Changes in pregnancy and childbirth practices in remote areas in Lao PDR within two generations of women: implications for maternity services

Abstract

This paper sheds light on the inter-generational changes in pregnancy and childbirth practices in remote areas of Lao PDR over a period of 30 years. The study consisted of focus group discussions with pregnant women aged 14–30, mothers and fathers of small children, and older women aged 40+ in six rural communities in two districts. Childbirth practices were gradually evolving and changing – most dramatically illustrated by the transition from forest-based to home-based delivery, and a few health facility-based deliveries when complications occurred. Today’s generation of women aged 40+ did not recommend all the practices of their mothers, but saw the need to adapt due to the social and medical risks they had experienced, especially high rates of neonatal death. Their daughters are doing the same. The increase in home-based deliveries should be regarded as significant progress in this setting in rural Laos. Understanding how young women interpret their options and incorporating that knowledge and the experience of successful local outreach programmes into health system policy and practice for maternity care, e.g. by strengthening the skills of community-based health workers, could contribute to improving maternal and neonatal survival and reducing health inequalities.

Résumé

Cet article fait la lumière sur les changements intergénérationnels dans les pratiques relatives à la grossesse et l’accouchement dans des zones isolées de la République Démocratique Populaire Lao, sur une période de 30 ans. L’étude consistait en discussions de groupes avec des femmes enceintes âgées de 14 à 30 ans, des mères et pères de jeunes enfants et des femmes âgées de plus de 40 ans, dans six communautés rurales de deux districts. Les pratiques évoluaient progressivement, ainsi que le montrait le plus clairement le passage d’un accouchement dans la forêt à une naissance à la maison, avec quelques accouchements dans des centres de santé en cas de complications. Les femmes âgées aujourd’hui de plus de 40 ans ne recommandaient pas toutes les pratiques de leurs mères, mais comprenaient la nécessité de s’adapter en raison des risques médicaux et sociaux qu’elles avaient connus, en particulier le taux élevé de décès néonatal. Leurs filles en font de même. Dans ce site du Lao rural, l’augmentation des accouchements à domicile devrait être considérée comme un progrès substantiel. Il serait possible d’améliorer la survie maternelle et néonatale et de réduire les inégalités sanitaires en comprenant comment les jeunes femmes interprètent leurs options et en incluant cette connaissance et l’expérience de programmes de proximité concluants dans les politiques du système de santé et la pratique des soins obstétricaux, par exemple en renforçant les compétences des agents de santé communautaires.

Resumen

Este artículo saca a la luz los cambios intergeneracionales en las prácticas relacionadas con el embarazo y el parto en zonas remotas de RDP Lao durante un plazo de 30 años. El estudio consistió en discusiones en grupos focales con mujeres embarazadas de 14 a 30 años de edad, madres y padres de niños pequeños y mujeres de 40 años o mayores, en seis comunidades rurales de dos distritos. Las prácticas relacionadas con el parto estaban evolucionando y cambiando gradualmente, lo cual es ilustrado de manera más drástica por la transición entre el parto en el bosque al parto domiciliario, así como algunos partos institucionales cuando ocurrían complicaciones. La generación actual de mujeres de 40 años o mayores no recomendó todas las prácticas de sus madres, pero vio la necesidad de adaptarse debido a los riesgos sociales y médicos que habían experimentado, especialmente las altas tasas de mortalidad neonatal. Sus hijas están haciendo lo mismo. El aumento en partos domiciliarios debería considerarse como un logro significativo en este entorno rural de Lao. Entender cómo las jóvenes interpretan sus opciones e incorporar ese conocimiento y la experiencia de programas exitosos de extensión comunitaria en las políticas del sistema de salud y en las prácticas de atención materna, por ejemplo al fortalecer las habilidades de trabajadores en salud comunitaria, podría contribuir a mejorar la supervivencia materna y neonatal y a reducir las desigualdades en salud.

