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Safe Birth and Cultural Safety in southern Mexico: Study protocol for a randomised controlled trial

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Background: Indigenous women in the southern Mexican state of Guerrero face poor maternal health outcomes. Living as they do at the very periphery of the Western health system, they often receive low-quality care from health services that lack human and financial resources. Traditional health systems remain active in indigenous communities where traditional midwives accompany women through motherhood. Several interventions have explored training birth attendants in Western birthing skills, but little research has focussed on supporting traditional midwives by recognising their knowledge. This trial supports traditional midwifery in four indigenous groups and measures its impact on maternal health outcomes. Methods: The study includes four indigenous populations in the State of Guerrero (Nahua, Na savi/Mixteco, Me'phaa/Tlapaneco and Nancue ñomndaa/Amuzgo), covering approximately 8000 households. A parallel-group cluster-randomised controlled trial will compare communities receiving usual care with communities where traditional midwives received support in addition to the usual care. The intervention was defined in collaboration with participants in a 2012 pilot study. Supported midwives will receive a small stipend, a scholarship to train one apprentice, and support from an intercultural broker to deal with Western health personnel; additionally, the health staff in the intervention municipalities will participate in workshops to improve understanding and attitudes towards authentic traditional midwives. A baseline and a final survey will measure changes in birth and pregnancy complications (primary outcomes), and changes in gender violence, access to healthcare, and engagement with traditional cultural activities (secondary outcomes). The project has ethical approval from the participating communities and the Universidad Autónoma de Guerrero. Discussion: Indigenous women at the periphery of Western health services do not benefit fully from the attenuated services which erode their own healthcare traditions. Western health service providers in indigenous communities often ignore traditional knowledge and resources, inadvertently or in ignorance, disrespecting indigenous cultures. Improved understanding between midwives and the official healthcare system can contribute to more appropriate referral of high-risk cases, improving the use of scarce resources while lowering costs of healthcare for indigenous families. Trial registration: ISRCTN12397283 . Retrospectively registered on 6 December 2016.
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S T U D Y P R O T O C O L Open Access
Safe Birth and Cultural Safety in southern
Mexico: study protocol for a randomised
controlled trial
Iván Sarmiento
, Sergio Paredes-Solís
, Neil Andersson
and Anne Cockcroft
Background: Indigenous women in the southern Mexican state of Guerrero face poor maternal health outcomes.
Living as they do at the very periphery of the Western health system, they often receive low-quality care from
health services that lack human and financial resources. Traditional health systems remain active in indigenous
communities where traditional midwives accompany women through motherhood. Several interventions have
explored training birth attendants in Western birthing skills, but little research has focussed on supporting
traditional midwives by recognising their knowledge. This trial supports traditional midwifery in four indigenous
groups and measures its impact on maternal health outcomes.
Methods: The study includes four indigenous populations in the State of Guerrero (Nahua,Na savi/Mixteco,
Mephaa/Tlapaneco and Nancue ñomndaa/Amuzgo), covering approximately 8000 households. A parallel-group
cluster-randomised controlled trial will compare communities receiving usual care with communities where
traditional midwives received support in addition to the usual care. The intervention was defined in collaboration
with participants in a 2012 pilot study. Supported midwives will receive a small stipend, a scholarship to train one
apprentice, and support from an intercultural broker to deal with Western health personnel; additionally, the health
staff in the intervention municipalities will participate in workshops to improve understanding and attitudes
towards authentic traditional midwives. A baseline and a final survey will measure changes in birth and pregnancy
complications (primary outcomes), and changes in gender violence, access to healthcare, and engagement with
traditional cultural activities (secondary outcomes). The project has ethical approval from the participating
communities and the Universidad Autónoma de Guerrero.
Discussion: Indigenous women at the periphery of Western health services do not benefit fully from the
attenuated services which erode their own healthcare traditions. Western health service providers in indigenous
communities often ignore traditional knowledge and resources, inadvertently or in ignorance, disrespecting
indigenous cultures. Improved understanding between midwives and the official healthcare system can contribute
to more appropriate referral of high-risk cases, improving the use of scarce resources while lowering costs of
healthcare for indigenous families.
Trial registration: ISRCTN12397283. Retrospectively registered on 6 December 2016.
Keywords: Traditional midwives, Cultural safety, Epidemiology, Randomised Controlled Trial, Equity in access,
Aboriginal health
* Correspondence:
CIET/PRAM, Department of Family Medicine, McGill University, 5858 Chemin
de la Côte-des-Neiges 3rd Floor, Suite 300, Montreal H3S 1Z1, Quebec,
Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá,
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.
Sarmiento et al. Trials (2018) 19:354
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Maternal mortality and morbidity remain inequitable
burdens for indigenous women in Mexico, as in many
other countries [1,2]. Modern obstetric care, especially
in emergencies, can be key to survival [3,4] and, in
remote indigenous communities where the needs might
be more pressing, women almost invariably receive
poorer-than-average health services [5,6]. Inappropriate
allocation of state resources and weakness of local gov-
ernments are part of the problem on the supply side [7].
On the demand side, lack of interaction with traditional
knowledge systems in Western medical facilities has led
many indigenous women to shun Western health
services [8]. One consequence, in many remote indigen-
ous communities, is that traditional midwives are the
only source of care available for maternal health [9].
Much of the research to address this state of affairs fo-
cusses on short-term training of non-traditional
task-oriented birth attendants, and training of traditional
midwives in Western birthing concepts and practices
[912]. A systematic review summarising 60 experimen-
tal and quasi-experimental studies of training traditional
birth attendants (TBAs) found a small reduction of peri-
natal and postnatal mortality, and that trainees remem-
bered the content of their training (improvement in
knowledge)[13]. A 2011 meta-analysis synthesised six
cluster-randomised controlled trials (RCTs) of training
and support of TBAs [14]. All six RCTs found a reduc-
tion in perinatal death (Number Needed to Treat (NNT)
35, 95%CI 2470) and neonatal death (NNT 98, 95%CI
66170). Three of the RCTs reported on maternal mor-
tality and showed a non-significant reduction.
A 2009 systematic review found low/moderate-quality
evidencesuggesting that training TBAs may improve
linkages with facilities and improve perinatal out-
comes, and meta-analysis showed an 11% reduction in
intrapartum and intrapartum-related neonatal mortality
[12]. A synthesis of systematic reviews published in 2014
concluded that in low- and middle-income countries
training TBAs, as a part of community-based intervention
packages showed significant improvement in referrals (RR
1.4, 95%CI 1.191.65),significant reductions in maternal
morbidity (RR 0.75, 95%CI 0.610.92), neonatal mortality
(RR 0.76, 95%CI 0.680.84) and perinatal mortality (RR
0.80, 95%CI 0.710.91)[15]. The success of programmes
was found to be context specific [16], and related to better
communication with formal healthcare systems [1618].
Throughout the academic literature, the term birth at-
tendantinstead of midwifeignores cultural issues and
the experience and full social role of traditional mid-
wives [19]. The research focus on training assumes the
inferiority of traditional midwifery, or their lack of com-
petence in birthing techniques [20]. The emphasis is on
compliance with Western midwifery, rather than on the
strengths of traditional midwifery [10]. The World
Health Organisation (WHO) excludes traditional mid-
wives from the category of skilled birth attendants, re-
serving this term for those midwives with formal
Western training [7,9]. We have not found any pub-
lished RCT that tests the value of supporting the original
practices of traditional midwives.
Terminology: authentic traditional midwives
Birth traditions in most indigenous cultures involve the
support of a traditional practitioner, frequently called in
the academic literature untrained traditional birth atten-
dants (TBAs) [9,21]. To clarify terminology, we distin-
guish between (1) authentic traditional midwives, whose
recognition by their communities is reflected in the
number of births they attend each year and the trad-
itional knowledge they hold, (2) casual or coincidental
birth helpers, who might help in a family or neighbour-
hood emergency and (3) skilled or trained birth atten-
dants, often conflated by acronym with TBAs, who
attend courses in Western birth practices and who might
receive official certification.
Our concern in this trial is exclusively authentic trad-
itional midwives, recognised in their own cultures and
accessed by their communities. We prefer not to abbre-
viate the term, in order to avoid confusion with Western
concepts of trained birth attendant or TBA. For econ-
omy of words we refer to them as traditional midwives.
