Discourse versus practice: are traditional practices and beliefs in pregnancy and childbirth included or excluded in the Ecuadorian health care system?

Abstract

Background

Traditional beliefs, knowledge and practices are formally integrated into the Ecuadorian health system. We sought to understand whether they are integrated in practice.

Methods

Qualitative data were collected in two rural parishes in the central highlands of Ecuador through four focus group discussions (30 participants), eight key informant interviews, three participatory exercises (24 participants), structured observations of health facilities and analysis of official documents.

Results

We found different levels of integration, coexistence, tolerance, and intolerance of traditional health beliefs and practices in health facilities. One parish has undergone dramatic social and cultural transformation, and the role of traditional birth attendants is limited. In the other parish, traditional indigenous norms and values persist, and traditional birth attendants are sought during pregnancy and childbirth. The degree to which traditional birth attendants, indigenous women and their families are included or excluded from public health services depends largely on decisions taken by local health professionals.

Conclusions

Formal policies in Ecuador stipulate that health care should be intercultural, but the role of traditional birth attendants is not necessarily incorporated in practice. The integration of culturally-informed beliefs and practices is critical for providing appropriate health services to members of vulnerable populations.

Introduction

In multicultural societies, the degree to which members of culturally and linguistically diverse populations participate in public health systems depends largely on their perception of the appropriateness of the services provided.¹ Hence, it is legitimate to question whether patients are included or excluded from health care based on their culturally-informed beliefs and practices. In particular, because of the sensitive nature of pregnancy and childbirth, women and their families may not seek services from public health care services if they do not meet their expectations, thus increasing the likelihood of adverse outcomes. While a system that promotes culturally and linguistically appropriate care has the potential to be inclusive, in practice this is not always the case. Likewise, public policies can formally provide for intercultural health, but in societies with substantial indigenous populations, health systems are inclusive only when they incorporate practices that women and their families value, thereby providing for truly intercultural health.

While gaps between public health systems and traditional health services remain in Latin America, many countries promote intercultural health, which refers not only to an acknowledgement of cultural diversity, but also to bidirectional flows of knowledge, information and respect for local health knowledge and practices.² Ecuador is recognized as a pioneer in intercultural health in Latin America because traditional health beliefs and practices associated with the country's indigenous population have been incorporated into health services in several well known examples.^3,4 This study seeks to determine the degree to which intercultural health practices in Ecuador are consistent with formal policy declarations.

A truly intercultural health system incorporates the norms, values and practices of different sociocultural groups; in Ecuador, this includes 14 indigenous groups and persons of African descent. Formally, intercultural health is enshrined in Ecuador's 2008 constitution, which establishes the right to health in the context of the country's social, cultural and linguistic diversity.⁵ These constitutional principles represent the basis for national legislation, which stipulates that the Ministry of Public Health (MSP) is responsible for ensuring that traditional, ancestral, and alternative practices are incorporated into the public health system. Operationally, all Ecuadorians have the right to appropriate, high-quality, intercultural services through the implementation of the Model of Integrated Attention of the National Health System (MAIS, for the title in Spanish). This model establishes local health teams composed of health professionals and Technicians in Primary Health Care (TAPS, for the title in Spanish), who are assigned to rural areas and urban neighborhoods, and who provide care based on an understanding of prevailing conditions and social determinants of health.⁶ According to this model, traditional medical practices should be complementary, reflecting local health cultures and forming the basis of services that are culturally, socially and linguistically appropriate. Additionally, technical guidelines regulate procedures in the priority areas of maternal and infant health. For example, traditional healers, including traditional birth attendants (TBAs), are recognized in principle as part of the health system⁵ although they are not accredited.

This qualitative study explores the degree to which Ecuadorian health services in pregnancy, labor, and childbirth are intercultural in practice, focusing on the participation of TBAs in the public health system. Understanding gaps between intercultural health in theory and practice can be useful for addressing this issue in other countries with diverse populations. We adapted the model that Nigenda and colleagues⁷ proposed to classify and compare national health systems in terms of integration, coexistence or tolerance of traditional practices. Our model adds a category (intolerance), recognizes the simultaneous presence of more than one category, and incorporates a summary analysis of the degree to which the categories are found in practice.

