Background: In Ecuador, indigenous women have poorer maternal health outcomes and access to maternity services. This is partly due to cultural barriers. A hospital in Ecuador implemented the Vertical Birth (VB) policy to address such inequities by adapting services to the local culture. This included conducting upright deliveries, introducing Traditional Birth Attendants (TBAs) and making physical adaptations to hospital facilities. Methods: Using qualitative methods, we studied the VB policy implementation in an Ecuadorian hospital to analyse the factors that affect effective implementation of intercultural health policies at the local level. We collected data through observation, in-depth interviews, a focus group discussion, and documentation review. We conducted 46 interviews with healthcare workers, managers, TBAs, key informants and policy-makers involved in maternal health. Data analysis was guided by grounded theory and drew heavily on concepts of “street-level bureaucracy” to interpret policy implementation. Results: The VB policy was highly controversial; actors’ values (including concerns over patient safety) motivated their support or opposition to the Vertical Birth policy. For those who supported the policy, managers, policy-makers, indigenous actors and a minority of healthcare workers supported the policy, it was critical to address ethnic discrimination to improve indigenous women’s access to the health service. Most healthcare workers initially resisted the policy because they believed vertical births led to poorer clinical outcomes and because they resented working alongside TBAs. Healthcare workers developed coping strategies and effectively modified the policy. Managers accepted these as a compromise to enable implementation. Conclusions: Although contentious, intercultural health policies such as the VB policy have the potential to improve maternity services and access for indigenous women. Evidence-base medicine should be used as a lever to facilitate the dialogue between healthcare workers and TBAs and to promote best practice and patient safety. Actors’ values influenced policy implementation; policy implementation resulted from an ongoing negotiation between healthcare workers and managers. Keywords: Health policy, Maternal health, Indigenous health, Intercultural health, Policy implementation * Correspondence: Ana.LlamasMontoya@lshtm.ac.uk London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock place, London WC1H 9SH, UK © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Llamas and Mayhew BMC Public Health (2018) 18:686 Page 2 of 10 Background Ecuador, there is little research thus far on the processes Ecuador is making progress towards improving maternal or impact of these policies. The few studies that have health  although significant disparities remain between been conducted show mixed results. In Peru following different ethnic groups [15, 36]. Data are not routinely dis- the introduction of a similar policy to the VB policy and aggregated by ethnic origin but some reports show that changes to strengthen health services, research found a Maternal Mortality Rate (MMR) is higher among indigen- sharp increase in facility deliveries  and met need for ous women (117 per 1000,000 live births) than white emergency obstetric care . Research in other Latin women (45 per 100,000 live births) [36, 38]. Process indi- American countries has found that potential health gains cators confirm ethnic inequities in reproductive health; for are compromised by implementation constraints due to example, the use of institutional delivery and skilled birth tensions between HWs and TBAs, and lack of commu- attendants, two key indicators in maternal survival , nity involvement [43, 44, 46, 47]. are significantly lower amongst indigenous women com- pared with non-indigenous women [8, 9]. Methods Traditionally, indigenous women in the study setting Theoretical framework have given birth at home, looked after by Traditional The policy implementation literature shows that ten- Birth Attendants (TBAs) who provided one-to-one re- sions among policy actors influence how policies are im- spectful care throughout pregnancy and postnatal period plemented. Lipsky contends that the gap between what . Other researchers have reported similar poor expe- policies set out to achieve and what happens in practice riences of maternity services among indigenous women, results because frontline providers exercise discretion in who feel discriminated against and find maternity ser- the way they implement, or ignore, policies, developing vices unacceptable due to the lack of quality of care, and coping mechanisms to deal with difficult implementa- respect for their culture and birthing practices [3, 7, 34]. tion environments. In this way, policy is effectively As a result of disparities in health outcomes and indi- re-interpreted and such modifications may render the genous women’s poor experiences in health services, best intentioned policies ineffective . Given the role there are persistent calls to make health services respon- of actors in policy implementation, we drew on “Street sive to the particular needs of indigenous women [8, 9, level bureaucracy” theory to guide our study . This 19, 28, 30, 33, 38]. Across Latin America countries are article explores the implementation of the VB policy in developing intercultural health policies which encom- an Ecuadorian hospital to analyse the factors that affect pass both indigenous traditional and western medicine