Traditional midwives are part of the traditional health
system of their communities [22]. Beyond their technical
role in pregnancy and birth, traditional midwives are
counsellors and indigenous knowledge bearers, transmit-
ters of culture and cultural values [23]. Some traditional
midwives take government training courses, similarly to
the skilledor trained birth attendants, when these
courses allow traditional midwives to obtain birth certifi-
cates for the children they deliver. Some traditional mid-
wives might incorporate aspects of Western obstetrics;
for example, cutting of the umbilical cord, into their
practice [24]. What distinguishes traditional midwives is
their rootedness in community and culture, and this is
confirmed by the confidence placed in them by their
communities. Usually female the Mephaa or Tlapa-
neco of Guerrero also have male parteros they accom-
pany the pregnancy, attend the birth and advise on care
of the newborn [25,26].
The pilot study
A pilot cluster-RCT tested the feasibility and acceptabil-
ity of an intervention to support authentic traditional
midwives between 2008 and 2012 [27]. The pilot was
not powered to determine the effect of the intervention,
but it did measure outcomes in the intervention and
control group, in order to establish that the intervention
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was not likely to have an adverse effect on maternal
morbidity and mortality.
The pilot study was conducted in Xochistlahuaca
municipality with Nancue ñomndaa (Amuzgo) communi-
ties and included 16 indigenous women clearly considered
to be traditional midwives by the communities. These
traditional midwives were randomly assigned into two
groups, one of which received a co-designed intervention
Each intervention midwife received financial support
to pay an apprentice (about US$8 per month); had ac-
cess to a local birthing centre (purpose-built, rented or
loaned); and received logistical support from a male
community health worker who could arrange transport
for women referred to the local hospital and who could
interact with the hospital staff on behalf of the trad-
itional midwives, many of whom could not speak Span-
ish. Control communities continued receiving usual
care, provided mainly by the healthcare centre (hospital
básico comunitario) located in the municipal capital of
Xochistlahuaca and by traditional midwives without ex-
ternal support. An unknown proportion of indigenous
women in the rural areas of the municipality did not re-
ceive healthcare either from Western health staff or
from traditional midwives.
The pilot showed that a larger trial would be feasible.
It allowed us to adjust the intervention, to design and
test questionnaires, to establish the local capacity needed
to conduct a larger study, and to identify costs of the
intervention. The pilot established the acceptability of
the intervention according to three criteria. First, the
intervention was safe; the groups with midwives receiv-
ing support did not have worse health outcomes and did
not report complicated cases related to the intervention
(see below). Second, the communities did not react
against the recovery of traditions; some previous experi-
ence had suggested that some community members,
particularly the younger ones, might interpret an inter-
vention to support traditional midwives as an attempt to
reduce the services provided by the Government. Third,
the staff at the local healthcare centres accepted an in-
creased involvement of midwives with no conflicts which
would make the health authorities stop the intervention.
The pilot found similar levels of pregnancy complica-
tions between women in exposed communities (24/94)
and controls (65/252) (OR 0.99, 95%CI 0.521.71). It
was not intended to measure mortality but, in the event,
results were compatible with a positive effect of support-
ing traditional midwives on reducing birth complications
(9/91 exposed and 57/248 controls reported birth com-
plications, OR 0.37, 95%CI 0.110.73). Women living in
the intervention area did not report any neonatal deaths
during the last year of the intervention (0/93, compared
with 6/254 in control area, chi-square = 2.2, p= 0.13).
The pilot also suggested advantages for women in terms
of skilled birth attendance (92/94 among exposed and
233/253 among controls were assisted by a traditional
midwife or physician, OR 3.95, 95%CI 1.015.59).
The significantly lower birth complications in inter-
vention communities were likely due to two factors: (1)
improved referrals as a result of the intercultural broker-
age; and (2) increased use of traditional midwives in the
intervention area, resulting in fewer women giving birth
without a skilled birth attendant. The pilot demonstrated
acceptability of the intervention among the communities
and the economical and logistical feasibility of support-
ing traditional midwifery. The pilot also built local cap-
acity for intercultural and multi-disciplinary research
that is scientifically valid and also takes full account of
the local cultural context.
The overall objective is to reduce maternal morbidity
and mortality in indigenous communities without fur-
ther marginalising or undermining their cultures. The
overall hypothesis is that recovery and strengthening of
traditional healthcare have a positive impact on indigen-
ous peoples health. An explicit intention is to develop
an intercultural approach that reduces the dependence
on external resources and promotes the cultural assets
of indigenous communities.
Specific objectives of the study are: (1) to assess the
impact on maternal health outcomes of a co-designed
intervention to support traditional midwives in four mu-
nicipalities of Guerrero; (2) to assess the secondary or
social outcomes of this intervention, including gender
violence against pregnant women and behaviours related
to traditional midwives; and (3) to evaluate the economic
cost of the intervention.
Research question: Among the four main indigenous
groups in Guerrero, does support for authentic trad-
itional midwives lead to non-inferior maternal health
outcomes and improved social outcomes within the
study period, when compared with usual care?
Theory of change: Intercultural brokers increase
effective contact with Western health services; this
improved referral generates better maternal outcomes by
allowing obstetric attention to focus on those who need
it most. Better maternal outcomes, along with the
apprentices and economic support provided by the inter-
vention, increase prestige of traditional midwives within
the communities. Midwivesprestige promotes cultural
continuity and strengthens the social fabric. Addition-
ally, this prestige expands their services among women
who do not need specialist obstetric intervention, thus
decreasing pressure on poorly funded healthcare ser-
vices. The no-longer-overloaded healthcare services are
Sarmiento et al. Trials (2018) 19:354 Page 3 of 15
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then better able to deal with emergency cases and those
in need of Western obstetric care, which further im-
proves maternal outcomes.
Design of the study
A parallel-group pragmatic cluster-RCT will test the
non-inferiority of maternal health outcomes of an inter-
vention to support authentic traditional midwives in four
indigenous groups (Mephaa, Nahua, Na savi and Nan-
cue ñomndaa) in four municipalities (Atlixtac, San Luis
Acatlán, Acatepec and Xochistlahuaca) in Guerrero State
(Fig. 1)[28].
The setting
Indigenous people make up one third of the worlds
poorest rural people, and this is also true of indigen-
ous people living in Guerrero, currently Mexicos
third poorest state [29,30]. Of the 481,000 indigen-
ous people in the state, Nahua make up 40%, Na savi
(Mixteco) 28%, Mephaa (Tlapaneco) 22% and Nancue
ñomndaa (Amuzgo) about 9%. They live in scattered
and often remote communities with poor access to
government services and rely mainly on subsistence agri-
culture. Most speak their traditional languages and
self-identify as indigenous. Government-conditional
cash-transfer programmes give a monthly US$15 incentive
to indigenous women for improving attendance to official
healthcare services and food consumption. Indigenous
people in Mexico have less than average access to the
countrys main health insurance system, and indigenous
peoples of Guerrero state have the lowest access among
indigenous groups nationally [31].
Where they are available outside of the cities, health
services are often poorly staffed and of poor quality. In
part, this is due to lack of qualified medical personnel.
In the Montaña region of Guerrero, home to the Na savi
and Mephaa peoples, there are no obstetric services
within 1 daystravel for the population of several hun-
dred thousand. Only one in four of Mexicos indigenous
women has completed secondary education, a require-
ment for training as a skilled birth attendantin govern-
ment programmes.
In Mexico, as elsewhere in Latin America, maternal
and perinatal mortality among indigenous peoples is
poorly documented. Indicators of indigenous maternal
and child health in Guerrero State are below the na-
tional average, and maternal deaths are three times
more common than in the non-indigenous population
[2,32]. Maternal mortality is five to six times the na-
tional average (281/100,000 in Zona Centro de Guer-
rero, compared with 51 in Mexico at large) and
infant mortality three to four times higher (89 com-
pared with 28 per 1000) [32,33].
Eighty indigenous communities in four municipalities
with a total of around 8000 households. The study will
include all indigenous women who give birth or become
pregnant during the study period, and their adult family
The intervention
The intervention has four components that incorpor-
ate the co-design exercise from the pilot study and
subsequent discussions with the midwives in the four
indigenous groups. The intervention comprises activ-
ities to invigorate the practice of traditional midwifery
and increase the interaction of traditional midwives
with the Western healthcare system. The intervention
does not define a protocol for the management of
motherhood in these communities; thus, Western
physicians and traditional midwives remain autono-
mous in their own practice.
Component 1. Material support for 30 authentic trad-
itional midwives. Each traditional midwife in the inter-
vention group will receive a monthly stipend of US$20.
This small financial support is meant to allow the trad-
itional midwives access to basic goods and increase the
Fig. 1 Map of the participating municipalities
Sarmiento et al. Trials (2018) 19:354 Page 4 of 15
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time that they have available for their practice and pa-
tient care; most of these traditional practitioners are
low-income elderly depending on their own work or on
support from their families. Additionally, the small
monthly payment will be a symbol of external esteem
for the role of these traditional midwives, thus increasing
their recognition among community members. Field co-
ordinators will be in charge of the payments to the trad-
itional midwives in the intervention municipalities.