Keywords:

• maternal and child health
• health policy and programmes
• childbirth
• remote rural communities
• birthing practices
• inter-generational change processes
• Lao PDR

Most of the priority interventions developed to address Millennium Development Goals 4 and 5 are intended to be delivered through established health services with low coverage levels.^1–5 Disadvantages in access to services tend to cluster, however; a 2005 study in nine low-income countries found that up to 20% of children did not receive even one of the child survival interventions provided in most countries.⁶

In Lao PDR, maternal, neonatal and child mortality levels are high, and coverage of skilled birth attendance and antenatal care differs significantly between urban and rural areas.² The maternal mortality ratio was estimated at 357 per 100,000 live births and the under-five mortality rate at 79 per 1,000 children in 2010–2011.⁷ Health care services are not working well in rural areas and access to services is significantly lower.⁸ There are indications in the current national health strategy, however, that the Government intends to address this situation, and the Ministry of Health has identified primary health care and maternal and child health (MCH) as priority areas.⁹ More integrated approaches are being put forward, particularly for MCH and immunization, decentralized service delivery, and an emphasis on improving quality of care.^10,11 Yet efforts to increase rural access to MCH care have received little attention so far.

Studies in 54 Countdown countries show that community-based interventions for MCH are more equally distributed and reach a broader segment of women than facility-based interventions, e.g. those that promote Vitamin A and exclusive breastfeeding.² These programmes tend to be provided by community health workers and other volunteers who have more time and better opportunities to interact with individual women during pregnancy and the first days after delivery.¹² Working with communities from within in the poorest settings can increase utilization of MCH services and reduce delays in deciding to seek care.¹³ In Lao PDR today, village health volunteers (VHVs) and traditional birth attendants (TBA) are being trained to link communities with health facilities,¹⁴ VHVs to provide health education, assist in outreach activities and provide access to essential drugs, and TBAs to support women during pregnancy and childbirth. In comparison, traditional decision-makers, such as grandmothers, female relatives and husbands, are rarely involved in MCH programmes.^15–17 In fact, they are at times considered a potential threat to progress and uptake of services.¹⁵

Against this background, we embarked on this study to increase knowledge on inter-generational differences in pregnancy and childbirth practices in remote rural communities of Lao PDR and the views of women and men of reproductive age and older women on access to and use of antenatal and delivery care.

In Lao PDR almost 80% of the population live in rural areas,¹⁸ and almost a third live more than 10 km from the nearest health centre.¹⁹ Women’s access to MCH services is improving but remains much lower in the rural areas.^7,20 In 2010–2011 in urban areas, almost 80% of pregnant women were assisted by skilled health personnel (live births in the preceding two years), in comparison with 33% of women living in rural areas with roads and 12% in rural areas without roads. Rural women were assisted at delivery by relatives, friends or others – 46% in areas with roads and 64% without roads – while TBAs assisted in 16% of deliveries and 4% were without any assistance. Antenatal care was not used by 80% of pregnant women in rural areas without roads.⁷

This paper sheds light on inter-generational changes in pregnancy and childbirth practices in remote areas of Lao PDR over a period of 30–40 years. It is based on data from a broader study on health care-seeking behaviours and quality of care.

Methodology

The study took place in February–March 2009 in three communities each in a selected district in one central province (Savannakhet) and one southern province (Xekong).^21,22 These were typical rural districts with populations of 29,000 and 26,000, respectively, and high levels of poverty. They included Buddhist Lao ethnic groups and ethnic minority groups of Talieng, Alak, Oy, Lave and Makong, who adhere to traditional religious practices.²³ There were five and six health centres in these districts, respectively. In both districts, of the three communities selected, two had less than two hours’ walk to the nearest health centre and one had more than four hours’ walk.

Focus group discussions (FGDs) were held with four different groups: women aged 14–30+ who were pregnant at the time of the study (32 women); women aged 20–35 who had children under five (44 women); fathers with children under five (36 men); and women aged 40+ who lived with a daughter or daughter-in-law who was pregnant or had children under five (46 women). Women were purposively selected so that households from all clusters in each community were represented. Lists of households were obtained with the help of the village authority. Though we aimed to select 6–8 women for each FGD, in two communities, fewer pregnant women were willing to participate.

The 40+ women had delivered their children 10 to 30 years before. We sought to ascertain whether practices during pregnancy and childbirth differed across generations and to obtain descriptive information about when and who women told about a pregnancy, support received from different sources, perceptions of antenatal care and preferences for where to give birth. In the FGDs with women aged 40+, changes in pregnancy and childbirth practices during and after their own reproductive years were also explored. Maternal mortality trends were only discussed briefly and are not reported here. The responses of the pregnant women and those with young children did not differ substantially, so the findings presented below represent all FGDs with the younger women, with the experience of women aged 40+ presented separately.

