Cultural aspects related to the health of Andean women in Latin America: a key issue for progress toward the attainment of the Millennium Development Goals

Standing up for your birth rights: An intersectional comparison of obstetric violence and birth positions between Quichua and Egyptian women

Obstetric violence is a pervasive phenomenon in reproductive health across the world. Denial of the choice in birth position is a common form of obstetric violence as horizontal positions are non-evidence based, yet routinely imposed. This contributes to the cultural barriers to access reproductive health care. The present study compares women's experiences in childbirth from the Quichua and Egyptian communities, exploring the intersectional factors that contribute to obstetric violence and the adoption of preferred birth positions to offer recommendations on implementing respectful and rights-based reproductive care. Two independent scoping reviews have been carried out and subsequently compared. The intersectional approach revealed how gender, race, and class have a multiplicative effect on the denial of choice in birth position as a form of obstetric violence. This phenomenon exacerbates the pre-existing health disparities that disproportionately affect women, indigenous and racialized groups, and people living in poverty. Culturally competent, multilevel, and multidisciplinary interventions, strengthening of health systems, and community participation are essential to combat discrimination and guarantee birth rights. Allowing women to choose their birth position is a low-hanging fruit to challenge the complex issue of obstetric violence and ensure a rights-based approach to reproductive health.

Intercultural Childbirth: Impact on the Maternal Health of the Ecuadorian Kichwa and Mestizo People of the Otavalo Region

OBJECTIVE

 Considering the increased frequency of maternal deaths reported from 2001 to 2005 for Indigenous and mestizo women from the Ecuadorian rural area of Otavalo, where the Kichwa people has lived for centuries, the objective of the present article is to describe how the efforts of the local health community and hospital workers together with a propitious political environment facilitated the implementation of intercultural childbirth, which is a strategy that respects the Andean childbirth worldview.

METHODS

 We evaluated a 3-year follow-up (2014-16) of the maternal mortality and the childbirth features (4,213 deliveries).

RESULTS

 Although the Western-style (lying down position) childbirth was adopted by 80.6% of the pregnant women, 19.4% of both mestizo and Indigenous women adopted the intercultural delivery (squatting and kneeling positions). Both intercultural (42.2%) and Western-style (57.8%) childbirths were similarly adopted by Kichwa women, whereas Western-style childbirth predominated among mestizo women (94.0%). After the implementation of the intercultural strategy in 2008, a dramatic decrease of maternal deaths has been observed until now in both rural and urban Otavalo regions.

CONCLUSION

 This scenario reveals that the intermingling of cultures and respect for childbirth traditions have decreased maternal mortality in this World Health Organization-awarded program.

Starting a neurosurgical service in a Southern Nigeria rural community. Prospect, challenges, and future-the Irrua experience

Neurosurgical services is an essential component of tertiary level of health care, this field is still evolving in Nigeria with lack of material and manpower. There is a near complete absence of neurosurgeons in the rural communities in Nigeria with over 95% resident in urban area. Starting a neurosurgical services takes a huge sacrifice from the neurosurgeon who is faced with a decision to do something in the presence of a near absence of material and manpower, and in turn circumvent processes with extra burden so as to ensure he/she provides leadership with respect to patients care and assists in the training of allied surgeons and other healthcare staffs to mitigate against morbidity and mortality. Our research is aimed to highlight the total number of patients attended to in the neurosurgical unit, challenges, prospect, and future.

Numbers that Matter: Right to Health and Peruvian Maternal Strategies

The rights to health and to culturally respectful care are inextricably linked in the documents supporting Peruvian Maternal Health Policy. Strategies of Intercultural Birthing and Maternal Waiting Houses were purported to reduce maternal deaths, while extending the right to health to marginalized indigenous women. Based on 17 months of field research in Peru, I argue that the narrow focus on achieving "good numbers" creates and sustains coercive modes of strategy applications. As a result, the on-the-ground implementation of these innovative strategies made them incompatible with right to health and culturally respectful care approaches.