Component 2. Scholarship support of one apprentice
for each midwife. The midwives in the intervention
group will each appoint one apprentice to receive a
monthly stipend of US$10; the midwife will decide on
the training programme and the criteria to evaluate the
achievements of her apprentice. The midwife will au-
thorise the payment for the apprentice, while the field
coordinators will be in charge of the disbursement. The
apprentices will support the practice of the traditional
midwives, particularly in tasks that the midwives can no
longer perform due to their age. This component will
foster the intergenerational transfer of traditional mid-
wifery practice and increase its recognition by commu-
nity members.
Component 3. Improving understanding and attitudes
of staff in the local government health centres towards
traditional midwives. In this component, senior re-
searchers from the Centro de Investigación de Enferme-
dades Tropicales in the Universidad Autónoma de
Guerrero (CIET) will lead a workshop in each municipal-
ity to present evidence about the role of traditional mid-
wives and the importance of intercultural skills for
Western medical practice. The workshop participants
will be the personnel from two primary healthcare cen-
tres and ten rural health posts in the intervention muni-
cipalities. The workshops will focus on presenting
technical data to the staff and will not include traditional
midwives, to avoid potential confrontation during this
initial stage. Although we expect changes in the attitudes
of the staff in the intervention municipalities, their clin-
ical practice remains independent of the project.
Component 4. Training of intercultural brokers (técni-
cos interculturales de salud). A total of 17 community-
appointed people will receive training. Inclusion criteria
are: being a member of the relevant ethnic group and
having basic understanding of traditional culture and
Western health services. Each community will follow
their own customs to select the candidates.
The training programme will build on previous experi-
ences from Colombia tailored to local conditions of
Guerrero [34], and its content will be organised into
three thematic lines: culture, nature and health (Table 1).
This triple thematic approach reflects a concept of
health promotion that seeks to implement actions with
positive impact not only on individual health but also on
the cultural and environmental domains. Each thematic
line comprises theoretical and practical sessions totalling
280 hours of class in 2 months. The training will take
place in Acapulco, under the supervision of CIET and with
support from Colombian instructors from the Centre for
Intercultural Medical Studies. The project will provide ac-
commodation and food for the trainees in Acapulco.
Another guiding principle of the training programme
for the intercultural brokers is the promotion of inter-
cultural dialogue between indigenous and Western cul-
tures [35]. This principle is the basis for the intercultural
brokerage that the trainees will undertake when they re-
turn to their communities [36].
Once in their communities, the brokers will design
a work plan applying the course contents to the spe-
cific needs that they identify for their communities.
Each broker will support one to two midwives, and
together they will cover two to three contiguous enu-
meration areas. The brokers will define these plans in
consultation with the traditional midwives supported
by them. The plan will consist of two linked compo-
nents: activities to accompany the traditional mid-
wives and actions for health promotion with an
emphasis on womens and maternal health. These ac-
tivities will follow a pattern of implementation where
the brokers will start with activities applying the con-
tents learned during the training upon themselves,
then they will involve their families and, finally, with
increasing confidence, they will involve other mem-
bers of their communities.
The intervention will be coordinated by a local
team based at CIET. The local team has more than
30 years of experience working in the rural areas of
Guerrero. The intervention begins immediately after
the training of intercultural brokers (component 4)
and will continue for 2 years. Any change in the
protocol will be notified to the registry of the trial
(Fig. 2, Additional files 1and 2).
Control communities receive usual healthcare services.
Usual perinatal care for indigenous women in the Mon-
taña region of Guerrero is provided by Western physi-
cians (54.6%), nurses (4.2%) and traditional midwives
without external support (20.7%); however, some 20.5%
of these women do not have any antenatal care. Among
those who received antenatal care, more than 3 out of
ten women received less than five antenatal check-ups,
the minimum indicated by Mexican standards [37].
In this region, Western physicians (36%), nurses (8%)
and traditional midwives without external support
(47.9%) provide usual care for childbirth. Some 8.1% of
the indigenous women had other or no source of care
[37]. Control municipalities have a healthcare centre
(hospital básico comunitario) in San Luis Acatlán as well
as two rural posts (centro de salud rural and unidad de
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consulta externa) in Atlixtac. In both cases, healthcare
facilities are located in the population centres and
provide services for the entire municipality. Women
in remote areas need several hourswalking or travel
by gravel road to reach the closest healthcare facility.
Regional general hospitals (Ometepec and Tlapa) at-
tend the complicated cases remitted from these com-
munities [38].
The intervention will become obvious to residents
in the intervention sites, and some outcomes (particu-
larly social cohesion) could be influenced by know-
ledge of intervention status. The main outcome
indicators (non-inferiority for morbidity and maternal
mortality) and other secondary outcomes would be
less susceptible to this bias.
Outcome measures
For objective (1), the central concern is the added
benefit of supporting traditional midwives in a con-
text of non-inferior maternal and neonatal mortality.
The limited size of the populations involved hinders
mortality estimates and increases reliance on inter-
mediate outcomes: birth problems among survivors of
pregnancy in the past year. We will measure maternal
mortality and morbidity and neonatal mortality through
direct questions in each household.
Secondary outcomes (objective (2)) include (a) reduc-
tion of social disruption, indicated by gender violence
against pregnant women and (b) improvement in inter-
mediate outcomes towards more engagement of women
in their culture of origin. The CASCADA model de-
scribes these intermediate outcomes in a results chain
based on the theory of planned behaviour, overcoming the
well-documented limitations of the Knowledge, Attitude
and Practices (KAP) model [39,40]: Conscious knowledge,
Attitudes, positive deviation from Subjective norms, inten-
tions to Change behaviour, Agency (individual and collect-
ive), Discussion/socialisation of possible action and,
finally, Action or change of practice [41]. Two randomised
trials in Pakistan and Mexico, a cross-sectional study in
Southern Africa, and a qualitative analysis of narratives in
three Southern African countries have used the CAS-
CADA model [4246].
Table 1 Content of the course for training intercultural brokers
in Guerrero State (May to June 2015)
Content Thematic
Introductory module
Western medicine, biomedical model and
traditional health
Memory, will, and concepts about medicinal plants
Traditional concept of heat and cold
Nature and environment Nature
Culture and intercultural dialogue Culture
Traditional knowledge
Module of applied concepts
Cultural context and identity in Mexico Culture
National and international legislation on
behalf of indigenous peoples
Internet, accounting basics and management
Cultural diversity
Oral tradition
Traditional values and principles
Indigenous education
Basics of ecology Nature
Soils and organic fertiliser
Participatory mapping
Tools for nature observation
Biological diversity and its relation with cultural
Territories conserved by indigenous communities
Food sovereignty and local food
The health system of Mexico and official health
The human body
Vital signs
First aid and injections
Management of emergencies
Wound care
Most prevalent health problems in Guerrero
(dengue, chikungunya, skin disorders, scorpion
sting, diabetes, violence and oral health)
Healthcare of a healthy child
Healthcare of a sick child (undernourishment,
acute diarrhoea, acute respiratory infection,
intestinal parasitic infections)
Final cross-cutting module
Womens health
Self-care promotion
Support of traditional midwifery
Table 1 Content of the course for training intercultural brokers
in Guerrero State (May to June 2015) (Continued)
Content Thematic
Practices and fieldwork
Practice: building a planting bed
Fieldwork: nature observation and planting bed
Fieldwork: botanical garden
Fieldwork: archaeological sites
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In this case, the CASCADA model will reflect con-
scious knowledge of the traditional midwife, a positive
attitude about using her services, a positive deviation
from a negative subjective norm about traditional mid-
wifery, intention to change in a future pregnancy, the
agency to implement these choices, discussion of the
choices with partners and, ultimately, interaction with
the supported traditional midwife.
The economic outcome measures (objective (3)) are
described below under Economic analysis.
The study will have two measurement points: a base-
line survey administered by trained bilingual indigenous
interviewers (February and March 2015) and a follow-up
survey using the same procedure and questions about
pregnancy experiences and outcomes to women preg-
nant during the past year (May 2017). The period of
inquiry for the final survey is defined to avoid any over-
lap with the pre-intervention period. Given the extent of
the region, logistical constraints mean it is not feasible
to have continuous or mid-term data collection.
