WHO recommendation on providing culturally appropriate skilled maternity care

A midwife talks to the community in a Malawi village.

WHO recommendation on providing culturally appropriate skilled maternity care



Ongoing dialogue with communities is recommended as an essential component in defining the characteristics of culturally appropriate, quality maternity care services that address the needs of women and newborns and incorporate their cultural preferences.

Mechanisms that ensure women's voices are meaningfully included in these dialogues are also recommended.

(Strong recommendation, very low-quality evidence)


Publication history

First published: May 2015

Updated: No update planned

Assessed as up-to-date: May 2015



  • Additional research is required.



In 2003 the World Health Organization (WHO) published "Working with individuals, families and communities to improve maternal and newborn health", (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons - over and above what happens in clinical services - why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter's health promotion components(2) were translated into MNH programme language and 12 promising interventions - identified through reviews of country experiences and the literature - were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

The need for culturally appropriate health facilities is core to WHO's mandate on Health For All(3) and cultural competencies of providers and services were identified as a key area of intervention in the WHO IFC Framework.(1) A recent qualitative systematic review confirms the importance of cultural factors in the decisions of women and families to use skilled care at birth.(4) Different programmes have adapted models of service delivery or service practices to incorporate acceptable and respectful care, trained service providers, employed mediators and interpreters and used participatory approaches to engage in dialogue with communities in order to address cultural factors that affect use of care.



The recommendation was developed using standardized operating procedures in accordance with the process described in the "WHO handbook for guideline development", guided by the GRADE approach.(5) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(6)

A systematic review was conducted on interventions to provide culturally appropriate maternity care.(7) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

What strategies to provide culturally appropriate skilled maternity care lead to an increase in use of skilled maternity care before, during and after birth?


Evidence Summary

Evidence on interventions to provide culturally appropriate maternity care was extracted from a systematic review conducted by Coast, Jones and Lattof (forthcoming).(7) The review was based on literature identified through a systematic mapping conducted by Coast et al.(8) and also through the MASCOT/ MH-SAR mapping. This literature was supplemented with hand-searches of the reference lists of relevant reviews and items included in the mapping, as well as further recommendations from experts. The review sought interventions designed primarily and explicitly to provide culturally appropriate skilled maternity care for defined ethno-linguistic or religious groups. Examples of interventions considered include those that adapt models of service delivery (e.g., the service setting, practices, materials and/or language) to provide culturally appropriate or acceptable care, interventions to provide staff training and interventions that employ service providers or mediators who share cultural characteristics with the relevant population. As suggested by the GDG, in this case we also searched for studies from high-income countries as it was felt that lessons could be learned from experiences with different ethnic groups in these settings.

A total of 14 studies were identified as meeting our inclusion criteria. The studies were conducted mostly in high-income countries, where they focused on sub-populations in Australia, Canada, Israel, the United Kingdom and the United States of America (USA). One study was conducted in Peru.

Interventions included selecting and/or changing a service provider to match the cultural characteristics of the study population, changing the service social setting, introducing and/or changing service practices, changing the language of services, changing the location of service delivery, using a participatory model in designing the intervention, providing staff training and changing the physical setting of the service. There was not sufficient evidence to determine which of these strategies or which combination of strategies were most effective.

For the outcome of birth with a skilled birth attendant or facility birth, the quality of the evidence was rated as very low.

Two observational studies reported on this outcome: one was a prospective cohort study conducted with an Indigenous population in Australia (Panaretto et al., 2005); the other was a pre and post comparative study conducted with poor indigenous Quechua communities in Peru (Gabrysch et al., 2009). The new childbirth care model in Peru reports increases in the percentage of births with an SBA and births in the health centre over time. A new ANC model in Australia showed that more women attending the programme gave birth at the hospital. Very low-quality evidence.(9, 10)

For the outcome of care with a skilled birth attendant or in a facility in case of complications/illness in women, the quality of the evidence was rated as very low.

Two retrospective studies with control groups reported on this outcome. Parsons and Day (1992) measured the effect of health advocates on careseeking among Turkish and Asian women in the UK, while Thompson et al. (1998) examined the effect of nursing case management and home visits on care-seeking among high-risk low-income Mexican- American women in the USA. Both studies report on antenatal admissions and length of stay but provide no data on use of a skilled birth attendant at birth. In Parsons and Day (1992), length of stay was significantly lower in the health advocates' intervention group, but there was no difference between the groups in the Thompson et al. (1998) study. There were too few antenatal admissions to calculate statistical differences in the Thompson et al. (1998) study but the study found more inpatient admissions and emergency room visits in the intervention group. In the Parsons and Day study (1992), antenatal admissions remained the same with the health advocates intervention and increased in the control group. Very low-quality evidence.(11, 12)

For the outcome of use of ANC, the quality of the evidence was rated as very low.

