Research to design behavior change interventions to improve maternal and newborn survival should explore the local context. Understanding "contextual domains" within the modern "medical culture" and traditional cultures that relate to cultural and social norms, religious and spiritual beliefs and gender relations can help in designing locally appropriate and effective program strategies.

The table below lists cultural domains to consider.

For rapid community-based development of maternal and newborn survival behavior change interventions, a pared-down approach can provide the information communities need to develop local solutions. Such complication narratives use a simple semi-structured format that allows participants to tell the birth story to members of their own community, in their own way and in their own words.

Complication narratives provide a retrospective look into the timing of events of an obstetric complication or emergency. The narratives are "verbal autopsies" when the woman died as a result of the obstetric complication or emergency. They can be conducted individually (narrative monologue) or in groups (narrative dialogue) with the woman who experienced the event, family members and attendants.

Pregnant women are often not decision-makers regarding careseeking during pregnancy, birth or the postpartum period. Discussions that include all of the people involved in the event provide a richer contextual background and "cultural clues." The group format often results in animated discussions that approximate interactions between family and community members during obstetric complications.

Even if it is difficult to identify them, it is important to include only women and families who have experienced a complication during the critical time period -- labor and delivery or in the first week after birth -- in the previous six months. People usually recall complications more accurately when they have occurred in the past six months. The critical life threatening time during and after birth is when most maternal and newborn deaths occur. For the purposes of community complication narratives, women whose "complications" occurred during early pregnancy should be screened out. Although traumatic, early pregnancy complications do not yield information about careseeking behaviors during true obstetric emergencies. For example, a miscarriage in early pregnancy is generally not life threatening. Complication narratives should focus on retained placenta, postpartum hemorrhage, prolonged labor/ruptured uterus, eclampsia and sepsis. This deliberately excludes pre-eclampsia, severe ante-partum hemorrhage and sepsis after unsafe abortion.

The CHANGE Project oriented community interviewers in both technique and subject matter. Their training included the "three delays" and "pathway to survival" models of categorizing obstetric careseeking behaviors, medical aspects of major obstetric complications, and practical training in non-directive, open-ended interview techniques - "active listening," when to request clarification, how to probe at appropriate points and how to redirect interviews that have gone off-track.

Research objectives of complication narratives:

• Provide a step-by-step analysis of the timing of household events that occur during an obstetric complication or emergency;
• Document the precise roles of individuals in the household and community in deciding to seek care;
• Document the factors influence whether a skilled care source is reached during an obstetric emergency; and
• Define the role of skilled providers/facilities in delays in quality care for obstetric emergencies.

Specific Objectives:

• Identify the steps in recognizing obstetric complications that occurred in a family, perceived causality of the complication and perceived appropriate action/chain of care seeking actions for the specific complication.
• Describe the contextual dimensions of careseeking decision-making in obstetric emergencies - who decides, how decisions are made, how long it takes to decide, what the specific "triggers to action" are, when a problem is seen as severe enough to require action.
• Document the cultural and contextual factors behind careseeking behavior/ care choices per specific complication and differences between behavior patterns for each complication.
• Explore the specific steps, timing and decision makers involved in reaching care source(s) during obstetric emergencies.
• Provide individual and household perspectives on the events involved in receiving quality care once skilled care source was reached.
• Understand skilled providers' perspectives on careseeking events related to receipt of skilled care: timing, technical choices and attitudinal responses of skilled providers.

In part because of the semi-structured, uninterrupted style of narrative interview methods and the level of detail elicited, analyzing the results can be time-consuming. Mapping reduces the amount of time needed and makes key findings more accessible. Mapping creates a "visual pathway" that community members and program planners can understand and use. Maps illustrate the non-linear, back-and-forth or zigzag careseeking movements and make it easy to visualize the "detours" off the pathway to survival and to calculate time spent on each step or detour.

• the medical diagnosis (type of obstetric complication)
  
• a breakdown of the "pathway" to survival- recognize, seek, reach, receive
• the time each careseeking component required
• the approximate time from onset of labor to receipt of appropriate treatment
• the number of providers/care sights consulted, and sequence of consultations
• reasons for seeking care from each care source
• delivery location
• birth outcome
• cost as reported by the respondents

If possible, check the family narrative with the skilled providers involved and hospital records.

