Maternity Care Services and Culture: A Systematic Global Mapping of Interventions

Abstract

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.

About the Authors:

Ernestina Coast

* E-mail: [email protected]

Affiliation: Department of Social Policy, London School of Economics and Political Science, London, United Kingdom

Eleri Jones

Affiliation: Department of Social Policy, London School of Economics and Political Science, London, United Kingdom

Anayda Portela

Affiliation: Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland

Samantha R. Lattof

Affiliation: Department of Social Policy, London School of Economics and Political Science, London, United Kingdom

Introduction

Global strategies to reduce maternal and newborn mortality and health have emphasised the need for scaling up the use of skilled maternity care [1]. Yet, experience has shown that provision of skilled care and availability of maternity care facilities does not necessarily lead to increased utilisation. A large body of literature describes how cultural factors affect women's use of services [2]–[4], including those resulting from differing ‘cultures’ of maternity care between service providers and populations served [5].

What is culture?

There is no one agreed definition of culture, but a focus on culture means emphases placed on aspects such as shared norms, beliefs and expectations, spoken language and behavioural customs [6]. In reality, it is difficult to separate out culture from social, economic and geographical context [7]. For example, members of a cultural group might not use a particular health service because they are too poor or because they know they will be discriminated against – highlighting the danger of conflating poverty with culture. Culture includes components that are both explicit and implicit. Hall [8] describes different levels of culture: a level that is explicit or manifest to outsiders (e.g., language, rituals, dress), a level of rules and norms that are known to group members but rarely shared with outsiders, and a level that is known and followed but not stated. Most societies have more than one culture within them. These cultural sub-divisions might take the form of social groups or strata (e.g., ethnic groups, religious groups, social classes, castes, ranks) marked by distinctive cultural attributes (e.g., beliefs, behaviour, perceptions, attitudes to illness and health, religion, language, manners, dress, housing, diet) alongside social and economic attributes (e.g., wealth, power, gender, education).

Culture and maternity care services

Childbirth, and the time around birth, is a social and cultural event that is often governed by norms. However, in most societies, the dominant culture, expressed through social institutions such as the health care system, regulates how health issues are both perceived and addressed. Differences between the cultures of health care services and service users have been recognised as a major issue in service delivery. Perceived or actual cultural insensitivity or incompetence of professionals can lead to perceptions of poor quality care by users or discrimination of certain users by providers, resulting in a lack of trust in services and service providers [9]–[11].

Many authors have recommended that cultural factors should be taken into account in the planning and delivery of services in order to effectively encourage service uptake as an important step in reducing maternal and newborn mortality [5], [12]–[16]. Intercultural approaches to the design and delivery of national policies are well-established in some countries, particularly in Latin America [17]. The need for ‘culturally-appropriate’ health facilities is core to the World Health Organization's (WHO) mandate on ‘health for all’ [18] and its strategy for improving maternal and newborn health [5]. However, research reveals the complexity of such endeavours. [19]. It is known that some interventions have been implemented in different world regions to address cultural factors that affect the use of maternity care services. However, the literature has not been synthesised.

Aims and objectives

This systematic mapping of the literature aims to understand the range of interventions that have been implemented to address cultural factors affecting women's use of skilled maternity care services. The study's objectives were to methodically identify and develop a map of the literature; categorise the range of interventions, the type of literature and the study designs included; and identify knowledge gaps.

Methods

Methods

The methodology for systematic mapping used in this study was developed from work at the Evidence for Policy and Practice Information and Co-ordinating Centre and is increasingly used in a range of social sciences [20]–[24]. The scope and types of literature included in a systematic mapping are normally broader than in a systematic review. The aim in this mapping is to describe as widely as possible all of the literature relating to the topic without limiting to studies that assess the strength or direction of the relationship, or even to empirical studies. We developed a protocol that was reviewed by an advisory group composed of content and method experts.

Inclusion/exclusion criteria

Potentially eligible studies included journal articles, and published and unpublished information from governments and other agencies, whether available in print or online, published in English, French and/or Spanish. Since the aim is to describe the nature and coverage of the literature, quality was not assessed and was not a criterion for inclusion. Multiple references based on the same sample were also not excluded (as would be the case in a systematic review in order to avoid bias).

Table 1 provides the specification of the items to be mapped. Whilst intervention aims and outcomes relate only to women's use of services during pregnancy, childbirth and after birth, intervention recipients may include, for example, household or family members, community leaders or maternity care providers. Skilled care is defined in this mapping as those services provided by a skilled attendant: an “accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. Traditional birth attendants, trained or not, are excluded” [25]. Where the distinction between skilled and unskilled care is not clear, an inclusive approach is adopted. However, interventions that focused primarily on traditional birth attendants' (TBAs) roles in the direct provision of childbirth services were excluded, as the focus of the paper is on skilled maternity care services. Interventions concerned with improving satisfaction, but not also the use of services, are excluded.

[Figure omitted. See PDF.]

Table 1. Specification of systematic mapping.

https://doi.org/10.1371/journal.pone.0108130.t001

Items must describe an implemented intervention in which a primary, focused aim or strategy is to address cultural factors as a vehicle to change use of maternity care services. This criterion excludes the following:

* Interventions that exclusively address economic or geographical access barriers for a defined cultural group, although overlaps between cultural factors on the one hand and economic and geographical factors on the other are acknowledged [7];

* Generic quality improvement interventions that consider and/or accommodate cultural factors explicitly or implicitly, but not as a primary, focused aim or strategy. Whilst it is acknowledged that an “important question may be what combination of interventions and ways of incorporating culture into generic quality improvement are most likely to improve quality of care and outcomes” [6], this question is beyond the scope of this mapping; and

* Items in which ‘cultural appropriateness’ is evaluated, but not incorporated in intervention design or implementation.

Search strategy

Electronic databases, registers and websites were assessed for their availability, relevance and likely coverage of the eligible literature. Ten electronic databases and two targeted websites were included and searched for items published from 1 January 1990 to 28 February 2013. Combinations of relevant search terms were developed and tested in a sample of databases for sensitivity to a list of references that were known to the research team and judged to be potentially relevant. Table 2 presents the final combinations of search terms used. Electronic searches were adapted to each database using appropriate truncations/wildcards. Titles and abstracts were normally searched, and Medical Subject Headings (MeSH) terms were included where possible. A call for papers was sent by the WHO to various organisations and topic experts. The references received were combined with the electronic search results.

[Figure omitted. See PDF.]