Eleven observational studies reported on this outcome. All studies were conducted in high income countries with ethnic minority women: five in Australia with Indigenous Aboriginal and Torres Strait Islander populations (Jan et al., 2004; Kildea et al., 2012; Nel and Pashen, 2003; Panaretto et al., 2005; Panaretto et al., 2007;); three in the US with minority groups including pregnant adolescents at high risk of poor outcomes (Julnes, 1994; Jewell and Russell, 2000; Thompson, Curry and Burton, 1998); two in the United Kingdom with Asian and Turkish women (Parsons and Day, 1992; Mason, 1990); and one in Israel with Bedouin women (Bilenko, Hammel and Belmaker, 2007). Interventions included health advocacy, liaison, linkage or brokerage for women; the employment of Indigenous health staff; group or individual support; home or clinic-based visits; and transport services. Overall results indicate a positive effect of culturally appropriate interventions on ANC use. Eight studies showed improvement on various measures of antenatal care utilization, including indexes of the adequacy of ANC, increases in the number of visits, or increases in women having at least six ANC visits (Bilenko, Hammel and Belmaker, 2007; Jan et al., 2004; Jewell and Russell, 2000; Julnes, 1994; Kildea et al., 2012, Nel and Pashen, 2003; Panaretto et al., 2005; Panaretto et al., 2007). Three report no difference in ANC use between those receiving the intervention and controls (Mason, 1990; Parsons and Day, 1992; Thompson, Curry and Burton, 1998). Very low-quality evidence.(9, 11-20)

For the outcome of postpartum care visits for women, the quality of the evidence was rated as low.

One RCT study (Marsiglia, Bermudez-Parsai and Coonrod, 2010) reported on this outcome in low-income Latina/Hispanic pregnant women in the USA. Results show a benefit of the cultural broker: attendance at the postpartum visit was 2.5 times more likely in the intervention group and women who met with the prenatal partners (cultural brokers) more often were more likely to attend the postpartum visit. Low-quality evidence.(21)


Implementation considerations

  • The GDG requested that, despite the wording of the recommendation, the implementation of this intervention should not be limited to dialogue (communication) but should also offer the opportunity to participate and to transform the way services are offered and community-health services relations.
  • Different interventions were employed in the 14 identified studies to provide culturally appropriate maternity care services. Most studies implied that these adjustments lead to increased satisfaction with services. These interventions might include one or a combination of the following elements: establishing, enhancing and evaluating dialogue between communities, policymakers, institutions and service providers; using cultural brokers as mediators; integrating culturally matched health staff (lay and skilled); adapting service practices to the cultural context where appropriate and feasible; and using and making respectful approaches central to dialogues between and within communities, institutions, service providers and policies.
  • Only three studies reported on costs and the same were very context specific.
  • Given that cultural beliefs and behaviour are impossible to isolate from the social and economic context in which they occur, interventions are likely to be most sustainable when they employ a participatory approach. Measures should be taken to support women, community members and groups, providers and institutions to establish and maintain respectful dialogue.
  • For service providers, the promotion of dialogue with communities should be embedded in their training and supported and evaluated over their career. Policies at the national and local level should be in place to establish an enabling environment and support dialogue with communities.
  • Culture is not static, and its dynamism needs to be recognized, anticipated and incorporated into maternity care services. The potentially harmful consequences of cultural stereotyping need to be avoided. Services designed for specific populations should take into account the potential harm of associated stigma. Efforts should be made to understand the cultural factors affecting use of care in the relevant context through prior studies and/or community participation in the design of the intervention.
  • In establishing respectful dialogue with communities, the following considerations were highlighted by the GDG:
    • Recognize and address power dynamics
    • Make links to respectful maternity care
    • Vulnerated populations are not vulnerable
    • Recognize gender hierarchies in institutions
    • Pre-service and in-service training of providers needs to take into account cultural competencies and clinical training sites should model these practices
    • Language is an important part of cultural considerations
  • Support government health services in strengthening skills as a mediator in bringing together a broad array of actors for dialogue with communities


Research implications

The GDG identified that further research on the following high-priority questions is needed:

  • The GDG identified that further research on the following high-priority questions is needed:
  • Studies should aim for optimal design and should document important process issues for implementation research to understand the effect of the different modalities of delivering the intervention.
  • Studies should standardize some of the outcome measures, allowing for the possibility of local contextualization and for additional measures beyond the traditional health outcomes, including women's satisfaction with services, strengthening of services and community relations.
  • Studies should include clear and common indicators for monitoring and evaluation and standardized measures of these and should use standard methods for capturing the opinions of women, the community and health staff on health services and quality.
  • Agreement is needed on priority actions and/or which combinations of essential actions should be further tested.
  • Intervention studies that provide strong(er) evidence of impact are needed.
  • Where interventions are complex, these should be supplemented with qualitative and/or other studies that may isolate which components of the intervention are responsible for the outcomes.
  • Studies should examine and present information on resource use where possible.
  • Studies in low and middle-income countries should be prioritized.
  • Where an intervention is designed explicitly to address cultural factors, sufficient detail should be provided in reporting for the audience to understand how the cultural factors were addressed and how the intervention was implemented.
  • When writing up studies, authors should provide more detailed information on the content of the interventions and how the interventions were implemented.
  • Progress has been made in some regions (e.g., LAC) to develop and include policies and standards of care with an intercultural approach. Case studies of these programmes should be developed to extract lessons learned.
  • A review of curricula and training programmes for health professionals should be undertaken to determine the extent to which cultural sensitivity and competencies have been included. An expert group can establish core cultural competencies that can be adapted at the national and local levels and incorporated into training or curricula for health professionals.
  • The intercultural dialogue approach can be used as a base to promote collaborative research towards simultaneous studies and/or multi-site studies, with guidance to funders.


Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015)full document and evidence tables


Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

Newborn Health


Supporting systematic reviews:

Coast E, Jones E, Lattof SR, Portela A. Effectiveness of interventions to provide culturally appropriate maternity care in increasing uptake of skilled maternity care: a systematic review. Health policy and planning. 2016;31(10):1479-91.



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WHO recommendation on providing culturally appropriate skilled maternity care  (2015). WHO Reproductive Health Library; Geneva: World Health Organization.