The surveys will use instruments tested during the
pilot study and will include questions about: maternal
deaths, neonatal deaths, number of times women are
seen by the traditional midwife during pregnancy, pro-
portion of births at home attended by midwives or with-
out external assistance, frequency of recourse to the
traditional midwife in case of pregnancy complications,
frequency of recourse to the traditional midwife in case
of complications with newborns, proportion of women
intending to have future births at home, infection post-
partum, and cost of birthing. Among women who gave
birth in health institutions, we also will ask questions
about their treatment, including birth position, availabil-
ity of translators, presence of family members at the
birth, presence of the traditional midwife at the birth,
bathing in cold water, treatment of the placenta, reten-
tion of amulets, and how respectful they consider their
treatment to have been.
Secondary outcomes measured in the follow-up survey
will include: prevalence of violent acts towards pregnant
Fig. 2 Schedule of enrolment, interventions and assessments for the study Safe Birth and Cultural Safety
Sarmiento et al. Trials (2018) 19:354 Page 7 of 15
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women, opinion as to whom the woman should consult
first when she learns that she is pregnant, opinion of who
should attend to the woman first if she has complica-
tions during pregnancy, opinion as to who should decide
whether to take the woman to the hospital if there are
complications during childbirth, perception of neigh-
bourspreferences as to who should provide antenatal
care, perception of neighbourspreferences as to home
vs institutional birth.
A qualitative mid-course peer evaluation using the Most
Significant Change technique with local stakeholders will
provide information about progress and the relevance of
secondary outcomes regarding cultural safety [47]. This
technique is a participatory method for monitoring and
evaluation of complex projects in which participants nar-
rate stories describing the most significant changes they
attribute to the intervention, and implementers review the
stories. This will provide information about change dy-
namics, identify issues in implementation and provide
moral support for the intercultural brokers.
Random allocation of the intervention
The total of 80 enumeration areas in the four municipal-
ities are home to the four main indigenous groups (Fig. 3).
If we allocated the intervention at the level of enumer-
ation areas, we would expect a substantial contamination
effect within each municipality (mothers from control
enumeration areas going to authentic traditional midwives
in the intervention enumeration areas) with strong
spill-over influence within the same indigenous group
served by the intervention midwives; through schools; and
through local government or non-governmental organisa-
tions (NGOs) taking up the emerging evidence to guide
interventions in control enumeration areas. This contam-
ination would reduce the measured difference between
control and intervention enumeration areas. To avoid this,
the study will centrally randomise the intervention to two
of the four municipalities (40 enumeration areas, 20 in
each municipality).
Data entry and security
Independent operators will enter questionnaire
responses twice, with verification of discordant entries
from the original questionnaires. Researchers will check
digitised data for logical errors. We will handle question-
naires from intervention and control sites in exactly the
same way, with data technicians unaware of the inter-
vention status of clusters.
Principal analysis
With 80 communities allocated evenly between the
intervention and control arms, the principal analysis of
primary outcomes will follow intention-to-treat princi-
ples using a cluster t-test (everyone included in each
cluster, per allocation). We will report outcomes as abso-
lute event rates among intervention and control groups,
risk difference with two-sided 95% confidence intervals
(95%CIs) and one-sided 97.5% confidence intervals for
the non-inferiority analysis, and relative risk reduction
(RRR) with 95%CI [48]. The intracluster correlation co-
efficient (ICC) will be calculated by dividing the
between-cluster variance by the variance within and be-
tween clusters.
Sensitivity analysis will focus on the different ethnic
groups and their accompanying government health ser-
vices. It will also examine the four intervention compo-
nents separately because, although all components are
available for all participating midwives, we expect a
range of implementation in practice.
Secondary analysis
In each cluster, we will collect relevant data from the
local government to determine rates of reported local
crime and level of engagement in civic affairs.
Individual-level data in a multilevel/hierarchical regres-
sion modelling technique will take into account group
Planned subgroup analysis and reporting include a focus
on the gender of the offspring. Age of the traditional mid-
wife is also of interest because it is a core issue in the re-
covery of traditional healing and care practices.
The statistical analysis of data will rely on CIETmap,
an open-source interface with the R programming lan-
guage [49].
Economic analysis
The economic dimension is not trivial. Intercultural dia-
logue can lead to new solutions for health promotion
based on adequate use of local resources [50]. Evaluation
of the work of traditional midwives should recognise
that far fewer official resources support their work than
support Western-trained birth attendants. Finally, cul-
tural loss and depletion of natural resources around in-
digenous communities mean that some authentic
traditional midwives cannot work at full capacity and in
these cases we may need to implement some actions to
strengthen traditional health systems or at least take into
account this imbalance in the measurement process.
In 2 years, the intervention might change some
population-based maternity outcomes, allowing aggre-
gated costs to be compared between intervention and
control municipalities. The concern is to quantify the
somewhat increased cost of adding the intervention and
the much-increased access this affords to indigenous
women. A starting point is an assessment of site-specific
maternal health services available to indigenous women
Sarmiento et al. Trials (2018) 19:354 Page 8 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
from a societal perspective, based on (1) the implemen-
tation costs of these services and (2) the implementation
costs of the Safe Birth and Cultural Safety project. Site
visits and in-person interviews with representatives of
services and of the project will assess local implementa-
tion costs. We will measure costs in Mexican pesos and
convert into US$ to allow for international comparison.
From the results of the final survey, we will identify dir-
ect benefits in terms of maternal mortality and morbidity
indicators, particularly birth complications. Additional
benefits we expect to evaluate are (1) change in access/up-
take of services and (2) secondary effects like increases in
social capital, health literacy, or community planning skills
in maternal health services. Finally, we will identify the
completeness and timing of implementation to provide a
context. We will express the relation between benefits and
differences in costs using cost-effectiveness ratios [51].
A third component of the economic analysis will pro-
ject the costs and effectiveness of implementing the pro-
ject using alternative models of intervention to enhance
sustainability. The specific objectives of this component
will be to predict the most cost-effective strategy for
wider implementation of Safe Birth and Cultural Safety.
It will also help to identify the resources (including local
government funding and community participation)
needed for rollout.
Missing data
All communities experience in-migration and
out-migration. We will add new arrivals to the study but
will not follow those leaving the clusters. We do not
have reason to expect differential out-migration between
intervention and control clusters. Self-selection (decision
not to participate or not to answer certain questions) in
the surveys is a concern. Those who opt not to respond
may be less involved with safe motherhood initiatives
thus affecting the measured effect. Therefore, we will
characterise subjects with missing data as far as possible
and analyse the effect of missing data using the multiple
imputation method in the Amelia II programme [52].
Sample size calculation
Borrowing from the field of bioequivalence, equivalency
trials and their statistical testing procedures focus on
non-inferiority margins [53]. We expect that supporting
traditional midwives does not result in worse primary
outcomes of maternal health than does the available
usual care in the region, principally because so few indi-
genous women in the study area access available ser-
vices. Under the non-inferiority hypothesis, the trial
might show equivalent or superior effects of the inter-
vention [54]. The pilot study suggested additional bene-
fits that secondary outcomes accrue from a culturally
safe intervention. In the absence of previous studies in
similar settings, we established a practical margin for
non-inferiority-based discussion of findings with local
authorities and indigenous communities. The resulting
computation of study power illustrates the possibilities
of demonstrating non-inferiority in these small commu-
nities of fixed size.
Fig. 3 Flow diagram of the study Safe Birth and Cultural Safety
Sarmiento et al. Trials (2018) 19:354 Page 9 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Based on 2013 data, we expected 5752 births across the
four municipalities [55]. This study size is too small to use
maternal mortality as an outcome over the funded dur-
ation of the trial, using 150% as the minimum
non-inferiority margin to be detected. For birth complica-
tions as primary outcome, this study size can detect differ-
ences within a practical margin for non-inferiority of 15%,
with 80% power at a significance level of 5% (Fig. 4).
For the secondary outcome of improved skilled birth
attendance (birth assisted by traditional midwife or
physician), the pilot study suggested a rate of 92% in
control communities (k-statistic 0.011). Follow-up of
1438 births in each cluster (two clusters per arm) would
detect a 6.2% increase in skilled attendance (92.1% to
97.8%) with 80% power at a significance level of 5%
(allowing us to set the non-inferiority margin at 15%).
These calculations assume no interaction effects with
cluster as unit of primary analysis in unmatched parallel
groups and relied on the trial simulator devised by Tay-
lor and Bosch [56].
Implications for health services
Strengthening traditional healthcare practices can lead
to better maternal health outcomes for at least three rea-
sons: a better use of local resources owned by communi-
ties; healthcare actions take into account the culture of
the people and the environmental characteristics of the
territory; and an increased level of cultural safety in ob-
stetric care.
