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Cultural Competence in Childbirth in Multicultural Ecuador: Lessons for Evaluation

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Cultural Competence in Childbirth in Multicultural Ecuador: Lessons for Evaluation Cultural Competence in Childbirth in Multicultural Ecuador: Lessons for Evaluation by Cinthia Josette Arévalo Gross B.A. in Economics and Finance, June 2008, Universidad San Francisco de Quito Master’s in Development Economics, March 2011, Facultad Latinoamericana de Ciencias Sociales (FLACSO-Ecuador) Master of Public Policy, May 2013, The George Washington University A Dissertation submitted to The Faculty of The Columbian College of Arts and Sciences of The George Washington University in partial fulfillment of the requirements for the degree of Doctor of Philosophy May 21, 2017 Dissertation directed by Kathryn Newcomer Professor of Public Policy and Public Administration . The Columbian College of Arts and Sciences of The George Washington University certifies that Cinthia Josette Arévalo Gross has passed the Final Examination for the degree of Doctor of Philosophy as of March 24, 2017. This is the final and approved form of the dissertation. Cultural Competence in Childbirth in Multicultural Ecuador: Lessons for Evaluation Cinthia Josette Arévalo Gross Dissertation Research Committee: Kathryn Newcomer, Professor of Public Policy and Public Administration, Dissertation Director Fernando Ortega, Professor of Public Health, Universidad San Francisco de Quito, Committee Member Karen E. Kirkhart, Professor, School of Social Work, David B. Falk College, Syracuse University, Committee Member ii © Copyright 2017 by Cinthia Josette Arévalo Gross All rights reserved iii Dedication I wish to dedicate this dissertation to the Shuar women who shared their knowledge about their childbirth traditions with me while I was pregnant with my daughter, Emma. Also, in gratitude to my family, in particular to Juan Carlos, Gina and Susana. Thank you for all your patience, love and support. iv Acknowledgments The author wishes to acknowledge the following people: Dr. Kathryn Newcomer. I am very grateful to have you as a mentor. Thank you for your knowledge, feedback, encouragement, and incredible support throughout this dissertation. Dr. Fernando Ortega. Thank you for all your time, feedback, and expertise regarding the medical concepts and the cultural context of Ecuador. I am very grateful. Dr. Karen Kirkhart. Thank you for your time, feedback and support. I am very grateful. Dr. Dylan Conger. Thank you for your ideas, feedback and patience. I am very grateful María Hinojosa. Thank you for your time, knowledge and for providing important information regarding intercultural childbirth services in Ecuador. Dr. José Pozo and Tania Laurini. Thank you for all your time and knowledge about the implementation of intercultural childbirth services in Morona Santiago. Thank you to the Shuar Federation (FICSH) and all the Shuar people and medical personnel in Macas, Méndez, and Sucúa who generously volunteered their time and shared their wealth of knowledge with me. I am deeply appreciative of your generosity and knowledge. The author would also like to thank the Clara Schiffer Fellowship for the support provided. v Abstract of Dissertation Cultural Competence in Childbirth in Multicultural Ecuador: Lessons for Evaluation Despite Ecuador’s increased public health spending and improvement in health outcomes, the Maternal Mortality Rate (MMR) in the country is high and has been increasing in tendency in the past decade. Furthermore, there is a clear gap in the proportions of institutional births between indigenous and non-indigenous women. Given the implementation of culturally adequate childbirth services in public hospitals in Ecuador, which occurred mostly after the Ministry of Public Health published technical guidelines for the cultural adaptation of childbirth services in 2008, this dissertation sought to assess the extent to which the availability of culturally adequate childbirth services affects the proportion of institutional deliveries and maternal mortality rates. After reviewing the main theoretical frameworks regarding the importance of culture in access to health care, this dissertation used a mixed-methods approach to analyze the determinants of institutional deliveries, and the effects of culturally adequate services on maternal health outcomes. In addition, this dissertation builds on the experience evaluating the impact of cultural competence in childbirth services to reflect on the need for culturally responsive intercultural evaluation. vi Table of Contents Dedication ................................................................................................................................. iv Acknowledgments ..................................................................................................................... v Abstract of Dissertation ............................................................................................................ vi List of Figures ......................................................................................................................... viii List of Tables ............................................................................................................................. x Chapter 1: Introduction .............................................................................................................. 1 Chapter 2: Supporting Theories and Literature ........................................................................ 13 Chapter 3: Methodology .......................................................................................................... 54 Chapter 4: What are the main factors associated with the choice of health-facility child delivery in a multicultural developing country like Ecuador? ................................................ 91 Chapter 5: To what extent do culturally adequate child delivery services improve: the proportion of institutional deliveries, health outcomes and perceptions of health care in Ecuador? ................................................................................................................................ 121 Chapter 6: Main Conclusions and Discussion ........................................................................ 162 References .............................................................................................................................. 182 Appendices............................................................................................................................. 195 vii List of Figures Figure 1.1: Public Health Spending as a % of GDP 2001-2013……………………………..….….4 Figure 1.2: Maternal Mortality Rate in Ecuador 1990-2015………………………………………..5 Figure 2.1: The process of cultural competence in the delivery of health care services – Campinha-Bacote .......…………………………………………………………………...………...20 Figure 2.2: Brach and Fraserirector’s Model for Reducing Health Disparities through the Implementation of Cultural Competency …………………………………………...…....………22 Figure 2.3: Analytic Framework to evaluate the effectiveness of the healthcare system to increase cultural competence ..………………….....................................……………...…………23 Figure 2.4: Determinants of Maternal Mortality..........………….....................………...…………33 Figure 2.5: Thaddeus and Maine’s ‘Three Delays Model’ .............................................................37 Figure 2.6: Proposed model of the effects of culturally adequate health facilities on maternal and child health outcomes ...............................................................................................................41 Figure 3.1: Procedural diagram: Convergent parallel design used to address research questions 1.a and 1.b. ......................................................................................................................................54 Figure 3.2: Validity centered in culture showing sources of justification/threat ............................82 Figure 3.3: Culturally Responsive Evaluation Framework ............................................................86 Figure 4.1: Institutional deliveries by ethnicity in Ecuador (2006 and 2014) ..............................114 Figure 4.2: Integrated model: factors associated with institutional delivery .................................118 Figure 5.1: Interviewees perceptions about the causes of maternal and infant deaths..................133 Figure 5.2: % of institutional deliveries in cantons with +/-3 years of data from the implementation of culturally adequate birthing rooms in at least one public hospital one (2003-2013) ..................................................................................................................................148 Figure 5.3: MMR of provinces with +/-3 years of data from the implementation of culturally viii adequate birthing rooms in at least one public hospital during the 2000-2015 period ...................154 Figure 5.4: Revised model of the effects of culturally adequate health facilities on maternal and child health outcomes .............................................................................................................160 ix List of Tables Table 3.1: Research Design Matrix….……………………….........……………………………….55 Table 3.2: Provinces with at least 1 public health facility adapted to offer intercultural childbirth services by 2015……………………………………................................................................…….64 Table 3.3: % of delivery rooms that meet the 19-item checklist of culturally adequacy ...............66 Table 4.1: Profile of the interviewees …………………................................................................92
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