Partera-Doula: Exploring the Integration of Traditional Midwives into the Mexican Public Hospital System to provide labor and delivery support

Purpose: To identify perceptions and barriers to integrating traditional midwives (TM) as labor support into the Mexican public hospitals (PH).

Background: Mexican TM are an important source of culturally valued pregnancy care, particularly in poor and indigenous communities. Currently, they are excluded from PH. Given the widely documented benefits of a doula (a trained person who provides labor support), one strategy to improve quality of care and maternal outcomes is to integrate TM as doulas in PH.

Methodology: Interviews and focus groups with TM and interviews with physicians, nurses and administrators conducted in the states of Morelos and Guerrero were used to identify attitudes about TM integration. The results were analyzed using grounded theory.

Results: Morelos TM avoid referring to PH because of previous negative experiences with clinical personnel and exclusion from further care of their patients. TM prefer referring to private physicians and cite their ability to act as doulas for their patients, faster care for their patients, and referral commissions as advantages to PH referrals. TM perceive the most significant barrier to acting as doulas in PH as hospital staff's negative attitudes towards TM. Morelos hospital staff are receptive but identify cultural factors and hospital protocol as the most important barriers to integration.

Implications: Integrating TM to provide doula services to their clients has potential to improve obstetrical care and maternal outcomes in Mexico in public hospitals. This role is seen as an attractive option for TM and PH staff but would require training for both parties.

Two page summary:

Background:

In an effort to improve maternal outcomes, the Mexican government has recently extended the coverage and range of maternal services provided to low income families at minimal cost through programs such as People's Health Insurance (Seguro Popular de Salud), Fair Start in Life (Arranque Parejo en la Vida) and Oportunidades (Hu et al, 2007). Despite increasing coverage of prenatal care and other maternity services, the perception of quality of care and treatment of patients in public sector health facilities, particularly among the poorest users, remains low (Bronfman-Pertzovsky et al, 2003; Puentes et al, 2006).

Traditional midwives (TM) attend 10% of births nationally and between 25-50% of births in poor, rural and/or indigenous communities (Muradas et al, 2007). TM live and work in their own communities and share the same cultural and socio-economic characteristics as their clients (Camey, 1996). They provide highly valued and symbolically important care such as herbal treatment, massages, and baths.

There is worldwide consensus that the safest births are those attended by skilled birth attendants (SBA) who have access to necessary equipment and emergency facilities (Liljestrand, 2000). There is also little controversy regarding the benefits of a doula, a trained woman providing emotional support to women in labor. Laboring with a doula decreases rates of cesarean section, use of anesthesia, and dramatically improves perceptions of well-being in labor and delivery (Langer et al, 1998; Scott, Klaus and Klaus, 1999; Trueba et al, 2000). Campero et al (1998) found that among lower middle class Mexican women delivering in a public hospital, the presence of doulas was associated with a more positive birth experience and better communication with medical staff compared to those who did not labor with a doula.

TM are ideal candidates to provide this type of labor support when women elect to come or are referred to clinics. However, TM are generally excluded from accompanying the patients once they refer to public hospitals or clinics. The project is evaluating the feasibility of integrating Mexican TM directly into clinic-based obstetric care in the role of a doula, an approach that has not previously been implemented or adequately evaluated in Mexico or in the maternal child health literature.

Methodology:

Interviews and focus groups with TM and interviews with physicians, nurses and administrators in public hospitals and clinics are currently being conducted in the states of Morelos and Guerrero. Morelos has a population of 1.7 million people with a mix of urban, peri-urban and rural communities. The maternal mortality ratio (MMR) in Morelos (44.8/100,000 live births) is lower than the national MMR of 62.1/100,000 live births. SBA attend 93% of deliveries (Lozano et al, 2006, Secretaria de Salud, 2000-2004). Its neighboring state, Guerrero, with 3.2 million inhabitants, has one of the highest MMR in Mexico at 99.8/100,000. Estimates of deliveries attended by SBA in Guerrero range from 42-81% and are highly dependant on location (Melendez, 2007, Lozano et al, 2006). In one remote and indigenous community in 2004, twenty deliveries out 2741 registered live births occurred in a health care facility (Melendez, 2007). According to available data, TM attend 22.8% of deliveries in Guerrero (Muradas et al, 2007), but these data may not reflect the situation in many remote and indigenous communities.