For many indigenous communities, place of birth and
engagement in childbirth are deeply connected to their
identity, viability of their cultures and territories, and
their systems of governance [57,58]. Some link the im-
positions associated with hospital births with marginal-
isation of their knowledge systems, and this can have
serious social and cultural consequences [59,60].
Traditional midwives hold detailed knowledge of each
woman during her pregnancy, placing them in an ideal
position to refer those who need specialised care like
caesarean section to Western obstetricians [61,62]. A
system built on these synergies could result in less de-
mand on already overloaded obstetric services,
higher-quality care for those who need it and, with more
resources available for those requiring surgical interven-
tions, fewer post-delivery complications [16,63].
Ethical considerations
We do not anticipate adverse events or side effects. As
communities in the pilot project adopted traditional mid-
wives supported by the project, they continued to use gov-
ernment services for complications that traditional
midwives do not deal with. In the pilot study significantly
lower complication rates and infection rates among those
using traditional midwives suggest improved referral and
self-referral. There were no negative reactions from the
government health services, which received increased re-
ferrals of high-risk cases.
The Ethics Committee of the Centro de Investigación
de Enfermedades Tropicales of the Universidad Autón-
oma de Guerrero approved the trial on 22 October 2013
(Reference 2013014). Community assemblies represent-
ing the indigenous peoples involved in the trial approved
the project between January and February 2015. We
adopted the ethical principles for medical research in in-
digenous communities proposed by the Research Group
on Traditional Health Systems [64].
Informed consent: After clarification of the catchment
area of each midwife, field coordinators from the project
will identify a suitable community leader able to speak
on behalf of the community. They will explain the pro-
posed study and that the community might or might not
be allocated to receive the intervention; then, they will
seek their permission to include the community. This
community leader will follow the traditional ways of the
indigenous communities to reach the final decision
about participation.
Informed consent for interviews: Trained interviewers
will explain to respondents the nature of the study and
the voluntary nature of their participation using suitable
local language. They will explain that participants may
decline to answer any questions that they do not wish to
answer, may refuse to participate in the activity, and may
end the interview at any time. Interviewers will clarify
the procedures to ensure confidentiality. They will then
ask respondents for oral informed consent for the inter-
view. The informed consent is oral because of the high
rates of illiteracy among the participants.
There will be no biological samples taken.
Ensuring confidentiality: Fieldworker and data operator
training will emphasise their responsibility for maintain-
ing confidentiality of all information accessed during the
work. We will report grouped findings in a way that
does not allow identification of any individuals or com-
munities. No names or identifiers will be recorded next
to individual questionnaire responses and reports of
findings will not identify individual communities.
Protection of emotional well-being: It is possible that
questions about infant and maternal deaths could
awaken distressing memories. If this happens, the inter-
viewer will stop the interview, assess the condition of
the respondent, use words of support, and immediately
inform the field coordinator. The field coordinator will
inform the project coordinator (an experienced re-
searcher and physician) to decide the actions needed to
ensure the welfare of the participant. The field coordin-
ator will be responsible for ensuring that these actions
are completed. Our experience suggests that the
opportunity to engage in household and community
Sarmiento et al. Trials (2018) 19:354 Page 10 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
protection to be uplifting and a self-affirmation for par-
ticipants. We will provide specific training for inter-
viewers about asking sensitive questions.
Normative pressure within communities: The pilot re-
vealed no pressure on women to seek help from the
traditional midwives in intervention communities. How-
ever, government conditional cash transfer programmes
may have a strong influence towards choosing to use
government supported health centres. The clinical
practice of the staff in the government health centres in
the intervention municipalities will remain independent
of the project.
Data security: Digital records will be secure and ac-
cessible only to the principal investigators. Original
paper records will be securely transported, stored,
retained and finally destroyed in accordance with CIET
guidelines for security, storage and eventual destruction
of paper records.
Fig. 4 Power of the sample in relation to the margin of non-inferiority for maternal mortality and birth complications
Sarmiento et al. Trials (2018) 19:354 Page 11 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Recent studies in indigenous communities confirm the
importance of sociocultural dimensions of safe mother-
hood [57,60,65,66]. Most indigenous communities face
a transition from ancient traditions to Western culture,
implying dual healing resources and a complex process
of health choices [67]. This cultural transition involves
changes in education and service delivery but is an in-
complete process in many places, leaving important gaps
[68]. For example, indigenous people shun Western ser-
vices as a reaction to feeling that their culture and values
are ignored [20,57,59,69]. Women in these settings fall
between the two cultures, where traditional services are
attenuated if not actively undermined, but where there is
not full access to Western services [70]. Therefore, pro-
motion of intercultural dialogue could open a way for
indigenous women to think more highly of Western ser-
vices and to use them more efficiently [68].
The support requested by the traditional midwives
during co-design of the intervention in the pilot study
included an apprenticeship programme. In this import-
ant sense, authentic traditional midwives represent re-
newal of their communities and the intergenerational
transfer of traditional midwifery skills. Traditional mid-
wives might be a factor in social cohesion, in marital
harmony or in the socialisation of young people. Support
for traditional midwives means support of recovery and
reinforcement of authoritative indigenous knowledge.
Most recent research follows the convention of upgrad-
ingthe skills of traditional midwives in Western concepts
of safe motherhood [63,7173]. Often, these approaches
rely on ill-suited methods and often inappropriate
teachers a young Western nurse who is supposed to
teachwomen three times her age and who might
dismiss or discourage indigenous practices [20,61].
This limited understanding of tradition and culture has
had deleterious effects on traditional midwifery roles
[19,72]. This trial shifts the focus to support for, rather
than replacement or reinvention of traditional mid-
wives. We are not aware of accounts of other trials tak-
ing this approach.
Training local community leaders as intercultural bro-
kers (técnicos interculturales) to bridge the intercultural
gap is the centrepiece of the trial. Our approach is to
foster intercultural dialogue in support of both the trad-
itional midwife and the Western obstetrician, each to do
what they do best. The argument has never been that
traditional midwives might carry out caesarean sections,
nor that Western obstetricians are well placed to sup-
port indigenous women on issues like work in pregnancy
or intimate partner violence. It makes sense to combine
primary, secondary and tertiary prevention of maternal
morbidity and mortality through an adequate interaction
between the two health systems.
Community health workers have long been recognised as
relevant to most service delivery priorities at the primary
healthcare level, particularly in under-served areas[74].
The intervention does not seek to train community workers
to deliver clinical services, but rather to train intercultural
brokers to liaise between communities and health services,
especially for promoting prevention strategies for maternal
and child morbidity [75]. This will be the first trial provid-
ing information about the value of this sort of training of
intercultural brokers in improving maternal outcomes.
This trial might contribute to the discipline of intercul-
tural epidemiology by adapting high-value epidemiological
methods to study traditional medical practices in remote
indigenous settings. Safe motherhood in cultural safety
must go beyond simply classifying indigenous women as
high risk, and beyond the degrading concept of otherness
implicit in cultural sensitivity and cultural competence [76].
A culturally safe approach recognises traditional culture as
an asset and the damaging effect that cultural loss and dis-
empowerment have on health status of individuals and
communities [77]. Although traditional health systems re-
main in widespread use [78], evidence about their health
impact is scarce and we need attuned epidemiological
methods to understand them [79]. We plan to disseminate
our results in academic settings as well as to communicate
evidence to communities through the intercultural brokers.
Advances of this protocol include use of the pragmatic
RCT design, with large clusters (entire municipalities)
reducing the contamination of control communities. The
involvement of traditional midwives in designing the inter-
vention is likely to be crucial to its success. This is an ex-
ample of developing better practices of intercultural health
based on a respectful intercultural dialogue [35,80].
Trial status
Research protocol, 28 February 2017.
Recruitment start date: 1 July 2015; recruitment end
date: 31 May 2017.
Additional files
Additional file 1: Standard Protocol Items: Recommendations for
Interventional Trials (SPIRIT) 2013 Checklist: recommended items to
address in a clinical trial protocol and related documents: Safe Birth
and Cultural Safety. Description of data: SPIRIT 2013 Checklist completed.
