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Maternal Health in the Andes

Summary and Keywords

During the pre-Columbian and colonial periods, Andean cosmological understandings shaped indigenous approaches to maternal health. Women typically gave birth at home with the assistance of a midwife (also called a partera or comadrona in Spanish). Birthing and post-partum care relied on local herbal remedies and followed specific social rituals. Women drank teas derived from anise or coca during the labor process, gave birth in a squatting position (toward Mother Earth, or Pachamama), and drank sheep soup after labor to replenish strength and warm the body. Rooms were kept dark because the common perception was that bright light injured newborn babies’ eyes. After labor, families buried or otherwise disposed of the placenta to keep the baby and mother healthy and facilitate lactation, as per Andean tradition.

Changes in maternal health rituals began in the 18th century, as colonial rule became more consolidated. The rise of a distinct medical profession and government interest in population growth gradually shifted responsibility for maternal health from the Catholic Church and charitable organizations to the state. Throughout the 19th and 20th centuries, the growing power and authority of the state and the medical profession led doctors and urban-based reformers to attempt to change long-standing Andean birthing practices, which they considered archaic and unsanitary. These reforms emerged from a desire to reduce infant mortality rates and to replace traditional healers with medical professionals who were trained, licensed, and regulated by the state. As reformers looked to replace Andean maternal health and healing practices with new scientific understandings of the female body and birthing process, they also worked to discredit and displace midwives’ knowledge and practices. In particular, they encouraged women to give birth in newly constructed hospitals and to seek the guidance of medical professionals, like obstetricians. However, these reforms met with limited success. In the Andes today, midwives still attend to roughly 50 percent of all births, and in some remote areas, the figure is as high as 90 percent. It is also more common today to see the merging of biomedical and ritual practices to increase women’s access to and acceptance of health services and to reduce overall mortality rates.

Keywords: Andes, abortion, contraception, maternal mortality, midwifery, puericulture, sterilization

Pre-Columbian Period

Before the Spanish arrived and colonized South America in the 16th century, the Inca civilization extended from modern Colombia to Chile along the Pacific coast. The Inca Empire, centered in the Andean city of Cuzco, was the largest and possibly most sophisticated pre-Columbian civilization in South America. Infrastructural marvels, such as roads and an elaborate system of vertical agricultural terraces, demonstrated the ability of Inca society to adapt and thrive in one of the world’s most mountainous regions. Inca leaders used a variety of peaceful methods to rule over an extensive and diverse territory, including cultural assimilation of different populations, maintenance of existing political structures in conquered territories, and creation of a vast bureaucratic system to sustain social harmony. Even though the Inca managed successfully to incorporate many diverse Andean groups into its expanding imperial enterprise, these groups often saw themselves as distinct from the Inca. Indeed, the Inca employed varied strategies to acculturate Andean indigenous populations into its empire, including tribute and labor requirements (mita), relocation of certain individuals or groups to different parts of the empire far from their home communities (mitmaq), and the marriage of local women to high-level Inca political and military leaders (kurakas) outside of their kinship networks.1

Many forms of worship and religious practices existed in Inca society, and Inca rulers pushed their conceptions of the world onto conquered populations. Inca leaders typically revered heavenly bodies, such as the sun and the moon, and paired them with natural forces. The sun and the moon also referred to a gender-divided universe, which shaped social relations and ordered everyday life. The sun, associated with the male sphere, governed the political realm and oversaw the process of imperial expansion. In contrast, the moon presided over the female domain, including fertility and women’s labor. The division of the Andean cosmos into spheres ruled by the sun and the moon was an imperial ideology, but this gender-divided universe was structured in a way that Andean peoples would understand because it incorporated many deities worshipped in non-Inca communities. The Inca use of the sun to represent its expanding empire distinguishes it from other indigenous groups.2

Increasingly, Inca society associated men with the heavens and women with Pachamama (Earth Mother), the fertility goddess that oversaw planting, harvesting, and procreation, which was appropriated from colonized societies and imbued with Inca religious significance. This division of the world into male and female realms was known as gender parallelism: two separate yet interdependent gender spheres, both of which were necessary for sustaining balance and harmony within Inca society. While these gender spheres were complementary, they did not create gender equality. Under Inca rule, Andean men and women had different responsibilities and social obligations that controlled their everyday lives through marriage rituals, inheritance patterns, and agriculture.3

The fact that the Inca were able to impose their political authority and cosmological worldview on colonized populations does not mean that all colonized groups readily accepted these familiar yet imperial ideologies. Andean communities often refused to adopt the Inca’s religious and cultural practices outright. Additionally, the fact that Inca rulers allowed colonized groups to maintain their political leaders and religious rituals after conquest, both as a strategy of political rule and a means to maintain peace and harmony within its empire, shows that Andean communities did not always wholeheartedly embrace Inca practices.4

Inca gender ideologies were also imposed onto Andean communities as a strategy of imperial domination. For this reason, it is reasonable to think that colonized Andean peoples did not necessarily share Inca ideas about pregnancy, childbirth, and reproduction, even if current scholarship is unable to document fully the extent to which local practices may have varied from those of the Inca. Indeed, Spalding’s study is perhaps notable for its absence of information about maternal health and childbirth practices in Huarochirí, a community on the western edge of the Andes mountains, near the Peruvian coast, that became part of the Inca empire in the 15th century.5

As remained common in the Andes for centuries, women in Inca society typically gave birth at home in a squatting position (toward Pachamama) with the assistance of a midwife or female family members. Post-partum care followed Andean cosmological understandings and social rituals, including providing women with tea made from local herbs and soup to replenish their strength. These rituals adhered to Andean understandings of the appropriate times to consume “hot” and “cold” foods. Since Andean cosmology described pregnancy as a hot state, it was considered appropriate to bathe or consume cold foods during this period. However, blood loss during childbirth put women in a cold state, so a woman’s body needed to be warmed by consuming herbal teas and being covered with blankets.6

Midwives provided essential knowledge about appropriate care during pregnancy, birth, and the postpartum period in Inca society. It can be difficult to discern the role of midwives in pre-Columbian Andean culture because Inca society recorded information in a non-written format. Written sources on traditional Andean healers dating from the colonial period represent the Spanish perspective, and Spaniards often disdained or persecuted Andean healers for witchcraft or sorcery. Nevertheless, we can glean information about the reverence for midwives in Andean society through colonial writings, indicating that women underwent special ceremonies and rituals to prepare for their role as midwives. As Bernabé Cobo, a Jesuit missionary from Spain, wrote in his Historia del Nuevo Mundo (1653), women commonly realized their calling to become midwives in dreams, where the gods called them into service, or after “extraordinary births” that produced special or unusual children. According to Felipe Guamán Poma de Ayala, a Quechua noble who criticized Spanish treatment of the indigenous population, midwives were distinct from other indigenous healers because people referred to them as comadres (godmothers) and beatas (blessed), since they facilitated fertility and childbearing. Andeans typically described midwifery as a religious mission.7

We know that indigenous women used local plants and herbs to regulate menstruation, induce childbirth, and abort unwanted pregnancies. Using the writings of French surgeon Martin Delgar, who traveled through Upper Peru in the 1740s, Adam Warren demonstrates that a variety of local strategies to regulate the female reproductive cycle and control pregnancy existed. Spanish colonial rulers found these practices abhorrent and associated them with indigenous culture and society, suggesting that these were long-standing and widespread Andean practices.8

Colonial Period

Women’s experiences with pregnancy and childbirth changed little after the Spanish conquest, at least initially. While population decline and displacement due to conquest, forced labor, and the arrival of European diseases meant that some traditions and practices were lost, many survived intact and continue to be practiced today. Although colonial administrators considered midwives superstitious hacks rather than qualified medical practitioners, limited availability of professional doctors and lack of state investment in maternity services meant that they still attended the vast majority of births for all social classes until the 18th century.

Childbirth during the colonial period was a risky endeavor, and maternal mortality rates were high due to labor complications and infection rates. Colonial families were often large; married women might give birth between five and ten times during their reproductive lives, although not all of their children would survive infancy.9 Before the 20th century, most procreation in Latin America took place outside the structure of legal marriage. Informal marriage arrangements, concubinage, and adultery produced a high number of illegitimate births. Sporadic record keeping of births, high rates of illegitimacy, and the informal nature of marriage and procreation during this period left a limited historical record for scholars to follow.10

The historical record also indicates that colonial administrators paid little attention to maternal health issues or child welfare in the early colonial period because they considered these practices part of the private sphere. During the period of Hapsburg rule (1516–1700), few hospitals existed in the Spanish colonies. Hospitals were located in colonial administration centers, such as Lima, and were run by charitable organizations or the Catholic Church. These early hospitals focused on curing diseases and other ailments rather than providing preventative medical care, and even though some contained separate spaces to attend to women, it is not clear that women utilized these spaces to give birth.11

In the 18th century, the Bourbon reforms changed the nature of healing in Spain’s colonies in the Americas. These reforms intended to improve administrative efficiency, stimulate the economy, and reinforce Spanish control over its American colonies by limiting local autonomy. As part of a secularizing effort, Bourbon era attacks on church privilege also impacted church-run hospitals. Bourbon reformers and administrators in Lima began to support the development of a medical profession to oppose the dominance of local healers and the Catholic Church over healing practices.

The Bourbon Reforms and resulting changes in health and healing in the Viceroyalty of Peru reflected late colonial anxieties and crises. In the late 18th century, colonial administrators were increasingly concerned about perceived population decline (although demographic data shows Peru’s population was stable or even growing). Concerns about population growth were symptomatic of a broader sense of crisis in the colonies, provoked by the large-scale indigenous rebellions of Tupac Amaru and Tupac Katari in the 1780s. Spanish elites thought the empire’s stability was at risk. Within this context, colonial officials put new emphasis on reproductive matters and promoted intimate forms of surgical intervention in the case of troubled pregnancies or labor complications.12 Catholic priests and government officials briefly advocated training rural priests to carry out post-mortem caesarean sections if the mother died during childbirth to lower infant mortality rates and increase rural populations. Rather than improving maternal health and welfare, these interventions focused on saving the souls of unborn babies and bolstering the power of priests in the Peruvian Andes. Peruvian priests began to lament the commonality of abortion and infanticide among an “uncivilized” and “barbaric” indigenous population and to claim that priestly supervision of women and medical training for midwives could improve maternal health.13

Physicians and other medical professionals echoed these priests’ claims that untrained midwives and ignorant indigenous mothers threatened the colonial system. Beginning in the 1760s, physicians and other professional medical practitioners criticized folk healers and curanderos as they looked to cement their own professional status. Some doctors specifically considered midwives a bane of society, claiming their lack of medical knowledge and training jeopardized the lives of women and children. Without understanding, or perhaps purposefully ignoring, the cultural and social importance of midwives in Andean cosmology, doctors argued that midwives’ practices harmed mothers and children and undermined the Bourbon state. In the 1780s, several measures proposed subjecting midwives to regular cleanliness inspections to ensure their practices were suitable for elite homes.14 This emphasis on elite homes, however, suggests attention to maternal health existed in urban centers like Lima and that little attention was paid to birthing practices in rural areas.

