Introduction

According to Peru’s 2018 Demographic and Family Health Survey (ENDES), the most populated region in the Peruvian Amazon, Loreto, has the lowest percentage of institutional births in the country: 74.5% (95% confidence interval (CI) 66.9–80.9)1. This rate is below the national average (92.6%) [1]. In rural areas in Loreto, the percentage of institutional birth is even lower (48.79%, 95% CI: 36.5–61.2). Infections are the main cause of neonatal death in this region, even among newborns with a healthy weight for gestational age and without genetic conditions that might compromise their life [2]. Moreover, between 2010 and 2012, the neonatal mortality rate in Loreto was 18.7 per 1,000 live births, more than double the national rate (8 per 1,000 live births in 2013) [3]. In order to understand the sociocultural factors contributing to these trends, in this paper, we describe the home birth preferences as well as the childbirth and newborn care practices of the of the Kukama-Kukamiria people, an indigenous group in the Peruvian Amazon.

The World Health Organization recommends promoting the use of institutional health services in order to ensure safe childbirth and prevent both maternal and neonatal mortality [4]. During institutional births, trained health professionals with the necessary equipment and supplies can rapidly act if complications occur [4]. In Peru, such institutional births are not feasible for some social groups (e.g. indigenous people) due to women’s preferences or their lack of access to health facilities. For example, among some indigenous people, women prefer to give birth at home because it is a sign of courage and prestige [5]. Women who stay at home can access traditional beverages to induce labor such as herbal infusions [6–8]. Home birth also involves the participation of family and community members that help with childbirth and the newborn’s physical and spiritual care, while also providing emotional support to the mother [5, 7, 9]. Regarding access barriers, studies have found that indigenous people in the Amazon do not trust health centers due to mistreatment and unnecessary procedures [7, 10]. Moreover, people find health facilities unwelcoming, ineffective, and time-consuming [11]. Little is known, however, about how traditional newborn care practices hinder institutional births or the perspective of community members (e.g. traditional birth attendants, community health workers) about childbirth preferences.

The Peruvian government has issued protocols and health policies aimed at making the country’s institutional birthing services culturally sensitive [12–14]. The most thorough of these protocols is the standing birth protocol issued by the Ministry of Health in 2016, which is based on a prior protocol from 2005 [13, 14]. These protocols not only prepare health providers to support a safe birth while respecting the woman’s preferred childbirth position, but also help recreate other aspects of home birth [12, 13]. The protocol allows the presence of one companion chosen by the woman giving birth, and it indicates which herbal infusions can be safely consumed by her as well as the supplies needed to assist in a standing birth (e.g. rope, mat) [12, 14]. These protocols do not mention the integration of traditional newborn care practices with institutional birthing services. This protocol applies to every health facility run by the government nationwide except for level one health posts which are too small to offer birthing services [12]. By 2009, most health facilities in the Peruvian Amazon had not incorporated the standing birth protocol from 2005 [15], and there is no evidence that they currently meet the cultural needs of indigenous women.

In a context of slow cultural adaptation of health facilities, community-based interventions can substantially reduce neonatal mortality through the incorporation of clean birth and newborn care practices to home births [16, 17]. In their systematic review and Delphi expert opinion process of clean birth and postnatal care practices, Blencowe and colleagues concluded that clean birth practices such as handwashing and clean delivery surface reduce neonatal sepsis deaths at home by 15% (IQR 10–20) [16]. Postnatal care practices at home such as clean cutting of the umbilical cord can reduce neonatal sepsis deaths by 40% (IQR 25–50) [16]. According to the authors, clean birth and newborn care interventions should be promoted through community-based behavioral change interventions, training of health workers and birth attendants, and clean birth kits [16]. It is unclear who the specific targets of these strategies are except for health workers and birth attendants. In order to successfully effect both cultural adaptation of institutional birthing services and clean birth and newborn care interventions at home, a broader understanding of home birth preferences as well as childbirth and newborn care practices is required.