(DOC 123 kb)
Additional file 2: WHO Trial Registration Data Set (Version 1.2.1): Safe
Birth and Cultural Safety. Description of data: information about the study
regarding WHO Trial Registration Data Set. (DOC 43 kb)
CASCADA: Conocimientos Actitudes normas Subjetivas intención de Cambiar
Agencia Discusión Acción (Conscious knowledge Attitudes Subjective norms
intention to Change Agency Discussion Action); CIET: Centro de Investigación
de Enfermedades Tropicales (Tropical Disease Research Centre) at the
Universidad Autónoma de Guerrero, in Mexico; ICC: Intracluster Correlation
Coefficient; KAP: Knowledge, Attitude and Practices; NNT: Number Needed to
Sarmiento et al. Trials (2018) 19:354 Page 12 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Treat; RCT: Randomised controlled trial; RRR: Relative risk reduction;
TBA: Traditional birth attendant
Germán Zuluaga, Carolina Amaya, Juan Pablo Pimentel and Ignacio Giraldo
trained the team of Intercultural brokers and offered intercultural advice for
the definition of the intervention. Abraham de Jesus García and Nadia Maciel
Paulino gave valuable support for fieldwork. The Centro de Investigación de
Enfermedades Tropicales of the Universidad Autónoma de Guerrero is the
sponsor of the project, its team in Acapulco have been actively involved in
the intervention.
The National Council of Science and Technology of Mexico (CONACyT,
PDCPN-2013-214858) is funding the cluster-RCT. McGill University is funding
fieldwork for middle-term evaluation of the intervention (T244294C0G). The
authors thank The Quebec Population Health Research Network (QPHRN) for
its contribution to the financing of this publication. The design, manage-
ment, analysis and reporting of the study are entirely independent from the
sources of funding.
IS participated in development of this proposal and is part of the team that
designed the training programme for intercultural brokers; he will perform
quantitative analysis and the qualitative mid-course evaluation. SPS participated
in the development of this proposal and will manage the trial fieldwork. NA
directed the pilot and participated in the development of the proposal; he
serves as guarantor of the data and principal epidemiologist. AC supported the
design of the trial and the final drafting of the article describing the protocol.
All authors will participate in the publication of study reports. All authors read
and approved the final manuscript.
Ethics approval and consent to participate
The Ethics Committee of the Centro de Investigación de Enfermedades
Tropicales of the Universidad Autónoma de Guerrero approved the trial on 22
October 2013 (Reference 2013014). Community assemblies representing the
indigenous peoples involved in the trial approved the project between
January and February 2015. The clinical practice of the government health
staff in the intervention sites intervention will remain independent of the
project. Each participant will give verbal informed consent.
Competing interests
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
CIET/PRAM, Department of Family Medicine, McGill University, 5858 Chemin
de la Côte-des-Neiges 3rd Floor, Suite 300, Montreal H3S 1Z1, Quebec,
Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario,
Bogotá, Colombia.
Centro de Investigación de Enfermedades Tropicales
(CIET), Universidad Autónoma de Guerrero, Calle Pino s/n Colonia El Roble,
postal code 39640 Acapulco, Guerrero, Mexico.
Received: 28 February 2017 Accepted: 29 May 2018
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... and logistical assistance from a male community health worker) had reduced birth complications compared with their counterparts in control communities. It also suggested other contributions of the intervention, like reduced gender violence [27]. The Safe Birth in Cultural Safety trial tests whether supporting traditional midwives on their own terms results in non-inferior maternal health outcomes while increasing cultural safety around childbirth. ...
... This participatory research applies the principles of cultural safety and aims to promote intercultural dialogue between Indigenous and Western health care traditions. The study was part of a bigger initiative to foster intercultural dialogue [27], in which parties with different cultural backgrounds converge to work out solutions around a shared concern of poorer maternal health outcomes [28,29] by respecting Indigenous skills and ways and recognising the needs of scientific evidence [30]. ...
... Since ethnicity clusters and midwives serve a fixed community base, we used a cluster design. We describe the trial methods fully elsewhere [27]. The study included two levels of clustering: municipalities and communities within municipalities. ...
Full-text available
Background: Available research on the contribution of traditional midwifery to safe motherhood focuses on retraining and redefining traditional midwives, assuming cultural prominence of Western ways. Our objective was to test if supporting traditional midwives on their own terms increases cultural safety (respect of Indigenous traditions) without worsening maternal health outcomes. Methods: Pragmatic parallel-group cluster-randomised controlled non-inferiority trial in four municipalities in Guerrero State, southern Mexico, with Nahua, Na savi, Me'phaa and Nancue ñomndaa Indigenous groups. The study included all pregnant women in 80 communities and 30 traditional midwives in 40 intervention communities. Between July 2015 and April 2017, traditional midwives and their apprentices received a monthly stipend and support from a trained intercultural broker, and local official health personnel attended a workshop for improving attitudes towards traditional midwifery. Forty communities in two control municipalities continued with usual health services. Trained Indigenous female interviewers administered a baseline and follow-up household survey, interviewing all women who reported pregnancy or childbirth in all involved municipalities since January 2016. Primary outcomes included childbirth and neonatal complications, perinatal deaths, and postnatal complications, and secondary outcomes were traditional childbirth (at home, in vertical position, with traditional midwife and family), access and experience in Western healthcare, food intake, reduction of heavy work, and cost of health care. Results: Among 872 completed pregnancies, women in intervention communities had lower rates of primary outcomes (perinatal deaths or childbirth or neonatal complications) (RD -0.06 95%CI - 0.09 to - 0.02) and reported more traditional childbirths (RD 0.10 95%CI 0.02 to 0.18). Among institutional childbirths, women from intervention communities reported more traditional management of placenta (RD 0.34 95%CI 0.21 to 0.48) but also more non-traditional cold-water baths (RD 0.10 95%CI 0.02 to 0.19). Among home-based childbirths, women from intervention communities had fewer postpartum complications (RD -0.12 95%CI - 0.27 to 0.01). Conclusions: Supporting traditional midwifery increased culturally safe childbirth without worsening health outcomes. The fixed population size restricted our confidence for inference of non-inferiority for mortality outcomes. Traditional midwifery could contribute to safer birth among Indigenous communities if, instead of attempting to replace traditional practices, health authorities promoted intercultural dialogue. Trial registration: Retrospectively registered ISRCTN12397283 . Trial status: concluded.
... Three pilot studies randomised an intervention to test the involvement of traditional midwives as facilitators of women groups, 38 the use of mHealth technologies to encourage referrals, 39 or support for traditional midwifery. 40 Following MMAT criteria, 29 our main concern about the qualitative studies was the soundness of data collection methods and the level at which the interpretation of the results was substantiated by data. The quantitative randomised controlled trials were non-blinded due to the participation of communities in the interventions. ...
... Four references reported on programmes exclusively focused on supporting traditional midwifery. [40][41][42][43] Few studies were explicit about how they approached cultural differences, and studies used different terminology and different interpretations of the same terminology. The terms included anthropologic or ethnographic, intercultural, integration of traditional midwives and strengthening of cultural traditions. ...
... Traditional midwives drew their maps in group sessions, building one map of protective factors and another of risk factors. 40 The second study of stakeholder perspectives summarised the views of eight intercultural researchers (three women and five men) with extensive experience in culturally safe health promotion (Mexico, Guatemala, Colombia, Canada, Nigeria, Botswana). All researchers had also contributed to the project that supported Indigenous traditional midwives (above), but none participated in the mapping sessions with the midwives. ...
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Objectives Collate published evidence of factors that affect maternal health in Indigenous communities and contextualise the findings with stakeholder perspectives in the Mexican State of Guerrero. Design Scoping review and stakeholder fuzzy cognitive mapping. Inclusion and exclusion The scoping review included empirical studies (quantitative, qualitative or mixed methods) that addressed maternal health issues among Indigenous communities in the Americas and reported on the role or influence of traditional midwives before June 2020. The contextualisation drew on two previous studies of traditional midwife and researcher perspectives in southern Mexico. Results The initial search identified 4461 references. Of 87 selected studies, 63 came from Guatemala and Mexico. Three small randomised trials involved traditional midwives. One addressed the practice of traditional midwifery. With diverse approaches to cultural differences, the studies used contrasting definitions of traditional midwives. A fuzzy cognitive map graphically summarised the influences identified in the scoping review. When we compared the literature’s map with those from 29 traditional midwives in Guerrero and eight international researchers, the three sources coincided in the importance of self-care practices, rituals and traditional midwifery. The primary concern reflected in the scoping review was access to Western healthcare, followed by maternal health outcomes. For traditional midwives, the availability of hospital or health centre in the community was less relevant and had negative effects on other protective influences, while researchers conditioned its importance to its levels of cultural safety. Traditional midwives highlighted the role of violence against women, male involvement and traditional diseases. Conclusions The literature and stakeholder maps showed maternal health resulting from complex interacting factors in which promotion of cultural practices was compatible with a protective effect on Indigenous maternal health. Future research challenges include traditional concepts of diseases and the impact on maternal health of gender norms, self-care practices and authentic traditional midwifery.
