Differences between the cultures of health care services and service users have been recognised as a major issue in service delivery, particularly in the delivery of maternity care services. In systematically mapping the literature on interventions implemented to address cultural factors that affect the use of maternity care services, Ernestina Coast, Eleri Jones, Annie Portela (WHO), and Samantha R. Lattof find that formulating and implementing culturally-sensitive programmes remain challenging despite the availability of good practices and success stories.
Scaling up women’s use of skilled maternity care is an important component of global strategies to improve maternal and newborn health, but the availability and provision of skilled care does not necessarily lead to increased utilization of maternity care services. A recent systematic mapping conducted at the LSE indicates a growing global awareness of the need to design culturally-appropriate maternity care services in order to improve service utilization and thus maternal and newborn health outcomes.
Whilst culture is often portrayed as a barrier to women’s use of maternal health services, it can also serve as a facilitator of women’s use of services. In countries like the United States and United Kingdom, interventions using bilingual and bicultural ‘link workers’ (also known as ‘cultural brokers’) aim to facilitate and improve communication between minority women and health professionals. Studies evaluating these interventions find that in addition to increasing women’s use of antenatal care services, this type of intervention also increases the likelihood that clients are offered an informed choice of health care.
In order to understand the nature and range of interventions that have been implemented to address cultural factors affecting women’s use of skilled maternity care services, we methodically identified and developed an inventory of the literature; categorised the nature and range of interventions, and the type of literature and study designs included; and identified knowledge gaps. After screening a total of 33,227 items generated by the search, the resulting inventory (n = 96) includes interventions from 35 countries. The need for ‘culturally-appropriate’ health facilities, core to the World Health Organization’s mandate on ‘health for all’ and its strategy for improving maternal and newborn health, has evidently been recognised around the world.
Through this process, we found that interventions research addressing culture and maternal health service use is heavily weighted in favour of evidence from high-income countries (n = 39), particularly from the United States, followed by Australia, Canada, and the United Kingdom. In these settings, interventions targeted specific sub-populations like immigrant or ethnic minority groups and native or Aboriginal communities.
The systematic mapping also indicates a critical need for creative, innovative interventions in lower-income countries. Whilst the inventory details interventions in 29 middle-income countries and 25 low-income countries, future research should consider additional interventions that evaluate the ways in which cultural factors can be systematically mainstreamed into programmes to increase maternal health care use.
Given that the cultural groups and the nature of cultural factors that affect use of skilled maternity care are context-specific, we inductively developed and defined five intervention categories in order to capture the inventory’s whole range of interventions and to distinguish between different types: (1) service delivery models, (2) service provider interventions, (3) culturally-appropriate health education interventions, (4) participatory approaches, and (5) culturally-appropriate mental health interventions.
Literature on interventions addressing cultural factors as evaluated models of practice remains limited, as analysis of the inventory indicates that few studies have used designs that provide strong evidence of intervention impact. The ‘participatory approaches’ category contains the majority of studies with designs providing evidence of effectiveness, followed by a smaller proportion in the ‘service provider interventions’ and ‘culturally-appropriate health education interventions’ categories. The small-scale, context-specific nature of many interventions of this type may partly explain this finding.
From narrative descriptions of interventions to studies evaluating impact through the use of randomised controlled trials, the inventory items clearly reflect great differences in levels of evidence. Whilst much of the identified literature states a clear aim to address cultural factors, studies often provide insufficient detail about how exactly the interventions addressed these cultural factors. Given that ‘culture’ is a complex concept with varied definitions and usages in the literature, this finding is perhaps unsurprising.
Though many of the inventory items unfortunately lack robust designs and sufficient detail to understand how exactly the interventions addressed cultural factors, this map provides a rich source of information for researchers, programmers, and policymakers seeking to deliver more responsive, effective maternity care services to culturally-diverse populations.
Ernestina Coast is an Associate Professor of Population Studies in LSE’s Department of Social Policy. Eleri Jones and Samantha R. Lattof are PhD candidates in Demography and Population Studies in LSE’s Department of Social Policy. Annie Portela is a Technical Officer in the World Health Organization’s Department of Maternal, Newborn, Child and Adolescent Health. Further information Coast, E., E. Jones, A. Portela, and S.R. Lattof. (2014) “Maternity Care Services and Culture: A Systematic Global Mapping of Interventions.” PLOS ONE 9(9): e108130.