Background
Maternal mortality continues to be an important public health issue that illustrates profound social inequities in poor and middle income countries [
1]. Mexico has undertaken important efforts in recent years to decrease maternal mortality [
2,
3]. However, Mexico did not reach the Millenium Development Goal of reducing the maternal mortality ratio by three-quarters. The current maternal mortality ratio is 38.3 per 100,000 live births and the country faces major challenges in order to achieve strong results related to the sustainable development goals (SDG) in this indicator [
4,
5]. The problem continues to be one of the primary expressions of health inequity, particularly among highly vulnerable groups such as the indigenous population [
3]. Among indigenous women, four levels of vulnerability are manifested: poverty, ethnic discrimination, gender discrimination and geographic inaccessibility to health services [
6].
Chiapas is among the states of Mexico with highest concentration of indigenous population (27.2 % of the total) and with 32.5 % not speaking Spanish [
7]. In 2012, Chiapas reported a maternal mortality ratio (MMR) of 59.8 per 100,000 live births, 40 % above the average and the third highest in the country [
4].
To change these indicators, health policies have been designed to increase access to and utilization of health services, particularly professional care related to labor and delivery, and obstetric emergencies [
2]. These efforts have been specifically focused on the poorest municipalities of the country with an emphasis on indigenous regions [
2]. As a result, the percentage of labor and delivery care provided by qualified personnel in Chiapas has increased from 42 % in 2007–55 % in 2011 [
8]. However, this increase has failed to meet the goal of 92 % of professional delivery care established by national authorities in the 2007–2012 health sector programs [
8].
Health authorities in Chiapas have introduced intercultural innovations to address barriers faced by indigenous women accessing professional maternal and delivery services [
9]. More specifically, providers’ capacity has been strengthened to offer vertical birthing as an alternative to the horizontal position, as well as to incorporate symbolic elements and traditional interventions such as crosses or
temascal the traditional steam bath with medicinal herbs [
9]. The inclusion of trained traditional birth attendants (TBAs) into the institutional prenatal and delivery care process has been strengthened, giving them also a role to promote health service access [
9]. One such initiative has been the construction of
Casas Maternas (Maternity Homes in English, hereafter referred to as CM) adjacent to health centers that offer expanded services or basic hospitals centers [
10]. The objective of the CM is for women to be able to receive labor and delivery care in accordance with their preference, in the birthing position they choose, attended to by TBAs, with the support of their family and ritual or symbolic elements from their own culture in settings with adequate hygienic conditions and timely access to effective medical assistance in the event of any complications [
10]. One of these CM was established in 2010 [
11] in the municipality of San Andrés Larráinzar, adjacent to the local basic hospital.
Evidence suggest that in spite of intercultural innovations, a significant number of women and their family members (husband, mother-in-law, mother, father) decide to not seek care at the health center for labor and delivery, and instead decide to receive care in their homes by TBAs or family members. Among the primary reasons for this preference is the husband’s negative perception of his wife being observed and probed by male health workers. This barrier to care stems from stereotypes of western doctors and hospital, the perception of discriminatory attitudes and treatment, shame related to nudity and genitals touched by strangers, the distance between their communities and the health centers, and economic limitations [
12‐
14].
Intercultural innovations can thus play a critical role to facilitate access to professional maternal and delivery services. Studies on the determinants of successful implementation of innovations in health has highlighted the understanding of innovation characteristics, the receptivity and support offered by the internal and external contexts where innovations are implemented, as well as the definition and understanding of roles played by actors and processes during implementation [
15]. This article describes the perceptions of indigenous users and non-users and of traditional birth attendants concerning facilitating and obstructing factors in the implementation of intercultural maternal health innovations. Research focused on the characteristics of the innovations and the internal context from the perspective of users as key actors in implementation. The innovations were analyzed from the perspective of the perceived quality and acceptability of medical services offered at the CM and the basic community hospital. The internal context was addressed by analyzing perceptions on the conditions related to availability and accessibility, and on the determinants of utilization.
