Meeting Patients´ Needs in Maternal Health Care
Health inequalities are a major cause of maternal mortality, which can be seen within ethnically diverse countries like Peru, but also persist in the more affluent European Union. Access to health care services is crucial, thereby addressing economic, geographic and cultural accessibility. A continuous effort by the government and civil society is needed to shape the social determinants of health and improve maternal health.
Two pregnancies – two challenges
Claudia Julca, a 20-year-old Quechua Peruvian woman1, has a weather tanned face that makes her look older. Life in the remote mountain area of the Andes is arduous, but even more with two young children, and being pregnant with the third. At the age of 16, her first pregnancy ended with a traditional delivery at home closely cared by her family and the local midwife she trusts. After a close friend of her died giving birth at home, she decided to rather hike two hours over a dangerous mountain path to the health center in Puno, a remote town in the Southern Andes, when pregnant for her other children. 
More than 1,000 km in the north west, Maria de la Vega, 25, is pregnant with her first child in Lima. Reaching her preferred hospital, the School of Doulas, when in labor will take only 30 minutes by car. Although the natural birthing center in Lima is not covered by her insurance, Maria is able to pay for it out of pocket.
De la Vega and Julca are two pregnant women in the same country, yet in completely different situations and at different risks. Although the Peruvian Ministry of Health strongly encourages all births to take place in centers with its approach “Every birth is of risk.”. On average 10% of births are still taking place at home, with up to 34% in remote areas of the Andes and Amazon. In comparison with a developed setting in Germany, 98% of births occur within the hospital and certified freestanding midwifery units are more common than home births (0.5% of all births).
“On a global level, 99 percent of maternal deaths occur in developing countries”1 Because of the lack of service and a high number of pregnancies, a woman´s life time risk of dying in labor is 1 in 76 in developing countries, compared to 1 in 7,300 in developed countries.
Maternal mortality is a very strong health indicator reflecting the health system´s performance as well as inequalities within and between countries. In 2000, maternal mortality reflected this social gradient with 361 maternal deaths per 100,000 live births in Puno compared to 52 per 100,000 live births in Lima.3 Attributable to Millennium Development Goals, maternal mortality rate has declined sharply in Peru in the last 10 years to 68 per 100,000 live births in 2015. However, it is still not comparable to the European Union (16 deaths per 100,000 live births in 2015) or Germany (6 deaths per 100,000 live births in 2015) and notable discrepancies between rural and urban areas and indigenous and non–indigenous Peruvians can still be observed. Similar discrepancies also exist the European Union, where women of non-European origin have a 60% higher maternal mortality rate.
In Germany, the relative risk of dying in labor for non-German women was 30% higher in 1996 with a decreasing tendency and socioeconomic status is considered to represent a strong mediator. In UK, the probability of severe maternal illness was 83% higher among black African women and 74% higher in Bangladeshi, after controlling for preexisting health conditions and socioeconomic factors.7 The latter including a wider set of economic, societal and political factors within the country shaping health outcomes.
In Peru, to some extent these disparities may be explainable by differences in the social determinants of health such as: health care utilization, as reflected by Julca and de la Vegas cases. A key to reduce health inequality is guaranteeing access to health care.
This article argues that socioeconomic determinants of health, such as ethnicity, culture, as well as access to health care, influence maternal health outcomes and that governments and civil societies should work continuously to alleviate these inequalities independently of the country´s developmental status.
Insurance coverage is key to ensure affordability of health services. Even though, the Peruvian government introduced Universal Health Coverage in 2009 and the emphasis of the SIS (Seguro Integral de Salud; statutory health insurance) on maternal and child health, 34.6% had no insurance in 2013 and out-of-pocket (oop) spending continues to be the main source of financing for health services. For the indigenous and the less affluent people, these oop spending is often not affordable. Julca´s odds of living in poverty are approximately 11%, since she belongs to the indigenous population, even after controlling for variables such as age, education status, work status and geographic origin.
