Preventing Maternal Deaths by Improving the Cultural Acceptability of Obstetrical Care

A Traditional Birth Attendant (TBA) demonstrates culturally appropriate newborn care after a home-based birth.

Each year, more than 500,000 women die from childbirth-related causes, primarily from obstetric complications, such as hemorrhage, sepsis, eclampsia, and obstructed labor.

Many of these deaths could be prevented if all women had access to good quality obstetric care. But even when health facilities that provide maternity care are physically accessible, in many places, they are unable to respond effectively to emergency situations and frequently provide poor quality care. Another barrier is that formal maternal services are culturally unacceptable to some women and their families, either because they feel they are not treated with respect or because services do not take into account cultural traditions.

Since 2003, QAP has supported an innovative approach to systematically address the underlying causes of preventable maternal deaths in Latin America using the improvement collaborative methodology pioneered in the United States. The Latin American Essential Obstetric Care (EOC) Improvement Collaborative is linking teams in over a dozen local health areas in Ecuador, Honduras, and Nicaragua in a coordinated effort to implement recognized best practices in maternal care at all levels of the health system, from referral hospitals to the community level.

In Ecuador, 12 hospitals and 8 healthcare centers serving a population of 1,143,600 across three provinces are participating in the collaborative. Quality improvement teams made up of Ministry of Health staff carry out targeted improvement activities, tracking their progress each month, and sharing their interventions and results with other teams.

In this role-play of a home birth, the woman in labor (red jacket) drinks an herbal tea to speed contractions. Family members assist her.

During the first year of improvement efforts, most teams in Ecuador focused on improving clinical care processes and establishing in-service training mechanisms to upgrade provider competency. Now that data show clear improvements in clinical care, the teams are shifting focus to other needed changes to increase communities’ access to and utilization of EOC services: cultural adaptation of services with participation of clients and community groups and community mobilization activities.

National health authorities leading the collaborative in Ecuador have initiated a series of workshops to bring together EOC providers, users committee representatives (users committees are groups of community representatives established under the Ecuadorian free maternity law), traditional midwives, and local government officials to analyze the barriers to cultural acceptability of obstetric care and then propose and monitor changes to how care is provided at local health facilities.

In a home-based birth role play, the mother takes the traditional squatting position, assisted by her "husband" and the TBA who receives the newborn from behind.

The first workshop was held on February 4, 2005 in Tungurahua Province involving health personnel, traditional birth attendants, and women representing communities. The meeting, coordinated by Family Care International in collaboration with QAP, was intended to test an approach to negotiating client participation in essential obstetric care quality improvement efforts, especially efforts directed at improving the cultural acceptability of services to users.

About 50 participants representing all different sectors of the community engaged in role-plays of both home-based and hospital-based births, illustrating the importance of different issues to different stakeholders. The role-plays led to a productive interchange between formal health workers and traditional midwives in which each side explained to the other their reasons for carrying out certain activities or procedures. The group then listed activities or practices important to an ideal birth and began a discussion of potential cultural adaptations that would make facility-based delivery more attractive to community women and their families. This discussion will lead to a second meeting in early March where the various stakeholders will develop suggestions about specific changes in facility-based care. These changes will be tested in a series of rapid improvement cycles over a period of 2-3 months and then evaluated by participants in a third meeting.

The changes in facility-based care emerging from these meetings will serve as a potential model for addressing the cultural adaptation and demand generation components of the EOC Collaborative in Ecuador, Honduras, and Nicaragua.

For more information on the Latin American EOC Improvement Collaborative, contact Dr. Jorge Hermida at drhermida@yahoo.com.