Given the high neonatal mortality and home birth rates in rural Peruvian Amazon, the slow cultural adaptation of institutional birthing services, and the efficacy of community-based interventions aimed at promoting both clean birth and newborn care practices, this study aims to understand the preferences for home births and investigate childbirth and newborn care practices among an indigenous group from the Peruvian Amazon. Results were used to develop a community-based intervention that trains community health workers to improve maternal and newborn care practices during home birth and could contribute to the cultural adaptation of institutional birthing services in the Peruvian Amazon.

Methods

Results

Characteristics of study participants

Over 27 days, we visited six communities and recruited 60 participants. On average, we stayed in each community for 5–6 days. We conducted interviews with 33 participants during the first phase and 27 during the second.

Table 1 shows the demographic information of the study participants. More than half of the study participants were women (39/60). The median age of the participants was 39. One third of the participants (19/60) were recent mothers (RM) who had experienced childbirth within one year prior to the interview. Recent mothers were between 18 and 40 years old and their median age was 27.5. The median number of children among recent mothers was 4.

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Table 1. Demographic information of study participants.

https://doi.org/10.1371/journal.pone.0250702.t001

The female relatives group (FR) was diverse in age since it was comprised of mostly sisters, mothers, and grandmothers of the recent mothers. The youngest female relative was 18 years old and the oldest was 74. The median number of children for female relatives was 8. A total of seven male relatives (MR) of recent mothers were interviewed. They were either their fathers or partners and their median age was 34. Ten participants were traditional healers (TH) and five of them were older traditional birth attendants. We also interviewed 12 community health workers (CHW), five women and seven men, whose median age was 49.5 years old. Community health workers are trained to monitor new pregnancies. Their role is to conduct home visits to pregnant women and newborns to check on any signs of health complications and report them to the health facility.

Discussion

This study explores the Kukama-Kukamiria people’s preference for home births and their childbirth and newborn care practices. Our findings show that women prefer home births over institutional births because it is a culturally charged practice that they cannot reproduce at a health center. Home birth makes women feel safe and supported. It is also a sign of bravery and a way to comply with traditional gender roles such as following their partner’s decisions. These preferences are also linked to experiences of mistreatment at health centers, lack of cultural adaptation of birthing services, and access barriers. Regarding newborn care, there are practices that contribute to hygienic childbirth such as handwashing and clean delivery surfaces. However, the discarding of the colostrum, the lack of skin-to-skin contact, and the range of responses regarding immediate breastfeeding and immediate drying are findings that show opportunities to improve the newborn care practices in these communities.

We found barriers to both health facility access and quality care. In relation to access, studies in the Peruvian Amazon and other low and middle-income countries have also found that distance and financial constraints limit people’s options to home birth [10, 23–26]. When exploring the causes of maternal death in Peruvian rural areas, Anderson found that money, distance, and transportation are factors that delay the provision of care for pregnant women, which can put them at risk of maternal death [23]. The evidence in Nepal suggests that other barriers to skilled birth care include the limited availability of skilled birth attendants and lack of community awareness regarding the importance of birthing services [27]. As for healthcare provision, a study among the Kukama-Kukamiria people found that going to a health center was considered a last resort because of their experiences of mistreatment [15]. Moreover, Avellaneda reported health providers’ lack of awareness of Kukama-Kukamiria traditional health practices and their unwillingness to incorporate such practices [6].

In accordance to this study’s findings, Avellaneda, Rivas, Otto, and Leon have also reported the use of traditional infusions and hot beverages to induce labor such as cotton leaf tea and malva or mallow, ginger, coffee, hot milk, tea, and hot water among Kukama-Kukamiria, Yaguas, and Awajun people [6–8]. Rivas also reported the use of black pepper, cocoa, coca leaf infusions, cooking oil, egg white, mallow leaf juice, and paracetamol [6, 7]. Our study shows that the lack of incorporation of those practices make women less interested in having an institutional birth. Health providers should follow the national protocols on standing birth, which also allows the use of certain traditional beverages [14].