Table 2. Search terms and their combinations.

https://doi.org/10.1371/journal.pone.0108130.t002

Screening process

All items identified through the search were screened initially on the basis of title and abstract. Where inclusion or exclusion could not be determined on the basis of title and abstract, the full text was screened. Figure 1 illustrates the screening process. EC, EJ, EH and SK contributed to screening the items individually. The following measures were taken for quality assurance: 1/all team members involved in screening independently screened the first 100 items. The whole team subsequently met to compare results, and discuss and resolve any differences in understanding of the inclusion/exclusion criteria. The criteria were further elaborated where necessary; 2/at the full text screening stage, any items that a team member considered borderline or problematic were noted. At the end of the process, EJ and EH independently screened all of the problematic items. Again, the whole team met to compare results, debate and resolve any differences. Decisions were made in favour of an inclusive approach where questions remained.

[Figure omitted. See PDF.]

Figure 1. Mapping results.

https://doi.org/10.1371/journal.pone.0108130.g001

Analysis

Data were extracted for analysis from all items in the map, including background information; a description of the intervention; details of the type of literature (and study if relevant); and details of relevant outcomes measured. Based on the map, we inductively developed and defined intervention categories. It was unfeasible to create perfectly discrete categories since many interventions are complex. Where an intervention could have fitted into more than one category, did not fit neatly into any category, or was not described in sufficient detail to understand its content, the item was placed in the category in which it was deemed to fit best. Data are presented in tables along with a narrative synthesis.

Results

After removing duplicates, the electronic database searches and website searches, combined with references suggested by experts, generated a total of 33,227 items for screening. The majority of items were not relevant. Following the screening, a total of 96 items were included in the map. The research team was unable to retrieve or screen a further 16 items.

Interventions addressing cultural factors affecting the use of skilled maternity care are not confined to a specific type of country. The map includes items from 35 countries across all world regions and the whole range of country income levels. Thirty-nine of the items were based in high-income countries, of which the majority were from the United States of America (USA), followed by Australia, Canada and the United Kingdom (UK). Items from the USA and UK predominantly included interventions targeting specific immigrant or ethnic minority groups, whilst items from Australia and Canada predominantly targeted indigenous communities. Only one item was based in continental Europe, although this may partly reflect the systematic mapping's restricted language coverage.

Of the remaining items, 25 were from low-income countries and 29 from middle-income countries, with three items located in multiple countries that cut across these categories. Sixteen items described interventions across nine countries in Eastern and Western Africa, and 14 items described interventions in Latin America. Twenty-seven items from Asia were dominated by literature from southern Asia.

Description of interventions

The five intervention categories we developed were: (1) service delivery models, (2) service provider interventions, (3) health education interventions, (4) participatory approaches, and (5) mental health interventions. We define the categories and describe the range of interventions within each below.

1. Service delivery models.

This category includes 24 items describing models of service delivery specifically designed (or adapted from existing models of service delivery) to provide culturally-appropriate services for targeted groups (Table 3). These models are largely complex interventions taking a broad range of measures, often including elements of the ‘service provider interventions’ and ‘participatory approaches’ described below as well as adaptations to the service setting, practices, materials and/or language. The category is dominated by interventions from Australia and Latin America.

[Figure omitted. See PDF.]

Table 3. Included items: Service delivery models.

https://doi.org/10.1371/journal.pone.0108130.t003

Several items from Australia describe comprehensive service delivery models for Aboriginal communities, implemented through a targeted health service [26]–[30]. For example, Nel and Pashen describe an indigenous medical centre managed by a community board and staffed by indigenous service providers [28]. Service users are seen in familiar surroundings, and Aboriginal health workers visit them to ensure attendance. Moreover, pregnant women are allowed to bring children and family members, in recognition of the cultural importance of extended family links. Several items in this category, particularly from Latin America, describe the introduction of culturally-appropriate ‘maternity waiting homes’ or ‘birthing houses’ [31]–[33]. Moreno and Lopez [34] describe this model of service delivery as part of a broad strategy to adapt a national plan in Ecuador for indigenous communities.

Different types of culturally-appropriate models of service delivery have been designed for indigenous communities [35], [36], ethnic groups [37], [38], refugees [39] and the general population [40]. For example, Gabrysch et al. [35] describe a delivery care model that was developed in Peru in cooperation with Quechua indigenous communities and health professionals, featuring a rope and bench for vertical childbirth, inclusion of family and TBAs in the service delivery process and during childbirth, and use of the Quechua language. One item in this category [41] is an outlier; in the item from Kazakhstan, the aim of a new culturally-appropriate service delivery approach is to introduce less medicalised care.

Some interventions refer to the provision of skilled home-based childbirth services explicitly in order to accommodate cultural norms [42], [43]. Several further interventions in which a culture-based rationale was cited for training TBAs were excluded since the TBA was solely responsible for the direct provision of childbirth services [44]–[49]. However, these interventions also aimed to harness the TBAs' cultural role to facilitate linkages with the formal health system and improve referral for obstetric complications.

2. Service provider interventions.

This category encompasses a range of interventions characterised by their focus on service providers. Analysis within this category revealed several sub-categories. One sub-category refers to three interventions in which the service provider is selected to match service users in terms of cultural characteristics [50]–[52] (Table 4). For example, Bilenko et al. [50] described an intervention in Israel in which a clinic for Bedouin families was staffed by an Arabic speaking Bedouin public health nurse. Few items describe this type of intervention as the sole focus. However, several items placed in other categories, particularly in the ‘service delivery model’ category, include this as one element of a broader intervention [26], [27].

[Figure omitted. See PDF.]

Table 4. Included items: Service provider interventions.

https://doi.org/10.1371/journal.pone.0108130.t004

A large sub-category comprises 14 interventions in which people who share cultural characteristics with a target service user group are employed to bridge the cultural gap between this group and service providers (Table 4) [53]–[66]. They may fulfil various roles including encouraging and helping women to access care [57], [59]; assisting women in communicating with healthcare providers [55], [56]; and advocating on their behalf [62]. They are sometimes referred to as ‘linkworkers,’ ‘peer health workers’ or ‘cultural brokers’. The category is dominated by items from the USA and the UK, where interventions have been implemented with specific immigrant or ethnic minority groups. This type of intervention has a long history, with many interventions implemented as early as the 1980s and 1990s. Again, several items placed in other categories, particularly in the ‘service delivery model’ category, include this position as one element of a broader intervention [26], [32].