The field team spent 1–3 days in each community. FGDs were held in the compound of the village head or the grounds of the Buddhist temple. They were carried out by two Laotian field workers with experience in group discussions in poor rural areas, of whom one is a co-author (BK). They were accompanied by a note-taker and a field manager to assist with logistics and meetings with local authorities for permission to conduct the study. Two of the FGDs were carried out in the ethnic minority language with a local interpreter who spoke Lao. Moderators began by acknowledging the wisdom regarding MCH of the participants. Women aged 40+ happily shared stories and experiences about their families, a sphere in which they are generally highly respected.²⁴ It was more challenging to get the younger, pregnant women to discuss these topics and we depended on one participant to break the ice.

The discussions were recorded and supplemented by handwritten notes. Condensed transcripts were produced in Lao or translated directly into English by the moderators. Analysis was inspired by the interpretative description approach,²⁵ and conducted in Nvivo 10 by HMA. Transcripts were coded into sub-topics and analysed within the same age and sex group and then compared across groups. No substantive differences were identified that could be explained by ethnic background.

Ethical approval was obtained from the National Ethic Committee for Health Research (N017/NECHR) of the Ministry of Health, Lao PDR.

Findings

When and who to tell about pregnancy

When the women aged 14–30 years first suspected they were pregnant, they either informed their husband or other women in the household (mother, grandmother or older sisters), or did not tell anybody. In all FGDs, shyness and embarrassment about admitting to sexual activity were presented as a key reason for young women not admitting to being pregnant. Uncertainty whether they were actually pregnant was another reason, especially when women were older and concerned about the risk of miscarriage, so some wanted to wait and see. One Lave woman, aged 70, said older women weren’t confident they were pregnant until they’d missed their period for three months or more.

In two FGDs with young, pregnant women, it was mentioned that women could go to a health centre for a urine pregnancy test.

The FGDs with mothers aged 20–35 emphasized that women felt the need for advice most during the first trimester of their first pregnancy, and consulted their mothers or sisters. In subsequent pregnancies, they felt better prepared to take care of themselves. If there were no complications, it was common not to tell anybody they were pregnant during the first trimester but wait until the husband, mother, or other relatives and friends realized it themselves, which they often did. On the other hand, if they were tired, nauseous, had particular food cravings, or did not feel strong enough to carry their normal workload, they would tell their husband to get support.

VHVs and TBAs were not mentioned as persons who were told about a pregnancy during the first trimester. TBAs would be informed in the second or third trimester to make arrangements for a home delivery.

Support to pregnant women

Women recognized pregnancy as a period of precaution while at the same time described it as a normal part of a woman’s life. The pregnant women talked about food taboos and cravings, workload, antenatal care and preparing for childbirth, and pregnancy complications.

Mothers, sisters and occasionally mothers-in-law were consulted for advice on food taboos early in pregnancy; the aim was to avoid eating foods that were believed to cause complications during childbirth. These were of such great concern that pregnant women in all six communities consulted older women on what to avoid at an early stage. The foods they were advised to avoid differed between ethnic groups, however, and included glutinous rice cake, stingrays, monkeys, rats and snakes.

Women hoped their husbands would share their workload during pregnancy, but in practice, this depended on household composition. For young couples with only young children, women’s workload remained largely the same. Those with older, unmarried children, female relatives or a husband at home who had time to help did expect help with tasks such as collecting water, cooking, heavy housework, rice farming and collecting firewood, at least late in pregnancy. Fathers said that while some men would assist their wives, this was far from common practice, and that help ranged from none to substantial support. The view that gained the broadest agreement among fathers was:

“Either our wives will take a rest or work… We will not object. If they want to work, we allow them because they themselves should know about their health better than us. But the TBA advises that from the 7th–8th month they have to take rest and not work so hard.” (Age 25, two children, Phoutai)

Miscarriages and other complications of pregnancy were situations which meant women could most easily get help. Mothers were very influential when they lived with their daughter or close by. Women without easy access to their mothers mentioned mothers-in-law or husbands as persons they would turn to. VHVs and TBAs were described as resources in the community during mild illness or pregnancy complications, but most importantly as a first contact point to reach other health staff:

“During pregnancy, if I don’t feel well then I tell my husband and my parents. After that my husband invites the VHV or the TBA to check me. If they cannot help, then they take me to the nurse and if I cannot walk the VHV invites the nurse to come to my house.” (Age 32, seven children, Alak)

“If we get sick during pregnancy and call the VHV, then she will suggest we go to the health centre or district hospital, because she cannot provide a health check-up.” (Age unknown, one child, Makong)

The women aged 40+ mentioned similar reasons why women in their day needed help, but they emphasized that compared to the younger women, they had received very limited help during their pregnancies, and only illness had been a reason for working less. They also said that in their day, men believed that hard work resulted in better childbirth outcomes, such as an easier delivery, which was not true among the younger men.