effective implementation of intercultural health policies and aim to increase access to services and reduce ethnic at the local level. health inequities [31, 32]. In our study setting, the local hospital implemented Study setting one such policy, the Vertical Birth (VB) policy, which in- The hospital where the study took place provides emer- volved building a room adjacent to the labour ward re- gency and short-stay outpatient and inpatient care in gy- sembling an indigenous house and a maternity waiting naecology and obstetrics, general medicine, paediatrics house. The room was equipped with ropes and bars that and general surgery. This hospital is located in a small allowed women to adopt vertical or upright positions town in the Ecuadorian Andes where 53% of the popula- during delivery, which was considered a critical factor in tion are indigenous and 48% are mestizo . A signifi- traditional indigenous birth practices. Efforts were made cant number of people, mostly indigenous people, do to maintain women’s modesty by providing them with not have a formal employment but work in family busi- appropriate gowns and installing curtains in the dilata- ness manufacturing and marketing traditional handcrafts tion room. Women were allowed to eat and drink during .This has made this town relatively prosperous and it labour, choose their birthing position and have a birth is argued that indigenous people have managed to lift companion. Early breastfeeding and bonding with the themselves out of poverty without losing their cultural neonate were promoted. In addition, healthcare workers identity (Hurtado in ). This area has also been iden- (HWs) received lessons in Kichwa (the local indigenous tified as the ‘intellectual cradle’ of the Ecuadorian indi- language), indigenous culture and training on clinical is- genous movement which was one of the strongest in sues such as delivering women in upright positions. Latin America  and was critical in the emergence of TBAs were also incorporated into the labour ward. The the VB policy . TBAs’ role was to support women and provide trad- itional care (e.g. massage, herbal remedies) throughout Data collection labour in collaboration with health professionals . This research adopted a qualitative methodology and In spite of the growing popularity of intercultural drew on the experiences and perspectives of actors in- health policies and the roll-out of the VB policy across volved in maternal health services in a local hospital in Llamas and Mayhew BMC Public Health (2018) 18:686 Page 3 of 10 Ecuador. The principal investigator (AL) collected data different themes to understand and interpret the VB pol- from October 2009 to December 2010 (18 months after icy implementation. We then carried out a comparative the VB was first implemented) through in-depth inter- analysis of respondents’ accounts and looked for diver- views. Interviews were conducted in Spanish by AL, a gent cases to refine our analysis [16, 42]. Data derived native speaker, and lasted 60 min on average. from different methods of data collection were then tri- Forty six respondents were selected for in-depth inter- angulated as a way of clarifying conflicting information, views using theoretical sampling and snowballing until providing a fuller picture of the research problem [41, saturation was reached and efforts were made to ensure 45] and enhancing reflexivity . We also drew heavily the sample included respondents with different profes- on street-level bureaucracy theory to interpret the VB sional role, seniority, place of work, views on the VB pol- policy implementation. The data excerpts selected here icy, gender, and ethnic group. The sample included are used to illustrate typical findings and/or eloquent ex- respondents working at the local hospital and surround- planations of the phenomena studied . ing primary health clinics as well as respondents work- ing at the provincial and national level (Table 1). Ethics approval and consent to participate Respondents were interviewed in places where confiden- The main study received ethical approval from the ethics tiality could be maintained. Interviews were digitally re- committee at the London School of Hygiene & Tropical corded and transcribed. One respondent declined to be Medicine and in Ecuador was approved by the ethics recorded and detailed notes were taken instead. committee of the Universidad of Otavalo and other During fieldwork AL conducted participant observa- stakeholders, including the hospital directorate. Respon- tion too, which was carried out in the local hospital, a dents were given information about the research and primary health clinic (PHC) clinic and an NGO clinic as verbal or written consent was obtained prior to each well as during social events with community members interview. Interviews were digitally recorded when and HWs. Data were also collected during a focus-group respondents consented; otherwise, detailed notes were discussion with policy-makers, HWs, managers and indi- taken. genous community leaders that AL attended as an observer. In addition, detailed field notes were taken and Results relevant documents collected for analysis. Documents A number of important issues emerged from the data and field notes were used to inform interview guides, regarding how the VB policy was negotiated and imple- triangulate results and contextualise findings. mented in the hospital. First we describe the interpreta- tions of the VB policy that different actors held. Next we Data analysis