The final sub-category refers to eight interventions with existing staff to enhance their cultural awareness or sensitivity. These interventions have been implemented across diverse contexts and include various teaching and/or learning approaches [67]–[74] (Table 4). For example, Smith and Davies [74] describe a knowledge exchange intervention in Canada that brings "communities together to enable them to understand each other's goals and cultures."

3. Health education interventions.

Within this category, 22 items from diverse settings describe a wide range of strategies employed with the aim of designing culturally-appropriate health education activities (Table 5). Interventions may use one or more strategies. Several interventions use preliminary studies investigating cultural factors to inform health education activities, although they differ in the extent to which they describe how these cultural factors were addressed in the actual intervention [75]–[80]. This finding may reflect different levels of emphasis on these factors in intervention design, but may also simply be a reporting issue. For example, Opoku et al. [79] and Olaniran et al. [80] both refer to the same intervention in Nigeria. However, whilst Opoku et al. [79] make a brief mention of using research on cultural factors to inform design, Olaniran et al. [80] describe in more detail the measures taken to address cultural factors. Culturally-appropriate health education messages were developed, trainers were selected who were fluent in the local language, and campaigns were carried out in churches.

[Figure omitted. See PDF.]

Table 5. Included items: Health education interventions.

https://doi.org/10.1371/journal.pone.0108130.t005

Related to a sub-category within ‘service provider interventions,’ one strategy within the category of health education interventions is to employ facilitators or trainers who share cultural characteristics with the relevant population [80]–[84]. For example, both Gennaro et al. [82] and Yeshi et al. [84] describe interventions employing village leaders as trainers.

Several items describe developing culturally-appropriate health education materials and practices, in terms of messages, language, modalities and/or images [80], [85]–[90]. For example, Omer et al. [89] describe using an education tool in Pakistan that reflects local materials and skills in embroidery, and DeStephano et al. [86] describe a culturally-tailored health education video series for Somali women in the USA. Finally, health education interventions have used participatory approaches [75], [84], [91]–[94]. These are distinguished from the ‘participatory approaches’ category on the basis that their primary focus is the delivery of education interventions.

4. Participatory approaches.

An inclusive approach was adopted for participatory interventions in this systematic mapping because a population's participation in intervention design and implementation may be considered inherently to address or accommodate cultural factors. Thus, all items in which the population's participation in intervention design and implementation was a primary and explicit strategy were included. Analysis of items in this category indicates different levels of explicit emphasis on ‘cultural’ factors, a distinction that is highlighted with sub-categories (Table 6).

[Figure omitted. See PDF.]

Table 6. Included items: Participatory approaches.

https://doi.org/10.1371/journal.pone.0108130.t006

The first sub-category comprises four items that describe the participatory approach adopted as an explicit strategy to address or accommodate cultural factors affecting the use of skilled maternity care [95]–[98]. For example, Hounton et al. [96] describe their intervention in Burkina Faso as one that involved “investment in communities through an understanding of their social structure and health seeking behaviours, through identification and partnership with credible community leaders, and through identification of culturally-sensitive and locally-acceptable approaches to address transport and referrals.” Jewell and Russell [97] describe another approach implemented in the USA of forming a state-wide network of grassroots county minority health coalitions to develop projects to eliminate cultural barriers to prenatal care for minority women.

The second sub-category includes four items [99]–[102] that explicitly refer to cultural factors affecting use of skilled maternity care but do not explicitly describe whether or how the intervention addressed these cultural factors.

While the final sub-category comprises 14 items [103]–[116] that neither discuss cultural factors affecting the use of care nor explicitly frame the intervention as a strategy to address cultural factors, they are mentioned because participatory interventions are considered within the inclusive approach of this mapping as ones that inherently accommodate cultural factors.

Manandhar et al. [110] and Osrin et al. [116] describe a participatory, community-based women's group intervention with a marginalised population with low access to services in Nepal, facilitated through a community action cycle. They do not frame the intervention as one designed to address cultural factors. Yet, Morrison et al. [98], referring to the same intervention in Nepal, was placed in the subcategory of ‘participatory approaches that focus explicitly on cultural factors,’ because the item describes formative research that was used to design the intervention to be acceptable and sensitive to the local culture. The implication is that the distinction between the three sub-categories may not always be a reflection of differences in intervention content; it may in some cases simply be a result of the emphasis in authors' reporting. This attests to the elusiveness of how culture is incorporated and addressed in many health interventions.

5. Mental health interventions.

This small category includes three fairly recent interventions focusing on perinatal depression, all aiming to overcome treatment barriers for Latina women in the USA [117]–[119] (Table 7). All three items describe adaptations to existing interventions and models. They use strategies for addressing cultural factors that are similar to those used in other categories, such as service providers sharing cultural characteristics of the target group, a more appropriate service setting, and/or more appropriate materials or therapy in terms of language or content.

[Figure omitted. See PDF.]

Table 7. Included items: Mental health interventions.

https://doi.org/10.1371/journal.pone.0108130.t007

Description of types of literature and study designs

The map includes a wide range of literature, from narrative descriptions of interventions to studies using randomised controlled trials (RCTs) to evaluate impact. Eleven items provide only narrative descriptions of the intervention, including details of the design process, the content or its implementation. Some items report on studies used to inform the design of an intervention now being implemented.

All other items present some type of evaluation data, whether for monitoring, outcome evaluation or impact evaluation. The majority of items present various forms of quantitative or qualitative data used for monitoring the intervention and/or to evaluate outcomes. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Of these, 14 use experimental designs including nine RCTs and five non-RCTs, and nine use observational-analytic designs including seven cohort studies.

Differences in study designs are evident across intervention categories. A large proportion of the studies with designs that aim to measure impact, particularly those with experimental designs, are in the ‘participatory approaches’ category. This is followed by a smaller proportion in the ‘health education interventions’ and ‘service provider interventions’ categories, and very few in the other categories combined.

Discussion

Global recognition of the need to address cultural factors affecting the use of skilled maternity care has led to a wide range of interventions being implemented across diverse settings in all world regions and across all country income levels. Overall, the map provides a rich source of information on the types of intervention options that have been attempted to address or accommodate cultural factors that affect the use of skilled maternity care. The articles included in the systematic mapping and others indicate a growing awareness of the need to incorporate culture into the design of appropriate care to improve maternal and newborn outcomes [120], [121] and to deliver more responsive, effective maternity care services.