“No pregnant woman could take a rest or relax before giving birth except if she got sick.” (Age 55, 12 children, three grandchildren, Lave)

“During my pregnancy I had nobody to give me advice or help with my work. I had to continue working until the day of delivery with chores such as carrying firewood, collecting water, pounding rice, and going to the forest to look for food. Only when I felt pain in my belly and got sick was I told to take a rest.” (Age 60, three children, seven grandchildren, Kaleung)

Antenatal care attendance

Antenatal care (ANC) was described by all age groups of women as most important for women who had previously had pregnancy or childbirth complications. Attitudes to ANC differed more between communities than by age, and in terms of extent of access to services. In the two most remote communities, there was limited knowledge of or experience with ANC services and they perceived the disadvantages to outweigh the advantages.

“Women here have never attended antenatal care because the health centre is far from our village. The other reason is that we do not feel sick so we do not need their services. Also, if we go to the health centre we have to spend money that we do not have.” (Age 20, first pregnancy, Makong)

In addition, there was reluctance to let a male nurse see and touch their bodies in a health facility. Finally, the lack of a vehicle to transport women in the last trimester was a constraint. Instead, the TBA would help to adjust the position of the baby late in pregnancy, easing women’s discomfort, which women felt was enough for them.

In communities with less than two hours’ walk to a health centre, the attitudes to ANC were more mixed. In two of these communities, there were no female nurses available at the closest health centre, which discouraged women from attending, and some women went to the district hospital for ANC instead. In the two remaining communities, women estimated that about half of pregnant women attended ANC at least once, which was described as most relevant if women were in pain or had discomfort or concerns that the baby was not growing.

“During antenatal care, the health staff measured my belly and adjusted my unborn baby to the right position. But I will only go if I feel pain in my belly. We are very busy with our housework and we have many children. To be able to leave the house we need someone to manage everything for us.” (Age 32, eight children, Lao)

Several positive aspects of ANC services were mentioned: provision of medicine if the baby was not growing enough, free tetanus vaccination, adjusting the baby’s position, assistance with pain, and advice on nutritious foods and rest during pregnancy. The women’s understanding of the relationship between ANC and skilled delivery care and whether they would avail themselves of either was explained in one group of pregnant women as follows:

“…because we never had this service before and because we did not have any health problems during our pregnancies. Moreover, our husbands did not take us to the service so we thought it might not be necessary. Also, the health centre does not have equipment for delivery – well, yes, we do plan to deliver at home – but even if we attended antenatal care we would have to deliver at home anyway.” (Unknown age, pregnant, seven children, Lao)

This particular group also said that the health centre nurses, who had some midwifery training and experience, assisted them if needed during home deliveries, which reflected an awareness of the value of skilled attendance.

The older women were also aware of the promotion of ANC and facility-based deliveries. Some of them who had experienced pregnancy complications had in fact sought medical care at a health facility, but none had made use of ANC services. In their time, it was the custom to have spiritual or herbal treatments for complications.

Childbirth: from the forest to home to facility-based deliveries in one lifetime

The FGDs with younger women agreed that while the majority of women nowadays give birth at home, facility-based deliveries were increasing in communities with good access to facilities equipped for childbirth. However, the notion of planning to deliver at a facility was encountered only among young pregnant women in the two communities where many women already attended ANC.

“I was at the district hospital for antenatal care when I was three months pregnant. I expect to deliver at the hospital because this is my first pregnancy and I am afraid that I will have difficulties.” (Age 26, first pregnancy, Kaleung)

The increased safety of facility-based deliveries was recognized and taken into account by young pregnant women and mothers but did not generally outweigh the disadvantages – the distance and need to travel, lack of transport to get there, not having relatives nearby to provide support, and constraints in arranging clothing, bedding and food for themselves and accompanying relatives. Furthermore, the staff would not allow many people to be present during childbirth and the out-of-pocket costs were high.

Home deliveries were also preferred because it is the tradition, TBAs and VHVs in the community were available and said to be a great support, parents and relatives were available to take care of the woman and her other children, and pregnant women felt more confident giving birth at home.