Methods

We analyzed Ecuadorian public health policies as stated in the constitution, laws and regulations, and explored perceptions, opinions and experiences related to pregnancy and childbirth from the perspective of public health professionals and TBAs in Cotopaxi province, Ecuador. Qualitative data were collected using complementary techniques through which information was gathered, organized, validated and analyzed.^8,9 Qualitative methods are appropriate in health research because behaviors and decisions are based in large part on beliefs, attitudes, and practices.^10,11 Conceptually, while the research is based on the grounded theory tradition,⁹ the innovation of our method rests in combining that approach with our modified version of the Nigenda model,⁷ allowing us to analyze qualitative data in the context of formal policy in order to compare discourse with practice.

Two principles guided the identification and recruitment of study participants. First, triangulation was employed to obtain information from different sources using various techniques. Second, saturation allowed for applying each technique until no new information was obtained.⁸ To achieve triangulation, we employed focus group discussions (FGD), key informant interviews (KI) and structured observation of public health facilities. FGDs were particularly important because they allowed participants to converse in natural and interactive settings in which they could freely express their perceptions, opinions, beliefs, and experiences in the context of comments formulated by others in the group.¹²

In order to explore levels of integration, coexistence, tolerance, and intolerance of traditional health beliefs and practices in health facilities, the study was conducted in two parishes in Cotopaxi province, located in Ecuador's central highlands: Guangaje, including the local health post and the public hospital in the nearby city of Pujilí and Pastocalle, including the new health center in the neighboring town of Lasso. For purposes of comparison, observations were also conducted in a maternal health center in Carapungo, a neighborhood in the capital city of Quito, because it is considered a model for intercultural health practices. Cotopaxi was selected because of its indigenous population and continued use of traditional health practices. While the proportion of Ecuadorians who identified themselves as indigenous in the most recent census of 2010 was 7%, Cotopaxi's indigenous residents represent 22.1% of the total. The corresponding figure for Guangaje was 99.3%, reflecting a strong and persistent indigenous identity. In contrast, 2.7% of Pastocalle's residents identified themselves as indigenous.¹³ While the inhabitants of Guangaje retain culturally-informed beliefs and practices, Pastocalle has undergone dramatic social, cultural, and economic transformation that has eroded those beliefs and practices. Most residents in Guangaje speak Kichwa and are engaged in small-scale agriculture on land that is still relatively isolated from markets and highways, while most of Pastocalle's residents speak Spanish, and many men and women provide wage labor services in nearby flower and vegetable plantations.

Between December 2014 and July 2015, four FGDs were conducted: with public health professionals (seven participants), local TAPS (six participants), and TBAs (two groups: Guangaje, 12 participants and Pastocalle, seven participants). In addition, eight KI interviews were conducted with an indigenous leader who was also a public health professional, the director of the Pujilí Hospital, two nurses in the Lasso health center, a male TBA, a medical anthropologist with three decades of experience in indigenous communities, a nurse experienced in indigenous maternal health and two national authorities in intercultural health. Data were analyzed using a three-stage coding process⁹: open coding for identifying basic concepts, axial coding for allowing categories and properties to emerge from the pattern of responses, and selective coding for integrating and refining topics and interrelations.

In order to validate the findings of the FGDs and KIs, we conducted three participatory group monitoring and evaluations exercises (PAME): two with medical personnel in the health centers in the two study areas and one with TBAs in Guangaje (24 participants in all).¹⁴ This process sharpened our understanding of consistencies and inconsistencies in the perceptions of public health professionals and TBAs regarding services provided to local women during pregnancy and childbirth.¹⁵ During these exercises, participants were divided into teams who formulated written responses to questions derived from the study's initial findings. The teams then met together to agree upon responses that addressed discrepancies between their perceptions and the study's findings.

Procedures followed were in accordance with the ethical standards of the Helsinki Declaration (1964, amended most recently in 2008) of the World Medical Association. Patients’ consent was obtained and all information is anonymised.

Results

Nigenda et al.⁷ establish three categories of interrelationship between public health systems and traditional health care providers: integration, coexistence and tolerance. We modified the model in three ways. First, we added intolerance as a fourth category. Second, our model provides for the simultaneous expression of more than one of these categories at the local level. Third, we added two parameters to the original model. Table 1 presents a matrix with our model of intercultural health in pregnancy and childbirth. Each of the four categories were analyzed according to three parameters: policies that govern the relationship between the public health system and traditional health practices related to pregnancy and childbirth; the degree to which established policies apply in practice; and a summary assessment of intercultural health in practice during pregnancy and childbirth. The matrix presented in Box 1 provides examples of comments formulated by public health professionals that illustrate different levels of integration, coexistence, tolerance, and intolerance as analyzed below.