Some women from this study reported feeling unsafe and uncomfortable at the health facility, especially if the provider was a man. In their study about women’s home birth preferences in rural Bangladesh [25], Saker and colleagues found that the lack of female doctors in the health facilities also contributed to this preference. Feelings of discomfort and unsafety, however, do not come exclusively from being treated by a male practitioner. They are also related to the lack of appropriate care. An ethnographic study in a Kukama-Kukamiria community found that despite health providers speaking Spanish as the majority of Kukama-Kukamiria people do, the health center was perceived as an unwelcoming place due to mistreatment and the lack of timely and effective care [7, 11].

Mistreatment in the health center such as receiving unconsented intrusive procedures is an important barrier to institutional births. A cross-sectional study in four low-income and middle-income countries found that 75% of the observed women who received an episiotomy did not consent to one [28]. Moreover, in 13% of the childbirths observed, women received a caesarean section without consenting to one [28]. In her study on the causes of maternal death in rural areas of Peru, Anderson found that women and their partners do not go to the health center to avoid health providers making “internal cuts” to them [7, 23]. A study conducted in 14 regional hospitals located in nine Peruvian cities, including two cities in the Amazon, found that violence during childbirth was reported by 97.4% of women (n = 1488) [29]. These findings reinforce the distrust that indigenous people have towards health services caused by the forced sterilization campaign conducted by the Peruvian government in the nineties [30]. Peruvian providers’ perspectives of mistreatment during institutional births is unknown, but studies in other countries suggest that providers are aware of verbally and physically abusing women themselves and observing their peers doing the same [31]. Some of the drivers of mistreatment and abuse are perceiving women as being difficult, lack of accountability, and stress [31]. Studies in other Latin American countries with a high proportion of indigenous people show that experiencing mistreatment during institutional births lowers the probability of returning to the health facility [32].

While institutional births are associated with access barriers and poor quality of care, our study shows that home birth represents a cultural practice that makes women feel safe and supported. Studies show that this satisfaction with home births leads women to maintain their preference for home births [32]. Other studies in low and middle-income countries have also shown that women prefer home births because it is a cultural practice that provides comfort, intimacy, and autonomy to women [33] while complying with their communities’ traditional views of childbirth [25]. Studies about home birth preferences in Brazil and Zimbabwe have found that home birth entails the participation of family and community members that provide emotional support to the mother and help with childbirth and the newborn’s physical and spiritual care [26, 34]. Qualitative studies of the Kukama-Kukamiria people show that the presence of relatives during childbirth is understood to drive away bad spirits [5]. The baby’s father also has an important role during childbirth because he motivates the mother when she is pushing [7, 35, 36]. According to the current standing birth protocol in Peru [14], pregnant women can choose one companion during institutional birth. This can be the father or any other family or community member. In light of our findings and related literature, this norm is insufficient. To make institutional birth more appealing to Kukama-Kukamiria women, more companions should be allowed in the childbirth room.

One key aspect of home births is the role of the godparents. Our findings show that having a godparent cut the umbilical cord is an important reason for having a home birth. The godparent’s cultural value has been reported in other studies of the Kukama-Kukamiria people [9]. It has also been reported that it is the godmother that makes the newborn become a human being [5]. The Kukama-Kukamiria people consider the relationship between the baby and the godmother the most important spiritual relationship that a person can have [7]. Our study contributes to literature on the cultural meaning of the umbilical cord cut by adding a new case that demonstrates the importance of the godmother in this process. It also contributes to it by showing that not integrating the role of the godparents into birthing services can be a barrier to institutional birth. Additionally, we found that the cut of the umbilical cord can be delayed if the godparent is not present during childbirth.