Doctors began to advertise the benefits of hygiene during pregnancy in Peru as early as the 1790s. The ability of doctors to influence healing patterns reflects their growing social importance as a profession in the Bourbon era as well as the enhanced state regulation of medicine, especially in elite society. Specifically, doctors advocated applying knowledge of anatomy and physiology to maternity care, and with the press’s assistance embarked on a crusade to delegitimize midwifery and other folk healing practices. Doctors blamed midwives for abortions, reflecting elite and Church concerns about the barbarity and immorality of abortions. It was also at this time that the state defined induced abortion as a crime.15

For these reasons, pre-natal health campaigns focused on preventing abortions, whether induced with herbs or other substances, or unintentionally initiated by physical violence or shock. They also emphasized breast feeding or using wet nurses to nourish babies, and tried to ease women’s discomfort with caesarean interventions during childbirth. These health discourses extolled the virtues of a rational, modern practice in obstetrics, and the Royal Protomedicato during the Bourbon era established a campaign to evaluate the competence of midwives. These regulations represent an increasingly powerful medical profession’s purposeful devaluation of female knowledge, justified by references to indigenous women’s illiteracy and informal training. In 18th-century Lima, however, too few doctors existed to attend to the city’s women; therefore, doctors continued to rely on midwives to attend births, although they tried to limit their role to a supplementary one. It is unclear if such regulation extended to Andean communities or not.16 Likely the Bourbon state and the medical profession lacked the resources and credibility to change birthing practices in rural Andean communities.

The Bourbon era’s growing interest in maternal health and welfare marks the beginning of an obsession with lowering infant mortality rates, which led to interventionist state policies in the realm of maternal health care that characterized subsequent centuries as well. As reformers redefined the state’s relationship to women and children, they also lay the foundation for an influential discourse linking women to motherhood and the domestic sphere. Nineteenth-century moral reformers and public health advocates frequently reproduced these discourses during moments of 19th-century nation building in Latin America.

Nineteenth Century

By 1830, all of Spain’s former possessions in South America were newly independent states. While the independence wars had uneven effects across the region, the general pattern demonstrates that independence movements disrupted local and regional economies, devastated existing political institutions, and destabilized the social order. The states that emerged in these newly forming nations were typically weak, unstable, and unable to exert political authority over their territories or populations. Ongoing contests between Liberals and Conservatives for national political control compounded economic and social problems and meant that political consolidation and stability remained elusive for many countries until the end of the century. For this reason, maternal health programs in the early 19th century were typically not controlled by national governments; instead, local authorities or benevolent societies and charities continued to monitor women’s and children’s health. By the end of the 19th century, most Latin American states were intensely interested in promoting maternal and child health as necessary components of economic growth and population stabilization.

Changes in maternal health programs reflected Latin America’s broader social, economic, and political transitions. Throughout the 19th century, Latin American societies became integrated into global capitalist trade networks, and their populations became more urban. Amidst changing social and economic conditions, elites became obsessed with notions of progress and modernization. Based on positivist principles of order and progress, Latin American elites used maternal health programs as a mechanism to civilize and modernize their national populations. In this way, maternal health programs were integral to nation building projects.

In the aftermath of independence, maternal health programs in the Andes continued to be linked with the Catholic Church and beneficent societies or charities. Growing elite interest in institutionalizing maternal and infant health care existed, but this practice happened unevenly across Andean nations. In the 1820s, the Peruvian government created two new institutions to attend specifically to maternal and infant health and welfare. The Casa de la Maternidad de Lima, built in 1826, was the first maternity institution in the Hispanic world associated with a hospital. Modeled on a Parisian maternity institution, it offered education on birthing practices. The second institution was the Clínica y Escuela de Parteras, opened in 1829, and later renamed the Colegio de Partos.17

The Casa de Maternidad was supervised by a French midwife, Benita Paulina Cadeau-Fessel. Born in Lyon, France, and trained at the Port-Royal maternity center in Paris, Cadeau-Fessel was a licensed French midwife intent on founding maternity institutions in the Americas. After failed attempts to create institutions in New Orleans and Guadalajara, Mexico, due in part to lack of interest by the regional authorities, Cadeau-Fessel and her husband arrived in Peru in 1826. In Lima, Cadeau-Fessel found doctors and politicians who embraced her proposals for modernizing and professionalizing midwifery services as a means to improve the Peruvian population and increase birth rates.18 At this time, Peruvian medical and political elites advocated for a series of measures to improve infant mortality and overall life expectancy, including vaccination campaigns against smallpox, which required convincing mothers, who were often reluctant to consent to invasive medical procedures, of the benefits of inoculations.19 In this way, elite interest in promoting improved midwifery services dovetailed nicely with these other initiatives, which were also an outgrowth of the Bourbon era’s obsession with population growth.20

At the Casa de Maternidad, Cadeau-Fessel founded the Andes’ first medical training program for midwives. She treated these local midwives, who were often women of lower-class or mixed-race status, with disdain and deemed their lack of formal training harmful to Peruvian women and children. However, drawing from her extensive knowledge of French midwifery and obstetrics practice, Cadeau-Fessel created courses that trained budding midwives in anatomy, physiology, natural birth practices, and delivery methods. Hundreds of Peruvian women, often from middle-class backgrounds, sought training in Cadeau-Fessel’s midwifery school and, after rigorous clinical instruction, became licensed and certified midwives. By the end of the 19th century, thanks to Cadeau-Fessel’s labor, Peru had a large group of well trained, professional midwives operating with the state’s support. This formal training and state legitimation of midwives’ knowledge granted these women elevated social status vis-à-vis folk healers and unlicensed midwives, but led to a complicated relationship with male doctors, who thought their knowledge was scientifically and culturally superior to that of female midwives.21

In part, Cadeau-Fessel’s work reflects a growing French influence on Latin American medical and social welfare institutions throughout the 19th century. Latin American medical education facilities were modeled on the French system, and doctors and national governments widely adopted French theories about child-raising and pediatric care during this time. Proponents of French medical theories, such as Cadeau-Fessel, often denigrated local Andean customs and practices. They also proclaimed French techniques superior and more modern as a means to highlight their own expertise and elevate their status.22 These imported ideas about maternal and infant health care influenced national programs well into the early 20th century.

As in Peru, concerns about maternal health and welfare in Bolivia represented the concerns of the state and of medical elites about professionalizing maternal health services by educating and licensing female midwives and local birth attendants. The first writings on maternal health appeared in Bolivia in the mid-19th century, marking an important moment in the diffusion of information about maternal health. The first, written by Dr. Casimiro Valenzuela in 1854, provided an explanation of general anatomy as essential knowledge for midwifery training for women. The second, written by Eduardo N. Del Prado in 1867, was an obstetrics manual describing female anatomy and a detailed examination of the birth process.23 However, unlike in Peru, these programs had little success, most likely as a result of limited government control over Bolivian territory and lack of political legitimacy. Doctors’ preoccupation with controlling and regulating midwives in Bolivia continued well into the 20th century.

In comparison, Ecuador has a spotty history of training midwives in the early and mid-19th century. A. State interest in regulating maternal health programs began in the 1890s, during a period of Liberal reforms. The state only built a formal maternity institution in the 1890s, although it quickly became a home for midwifery classes and a space for women to give birth.24

Nineteenth-century maternal health developments in the Andes reflect regional Latin American trends of medical professionalization and state concern over infant and maternal mortality rates. Across Latin American nations, male doctors trained in gynecology, obstetrics, and pediatrics decried high infant and maternal mortality rates as having a detrimental effect on national welfare. Doctors often demanded increased authority over medical matters, and this moment of medical professionalization fostered a desire to control and regulate female midwives. Additionally, 18th-century discourses about maternal health in Lima returned at the end of the 19th century, when high mortality rates again concerned Andean medical elites and government officials. Newly centralized states looking to consolidate their power and homogenize their populations employed hygienic ideals and public health campaigns in their drive to create modern nations.25 This “nationalizing mission” put maternal welfare at the center of nation- and state-building efforts to assert political authority, unify disparate populations, and promote economic growth and development.26

While Argentine, Brazilian, Mexican, and Chilean doctors were early vocal advocates in these fields, by the century’s end, doctors across the region were participating in international debates about how best to ensure national health and welfare by caring for women and children.27 However, maternal health advocates in countries like Bolivia and Ecuador often struggled to achieve state support until well into the 20th century, due to ongoing political upheavals and economic instability.

Early Twentieth Century

By the early 20th century, Andean states began to assume primary responsibility for public health, at least rhetorically. To overcome obstacles to state control of health services, such as financial limitations, political instability, and disorganization among medical elites, national governments partnered with a nascent medical profession eager to consolidate its authority over healing practices. As in the late 18th century, 20th-century doctors and governing elites resumed their obsession with population growth and fretted over perceived depopulation of their territories. This state-sponsored pronatalism linked a nation’s “human capital”—healthy children who grew into strong workers and loyal citizens—to national progress.28 The popularity of these ideas at this time reflects a trend where elites considered population a source of wealth and a basis for national development. They legitimized the notion that population was an object that could be controlled by state action or programs. This state emphasis on enhancing human capital differed dramatically from the 18th and 19th centuries, when colonial and national administrations often did not keep records about maternal and infant mortality statistics, leaving that responsibility to the Catholic Church and beneficent societies. We can also distinguish this historical moment from the post-World War II era, when concern about overpopulation came into vogue and led to population control policies during the Cold War. Kim Clark points out that state concern about depopulation in Ecuador was likely overblown, and statistical evidence from Quito suggests that Ecuador’s population was stable, if not growing.29 However, Bolivia had one of the highest mortality rates in the world and suffered dramatic population decline after the disruptive and bloody war with Paraguay over the Chaco region (1932-1935), so state concern about depopulation was likely justified. Bolivian doctors and government officials continued wringing their hands about population statistics well into the 1950s and 1960s.30 Elite anxiety about population growth—whether real or exaggerated—led to a growing state concern for women’s health. Political leaders considered mothers necessary to produce healthy children as future citizens and workers for the nation’s economic benefit.