explore the tensions between western and indigenous AL coded and managed the data using Nvivo 8 and ana- medical models of care, particularly the involvement of lysed it manually in Spanish. Quotations were translated TBAs in hospitals. Finally, in the light of findings on in- by AL who is bilingual. Data analysis took place in two terpretations and tensions we analyse the negotiations stages. During fieldwork we used elements of grounded around policy implementation itself. theory; we took an iterative approach between data col- lection and analysis and we used inductive and deductive Actors’ interpretations of the VB policy methods simultaneously [13, 16, 41]. Once data collec- For indigenous respondents, regardless of their profes- tion ended, we focused on analysing interview tran- sional role as HWs, managers, policy-makers, TBAs or scripts and field notes. We identified and described the community leaders, the VB policy was an expression of key elements of respondents’ accounts. We compared traditional medicine and as such a core element of their and looked for relationships and associations between indigenous ethnic identity. Indigenous respondents stated Table 1 Respondents interviewed by place of work and ethnic background Respondent Place of work Ethnic background Local hospital PHC clinics Others Indigenous/Mestizo HCWs 13 6 0 0/19 Community leaders & key informants 7 6/1 Managers 4 4 4 3/9 TBAs 4 4/0 Policy-makers 4 1/3 Total 21 10 15 14/32 Llamas and Mayhew BMC Public Health (2018) 18:686 Page 4 of 10 that the VB policy implementation in the maternity de- having a VB. Complications included post-partum haem- partment of a public hospital was an achievement of the orrhage resulting from an increase in vaginal tears and indigenous movement because, after years of struggle, the incomplete delivery of the placenta; an increase of dilata- State was starting to recognise traditional medicine as a tion and curettage (D&C) procedures; lack of asepsia, as valid medical system. The VB policy implementation was HWs could not keep a sterile field because women con- referred to by indigenous respondents as an opportunity stantly moved and contaminated the fields with excre- to strengthen traditional medicine and indigenous identity ments when they pushed, and the impossibility to as well as to advance indigenous right to health; ultim- perform episiotomies which they used to expedite or fa- ately, the VB policy meant a more equitable relationship cilitate delivery and avoid vaginal tears, particularly in between mestizo and indigenous culture. first-time mothers (primiparous). Interview and observa- tion data suggest that these complications may have For our community the vertical birth has been a been caused by the way in which HWs managed upright thousand-year-old tradition but western medicine did deliveries. As some HWs pointed out: not recognise it. They said that it damaged women’s health, that the vertical birth was very bad... Yet, we At the beginning [of the VB implementation], perhaps say that what [health professionals] do in hospitals is because we were not very experienced, there was an bad because they maltreat babies and women and they increased incidence of vaginal tears amongst women don’t provide adequate care (...). Now, the Ministry of who had a vertical birth, there were more D&C Health has recognised an alternative medical system because there were retained placentas (Mestizo HW). and for us it is very important because it shows that we are making advances in achieving our right to Furthermore, HWs stated that they lacked resources health. (Community leader, Indigenous). to deal with potential complications, chiefly uninter- rupted access to theatre, and qualified staff to monitor Managers and policy-makers emphasised the current labouring women. Therefore, HWs concluded that the legal and policy framework that supported the VB policy VB was most suitable for low-risk women and women and contrasted past and present health policy: Ecuador who had more than one child (multiparous women) and had gone through a “dark neoliberal process”, as one advised high-risk women (e.g. primiparous, slow labour) policy-maker put it, in which citizens’ rights were not to have a lithotomy birth. guaranteed. The new Constitution passed in 2008 meant Apart from TBAs and managers, only two HWs spon- a break from the past as the State recognised its respon- taneously stated that upright birthing positions brought sibility to fulfil citizens’ right to health and intercultural- significant clinical benefits for the labouring woman. lity as an overarching principle to inform health policy. These respondents had experience with VBs during their Whilst HWs also supported the VB policy goal, it early careers working in indigenous communities and brought into focus tensions between western and trad- were sensitive to the plight of indigenous women. One itional medicine which led, initially, to considerable op- of them reported that she supported the VB policy pre- position. Most HWs were concerned about the clinical cisely because of its clinical benefits. implications they attributed to the VB policy and the introduction of TBAs in the maternity department. How would we, as health professionals, be involved in something that we thought was bad Tensions between western and traditional medicine for patients? But we thought it was good for Clinical complications attributed to the VB policy [patients], we saw cases of breech presentation Based on their initial