The mapping reveals examples of good practice and success stories. However, some of the literature identified, whilst stating a clear aim of addressing cultural factors, provides insufficient detail to understand exactly how they were addressed. It is clear that the complexities of formulating and implementing culturally-responsive programmes remain [16], [122]–[126]. In some of the literature found, culture is positioned as a barrier to maternal health service use, rather than an attribute of the population that services seek to serve. The type of cultural groups in a setting and the nature of cultural factors that affect use of skilled maternity care are context-specific, and give rise to a need for different kinds of intervention approaches that both anticipate and respect a community's culture, values and beliefs. This finding is reflected in the map by the clustering of items from specific contexts in specific categories of intervention.

Cultural beliefs and behaviour are impossible to isolate from the social and economic context in which they occur [7]. Interventions research around culture and maternal health service use is heavily weighted in favour of evidence focusing on sub-populations in high-income countries. We know that 99% of maternal deaths occur in low income settings and that scaling up the use of skilled maternity care will reduce global maternal morbidity and mortality [18]. We know that focusing only on the supply side of maternity care does not necessarily lead to increased use, and that culture is often invoked as an explanation for this supply-demand gap. Our systematic mapping shows that there is a critical need for better documentation of interventions, with an emphasis on lower-income countries, and better study methods to evaluate the ways in which cultural factors can be systematically mainstreamed into programmes to increase maternity care service use. Literature on interventions addressing cultural factors as evaluated models of practice remains limited. This finding may be to some extent related to the small-scale, context-specific nature of many interventions of this type.

We exclude several interventions with TBAs providing childbirth services because our focus is on use of skilled maternal health care (see category 1). However, within these items, there are several examples where the TBAs cultural role is also harnessed to facilitate linkages with formal health services. Although WHO guidance has moved away from promoting approaches that involve TBAs in the direct provision of care at birth, it also emphasises the importance of building links with TBAs and finding new roles so that this valuable resource can continue to support women during pregnancy, childbirth and after birth, and serve as an important link between services and communities [127]. Future interventions incorporating WHO guidance on the need for women to be attended by health care workers with the appropriate skills and training may consider employing traditional health workers in alternative roles. Going beyond public health programmes, there is also a need to incorporate cultural knowledge and responsiveness into health education, the development of health policies, and the delivery of culturally-competent health care.

Limitations

Limitations arising from the inevitable conceptual challenges of any attempt to map or categorise items focusing on ‘culture’ are acknowledged. Culture is a complex, elusive concept that is challenging to define, leading to diverse definitions and operationalisations in the literature. Usages of the term are not always helpful, and the concept is susceptible to assumptions and over-generalisation. Making distinctions between interventions that address cultural factors and those that address other factors that affect use of skilled care was not a straightforward task. Distinguishing between interventions that address cultural factors as the primary and explicit aim on the one hand, and those in which cultural sensitivity is incorporated as part of generic quality improvement on the other, inevitably involves subjective judgement.

One particular challenge was the research question's focus not on what was actually ‘done’ in the intervention, but rather on what the intervention sought to address, which was reflected in the search terms. However, what the intervention seeks to address is not always carefully described by authors.

The above conceptual challenges all had implications for what was eventually identified and included. Identifying relevant items depended in part on the research team's judgement of where the line should be drawn around those to be included (outlined in Table 1). This effort was the first attempt of its kind to map such interventions; however, the range of interventions was unknown at the design stage, making it necessary for the research team to confer frequently and to continue drawing lines throughout the screening process. Moreover, at both the searching and screening stages, identifying relevant items depended in part on how authors of potentially relevant items framed their reporting, and also on the research team's ability to overcome challenges to identifying (from the text available) those that meet the criteria. The research team was aware of the challenges at the outset and continuously sought to address them from the design stage through to the final synthesis. Nevertheless, any shortcomings remain a limitation of this systematic mapping.

Relevant items may have been missed through method limitations. More specifically, any relevant literature in languages other than English, French or Spanish would have been missed. Because searches were not designed to focus on participatory approaches, some literature on these interventions may have been missed. Also, since it would have been unfeasible to search all of the infinite potential sources of grey literature, the possibility that some items of this type were missed is high. The possibility that some in-service reports on small-scale interventions that were not intended or prepared for wider circulation were missed is particularly high. Finally, we were unable to retrieve 16 items for screening that may have been eligible for inclusion. These 16 items largely represented interventions implemented in low- and middle-income countries.

Conclusion

The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. However, many sources lack sufficient description or robust designs that allow us to draw firm conclusions. This may be to some extent related to the small-scale, context-specific nature of interventions of this type. Addressing the impacts of interventions to address cultural factors affecting the use of maternity care services is an issue of importance for researchers, programmers, and policy makers. It requires an inter-disciplinary approach and active dialogue with communities in order to understand their cultural systems, health beliefs, health practices and preferences. In order to better serve the varied needs of communities with culturally-diverse populations, the following recommendations are made for future research and reviews:

* The interventions in this map are inherently context-specific. Nevertheless, further intervention studies with harmonised outcomes, appropriate research methods and robust designs are warranted, which may provide valuable evidence on the impact (including benefits or potential harms) of a type of intervention model.

* Where an intervention is designed explicitly to address cultural factors, sufficient detail should be provided in reporting for the audience to understand how they were addressed (i.e., by specifying the links between the cultural factors identified and the content of the intervention).

* A full systematic review may be warranted of the more cohesive set of interventions designed to provide culturally-appropriate skilled maternity care for defined ethno-linguistic or religious groups. This would allow both the quality and outcomes of intervention studies to be examined.

Acknowledgments

Brian Gaschler (LSE) and Stephanie Kumpunen (LSE) (SK) provided research assistance during the design of the search strategy. Dr Eleanor Hukin (LSE) (EH) and Stephanie Kumpunen (SK) provided research assistance during the search, screening and coding phases. The authors wish to thank the members of the advisory group for their support throughout the process including: Jessica Davis, Sebanti Ghosh, Azza Karam, Cicely Marston, and Tina Miller. Disclaimer: Anayda Portela (AP) is a staff member of the WHO. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the WHO.

Author Contributions

Conceived and designed the experiments: EC EJ AP. Performed the experiments: EC EJ SL. Analyzed the data: EC EJ AP SL. Contributed reagents/materials/analysis tools: EC EJ AP SL. Wrote the paper: EC EJ AP SL.

Citation: Coast E, Jones E, Portela A, Lattof SR (2014) Maternity Care Services and Culture: A Systematic Global Mapping of Interventions. PLoS ONE 9(9): e108130. https://doi.org/10.1371/journal.pone.0108130

References

1. WHO (2005) The World Health Report 2005: Make every mother and child count. Geneva: World Health Organization.

2. Acsadi GT, Johnson-Acsadi G (1991) Social and cultural factors influencing maternal and child mortality in Sub-Saharan Africa with special reference to eastern African countries. New York, New York, Defense for Children International-USA, 1991. pp. 73–96.