Integration and its limits

In formal terms, traditional health knowledge, beliefs and practices are fully incorporated into Ecuador's public health system, which guarantees patients’ rights, including the participation of TBAs. Technical guidelines incorporate those rights and require that women's preferences be respected, that families be present during delivery if so desired, and that installations and training of personnel be appropriate to those preferences.^5,6,16

Evidence of integration of public and traditional services can be found at three points in the health system. First, the intercultural health office in the MSP is responsible for developing, implementing and monitoring technical guidelines, programs and activities related to the provision of culturally-appropriate health. Second, the MAIS model establishes local health teams, including TAPS, who are local residents with 2 years of training who serve as health promotors and intermediaries between public health professionals and the local population. In predominantly indigenous areas, TAPS speak the indigenous language and are familiar with cultural components of health beliefs and practices. Third, the MAIS model requires that health facilities provide culturally-appropriate services and installations (including birthing rooms) that respond to cultural preferences.⁶

Examples of integrated health services are well known in Ecuador; in particular, the community maternal health clinic Jambi Wasi, in the northern city of Otavalo, which has served as an example of intercultural health.^3,4 Other examples of integrated and intercultural health services exist elsewhere in Ecuador, particularly in areas of predominantly indigenous residence and even in urban settings.¹⁶ For example, the maternal health center in Quito's sprawling neighborhood of Carapungo provides prenatal care and deliveries according to the preferences of their multiethnic pool of patients, whose basic rights are rigorously respected.

Evidence of integration was also found in the two parishes included in this study, but it was partial or conditional in that, as is the case elsewhere in Ecuador,^3,5,17 the culturally informed preferences of women and their families, including the participation of TBAs is less a product of public policies than of initiatives of specific public health professionals, who put their respect for traditional health beliefs and practices into effect when they interact with women, their families and TBAs (see Figure 2). In contrast, several structural factors limit health services integration. First, the legal and regulatory framework is ambiguous with respect to the specific ways in which the participation of TBAs should be integrated into care provided by public health facilities. Moreover, TBAs do not receive salaries or compensation for their expenses and they receive equipment, materials, and training only sporadically. Second, integrated services are limited by the institutional weakness of the MSP intercultural health office, which according to KIs and our observations, appears to have considerable responsibility but which in practice has a merely advisory function. In fact, this office's recommendations are regarded elsewhere in the MSP as contradictory to other priorities or in the best of cases as being unimportant.

Integration of services in pregnancy and childbirth at the local level is limited to the degree that specific health professionals may or may not allow TBAs to participate in deliveries. For example, TBAs in Pastocalle rarely attend childbirths because nearly all women now go the health center in Lasso or other nearby hospitals for delivery. These TBAs now limit their services to traditional prenatal procedures such as massages and the administration of herbal remedies to relieve discomfort and to facilitate delivery. This change reflects broader cultural transformations in Pastocalle, where the Kichwa language is little spoken, few women wear traditional clothing, and many provide wage labor services outside the community. The preference for institutionalized deliveries in Pastocalle is particularly striking because the new Lasso health center was the first in the country built to conform to new regulatory and legal mandates that address intercultural health. Nevertheless, the alternative for deliveries according to traditional beliefs and practices are not promoted and rarely offered. In contrast, women in Guangaje speak Kichwa as their first language, wear traditional clothing, and work in subsistence agriculture on family smallholdings. In this setting, women prefer home births attended by TBAs and opt for hospital deliveries (usually in the public hospital in Pujilí) only in the case of emergencies. Moreover, while the MSP has established guidelines for culturally-appropriate deliveries, including the provision of necessary materials and equipment,⁴ their mere availability does not guarantee that services respect culturally-based preferences. As we observed, the new health center in Lasso and the older Pujilí Hospital have special rooms designed for culturally appropriate deliveries for women in Pastocalle and Guangaje, respectively, but they provide neither a warm and inviting atmosphere nor the physical and emotional support that women traditionally receive from TBAs; consequently, they are rarely used.