Determinants of patterns of maternal and child health service utilization in a rural community in south eastern Nigeria

BACKGROUND

Women and children constitute a large proportion of any population. They are the most vulnerable to morbidity and mortality especially in developing countries. In many situations the problem of poor maternal and child health stems from the poor use of available services even when they are not of optimum quality. This study seeks to describe the patterns of utilization of Maternal and Child health (MCH) services in a rural area of Enugu State, and identify factors that are associated with and responsible for determining them.

METHODS

The study used a cross sectional analytic design. Pretested semi structured questionnaires were administered by interviewers to 602 women from a rural community in Enugu state, South east Nigeria. Two focus group discussions (FGDs) involving 8-10 men/ women each were conducted to identify factors affecting service utilization. Chi square analysis was done to identify factors associated with Maternal and Child Health services utilization. Logistic regression was used to identify determinants of utilization patterns. N vivo software was used to analyze findings of the FGDs.

RESULTS

The study revealed that increasing age, educational level, monthly income, number of children and occupation of both women and their husbands were associated with increased MCH service utilization. Average monthly income (OR: 1.317, p = 0.048, CI: 0.073-0.986) and number of children (OR: 1.196, p < 0.01,CI: 1.563-7.000) were determinants of increased use of child care services while educational level (OR: 0.495, p < 0.001, CI: 1.244-2.164) and age (OR: 0.115, p < 0.001, CI: 0.838-0.948) determined better use of delivery and family planning services respectively.

CONCLUSIONS

Improved use of MCH services is related to socio economic challenges women face such as illiteracy and low income. Furthermore, the way health facilities and their staff are perceived by rural women affect how they use some of these services and should be considered in programs which seek to reduce maternal and child mortality. Behavioral change programs with high local content need to be implemented within rural areas especially among younger, illiterate women .

Interventions to provide culturally-appropriate maternity care services: factors affecting implementation

Background

The World Health Organization recently made a recommendation supporting ‘culturally-appropriate’ maternity care services to improve maternal and newborn health. This recommendation results, in part, from a systematic review we conducted, which showed that interventions to provide culturally-appropriate maternity care have largely improved women’s use of skilled maternity care. Factors relating to the implementation of these interventions can have implications for their success. This paper examines stakeholders’ perspectives and experiences of these interventions, and facilitators and barriers to implementation; and concludes with how they relate to the effects of the interventions on care-seeking outcomes.

Methods

We based our analysis on 15 papers included in the systematic review. To extract, collate and organise data on the context and conditions from each paper, we adapted the SURE (Supporting the Use of Research Evidence) framework that lists categories of factors that could influence implementation. We considered information from the background and discussion sections of papers included in the systematic review, as well as cost data and qualitative data when included.

Results

Women’s and other stakeholders’ perspectives on the interventions were generally positive. Four key themes emerged in our analysis of facilitators and barriers to implementation. Firstly, interventions must consider broader economic, geographical and social factors that affect ethnic minority groups’ access to services, alongside providing culturally-appropriate care. Secondly, community participation is important in understanding problems with existing services and potential solutions from the community perspective, and in the development and implementation of interventions. Thirdly, respectful, person-centred care should be at the core of these interventions. Finally, cohesiveness is essential between the culturally-appropriate service and other health care providers encountered by women and their families along the continuum of care through pregnancy until after birth.

Conclusion

Several important factors should be considered and addressed when implementing interventions to provide culturally-appropriate care. These factors reflect more general goals on the international agenda of improving access to skilled maternity care; providing high-quality, respectful care; and community participation.

Moyamoya Disease in an 8-Year-Old Boy: Direct Bypass Surgery in a Province of Peru

BACKGROUND

Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors.

CASE DESCRIPTION

Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru.

CONCLUSIONS

The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.

Physically Demanding Labor and Health Among Indigenous Women in the Ecuadorian Highlands

Physically demanding work carried out during long workdays affects women's health. In rural and agrarian societies, women perform a variety of domestic and productive tasks, often from dawn to dusk, with little or no leisure time. This paper presents the results of a survey of indigenous women in six rural communities in the Ecuadorian highlands. It was conducted to measure the amount of time women spend on physically demanding work in the context of food security, parity outcomes, and access to prenatal health care. The findings demonstrate that these women work very long workdays and also experience food insecurity and poor access to prenatal health care.