3. Evans EC (2012) A review of cultural influence on maternal mortality in the developing world. Midwifery

4. Thaddeus S, Maine D (1994) Too far to walk: maternal mortality in context. Soc Sci Med 38: 1091–1110.

5. WHO (2003) Working with individuals, families and communities to improve MNH. Geneva: World Health Organization.

6. Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA (2007) Cultural leverage: interventions using culture to narrow racial disparities in health care. Med Care Res Rev 64: 243S–282S.

7. Helman C (2000) Culture, health, and illness. Oxford; Boston: Butterworth-Heinemann. 328p p.

8. Hall ET (1984) The Dance of Life: The Other Dimension of Time. Garden City, New York: Anchor.

9. Gabrysch S, Campbell OM (2009) Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 9: 34.

10. Gabrysch S, Lema C, Bedrinana E, Bautista MA, Malca R, et al. (2009) Cultural adaptation of birthing services in rural Ayacucho, Peru. Bull World Health Organ 87: 724–729.

11. Glei DA, Goldman N, Rodrıguez G (2003) Utilization of care during pregnancy in rural Guatemala:does obstetrical need matter? Social Science and Medicine 57: 2447–2463.

12. Camacho AV, Castro MD, Kaufman R (2006) 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. International Journal of Gynaecology and Obstetrics 94: 357–363.

13. Mackian S, Bedri N, Lovel H (2004) Up the garden path and over the edge: where might health-seeking behaviour take us? Health Policy and Planning 19: 137–146.

14. Miller T (1995) Shifting boundaries: Exploring the influence of cultural traditions and religious beliefs of Bangladeshi women on prenatal interactions. Women's Studies International Forum 18: 299–309.

15. Simwaka BN, Theobald S, Amekudzi YP, Tolhurst R (2005) Meeting millennium development goals 3 and 5. British Medical Journal 331: 708–709.

16. UNFPA (2005) Cultural Programming: Reproductive health challenges and strategies in East and South-East Asia. Bankgkok, Thailand: UNFPA.

17. Castro MD (2012) SISTEMATIZACIÓN DE BUENAS PRÁCTICAS EN EL DESARROLLO DE MODELOS DE ATENCIÓN A LA SALUD MATERNA CON PERTINENCIA INTERCULTURAL: Informe basado en el análisis de experiencias de Bolivia, Ecuador, Guatemala y Perú UNFPA-FCI. 51 p.

18. WHO (2007) Maternal mortality in 2005: estimates developed by WHO UNICEF, UNFPA, and the World Bank. Geneva: WHO.

19. WHO (2007) Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. Geneva: WHO.

20. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O, et al. (2005) Storylines of research in diffusion and innovation: a meta-narrative approach to systematic review. Social Science and Medicine 61: 417–430.

21. Oakley A, Gough D, Oliver S, James T (2005) The politics of evidence and methodology: lessons from the EPPI-Centre. Evidence and Policy 1: 5–31.

22. Abrami PC, Bernard RM, Wade CA (2006) Affecting policy and practice: issues involved in developing an Argument Catalogue. Evidence and Policy 2: 417–437.

23. Coast E, Leone T, Jones E, Hirose A (2012) Poverty and postnatal depression in low and middle income countries: a systematic mapping. Health and Place

24. Leone T, Coast E, Narayanan S, Graft Aikins A (2012) Diabetes and depression comorbidity and socio-economic status in low and middle income countries (LMICs): a mapping of the evidence" Globalisation and Health 8.

25. WHO (2004) The critical role of the skilled attendant. Geneva: World Health Organization.

26. Homer CSE, Foureur MJ, Allende T, Pekin F, Caplice S, et al. (2012) ‘It's more than just having a baby’ women's experiences of a maternity service for Australian Aboriginal and Torres Strait Islander families. Midwifery 28: E449–455.

27. Jan S, Conaty S, Hecker R, Bartlett M, Delaney S, et al. (2004) An holistic economic evaluation of an Aboriginal community-controlled midwifery programme in Western Sydney. J Health Serv Res Policy 9: 14–21.

28. Nel P, Pashen D (2003) Shared antenatal care for indigenous patients in a rural and remote community. Aust Fam Physician 32: 127–131.

29. Panaretto KS, Lee HM, Mitchell MR, Larkins SL, Manessis V, et al. (2005) Impact of a collaborative shared antenatal care program for urban Indigenous women: a prospective cohort study. Med J Aust 182: 514–519.

30. Panaretto KS, Mitchell MR, Anderson L, Larkins SL, Manessis V, et al. (2007) Sustainable antenatal care services in an urban Indigenous community: the Townsville experience. Med J Aust 187: 18–22.

31. Eckermann E, Deodato G (2008) Maternity waiting homes in southern Lao PDR: The unique ‘silk home’. Journal of Obstetrics and Gynaecology Research 34: 767–775.

32. Schooley J, Mundt C, Wagner P, Fullerton J, O′Donnell M (2009) Factors influencing health care-seeking behaviours among Mayan women in Guatemala. Midwifery 25: 411–421.

33. Tucker K, Ochoa H, Garcia R, Sievwright K, Chambliss A, et al. (2013) The acceptability and feasibility of an intercultural birth center in the highlands of Chiapas, Mexico. BMC Pregnancy Childbirth 13: 94.

34. Moreno E, Lopez N (2013) Mother and child health in Ecudaor: Working together to build the Sumak Kawsay. Bulletin von Medicus Mundi Schweiz 127

35. Gabrysch S, Lema C, Bedrinana E, Bautista MA, Malca R, et al. (2009) Cultural adaptation of birthing services in rural Ayacucho, Peru. Bulletin of the World Health Organization 87: 724–729.

36. Bender D, Santander A, Balderrama A, Arce A, Medina R (1995) Transforming the Process of Service Delivery to Reduce Maternal Mortality in Cochabamba, Bolivia. Reproductive health matters 3: 52–59.

37. Affonso DD, Mayberry LJ, Graham K, Shibuya J, Kunimoto J (1993) Prenatal and postpartum care in Hawaii: a community-based approach. Journal of Obstetric and Gynecological Neonatal Nursing 22: 320–325.

38. Mayberry LJ, Affonso DD, Shibuya J, Clemmens D (1999) Integrating cultural values, beliefs, and customs into pregnancy and postpartum care: Lessons learned from a Hawaiian public health nursing project. Journal of Perinatal & Neonatal Nursing 13: 15–26.