Pronatalism was just one international trend that shaped Andean state policies toward maternal health programs in the 20th century. As in the 19th century, French philosophies about child-rearing also influenced Latin American physicians at the turn of the century. Puericulture, or scientific theories of child rearing that emphasized hygienic principles and maternal protection, guided state-sponsored maternal health campaigns. Puericulture’s proponents advocated targeting women to produce improvements in child health and welfare. Their programs stressed the importance of educating women about their role as housewives and mothers for the nation’s overall benefit. Specifically, programs aimed to overcome women’s supposed maternal ignorance through education about their domestic responsibilities (including cleaning and housework), proper childcare, hygiene regimens, nutrition, and the benefits of breastfeeding for infant development.31

In Bolivia, for instance, Dr. Jaime Mendoza, a doctor and novelist, stressed that poor diets and alcohol consumption by breastfeeding mothers caused infant malnutrition. Mendoza and his contemporaries advocated a series of measures to enhance child welfare by improving maternal health, including suggesting that companies create day care centers to nurture the children of working mothers. Other doctors focused on expanding educational initiatives for new mothers and emphasized state intervention in domestic affairs through visiting nurses and social workers. More radical reformers demanded the state address socioeconomic inequality to improve the health and welfare of poor women. Finally, doctors requested a dramatic expansion of maternal health infrastructure, including free maternity clinics, special homes for unmarried pregnant women, child care facilities, prevention of illegal abortions, and rural health services, even though the national government was far from being able to implement all of these policies due to a lack of funding and personnel.32 Many of these policies singled out poor, working-class, or indigenous mothers as the most in need of state intervention.

The science of racial improvement and better breeding, or eugenics, also impacted Andean maternal health care developments. As with puericulture, Latin American physicians favored French approaches to national racial improvement over Anglo-Saxon models. Elites in Brazil, Mexico, and Argentina favored a positive eugenics approach based on neo-Lamarckian rather than Mendelian genetics. Both branches of eugenicists believed that national populations could be improved through state policies. Mendelian genetics, popular in Europe and the United States, emphasized the importance of heredity; they claimed that both positive and negative characteristics were innate, unchanging, and passed along to subsequent generations. State eugenic policies in these societies ranged from positive encouragement of individuals with supposedly superior genetic material (“fit” individuals) to reproduce through incentives such as family allowances, to more negative approaches, like sterilizations, euthanasia, and confinement in asylums, designed to limit the reproduction of unfit populations.33

In contrast, neo-Lamarckian eugenicists believed in acquired rather than innate characteristics. Adherents of this theory put more emphasis on environmental factors, nurture, education, and hygiene as determinants of fit or unfit characteristics. Following these ideals, Latin American eugenic programs emphasized sanitation and hygiene, state supervision of child and maternal health, and moral reform of marriage and family structures as a means to national progress and racial improvement. Latin American eugenicists favored neo-Lamarckian eugenics for several reasons, including the region’s long cultural and scientific orientation toward France, as well as the fact that neo-Lamarckian ideas allowed elites to reject biologically deterministic arguments, based on Mendelian genetics, that mixed race and tropical populations were innately inferior to Anglo-Saxon ones.34

In Bolivia, eugenic proponents correlated maternal health with eugenic designs. Elites believed improved maternal health programs could culturally “whiten” the indigenous population. In particular, women’s health became inseparable from discussions about racial improvement because doctors singled out indigenous women as unhygienic and potential disease carriers. Bolivian eugenics programs took the shape of moral reform movements that addressed alcohol consumption, prostitution, and concubinage, as well as public health efforts targeting hygiene, sanitation, and venereal disease.35 Additionally, to produce stronger families and improve children’s health and welfare, the government, in the 1940s, approved family subsidies, paternity tests, and common law unions to protect working-class women’s health, albeit after great debate.36 Peruvian eugenicists, obsessed about regulating the fertility of the lower classes and of Andean migrants to the cities, implemented policies to create “well-constituted families.”37 It is less clear how these discourses impacted Ecuador, although other state policies aimed at the political, social, and economic incorporation of the “Indian” into national life existed. As happened in other Andean countries and Mexico, Ecuadorian leaders adopted a national ideology of mestizaje, or racial and cultural mixing. This ideology suggested that undesirable indigenous traits would disappear if highland Andeans learned to dress, talk, and live like their urban Hispanic and mestizo counterparts.38 Overall, Andean national governments thought women would play a civilizing role by raising future citizens along moral and hygienic prescriptions, which would ultimately improve the race and facilitate cultural mestizaje.

Additionally, Pan-Americanism influenced the development of Latin American countries’ maternal health programs in the 20th century. The International Sanitary Bureau’s founding in 1902, later renamed the Pan-American Sanitary Bureau (PASB) in 1923, contributed to the development of a regional discourse on public health as a hemispheric wide priority requiring the cooperation of all American nations. However, it was not until the 1940s that PASB identified the scientific and hygienic management of maternal and infant health as an area of programmatic importance. Prior to the 1940s, eugenic proponents, puericulture enthusiasts, and health reformers across the Americas spearheaded a series of international congresses on public health concerns. In this growing Pan-American spirit, a group of “maternalist feminists” (women who embraced motherhood and femininity to advocate for women’s political rights and pro-family policies) wanted to bring the plight of mothers and children to PASB’s attention. They arranged a series of Pan-American Child Congresses that brought policy makers, doctors and nurses, social reformers, and women’s rights advocates together to improve the welfare of poor and working-class women and children. This movement reflects a trend of upper-class women’s increasing activity in the development of infant and maternal care programs, either as educators or as citizens. These women organized campaigns, conferences, and support groups for mothers alongside prominent doctors, hygienists, and moral reformers.39 Particular measures discussed and adopted during these congresses included maternity leave, breastfeeding campaigns, and nutrition programs for pregnant and lactating women. Although these congresses were held in places like Argentina, Uruguay, and Chile, they drew attendees from across Latin America, including the Andean countries.40

This growing awareness of maternal health as a specific subset of broader public health programs initiated a renewed interest in scientifically managing pregnancy and childbirth in the Andes.41 Doctors claimed that ignorant, untrained, and unskilled midwives caused high maternal and infant mortality rates. Although medical professionals would have preferred to completely eradicate the empirical practice of midwifery, it was always an unrealistic mission. In Ecuador and Bolivia, the vast majority of medically trained doctors lived and worked in urban areas and had little-to-no interest in disrupting their personal comfort or sidelining their professional ambitions to provide medical care in rural regions. For this reason, Andean governments often mandated that doctors spend a year or two in provincial service after receiving a medical degree.42 The lack of medical professionals to attend to rural women’s health care needs also led the state to create programs to train midwives or traditional birth attendants. Programs in obstetricia (the science of pregnancy and birth) made midwives’ knowledge scientific rather than cultural and defined the midwife’s role as a medical one, without its traditional social and ritual functions. This “cultural hygienization of reproductive health care” attempted to displace existing forms of female knowledge with modern, male-dominated, scientific birth practices.43 Doctors considered it “a matter of biomedical authority.”44

As previously described, Peru was the first Andean country to systematically train midwives, a process that began in the early 19th century under the tutelage of the French midwife Benita Paulina Cadeau-Fessel.45 Midwifery training programs existed in Ecuador in the early part of the 20th century, but no sustained graduation of professional midwives happened until the establishment of the School of Obstetrics within the faculty of Medicine in Quito, in 1939.46 This program created new professional opportunities for women in nursing and obstetrics, although it also generated tension and competition between trained midwives and medical doctors.47 In Bolivia, the idea to provide medical training to midwives came from a Uruguayan doctor, Luis Morquio, an important figure in the Pan American Child Congresses and an advocate for maternal and infant health care. Inconsistent midwifery training programs had existed in La Paz since 1916, and these programs expanded during the 1930s to bring midwives under doctors’ supervision.48 In both Ecuador and Bolivia, the state sent trained midwives to rural areas to expand women’s access to maternal health services. These outreach programs included prenatal and postnatal checkups, attending home births, and lessons in hygiene and infant care.49

Despite state interest in expanding maternal health programs in the early 20th century, it is safe to assume that, for the majority of Andean women, the childbirth process did not change much. Childbirth was considered dangerous for Ecuadorian women in the early 20th century, and high maternal mortality rates existed for women of child-bearing age. The Ecuadorian state only regularized maternal health care in the mid-1930s.50 In Bolivia, the national government built new maternity centers in the 1920s, but doctors routinely criticized their lack of resources.51 Although maternal health was codified as national law in Bolivia in the 1930s and 1940s, by the 1950s, little preventative medicine or public health infrastructure existed. It was not until the 1950s that the state oversaw a dramatic expansion of maternal health facilities outside of Bolivia’s main cities, including expanded midwifery training programs, mothers’ clubs, mobile health units, rural health centers, and new maternity clinics in lowland and border communities.52

Overpopulation and Population Control, 1950–2000

Early 20th-century maternal health programs are best described as pronatalist—state policies aimed at expanding population size to improve economic development. While this state emphasis on population growth remained prominent in Peru and Bolivia after the 1950s, health experts and political elites also grappled with a new idea popular with U.S. policy makers: the notion that overpopulation was detrimental to national economic growth and political stability. Sometimes referred to as anti-natalism, this neo-Malthusian approach to population control linked economic development with smaller populations and families. In the context of the Cold War, the United States often used cooperative public health programs as ideological tools for securing the allegiance of Latin American nations. U.S. population control proponents argued that high fertility rates threatened economic growth and fostered political instability that could allow communist doctrine to make in-roads in the Americas. Latin American leaders contended with these U.S. ideologies, and some countries, like Chile and Mexico, embraced population control measures as national policy (albeit not without contestation).53 However, the continued presence of pronatalist agendas in the 1950s and 1960s demonstrate the rejection by Andean governments of U.S. population policies asking Latin American countries to limit population growth.