Moreover, TBAs and KIs reported that women's mistrust and fear of hospital-based services limits integration, so that opportunities for bringing them into the public health system are lost, reflecting the inability of the top-down health Ecuadorian health model to efficiently implement local culturally-informed practices and beliefs.¹⁸ Since regulations that provide for integration are ambiguous in that they lack specific indicators for the inclusion of TBAs, their role in hospital-based deliveries is left to the discretion of public health professionals.

Coexistence

The second category of interrelationships between the public health system and traditional health practitioners consists of the simultaneous–but separate–provision of services during pregnancy and childbirth by TBAs and public health professionals. Of the four categories, coexistence was the most frequently observed in practice, such that if Nigenda's model were applied to Ecuador as a whole, this would be the appropriate classification. TBAs stated in FGDs that they are generally able to provide traditional services but do so outside the public health system. Nearly all women in Pastocalle go to the health center in Lasso or other facilities for delivery, which reflects both profound sociocultural transformation that has blurred most aspects of indigenous identity and greater trust of the public health system. Preferences are reinforced by women's incorporation into wage labor markets because formally employed workers must document the maternal leave to which they are entitled. Hospitals and health centers can emit the required certificate, but TBAs cannot. The coexistence of TBAs in Pastocalle is reflected in continued preference for their traditional prenatal services.

In contrast, FGD participants in Guangaje report a different pattern in that women continue to prefer home deliveries attended by local TBAs, who also provide traditional prenatal care, including massages, herbal teas and repositioning of the fetus. Nevertheless, while the existence of TBAs may be formally accepted because their services are provided for in technical guidelines, they are not treated as colleagues by most public health professionals, nor do they usually participate in institutionalized deliveries. Conversely, public health professionals rarely perform home visits.

TAPS and health professionals report that following home births, newborns in Guangaje are usually taken to the local health center. The promotional work of the TAPS facilitates this process, and the health center provides the families with incentives for postnatal exams in the form of baby clothes, towels, and the like. In addition, KIs reported that the Ecuadorian civil registration law requires that newborns receive their birth certificates, which are only facilitated by private or public health facilities (but not TBAs). Again, while technical guidelines and performance indicators are designed to ensure culturally-appropriate health services, the services actually provided may not be perceived as appropriate, even when health centers are equipped to do so. The role of TBAs is critical in this process because of the legitimacy they are accorded by families. In indigenous communities, strangers are accepted only through a complex process of confidence building, whereas the rapid turnover of public health personnel is not conducive to gaining confidence.

Unfortunately, public health professionals receive little formal training in culturally-informed health beliefs and practices or in providing culturally-appropriate services, and few speak indigenous languages.¹⁶ Additionally, they often work under pressure and may not be able to spend the necessary time to develop the interpersonal relationships that are so important to indigenous patients. More broadly, KIs reported that that the beliefs and practices of their patients and TBAs are not important to the provision of quality care during pregnancy and delivery because they feel that formal medical education trains them to provide appropriate and adequate services, while the informal training and experience of TBAs does not. In this context, coexistence refers to more than policies that guide relationships between the public health system and traditional practitioners. In practice, it is observed in the interactions between health professionals and TBAs, by which traditional health beliefs and practices are not fully accepted. Hence, in practice, TBAs often do not participate in deliveries in public health facilities, so that coexistence does not necessarily connote intercultural health. In some instances, a superficial appearance of coexistence and even integration exists; MSP personnel provide occasional training sessions to TBAs in Guangaje, which suggests a level of acceptance. Nonetheless, PAME exercises revealed that they impart the message that TBAs should be intermediaries between women and the public health system and that essential services should be provided in health facilities. Similarly, in Pastocalle, the role of TBAs in prenatal care is acknowledged but not valued by public health personnel, and TBAs generally play no role in deliveries.

Tolerance

In some cases, local public health professionals provide services without recognizing traditional health beliefs and practices. They may understand that TBAs exist, but they make no effort to institute contact or interaction between the two systems. Formally, TBAs are allowed to accompany their patients in public health facilities (suggesting integration or at least coexistence), but if they are allowed into hospitals or health centers, they play little or no role in prenatal care or deliveries. Rather, they become mere spectators with no valid role to play.

In these instances, TBAs are tolerated without taking advantage of their potential contribution to the well-being of women or newborns. Even instituting culturally-appropriate delivery rooms has not meant that TBAs are received with anything more than tolerance. Without taking into account the participation of TBAs, the environment present in home births is not reproduced in the installations observed in Lasso or Pujilí.