39. Reavy K, Hobbs J, Hereford M, Crosby K (2012) A new clinic model for refugee health care: adaptation of cultural safety. Rural & Remote Health 12: 1–12.

40. Kim J (2003) Survey on the programs of Sanhujori centers in Korea as the traditional postpartum care facilities. Women & Health 38: 107–117.

41. Kenney AM, Siupsinskas G, Sharman D, Adilbekova R, Zues O (2005) Technical report: Introducing international approaches to safe motherhood in Zhezkazgan: results of a pilot project in Kazakhstan. Almaty, Kazakhstan, Abt Associates, ZdravPlus, 2005 Apr. [55] p. p.

42. Ahmed T, Jakaria S (2009) Community-based skilled birth attendants in Bangladesh: attending deliveries at home. Reproductive health matters 17: 45–50.

43. Blum LS, Sharmin T, Ronsmans C (2006) Attending Home vs. Clinic-Based Deliveries: Perspectives of Skilled Birth Attendants in Matlab, Bangladesh. Reproductive Health Matters 14: 51–60.

44. Alto WA, Albu RE, Irabo G (1991) An alternative to unattended delivery–a training programme for village midwives in Papua New Guinea. Soc Sci Med 32: 613–618.

45. Bailey PE, Szaszdi JA, Glover L (2002) Obstetric complications: does training traditional birth attendants make a difference? Revista Panamerica de Salud Publica Pan American Journal of Public Health 11: 15–23.

46. Dehne KL, Wacker J, Cowley J (1995) Training birth attendants in the Sahel. World Health Forum 16: 415–419.

47. Hoff W (1997) Traditional health practitioners as primary health care workers. TROPICAL DOCTOR 27 Suppl 152–55.

48. Rowen T, Prata N, Passano P (2011) Evaluation of a traditional birth attendant training programme in Bangladesh. Midwifery 27: 229–236.

49. Smit JJ (1994) Traditional birth attendants in Malawi. Curationis 17: 25–28.

50. Bilenko N, Hammel R, Belmaker I (2007) Utilization of antenatal care services by a semi-nomadic Bedouin Arab population: evaluation of the impact of a local Maternal and Child Health Clinic. Matern Child Health J 11: 425–430.

51. Dundek LH (2006) Establishment of a Somali doula program at a large metropolitan hospital. Journal of Perinatal & Neonatal Nursing 20: 128–137.

52. Nauman T (1995) Mexico: birth revolution. POPULI 22: 8.

53. Chowdhury M (1998) The role of traditional birth attendants in a safe delivery programme in Bangladesh. TROPICAL DOCTOR 28: 104–106.

54. Friedsam D, Haug G, Rust M, Lake A (2003) Tribal benefits counseling program: Expanding health care opportunities for tribal members. American Journal of Public Health 93: 1634–1636.

55. Hazard CJ, Callister LC, Birkhead A, Nichols L (2009) Hispanic Labor Friends Initiative Supporting Vulnerable Women. Mcn-the American Journal of Maternal-Child Nursing 34: 115–121.

56. Hicks C, Hayes L (1991) Linkworkers in antenatal care: facilitators of equal opportunities in health provision or salves for the management conscience? Health Services Management Research 4: 89–93.

57. Julnes G, Konefal M, Pindur W, Kim P (1994) Community-based perinatal care for disadvantaged adolescents: evaluation of The Resource Mothers Program. J Community Health 19: 41–53.

58. Ley CE, Copeland VC, Flint CS (2011) Healthy Start Program Participation: The Consumers' Perspective. Social Work in Public Health 26: 17–34.

59. Marsiglia FF, Bermudez-Parsai M, Coonrod D (2010) Familias Sanas: an intervention designed to increase rates of postpartum visits among Latinas. Jouranl of Health Care for the Poor & Underserved 21: 119–131.

60. Mattson S, Lew L (1992) Culturally sensitive prenatal care for Southeast Asians. Journal of Obstetric & Gynecological Neonatal Nursing 21: 48–54.

61. Meister JS, Warrick LH, de Zapien JG, Wood AH (1992) Using lay health workers: case study of a community-based prenatal intervention. J Community Health 17: 37–51.

62. Parsons L, Day S (1992) Improving Obstetric Outcomes in Ethnic-Minorities - An Evaluation of Health Advocacy in Hackney. Journal of Public Health Medicine 14: 183–191.

63. Stamp GE, Champion S, Anderson G, Warren B, Stuart-Butler D, et al.. (2008) Aboriginal maternal and infant care workers: partners in caring for Aboriginal mothers and babies. Rural and Remote Health 8.

64. Thompson M, Curry MA, Burton D (1998) The effects of nursing case management on the utilization of prenatal care by Mexican-Americans in rural Oregon. Public Health Nursing 15: 82–90.

65. Warrick LH, Wood AH, Meister JS, de Zapien JG (1992) Evaluation of a peer health worker prenatal outreach and education program for Hispanic farmworker families. J Community Health 17: 13–26.

66. Woodard GRB, Edouard L (1992) Reaching Out - A Community Initiative for Disadvantaged Pregnant Women. Canadian Journal of Public Health-Revue Canadienne De Sante Publique 83: 188–190.

67. Adams V, Miller S, Chertow J, Craig S, Samen A (2005) Having a “safe delivery”: conflicting views from Tibet. Health Care for Women International 26: 821–851.

68. Andrus NC, Partner SF, Leppert PC (1997) Analyzing strategies for developing a prenatal health care outreach program to reduce social and cultural barriers. J Health Hum Serv Adm 20: 230–241.

69. Bardack MA, Thompson SH (1993) Model prenatal program of Rush Medical College at St. Basil's Free Peoples Clinic, Chicago. Public Health Rep 108: 161–165.

70. Clapham S, Pokharel D, Bird C, Basnett I (2008) Addressing the attitudes of service providers: increasing access to professional midwifery care in Nepal. TROPICAL DOCTOR 38: 197–201.

71. Fahey JO, Cohen SR, Holme F, Buttrick ES, Dettinger JC, et al. (2013) Promoting Cultural Humility During Labor and Birth. Journal of Perinatal & Neonatal Nursing 27: 36–42.

72. Kreiner M (2009) Delivering diversity: newly regulated midwifery returns to Manitoba, Canada, one community at a time. Journal of Midwifery & Womens Health 54: e1–e10.

