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BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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. TRIAL REGISTRATION: 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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RESUMO

BACKGROUND: Indigenous women in the southern Mexican state of Guerrero face poor maternal health outcomes. Living as they do at the very periphery of the Western health system, they often receive low-quality care from health services that lack human and financial resources. Traditional health systems remain active in indigenous communities where traditional midwives accompany women through motherhood. Several interventions have explored training birth attendants in Western birthing skills, but little research has focussed on supporting traditional midwives by recognising their knowledge. This trial supports traditional midwifery in four indigenous groups and measures its impact on maternal health outcomes. METHODS: The study includes four indigenous populations in the State of Guerrero (Nahua, Na savi/Mixteco, Me'phaa/Tlapaneco and Nancue ñomndaa/Amuzgo), covering approximately 8000 households. A parallel-group cluster-randomised controlled trial will compare communities receiving usual care with communities where traditional midwives received support in addition to the usual care. The intervention was defined in collaboration with participants in a 2012 pilot study. Supported midwives will receive a small stipend, a scholarship to train one apprentice, and support from an intercultural broker to deal with Western health personnel; additionally, the health staff in the intervention municipalities will participate in workshops to improve understanding and attitudes towards authentic traditional midwives. A baseline and a final survey will measure changes in birth and pregnancy complications (primary outcomes), and changes in gender violence, access to healthcare, and engagement with traditional cultural activities (secondary outcomes). The project has ethical approval from the participating communities and the Universidad Autónoma de Guerrero. DISCUSSION: Indigenous women at the periphery of Western health services do not benefit fully from the attenuated services which erode their own healthcare traditions. Western health service providers in indigenous communities often ignore traditional knowledge and resources, inadvertently or in ignorance, disrespecting indigenous cultures. Improved understanding between midwives and the official healthcare system can contribute to more appropriate referral of high-risk cases, improving the use of scarce resources while lowering costs of healthcare for indigenous families. TRIAL REGISTRATION: ISRCTN12397283 . Retrospectively registered on 6 December 2016.

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