Intolerance

FGD participants revealed instances in which traditional health beliefs and practices were not integrated, allowed to coexist, or even tolerated. Rather, TBAs face institutionalized intolerance, being barred from entering public health facilities and delivery rooms on the orders of attending physicians or even guards at hospital entrances. These experiences suggest that the perceptions and opinions of public health professionals overrule both the law and the preferences of patients and families in that knowing what is formally required, these professionals may choose to exercise their own judgement of how procedures are to be followed. Intolerance is also reflected in the lack of official accreditation; in spite of recommendations to the MSP to the contrary TBAs are essentially unlicensed practitioners subject to malpractice legislation that could result in prosecution and imprisonment if their services result in complications or death due to what is construed to be incompetence, negligence or imprudence.¹⁶

Discussion

The first article of Ecuador's constitution defines the country as intercultural,⁵ and while indigenous people account for only 7% of the population,¹³ they represent a central part of the country's identity. Despite persistent poverty¹⁹ and inequalities in health care,²⁰ Ecuador is recognized as pioneer in the rights of indigenous people, so its experience in providing intercultural health services is relevant to other ethnically diverse countries in Latin America and elsewhere where indigenous health issues are particularly relevant^21,22 The challenge of making health systems more inclusive and equitable is universal; many persistent gaps in health services are related to cultural and linguistic barriers that inhibit the participation of both indigenous families and traditional health care providers.¹⁶ Pregnancy and childbirth are particularly sensitive issues in health care, and it is important that services be culturally and linguistically appropriate in order that women and families who have eschewed public health services be included.⁵

Whereas Ecuador is said to be at the forefront of intercultural health care, traditional beliefs and practices are not fully integrated into the public health system in practice. Regardless of the content of policies, laws, and regulations, incorporating traditional beliefs and practices of TBAs into public health services depends primarily on the willingness of individual public health professionals to understand and respect their patients, allow TBAs to participate in prenatal care and institutionalized deliveries, and engage in bidirectional flows of information and knowledge. When this does not occur, the two systems are not fully integrated, so that TBAs are either allowed to coexist, merely tolerated, or not tolerated at all. Consequently, indigenous women continue to be excluded from the public health system, and pregnancy and birth outcomes are likely to be negatively affected. In order to reduce health inequalities, the public health system must be inclusive, in part by respecting culturally-informed beliefs and practices.

Like other qualitative studies, our research faced potential limitations related to generalizability. While the health center in Lasso was the first in the country based on the MAIS model and the Pujilí Hospital has long provided services to a large indigenous population, we did not observe fully intercultural services provided elsewhere in the country.³ We focused purposively on two parishes situated in one of Ecuador's most heavily indigenous provinces,¹³ so that we would expect local public health professionals to be as attuned to traditional beliefs and practices as elsewhere in the country, increasing confidence in the generalizability of our results.

A second limitation is that we studied the perspectives of public health professionals, TBAs, and TAPs; future research should incorporate the perspectives of women and their families and strategies they use to navigate traditional and public health services during pregnancy and childbirth.

Conclusions

This work presents a method for analyzing the consistency between intercultural health as policy and practice. In the Ecuadorian case, while constitutional, legal and regulatory provisions mandate intercultural health care, the role of TBAs in pregnancy and childbirth is not consistently respected in practice. The integration of culturally-informed beliefs and practices into public health systems is critical to including vulnerable populations because that approach allows for addressing reasons for which women and their families eschew potentially life-saving services. Hence, our principal recommendation is that countries with significant indigenous (or other culturally distinct) groups should seek to understand interrelationships between public health services and traditional health systems as well as potential inconsistencies between regulatory discourse and persistent gaps in health care in practice. This approach is critical to empowering indigenous and other culturally distinct populations, promoting productive dialogue, providing appropriate health services, and reducing health disparities.

Authors’ contributions: CG, WW, and AS conceived the study and discussed the protocol. CG and WW conducted the interviews and focus group discussions. CG, WW, and AS analyzed and interpreted the data. CG, WW, and AS drafted the manuscript. All authors read and approved the final manuscript. WW is the guarantor of the paper.

Acknowledgements: The authors are grateful to participants in the focus group discussions and key informant interviews.

Funding: This work was supported by an internal pilot grant from the Brown School at Washington University in St. Louis.

Competing interests: None declared.

Ethical approval: Ethical approval was provided by the Universidad San Francisco Committee for Ethics in Human Subject Research.

References

Author notes