Even in well-fare states like Germany with almost universal health coverage, socioeconomic status and thus affordability of health services contribute more to maternal health disparities than nationality or ethnicity.9
It is of note that economic accessibility is not a one-way street. Due to many underlying factors such as a potentially lower reimbursement, racism and language barriers, the quality of services provided may differ. In Germany, perinatal quality parameters were observed to diverge between Germans and Turkish immigrants, associated with quality differences in the care provided to immigrants.
With insurance status being equally distributed across the country (63% in Lima and 61% in Puno), health services might still not be accessible in remote areas. Since the high mountains of the Andes and the thick Amazonian jungle are sparsely populated, the distribution of health services and health workers follows economic growth and population density at the costal and urban area. Of the approximately 200 000 health workers in Peru, 53% practice in Lima.8 There are few nurses and midwifes. The World Bank counts 1.4 per 100,000 inhabitants in Peru, compared to 12.9 in Germany. Here, 90% of midwifes drive less than 40km by car to home births. However, the declining birth rates and cost pressure let the number of maternity wards in hospitals subsequently decrease, especially in scarcely populated states like Saarland, Baden-Wurttemberg and Mecklenburg Western Pomerania, leaving potential supply shortages.
The WHO estimates that a density below 23 physicians, nurses and midwives per 10,000 people is associated with elevated maternal mortality rates. Peru, with its human resources for health density at 29.6 in 2015 being mainly concentrated in the urban areas of Lima, Callao and Arequipa, is thus facing a relative shortage. This centralization of health services in both countries leads to the indigenous population, particularly women and children, having less access to basic health services in Peru9, while in Germany, demographic changes are expected to sharpen service provision in rural areas.
Thirdly, there are ethnic and cultural differences impeding access to health care services mostly for the indigenous population. In Peru, a mistrust towards healthcare professionals can be observed which may lead to a lower use of services in indigenous communities especially after the “family planning program” of the former Prime Minister Fujimori in the 1990s.
He introduced a “family planning” program that predominantly targeted poor and indigenous women who were sterilized without information nor consent, either by intensive persuasion or forcing. During the 6-year period over 270 000 women were surgically sterilized, the highest percentage were Quechua and Aymara in the southern highland of Peru.  The program was intended to control poverty and improve health outcomes, since indigenous women tended to have more children and less access to health. This human rights abuse still nourishes the mistrust in government implemented health centers and western traditions of birth giving.
Since then, Peru has done a lot to alleviate this mistrust. For example, the cultural adaption of birthing practices. For her third child, Julca wants to be one of the 5000 Peruvian women that give birth vertically per year, an ancestral tradition1, in which the woman stands up, seated or squatting to allow the baby to orientate itself to the birth canal and thus facilitate its delivery.
Bridging the gaps
A surprising, yet underappreciated, member of the health workforce might play a key role on maternal health care. Community Health Workers (CHW), also called ‘health aides’, work in communities and provide basic health and preventive care and education,   are bridging the gaps, not only in terms of communication and trust building,19 but also in terms of service provision in remote areas. The approximately 35,000 CHW reassure trust in the government system by simply speaking the same language being highly-valued in Quechua speaking communities.15 CHW and the adaption of traditional birthing practices in centers made a difference: the number of women choosing home birth over health centers decreased from 94% to 13% in 2009.19 More importantly, 90% of the women were satisfied with the service and would recommend it to others, indicating that patient needs are met. Due to the absence of evidence regarding the quality of services provided by CHW and the lack of consensus on the definition, role and framework, the concept of CHW is not easily transferrable to other countries and is not unrestrictedly recommended. Moreover, as the CHW programs mostly rely on volunteers, their sustainability is questionable. 19
Similarly, voluntary worker also supported the health system in 2015/16 with the unprecedented influx of refugees in Germany. Thanks to them, the system appeared highly absorptive and Germany showed an open culture. Voluntary workers and CHW represent thus a way to overcome racism, which may be one of the primary causes of persistent health inequalities in Peru and in Germany regarding Turkish immigrants, since on a broader scale, German hospitals have not yet comprehensively embraced interculturality.12
In conclusion, maternal health care inequalities are striking in heterogeneous, multiethnic societies like Peru, but also dominant in Welfare states like Germany. The unequal access to health care represents one of the most important factors contributing to these disparities. Evidence suggests that income inequality between indigenous and non-indigenous Peruvians persists and wealth has been mainly restricted to urban areas with more resources and better accessibility.8 However, a mere expansion of infrastructure is not enough to meet people´s needs, especially in such an extreme situation as birth giving and especially in multiethnic societies, like Peru. Thus, cultural aspects and traditions should be regarded in health service provision to increase access and utilization and improve health outcomes.
