Abstract
Maternal mortality continues to claim the lives of thousands of women in Latin America despite the availability of effective treatments to avert maternal death. In the past, efforts to acknowledge cultural diversity in birth practices had not been clearly integrated into policy. However, in Otavalo (Ecuador) a local hospital pioneered the implementation of the ‘Vertical Birth’—a practical manifestation of an intercultural health policy aimed at increasing indigenous women’s access to maternity care. Drawing on agenda-setting theory, this qualitative research explores how the vertical birth practice made it onto the local policy agenda and the processes that allowed actors to seize a window of opportunity allowing the vertical birth practice to emerge. Our results show that the processes that brought about the vertical birth practice took place over a prolonged period of time and resulted from the interplay between various factors. Firstly, a maternal health policy community involving indigenous actors played a key role in identifying maternal mortality as a policy problem, defining its causes and framing it as an indigenous rights issue. Secondly, previous initiatives to address maternal mortality provided a wealth of experience that gave these actors the knowledge and experience to formulate a feasible policy solution and consolidate support from powerful actors. Thirdly, the election of a new government that had incorporated the demands of the indigenous movement opened up a window of opportunity to push intercultural health policies such as the vertical birth. We conclude that the socioeconomic and political changes at both national and local level allowed the meaningful participation of indigenous actors that made a critical contribution to the emergence of the vertical birth practice. These findings can help us advance our knowledge of strategies to set the agenda for intercultural maternal health policy and inform future policy in similar settings. Our results also show that Kingdon’s model was useful in explaining how the VB practice emerged but also that it needs modifications when applied to low and middle income countries.
Highlights
As we move into a post-Millennium Development Goals (MDGs) era, maternal mortality remains unacceptably high (UN 2014) despite the availability of effective treatments to avert maternal deaths (Campbell and Graham 2006)
Data show that a maternal health policy community emerged that consisted of a relatively stable group of indigenous and mestizo healthcare workers (HCWs), managers and policy-makers involved in maternal and indigenous health in Otavalo
Our results show that this influential maternal health policy community was formed by large numbers of indigenous people; they were instrumental in identifying maternal mortality rate (MMR) amongst indigenous women in the region as a public health problem arising from ethnic inequities, defining its causes and the subsequent events that led up to the vertical birth (VB) practice
Summary
As we move into a post-Millennium Development Goals (MDGs) era, maternal mortality remains unacceptably high (UN 2014) despite the availability of effective treatments to avert maternal deaths (Campbell and Graham 2006). Indigenous people bear the burden of ill health (Casas et al 2001; Montenegro and Stephens 2006). Indigenous health is characterized by stark inequities between the indigenous and non-indigenous population that are the result of socioeconomic factors combined with historical and culturally specific factors (King et al 2009). Indigenous people are amongst the most disadvantaged in society (Hall and Patrinos 2010) and, estimating indigenous maternal mortality is difficult because data are not disaggregated by ethnicity, process indicators show sharp contrasts between indigenous and non-indigenous women. In Ecuador only 30% of indigenous women had a skilled attendant at birth compared to 80% of non-indigenous women (Endemain 2004)
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