The role of civil society in strengthening intercultural maternal health care in local health facilities: Puno, Peru

Background and objective

Peru's Ministry of Health has made efforts to increase the cultural inclusiveness of maternal health services. In 2005, the Ministry adopted an intercultural birthing policy (IBP) that authorizes and encourages the use of culturally acceptable birthing practices in government-run health facilities. However, studies suggest that indigenous women may receive inconsistent benefits from these kinds of policies. This article examines whether a grassroots accountability initiative based on citizen monitoring of local health facilities by indigenous women can help to promote the objectives of the IBP and improve intercultural maternal health care.

Design

Findings are drawn from a larger qualitative research study completed in 2015 that included fieldwork done between 2010 and 2011. Semi-structured interviews were conducted with 23 women working as citizen monitors in local health facilities in Puno and 30 key informants, including frontline health workers, health officials, and civil society actors in Puno and Lima, and human rights lawyers from the Defensoría del Pueblo Office in Puno.

Results

Monitors confirmed from their own personal experiences in the 1990s and early 2000s that respect for intercultural aspects of maternal health care, including traditional indigenous birthing practices, were not readily accepted in publicly funded health facilities. It was also common for indigenous women to face discrimination when seeking health service provided by the state. Although the government's adoption of the IBP in 2005 was a positive step, considerable efforts are still needed to ensure high-quality, culturally appropriate maternal health care is consistently available in local health facilities.

Conclusions

Despite important progress in the past two decades, policies aimed at improving intercultural maternal health care are unevenly implemented in local health facilities. Civil society, in particular indigenous women themselves, can play an important role in holding the state accountable for quality care.

Effectiveness of interventions to provide culturally appropriate maternity care in increasing uptake of skilled maternity care: a systematic review

Addressing cultural factors that affect uptake of skilled maternity care is recognized as an important step in improving maternal and newborn health. This article describes a systematic review to examine the evidence available on the effects of interventions to provide culturally appropriate maternity care on the use of skilled maternity care during pregnancy, for birth or in the postpartum period. Items published in English, French and/or Spanish between 1 January 1990 and 31 March 2014 were considered. Fifteen studies describing a range of interventions met the inclusion criteria. Data were extracted on population and intervention characteristics; study design; definitions and data for relevant outcomes; and the contexts and conditions in which interventions occurred. Because most of the included studies focus on antenatal care outcomes, evidence of impact is particularly limited for care seeking for birth and after birth. Evidence in this review is clustered within a small number of countries, and evidence from low- and middle-income countries is notably lacking. Interventions largely had positive effects on uptake of skilled maternity care. Cultural factors are often not the sole factor affecting populations' use of maternity care services. Broader social, economic, geographical and political factors interacted with cultural factors to affect targeted populations' access to services in included studies. Programmes and policies should seek to establish an enabling environment and support respectful dialogue with communities to improve use of skilled maternity care. Whilst issues of culture are being recognized by programmes and researchers as being important, interventions that explicitly incorporate issues of culture are rarely evaluated.

The emergence of the vertical birth in Ecuador: an analysis of agenda setting and policy windows for intercultural health

