery, and sees yet a different midwife and doctor for that care, because they are under the jurisdiction of the National government. Divide and conquer. All the midwives work for, and get paid by, a different system, but doctors can legally work across systems. Additionally, physicians get paid by insurance carriers, public reimbursement systems AND clients. Each Municipality gets reimbursed by the federal health care budget (the Ministry of Health) at a current rate of 760 pesos per patient visit (about $1.35), so one can imagine the importance of quantity over quality of patient visits. The Municipality covers all other costs such as maintenance, construction, salary or supply disbursement of the Consultorios, and this depends on investments made by each individual city government. So, the very wealthy neighborhoods like Providencia in Santiago have very pretty Consultorios with big budgets, while the majority of little towns scattered throughout the deserts and forests of Chile have city budgets that probably resemble a typical North American single household budget. Since salaries fall under

the jurisdiction of these municipal budgets, midwives and other health personnel are paid according to where they work, not according to what they do. FONASA and ISAPRE are the two health care systems of payment reimbursement, and understanding these two systems will help us to understand what motivates midwives to want to maintain the status-quo of medical-technological centered health care. FONASA is the National Fund for Health and covers all primary, secondary or tertiary health care on a sliding scale according to income, from indigents to millionaires. FONASA, then, is the equivalent to Socialized Medicine, or Medicare. Between 75-80% of all women in Chile belong to the FONASA system. (Ministerio de Salud de Chile, Programa de la Mujer, 1999.) ISAPRE (Provisional Health Institute) began in 1983 when the health care systems were divided up under the military government, and are a consortium of individual insurance companies, primarily owned by doctors and pharmaceutical companies. Each ISAPRE Company has their own Consultorios, with their own doctors, specialists, laboratory, radiography, and midwives. Medical personnel have hospital privileges at both public and private hospitals, because ISAPRE is a reimbursement system, like FONASA, only more expensive. Midwives are paid salaries by the ISAPRE, not by the client. Since, by law, all prenatal and post-partum care is free, the ISAPRE's have to recuperate their costs by paying lower salaries for midwives, and also have a say in time structuring for

appointments, follow-up visits or counseling. If the pregnant woman wants to have an obstetrician, she has to pay extra. The woman of course always wants to see the OB because she soon discovers that the midwife with whom she has her prenatal visits will not attend her birth! The doctor, however, will, for a fee. So, as with FONASA clients, ISAPRE clients see one midwife for their prenatal visit, another if she is high risk, another for her labor and still another for her childbirth. The primary attention is on the system and on the doctor, not on the pregnant woman. In the public hospital system there is a "package of care" that is standardized and is paid for by either FONASA or ISAPRE. Every woman knows from her prenatal visits or her previous experience what will happen to her in the hospital, because these practices are routine and standard: Preparation shaving of all pubic hair, enema, IV with oxitocin, fetal monitor, nothing by mouth, epidural anesthesia (offered after she has dilated 5 cm) and thus, no walking. Labor being in an open ward with 4 to 8 other women in labor, no partners allowed ("there would be no privacy for the other women" says one midwife), IV drips, fetal monitors, etc. There is a midwife who comes in once in a while, but she also has to take incoming patients, attend births, and cover the ER for any high-risk incoming patient, so it is to the patients benefit to get her pain medication early because she may not see the midwife again.

Delivery taken to another room, which usually doubles as the operating room (cold, high ceilings, overhead operating lamp), legs up in stirrups, drapes, arms strapped, anesthesia stand-by, episiotomy (automatic), the midwife delivers the baby, while another midwife attends the newborn. In public institutions, the midwife attends ALL normal births (with doctor stand-by in case of emergencies) unless the mother has already paid extra for the doctor. The definition of a normal birth falls under North American categories: no breech, no twins, forceps, shoulder dystocia, placental problems, fetal distress, hemorrhage, etc.

Post-partum baby is shown to mother then taken over to neonatology for washing, weighing and wrapping, vitamin K injection and antibiotic eye ointment, then obligatory 4 (or more) hours of observation. Meanwhile, the mother is sewn up (either from episiotomy or cesarean) and taken to recovery room (still no visitors) for one hour, then to the open ward where there may be from 4 to 12 other beds with new mothers. Fathers only are allowed to visit now, but only during visiting hours.

Admittedly, a few hospitals have adopted what UNICEF has been trying valiantly to promote as their criteria for a "Baby-Friendly Hospital" (not mother friendly) wherein the baby is given to the mother immediately after birth and allowed to breast feed, and the father is allowed to visit his newborn whenever he wants to. The major obstacles to the promotion of fathers or significant others in the rooms have been, interestingly, the midwives themselves or the nursing assistants, not the doctors! Some public hospitals have been making some changes lately, and the smaller ones (40 beds or less) have made the most advances toward this visiting

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policy. Large public hospitals in Chile remind one of how health care was in the United States in the 1940's and 50's: hospital friendly. FONASA, interestingly, has recently passed a law for reimbursement costs stating that normal vaginal birth and cesarean will be reimbursed at exactly the same price. This was done in an effort to encourage a reduction in the 45% to 75% cesarean rate in public hospitals. If your institution is going to be paid the same for a cesarean as for a vaginal birth, and you will be paid the same salary because you work for the institution, not the client, one would assume that your institution would opt for the least costly system of care (operating room costs, anesthesia, extra personnel, etc.) and promote vaginal births. There are 4 factors influencing this toward the opposite: 1. MD's in the public system refuse to attend births unless the woman pays him a fee above and beyond the required percentage of FONASA, and he retains all options to operate or not by one simple coercion: "Seora, do you love your baby, or not?" She has no options because ALL the doctors at her public hospital have organized themselves to make this emotional and economic blockade. She is also prohibited (by the doctors) to change doctors if she wants a different type of care. 2. A normal labor and delivery may last long into the night, and this physician has to see patients tomorrow! A normal cesarean lasts about one hour, barring complications.