Another cultural aspect of home birth that contributes to women’s home birth preference is being considered brave. The relationship between home birth, courage, and prestige has been found in other studies among the Kukama-Kukamiria people. These studies have explained that for the Kukama-Kukamiria people, the act of pushing during birth in an intimate space surrounded by relatives is highly valued because women can show their strength. Childbirth is related to strength, which is perceived as the ability to perform a laborious task that requires discipline and implies sweating [37]. This is a demonstration of spiritual vitality. Among Yine women, another indigenous group from the Peruvian Amazon, the socially accepted way to have babies is through physical effort that causes pain and sweat and without any help [37]. Our study not only reinforces these findings but also shows how the association between home birth and bravery can be a barrier to institutional birth. However, the few people we found who also consider women having institutional births to be brave, suggests a potential cultural change that could lead to more institutional births. To reinforce this cultural change and given what we know about the link between home birth and bravery and the perception of the health center as a place where women are powerless (i.e. subjects of mistreatment and unconsented procedures), we suggest that interventions should emphasize that institutional births are for all women, not just those experiencing complications, and that women can decide their childbirth positions during institutional births. We also recommend allowing more companions than the one that is currently permitted during institutional births.

Although our findings show the positive impact of family and community members in women’s preference for home birth (i.e. feeling safe and supported and being considered brave), we also found that home births are related to women’s limited decision-making power. In Saker and colleagues’ study [25], the decision to have a home birth was made by the men and elderly members of the family. A systematic review of access barriers to obstetric care at health facilities and a literature review of determinants of institutional births show that women’s decisions are heavily influenced by their partners’ preferences [38, 39]. According to these studies, women need their husbands’ or relatives’ permission to have an institutional birth, and they may lack control over the material resources necessary to afford or access one [38, 39]. Enhancing women’s decision-making capacity has to be a primary goal of any intervention promoting clean home births or institutional births.

In relation to newborn care practices, we detected delays in and lack of skin-to-skin contact and immediate breastfeeding. According to Moore and colleagues, this can be harmful to the newborn and the mother because skin-to-skin contact improves breastfeeding, which is a protective factor against illness for newborns [40]. Other reported advantages of skin-to-skin contact are improving suckling competence, maternal satisfaction, and temperature control of the newborn as well as reducing primary postpartum hemorrhage [39, 41, 42]. Previous studies of the Kukama-Kukamiria people have also found delays in immediate breastfeeding [15, 17, 29]. The lack of skin-to-skin contact that we found should be addressed by health officers. We recommend educational campaigns targeting community health workers, pregnant women, and traditional birth attendants about the importance of skin-to-skin contact. Moreover, we recommend addressing one of the main reasons for the delay of such contact–waiting for the godparent to cut the cord. For instance, recommending that the newborn rest on the mother’s chest even if the cord has not yet been cut, is a possibility.

For most mothers in our study, the colostrum is stored milk that hurts the baby and should be thrown away. Kukama-Kukamiria participants from other studies were not familiar with the term colostrum either [9]. They called it “first milk” instead and discard it because they did not know its benefits for the baby [9]. The unique nutritional value of colostrum varies between feeds and stages of lactation [43], but it is known to improve intestinal maturation and has antibodies against multiple enteric pathogens [44, 45]. Further, the WHO recommends immediate breastfeeding within the first hour because it reduces neonatal mortality [46]. Our findings show the negative perception of the colostrum among Kukama-Kukamiria women, which can be targeted by future interventions aimed at improving newborn health.

In relation to newborn care, participants mentioned some beneficial practices such as disinfecting the scissors used to cut the umbilical cord and handwashing. These practices have been reported in other Latin American countries, showing that traditional birth attendants are aware of internationally recommended newborn care protocols [47]. Educational campaigns for newborn care should keep emphasizing the benefits of these practices since there are other studies of the Kukama-Kukamiria people that found people cutting the cord with non-sterilized sharp objects (e.g. razor, knife) that can generate infections [11]. Handwashing in particular should continue to be addressed at both the community and the government level since access to clean water is limited in this area. Even if participants report washing their hands and childbirth surfaces, the quality of the water used could still put the newborn’s health at risk. Clean water and sanitation are paramount for newborn care.

