Written by Elvin Geng, MD, director of the Center for Dissemination & Implementation at the Institute for Public Health
What We’re Reading – Center for Dissemination and Implementation Director’s Pick:
Over the last decades, increasing skilled attendance at birth has been considered a crucial evidence-based intervention for reducing maternal mortality in many Low and Middle Income Countries. Much public health effort has been expended to ensure facility delivery. Yet despite greater implementation in Zimbabwe, where skilled attendants rose from 65% to 77%, neonatal mortality has barely changed. Through over 70 interviews with women in Zimbabwe who had recently given birth, the investigators in this article found that the public health targets created social norms for women to delivery at facilities, yet the most vulnerable women with the least social support and material resources often found themselves pressured to “follow the rules” at the time of delivery without adequate supports. As a result, many delivered at home or on the way to the facility in unsafe settings. In fact, as attended delivery was pushed, home delivery became stigmatized, and women who delivered at home were “blamed” for endangering their babies. Heartbreakingly, many women delivered on the road to the hospital — sometimes alone and in an unsafe setting — even though they knew they would not reach the facility, in order to demonstrate that they tried to avoid social opprobrium.
The authors note “Public health policies and programmes promoting social change should actively identify and mitigate unintended consequences among the most vulnerable who are unable, or unwilling, to comply.” This study provides critical lessons for implementation science. First, complex changes to health systems as a rule have unintended consequences, and implementation researchers must be tireless in efforts to identify unintended harms. Second, efforts to increase uptake of evidence-based interventions often reflect and magnify inequities; in order to be equitable, implementation research must actively resist existing structures. Third, the burden of change in social systems will as a rule fall on those with the least power. Implementation researchers must understand positionality and power even as we seek to create change. I encourage everyone to read this painful but powerful paper.