Safe birth in cultural safety in southern Mexico: a pragmatic non-inferiority cluster-randomised controlled trial

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.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.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).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.Retrospectively registered ISRCTN12397283 . Trial status: concluded.In many Indigenous communities, traditional midwives support mothers during pregnancy, childbirth, and some days afterwards. Research involving traditional midwives has focused on training them in Western techniques and redefining their role to support Western care. In Guerrero state, Mexico, Indigenous mothers continue to trust traditional midwives. Almost half of these mothers still prefer traditional childbirths, at home, in the company of their families and following traditional practices. We worked with 30 traditional midwives to see if supporting their practice allowed traditional childbirth without worsening mothers' health. Each traditional midwife received an inexpensive stipend, a scholarship for an apprentice and support from an intercultural broker. The official health personnel participated in a workshop to improve their attitudes towards traditional midwives. We compared 40 communities in two municipalities that received support for traditional midwifery with 40 communities in two municipalities that continued to receive usual services. We interviewed 872 women with childbirth between 2016 and 2017. Mothers in intervention communities suffered fewer complications during childbirth and had fewer complications or deaths of their babies. They had more traditional childbirths and fewer perineal tears or infections across home-based childbirths. Among those who went to Western care, mothers in intervention communities had more traditional management of the placenta but more non-traditional cold-water baths. Supporting traditional midwifery increased traditional childbirth without worsening health outcomes. The small size of participating populations limited our confidence about the size of this difference. Health authorities could promote better health outcomes if they worked with traditional midwives instead of replacing them.

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