Independent of the countries´ wealth and developmental status, these challenges may arise also with externa shocks, like refugee influx in Germany recently and persist in ethnic minorities in developed countries of the European Union. Ensuring access to health to reduce inequalities constitutes thus a continuous effort for the governments, with civil society largely contributing in the form of volunteering.
 Ingar, C. 2007. Midwifery and Women´s Health in Peru: Visions and Dreams. [Online] Available at: https://midwiferytoday.com/mt-articles/midwifery-and-womens-health-in-peru-visions-and-dreams/ [Accessed: April 24th, 2018].
 Figure is calculated by the authors: 3587 home births in 2010 [Online] Avaliable at; https://www.ajog.org/article/S0002-9378(12)01074-5/fulltext, [Accessed May 7th, 2018]
 United Nations Children’s Fund, “The State of the World’s Children 2009: Maternal and Newborn Health” (New York: UNICEF, December 2008 ).” Cited in Bristol, N. 2009. Dying To Give Birth: Fighting Maternal Mortality In Peru; Health Affairs. [Online] Available at: https://doi.org/10.1377/hlthaff.28.4.997 [Accessed: April 24th, 2018].
 World Bank, 2015. Maternal mortality ratio (modeled estimate, per 100,000 live births). [Online] Available at:https://data.worldbank.org/indicator/SH.STA.MMRT?locations=PE [Accessed: April 23rd, 2018].
 World Health Organization. Data and statistics. [Online] Available at: http://www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn-health/data-and-statistics [Accessed: April 24th, 2018].
World Bank, 2015. Maternal mortality ratio (modeled estimate, per 100,000 live births). [Online] Available at: https://data.worldbank.org/indicator/SH.STA.MMRT?locations=DE [Accessed: May 7th, 2018].
World Health Organization, Europe, Data and Statistics. [Online] Available at: http://www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn-health/data-and-statistics [Accessed April 24th, 2018]
 Razum, O., Jahn, A., Blettner, M. and Reitmaier, P., 1999. Trends in maternal mortality ratio among women of German and non-German nationality in West Germany, 1980-1996. International journal of epidemiology, 28(5), pp.919-924.
 Alcalde, J., Nigenda, G. and Lazo, O., 2013. Financiamiento y gasto en salud del Sistema de Salud en Perú.
 Hall, G., Patrinos, H. A., 2005. Pueblos indígenas, pobreza y desarrollo humano en América Latina: 1994-2004. B. Mundial (Ed.). Washington DC: Banco Mundial.
 David, M., Pachaly, J. and Vetter, K., 2006. Perinatal outcome in Berlin (Germany) among immigrants from Turkey. Archives of gynecology and obstetrics, 274(5), pp.271-278.
 World Health Organization, 2015. Tracking universal health coverage: first global monitoring report. World Health Organization.
World Bank, 2015. Nurses and midwives (per 1,000 people). [Online] Available at https://data.worldbank.org/indicator/SH.MED.NUMW.P3?end=2012&locations=DE-PE-DZ-CL-EE-FR-PA-SK-XN&start=1990 [Accessed: April 25th, 2018].
 Loytved, C. (2017). Außerklinische Geburtshilfe in Deutschland: Qualitätsbericht 2016. Verlag wissenschaftliche Scripten.
Zahl der Geburtsstationen in Krankenhäusern zurückgegangen Online] Available at: https://www.aerzteblatt.de/nachrichten/73192/Zahl-der-Geburtsstationen-in-Krankenhaeusern-zurueckgegangen [Accessed: May 7th, 2018].