Discussion
This study permitted the exploration of the perceptions of indigenous women from the Chiapas highlands regarding the barriers and facilitators for the effectiveness of intercultural innovations in the internal context of health services where they were implemented. Labor and delivery services in the health sector institutions, particularly in the Casa Materna and Basic Community Hospital of San Andrés Larráinzar were compared to services provided by TBAs in their home communities. Important limitations of this study were the observation of a single hospital and CM, the reduced number of women interviewed as well as the need to rely on a trained translator. The findings should therefore be treated with some care, although results show a high degree of external validity.
The evidence presented suggests that from the perspective of indigenous women, the difficulty of communicating with health institution personnel is one of the primary barriers to service utilization, given that the majority of medical personal at health centers do not speak the same language as the indigenous users. Intercultural innovations have had limited impact in improving communication. According to Sachse et al. [
14], health services should hire personnel who speak the local communities’ language to serve as translators for the women during care. However, having personnel who speak the local communities’ language is not sufficient. Based on findings from Nazar et al. [
26] the participation of translators who do not share a bio-medical orientation does not guarantee the correct transmission of information given by the doctors to women, or in the case of requiring great precision of information, those individuals are unable to provide such precision. As such, not only should institutions have personnel that are able to communicate with users in their native language, it is also necessary to guarantee that the information given maintains the accuracy intended by the doctors.
In addition to language problems, indigenous women in Chiapas face economic limitations to accessing health services related to more than their transportation. The cost of food and transportation for family members that accompany the women to the hospital must also be considered. Intercultural innovations were not designed to help overcome the economic barriers. Several authors report findings coinciding with those found in our study, signaling that one of the primary reasons women do not seek care at institutional health services is due to lack of economic resources; they must consider not only their own expenses but also those of accompanying family members because these women do not seek health services alone [
26,
27].
Another important element evidenced by the current study is that it appears that medical personnel are not always available at the health institutions, and as such the women fear seeking services and finding that personnel are absent. Intercultural innovations are likely to fail if their professional component is not consistently delivered and co-ordinated with the indigenous component. The literature documents that at the national level the absence of personnel in medical units is frequent, with higher intensity of absence on the night shift and during the weekend [
26].
These factors may explain findings of others studies showing that health services utilization and coverage of interventions during pregnancy, delivery and postpartum are lowest among indigenous women in Mexico. For example, a study conducted with responses from 5766 women from the 2012 National Health and Nutrition Survey demonstrated gaps in the continuum of care during pregnancy and delivery in Mexico among indigenous women (0.759; CI95 %: 0.740–0.779) vs. 0.831 [0.823–0.838] in non indigenous women [
28]. Additionally, previous studies had found that coverage of adequate antenatal care (timely, frequent and complete care) is lower among indigenous (59 %, CI:53;65) than non-indigenous (68 %, CI:66;70) women [
29].
A finding that we should pay particular attention to is that indigenous women, specifically non-users of health services during delivery, only identified the need to seek health services in the event of a complication. Intercultural innovation failed to place emphasis on the need for prevention within a continuum of care. For health system performance, it is desirable for women to seek services at health institutions in a timely manner, even when there are no evident complications. Previous research, such as that conducted by Freyermuth et al. [
30], show evidence of increased risk of fatal outcomes in labor and delivery services delivered outside of health institutions, given that warning signs during birth were not identified by women or their family members. These arguments provide the basis for the efforts on behalf of the health sector to increase awareness among the population that labor and delivery services should be provided by qualified personnel to minimize risk.
The lack of trust in health institutions is another one of the reasons reported by interviewees for not utilizing health services. Our findings suggest intercultural innovations have increased trust in professional services, although with limitations. These findings coincide with those reported by Sánchez Pérez, et al. [
15], which found that lack of trust by women of health service providers was due to either the majority being men, or because the biomedical practices were not aligned with their customs. Such evidence was also illustrated by Valdez et al. [
31], suggesting that routine medical practices could affect labor and delivery service utilization, and not only among indigenous women.