Maternal mortality continues to claim the lives of thousands of women in Latin America despite the availability of effective treatments to avert maternal death. In the past, efforts to acknowledge cultural diversity in birth practices had not been clearly integrated into policy. However, in Otavalo (Ecuador) a local hospital pioneered the implementation of the 'Vertical Birth'-a practical manifestation of an intercultural health policy aimed at increasing indigenous women's access to maternity care. Drawing on agenda-setting theory, this qualitative research explores how the vertical birth practice made it onto the local policy agenda and the processes that allowed actors to seize a window of opportunity allowing the vertical birth practice to emerge. Our results show that the processes that brought about the vertical birth practice took place over a prolonged period of time and resulted from the interplay between various factors. Firstly, a maternal health policy community involving indigenous actors played a key role in identifying maternal mortality as a policy problem, defining its causes and framing it as an indigenous rights issue. Secondly, previous initiatives to address maternal mortality provided a wealth of experience that gave these actors the knowledge and experience to formulate a feasible policy solution and consolidate support from powerful actors. Thirdly, the election of a new government that had incorporated the demands of the indigenous movement opened up a window of opportunity to push intercultural health policies such as the vertical birth. We conclude that the socioeconomic and political changes at both national and local level allowed the meaningful participation of indigenous actors that made a critical contribution to the emergence of the vertical birth practice. These findings can help us advance our knowledge of strategies to set the agenda for intercultural maternal health policy and inform future policy in similar settings. Our results also show that Kingdon's model was useful in explaining how the VB practice emerged but also that it needs modifications when applied to low and middle income countries.

Implementing a culturally appropriate birthing policy: Ethnographic analysis of the experiences of skilled birth attendants in Peru

Policies about skilled birth attendants (SBA) need to account for cultural acceptability of care rendered by SBAs. Few studies have assessed these policies from the perspective of SBAs. I identify challenges and analyze the experiences of SBAs implementing a culturally appropriate birth care policy in Peru. I collected data during 15 months of ethnographic research: conducting semi-structured interviews and informal conversations with 5 SBAs in 2 villages and with health officials. I compared interview results with my observations of consultations and of labor and delivery. Weak institutional support, lack of training, negative perceptions of the policy inhibited implementation, as did detrimental effects on future personal and professional opportunities. SBAs in Peru face many challenges when trying to establish intercultural birth care. My recommendations include provision of focused training, promoting a more diverse workforce, and increasing community engagement.Journal of Public Health Policy advance online publication, 19 May 2016; doi:10.1057/jphp.2016.19.

Institutional Delivery and Satisfaction among Indigenous and Poor Women in Guatemala, Mexico, and Panama

Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44-2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18-1.81), primiparous (aRR = 1.44, 95% CI: 1.24-1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21-1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04-1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05-1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02-1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.

Indigenous practices of pregnant women at Dilokong hospital in Limpopo province, South Africa

BACKGROUND

Indigenous practices (IPs) are experiences generated by people who are living in a specific regional context and cultural group. IPs are shaped by cultural traits that are passed from one generation to the next. IPs practices are rooted and embedded in society and, therefore, the practices become part of the people's lifestyle. It is difficult to try and change these practices as people have adhered to them throughout their entire lives. The believe system plays a major role in health care seeking behaviour of individuals because they are informed by the IPs that are observed in their environment.

OBJECTIVES

To explore and describe the IPs of pregnant women at Dilokong hospital in Limpopo province.

METHOD

A qualitative, descriptive, explorative and contextual research design was used for the participants to describe the IPs used by pregnant women. Data were collected through unstructured one-on-one interviews.

RESULTS

The following four themes with sub-themes emerged from the data: IPs based on ancestral knowledge; IPs based on spiritual diviners versus church principles; restricted practices versus instructions followed during pregnancy; and labour and IPs during labour and delivery.

CONCLUSION

IPs are regarded as an honourable health intervention by traditional health practitioners (THPs), families and pregnant women. IPs like cords around women's waists are still observed during physical examinations. However, there is a reduction of prescribed indigenous oral medication used to accelerate labour because of their potential toxicity.

Maternity care services and culture: a systematic global mapping of interventions

Background

A vast body of global research shows that cultural factors affect the use of skilled maternity care services in diverse contexts. While interventions have sought to address this issue, the literature on these efforts has not been synthesised. This paper presents a systematic mapping of interventions that have been implemented to address cultural factors that affect women's use of skilled maternity care. It identifies and develops a map of the literature; describes the range of interventions, types of literature and study designs; and identifies knowledge gaps.

