deaths per 1,000 live births) reflect the isolation and poverty of these people (Howard-Grabman, Seoane, and Davenport, 1993). Women with complications would have to be referred to La Paz or Oruro, the two closest cities, which takes 4 to 6 hours over difficult roads. Traditional birth attendants do not exist, although traditional healers are sometimes consulted when complications arise. Husbands are the main providers of assistance in labor and delivery.

A simple model for community-level problem solving was implemented, consisting of four steps:

  1. identification and prioritization of maternal and neonatal health problems ("auto-diagnosis") by 50 women's groups;

  2. development of strategies and actions to solve the problems by the women's groups and members of their communities and local authorities;

  3. implementation of the groups' plans which involved: training 45 parteras (empirical midwives); educating both women and men in management of hemorrhage; providing family planning services in seven communities in collaboration with a local nongovernmental organization; developing and distributing a home-based women's health card, a manual for parteras, four booklets for women on reproductive health and five radio programs with a local nongovernmental organization;

  4. participatory evaluation.

Over one-half of women in the 52 communities participated in this process between 1991 and 1993. As they and their families became more involved, health practices and service utilization changed: tetanus toxoid immunization coverage, iron tablet distribution, immediate breastfeeding, consumption of iodized salt, prenatal and postnatal care visits, and the number of women attended by a trained birth attendant increased.

The intervention was evaluated using a pre- and postintervention treatment and comparison-area design, with data collected from a village-based information system. The most striking result was a reduction in the number of perinatal deaths, from 75 to 31 deaths over a 2-year period. This decrease was likely due to more immediate neonatal care. For each delivery, a person was designated to take responsibility for drying and warming the child before the placenta was delivered and placing the baby on the mother's breast within the first hour of life. (Previously, the newborn baby was set aside until after delivery of the placenta.) Use of modern contraceptives rose from 0 to 27 percent, reflecting that several of the groups had identified "too many children" as their main health concern (Howard-Grabman, Seoane, and Davenport, 1993).

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