Before the arrival of the Spanish, Andean women commonly used herb-based methods of regulating menstrual cycles, and there is little evidence to suggest these traditional family planning methods changed dramatically for rural women during the 19th and 20th centuries.54 Women in highland Peruvian villages, in the 1960s and 1970s, were interested in controlling their fertility to limit their family size, but not to prevent pregnancy altogether. Although modern forms of contraception were available, many village families lacked access to and information about these medications. For this reason, women developed several alternative fertility control methods, including douching after intercourse, sleeping in a different room or with children to avoid sexual relations, and throwing the placenta into a river rather than burying it, as is the tradition for promoting continued fertility.55

A range of responses to these emerging discussions about overpopulation, family planning, and birth control existed within Peru’s different social groups. U.S. programs like the Agency for International Development (USAID) and the Peace Corps, as well as philanthropic organizations like the Rockefeller and Ford Foundations, pushed population control strategies as the pathway to economic growth. Some organizations, like the Pathfinder Fund (a global family planning non-governmental organization, or NGO, founded in 1957 by Clarence Gamble, heir to the Proctor and Gamble corporation), found early support for family planning and contraceptive programs among Peru’s Protestant community.56 The Peruvian government was initially responsive to these global ideas, and the Fernando Belaúnde administration (1963 to 1968) created the Centro de Estudios de Población y Desarrollo (Center for Studies of Population and Development) with assistance from USAID, the Rockefeller Foundation, and the Ford Foundation. This center supported family planning, but also promoted maternal and prenatal care.57

When the Peruvian military general Juan Velasco Alvarado came to power in 1968, he began to systematically eliminate family planning services. He closed the aforementioned Centro de Estudios de Población y Desarrollo in 1973, due to concern about U.S. power over national policy and its association with the Planned Parenthood Federation. This decision reflected growing third-world resistance to population policies imposed on the developing world by the United Nations and first-world countries. Velasco’s emphasis on asserting national sovereignty over population control policies was also congruent with Catholic doctrine. It situated family planning discussions within the Catholic tradition and emphasized that birth spacing (as family planning was frequently called) was the duty of responsible Catholic parents and Peruvian citizens—in other words, a family decision rather than a woman’s decision. While Peruvian bishops acknowledged the social problems caused by rapid population growth, they did not think birth control programs should supplant development initiatives. Instead, they promoted educational programs to teach families responsible parenthood coupled with spiritual and material support for children. These bishops established clinics that offered educational activities and distributed birth control pills specifically in Lima’s poor neighborhoods; we do not know if these programs extended to the highlands.58 Although the government reintroduced some family planning activities in the late 1970s, women did not have regular access to contraceptive methods until the 1980s. Additionally, at this time, Peru’s feminist movement succeeded in promoting the ability to limit family size as a right of couples. The Catholic Church remained opposed to widespread contraception and argued that access to birth control would lower moral standards and increase promiscuity.59

Bolivia offered resistance to U.S.-backed family planning measures and promoted pronatalist policies well into the late 20th century.60 Throughout the 1950s and 1960s, the Bolivian government received unprecedented amounts of U.S. aid in the form of food assistance, military materiel, economic support, and social programs. For this reason, the United States had influence over Bolivian policies, and North American eugenic ideas shaped public health and social programs. By the 1960s, global concerns about overpopulation in the Third World meant that U.S. officials pressured Bolivian politicians to adopt population control measures. Since Bolivia was a predominantly Catholic country whose leaders considered it to be under-populated instead of overpopulated, Bolivian elites and doctors were not particularly supportive of these programs.61

Tensions between the United States and Bolivia erupted in 1969, when Bolivian filmmaker Jorge Sanjinés released his now-famous film Yawar Mallku, or Blood of the Condor. The film dramatized allegations raised by a local radio show in 1967, that U.S. Peace Corps volunteers were sterilizing indigenous women in the countryside without their knowledge or consent. In reality, Peace Corps volunteers were distributing contraception and, with missionaries’ assistance, inserted intra-uterine devices, or IUDs, in women on a supposedly voluntary basis. There is no evidence that sterilizations were a frequent occurrence. Nevertheless, these accusations fueled rumors about widespread U.S.-backed sterilization programs that led to the expulsion of the Peace Corps from Bolivia in 1971.62

This episode in Bolivian history captures complex local attitudes toward U.S.-backed population control measures as a form of imperialism and an attempted extermination of indigenous peoples. The accusations also created ongoing mistrust of contraception and population control policies. For instance, Bolivia’s military dictatorships in the 1970s made the distribution of birth control illegal, and even as late as the 1980s, rumors circulated that U.S. food aid contained sterilizing agents.63 Some women refused to be vaccinated or consume milk rations donated by U.S. Food for Peace programs for fear they would become infertile.64 As late as the 1990s, women’s health advocate Ineke Dibbets reported that Bolivian women remained suspicious of population control programs, contraception, and family planning as Western interference or sterilizing efforts.65

Whereas accusations of widespread sterilizations in Bolivia amounted to little more than powerful rumors, in Peru a state-sponsored sterilization program took place during the Alberto Fujimori regime (1990–2000). Coercive surgical sterilization measures after 1995 were aimed at easing Peruvian poverty and reducing fertility rates by legalizing tubal ligations for women and vasectomies for men. The government purposefully withheld oral contraceptives from the population and provided material incentives to women to encourage permanent sterilization. These policies disproportionately targeted poor women in highland communities who often lacked information about reproductive technologies and had difficulty controlling their fertility. Due to high maternal mortality rates, state policies singled out communities where women preferred to give birth at home in the company of a midwife rather than travel long distances to access medical care they often found untrustworthy.66

Scholars estimate that between 1996 and 1998, about 220,000 sterilizations took place, including childless and post-menopausal women. In a clear breach of human rights laws, interviews with Peruvian women suggest they were misinformed or even coerced into undergoing surgical procedures they did not completely understand. These women reported that sometimes doctors bribed them, and they were occasionally threatened with criminal sanctions. These procedures were often done in substandard conditions, sometimes without anesthesia. Poorly trained medical staff resulted in frequent complications, and doctors did not always conduct follow-up exams to check on their patients’ health.67 Some poor women, however, actively sought out the free treatments and traveled in order to receive them, and some women used the sterilization program as a way to get around cultural or religious aversion to birth control or to circumvent a male partner’s resistance to limiting pregnancies.68

Peru’s feminist movement played a vital role in bringing these policies out into the open and denouncing the procedures.69 Some sectors of the Peruvian feminist movement supported Fujimori’s program, which expanded access to birth control, for which the feminist movement had advocated for decades. Additionally, some feminist groups had developed a tactical alliance with the Fujimori administration to fight against the Catholic Church, which was trying to repeal expanded family planning services implemented in Peru after the Cairo International Conference on Population and Development in 1994. Due to Peruvian feminists’ connections with the global feminist movement, developed in Cairo and subsequently at the United Nation’s World Conference on Women in Beijing in 1995, the Fujimori administration used the language of family planning to win the support of the Peruvian feminist movement and the backing of international agencies like USAID. In doing so, the administration appropriated transnational feminist discourses about women’s health and reproductive rights to mask an exceptionally neo-Malthusian state campaign to limit the reproduction of indigenous and lower-class Peruvians.

However, it eventually became clear that Fujimori’s goal was poverty reduction, not women’s rights or increased access to family planning services. For instance, the clear preference for sterilization over other forms of contraception inherently contradicted the Cairo conference’s emphasis on women’s choice and access to education about different types of birth control. Yet, when allegations of abuse surfaced, feminist organizations that were unambiguously connected with state programs had a hard time denouncing the sterilizations and demanding accountability because of their relationship with the state and their reliance on international financial support. Feminist groups not connected to the Peruvian state most strongly condemned the program, even in the face of physical intimidation and threats of violence. Others partnered with an unusual ally, the Catholic Church, to demand an end to the abusive sterilization program and for changes in the administration’s approach to family planning.70

Despite a sketchy history linking family planning services and birth control in Andean countries to U.S. imperialism and state coercion, current contraception use is on the rise. A 2011 World Health Organization survey on contraceptive use demonstrated that the percentage of married or cohabiting women reporting using at least one contraception method was 60.5 percent in Bolivia, 72.7 percent in Ecuador, and 73.2 percent in Peru.71 These numbers give credence to the assertion that, at least in Bolivia, women want access to family planning and contraception, even if men and politicians act in opposition.72


Like birth control practices, documented strategies for inducing abortions date back to the colonial period. In that era, medical and political elites argued that abortion contributed to population stagnation and decline. Though little was done to regulate this practice, in part due to the medical establishment’s lack of authority over diverse and disparate Andean populations, by the mid-20th century states frequently referred to abortion as a maternal health problem. Indeed, induced abortions were common in 20th-century Latin America as a means of controlling one’s fertility or spacing births. Doctors in mid-20th-century Bolivia, however, believed that abortion was a threat to the nation’s future because it prevented women from fulfilling their biological and civic duties to produce the human capital necessary for future growth and prosperity.73 Especially within the context of 20th-century pronatalism, the medical establishment considered abortion a grave infraction against the nation’s health and welfare.