Some of the older, ethnic minority women (Alak and Lave) had seen the most profound changes in relation to childbirth compared to 30 years before. They had not only told no one they were pregnant but had delivered “secretly” in the forest outside their villages alone, unless their own mother or grandmother went with them. Because of the isolation and fear, however, forest delivery was already an issue when they were having their children.

“I had my first child when I was about 15 years old, about 25 years ago. I did not deliver in the forest because my parents-in-law did not allow me. They were afraid that I and my baby would die in the forest because there was nobody to help me. All of my children were delivered at home. Since then, I think there are many women who have delivered their babies at home.” (Age ˜40, seven children, nine grandchildren, Alak)

“I delivered my first three children in the forest and the other three at home. I delivered in the forest because I was shy of my parents-in-law and siblings. But for the rest of my children I delivered at home because it was at night and I had no time to go to the forest, but also because two of my first babies died 2–3 hours after delivery. There was nobody to help and the deliveries were difficult. So for the rest of my deliveries, my husband did not allow me to go to the forest; I was allowed to deliver in the kitchen.” (Age 45, three children, four grandchildren, Alak)

Neonatal death was identified by these women as one of the reasons for the increased practice of home deliveries. In five of the six communities, we asked women how many children they had and how many they had lost. The loss of a newborn or a young child had been experienced by a majority of the 38 older women: 28 had lost at least one child and 13 had lost three children or more. Among the 25 younger pregnant women, in contrast, 7 had lost one or more children. This difference between the youngest and oldest women was significant, and the older women recognized this.

No accurate data exist, to our knowledge, on the past or present prevalence of forest deliveries or the survival rate. In 1996 it was estimated that 1% of deliveries took place in the forest but this is now thought to be a considerable under-estimation.²⁶ A study published in 2008 found that the number of forest deliveries varied by season.²⁷ No one in our study reported that forest deliveries were still practised in their communities, and only one woman had recently delivered alone in a rice field.

Childbirth is perceived as an event that links the material and spiritual world and requires the management of “impurities” to prevent misfortune in the family.²⁶ Blood represents impurity, which is why deliveries could not be carried out at home or in the village. Adaption in order to address women’s fears of delivering alone and reduce high mortality rates, however, is illustrated in the recent practice in one of the Makong communities in our study of building temporary birthing huts, in or close to the village, for individual women to deliver in, which are destroyed after the birth. This practice has also been documented among the Katang²⁶ and Katu ethnic groups.²⁸

One of the implications of home deliveries noted as important by the oldest women was that they were able to receive support from family members – grandmothers, mothers, mothers-in-law, older siblings – or a TBA. There was starting to be less secrecy and more chance to talk about pregnancy by that time as well.

Views on changes in pregnancy and childbirth practices

When the women aged 40+ compared their own experiences with those of currently pregnant women they emphasised that younger women had more opportunities to receive support during pregnancy and childbirth, even if they didn’t always use them.

“Today, during pregnancy, some women go to see the health staff for antenatal care, but some don’t. But for those who have difficulty in delivery, they will go to deliver at the hospital. My daughter-in-law is among the new generation, but she has never been to the hospital for delivery.” (Age ˜50, ten grandchildren, Kaleung)

“In the past, I would tell my mom and she would take me for spiritual treatment as there was no health centre then. Now, when pregnant women do not feel well they go the health centre first.” (Age 60, five children, 15 grandchildren, Makong)

“In the past, women were very nervous during pregnancy; nowadays, women are still nervous but they have nurses and VHVs to help them so it is much better now.” (Age unknown, six children, nine grandchildren, Lao)

Changes in how home-based deliveries were conducted were also observed and ascribed to the advice and support received from VHVs and TBAs.

“When I delivered I cut the umbilical cord myself. During delivery I had my husband and my parents assisting me. Once the baby was coming out, we had nothing special to put the baby in, we just held it and cut the cord ourselves with a sharp bamboo stick that we had specially prepared by putting it on the fire for a while to warm it up.” (Age unknown, three children, six grandchildren, Kaleung)

“Nowadays, many people come together to assist in the delivery. It is safer and more comfortable than before, especially since we now have the TBA and VHV to assist. The husband is the only man allowed to come into the room. The person who cuts the umbilical cord nowadays is the TBA or VHV, as the parents are afraid and not confident to cut it by themselves. And a bamboo stick is no longer used to cut the cord, they use scissors instead.” (Age unknown, six children, 12 grandchildren, Kaleung)

Food restrictions during pregnancy were also thought to be diminishing in importance. Increasing contact with health service staff has inspired these types of changes in addition to the realization that child loss could be reduced.

