Bill & Melinda Gates Foundation

The Role of Culture Change in Making Childbirth Safer

September 06, 2012

Michelle Obama has been in the news quite a bit these days. Her Let’s Move initiative to combat the rise of obesity in America, in particular, has us thinking about how culture impacts health.  Obesity in the U.S. is due in part to the popular practice of eating highly processed, fatty “fast” foods combined with little exercise. This part of our culture is leading to serious negative health consequences like high rates of high blood pressure, heart disease, cancer, and diabetes. Still, it is an accepted behavior in many communities across our country.

The question then becomes: what happens when culture and accepted behaviors are actually harmful; when science and culture collide?

In many of the poorest parts of Africa young girls are allowed to spend days in labor to deliver a baby. It is customary in many places that pregnant girls and young women, particularly teenagers, are considered by their family and community to be strong enough to deliver at home, even if the labor goes on for days. What is tragic, though, is that often times these young women have not sufficiently matured physically, and as a result, the baby is too large for the size of the birth canal and unable to come out. In addition to this teenage girl having the tragedy of losing her baby, many times this obstructed labor has horrific consequences for her as well, leading to fistula and a life of incontinence, and sometimes death.

A fistula essentially is a hole in the vagina that causes a woman to leak urine or even feces continually. It has devastating repercussions on a woman, physically, socially, and mentally. It can cause frequent infections, kidney disease, and nerve injuries. Oftentimes the woman is socially ostracized and marginalized in her community for being unclean. What makes it worse is that it is largely preventable by recognizing when childbirth is not progressing and performing an emergency procedure to save the mom’s and baby’s lives.  

But, it’s part of the culture that young, new mothers should be strong enough to deliver at home. This brings me back to the question at hand: what can we in the global health community do when culture kills? When we act, how can we do so responsibly within the cultural context?

It’s a fine line between changing cultures and changing behaviors. Behavior change is a major focus of many global health interventions, promoting safer behaviors to lessen risks that are part of the culture yet bring adverse health outcomes. These programs are based on scientific evidence that shows how to reduce risks or prevent disease.

For example, HIV prevention programs promote behavior change to reduce the number of sexual partners, an acknowledged part of the culture in many places and also a high-risk practice for spreading HIV. As another example, some communities have changed the practice of female genital mutilation to no longer cut a young girl but will still celebrate the ceremony and the passage into adulthood, making it safer for young girls while maintaining the culture.

And in the case of fistula, health programs promote childbirth in hospitals and health centers , particularly for young girls, to ensure that she has qualified providers to assist with delivery and to provide emergency care so her baby lives and she continues with a healthy life. There are also programs to promote the delay of child bearing and early marriage until a young woman is physically ready.

Changing behaviors is not an easy task, and changing cultures is even more difficult and can be very sensitive. Any intervention in global health must start with the community, not the intervention. We can successfully develop, introduce and scale up an intervention only when we understand the desires, motivations, and choices of the user - essentially, only when we consider the culture of a community.

In the case of fistula, we have the scientific knowledge and public health practice to prevent fistula; what we need are culturally sensitive yet acceptable approaches to shifting behaviors and social norms for childbirth.

We start with the community’s desire to have healthy babies and healthy mothers. Within that context, we look to behaviors that need to change to match that cultural expectation. 

How can you can help? Learn more and spread the word. For more information on fistula and its devastating effects, check out One by One and  The Fistula Foundation. And the Global Fistula Care Map tracks what care is provided for women with fistula and where.

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