Culturally appropriate delivery care:A right of women and newborns

Área de Salud Nº 12 Hospital Raúl Maldonado MejíaCantón-Cayambe

Information: August 2010 to December 2010

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Introduction

The current Constitution of Ecuador in force recognizes our country as multi-ethnic, multinational and intercultural, which allows us to accept and promotethe practice and development of existing traditional medicine in Ecuador.

Therefore, the Ministry of Public Health of Ecuador - Provincial Health Direc-torate of Pichincha, through the Intercultural Health Sub-process, carries outthe implementation of culturally appropriate childbirth with an important re-cognition, revaluation, and retrieval of knowledge and cultural practices of an-cestral medicine, promoting training and accreditation to the elders of ancientmedicine recognized in the community.

Culturally Appropriate Births is a strategy that allows us to meet the objectivesof the National Plan for Accelerated Reduction of Maternal and Neonatal Mor-tality and the National Plan of Good Living (PNBV), whose goals are: to reduceby 35% maternal and neonatal premature mortality and increase to 70% co-verage of institutional delivery.

After a process of adapting the physical infrastructure, purchase of furnitureand visits to culturally appropriate birth experiences (2008 to 2009), the im-plementation phase of this model was started in August of 2010 at the RaulMaldonado Mejia Hospital of the Cayambe Canton with technical supportfrom the Provincial Health Department of Pichincha, CARE Ecuador and thepolitical decision of the Head of Center No. 12, including capacity buildingactions, adaptation of environments for psycho prophylaxis and childbirth andsupplementation of medical equipment.

In this sense, this document compiles and makes visible the learning and ad-vances in attention to childbirth with a cultural relevance and focus on rights,from August 2010 to December 2011, where women and their partners wereprotagonists of the birth of their children accompanied by qualified institutio-nal and community health personnel. We hope that our experience will con-tribute to improving the quality of life of the population and the exercise ofthe rights of pregnant women and newborns in the framework of intercultu-ralism. The achievements so far have been made possible by the humaneand professional commitment of our staff that deserve our greatest recogni-tion and gratitude.

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The awareness programs on intercultural childbirthcame upon several topics of great importance, we hu-manized in the care. We now work with the communityand their midwives. We no longer work in isolation.

Silvana Cupuirán, Obstetrician.

The experience takes place in the Health Center No. 12Raul Maldonado Mejia Hospital located in the CayambeCanton in the Pichincha province which reports a popula-tion of 79,847 inhabitants. 69% of which are Kichwa fromthe Kayampi village, mostly poor and from rural areas withlimited geographic access. These figures show that users

1.1.1Awareness The first step was the awareness of medical and adminis-trative staff of the Health Center No. 12 and mainly fromthe Raul Maldonado Mejia Hospital, on interculturality,rights and Culturally Appropriate Births "CAB”, in order toimprove understanding and gain acceptance of the imple-mentation of this strategy, which also allows greater accessto institutional births, improve quality of care with intercul-tural adaptation and guarantee the fulfillment of the rightsof women and newborns to a humanized labor and birth.

1. Implementation of culturally appropriate births: a right of women and newborns

User of maternal health care of the Raul Maldonado Mejia HospitalAdaptation for comprehensive

birth care

Application of protocols

Social participation

and coordination

LearningCapacity building

of Health Center No. 12 are from different cultures and socio-economic contexts, so it is essential that health services areculturally relevant.

Based on the Technical Guide for the Assistance of CulturallyAppropriate Births of the Ministry of Public Health, recommen-dations from the World Health Organization on the birth andsuccess stories nationally and internationally, a safe labor andbirth model is implemented, humanized and culturally appro-priate, sustainable and replicable locally, nationally or interna-tionally. For this we defined five key components:

Results:90% of the administrative and medical staff of theRaul Maldonado Mejia Hospital have been made awareof and are supporting the implementation of CAB.

Testimony

1.1 Capacity Building

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1.1.2 Training

Since 2002 the training process was started and inAugust 2010 to December 2011 it was intensified anda program of continuous training (workshops, nationaland international courses and national and internationalinternships) was implemented for health personnel ofthe Health Center No. 12, on essential maternal andnewborn care, early stimulation and psycho prophylaxisof childbirth, humanization of birth, culturally appro-priate delivery with scientific evidence and care of thenewborn, with technical support from the Ministry ofPublic Health.

The training proposal also contemplated the knowledgestrengthening and skills of traditional midwives in theidentification and referral of obstetric emergencies, re-cruitment and referral of pregnant women for prenatalcare and childbirth at the cantonal hospital.

