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.