For example, in remote rural Guinea, CHANGE Project complication narratives showed that many women chose local traditional birth attendant (TBA) care in spite of monetary fines imposed by local health committees to encourage use of skilled providers. Because of differences in emergency careseeking behaviors between locations both near and far from the regional health facility separate behavior change strategies were developed for each.

CHANGE Project complication narratives in Western Kenya documented multiple careseeking "detours." Some women with obstetric complications were taken first to indigenous religious groups for prayer healing. These groups strongly advised against use of Western medical care so several women were kept there for days or weeks before they sought skilled care. For other women, confusion about the qualifications and capabilities of local "doctors" resulted in careseeking from sources other than legitimate professional skilled care providers. Traditional birth attendants (TBAs) were often "caught in the crossfire" during lengthy family disagreements in the household about where and when to move a woman with complications to a skilled provider for care.

Careseeking detours and delays occasionally persisted beyond labor and delivery, extending well into the postpartum period. Several women who had reached skilled care for birth were not able to receive skilled care in the postpartum period.

Family members of women who died provided moving and eloquent "testimonials" in which they strongly urged other families not to make the same careseeking mistakes they had made.

Complication narratives in remote rural Nepal illustrated factors such as ritual isolation of women during childbirth, often in cowsheds. They also found that families relied on male traditional healers to determine the origin of obstetric complications (thought to be spiritually-induced) and deliver treatment by "blowing" on the woman to counteract the spiritual influences.

The Nepal narratives documented "laj", a widespread feeling of shame that limited women's ability to inform others or ask for help even in extreme obstetric emergencies. Cultural fatalism resulted in a "wait-and-see" approach to careseeking and acceptance of maternal death as an outcome of complications. In Nepal, these contextual factors have been incorporated into a national multi-media campaign to improve maternal survival and enhance more conventional activities to increase awareness of obstetric danger signs.

Documenting these specific careseeking "detours" is essential to "re-route" women with complications back onto the pathway to survival.

For complication narratives, the CHANGE Project found that often the most useful information came from discussions that began by simply switching on the recorder, and asking the opening question: "Let's start when (the woman) went into labor. Tell me what happened...".

The CHANGE Project recommends that any project working to improve maternal and newborn survival use complications narratives, even if only one research technique can be used due to time or resource constraints. Complication narratives provide the richest and most detailed information on careseeking practices.

Kureshy, N. Review of Select Family and Community Practices for Safe Motherhood unpublished manuscript WHO Geneva/ MotherCare 2000

Loza, S, et al. The original research from Egypt ** HMHC Cairo 1997

Manandhar, M. Obstetric Health Perspectives of Magar and Tharu Communities: A Social Research Report to Inform the Nepal Safer Motherhood Project's IEC Strategy. HMGN Nepal Safe Motherhood Program/ DFID/ Options, Kathmandu, March 2000.

Moore, M, Copeland, R, Chege, I, Pido, D and M Griffiths. A Behavior Change Approach to Investigating Factors Influencing Women's Use of Skilled Care in Homa Bay District, Kenya, The CHANGE Project, Academy for Educational Development/The Manoff Group. Washington, DC December 2002

Moore, M and M Manandhar. Detours and Delays on the Pathway to Maternal Survival. Unpublished draft manuscript, Washington, DC July 2003

MotherCare. Behavioral Dimensions of Maternal Health and Survival: A consultative Forum. MotherCare, CHANGE Project, World Health Organization MotherCare Matters 9(3) September 2000

Nachbar, N, C Blume and A Parekh. Assessing safe Motherhood in the Community: A Guide to Formative Research. MotherCare JSI. Arlington, VA September 1998

The Nepal Maternal and Neonatal Health Program SUMATA Initiative (MNH/Nepal). The Communication Initiative, www.comminit.com March 2003

Sibley, Lynn et al. Home Based Lifesaving Skills (HBLSS): At-a-Glance. NGO Networks. Washington, DC March 2003

Thaddeus, S and D Maine. Too Far to Walk: Maternal Mortality in Context. Social Science and Medicine 38 (80 1091-1110 1994

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