experiences, HWs consistently re- in which the woman would stand up and delivered ported that VB deliveries carried more risks than births easily. Then, how could I not support it? (Mestizo in lithotomy position (with the patient lying on her back HW). with her knees flexed and thighs apart). Several HWs ar- gued that they never learned to conduct upright deliver- ies during their undergraduate training and that the Articulating traditional medicine and biomedicine doctor hired to train them up was incompetent. As these Of all the changes brought about by the VB policy, re- HWs explained, they observed how the trainer practised spondents’ accounts indicate that the most controversial and they attributed the increase in obstetric complica- one was the integration of TBAs on the labour ward tions to his poor aseptic technique. HWs thus felt un- which brought into focus tensions between traditional able to conduct VBs safely. HWs recalled how during medicine and biomedicine. the early implementation period there were various ob- TBAs and indigenous respondents (health managers stetric near-misses and neonatal deaths amongst women and policy-makers) emphasised that TBAs’ role was to Llamas and Mayhew BMC Public Health (2018) 18:686 Page 5 of 10 link the community and the hospital, advocate for implies that they can’t carry out their normal work... women and protect them from HWs’ discrimination. This is an understandable position but it becomes a barrier to accept a life-saving treatment. The TBA told There is still discrimination in the [hospital], there are this woman ‘I can do a manteo’... [the patient] came still HWs that don’t agree with TBAs and women who back five hours later which was lethal for the baby want a vertical birth. I recently had a problem with a (Mestizo HW). nurse. The nurse was very rude to a patient; she was shouting at the patient: ‘that’s what [labour] is like, let Some doctors and midwives also resented working me sleep!’. I stood next to the patient, I didn’t leave alongside TBAs because they felt their skills, acquired her side. [The patient] told me: ‘Thank God you are through long years of study and work, were being lev- here!’ and I said: ‘We need to get through this; I’m not elled to those of unqualified and unskilled practitioners. leaving your side’. I didn’t leave [the patient] until she delivered. I also told the nurse: ‘the patient is getting I respect TBAs but they don’t follow guidelines on upset’ and the nurse answered: ‘I’m not a bad person, asepsia. Then, why did we build a hospital? Why did I’m just explaining to her how things are.’ (TBA). we study eight, nine or even twelve years to become specialists? A hospital should be the cleanest place, Many HWs equated TBAs and traditional medicine particularly in theatre or the delivery room, everything with the VB and referred to them all as unscientific, po- is disinfected and then someone from the street, tentially dangerous, obsolete and opposed to modern wearing street clothes comes and touches medical biomedicine. instruments. What are we talking about? So, it’s five-hundred years of medicine gone to waste; it’s We can’t say that TBAs are right because they useless! (Mestizo HW). practise according to their traditions, because we have science and science is based on evidence. In spite of the criticisms that HWs levelled against (Mestizo HW). TBAs, many HWs also identified several ways in which TBAs contributed to patient care. HWs, even those who HWs stated that since they were ultimately account- did not fully support TBAs presence in the hospital, able for patients’ outcomes, it was their role to make stated that they valued some TBAs skills such as giving clinical decision; TBAs should not conduct deliveries in massages, herbal remedies, the emotional support given hospital and should be supervised by them. Further, to labouring women, their knowledge about homebirths HWs believed that TBAs’ role should be limited to those and their ability to rotate foetuses in very specific cases. aspects that they considered positive, such as linking the However, HWs said that TBAs’ most important contri- hospital and the community and supporting women in bution was linking the hospital and community and that labour. A minority of HWs added that TBAs should not the presence of TBAs increased indigenous women’s be in hospital at all and that TBAs were only appropriate trust in the hospital. in rural areas where there was no access to medical care. According to HWs, TBAs sometimes compromised pa- I think TBAs play an important role, we could have tient care by contaminating sterile areas as TBAs were even avoided the maternal death we had because not familiar with aseptic techniques or gave women con- [indigenous women] don’t come for fear of the flicting advice which could result in delaying emergency hospital and doctors... but if [indigenous women] see obstetric care and poor outcomes. a TBA they feel more confident. (Mestizo HW). A HW recalled the case of a woman whose baby was breech and was advised by her doctor to have a caesar- ean section. The TBA however advised against it; she Negotiating the VB policy implementation did a ‘manteo’ (tossing the patient in a blanket to turn At the time of data collection, the VB policy was re- the baby from breech into cephalic position) so the pa- ported by respondents to be an “established” and “suc- tient could have a vaginal delivery. The patient then left cessful” policy but our findings indicate that the initial the hospital and returned