Discussion

By taking a historical perspective, we found many changes taking place in relation to pregnancy and childbirth which are moving towards global recommendations, even if gradually and even though they remain far from the goal of four antenatal visits and skilled assistance during delivery. In this study setting, VHVs and TBAs were the main point of contact between the health system and pregnant women, but women also received support and advice from their mothers and husbands during the critical periods of the first trimester and delivery. The influential role of grandmothers in childbirth practices has been documented in one recent study from Laos.²⁹

Nevertheless, urban and remote rural areas of Laos are currently worlds apart as regards utilization of maternity services.⁷ The dramatic transition within the older women’s lifetimes in the remote areas we visited, from no ANC to some, and from giving birth alone in the forest to childbirth at home or in a health facility was striking, despite distance, cost and continuing limited access to services. Our findings highlight the importance of working with local communities to enhance their utilization of MCH services by tailoring services and training community-based providers to local social and cultural realities.³⁰ Building roads, providing some form of transport, and addressing costs are also issues that arise from this study.

The Lao government’s intentions are to improve the condition of women in remote rural communities, e.g. through the implementation of a free maternal and child health policy³¹ and improved access to trained midwives. Laos has also recently started training professional community midwives who will work out of health centres; in 2012, the first 299 midwives were accredited.³² In neighbouring Cambodia, the birthing pattern has radically changed over the past 10 years, attributed at least in part to the availability of midwives in health centres. In 2000, 11% of women gave birth in facilities with a skilled birth attendant compared to 55% in 2010³³ The integration of MCH services with community outreach of childhood vaccinations is another strategy being studied by the Lao government, though a recent assessment found that the current low vaccination coverage in remote areas might not be sturdy enough to integrate MCH services. Gradual integration, in tandem with improved coverage of the vaccination programme was, however, recommended.¹⁰

Women’s appreciation of the VHVs in this study was due in part to their support in treating minor illness in children,²² and less frequently for their promotion of ANC or exclusive breastfeeding. There are limited data available on VHVs’ actual performance in our study communities or the country in general. In the southern and central parts of Laos, however, limitations have been noted in the knowledge and skills of VHVs in managing essential drugs.³⁴ Another study found that VHVs were in serious need of better support and training, and the VHV selection process needed to be improved.¹⁰ Failure of VHVs to report health data has been associated with long distances between VHVs and health centres and too few training sessions.³⁵ It seems that VHVs, along with TBAs, who often have not received training from the Ministry of Health, are carrying a heavy burden of responsibility for primary health care alone in remote communities.³⁶ Strengthening their skills and developing their community-based activities on MCH, such as familiarising women with ANC and delivery services and giving accurate advice on food taboos, could be an effective way to support poorly served remote areas. Programmes for the mobilization of lay experts and volunteers in community-based interventions show encouraging results for health outcomes in other countries,³⁷ and could serve as a source of inspiration for Laos as well.

Addressing power dynamics within families related to pregnancy and childbirth is an important issue for the effectiveness of community-based programmes.³⁸ Young women’s interactions with senior women in their families occur in a context of power and domination, which we found in earlier studies to lead to potentially conflicting views on health-care seeking.²¹ But the interactions between women from different generations can have both negative and positive consequences. A recent meta-analysis of studies in seven intervention communities in four countries found that participation in women’s groups, some of which directly involved grandmothers, demonstrated a reduction of maternal mortality of 37%.³⁷ Successful interventions like these could be adapted too.

Laos is well known for its ethnic diversity, but we found no evidence that cultural practices created constraints on using the health system. Instead, we found that ethnic traditions might suggest different types of interventions to move the use of maternity services forward. The temporary birthing huts are one example.²⁸ Health facilities could also do more to accommodate the preferences of women and their families, such as allowing family members to be present at a birth. The challenge is to reach women in remote areas, and this study contains many pointers, and highlights the inter-generational changes taking place in pregnancy and childbirth practices even in the most remote communities. Community-based interventions building on these changes could improve uptake of safe motherhood goals if services are and are seen to be of good value.

Acknowledgements

We are grateful to the women and men who agreed to share their experiences in relation to pregnancy and childbirth. We thank Indochina Research Lao and Chansada Souvanlasy for the compassionate fieldwork. We acknowledge the contribution of Sysaath Phimmasone who sadly died in a motorcycle accident soon after the fieldwork. The study was funded by the World Bank.