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3. Chilean women have been bombarded with propaganda for over 40 years, convincing them that having their baby in the hospital, with "all the latest technology", is safest for their baby. This is a very class-conscious, upwardly mobile and supremely pretentious society (people carry around wooden models of cellular phones and talk into them in public). I talked with several college-educated women about their options for having a baby, and they told me bluntly "I think a cesarean is best because my doctor told me that my vagina will stay tight, otherwise my husband would leave me for another woman." Also, "Why should I lower myself to biology? I want a pain free, quick delivery, and besides they make these cute designer bikini cuts now." "Most of all I want a healthy baby, and the doctor says he can't guarantee that with a vaginal birth, all kinds of things may go wrong." 4. Finally, incredibly, a pediatrician who work's for the Chilean version of the annual Jerry Lewis Telethon here that gathers money for treating children with birth defects, has said on television, "I would recommend a cesarean for any woman who wants to avoid having her child seen on this program." The focus of every birth here is on the product (the baby) and the "producer" (the father), not on the carrier (the mother). A recent study was done here where we live in the Fifth Region (a mostly agricultural and tourist state, with a population of almost 2 million, and the highest teen pregnancy rate in the country), demonstrating that in public hospitals the cesarean rate was over 45% for FONASA patients, and up to 75% for ISAPRE patients. Through exit interviews it was discovered that the main reason for this high incidence was "client demand". But, as I explained at the beginning of

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the article, Latin America is very much a culture that esteems authority figures. Many times I have heard women say, "I don't want him to ask me what I want, he's the doctor! He should know what is best for me!" The Good News - Remember the significant number of people who were exiled overseas for about 20 years on their "Pinochet scholarship"? Well, they are back now, and in positions of administration and decision-making. We have met with doctors, nurses, educators, administrators, and yes midwives, who are just as appalled as they can be about the maternal health care situation here, and have dedicated themselves, mostly on their pathetic public salaries, to doing something to change this. We have met with midwives working in pubic clinics, in the University system as professors, in the regional health care system as policy planners, and even one or two who attend births at the hospitals. If midwives can legally attend births, inside or outside the hospital, why don't they? There are not even any legal requirements for a physician back up. Although ISAPRE won't reimburse a home birth, they will reimburse midwifery costs. So, if the road is clear and wide open for midwives to attend home births, why don't they? Because the pregnant woman always demands the hospital, demands to be attended by a doctor, and the majority are beginning to insist on cesarean births. Also, midwives in the University system are trained to perpetuate the

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medical/technological system, which is by definition for doctors and hospitals. Mariana Arancibia, a professor at the University of Valparaiso School of Midwifery, tells me that the curriculum, which was written in the 1950's, pointedly ignores home births and only trains midwives in hospital births with medical attendance. She only learned how to attend home births herself while she was living in exile in Sweden. It is a seemingly enormous and uphill struggle, but we have met many people who want to dedicate themselves toward making motherhood a beautiful and transformative event again. It is, after all is said and done, the Chilean women themselves who trust absolutely in authoritative personality and not in her own authoritative process about pregnancy and birth.

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MIDWIFERY TRAINING IN CHILE University trained midwives since 1836. A French obstetrician convinced his colleagues that by persuading lay midwives to bring their patients into hospitals, it would benefit maternal infant mortality rates. To do this, he argued, you need to train and professionalize the midwives, and thus began the first 2 year University Midwifery Program in all the Americas, with a curriculum invented and taught by doctors. Since 1954 it has been a 4-year course of study at University, in Midwifery and Puericultura (the study of infants), taught exclusively by professional midwives. Entrance requirements are based on points from the Scholastic Aptitude Test that every high school graduate must take if they want to enter University studies. First year of study are basic required courses, such as biology, chemistry, sociology and English (!). From the second through the fourth year the midwifery student studies theory and begins her practicum: beginning with basic "nursing skills" like blood pressure, lab tests, TPR and starting IV's, etc. then progressing to prenatal exams, pelvic exams, Pap and other vaginal exams, labor monitoring, episiotomies, suturing, post-partum care, and neonatology. In Chile the midwife is the person who works in the neonatal intensive care unit, and is responsible for well-baby care in the public health system up to the first month of age. The fifth year consists in internship. In Chile this consists of a sort of Public Service, and the placement depends on the needs of the public health care system as well as the needs of the student. A research paper is required for graduation on a public health issue, such as teenage pregnancy rates, AIDS and breastfeeding, etc. and oral and written exams are expected to be passed in order to graduate. There is no requirement for continuing education credit or license renewal. Once you have graduated from University and have passed the exams, you are a Midwife for Life. The same criteria are for physicians, nurses, therapists or any other health care provider. However, many conferences are given and are widely attended throughout the year. These womens health conferences are conducted by and for MD's.
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