Internships performed nationally and internationallyallowed to reinforce, strengthen and share scientificand ancestral knowledge, motivate health personnel(Department of Health and Provincial Health Directo-rate of Pichincha) and traditional midwives in CAB. Si-milarly support and commitment of Health Committeesand Parish Councils, who participated in these activities,increased.

Hospital staff involved in training processes

Testimony

Exchange visit to observe the CAB model by the ProvincialDepartment of Health of Azuay

At first some people were reluctant to make chan-ges, but they joined in the training and changed. Ifeel we've improved as individuals and as profes-sionals, the training has been invaluable. You cansee that the hospital treats their patients better. Ifeel happy about this development.

Maria Hinojosa 26,Emergency Nurse

To implement the knowledge acquired, educationalmaterials were developed for the identification of ma-ternal danger signs and preparation of birth / familyemergency plans, which are given out in health centersand the hospital of Health Center No. 12 and by thetraditional midwives.

Hospital staff engaged in awareness-raising efforts

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Results

Testimony

The training took into account all staff and that motiva-ted us. Midwives were included in the program andallowed us to know how they took care of pregnantwomen; we feel the affective bonding of midwiveswith pregnant women.

Laura VasquezLeader of Hospitalization Service

35 health professionals trained and applying knowledge on standards and protocols ofmaternal and neonatal care and Culturally Appropriate Births and neonatal care.

27 health professionals (midwives, nurses and nursing assistants) with knowledge ofpsycho prophylaxis of births.

42 midwives applying knowledge for capture and institutional prenatal care, referral ofpregnant women for institutional delivery care and obstetric emergencies.

100% of pregnant women attending health centers and hospitals, identifying dangersigns and implementing birth / family emergency plans.

Medical staff engaged in awareness-raising processes

Source: Raul Maldonado Mejia Hospital

Cayambe midwives participating in training Dr. Jorge Bejarano, CARE and community midwife

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1.2 Adaptations for Comprehensive Birth Care

In order to improve the quality and warmth of the CAB care, a room for prenatal stimulation and psycho prophylaxisof the birth was implemented, adaptations were made to environments of the labor and birthing rooms, and thenecessary equipment to appropriately serve users was completed.

Since May 2011, the hospital offers prenatal stimu-lation and psycho prophylaxis of birth service thatallows a pregnant woman and her family to:

a) Have detailed information about theprocess of pregnancy, childbirth andpostpartum.

b) Seek help in an obstetric danger andimplement the birth and familyemergency plan.

c) Acquire knowledge about the care andrisks of the newborn as well as familyplanning.

d) Understand their rights andresponsibilities

e) Do breathing exercises that will behelpful during labor and train themuscles that must make a specificeffort.

The psycho prophylaxis has proven scientifically theimpact on the health of the mother, fetus and new-born, as the pregnant woman on acquiring kno-wledge about her pregnancy and childbirth, takesconfidence in her self-care during the perinatal pe-riod, motivation to have the control during labor andjoy to welcome their son / daughter.

To implement this service a room with mats, ballsfor psycho prophylaxis, pillows, weights for strengthtraining, educational videos, relaxing music, anatomi-cal models, and edu-communicational equipment,was adapted.

Psychoprophylaxis workshops Psychoprophylaxis workshop in thedelivery room

1.2.1 Psycho prophylaxis Birth Room

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User who chose the squatting position, during culturallyappropriate childbirth

1.2.2 Labor and birth roomThe labor room was adapted with two beds, balls, waterheater and dispenser for tea preparation according to localtradition, in order to implement the psycho prophylaxis ofchildbirth with family accompaniment in an environmentwith the appropriate temperature.

The birth room has furniture, medical equipment, appro-priate room temperature and relaxing background musicto provide a warm and comfortable environment to theusers, allowing:

a) Apply the rules and protocols for care of pregnantwomen and newborns.

b) Guarantee the rights of the mother to choose theposition (sitting, kneeling, standing or lying down)during the delivery stage of labor. Accompanimentof a family member and support of a healthprofessional or a traditional midwife.

c) Avoid or minimize fetal distress, as the right of thenewborn, ensuring immediate attachment and earlylactation.

Testimony

We orient them, provide all information related tothe positions that they may choose and freelydecide which is the most comfortable for them.

Laura GomezNurses Assistant

Testimony

We feel more confident and qualified to attend cul-turally appropriate births. Our reward is the happinessof women with their newborn babies.

