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1. Write a paragraph describing the extent to which a socioecological framework incorporating issues related to social determinants has been applied to your area of research. Are there opportunities for improving our understanding of or approach to disparities in your area with a greater emphasis on a socioecological framework? Maternal mortality disproportionately affects women in low-income countries and remains a pressing priority for the global health community. Guatemala has one of the highest maternal mortality ratios in Latin America and 70% of maternal deaths occur among women of indigenous communities . Although indigenous groups comprise 40% of the country population, disparities in education, healthcare and wealth between the mainly Spanish-speaking, non-indigenous and indigenous communities are striking. Guatemalan national health data estimates that maternal mortality rates in the indigenous population are twice as high as the non-indigenous population. The World Health Organization (WHO) recommends all births be attended by a skilled health worker preferably in a healthcare facility. In Guatemala, the proportion of women who deliver in facilities is 65% but can be as low as 35% in Departments that are predominantly indigenous. In an attempt to meet the 2015 Millennium Development Goals, the Guatemalan Ministry of Health applied parts of a socioecological framework to increase the number of facility-based births in indigenous communities. These efforts included understanding the cultural context of birth and allowing traditional birth attendants to assist in deliveries as well as provide indigenous language translation services in some facilities. Further research is needed to understand barriers within a socioecological framework not only related to access to care but quality of care and power dynamics in health care delivery during childbirth. 2. In the WHO reading, A conceptual framework for action on the structural determinants of health, the authors describe structural stratifies (e.g. income, education, etc.) and intermediary determinants such as material and psychosocial circumstances. Pick 3 of these factors (at least one structural and one intermediary). Explain why you chose the factors (might use Braveman article to provide justification) and describe how each could be an important determinant of a health outcome of your choosing. The association could be reported in published research or it could be your hypothesized relationship. Consider whether how these factors might function over the life course and/or intergenerationally. The outcome of facility-based childbirth in Guatemalan indigenous communities is complex. Barriers such as language, transport, cultural practices down to the meaning of childbirth all contribute to informing decisions on whether or not to deliver in a facility. Structural determinants such as education and race/ethnicity impact reproductive health decisions as well as the intermediary determinant of the health system. Education (structural): Childbirth in a health facility for an indigenous woman may require language proficiency in Spanish and a level of health literacy in order to understand consent. While the language of primary schools is in Spanish, attaining a certain level of education may not guarantee fluency or confidence in speaking to health care workers or understanding explanations of care received. This can create a vulnerable position for women and families that may prevent them from choosing a facility based delivery and instead opt for a birth with a traditional birth attendant at home. Limited education may put a pregnancy at greater risk for lack of prenatal care and reception of health messages. Maternal education can be directly impacted over the life course based on family priorities or income to support longer education. Race/Ethnicity (structural): As mentioned above, health disparities in maternal mortality among indigenous communities as well as facility based childbirth exist in Guatemala. As a social group, indigenous communities often face discrimination particularly within the healthcare system in response to traditional practices around childbirth. According to Walsh (2006), fertility and childbearing is deeply spiritual and the traditional birth attendant acts as a sacred guide through pregnancy and childbirth. There is no formal medical training or apprenticeship but rather a belief that knowledge is transferred through dreams from the spiritual realm. Birth itself is approached as a religious ceremony with an emphasis on prayer, massage and symbolic ritual. Within this cultural paradigm, the push by the Ministry of Health on World Health Organization recommendations to increase deliveries in health facilities attended by a skilled health provider may be undesirable for the majority of indigenous women who value the deep spiritual and cultural meaning of birth guided by a traditional midwife. Health System (intermediary): While work has progressed around the issues of access barriers with a focus on physical accessibility and availability of clinical staff, research on acceptability as a potential barrier reveals deeper layers around decisions for facility-based childbirth. Disrespect and discrimination during childbirth related to ethnicity can reasonably prevent families from wanting to deliver at a health facility. Also, historic mistreatment and non-consented care affects the life course and a community’s perception of quality and ultimately acceptance of health care services.
References Walsh, L. (2006). Beliefs and rituals in traditional birth attendant practice in Guatemala. Journal of Transcultural Nursing. 17(2):148-154.
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Thanks for your response. That is interesting that the Guatemalan government explicitly applied the socioecological model to the process outcome of facility-based births - which I assume they knew was on the pathway to poor birth outcomes for indigenous communities? It sounds like their approach made efforts to be responsive to the context and needs of the population, which is clearly not always the case in interventions on women's reproductive health, where the outcome can take precedence over whether the process is respectful and grounded in human rights. I definitely agree with that thinking about how the dynamics of interpersonal care plays out on the ground is important, as the intentions of policy makers can sometimes be lost in translation on the ground (and vice versa). I am also wondering if they took into account issues such as transportation and child care for families when women were giving birth?
Your structural and intermediate factors are well described. I am also wondering about the role that the historical context has more broadly - e.g. not just about the history of mistreatment in health care system, but more broad based issues related to discrimination, gender-based violence, and violence targeting indigenous communities leading to mistrust of the government.