According to Valdez et al. [
31], the maneuvers most frequently conducted during labor in institutional settings include vaginal examination, episiotomy, catheter insertion, enema and administering oxytocin infusions among others, which have been demonstrated to be unnecessary during labor. While our results did not address the need for interventions, it is clear that intercultural services should pay special attention to curbing unneeded interventions, which may harm trust even if the risk of harming patients is minimal The indigenous women interviewed mentioned their discomfort during different routine medical maneuvers that are practiced with them while receiving labor and delivery care at the health centers. As such, women experience cultural shock while receiving labor and delivery services due to the procedures and practices conducted without taking into account their beliefs, traditions and needs (for example, excessive use of instruments, IDU placement, undressing, using a language they are not fluent in, being alone, being seen by male personnel) [
32].
Intercultural innovations failed to lift restriction on family members or TBAs being allowed into hospital facilities during labor. Women expressed the fear this hospital practice provokes. It has been documented that women suffer from anxiety, uncertainty and fear when seeking services at medical facilities due to facing a model of care that does not permit their family members of partners to remain close by, as opposed to care delivered at home where they can count on family accompaniment [
33,
34]. Based on the testimonials collected during this study, women express feeling more secure, supported and calm with the presence of a family member while receiving services.
An important aspect to consider is the women’s identification of TBA services and their preference for being seen by a member of the same sex during labor, and moreover someone they can identify with culturally [
26,
30]. Intercultural innovations failed to ensure that women doctors and nurses are charged with routine examinations. The basis for these preferences has been previously documented. The TBAs carry out important activities in regards to services for pregnant women, and many times their participation goes beyond labor and delivery care. They enact a symbolic role and provide not only physical care but social, spiritual care and trustworthy services based on the close familiar relationship that is perceived [
33,
35].
The results of this study suggest the persistence of important limitations of institutional health services and intercultural innovations to attract indigenous women and encourage their utilization of services in an event as transformative as birth, from the context of the implementation of a policy of multiculturalism in the state. Women reported what would be violations of reproductive rights and the right to a safe motherhood. Evidence of this is the reported insertion of an IUD without previous consent, repeated vaginal examinations without informing the women about the need for such a procedure, limited access to information due to the unavailability of personnel who speak the local language [
21,
31].
As it stands, biomedical practices and efforts to introduce intercultural innovations in health institutions may be reproducing a model of cultural incompetence that leads to the reduction, discrimination and exclusion of cultural minority groups, who additionally may be at a disadvantage [
36,
37]. It is necessary to strengthen the capacity of the health system and review strategies that have been implemented with the aim of successfully incorporating practices with an intercultural focus for labor and delivery.
The Integrated Strategy to Accelerate the Reduction of Maternal Mortality in Mexico, which allows the incorporation of TBAs into health institutions, should be strengthened [
2]. Based on this study’s findings, and considering the body of knowledge it is contributing to, TBAs associated with health services encounter medical hegemony and find themselves in subordinate positions with health professionals [
38,
39]. Our results coincide with what other authors have described, that currently implemented policies in fact reproduce vertical models and frameworks, relationships of power-subordination among providers, etc. and are not reflective of models that fully integrate an intercultural vision [
40]. Current policies only go so far as to promote the restructing of labor and delivery care for women, but without identifying pathways or processes for actually changing the practices that over-medicalize labor and delivery services in health institutions.
An example of how the Mexican health systems should respond to these findings may be the implementation and/or strengthening of the Project Casa de la Mujer Indígena or
Casas Model [
41] an initiative that brings together the local indigenous community, civil society organizations (NGO’s) and public institutions, in order to create a physical space to improve health care and patient satisfaction among indigenous women. This initiative intents to bridge the cultural distance between institutionalized, hegemonic forms of health care and indigenous forms of understanding and tending to health – especially reproductive health– within each community. Previous studies had identified some limitations and opportunity for improvement in this model. According to Pelcastre's evaluation [
41], the model may be strengthened through the following elements: community ownership and participation; inter-agency partnership and networks; budget oversight and external advisor or advisory board, responsible for supporting training activities and generating applicable evaluation and research agendas [
41].
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MAGB participated in the design of the study and in field-work co-ordination. MIC, IBHP participated in the analysis and interpretation of data, drafting and revising the manuscript and has given final approval. SMN, BPV and MAGB involved in revising the manuscript and gave final approval. All authors read and approved the final manuscript.