Ill-treatment, coupled with high hospital fees and culturally insensitive behaviour, means many women in Peru prefer to give birth at home. The government is now trying to encourage women back.
When Jenny Rodríguez attended her first hospital ante-natal check-up, health workers invited her to participate in classes for expectant mothers. "We learn about the baby, we learn exercises and how to relax," she says enthusiastically.
Rodríguez, from one of the shantytowns that ring the capital Lima, is confident that trained and supportive carers will help her cope with labour and deliver a healthy baby.
A common-place event for a pregnant woman, you might think. Not in Peru, where studies have shown many women experience discrimination and abuse by punitive health workers offering sub-standard care.
The scope of ill-treatment has been well documented. In 1999 the Latin American and Caribbean Committee for the Defence of Women's Rights (CLADEM) and the US-based Center for Reproductive Law and Policy produced evidence of widespread physical and psychological violence against women in public health facilities, including maternity wards.
Many labouring women endure verbal and physical abuse from judgmental health workers who equate childbirth with punishment for having sex.
"The nurses and technicians yelled at me," one woman told CLADEM researchers. "'Who forced you to have kids? What were you expecting? If you open your legs to your husband, get ready for birth'." Another recounted how a nurse "told me I should push. At that moment I couldn't. I cried out. The nurse slapped me."
Women have even been sterilised without their consent after a first child -some as young as 19 years old. Haemorrhaging women needing emergency obstetric services have been turned away when they were unable to pay hospital fees. Fees for some drugs and services -even in government hospitals -are an expensive option in Peru where, according to the World Bank, almost half the population lives on less than $2 a day.
CLADEM'S findings – along with two reports by Peru's Ombudsman's Office, an official department dealing with citizen complaints about government policy -revealed that such ill-treatment is meted out to those women who are also most likely to die as a result of pregnancy. That means the young, urban and rural poor and Amerindians.
While maternal deaths dropped from 265 per 100,000 live births in 1996 to 185 in 2000, the national average is still the region's highest. It is also misleading: in the rural districts of Ayacucho, Huancavelica and Puno, the ratio can be as high as 400 to 600 deaths per 100,000 live births compared to 40 in Lima.
"Rural women say they don't go to the hospital, first because they're mistreated, and second because they have to pay," says Dr Raquel Hurtado, a community health paediatrician researching maternal deaths.
And indigenous women complain that health workers are verbally abusive and make them undress for delivery, which is unacceptable to their culture. "Most indigenous women avoid the [government] health system at all costs," says Mary Elizabeth Bathum, a family nurse practitioner and Catholic missionary who runs a small health clinic in Puno, southern Peru.
Rocío Villanueva, who heads the women's rights section at the Ombudsman's Office, says that while the government wants women to give birth in local, government- run health centres in order to lower maternal deaths, the system offers "only one way of viewing childbirth".
The Ministry of Health is experimenting with more homely birthing rooms where women have more choices on how to deliver. One choice they are offered is to squat -the customary position for childbirth among many indigenous women -instead of demanding they lie down to deliver, a position which has been proven to slow down delivery.
Language is often a barrier – health personnel rarely speak local languages and must rely on translators.
Hurtado believes women will continue to boycott health facilities unless they offer a respectful service that adapts to aspects of local cultures.
Even when women do attend a hospital, preventable deaths occur. Some women die because of delays in transporting them to a better-equipped facility when complications arise. Other delays happen because of the lack of autonomy of obstetric nurses, with decision-making power resting in the hands of a few senior doctors.
Addressing cases of mistreatment or negligence and changing power relationships between health workers and patients, as well as between different hierarchies of staff in the health system, will not be easy.
"Violation of women's rights by functionaries of the public health system continues to be a problem," says Silvia Loli, CLADEM's Peru coordinator. She believes the apparent lack of compassion of some health workers is due to a lack of emotional and professional support: "They're constantly faced with illness, hunger, malnutrition and death."
Beyond the labour wards and delivery rooms, there is another change on the horizon which many fear will make things even worse for women.
Catholic health minister Luis Solari is proposing a bill that would extend doctors' rights to become medical "conscientious objectors" -refusing to provide services that violate their personal beliefs. The bill is very broad, and could cover contraceptive provision and emergency post-abortion care.
Unsafe, illegal abortion is the second leading cause of maternal death in Peru, particularly among vulnerable adolescents. "There need to be norms that define which doctors are objectors and which are not, and in what cases," says Villanueva.
"This is another case of the doctor's role taking precedence over the woman's rights," warns Loli.
Villanueva fears if the bill is passed, it will mean that where a rural community may have only one doctor, "if that doctor is an objector, the community would be left without services."
Women already suffer from a lack of services in such areas. In Peru the Caesarian-section rate is lowest -between two and three per cent -in the regions where maternal mortality is highest. When the rate is under five per cent, say experts, it shows that hospitals do not have the capacity to handle emergencies.
"The women who should have C-sections are buried instead. This is a matter of human rights and the government's lack of responsibility," Hurtado charges.
Hurtado hopes her study in Puno will lead to higher quality maternal health-care policies appropriate for Peru's heterogeneous population.
"Enjoying the latest scientific advances is… a health-care right," she says, "but it's necessary to respect the culture."