after a few hours with the baby stages of implementation were marked by intense con- partially delivered; the baby’s head had got stuck in the flict within the team. Managers, who supported the VB birth canal and had died. Reflecting on this case, the policy provided training and resources for clinical (e.g. HW stated that: upright delivery techniques) and non-clinical (e.g. inter- personal skills) components. They also capitalised on the [Indigenous women] think that the best is to have a support of political figures and institutions and made vaginal delivery because having a caesarean section use of incentives (e.g. praising and extending contracts Llamas and Mayhew BMC Public Health (2018) 18:686 Page 6 of 10 supporters of the VB policy) and sanctions (e.g. firing respondent pointed out, the objective was to discredit and side-lining detractors of the VB policy) to enforce the trainer and therefore, the VB policy. implementation. Despite power discrepancies, HWs VB supporters manipulated quantitative data too: a found creative strategies to resist or compromise the HW who was involved in various obstetric emergencies VB policy though managers ultimately succeeded in of women having VBs expressed her disbelief when man- enforcing implementation as they were more powerful agers produced a report in which no obstetric complica- than HWs. tions from VB policy were reported. Managers argued that a random sample of three cases had been se- lected but the number of cases (n =50) was so small Capitalising on political and institutional support that the entire sample could have been taken accord- Those respondents who backed the VB policy explained ing to this HW. that the unwavering support given by political and MOH authorities at the national and local level was one [The report results] were not true, there were lots of of the main factors that enabled implementation. To re- complications. Why don’t [managers] tell the truth? spondents, this support was evidenced by the various (...) [Managers] tried to make it look as if the VB was visits that the Minister of Health herself and other senior wonderful but it wasn’t true, at the beginning it was MOH officials made to the hospital. The VB policy was very difficult. (Mestizo HW). firmly supported by the United Nations Population Fund (UNFPA), the local government and the indigenous The uptake of VBs amongst patients was another issue community. The role of these actors in the VB policy is raised by supporters and detractors to shape perceptions explored in detail elsewhere . The hospital manage- of the VB policy. For example, supporters portrayed the ment team, led by an indigenous doctor as hospital VB policy as a success because they claimed it had re- director, was very committed to the VB policy. As imple- sulted in a 9% increase in access to hospital maternity mentation progressed, the VB policy gained supporters services, mostly indigenous women from rural areas. within the hospital. Elaborating on this a manager said: However, hospital data were not routinely disaggregated by ethnic origin or place of residence. Furthermore, hos- When the opposition [to the VB policy] got too pital data show that the number of hospital deliveries strong, it was made clear [to those who opposed the followed an upward trend since at least 2004 and that VB policy] that the hospital director was not alone; the increase in use of hospital services was mirrored by his decisions were supported by the [indigenous other specialities where intercultural health policies had organization] and if [HWs] opposed the [VB policy], not been introduced. indigenous leaders would come to [the hospital] to To affect VBs uptake, interview data show that both demand explanations. There were even rumours that parties sought to allocate staff who agreed with their indigenous people would occupy the hospital (...). The position to the labour ward. In this way, managers hired, provincial health director and the health sub-secretary extended the contracts of HWs willing to support the at the national level gave us a lot of support (...). The VBs policy implementation or allocated them to the national health sub-secretary told [the management labour ward and sanctioned those HWs who opposed it. team]: ‘if anything happens, if [HWs] don’t comply, For example, various respondents brought up the case of you call me directly’. (Indigenous Manager). a HW who reportedly lost her job because she had re- fused to perform a VB and was rude to a patient. An- other case cited by respondents was that of a doctor Influencing perceptions on the VB policy: use (and misuse) whose contract was reportedly terminated after he pre- of data sented a study showing a higher incidence of complica- According to interview data both parties sought to influ- tions amongst women having a VB and recommended ence people’s perceptions of the VB policy by challenging the discontinuation of the VB policy. Whether or not its safety and uptake amongst patients and in this way these were the actual reasons why managers fired these gain further support or opposition to it. HWs, HWs reported increasing their compliance with HWs’ initial experiences conducting VBs had raised the VB policy as they feared losing their jobs. In turn, serious concerns about its safety and they were keen on interview data show that HWs tried to reduce the up- collecting data to assess VBs health outcomes. However, take of VBs amongst patients by refusing to conduct HWs selectively sampled medical histories of