Methods and Findings

Searches conducted systematically in ten electronic databases and two websites for literature published between 01/01/1990 and 28/02/2013 were combined with expert-recommended references. Potentially eligible literature included journal articles and grey literature published in English, French or Spanish. Items were screened against inclusion and exclusion criteria, yielding 96 items in the final map. Data extracted from the full text documents are presented in tables and a narrative synthesis. The results show that a diverse range of interventions has been implemented in 35 countries to address cultural factors that affect the use of skilled maternity care. Items are classified as follows: (1) service delivery models; (2) service provider interventions; (3) health education interventions; (4) participatory approaches; and (5) mental health interventions.

Conclusions

The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. A range of literature was identified, from narrative descriptions of interventions to studies using randomised controlled trials to evaluate impact. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Based on the findings, we identify avenues for further research in order to better document and measure the impact of interventions to address cultural factors that affect use of skilled maternity care.

Choosing between Traditional Medicine and Allopathy During Pregnancy: Health Practices in Prenatal and Reproductive Health Care in Ecuador

Research and programmes to date have addressed the prevalence of maternal morbidity and mortality in many developing countries. Literature has explored the direct and indirect factors influencing maternal risk, and programmes have attempted to mitigate many of the persistent factors. While addressing health system factors and socioeconomic barriers is imperative, understanding women’s perceptions within the cultural context in which they live is a necessary step for improving interventions aimed at reducing maternal morbidity and mortality. This study seeks to contribute to the existing evidence regarding Ecuadorian women’s prenatal health care seeking perceptions and behaviours. The paper will explore and describe the perceptions and experiences of pregnant women attending the antenatal intercultural clinic regarding the care they receive from both midwives and obstetricians. It will also provide recommendations for improving current strategies being implemented in Ecuador in the domain of prenatal and reproductive health care, with a special focus on indigenous people and intercultural health.

Ensuring intercultural maternal health care for Mayan women in Guatemala: a qualitative assessment

Indigenous (Mayan) women in Guatemala experience a disproportionate burden of maternal mortality and morbidity, as well as institutional failures to respect their rights. The Guatemalan Ministry of Health has started to offer 'intercultural' services that respect Mayan obstetric practices and integrate them with biomedical care. We purposefully selected 19 secondary-level public health facilities of 9 departments that provided maternal healthcare to indigenous women. We carried out semi-structured interviews with biomedical providers (44), Mayan midwives or comadronas (45), and service users (18), exploring the main characteristics of intercultural care. We found that most facilities initiated the implementation of culturally appropriate services, such as accompaniment by a comadrona or family member, use the traditional teas or choosing the birthing position, but they still lacked standardisation. Comadronas generally felt excluded from the health system, although most biomedical providers reported that they were making important strides to be respectful and inclusive. Most users wanted the option of culturally appropriate services but typically did not receive them. In the health facilities, biomedicine is still the dominant discourse. Efforts at offering intercultural care still need strengthening and further monitoring. Involvement and participation of comadronas and indigenous women is key to moving forward to true intercultural services.

Rural Indonesia women's traditional beliefs about antenatal care

Background

The Indonesia Maternal Mortality Rate (MMR) of 420/100.00 live births remains among the highest in East Asia while coverage of births assisted by skilled providers is still low. Traditional beliefs have been a key factor associated with the choice between midwives or traditional birth attendants (TBA) and the low number of antenatal care visits in rural West Sumatra.

Methods

We conducted three focus groups with 16 women from rural West Java to describe their perception regarding issues related to traditional beliefs. Focus group discussions provided data for the content analysis.

Results

The majority of the 16 women interviewed was from Village Dago, West Java and had only an elementary school education. Their ages ranged from 19 to 40 years. Most were multiparous housewives with an income of IDR 918.750 per month, which was lower than the monthly income in West Java (IDR. 1.172.060). Emerging from the focus group discussion were four main themes regarding their pregnancy and traditional beliefs: 1) pregnancy was a normal cycle in women’s life (pregnancy is a natural phenomena, not a sickness; no recognition of danger signs during pregnancy and death of baby or mother during pregnancy was brought about by God’s will); 2) women followed the traditional beliefs (positive motivation to follow the traditional beliefs and fear of not following the traditional beliefs); 3) relying on TBA called paraji rather than midwife (parajis are kind, tolerant and patient and have more experience than midwives; more accessibility than midwives and encouragement of natural birth) and 4) midwives are more secure than paraji; (they use a medical standard of care).