Historically, cultural aspects of childbirth have been considered by the Peruvian government as barriers to safe pregnancy and childbirth since they usually lead to home birth instead of institutional birth. However, several policies aimed at integrating traditional practices into institutional birthing services have been approved since 2005 [12, 13]. For instance, the 2005 standing birth protocol and its updated version in 2016 allow the consumption of certain traditional beverages during labor and the participation of one companion during childbirth [12, 13]. This is important progress, but our study shows that women are not aware of these changes. Moreover, the implementation of the protocol is limited [15]. In our complementary formative research for the Mamas del Rio program, we found that none of the 10 health facilities serving Kukama-Kukamiria people had the 13 supplies (e.g. mats, ropes, stool) required to adapt their services to accommodate the standing birth protocol. Five of those facilities had only two supplies and the other five had none. Since the lack of implementation of such protocols is a barrier to institutional births, a nationwide evaluation of protocol implementation should be conducted. We recommend that the supplies be distributed to every health center, prioritizing those that primarily serve indigenous people, and that communities be informed about the cultural adaptation of birthing services.

This study shows the limitations of the current standing birth protocol and can inform future changes to ensure the cultural adaptation of birthing services in the Peruvian Amazon. For instance, allowing only one companion might be a barrier to institutional births since women are used to having their close relatives and a birth attendant during childbirth. We recommend increasing the number of companions to at least four people so that the partner, the mother, a childbirth attendant, and a godparent can be present. The cultural adaptation of birthing services should also integrate the role of the godparent in cutting the umbilical cord. The mechanisms to report and hold health providers accountable for mistreatment should also be improved and including community health workers in this process is key.

Finally, recognizing that institutional births are not always feasible or desired and focusing on making home births clean and safe is crucial to reduce maternal and neonatal death [16, 17]. Our study shows that hygienic birth practices (e.g. handwashing, scissors sanitization) are common in the community, but structural factors such as access to water and sanitation are necessary to ensure their effectiveness. Based on our study results, home births in the Peruvian Amazon could be safer if practices such as immediate drying, skin-to-skin contact, and breastfeeding including the colostrum are implemented at the community level. To be successfully implemented, however, this biomedical information needs to fit into an existing sociocultural system of childbirth and newborn care instead of directly conflicting with people’s customs and experiences [48]. The results of this study are part of the formative research used to build the Mamas del Rio program, which includes a training program for community health workers aimed at improving essential newborn care practices and neonatal healthcare. This is achieved through educational home visits by community health workers to pregnant women and mothers with newborns. Supportive program components of Mamas del Rio include the training of traditional birth attendants, the improvement of healthcare facilities, and comprehensive supervision of community health workers’ tasks. We recommend replicating the Mamas del Rio program nationwide.

Strengths and limitations

This study has a few limitations. Interview-based studies face issues of social desirability and recall bias that can be particularly salient when reporting about healthcare practices that involve vulnerable groups such as newborns. We recommend that future research complements interview data with ethnographic observations of home births and institutional births since this method provides a better understanding of the meaning of practices for participants and gives the researchers first-hand information.

Another limitation of this study is that participants hold multiple roles in their communities but were placed in one specific group. For instance, some female relatives were also traditional birth attendants. As a result, we encountered few differences between groups. This is a challenge when conducting research with small, isolated, and underserved communities where division of labor is limited and social cohesion is strong. This makes people’s beliefs and customs very similar, which makes the incorporation of community members in intervention programs crucial to their success.

Qualitative studies like ours have small samples so the results are not representative of the whole country or every indigenous group in Peru. However, these type of studies are rich in description and reveal the mechanisms that lead to certain behaviors like home birth and newborn care. Another strength of our study comes from the two phases of data collection. This gave us the opportunity to follow up and ask additional questions to better understand home birth preferences and childbirth and newborn care practices.

Conclusion

Our study contributes to the understanding of women’s preference for home births as well as childbirth and newborn care practices in the Peruvian Amazon. The Kukama-Kukamiria people prefer home birth over institutional birth because they see it as a meaningful, inexpensive, practical, and socially prestigious practice. On the other hand, institutional births are costly, difficult to access, and put women at risk of mistreatment and abuse. Favorable childbirth practices in home birth are handwashing and cleaning delivery surfaces. The discarding of the colostrum, lack of skin-to-skin contact, and delays in immediate drying and breastfeeding should be targeted by public health interventions to improve maternal and neonatal health outcomes.

Acknowledgments

We want to thank all of the community members who participated in the study.