73. Sathar Z, Jain A, RamaRao S, ul Haque M, Kim J (2005) Introducing Client-Centered Reproductive Health Services in a Pakistani Setting. Studies in Family Planning 36: 221–234.

74. Smith D, Davies B (2006) Creating a new dynamic in Aboriginal health. Can Nurse 102: 36–39.

75. Bhagat R, Johnson J, Grewal S, Pandher P, Quong E, et al. (2002) Mobilizing the community to address the prenatal health needs of immigrant Punjabi women. Public Health Nursing 19: 209–214.

76. Belizan JM, Barros F, Langer A, Farnot U, Victora C, et al. (1995) Impact of health education during pregnancy on behavior and utilization of health resources. Latin American Network for Perinatal and Reproductive Research. American journal of obstetrics and gynecology 173: 894–899.

77. Doctor HV, Findley SE, Ager A, Cometto G, Afenyadu GY, et al. (2012) Using community-based research to shape the design and delivery of maternal health services in Northern Nigeria. Reproductive health matters 20: 104–112.

78. Gies S, Coulibaly SO, Ouattara FT, Ky C, Brabin BJ, et al. (2008) A community effectiveness trial of strategies promoting intermittent preventive treatment with sulphadoxine-pyrimethamine in pregnant women in rural Burkina Faso. Malar J 7: 180.

79. Opoku SA, KyeiFaried S, Twum S, Djan JO, Browne ENL, et al. (1997) Community education to improve utilization of emergency obstetric services in Ghana. International Journal of Gynecology & Obstetrics 59: S201–S207.

80. Olaniran N, Offiong S, Ottong J, Asuquo E, Duke F (1997) Mobilizing the community to utilize obstetric services, Cross River State, Nigeria. The Calabar PMM Team. International Journal of Gynaecology & Obstetrics 59 Suppl 2S181–189.

81. Clemmons L, Coulibaly Y (1999) Cultural resources and maternal health in Mali. Washington, D.C., World Bank, Africa Region, Knowledge and Learning Center, 1999 Sep. 4 p. p.

82. Gennaro S, Thyangathyanga D, Kershbaumer R, Thompson J (2001) Health promotion and risk reduction in Malawi, Africa, village women. Journal of Obstetric and Gynecological Neonatal Nursing 30: 224–230.

83. Ratnaike RN, Chinner TL (1992) A community health education system to meet the health needs of Indo-Chinese women. J Community Health 17: 87–96.

84. Yeshi C, Wangdui P, Holcombe S (2009) Health and Hygiene Behaviour Change: Bottom-Up Meets Top-Down in Tibet. Development in Practice 19: 396–402.

85. Coley SL (2012) New Baby in a New Country: Supporting Local Immigrant Pregnant Mothers through “Moms Matter”. International Journal of Childbirth Education 27: 57–62.

86. DeStephano CC, Flynn PM, Brost BC (2010) Somali prenatal education video use in a United States obstetric clinic: A formative evaluation of acceptability. Patient Education and Counseling 81: 137–141.

87. Karl-Trummer U, Krajic K, Novak-Zezula S, Pelikan JM (2006) Prenatal courses as health promotion intervention for migrant/ethnic minority women: high efforts and good results, but low attendance. Diversity in Health & Social Care 3: 55–58.

88. Midhet F, Becker S (2010) Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reproductive Health

89. Omer K, Mhatre S, Ansari N, Laucirica J, Andersson N (2008) Evidence-based training of frontline health workers for door-to-door health promotion: A pilot randomized controlled cluster trial with lady health workers in Sindh Province, Pakistan. Patient Education and Counseling 72: 178–185.

90. Perreira KM, Bailey PE, de Bocaletti E, Hurtado E, Recinos de Villagran S, et al. (2002) Increasing awareness of danger signs in pregnancy through community- and clinic-based education in Guatemala. Maternal & Child Health Journal 6: 19–28.

91. Dynes M, Rahman A, Beck D, Moran A, Rahman A, et al. (2011) Home-based life saving skills in Matlab, Bangladesh: a process evaluation of a community-based maternal child health programme. Midwifery 27: 15–22.

92. Gummi FB, Hassan M, Shehu D, Audu L (1997) Community education to encourage use of emergency obstetric services, Kebbi State, Nigeria. International Journal of Gynecology & Obstetrics 59: S191–S200.

93. Sibley L, Buffington ST, Beck D, Armbruster D (2001) Home based life saving skills: Promoting safe motherhood through innovative community-based interventions. Journal of Midwifery & Womens Health 46: 258–266.

94. Turan JM, Tesfagiorghis M, Polan ML (2011) Evaluation of a Community Intervention for Promotion of Safe Motherhood in Eritrea. Journal of Midwifery & Womens Health 56: 8–17.

95. Bhattacharyya K, Murray J (2000) Community assessment and planning for maternal and child health programs: A participatory approach in Ethiopia. Human Organization 59: 255–266.

96. Hounton S, Byass P, Brahima B (2009) Towards reduction of maternal and perinatal mortality in rural Burkina Faso: communities are not empty vessels. Global health action 2.

97. Jewell NA, Russell KM (2000) Increasing access to prenatal care: an evaluation of minority health coalitions' early pregnancy project. J Community Health Nurs 17: 93–105.

98. Morrison J, Osrin D, Shrestha B, Tumbahangphe KM, Tamang S, et al. (2008) How did formative research inform the development of a women's group intervention in rural Nepal? Journal of Perinatology 28: S14–S22.

99. Kaur P (1994) Providing choices for a marginalized community. A community-based project with Malaysian aborigines. PLANNED PARENTHOOD CHALLENGES 23–25.

100. Mushi D, Mpembeni R, Jahn A (2010) Effectiveness of community based Safe Motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC Pregnancy Childbirth 10: 14.

101. O′Rourke K, Howard-Grabman L, Seoane G (1998) Impact of community organization of women on perinatal outcomes in rural Bolivia. Revista Panamerica de Salud Publica Pan American Journal of Public Health 3: 9–14.

102. Orozco-Nunez E, Gonzalez-Block M, Kageyama-Escobar L, Hernandez-Prado B (2009) The experience of the Mexican maternal health care program Arranque Parejo en la Vida. Salud Publica De Mexico 51: 104–113.

103. Afsana K (2012) Empowering the Community: BRAC's Approach in Bangladesh; Hussein J, McCawBinns A, Webber R, editors. Cambridge, MA: CABI Publishing. 170–180 p.

104. Ahluwalia IB, Schmid T, Kouletio M, Kanenda O (2003) An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. International Journal of Gynecology & Obstetrics 82: 231–240.