Alicia Chicaiza, ObstetricianIn charge of Culturally Appropriate Births

Culturally appropriate delivery room

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1.3 Application of Protocols-Guide

For the successful implementation of culturallyappropriate births, care protocols for the CABfocused on rights were implemented:

• We identify the traditions of women to meet theirneeds and requirements during pregnancy,childbirth and postpartum.

• We promote the dignity and humanization ofchildbirth, with the active participation of womenin labor, where they are the protagonists of thesame with the support of health personnel (doctor,obstetrician, traditional midwife) and family.

• We respect the right of women on clothing(mother and newborn), food and tea anddestination of the placenta according to culturaltraditions and rules of biosafety of the Ministry ofPublic Health.

• We allow the patient to choose the position(vertical or horizontal) in which she is morecomfortable with for childbirth and who will attendher delivery, as well as the accompaniment of herspouse, partner or family member during childbirthand postpartum to provide emotional support andco-participate in the experience of parenthood.

• We apply obstetric and neonatal care practices withhealth personnel who provide dignified, respectfultreatment, with technical quality, warmth andcultural values, in a cozy acclimatized environmentthat allows the complementarity of conventionaland traditional medicine.

• We eliminating the routine practice of shaving thepubic hair, administering an enema before birthand artificial premature rupture of membranes; aswell as the routine use of episiotomy.

• We implemented the physical, emotional andpsychological support to the patient, her partnerand family during labor and postpartum.

• We guarantee the early attachment of thenewborn, immediate breastfeeding and sharedrooming for mother / newborn.

Advantages of vertical childbirth•

• Provides important psycho-emotionalbenefits to the mother, such asreducing pain, feeling of freedom,control and participation, greatersatisfaction during and after delivery.

• The weight of the uterus, baby,placenta, amniotic fluid and blood,favors the decent of the womb anddoes not put pressure on the lungs.

• Gravity favors engagement and fetaldescent.

• Reduces the duration of labor, boththe period of expansion as well as thedelivery.

• There is a significant reduction of fetaldistress.

.

Dr. Franklin Dominguez, Coordinator

Matilde Farinango, former Director of the Raul Mal-donado Mejia Hospital

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Testimony

Results

"I felt calm because my husband was there ... whensitting it seems that the baby comes out faster,while before I was lying on the stretcher with oneleg here and the other one here and the doctor andthe nurses were telling me to push more, it was likemore complicated, making me more nervous. ""When I got to the delivery room they asked me inwhich position I wanted to give birth, they firstmade me lie down on a bedspread, then made me

kneel and I did not like it either, then I asked to sit... then I felt more comfortable...and then the babycame out quickly... this experience was different,because it took me into account ... like someonewho cares about someone".

Miss. Diana Diaz, first user who inauguratedthe culturally appropriate birth service.

Free position Conventional position Total deliveries

Deliveries at the Cayambe HospitalJanuary-December 2011

131 pregnant women received prenatal stimulation and psycho prophylaxis of childbirthworkshops.

419 users exercised their right to choose the position at the time of delivery andaccompaniment of their partner or a family member.

This is the first time I went in to the birth of a child. I saw my sixth child born. I supported my wife who decidedto give birth sitting. I positioned myself behind her to embrace her and give her strength, when I saw that mydaughter I wanted to scream out. I did not miss a thing. I feel happy.

Gustavo Gabriel Majin-husband and father who experienced the benefits of culturally appropriate delivery.

Testimony

Family attended to through culturally appropriatechildbirth

Source: Raul Maldonado Mejia Hospital

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1.4 Social participation and coordinationFrom the year 2002 the implementation of the InterculturalManagement Model in the Health Center No. 12, Cayambe,commenced, maintaining a permanent intervention processwhich was strengthened in April 2010, under the leadershipand technical advice of the Intercultural Health of the Pro-vincial Health Directorate of Pichincha "DPSP" (for its initialsin Spanish), with technical and financial support of CAREEcuador, Casa Campesina (Peasant House) and Ayuda enAccion (Help in Action).

CARE Ecuador contributed to the sensitization process, ins-titutional-community training, equipment to improve CABenvironments, implementation of the psycho prophylaxisof childbirth and technical assistance in the implementation

process; Casa Campesina strengthened the process of par-ticipation and re-appreciation of the knowledge of the mid-wives from the village of Kayampi; Ayuda en Accion sup-ported in developing the strategic plan with an interculturalapproach and the Provincial Health Directorate of Pichincha- DPSP provided their leadership and technical advice.