Abortion was legally classified as a crime (homicide) in Peru in the mid-19th century, although actual legal punishment for women was uncommon. More severe penalties for abortion were codified into law in 1862, especially for people who performed abortions. As in previous decades, these laws were unfairly applied, and women considered “reputable” were less likely to be punished than their lower-class counterparts. By the early 20th century, doctors’ and policy makers’ thinking shifted toward protecting women from abortion rather than punishing them for it. A 1924 law legalized therapeutic abortion—abortion performed by a doctor with a woman’s consent—although doctors feared this law would lead to a growing demand for abortions and a more carefree attitude toward procreation and pre-marital sex. As illegal abortions continued to remain a common method of fertility regulation for women, doctors increasingly classified it as a public health menace. Since complications from illegal abortions often required surgical interventions or led to the death of the woman and the fetus, medical advocates called for preventative health measures and prenatal care as a means to stop harmful abortions, symbolizing a move toward more medical oversight of pregnancy.74 Despite movements to decriminalize abortion in the 1990s, it remains illegal in Peru today, except when the mother’s life is in danger.75

Doctors in Bolivia also came to see abortion as a maternal health issue in the 20th century. In the 1940s, the single most common cause for women to be admitted to the General Hospital’s gynecology department in La Paz was incomplete abortions or complications derived from such a procedure. More than 50 percent of women in the gynecology ward admitted they had undergone one or more abortions, even though induced abortion was illegal at the time. For this reason, doctors persuaded public officials of the necessity to regulate female reproduction.76

As in Peru, abortion is still illegal in Bolivia today except in cases of rape or incest, or to prevent the mother’s death. Bolivian courts are currently considering decriminalizing abortion, and while the government is openly divided on the issue, President Evo Morales has publically stated that he believes abortion is a crime.77 This long-standing prohibition of abortion is partly a legacy of the Peace Corps birth control controversy of the 1960s, which led to the association of birth control with imperialism and eugenics. As a result, women’s access to birth control and reproductive planning information is severely limited, resulting in a higher abortion rate, especially during moments of economic crisis, as happened in the 1980s. Since the 1950s, however, women have increasingly demanded access to abortions and gone to extraordinary lengths to get them. Women’s rights organizations, formed in the 1980s after Bolivia’s democratic transition, make available information about and access to clandestine abortion providers. For this reason, even though abortion is technically illegal, women, doctors, public officials, and policy makers are well aware of abortion’s ongoing presence in society. Abortion in Bolivia, at least in the cities of La Paz and El Alto, is safer and easier to access than ever; although it remains stigmatized, it is commonly referred to as an “open secret.”78

Similar to Bolivia and Peru, abortion in Ecuador is also illegal except when necessary to prevent the mother’s death. The current Ecuadorian president, Rafael Correa, stated in 2013 that he will never approve decriminalization of abortion, and that he would rather resign than cave to pressure by women’s groups, human rights organizations, and the United Nations.79 An historical examination of abortion in Ecuador is needed to understand the similarities and differences between abortion policies and politics in Andean countries.

Continuities and Changes in Maternal Health in Recent Decades, 1980s to the Present

Maternal health care in the Andes in the past few decades exhibits several continuities with the past. First, continuing high maternal mortality rates and lack of access to health services in rural areas show the ongoing difficulty for governments to provide basic services to their populations. Second, large numbers of births still take place at home under a midwife’s supervision, which hints at the medical profession’s failure to achieve its goal of modernizing and medicalizing birthing practices. Finally, tensions continue to exist between empirical and biomedical health providers, specifically between midwives and obstetricians. However, cross-cultural communication and cooperation between Andean and urban healers is a growing trend. Indeed, in recent years, many Andean governments think that incorporating empirical midwives and their knowledge into Health Ministry services could vastly improve health access and lower mortality rates.

Andean countries today still have high maternal mortality rates, although current trends suggest improvement on this front. As of 2013, according to the World Health Organization, Bolivia has a Maternal Mortality Ratio (MMR) of 200 deaths per 100,000 live births, down from 510 in 1990. Ecuador’s MMR dropped from 160 in 1990 to 87 in 2013, and Peru’s declined from 250 to 89 during the same period.80 However, Peru’s Andean region has much higher maternal mortality rates than the coastal region.81 According to the World Health Organization, as of 2010, maternal mortality rates in Peru and Ecuador are on par with Latin America’s overall average. Comparatively, Bolivia’s maternal mortality rate aligns with the average for the greater developing world, similar to those of Southern Asia and the Caribbean, but substantially lower than Sub-Saharan African rates.82 This data demonstrates that maternal mortality remains a greater concern for Bolivia than for its Andean neighbors, but that its rates are not among the highest in the world.

While women’s access to maternity hospitals, pre- and postnatal care, and professional gynecology and obstetrics services have increased in each country’s major urban areas, it is likely that the birthing process has changed little for the vast majority of indigenous women in rural communities. A colonial era observer could easily have provided an account similar to a midwife-attended birth, transcribed by the anthropologist Joseph Bastien, from a Bolivian community in 1981. At the height of labor, the midwife gave the mother a maté (tea) of anise to increase contractions. The mother gave birth in a squatting position over a sheepskin rug, and the midwife gently guided the baby with her hands. The midwife took care to shield the baby from light because Andeans believe that bright lights injure the baby’s eyes. For this reason, the birthing room was kept dark and lit only with candles. After delivery, the husband brought his wife a bowl of sheep soup to help replenish her strength.83

Women’s preference to give birth while kneeling or squatting rather than lying down is just one example of the continuity of birthing practices rooted in pre-Columbian cosmology. Another practice is the continued influence of “hot” and “cold” states to determine appropriate foods for pregnancy and the post-partum period. Methods of extracting and discarding the placenta also have a long history in the Andean region, and the placenta is often considered to be a “second birth,” complete with its own rituals. Certain Andean inhabitants believe that the placenta will move up through the body and choke the woman. To deal with this threat, the umbilical cord is tied to the mother’s leg until the placenta is expelled. In other parts of the Andes, women stay squatted until the placenta emerges, and umbilical cord is not cut until that happens.84 The afterbirth requires proper disposal to ensure future health and fertility, which is typically done by burying it. These practices, which vary by region (including different herbs and methods of straightening the baby before childbirth), are not all uniquely Andean practices; they have some resonance with European humoral theory and midwifery practices in other geographical locations and time periods.

Women continue to rely upon and revere the specialized knowledge of Andean midwives and contrast their home births with hospital experiences. Bolivian women in the 1990s often preferred a midwife’s ability to determine stages of pregnancy by looking at the veins, to identify imminent labor by a woman’s pulse, and to use massage to put the baby into position.85 They compared this delicate treatment with repeated vaginal examinations that happened in a hospital setting, which left some women feeling violated and uncomfortable. The midwife’s non-invasive approach was contrasted with the rushed, uncomfortable, sterile penetration of a modern hospital.86 In El Alto, Bolivia, in the 1990s, the vast majority of women preferred to give birth at home, either alone, with the help of a relative, or with a midwife’s assistance in 30 to 40 percent of cases.87

An ethnographic study of two Peruvian towns in 1981 found that some women preferred to give birth at home after finding hospital birth to be a frightening and demeaning process. One woman specifically identified that there was no one to care for her, bring her tea, or cover her when she was cold due to understaffing and overcrowding at the maternity institution. At home, women expected their mothers and other community women, like midwives, to attend to them with food, teas, and massages to ease the labor process. Men were involved as well, in some places, to support the mother in the squatting position or to wash the baby after birth. In a generational shift, younger women, women who survived difficult pregnancies (such as breech births), and women with more familiarity with coastal or city life tended to favor hospital birth, which they believed lower the risk of labor or postpartum complications. Prior to the 1970s, rural Peruvian women genuinely had few opportunities to attend a hospital to give birth, while the newer trend of women preferring to give birth in a hospital corresponded to a decline in specialized midwives; either women were going to hospitals due to lack of access to midwives, or increasing access to maternity hospitals was supplanting women’s reliance on midwives.88

A World Health Organization study noted that between 1990 and 2013, the percentage of births supervised by trained individuals rose from 46.4 percent to 80.2 percent in Bolivia, reflecting the shift taking place within Andean countries in the 1970s and 1980s, where medically trained personnel were increasingly attending to births. In Peru the figure rose from 49 percent to 87.7 percent during the same time period, and in Ecuador skilled professionals attended at least 98 percent of births.89

These shifts do not suggest that midwifery or Andean customs are dramatically on the decline, however. So-called “local knowledge,” such as traditional birth practices and midwifery, is still considered an obstacle to the implementation of modern, Western-style medical practices and has become a scapegoat for high maternal and infant mortality rates. The Bolivian medical profession argues that increased medicalization and professionalization of childbirth would lead to lower mortality rates. That logic may be flawed in that maternal death rates have actually decreased with the assistance of local midwives in Bolivia. However, midwives are chastised for intervening too much or too little, or for not recommending difficult cases to local hospitals, although these hospitals are often reluctant to accept these cases.90

There has been little attempt to learn from the practical and cultural knowledge of midwives, which has characterizing the disdain of doctors for Andean healers dating back to the colonial era. Some doctors used midwives as a bridge to reach out to local women, but only so long as midwives served the medical profession’s interests.91 Bolivian doctors often tried to change midwifery practices without understanding their social and cultural function and failed to understand why peasants were suspicious of or refused doctors’ medical services. Frustration led members of the Ministry of Rural Health, in partnership with public health NGOs, to invite doctors to witness a midwife attended birth, which the majority of them had never seen. After the birth, the doctors, who were concerned about germs, encouraged the midwives to adopt the use of surgical gloves and sterilized implements, including a disinfected razor blade to cut the umbilical cord. But they also learned that women avoided giving birth in hospitals due to hospitals’ lack of respect for Andean traditions. Typical complaints included bright lights and white walls, insisting women lie down to give birth when they preferred squatting, and preventing family members from bringing food and tea after delivery.92 Additional complaints focused on doctors’ unwillingness to treat the placenta as a separate birth process or on not allowing women to take the placenta home from the hospital for burial.93

The growing willingness to merge biomedical and Andean birthing practices in Bolivia and Peru since the 1980s has facilitated communication between traditional birth attendants and the medical profession. Following the interchange described above, for instance, the Health Ministry sponsored a series of workshops where practitioners of modern and traditional medicine engaged in conversations about health matters and Andean social and cultural practices around birth.94 The importance of female midwives in extending maternal health care in remote regions that may not have had ready access to medical facilities was clear. When midwives were grounded in the community and chosen with the local population’s support, they could gain women’s trust and better serve the community because they understood local languages, customs, and rituals. Those with fewer community connections could migrate to urban areas to work for the Health Ministry or relocate to regions where they were better compensated for their services. The key to making this collaboration work was cross-cultural communication and culturally sensitive training methods that equipped midwives with scientific knowledge of anatomy and physiology and provided technological, administrative, and institutional support. These midwives could also help overcome conflict between local customs and what health promoters teach women, including information about choosing between breast milk and bottle formula in order to space births (because lactating mothers will not ovulate). Midwives could also provide advice on family planning, ranging from birth spacing to fertility suppression, in a culturally sensitive manner.95