VB pa- VBs altogether, reallocating team members who sup- tients, particularly those cared for by the (unpopular) ported the VB policy to outpatients, misreporting VBs as trainer, looking for evidence of complications such as va- lithotomy births and not helping illiterate TBAs to docu- ginal tears and incomplete delivery of the placenta. As a ment their input in patient care. Llamas and Mayhew BMC Public Health (2018) 18:686 Page 7 of 10 Changing HWs’ attitudes and behaviours towards Managers and policy-makers agreed that staff attitudes indigenous patient had improved substantially but several respondents Research findings suggest that the implementation of warned that historical trends were slow to reverse. In the VB policy contributed to shaping HWs’ attitudes and the words of a respondent: behaviours towards indigenous women in a number of ways. According to respondents, in the past discrimin- The main challenge is still how [HWs] treat indigenous ation against indigenous women in the health service users (...). Ecuador is a country with a long history of was commonplace and evidenced by long waiting times colonialism, discrimination and exclusion of indigenous and HWs’ rudeness. This resulted in inequitable access peoples. This is clearly demonstrated by the way State to services and health outcomes for indigenous women. services such as health and education are delivered. Indigenous peoples were considered invisible and [Health] professionals were quite rude to [indigenous] therefore government employees never thought to patients; for instances, once they told an [indigenous] guarantee their rights. You can easily make cultural woman: ‘You must have a tubal ligation!’ in such a adaptations in hospitals but if HW attitudes don’t way that [health professionals] were imposing it (…) change then you have the same discrimination using inappropriate and unprofessional words. in [hospitals] with vertical birth rooms. (Mestizo [Indigenous] patients felt coerced, they complained Policy-maker). about maltreatment and didn’t want to go to the hospital. (Mestizo HW). Discussion However, respondents noted that the VB policy had Lipsky argues that the job of street-level bureaucrats contributed to shaping HWs attitudes towards indigen- (SLB) is highly scripted to achieve policy objectives and ous women. that despite having a strong sense as service workers, SLB, often cannot perform to the highest standard for They used to say that before [the VB policy] there was each individual case due to lack of resources. In trying maltreatment, discrimination because doctors insulted to manage their difficult jobs, SLB exercise discretion patients, they would tell [indigenous patients] off... and develop coping mechanisms that narrow the gap be- but we are young doctors and we don’t agree with tween their ideals and reality . A number of studies [maltreating patients]. We try to be the kindest and have used Lipsky’s theory to explore HWs response to most understanding with the patient. (Mestizo HW). policies in the public health sector in low and middle in- come countries [39, 48] and our study adds to this grow- As part of the VB policy, the new management team ing body of literature. actively sought to increase HWs’ accountability and Our study revealed that HWs developed coping mech- monitor their behaviour by supporting TBAs when they anisms not in response to lack of resources but in re- reported HWs rudeness towards women and making use sponse to a clash of values. Our results show that while of patients’ feedback. Managers operated an “open doors” HWs supported the values enshrined by the VB policy policy to encourage patients’ feedback. HWs and man- (i.e. promoting ethnic equity) they also believed that VBs agers noticed a surge in indigenous patients’ complaints led to obstetric complications, which run counter to (usually about long waiting times and HWs rudeness) as professional values of non-maleficence and acting on the they felt “empowered” when an indigenous doctor be- patient’s best interest. came hospital director. The introduction of TBAs in the maternity service was arguably the most contentious aspect of the VB policy. [Indigenous] patients had trust in us; they could come HWs resented working alongside TBAs as they felt that to the director’s office (...) and tell us about the their skills were being levelled against those of unquali- problems in the hospital such as that [HWs] didn’t fied indigenous women, and that TBAs represented and want to see them and that they had to wait very long. promoted a medical system perceived as “unscientific” (Indigenous Manager). and “backwards”. HWs dealt with this tension by re- defining the TBA’s role. They did not allow TBAs to de- Several HWs received verbal and written memos ask- liver babies in hospital. Instead, HWs allocated TBAs ing them to clarify an incident. Often managers were jobs they considered limited the risks TBAs posed to pa- satisfied with HWs’ explanations but applied sanctions if tients (e.g. cleaning), and jobs that maximized benefits they felt HWs were at fault. To avoid sanctions, several for the patients or did not interfere with their own jobs HWs reported improving their behaviour towards indi- (e.g. acting as doulas, translating and linking the com- genous women. munity and the hospital). Llamas and Mayhew BMC Public Health (2018) 18:686 Page 8 of 10 Another coping mechanism used by HWs to deal with on a case-by-case basis, demanding explanations from the VB policy was to define the