Crossing boundaries for maternal health: a qualitative investigation into the role of community health workers as frontline providers of maternal care in the Peruvian Andes

Abstract

Despite its status as a middle income country, Peru has one of the highest maternal mortality rates in the Americas. In the Andes region, poor, rural indigenous women are more likely to die from pregnancy related complications than their urban counterparts because they are denied the same level of maternal health services other women in the country receive. Barriers to care include geographic isolation, health staff members who do not speak indigenous languages, and cultural and ethnic discrimination. As a result, indigenous Andean women in need of maternal health services face a significant degree of social exclusion and institutionalized racism which hinders the accessibility, acceptability, and quality of maternal health services offered to them. One approach to improving access to health services has been through the use of Community Health Worker (CHW) programs. Although CHWs are recognized as an important frontline health source, there is a significant lack of literature concerning their role as community level providers of maternal health services. Using a combined grounded theory and case study methodology, this qualitative study investigates the experiences of CHWs working in Andean communities and their relationships with other community members and health and social service professionals. Findings from this study suggest that CHWs can be enabled to bring care directly to their communities in a way that community members can relate to and feel comfortable with while also forming part of the wider health system. Focusing on participants' reports of challenging cultural and ethnic boundaries through a process of ethnic bargaining and adopting professional affiliation, this study identifies CHWs as a potentially vital link between rural community members and other providers of these services. If the right factors are met, such as finding ways to navigate the tensions between traditional and biomedical health care models, CHWs can be considered critical community level health providers who can communicate the value of both models, thereby improving the accessibility, acceptability and quality of maternal health services. However, the root causes leading to social, structural and institutional boundaries to care still need to be addressed. As such, this study aims to fill a significant gap in current research on the role of CHWs in Peru, specifically in the ways they are enabled to negotiate ethnic discrimination within the health system.