... 14 Part of a larger initiative project to understand the role that traditional midwifery has in safe birth in cultural safety, this scoping review aims to contribute to intercultural dialogue between traditional and Western health systems. 15 Our objective is to collate and assess evidencethat identifies factors, including the role and influence of traditionalmidwives, that affect maternal health in indigenous communities in theAmericas. The larger project will develop a composite theory of change from three knowledge bases: (1) the scoping review described in this protocol; (2) the research team's understanding of the intercultural dialogue dynamics as these relate to safe birth; and (3) traditional midwives' understanding of safe birth. ...
... Representing each knowledge set as a fuzzy cognitive map, we will adapt the Weight of Evidence 16 approach to combine the three sources into one model to inform decision making and a stakeholder-led analysis of a cluster randomised controlled trial. 15 In this protocol, we focus on the procedures to conduct the scoping review and mention the additional use of the review results. A full description of the procedure to combine the three knowledge sources is the subject of an additional report. ...
... Guerrero and the views of the research team involved in a cluster-randomised controlled trial supporting traditional midwifery. 15 This will be completed and reported separately. ...
Full-text available
Introduction: Indigenous mothers often receive culturally unsafe services that do not fully respond to their needs. The objective of this scoping review is to collate and assess evidence that identifies factors, including the role and influence of traditional midwives, that affect maternal health in indigenous communities in the Americas. The results will map Western perspectives reflected in published and unpublished literature to indicate the complex network of factors that influence maternal outcomes. These maps will allow for comparison with local stakeholder knowledge and discussion to identify what needs to change to promote culturally safe care. Methods and analysis: A librarian will search studies with iterative and documented adjustments in CINAHL, Scopus, Latin American and Caribbean Health Sciences Literature (LILACS), MEDLINE, Embase and Google Scholar without any time restrictions, and use Google search engine for grey literature. Included studies will be empirical (quantitative, qualitative or mixed); address maternal health issues among indigenous communities in the Americas; and report on the role or influence of traditional midwives. Two researchers will independently screen and blindly select the included studies. The quality assessment of included manuscripts will rely on the Mixed Methods Appraisal Tool (MMAT). Two independent researchers will extract data on factors promoting or reducing maternal health in indigenous communities, including the role or influence of traditional midwives. Fuzzy cognitive mapping will summarise the findings as a list of relationships between identified factors and outcomes with weights indicating strength of the relationship and the evidence supporting this. Ethics and dissemination: This review is part of a proposal approved by the ethics committees at McGill University and the Centro de Investigación de Enfermedades Tropicales in Guerrero. Participating indigenous communities in Guerrero State approved the study in 2015. The results of the scoping review will contribute to the field of cultural safety and intercultural dialogue for the promotion of maternal health in indigenous communities.
... Our objective was to systematize the knowledge of traditional midwives about risks and protective factors for maternal health among indigenous communities in southern Mexico, to improve the interface between traditional practitioners and the local health services [17]. The work in this manuscript is part of a bigger project to promote safe birth in cultural safety among indigenous communities in the south of Guerrero State. ...
... The work in this manuscript is part of a bigger project to promote safe birth in cultural safety among indigenous communities in the south of Guerrero State. The overall project includes a cluster randomized controlled trial comparing maternal health outcomes in indigenous communities with and without a co-designed intervention to support the role of traditional midwives [17]. The intervention asserts the principles of cultural safety [18] and intercultural dialogue [19]. ...
... We recruited 29 indigenous traditional midwives, 18 from the Me'phaa indigenous group (Tlapaneco) in the municipality of Acatepec and 11 from the Nancue ñomndaa (Amuzgo) indigenous group in the municipality of Xochistlahuaca. A household survey in 2015 interviewed each indigenous woman who had delivered their children in the last two years [17]. The answers allowed us to identify active traditional midwives with de facto recognition in their communities, based on the number of births they attended, the health outcomes of their patients, and the traditional knowledge they hold. ...
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Background: Effective health care requires services that are responsive to local needs and contexts. Achieving this in indigenous settings implies communication between traditional and conventional medicine perspectives. Adequate interaction is especially relevant for maternal health because cultural practices have a notable role during pregnancy, childbirth and the postpartum period. Our work with indigenous communities in the Mexican state of Guerrero used fuzzy cognitive mapping to identify actionable factors for maternal health from the perspective of traditional midwives. Methods: We worked with twenty-nine indigenous women and men whose communities recognized them as traditional midwives. A group session for each ethnicity explored risks and protective factors for maternal health among the Me'phaa and Nancue ñomndaa midwives. Participants mapped factors associated with maternal health and weighted the influence of each factor on others. Transitive closure summarized the overall influence of each node with all other factors in the map. Using categories set in discussions with the midwives, the authors condensed the relationships with thematic analysis. The composite map combined categories in the Me'phaa and the Nancue ñomndaa maps. Results: Traditional midwives in this setting attend to pregnant women's physical, mental, and spiritual conditions and the corresponding conditions of their offspring and family. The maps described a complex web of cultural interpretations of disease - "frío" (cold or coldness of the womb), "espanto" (fright), and "coraje" (anger) - abandonment of traditional practices of self-care, women's mental health, and gender violence as influential risk factors. Protective factors included increased male involvement in maternal health (having a caring, working, and loving husband), receiving support from traditional healers, following protective rituals, and better nutrition. Conclusions: The maps offer a visual language to present and to discuss indigenous knowledge and to incorporate participant voices into research and decision making. Factors with higher perceived influence in the eyes of the indigenous groups could be a starting point for additional research. Contrasting these maps with other stakeholder views can inform theories of change and support co-design of culturally appropriate interventions.
... CIET researchers, traditional midwives and Indigenous community health promoters together designed and piloted an intervention to support traditional midwives' role at the base of the pyramid. 50 Sixteen Indigenous traditional midwives requested facilities for simple birth centres, where they could train new apprentices, assist pregnant women and attend births. They also requested logistical support from a community health promoter linked with the project. ...
... With the pilot data suggesting acceptability and safety of an intervention that strengthens traditional midwives, the team designed a cluster randomised controlled trial in which traditional midwives would extend further their authoritative role. 50 The goal of codesign was to allow each party to bring what they are best at, be it design a randomised control trial or manage spiritual content or counselling men. The cultural authorities of participating Indigenous communities and the ethics committees at CIET and McGill University approved this step. ...
Indigenous communities in Latin America and elsewhere have complex bodies of knowledge, but Western health services generally approach them as vulnerable people in need of external solutions. Intercultural dialogue recognises the validity and value of Indigenous standpoints, and participatory research promotes reciprocal respect for stakeholder input in knowledge creation.As part of their decades-long community-based work in Mexico's Guerrero State, researchers at the Centro de Investigación de Enfermedades Tropicales responded to the request from Indigenous communities to help them address poor maternal health. We present the experience from this participatory research in which both parties contributed to finding solutions for a shared concern. The aim was to open an intercultural dialogue by respecting Indigenous skills and customs, recognising the needs of health service stakeholders for scientific evidence.Three steps summarise the opening of intercultural dialogue. Trust building and partnership based on mutual respect and principles of cultural safety. This focused on understanding traditional midwifery and the cultural conflicts in healthcare for Indigenous women. A pilot randomised controlled trial was an opportunity to listen and to adjust the lexicon identifying and testing culturally coherent responses for maternal health led by traditional midwives. Codesign, evaluation and discussion happened during a full cluster randomised trial to identify benefits of supporting traditional midwifery on maternal outcomes. A narrative mid-term evaluation and cognitive mapping of traditional knowledge offered additional evidence to discuss with other stakeholders the benefits of intercultural dialogue. These steps are not mechanistic or invariable. Other contexts might require additional steps. In Guerrero, intercultural dialogue included recovering traditional midwifery and producing high-level epidemiological evidence of the value of traditional midwives, allowing service providers to draw on the strengths of different cultures.
... The present qualitative protocol is part of an ongoing partnership with traditional midwives and local academics in Guerrero State, Mexico. The goal of this partnership is to understand the role of traditional midwives and the impact that they can have in safe birth and cultural safety (Sarmiento, Paredes-Solís, Andersson, & Cockcroft, 2018). In this context, we used Fuzzy Cognitive Maps (FCM) (Giles, Haas, Šajna, & Findlay, 2008) to describe traditional midwives' perspective on what factors promote or hinder safe birth in their communities. ...
... A group of thirteen traditional midwives and their apprentices who have been engaged in a collaborative project since 2015 (Sarmiento et al., 2018). They also participated in the session to draw the FCMs in November 2016. ...