TM were recruited through TM's associations, referrals from other TM, Secretary of Health registries and community organizations. In Morelos, we attempted to sample from a variety of geographical areas throughout the state. In Guerrero, we focused on sampling TM in regions with high MMR. Structured interviews focused on TM's current practices, referral practices, experiences with the public health care system and attitudes about acting as a doula in the public system. Twelve TM's interviews have been conducted in Morelos and point of saturation has been achieved. Focus groups were conducted to understand TM's views about several different strategies of acting as doulas in the public hospitals. We are in the process of completing an additional 5-10 interviews with TM living in areas of Guerrero with the highest MMR and high concentrations of indigenous peoples.

Interviews with ten clinical staff including physicians, nurses and hospital/clinic administrators were conducted in the referral public hospitals in Morelos municipalities. We estimate interviewing a total of 5-10 providers from Guerrero.

Interviews were transcribed, coded and analyzed using Nvivo. The analytical approach was based on grounded theory (Strauss and Corbin described in Creswell, 1997).

Results:

Morelos midwives are between 43-86 years old (median age = 57 years). Educational level ranged from no school to 8th grade education with a technical specialty. They had between 1-10 prenatal visits per week (average = 3-4) and attended between 0-10 deliveries (average of 2-3).

TM characterized the majority of their clients as poor and reported that most are recipients of social and health benefits programs. Since the recent nationwide availability of Seguro Popular, TM in Morelos report a decreased number of deliveries and a resultant decrease in income. However, they report no drop in number of prenatal visits. They state that women come to them for three main reasons: 1) women trust TM more than doctors because they provide more humanistic care 2) TM charge less than private practitioners and 3) women (and/or their husbands) do not want to be attended by male physicians.

Most TM have referred to private physicians in case of a complication and most of them accompanied the woman to the physician's clinic to provide continuity and emotional support. TM were sometimes paid by the private physician for their services. They prefer to refer to private physicians for two reasons: 1) negative experiences in public hospitals with staff who scolded or spoke harshly to them or their patients and/or 2) perceived inappropriate triaging and long waiting times.

TM are uniformly in favor of acting as doulas in the public health hospitals. They are interested in both referring their own patients to the public hospital and acting as a staff doula by taking shifts at the hospital. They perceive the most significant barrier to their integration into public hospitals as the negative attitudes of clinical staff towards TM. Some also recognize the potential difficulties in adjusting to hospital protocols and in abstaining from clinical intervention when they perceive clinician error.

Morelos hospital staff were receptive to both TM accompanying their own patients to the hospital or to having staff TM act as doulas during shifts. They identified the most important barriers to integration as cultural misunderstandings between TM and clinical staff and concerns for maintaining hospital protocol.

Implications:

Scholars working in Mexico have repeatedly called for the integration of traditional midwives into the formal health system as an important step to improving accessibility to care among the most vulnerable populations (Cunnigham and Cos-Montiel, 2003; Camey et al., 1996). However, their specific role and duties has not been clear. TM are currently integrating themselves into the private health care system by establishing professional relationships with private physicians and continuing to support their patients after transfer of care. This is an ideal time to integrate TM as paid doulas into the public health care system. TM have an existing model of working within a biomedical setting and providing emotional support for their clients. Their income has declined because more women with Seguro Popular are delivering in hospitals. Both rural and urban small private clinics have been documented as providing lower quality maternity services than public clinics, particularly in poor and indigenous communities (Barber, 2006, Barber et al, 2007). Encouraging TM to act as doulas in public hospitals has the potential to improve maternal outcomes in Mexico by a) increasing the number of deliveries attended by SBA b) increasing referrals to public hospitals over private physicians and c) improving the birth experiences and perception of quality of care among Mexican women delivering in public hospitals.

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