105. Azad K, Barnett S, Banerjee B, Shaha S, Khan K, et al. (2010) Effect of scaling up women's groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial. Lancet 375: 1193–1202.

106. Kaseje D, Olayo R, Musita C, Oindo CO, Wafula C, et al. (2010) Evidence-based dialogue with communities for district health systems' performance improvement. Global public health 5: 595–610.

107. Keyser DJ, Pincus HA (2010) From community-based pilot testing to region-wide systems change: lessons from a local quality improvement collaborative. Programme in Community Health Partnerships 4: 105–114.

108. Kwast BE (1995) Building a Community Based Maternity Program. International Journal of Gynecology & Obstetrics 48: S67–S82.

109. Lewycka S, Mwansambo C, Kazembe P, Phiri T, Mganga A, et al. (2010) A cluster randomised controlled trial of the community effectiveness of two interventions in rural Malawi to improve health care and to reduce maternal, newborn and infant mortality. Trials 11: 88.

110. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, et al. (2004) Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 364: 970–979.

111. More NS, Bapat U, Das S, Alcock G, Patil S, et al. (2012) Community mobilization in Mumbai slums to improve perinatal care and outcomes: a cluster randomized controlled trial. PLoS Med 9: e1001257.

112. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, et al. (2011) Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: study protocol for a cluster randomised controlled trial. Trials 12: 128.

113. Rath S, Nair N, Tripathy PK, Barnett S, Rath S, et al. (2010) Explaining the impact of a women's group led community mobilisation intervention on maternal and newborn health outcomes: the Ekjut trial process evaluation. Bmc International Health and Human Rights 10

114. Skinner J, Rathavy T (2009) Design and evaluation of a community participatory, birth preparedness project in Cambodia. Midwifery 25: 738–743.

115. Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, et al. (2010) Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 375: 1182–1192.

116. Osrin D, Mesko N, Shrestha BP, Shrestha D, Tamang S, et al. (2003) Reducing childhood mortality in poor countries - Implementing a community-based participatory intervention to improve essential newborn care in rural Nepal. Transactions of the Royal Society of Tropical Medicine and Hygiene 97: 18–21.

117. Baker-Ericzen MJ, Connelly CD, Hazen AL, Duenas C, Landsverk JA, et al. (2012) A Collaborative Care Telemedicine Intervention to Overcome Treatment Barriers for Latina Women With Depression During the Perinatal Period. Families Systems & Health 30: 224–240.

118. Grote NK, Bledsoe SE, Swartz HA, Frank E (2004) Culturally relevant psychotherapy for perinatal depression in low-income ob/gyn patients. Clinical Social Work Journal 32: 327–347.

119. Le HN, Zmuda J, Perry DF, Munoz RF (2010) Transforming an evidence-based intervention to prevent perinatal depression for low-income Latina immigrants. Americal Journal of Orthopsychiatry 80: 34–45.

120. Pell C, Meñaca A, Were F, Afrah NA, Chatio S, et al. (2013) Factors Affecting Antenatal Care Attendance: Results from Qualitative Studies in Ghana, Kenya and Malawi. PLoS ONE 8: e53747.

121. Finlayson K, Downe S (2013) Why Do Women Not Use Antenatal Services in Low- and Middle-Income Countries? A Meta-Synthesis of Qualitative Studies. PLoS Med 10: e1001373.

122. Goodburn E, Campbell O (2001) Reducing maternal mortality in the developing world: Sector-wide approaches may be key. Social Science and Medicine 35: 967–977.

123. UNFPA (2005) Culture Matters - Working with Communities and Faith-based Organizations: Case Studies from Country Programmes. United Nations Population Fund (UNFPA). 1–103 p.

124. UNFPA (2008) Culture Matters - Lessons From a Legacy of Engaging Faith-Based Organizations as Cultural Agents of Change. United Nations Population Fund (UNFPA). 1–113 p.

125. UNFPA (2010) Promoting Equality, Recognizing Diversity - Intercultural Sexual and Reproductive Health among Indigenous Peoples in Latin America. United Nations Population Fund (UNFPA). 1–27 p.

126. UNFPA (2011) Social and Cultural Determinants on Sexual and Reproductive Health - Studies From Asia and Latin America. United Nations Population Fund (UNFPA). [Online]. Available from: http://www.unfpa.org/public/home/publications/pid/8825.

127. WHO (2010) Working with individuals, families and communities to improve maternal and newborn health. Geneva: World Health Organization.

128. Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V (2003) Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav 30: 133–146.

129. Dickerson T, Crookston B, Simonsen SE, Sheng XM, Samen A, et al. (2010) Pregnancy and Village Outreach Tibet A Descriptive Report of a Community- and Home-Based Maternal-Newborn Outreach Program in Rural Tibet. Journal of Perinatal & Neonatal Nursing 24: 113–125.

130. Greenberg EL, Perz M, Sockalingam S, Hayes M (1996) Multicultural maternal and child health outreach: Washington State strategies to assure access for Asian and Pacific Islander women and children. Journal of Public Health Management and Practice 2: 66–71.

131. Larson K, McGuire J, Watkins E, Mountain K (1992) Maternal care coordination for migrant farmworker women: program structure and evaluation of effects on use of prenatal care and birth outcome. Journal of Rural Health 8: 128–133.

132. McAree T, McCourt C, Beake S (2010) Perceptions of group practice midwifery from women living in an ethnically diverse setting. Evidence Based Midwifery 8: 91–97.

133. Nurena CR (2009) Incorporation of an intercultural approach in the Peruvian health care system: the vertical birth method. Revista Panamerica de Salud Publica Pan American Journal of Public Health 26: 368–376.

134. Zangari A (2009) El enfoque intercultural en la atención de la salud materna: una estrategia de aplicación -The intercultural approach in maternal health care: an implementation strategy. In: Menardi LC, Zangari A, Navarro RC, editors. Yachay Tinkuy: Salud E Interculturalidad en Bolivia Y America Latina. Bolivia: PROHISABA, Cooperacion Italiana, Editorial Gente Comun. pp. 454–478.

135. Clemmons L, Coulibaly Y (1995) Africare/Mali: creative communication for maternal health. PVO CHILD SURVIVAL TECHNICAL REPORT 4: 5–6.

136. Clemmons L, Coulibaly Y (1999) Turning the ordinary into the extraordinary: The Green Pendelu and maternal health in Mali. Arlington, Virginia, Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival [BASICS], 1999 Oct. pp. [15] p.