Conclusions

Women’s beliefs grounded in religion and tradition permeated the village culture making it difficult to counter their long held health practices with practices based on recent advances in health care. Use of TBA in this village was still dominant and women believed that following traditional beliefs led to a healthy pregnancy therefore, they also followed all relatives’ suggestions. Understanding the complexities of local culture is the first step to improving women’s awareness of how to preserve their pregnancy and prevent complications.

Maternity waiting homes and institutional birth in Nicaragua: policy options and strategic implications

With the aim of promoting institutional births and reducing the high maternal and child mortality rates in rural and poor zones, the government of Nicaragua is supporting the creation of maternity waiting homes. This study analyzes that strategy and examines the factors associated with the use of maternity waiting homes and institutional birth. To that end, we apply a quantitative approach, by means of an econometric analysis of the data extracted from surveys conducted in 2006 on a sample of women and parteras or traditional birth attendants, as well as a qualitative approach based on interviews with key informants. Results indicate that although the operation of the maternity waiting homes is usually satisfactory, there is still room for improvement along the following lines: (i) disseminating information about the homes to both women and men, as the latter frequently decide the course of women's healthcare, and to parteras, who can play an important role in referring women; (ii) strengthening the postpartum care; (iii) ensuring financial sustainability by obtaining regular financial support from the government to complement contributions from the community; and (iv) strengthening the local management and involvement of the regional government. These measures might be useful for health policy makers in Nicaragua and in other developing countries that are considering this strategy.

Unintended pregnancy in the amazon basin of Ecuador: a multilevel analysis

BACKGROUND

It has been estimated that each year 80 million women in the world experience an unintended pregnancy. In Ecuador, recent research has revealed that 36.3% of total births are unintended; the research also details significant geographical, ethnic and socioeconomic variations. These studies focused on individual risk factors and were based on large national surveys where local samples, particularly from rural remote areas, were small. The purpose of this study was to investigate the influence of contextual and individual factors on unintended pregnancies in the Amazon Basin of Ecuador.

METHODS

Women aged 15-44 were selected through an ongoing community-based cross-sectional survey conducted in the Orellana province between May and December 2006. Data were fitted using multilevel logistic regression, adjusting for both individual-level and community-level factors as fixed effects and allowing for heterogeneity between communities.

RESULTS

The overall prevalence of unintended pregnancy was 62.7%. Two-thirds (73.7%) of indigenous women reported having had at least one unintended pregnancy. Being young, single, and indigenous were significant risk factors for unintended pregnancy, alongside having low access to education and having more than two children. No relationship was found between socioeconomic status and the use of contraceptives. All the variation between communities was explained by individual-level factors.

CONCLUSIONS

This study showed the significance of individual factors in increasing the risk of unintended pregnancy, while the role of community factors was found to be negligible. In order for all women to be able to realize their right to reproductive autonomy, there needs to be a diverse range of solutions, with particular attention paid to cultural issues.

Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia

Background

Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia.

Methods

Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours.

Results

The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system.

Conclusion

The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.

Women's right to health and the Millennium Development Goals: promoting partnerships to improve access

The Millennium Development Goals (MGD) represent a commitment of 189 member states that adopted them during the Millennium Summit in September 2000. This UN General Assembly recognized that gender equality and women's empowerment are both central to achieving sustainable development by means of combating poverty, hunger and disease. Neither reproductive nor sexual health was explicitly articulated in the original MDGs and indicators-a critical omission, as globally women are more disadvantaged than men. However, a clear link exists between all of the MDGs and the reproductive and sexual health of women, who cannot contribute to sustainable development, unless their right to health is met through improved access. The FIGO 2006 World Report on Women's Health addresses many issues critical to the success of the MDGs, with a focus on how partnerships have become a crucial vehicle to improve access to health for women.