Peru followed a similar trend, including Health Ministry training of traditional birth attendants in biomedical birth techniques. At first, these programs focused on supplanting local birthing customs with biomedical practices; but, as in Bolivia, these biomedical practices often made women uncomfortable. Instead, these programs began to emphasize teaching midwives hygiene and anatomy, and training them to identify danger signs during labor than might require hospitalization or surgical intervention. The Health Ministry further advocated the integration of biomedical techniques and Andean practices to attend to the cultural needs of patients. These practices included allowing women to give birth in vertical positions, increasing room temperatures, swapping white bed sheets for darker colors, allowing family members to be present at birth, and permitting family to bring food and drink, such as labor inducing herbal teas, to the birthing room. Overall, this integration of traditional birth attendants into the public health system led to reduced mortality rates.96

As with midwifery training programs and integration of biomedical and local healing knowledge, the success of any statewide maternal health program requires gaining women’s trust and having them understand programs’ merit and value. Educational outreach programs similar to those started in the 20th century demonstrate additional continuity of maternal health programs. One notable example in Bolivia is the promotion of mothers’ clubs to foster female solidarity and information sharing. Beginning in the 1950s, Bolivia’s revolutionary government promoted mothers’ clubs as avenues to eradicate women’s ignorance about their maternal responsibilities. These early versions of mothers’ clubs were typically associated with hospitals or health centers, where nurses supervised women and taught them about hygiene and nutrition.97 Bolivian mothers’ clubs still operate today, although sometimes under the auspices of Bolivian NGOs rather than health centers.98 These clubs proliferated in La Paz and El Alto in the 1980s, with the assistance of NGOs that mediated between the state and local populations over access to health services, housing, nutrition, and economic development. In the 1980s and 1990s, a period of dramatic economic crisis in Bolivia, mothers’ clubs distributed food to almost a sixth of the population. Although women began to argue that mothers’ clubs food distribution programs fostered dependency and passivity, many clubs gradually became grassroots activist-oriented organizations where urban women cooperatively agitated for better access to food, education, and financial credit to improve their quality of life and economic opportunities.99

Recent statistics documenting a decline in maternal mortality rates and increase in the number of professionally attended births suggest dramatic improvement in Andean women’s overall access to state-sponsored maternal health services. However, this shift has not diminished the importance of long-standing Andean rituals and practices around birth and reproduction. The continued prevalence of midwife-attended births, and maintenance of rituals relating to hot and cold foods and disposing of the placenta, indicate that increasing access to state medical services have not supplanted centuries-old traditions. Instead, we see an increasing willingness on the part of states and the medical profession to integrate Andean and biomedical maternal health practices to produce culturally sensitive birth services that enhance maternal health and welfare and lower mortality rates.

Discussion of the Literature

It is clear that the topic of maternal health in the Andes is vastly understudied from an historical perspective. While there is a growing literature on the gendered nature of public health programs in Latin America, with specific attention paid to the state’s increasing oversight of maternal and infant health care, the vast majority of this literature focuses on the late 19th and early 20th centuries and on countries such as Argentina, Mexico, Brazil, and Chile.100 There is also a tendency to focus on urban spaces such as Mexico City, Buenos Aires, Lima, and Rio de Janeiro, and realistically these were settings where records were better kept and preserved. Access to primary source materials clearly limits historians’ ability to make and support historical arguments, and for this reason we know less about maternal health programs in rural settings for the vast majority of Latin American history.101

The topic of maternal health and welfare in the Andes during the colonial period requires much more investigation. The existing knowledge we have is often framed within discussions of Andean culture and society and the transition from Inca to Spanish rule. For instance, Irene Silverblatt frames her discussion of midwives within the context of gender relations in precolonial and colonial society.102 Adam Warren provides additional information about colonial attitudes toward reproduction and abortion, but does so in relation to the link between Church doctrine and colonial healing practices, or within the changing parameters of public health programs and administration between the Hapsburg and Bourbon periods.103 Even within studies specifically devoted to maternal health programs, the focus remains on urban settings, as is the case with Claudia Rosas Lauro’s study on Lima.104

We have slightly more information on maternal health in the 19th century, yet the majority of historical studies are still limited to urban areas, leaving unanswered questions about the state of maternal and infant health in rural regions. Due to the available sources, these also tend to produce state-centric histories. As is true for broader Latin American historiography on public health and medicine, historians tend to place maternal and infant health programs in the 19th and 20th centuries within the framework of nation building, medical professionalization, and modernization. Post-independence Andean nations were fragile, with damaged economies and fragmented political structures. The historical trend is to link emerging state interest in maternal health with a nascent medical profession’s interest in asserting medical authority over healing practices.105 Scholars have also shown how growing elite concern for high mortality rates and potential depopulation of their societies have legitimized intervention by the state and by the medical profession in women’s childbirth and childrearing practices.106

Additionally, authors of 19th and 20th-century studies have pointed out elites’ obsession with positivist notions of progress and modernization. By the turn of the century, Peruvian, Bolivian, and Ecuadorian elites embraced French puericulture and neo-Larmarckian eugenic ideas to work toward their societies’ racial improvement. As Ann Zulawski and Nicole Pacino demonstrate for Bolivia, public health proponents believed that the country’s large indigenous population could be improved through state policies. In the realm of maternal and infant health care, state programs included properly educating women about their civic responsibility to raise hygienic and healthy future citizens to enhance the nation’s human capital.107 Kim Clark raises a similar point in her study of the growth of midwifery and nursing as medical professions open to women in Ecuador.108 In this way, historians demonstrate that maternal health proponents and practitioners saw race and gender as inseparable from conversations about national health and wellbeing. These links became central to advancing state-generated discourses of modernization, mestizaje, and cultural unity.

The 20th and 21st centuries are the most well covered in the historical literature, although much more work is necessary to have a thorough understanding of the similarities and differences of maternal health programs across the Andean countries. In part, anthropological studies and reports from NGOs contribute to our knowledge about maternal health in this era. Additionally, more stable government institutions, a growing emphasis on record keeping, and the impact of international organizations such as the Pan-American Sanitary Bureau mean that sources are more widely available for study. Furthermore, historians have utilized oral history methodology to move beyond state perspectives. Interviews with women, government officials, and women’s health activists, by Erica Nelson and Natalie Kimball in Bolivia, have dramatically increased our understanding of how ordinary people reacted to the government interventionist programs and civilizing discourses.109 Kim Clark’s oral interviews demonstrate women’s increasing professional opportunities within a growing Ecuadorian public health infrastructure in the 20th century.

Finally, scholars have turned their attention to examining the influence of international trends and discourses on national public health models. We have a decent understanding of how medical and governmental elites in the 19th and 20th centuries adopted French puericulture models and Lamarckian eugenic discourses, but adapted them to fit their specific national realities. For the latter half of the 20th century, scholars have begun to examine how global family planning movements and overpopulation discourses impacted Andean countries. Erica Nelson and Molly Geidel show how Bolivians rejected western family planning programs as imperialist and genocidal, leading to an ongoing mistrust of both U.S. aid and contraception.110 For Peru, Raúl Necochea highlights transnational influences on Peruvian population control strategies, but also pays specific attention to the conflicting motivations of state institutions, public health reformers, and religious leaders for promoting family planning.111 This focus on cultural, medical, and scientific exchanges instead of diplomatic and foreign policy or economic aid programs is especially important for shedding new light on U.S.-Latin American interactions in the context of the Cold War.

Primary Sources

Judging from published scholarly research, there are very few in-depth archival collections in the Andean countries on maternal health programs. For Bolivia, there is a collection of patient records from the Instituto de Maternidad “Profesor Dr. Natalio A. Aramayo” at the Archivo Histórico de La Paz, beginning in 1955. A brief description of the collection can be found online. The Facultad de Medicina in the city of Sucre has a collection of medical theses, some of which focus on maternal health programs. Zulawski also cites patient records and statistics relating to women’s health and gynecology from the Hospital General in La Paz. Finally, Kimball uses patient records and statistics relating to maternal health and births for the most recent decades from the Hospital de la Mujer in La Paz and the Hospital Municipal Boliviano-Holandés in El Alto.

Historical research in Peru seems to focus on published primary sources rather than archival collections. Warren uses published writings, as does Quiroz. Quiroz also uses correspondence relating to medical professions, including obstetrics, beginning in the 1850s that are located at the Facultad de Medicina de Lima. She also cites the Ministerio de Justicia, Beneficencia e Instrucción, 1826-1909 collection at the Archivo General de la Nación in Lima. She also references the papers of Benita Paulina Cadeau-Fessel (the French midwife who oversaw 19th-century maternal health and midwifery training programs in Lima) at the Bibliothèque Nationale de France. Cadeau-Fessel’s published works can also be found at a variety of university libraries in the United States, including Harvard and Yale. Copies of four of her midwifery manuals are housed at the National Library of Medicine in Bethesda, Maryland, one of which, Práctica de Partos, 1830, can be downloaded in its entirety.

For 20th-century Peruvian history, Necochea uses criminal records at the Archivo General de la Nación and the Archivo Penal de Lima, making specific reference to the illegal abortion cases documented in the sección de causas penales. He points out that every regional archive in Peru will have a sección de causas penales with illegal abortion cases. He also utilizes sources from the Centro de Documentación de la Historia de la Mujer in Lima, although he sadly notes that it is no longer open to the public due to lack of funds.

For Ecuador, Clark cites several archival collections located in Quito. She references the following documentation: meeting minutes and institutional documentation from the Archivo de la Escuela Nacional de Enfermeras; the Archivo de la Fundación Legislativa; and enrollment data from the Archivo General de la Universidad Central. Collections located at the Museo Nacional de Medicina include correspondence, contracts, and petitions from the Archivo de la Asistencia Pública; correspondence and petitions from the Archivo del Servicio de Sanidad; and correspondence from the Archivo del Hospital Civil San Juan de Dios. Other collections not cited in Clark’s book appear on the institution’s website, including the Antigua Maternidad de Quito, the Maternidad Isidro Ayora, a collection of doctoral theses from the Facultad de Ciencias Médicas de la Universidad Central del Ecuador on topics such as nursing and obstetrics/midwifery.

In the United States, some information is available on grants provided by the Ford Foundation and the Population Council for population control research and policies in Peru and Ecuador in the 1950s and 1960s at the Rockefeller Archive Center in Sleepy Hollow, New York. Necochea also references the papers of Joseph Mayone Stycos, who was one of the Population Council’s first fellows in the 1950s, founder of the International Population Program in 1962, and author of several sociological studies on population issues. His papers are located at Cornell University in Ithaca, New York. The archives of the Planned Parenthood Federation of America, in Northampton, Massachusetts, has a folder relating to programs in Peru in the 1940s and 1950s.