 World Health Organization, 2016. Achieving the health-related MDGs. It takes a workforce. WHO, Geneva, February.
 Ministry of Health (MINSA) Información de recursos humanos en salud. Dirección General de Gestión del Desarrollo de Recursos Humanos. Lima: MINSA; 2015. p. 57.
 Brown, A., Malca, R., Zumaran, A. and Miranda, J.J., 2006. On the front line of primary health care: the profile of community health workers in rural Quechua communities in Peru. Human resources for health, 4(1), p.11.
 Suárez-Bustamante, M., Segura García, L. and Mendoza, R., 2000. Inequidad en el uso de los servicios de salud en niños y adultos de tres poblaciones rurales del Perú. Med. fam.(Caracas), 8(1/2), pp.6-13.
 Boesten, J., 2007. Free Choice or Poverty Alleviation? Population Politics in Peru under Alberto Fujimori. European Review of Latin American and Caribbean Studies, 82, p.3.
 del Aguila, E.V., 2006. Invisible women: Forced sterilization, reproductive rights, and structural inequalities in Peru of Fujimori and Toledo. Estudos e Pesquisas em Psicologia, 6(1), pp.109-124.
 Gabrysch, S., Lema, C., Bedriñana, E., Bautista, M.A., Malca, R., Campbell, O.M. and Miranda, J.J., 2009. Cultural Adaptation of birthing services in rural Ayacucho, Peru. Bulletin of the World Health Organization, 87(9), pp.724-729.
 Rifkin, S.B. 2010. Community Health Workers. In: Carrin, G., Buse, K., Heggenhougen, K. and Quah, S.R. Health systems policy, finance, and organization. Academic Press, pp. 381 – 390.
 World Health Organization, 2007. Community health workers: What do we know about them. Geneva: WHO Department of Human Resources for Health.
 Ministerio de Saluda, 2017. Minsa reconoce labor de los Agentes Comunitarios de Salud. Available at: http://www.minsa.gob.pe/?op=51¬a=16612 [Accessed: 20 April 2017].
 George, A.S., Mehra, V., Scott, K. and Sriram, V., 2015. Community participation in health systems research: a systematic review assessing the state of research, the nature of interventions involved and the features of engagement with communities. PLoS One, 10(10), p.e0141091.
 Razum, O., 2017. Refugee migration to Germany: did the health system show resilience? Oliver Razum. European Journal of Public Health, 27(suppl_3).
 Kapilashrami, A., Hill, S. and Meer, N., 2015. What can health inequalities researchers learn from an intersectionality perspective? Understanding social dynamics with an inter-categorical approach?. Social Theory & Health, 13(3-4), pp.288-307.
 Petrera, M., Valdivia, M., Jimenez, E. and Almeida, G., 2013. Equity in health and health care in Peru, 2004-2008. Revista Panamericana de Salud Pública, 33(2), pp.131-136.
Felicitas Schmidt is a medical doctor working in Pneumology and Infectious Diseases who recently graduated from Ludwig-Maximilian University Munich with practical experience in the US, Tanzania and Australia. Due to her strong interest in the social determinants of health and health inequalities, she studied a Master´s in Public Health and has been engaged in health care policy ever since her undergraduate degree in Philosophy, Politics and Economics at the Free University of Bolzano and the HEC Lausanne. This interest also led her to IGES Institute in Berlin and at the Weill Cornell College of Medicine in New York for research purposes. She is also an active member of the German Network of Young Professionals in Public Health and the Competence Network Public Health COVID-19. Angela Requena is an International Affairs and Interprofessional Healthcare Coordinator at the Peruvian University of Applied Sciences (UPC) with a background in oral health promotion programmes and leading positions in public health initiatives at the UPC. She obtained a Master’s degree in Public Health at the University of Edinburgh and has been engaged in interprofessional health care research ever since. Her unique training has led her to be keynote speaker for several non profit organisations in the USA and Peru. She plans on tackling healthcare inequalities from her position at UPC and continuing her work with nonprofit international organisations.