Bridging the cultural gap between modern and traditional providers to improve delivery care in Ecuad

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Bridging the cultural gap between modern and
traditional providers to improve delivery care in
Ecuador

• Jorge Hermida, Steve Harvey, Daniel Gonzalez,
  Genny Fuentes and Bernarda Salas
• The Health Care Improvement Project, HCI/URC
• Women Deliver Conference
• London, October 2007

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Place of birth by ethnic group
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Barriers to in-facility delivering

• Economic Free Maternity Law subsidizes cost of
  delivery care, but 28 of MOH facility users paid
  for services anyway, compared to more than 95 at
  private facilities
• Geographic Municipalities are mandated by law to
  provide transport for obstetric complications,
  but not widely implemented in practice
• Cultural Delivery care is deeply rooted in
  culture, two systems exist without links

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Reasons mother gave birth at home
Source ENDEMAIN 2004 n 697
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Positive aspects of giving birth at home
Source ENDEMAIN 2004 n 697
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What mother liked about health facility where she
delivered
Source ENDEMAIN 2004 n 2,065
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Aspects of care that need improvement
Source ENDEMAIN 2004 n 2,065
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Bridging the cultural gap to improve Delivery Care

• Hypotheses
• Hospital providers, community providers (TBAs),
  users representatives and local governments can
  work together and change the way delivery care is
  provided making it more culturally responsive,
  through a negotiation-action process
• Users will be more satisfied with delivery care
  after these changes
• Users will use more MOH facilities to deliver

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Design of the study
Intervention Hospitals Control hospitals
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Description of the intervention

• Workshop 1 (May 07)
• Understand how facilities TBAs and families
  provide delivery care
• Identify major cultural gaps
• Workshop 2 (July 07)
• Discuss and program major changes on main
  cultural gaps
• Workshop 3 (Nov. 07)
• Share experiences, discuss obstacles and ways to
  overcome those

• Action Period 1
• Communicate initiative to all providers and to as
  many users as possible at communities
• Meet and analyze cultural gaps
• Action Period 2
• Implement changes addressing resistance
• Action Period 3
• Implement new changes
• Gather more local support

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Processes being improved (first round)

• Allowing a member of the family or TBA to be
  present during delivery at hospital
• Role of TBA while in-hospital delivery intensely
  debated
• Mostly husbands participate during delivery
• Hospitals writing new rules
• Improve interpersonal relation between providers
  and users
• Meetings between hospital staff, TBAs and users
  not in the role of patients
• Workshops for hospital staff including rights of
  patients

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Processes being improved (first round)

• New role for TBAs in the district
• Accreditation based on community recognition
• Training on identifying obstetric/newborn
  complications and referral
• Clothing, keeping temperature warm
• Delivering women allowed to keep their clothes on
• New thermal blankets, space heaters
• Delivering women are given warm traditional herb
  teas during/after delivery
• Eliminating bathing before delivery
• Disseminating information about changes and
  rights of users

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First workshop
Second workshop
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Acknowledgements

• For more information, contact Dr. Jorge Hermida
  jhermida_at_urc-chs.com
• This work was supported by the U.S. Agency for
  International Development (USAID) through the
  Quality Assurance Project (Contract No. Number
  GPH-C-00-02-00004-00) and the Health Care
  Improvement Project (Contract No.
  GHN-I-00-07-00003), both managed by University
  Research Co., LLC (URC).