Further Reading

Brady, Barbara. “Local Knowledge in Health: The Case of Andean Midwifery.” In Knowledge and Learning in the Andes: Ethnographic Perspectives, edited by Henry Stobart and Rosaleen Howard. Liverpool, U.K.: Liverpool University Press, 2002.Find this resource:

    Clark, A. Kim. Gender, State, and Medicine in Highland Ecuador: Modernizing Women, Modernizing the State, 1895–1950. Pittsburgh, PA: University of Pittsburgh Press, 2012.Find this resource:

      Necochea López, Raúl. A History of Family Planning in Twentieth-Century Peru. Chapel Hill: University of North Carolina Press, 2014.Find this resource:

        Pacino, Nicole. “Creating Madres Campesinas: Revolutionary Motherhood and the Gendered Politics of Nation Building in 1950s Bolivia.” Journal of Women’s History 27.1 (Spring 2015): 62–87.Find this resource:

          Pieper-Mooney, Jadwiga E. “Re-visiting Histories of Modernization, Progress, and (Unequal) Citizenship Rights: Coerced Sterilization in Peru and in the United States.” History Compass 8.9 (2010): 1036–1054.Find this resource:

            Quiroz, Lissell. “De la comadrona a la obstetriz: Nacimiento y apogeo de la profesión de partera titulada en el Perú del siglo XIX.” Dynamis 32.2 (2012): 415–437.Find this resource:

              Rosas Lauro, Claudia. “Madre sólo hay una: Ilustración, maternidad y medicina en el Perú del siglo XVIII.” Anuario de Estudios Americanos 61.1 (2004): 103–138.Find this resource:

                Warren, Adam. “Pastoral Zeal and ‘Treacherous’ Mothers: Ecclesiastical Debates about Cesarean Sections, Abortion, and Infanticide in Andean Peru, 1780–1810.” In Women, Ethnicity, and Medical Authority: Historical Perspectives on Reproductive Health in Latin America, edited by Tamera Marko and Adam Warren. CILAS Working Paper 21. San Diego: Center for Iberian and Latin American Studies, 2004.Find this resource:

                  Warren, Adam. “An Operation for Evangelization: Friar Francisco Gonzalez Laguna, the Cesarean Section, and Fetal Baptism in Late Colonial Peru.” Bulletin of the History of Medicine 83.4 (2009): 647–675.Find this resource:

                    Warren, Adam. “Between the Foreign and the Local: French Midwifery, Traditional Practitioners, and Vernacular Medical Knowledge about Childbirth in Lima, Peru.” História, Ciências, Saúde 22.1 (2015): 179–200.Find this resource:

                      Zulawski, Ann. Unequal Cures: Public Health and Political Change in Bolivia, 1900–1950. Durham, NC, and London: Duke University Press, 2007.Find this resource:


                        (1.) See Irene Silverblatt, Moon, Sun, and Witches: Gender Ideologies and Class in Inca and Colonial Peru (Princeton, NJ: Princeton University Press, 1987); and Karen Spalding, Huarochirí: An Andean Society under Inca and Spanish Rule (Stanford, CA: Stanford University Press, 1984).

                        (2.) Silverblatt, Moon, Sun, and Witches, 41.

                        (3.) Silverblatt, Moon, Sun, and Witches, 187.

                        (4.) Silverblatt, Moon, Sun, and Witches, chapter three; and Spalding, Huarochirí.

                        (5.) Spalding, Huarochirí.

                        (6.) Barbara Bradby, “Local Knowledge in Health: The Case of Andean Midwifery,” in Knowledge and Learning in the Andes: Ethnographic Perspectives, ed. Henry Stobart and Rosaleen Howard (Liverpool, U.K.: Liverpool University Press, 2002), 181.

                        (7.) Silverblatt, Moon, Sun, and Witches, 29–31.

                        (8.) Adam Warren, “Pastoral Zeal and ‘Treacherous’ Mothers: Ecclesiastical Debates about Cesarean Sections, Abortion, and Infanticide in Andean Peru, 1780–1810,” in Women, Ethnicity, and Medical Authority: Historical Perspectives on Reproductive Health in Latin America (CILAS Working Paper 21), eds. Tamera Marko and Adam Warren (San Diego, CA: Center for Iberian and Latin American Studies, 2004), 16; and Adam Warren, “An Operation for Evangelization: Friar Francisco Gonzalez Laguna, the Cesarean Section, and Fetal Baptism in Late Colonial Peru,” Bulletin of the History of Medicine 83.4 (2009): 647–675.

                        (9.) Susan Migden Socolow, The Women of Colonial Latin America (Cambridge, U.K.: Cambridge University Press, 2000), 66–67.

                        (10.) Elizabeth Anne Kuznesof, “The House, the Street, Global Society: Latin American Families and Childhood in the Twenty-first Century,” Journal of Social History 38.4 (2005): 859–872; and Anne-Emanuelle Birn, “Child Health in Latin America: Historiographic Perspectives and Challenges,” História, Ciências, Saúde 14.3 (2007): 677–708.

                        (11.) Adam Warren, Medicine and Politics in Colonial Peru: Population Growth and the Bourbon Reforms (Pittsburgh, PA: University of Pittsburgh Press, 2010), 15–48.

                        (12.) Warren, Medicine and Politics, 4–6.

                        (13.) Warren, “Pastoral Zeal and ‘Treacherous’ Mothers,” 16.

                        (14.) Warren, Medicine and Politics, 59–60.

                        (15.) Claudia Rosas Lauro, “Madre sólo hay una: Ilustración, maternidad y medicina en el Perú del siglo XVIII,” Anuario de Estudios Americanos 61.1 (2004): 103–138; and Warren, Medicine and Politics.

                        (16.) Rosas Lauro, “Madre sólo hay una.”

                        (17.) María Emma Mannarelli and Betty Alicia Rivera Caro, “Una aproximación histórica a la salud infantil en el Perú: Las mujeres en el cuidado de la infancia (1900-1930),” Investigaciones Sociales 15.27 (2011): 448.

                        (18.) Lissell Quiroz, “De la comadrona a la obstetriz: Nacimiento y apogeo de la profesión de partera titulada en el Perú del siglo XIX,” Dynamis 32.2 (2012): 415–437; and Adam Warren, “Between the Foreign and the Local: French Midwifery, Traditional Practitioners, and Vernacular Medical Knowledge about Childbirth in Lima, Peru,” História, Ciências, Saúde 22.1 (2015): 179–200.

                        (19.) Warren, Medicine and Politics, 78–117.

                        (20.) Warren, “Between the Foreign and the Local.”

                        (21.) Quiroz, “De la comadrona a la obstetriz”; and Warren, “Between the Foreign and the Local.”

                        (22.) Warren, “Between the Foreign and the Local.”

                        (23.) Dr. Rubén Darío Costa Benavides, “Aportes Gineco-Obstétricos del siglo XIX en Bolivia,” Revista Científica 5:5 (September 2007): 19–20.

                        (24.) A. Kim Clark, Gender, State, and Medicine in Highland Ecuador: Modernizing Women, Modernizing the State, 1895–1950 (Pittsburgh, PA: University of Pittsburgh Press, 2012), 115.

                        (25.) María Emma Mannarelli, Limpias y modernas: Género, higiene, y cultura en la Lima del novecientos (Lima, Peru: Flora Tristán, 1999).

                        (26.) Birn, “Child Health in Latin America,” 685.

                        (27.) See Kristin Ruggiero, “Honor, Maternity, and the Disciplining of Women: Infanticide in Late Nineteenth-century Buenos Aires,” Hispanic American Historical Review 72.3 (1992): 353–373; James E. Wadsworth and Tamera L. Marko, “Children of the Patria: Representations of Childhood and Welfare State Ideologies at the 1922 Rio de Janeiro International Centennial Exposition,” The Americas 58.1 (2001): 65–90; Anne-Emanuelle Birn, “‘No More Surprising Than a Broken Pitcher’? Maternal and Child Health in the Early Years of the Pan American Sanitary Bureau,” Canadian Bulletin of Medical History/Bulletin Canadien d'histoire de la Médecine 19.1 (2002): 17–46; and María Soledad Zárate, “De partera a matrona: Hacia la asistencia profesional del parto en Chile en el siglo XIX,” Calidad en la Educación 27 (2007): 284–297.

                        (28.) See Ann Zulawski, Nicole Pacino, and A. Kim Clark on the importance of human capital in Bolivia and Ecuador.

                        (29.) Clark, Gender, State, and Medicine in Highland Ecuador, 50–51.

                        (30.) Nicole Pacino, “Creating Madres Campesinas: Revolutionary Motherhood and the Gendered Politics of Nation Building in 1950s Bolivia,” Journal of Women’s History 27.1 (Spring 2015), 62–87.

                        (31.) For Peru, see Raúl Necochea López, A History of Family Planning in Twentieth-Century Peru (Chapel Hill, NC: University of North Carolina Press, 2014), 14–31. For Bolivia, see Ann Zulawski, Unequal Cures: Public Health and Political Change in Bolivia, 1900–1952 (Durham, NC: Duke University Press, 2007), 118 Unequal Cures: Public Health and Political Change in Bolivia 156; and Pacino, “Creating Madres Campesinas.”

                        (32.) Zulawski, Unequal Cures, 124–126.

                        (33.) Nancy Leys Stepan, The Hour of Eugenics: Race, Gender, and Nation in Latin America (Ithaca, NY: Cornell University Press, 1991).

                        (35.) Zulawski, Unequal Cures, 118–156.

                        (36.) Laura Gotkowitz, A Revolution for Our Rights: Indigenous Struggles for Land and Justice in Bolivia, 1880–1952. (Durham, NC, and London: Duke University Press, 2007), 174–179.

                        (37.) Necochea, A History of Family Planning, 14–51.

                        (38.) A. Kim Clark, “Racial Ideologies and the Quest for National Development: Debating the Agrarian Problem in Ecuador (1930–50),” Journal of Latin American Studies 30.2 (1998): 373–393.

                        (39.) Mannarelli and Rivera Caro, “Una aproximación histórica a la salud infantil en el Perú,” 445–455.

                        (40.) Birn, “Child Health in Latin America,” 691–693; and Birn, “No More Surprising than a Broken Pitcher?”