Full-text available
Culturally unsafe approaches have governed the study of Indigenous birthing systems in the South of Mexico. The actions that these approaches promote tend to perpetuate the dominance of Western views in the shaping of health care systems; thus, reducing their cultural pertinence and quality. In this protocol, we propose a methodology to understand the most relevant factors associated with safe birth according to the knowledge of traditional Indigenous midwives. We propose to use conversations as a methodology to promote intercultural dialogue. Conversations recognize mutual interaction and construction of meaning, thus allowing for Western and Indigenous practitioners to interchange knowledge and mutually enrich each other. Three experienced traditional midwives will participate in one-to-one conversations with an indigenous researcher. They will provide the first level of understanding on the meaning of relevant factors for safe birth in their communities. A group of non-indigenous Academic researchers will participate in the process sharing their knowledge about the issue and support the analysis process. These initial results will go to a group session with traditional midwives and their apprentices to check the content, suggest additional elements and share the knowledge among them. This study is part of a bigger effort to support and strength the practices of the traditional midwives in these communities.
... Furthermore, they recognized that traditional health practices are accessible and inexpensive health resources with the potential to reduce dependence on an overburdened healthcare system. 32 Cultural safety acknowledges and addresses power imbalances between service users and healthcare providers. 33 This can be promoted by inviting patients to be partners in the health-decision making process. ...
Full-text available
Problem: The Colombian government provides health services grounded in the Western biomedical model, yet 40% of the population use cultural and traditional practices to maintain their health. Adversarial interactions between physicians and patients from other cultures hinder access to quality health services and reinforce health disparities. Cultural safety is an approach to medical training that encourages practitioners to examine how their own culture shapes their clinical practice and how to respect their patients’ worldviews. This approach could help bridge the cultural divide in Colombian health services, improving multicultural access to health services and reducing health disparities. Intervention: In 2016, we conducted a pilot cultural safety training program in Cota, Colombia. A five-month training program for medical students included: (a) theoretical training on cultural safety and participatory research, and (b) a community-based intervention, co-designed by community leaders, training supervisors, and the medical students, with the aim of strengthening cultural practices related to health. Evaluation used the Most Significant Change narrative approach, which allows participants to communicate the changes most meaningful to them. Using an inductive thematic analysis, the authors analyzed the stories and discussed these findings in a debriefing session with the medical students. Context: Cota is located only 15 kilometers from Bogota, the national capital and biggest city of Colombia, so the small town has gone through rapid urbanization and cultural change. A few decades ago, inhabitants of Cota were mainly peasants with Indigenous and European traditions. Urbanization displaced agriculture with industrial and commercial occupations. One consequence of this change was loss of cultural health care practices and resources, for example, medicinal plants, that the community had used for centuries. Impact: A group of 13 final-year medical students (ten female and three male, age range 20–24) participated in the study. The medical students listed four areas of change after their experience: increased respect for traditional health practices to provide better healthcare; increased recognition of traditional practices as part of their cultural heritage and identity; a desire to deepen their knowledge about cultural practices; and openness to incorporate cultural practices in healthcare. Lessons Learned: Medical students reported positive perceptions of their patients’ cultural practices after participating in this community-based training program. The training preceded a positive shift in perceptions and was accepted by Colombian medical students. To the best of our knowledge, this was the first documented cultural safety training initiative with medical students in Colombia and an early attempt to apply the cultural safety approach outside the Indigenous experience.
A recurring issue in intercultural research is whose knowledge informs conceptualization and design of projects or interventions. Fuzzy cognitive mapping uses arrows and weights to represent stakeholder knowledge on causal relationships and can generate composite theories to inform research and action. Cognitive mapping is accessible across different cultures, but participant weighting is not always straightforward. We describe a procedure to combine and condense maps from different stakeholders and an alternative operator-independent weighting procedure adapted from Harris’s discourse analysis.
Background: Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis. Objectives: To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services. Search methods: We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019. Selection criteria: We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s). Data collection and analysis: Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events. Main results: We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies. Authors' conclusions: The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.
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Background A modified theory of planned behaviour (acronym CASCADA) proposes that Conscious knowledge precedes a change in Attitude, which in turn precedes positive deviations from negative Subjective norms, intention to Change, perception of Agency to change, Discussion of possible action, and Action itself. We used this as a results chain to investigate gender-specific behaviour dynamics in chemical-free dengue prevention. Methods Secondary analysis of the Mexican arm of a cluster randomised controlled trial used household survey data on intermediate outcomes of dengue prevention behaviour. We used a matrix of odds ratios between outcomes, transformed to a symmetrical range (−1, 1), to compute fuzzy transitive closure of the results chain for control and intervention clusters, then for male and female respondents separately in each group. Transitive closure of a map computes the influence of each factor on each other factor, taking account of all influences in the system. Cumulative net influence was the sum of influences across the results chain. Results Responses of 5042 women and 1143 men in 45 intervention clusters contrasted with those of 5025 women and 1179 men in 45 control clusters. Control clusters showed a distal block (negative influence) in the results chain with a cumulative net influence of 0.88; intervention clusters showed no such block and a cumulative net influence of 1.92. Female control respondents, like the overall control picture, showed a distal block, whereas female intervention responses showed no such blocks (cumulative net influence 0.78 and 1.73 respectively). Male control respondents showed weak distal blocks. Male intervention responses showed several new negative influences and a reduction of cumulative net influence (1.38 in control and 1.11 in intervention clusters). Conclusions The overall influence of the intervention across the results chain fits with the trial findings, but is different for women and men. Among women, the intervention overcame blocks and increased the cumulative net influence of knowledge on action. Among men, the intervention did not reinforce prevention behaviour. This might be related to emphasis, during the intervention, on women’s participation and empowerment. The fuzzy transitive closure of the CASCADA map usefully highlights the differences between gender-specific results chains. Trial registration ISRCTN27581154.
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Background: Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services. Design: Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC). Results: Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17-1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92-1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73-0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77-0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72-0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate. Conclusions: Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.
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To test whether community mobilization adds effectiveness to conventional dengue control. Pragmatic open label parallel group cluster randomized controlled trial. Those assessing the outcomes and analyzing the data were blinded to group assignment. Centralized computerized randomization after the baseline study allocated half the sites to intervention, stratified by country, evidence of recent dengue virus infection in children aged 3-9, and vector indices. Random sample of communities in Managua, capital of Nicaragua, and three coastal regions in Guerrero State in the south of Mexico. Residents in a random sample of census enumeration areas across both countries: 75 intervention and 75 control clusters (about 140 households each) were randomized and analyzed (60 clusters in Nicaragua and 90 in Mexico), including 85 182 residents in 18 838 households. A community mobilization protocol began with community discussion of baseline results. Each intervention cluster adapted the basic intervention-chemical-free prevention of mosquito reproduction-to its own circumstances. All clusters continued the government run dengue control program. Primary outcomes per protocol were self reported cases of dengue, serological evidence of recent dengue virus infection, and conventional entomological indices (house index: households with larvae or pupae/households examined; container index: containers with larvae or pupae/containers examined; Breteau index: containers with larvae or pupae/households examined; and pupae per person: pupae found/number of residents). Per protocol secondary analysis examined the effect of Camino Verde in the context of temephos use. With cluster as the unit of analysis, serological evidence from intervention sites showed a lower risk of infection with dengue virus in children (relative risk reduction 29.5%, 95% confidence interval 3.8% to 55.3%), fewer reports of dengue illness (24.7%, 1.8% to 51.2%), fewer houses with larvae or pupae among houses visited (house index) (44.1%, 13.6% to 74.7%), fewer containers with larvae or pupae among containers examined (container index) (36.7%, 24.5% to 44.8%), fewer containers with larvae or pupae among houses visited (Breteau index) (35.1%, 16.7% to 55.5%), and fewer pupae per person (51.7%, 36.2% to 76.1%). The numbers needed to treat were 30 (95% confidence interval 20 to 59) for a lower risk of infection in children, 71 (48 to 143) for fewer reports of dengue illness, 17 (14 to 20) for the house index, 37 (35 to 67) for the container index, 10 (6 to 29) for the Breteau index, and 12 (7 to 31) for fewer pupae per person. Secondary per protocol analysis showed no serological evidence of a protective effect of temephos. Evidence based community mobilization can add effectiveness to dengue vector control. Each site implementing the intervention in its own way has the advantage of local customization and strong community engagement. ISRCTN27581154. © Andersson et al 2015.
In chapter 2, I examined the two ideas of border crossing and culture brokerage primarily from the literature and I indicated that the two ideas differ – border crossing is about identity whereas being a culture broker was a role that a person could undertake. I also argued that the border crosser is related to the ‘marginal man’ whereas the culture broker relates to the ‘middleman’ position, ideas with their origins in anthropology.
To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.