To achieve the participation and improvement in the qualityof health services, especially maternal, health committeeswho develop action plans in conjunction with health centersand the hospital in Cayambe are being strengthened. Inthis sense health committees and traditional midwivescontribute to the organization to address obstetric emer-gencies.

We work differently in the community, we have another vision, women want to feel heatat childbirth. They want to be near their family and not feel strange. Before they did notwant to go to hospital because they feared being treated badly but now that we tell themhow it has changed, they are coming to the hospital to give birth. We are already workingwith the hospital and we can go in with the pregnant woman and support her in labor.

Maria Carolina Inlago, MidwifeSanta Rosa de Ayora Community

Testimony

TestimonyCarolina Inlago, in the culturally appropriate deli-

very room, Cayambe Hospital

The Provincial Health Directorate of Pichincha "DPSP” - Ministry ofHealth and CARE Ecuador in the canton of Cayambe have had a majorimpact on improving the quality of health services provided at medicalcenters. The launch of the intercultural delivery or culturally appropriatebirth initiative is an example of this, as it has meant an integral work ofawareness, education to health personnel and subsequently theadaptation of the physical space. The initiative seeks to directly influencein the reduction of maternal and neonatal death, recovering the culturalknowledge of the area.

Néstor Quilo, Technician from the Intercultural Health of the Provincial Health Directorate of Pichincha

Nestor Quilo, visiting Dolores Lara, midwife from the Ayora Parish

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1.5 Learning

• Having the support, institutional commitment and withregulations for CAB is important because the processbecomes viable.

• The application of CAB facilitates the exercise of the rightsand responsibilities of pregnant women.

• The sensitization process is the most recognized by staffin their attitude and empowerment on the CAB.

• Taking into account in the construction process at all levels(management, administration, finance, health care andsupplemental services or support) of the organizationenables the understanding of the importance of thesetypes of processes, know the administrative and technicalchanges involved in implementing the CAB and theimpact at a health care level and of the population.

• The training with the incorporation of interns is seen insignificant institutional changes when they are directed atall levels of the organization; contribute to capacitybuilding of health staff and at management level.

• Generating spaces of coexistence and participatoryconstruction of the CAB as a complement to the training,as well as recognition of professional and personalcommitment of staff, creates motivation andempowerment.

• Knowing and understanding the culture and Andeanworldview allows health professionals to respect andidentify with the customs and traditions in relation to carein childbirth.

• It is important to adapt the conditions of comfort, safety,hygiene and dignity for the mother as well as the comfortand safety of personnel attending births.

• Women who give birth in humanized spaces andrespecting their rights, have a better recognition of thequality, more satisfaction and confidence in the service.

• The accompaniment of a relative during childbirthprovides security, makes the pain of contractions moretolerable and facilitates the labor progress.

• Implement culturally appropriate delivery reduces theamount of supplies that are used in relation to the othertypes of delivery or cesarean section, resulting in lowercosts to the hospital.

• Involving the community in the process of institutionalchange allows for more effective results.

• Working in partnership (public sector, civil society andcommunities) allows for optimization of resources,improvement of coordination and joint relationships, andcontributes to the sustainability of the actions in reducingmaternal and neonatal mortality.

• The inclusion of traditional midwives in maternal care,allows for the increase of referrals for prenatal care,institutional delivery and emergency obstetric care.

1.6 Monitoring and Evaluation

The implementation of the CAB has a permanent support,monitoring and evaluation of planned actions and targets,which are analyzed and modified when necessary. Thisprocess is carried out in conjunction with staff fromdifferent hospital departments.

There have been several meetings of learning with hospitalofficials and community leaders, in which they haveanalyzed the institutional changes during implementationof the CAB.

Thanks to the commitment, willingness and professiona-lism of the officials of the Health Center No. 12 it has beenpossible to progressively implement culturally appropriatedelivery. The resistance to the new processes has beengradually overcome. We thank all the willingness and pro-

fessional mystique to undertake the humanized childbirthservice. We recognize the effort generated by the differentadministrative, operational and medical areas to imple-ment this experience which is recognized by patients andfamilies.

Our appreciation to all officers of Health Center No. 12, for their support in the implementation of intercultural health care and culturally appro-priate childbirth

2. Acknowledgment

Para mayor información:• Dirección Provincial de Salud de Pichincha - Mejía y García Moreno - Teléfono: 258 0185 Extensión: 3066• Area de Salud Nº 12 - Hospital de Cayambe - Teléfono: 236-0072 Extensión: 21• CARE Internacional en el Ecuador - Teléfono: 225 36 15 Extensión: 2208