eligibility for VBs. HWs HWs and applying sanctions as they saw fit. Managers allowed multiparous low-risk women to have VBs but monitored HWs’ behaviour through TBAs too. TBAs, as actively discouraged primiparous women from having insiders, knew the hospital’s inner workings and, al- one because HWs considered them at higher risk of de- though significantly less powerful than HWs, they devel- veloping complications and needing an episiotomy, oped subtle strategies to get better care for their patients which could not be performed in upright positions. without fuelling an outright conflict. TBAs would, for in- HWs also advised women to have a lithotomy birth stance, remind HWs of the patients’ needs and would when labour was considered high-risk or not progressing physically stand next to their patients. HWs believed adequately (e.g. slow head descent). that TBAs had the managers’ support and would mould We found that HWs’ perceptions and discretionary re- their behaviour to avoid sanctions. sponses to the VB policy restricted women’s choice for Second, managers used incentives and sanctions to fa- VBs and limited TBAs’ role in hospital. At the same cilitate implementation. For example, managers praised time, these strategies allowed HWs to restore some de- HWs who displayed positive attitudes towards indigen- gree of control over their jobs and cope with the pres- ous women and extended their contracts. Managers also sure they were under to implement the VB policy. HWs sanctioned HWs whose behaviour fell below expected were thus de facto policy-makers, as Lipsky’s theory sug- standards. For instances, the reported dismissal of a HW gests, but they operated within the constraints imposed who refused to conduct VBs increased compliance with by managers, confirming findings by other researchers the VB policy as HWs feared losing their jobs. Managers [1, 25]. Managers appeared to accept HWs’ reinterpret- also drew on the continuous support of national and ation of the VB policy as a compromise to enable imple- local policy-makers, and the indigenous community to mentation to go ahead, even if the policy was modified make it clear that implementation was not a matter of as a result. That is, policy implementation resulted from choice but mandatory and that dissent with the policy an ongoing negotiation between HWs and managers. would be sanctioned. Another way in which HWs in our study narrow the Through these interventions of managers, HWs had to gap between their ideals and the reality is by providing reflect on how their attitudes influenced indigenous their best care for a subset of the population and women’s access to health services and outcomes. In neglecting others they considered less worthy. In estab- doing so, HWs were able to align their professional and lishing who is worthy or unworthy of their best care, personal values with those of the policy and to recognize HWs draw on social prejudices and stereotypes, and in their critical role in guaranteeing indigenous women’s doing so reflect the value that the State and society place right to health. The importance of reflective practice has on different people. Historically, indigenous people also been noted by other researchers . across the world have been largely marginalized and dis- Our results demonstrate that actors’ professional and advantaged by State services [4, 7, 31, 40]. Indigenous personal values influenced how they interpreted, pro- women in Ecuador for example have reported degrading moted or resisted and eventually delivered the VB policy. treatment in health services and receiving substandard In this way, the study confirms an extension of Lipsky’s care (e.g. being shouted at, being left alone in active theory identified by Aniteye and Mayhew  who found labour). This has kept indigenous women from accessing that providers values, not only resource constraints as health services which has negative implications for ma- proposed by Lipsky, play a critical role in shaping actors’ ternal and neonatal health outcomes . Entrenched responses to policies. Our findings also confirm the ad- ethnic discrimination in health services is difficult to justments Lipsky himself made to his framework, that overcome and many intercultural health policies have the management level also plays a critical role in front- failed because they have neglected this critical aspect line interpretation of policy [12, 25]. . In this sense, the greatest contribution of the VB Our findings have a number of practice implications. policy was to tackle head-on HWs’ discriminatory Despite HWs reservations, the evidence shows that attitudes towards indigenous women. We identified the some interventions promoted by TBAs are supported by following enabling factors: scientific evidence. For example, mobilising during the First, managers set HWs clear expectations of behav- first stage of labour (dilatation) reduces its length . iour towards indigenous women. Managers monitored Likewise, upright positions during the second stage closely HWs’ behaviour through patient’s feedback. Pa- (pushing) are associated with a shorter duration, less tients’ complaints were mainly motivated by long waiting assisted deliveries, less episiotomies, less severe pain and times and HWs degrading treatment which were seen by fewer abnormal foetal heart rate patters but an increase indigenous people as evidence of ethnic discrimination in second degree tears and estimated blood loss . In- in the health service. Managers responded to complaints take of