                        (41.) Clark, Gender, State, and Medicine in Highland Ecuador, 112–142; and Zulawski, Unequal Cures, 118–156.

                        (42.) Pacino, “Creating Madres Campesinas”; and Clark, Gender, State, and Medicine in Highland Ecuador, 127.

                        (43.) Gertrude Fraser, “Modern Bodies, Modern Minds: Midwifery and Reproductive Change in an African American Community” in Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp (Berkeley: University of California Press, 1995), 45.

                        (44.) Zulawski, Unequal Cures, 119.

                        (45.) Quiroz, “De la comadrona a la obstetriz”; and Warren, “Between the Foreign and the Local.”

                        (46.) Clark, Gender, State, and Medicine in Highland Ecuador, 115.

                        (47.) Ibid, 124–127.

                        (48.) Zulawski, Unequal Cures, 126–128 and 138–139.

                        (49.) Clark, Gender, State, and Medicine in Highland Ecuador, 127–128; and Pacino, “Creating Madres Campesinas.”

                        (50.) Clark, Gender, State, and Medicine in Highland Ecuador, 127–128.

                        (51.) Zulawski, Unequal Cures, 128–135.

                        (52.) Pacino, “Creating Madres Campesinas.”

                        (53.) Jadwiga Pieper-Mooney, The Politics of Motherhood: Maternity and Women’s Rights in Twentieth-century Chile (Pittsburgh, PA: University of Pittsburgh Press, 2009); and Gabriela Soto Laveaga, “‘Let’s Become Fewer’: Soap Operas, Contraception, and Nationalizing the Mexican Family in an Overpopulated World,” Sexuality Research & Social Policy 4.3 (2007): 19–33.

                        (54.) Warren, “Pastoral Zeal and ‘Treacherous’ Mothers,” 16.

                        (55.) Susan C. Bourque and Kay Barbara Warren, Women of the Andes: Patriarchy and Social Change in Two Peruvian Towns (Ann Arbor: The University of Michigan Press, 1981), 89.

                        (56.) Raúl Necochea López, “Gambling on the Protestants: The Pathfinder Fund and Birth Control in Peru, 1958–1965,” Bulletin of the History of Medicine 88.2 (2014): 344–371.

                        (57.) Raúl Necochea López, “Priests and Pills: Catholic Family Planning in Peru, 1967-1976,” Latin American Research Review 43.2 (2008): 41.

                        (58.) Necochea, “Priests and Pills: Catholic Family Planning in Peru, 1967-1976”; and Necochea, A History of Family Planning, 126–148.

                        (59.) Carlos Cáceres, Marcos Cueto, and Nancy Palomino, “Sexual and Reproductive Rights Policies in Peru: Unveiling False Paradoxes,” in SexPolitics: Reports from the Front Lines, Richard Parker, Rosalind Petchesky, and Robert Sember, eds. (Rio de Janeiro: Sexuality Policy Watch, 2007), 133–135.

                        (60.) Pacino, “Creating Madres Campesinas”; and Erica Nelson, Birth Rights: Bolivia’s Politics of Race, Region, and Motherhood, 1964–2005 (PhD diss., University of Wisconsin-Madison, 2009).

                        (61.) Nelson, Birth Rights, chapter one.

                        (62.) Molly Geidel, “’Sowing Death in Our Women’s Wombs’: Modernization and Indigenous Nationalism in the 1960s Peace Corps and Jorge Sanjines’ Yawar Mallku,” American Quarterly, 62.3 (2010): 763–786; and Nelson, Birth Rights, chapter one.

                        (63.) Nelson, Birth Rights, 231–234.

                        (64.) Joseph W. Bastien, Drum and Stethoscope: Integrating Ethnomedicine and Biomedicine in Bolivia (Salt Lake City: University of Utah Press, 1992), 162.

                        (65.) Ineke Dibbits, Lo que puede el sentimiento: La tématica de la Salud a partir de una experiencia de trabajo con mujeres de El Alto Sur (La Paz: TAHIPAMU, 1994), 97–117.

                        (66.) Jadwiga E. Pieper-Mooney, “Re-visiting Histories of Modernization, Progress, and (Unequal) Citizenship Rights: Coerced Sterilization in Peru and in the United States,” History Compass 8.9 (2010): 1036–1054.

                        (67.) Cáceres, Cueto, and Palomino, “Sexual and Reproductive Rights Policies in Peru,” 138–144.

                        (68.) Necochea, A History of Family Planning, 1; and Mooney, “Re-visiting Histories of Modernization,” 1046.

                        (69.) Cáceres, Cueto, and Palomino, “Sexual and Reproductive Rights Policies in Peru,” 138–144.

                        (70.) Christina Ewig, “Hijacking Global Feminism: Feminists, the Catholic Church, and the Family Planning Debacle in Peru,” Feminist Studies 32.3 (Fall 2006): 632–659.

                        (71.) World Health Organization, World Health Statistics 2011 (Geneva, Switzerland: World Health Organization, 2011), 28.

                        (72.) Bastien, Drum and Stethoscope, 162.

                        (73.) Zulawski, Unequal Cures, 119.

                        (74.) Necochea, A History of Family Planning, 52–78.

                        (75.) Cáceres, Cueto, and Palomino, “Sexual and Reproductive Rights Policies in Peru,” 135.

                        (76.) Zulawski, Unequal Cures, 140–142.

                        (77.) Emily Achtenberg, “For Abortion Rights in Bolivia, a Modest Gain,” North American Congress on Latin America (NACLA), February 28, 2014.

                        (78.) Natalie Kimball, An Open Secret: The Hidden History of Unwanted Pregnancy and Abortion in Highland Bolivia, 1952–2010 (PhD diss., University of Pittsburgh, 2013).

                        (79.) “Ecuador Abortion: President Correa Threatens to Resign,” BBC News, October 11, 2013.

                        (80.) World Health Organization, “Maternal Mortality Country Profiles.”

                        (81.) Lucia Guerra-Reyes, “Implementing an Intercultural Birth Care Policy: The Role of Indigenous Identity in Peruvian Medical Care,” Anthropology News (March 2009): 13–14.

                        (82.) World Health Organization, Trends in Maternal Mortality: 1990 to 2010, WHO, UNICEF, UNFPA and The World Bank Estimates (Geneva, Switzerland: World Health Organization, 2012), 26.

                        (83.) Joseph W. Bastien, Healers of the Andes: Kallawaya Herbalists and Their Medicinal Plants (Salt Lake City: University of Utah Press, 1987), 78–79.

                        (84.) Bradby, “Local Knowledge in Health,” 181–187.

                        (85.) Ibid., 179–180.

                        (86.) Bradby, “Local Knowledge in Health,” 177–178; and Barbara Bradby, “Like a Video: The Sexualization of Childbirth in Bolivia,” Reproductive Health Matters 6.12 (1998): 50–56.

                        (87.) Dibbits, Lo que puede el sentimiento, 75–76.

                        (88.) Bourque and Warren, Women of the Andes, 91–95.

                        (89.) World Health Organization, “Maternal Mortality Country Profiles.”

                        (90.) Bradby, “Local Knowledge in Health,” 170.

                        (92.) Bastien, Healers of the Andes, 78–80; and Bastien, Drum and Stethoscope, 138–142.

                        (93.) Barbara Bradby, “Will I Return or Not? Migrant Women in Bolivia Negotiate Hospital Birth,” Women’s Studies International Forum 22.3 (1999), 296.

                        (94.) Bastien, Healers of the Andes, 78–80; and Bastien, Drum and Stethoscope, 138–142.

                        (95.) Bastien, Drum and Stethoscope, 150–162.

                        (96.) Guerra-Reyes, “Implementing an Intercultural Birth Care Policy,” 13–14.

                        (97.) Pacino, “Creating Madres Campesinas.”

                        (98.) Bradby, “Local Knowledge in Health,” 175.

                        (99.) Marcia Stephenson, Gender and Modernity in Andean Bolivia (Austin: University of Texas Press, 1999), 196–197.

                        (100.) For Argentina, see Donna Guy, Sex & Danger in Buenos Aires: Prostitution, Family, and Nation in Argentina (Omaha: University of Nebraska Press, 1991) and Kristin Ruggiero, Modernity in the Flesh: Medicine, Law, and Society in Turn-of-the-century Argentina (Stanford, CA: Stanford University Press, 2004); for Mexico see Alexandra Minna Stern, “Responsible Mothers and Normal Children: Eugenics, Nationalism, and Welfare in Post revolutionary Mexico, 1920–1940,” Journal of Historical Sociology 12.4 (1999): 369–397, Ann Blum, “Public Welfare and Child Circulation, Mexico City, 1877 to 1925”, Journal of Family History 23.3 (1998): 240–271, and Anne-Emanuelle Birn, Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (Rochester: University of Rochester Press, 2006); for Brazil see Marko, “Children of the Patria,” Stepan, The Hour of Eugenics, and Okezi Otovo, To Form a Strong and Populous Nation: Race, Motherhood, and the State in Republican Brazil (PhD diss., Georgetown University, 2009); and for Chile see Pieper-Mooney, The Politics of Motherhood, and Nara Milanich, Children of Fate: Childhood, Class, and the State in Chile, 1850–1930 (Durham: Duke University Press, 2010).

                        (101.) There are some exceptions here, including work done by Anne-Emanuelle Birn, Ana María Kapelusz-Poppi, Ann Zulawski, and Nicole Pacino.

                        (102.) Silverblatt, Moon, Sun, and Witches.

                        (103.) Warren, “Pastoral Zeal and ‘Treacherous’ Mothers”; and Warren, Medicine and Politics.

                        (104.) Rosas Lauro, “Madre sólo hay una.”

                        (105.) Quiroz, “De la comadrona a la obstetriz”; and Clark, Gender, State, and Medicine.

                        (106.) Clark, Gender, State, and Medicine.

                        (107.) Zulawski, Unequal Cures; and Pacino, “Creating Madres Campesinas.”

                        (108.) Clark, Gender, State, and Medicine.

                        (109.) Nelson, Birth Rights; and Kimball, An Open Secret.

                        (110.) Nelson, Birth Rights; and Geidel, “‘Sowing Death in Our Women’s Wombs’.”

                        (111.) Necochea, “Priests and Pills”; “Gambling on the Protestants”; and A History of Family Planning.