light food during labour has not been found to Llamas and Mayhew BMC Public Health (2018) 18:686 Page 9 of 10 increase the risk of vomiting or to influence obstetric indigenous women’s access to maternity services and im- and neonatal outcomes . The use of routine episiot- prove maternal and neonatal health outcomes. These omy, as performed by HWs in Otavalo, is also associated findings are particularly important given the current em- with more severe perineal trauma and more healing phasis many Latin American countries place on promot- complications. Most importantly, performing routine ing intercultural health policies. episiotomies do not prevent those complications they in- Based on our findings we conclude that promoting tend to avoid (i.e. severe perineal trauma, painful sexual indigenous women’s access to health services should intercourse, or urinary incontinence) . Finally, con- involve more than token cultural adaptations to mater- tinuous support for women in labour (e.g by a relative, a nity services. Addressing discriminatory attitudes to- HW or a TBA) has meaningful clinical benefits for wards indigenous women should be at the core of any mothers and babies such as more normal delivers, less intercultural health policy; managers are key players in assisted births and caesarean sections, less use of anal- facilitating these changes. gesia, shorter labours and less need for neonatal resusci- Finally, on a theoretical level, and consistent with tation . Current national maternal clinical guidelines research elsewhere, this study shows that Lipsky’s  are consistent with international studies though this street-level bureaucracy theory is useful to analyse policy evidence was ignored by HWs. Given HWs palpable implementation in low and middle income countries. This interest in practising “modern” medicine, portraying the study confirms an extension of Lipsky’stheory whereby VB as a policy that promotes evidence-based interven- providers’ values, not only resource constraints, shape tions (as well as ethnic health equity) could be used as a actors’ responses to policies and that negotiation between lever to facilitate implementation. This would require HWs and managers enables policy implementation. training HWs on research methodology and its applica- tion to clinical practice. It is also plausible that since the Endnotes goal of the VB policy was difficult to criticise for it ul- 1 Referring to 500 years since the Spanish colonisation timately promoted ethnic equity, some HWs may have of South America. referred to the lack of scientific basis of the VB policy as an acceptable and non-sanctionable rationale to express Abbreviations their dissent with the policy. D&C: Dilatation and curettage; HWs: Health workers; MOH: Ministry of health; NGO: Non-govermental organization; PHC: Primary health care; SLB: Street- While integrating TBAs in the health service was very level bureaucrats; TBAs: Traditional birth attendants; UNFPA: United Nations contentious, as it has been also noted by other re- population fund; VB: Vertical birth searchers in Ecuador , our findings demonstrate that TBAs can have a positive effect in addressing discrimin- Acknowledgements We would like to thank our participants in hospital and the community as well ation in the health service and supporting particular as Dominique Behague, Carolyn Stephens, Paulina Ruiz and our reviewers for evidence-based interventions in maternal care [18, 24, their contribution to this research. We would also like to thank our funders the 35]. Furthermore, international studies have found that Medical and Research Council and the Economic and Social Research Council for their financial support. integrating TBAs in the health service improves the use of skilled birth attendant, perinatal mortality and pos- Funding sibly maternal mortality [2, 5, 20, 50]. Nonetheless, TBAs This study was funded by the Medical and Research Council and the Economic can also jeopardise women’s health and this needs to be and Social Research Council. addressed; our study found that in some cases TBAs’ ad- vice resulted in delaying life-saving interventions. In this Availability of data and materials The datasets generated and/or analysed during the current study are not context TBAs have an important role to play to improve publicly available because it is not possible to protect participants’ anonymity maternal and neonatal health but it should not involve and confidentiality. making clinical decisions. Instead, their role in hospitals should be to promote the evidence-base interventions Authors’ contributions aforementioned (e.g. supporting labouring women) and AL and SM were involved in the design, data analysis and write up of this study. Data were collected by AL. Both authors read and approved the final work in partnership with HWs. Providing a space where manuscript. HWs and TBAs can communicate respectfully and hav- ing clearly defined agreed roles could ease the tensions Ethics approval and consent to participate that may arise when two different medical systems are This study was approved by the ethical committee of the London School of Hygiene and Tropical medicine and the University of Otavalo as well as from articulated and support policy implementation. local stakeholders. We confirm that participants received information and gave oral or written consent to take part in this study. 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Published: Jun 4, 2018
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