Pan American Health Organization · 2023
Excel assessment tool and manual for evaluating and improving intercultural childbirth care for indigenous and ethnic-minority women
- Issuer
- Pan American Health Organization
- Edition
- 2023
- Audience
- Maternal health service managers, quality-improvement teams, midwives, obstetricians, public-health professionals, indigenous health programme coordinators
- Evidence
- Consensus-based good practices; validated through technical missions in Argentina, Bolivia, Colombia, Ecuador, Guatemala, Honduras, Paraguay, and Peru
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This manual accompanies an Excel-based assessment tool designed to evaluate and promote culturally safe childbirth care for indigenous women and other ethnic minorities in the Americas. The tool assesses five key dimensions: autonomy of indigenous women (17 indicators), communication and treatment (8 indicators), community participation (3 indicators), health service infrastructure (3 indicators), and institutional strengthening (12 indicators), totalling 43 practices and quality standards.
The tool captures three perspectives—health workers, indigenous women, and outside observers—through interviews, observation, or self-administration. Each practice is rated on a 1–5 scale reflecting the degree of standard application, with results presented in a traffic-light system: red (80%). Annual administration in facilities serving at least 10 indigenous women and 10 health workers is recommended to monitor progress and identify improvement priorities.
The approach is grounded in knowledge dialogues, respect for traditional practices, and consensus on quality maternal and neonatal care. While developed for indigenous populations, the tool can be adapted for Afro-descendant women or other ethnic groups across different care settings during pregnancy, labour, delivery, and the postpartum period.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Assess 43 practices across 5 dimensions: autonomy (17 indicators), communication (8), community participation (3), infrastructure (3), and institutional strengthening (12)
- Evaluate from three perspectives: health workers (40 indicators), indigenous women (30 indicators), and outside observers (43 indicators)
- Rate each practice on a 1–5 scale: 1 = does not meet standard, 2 = meets some conditions, 3 = meets several conditions, 4 = meets most conditions, 5 = meets all conditions and exceeds expectations
- Use traffic-light results system: red (<40% standard application), orange (40–60%), yellow (60–80%), green (>80%)
- Administer annually to at least 10 indigenous women users and 10 health workers per facility
- Respect women's autonomy regarding accompaniment, birth position, placenta management, use of medicinal plants, food choices, dress, and contraceptive counselling
- Ensure communication in local language, culturally appropriate signage and educational materials, informed consent, and confidentiality
- Maintain continuous knowledge dialogue with local populations and involve communities in service design and hours of operation
Number of practices and indicators assessed, by dimension and evaluator perspective
Table extracted from the guideline
| Dimension | Total indicators | Health workers | Indigenous women | Outside observers |
|---|---|---|---|---|
| Autonomy of indigenous women | 17 | 17 | 17 | 17 |
| Communication and treatment | 8 | 5 | 8 | 8 |
| Community participation | 3 | 3 | 2 | 3 |
| Health service infrastructure | 3 | 3 | 3 | 3 |
| Institutional strengthening | 12 | 12 | 0 | 12 |
| **Total** | **43** | **40** | **30** | **43** |
Source: Pan American Health Organization, Tool for Promoting Culturally Safe Childbirth: Basic Manual. Reproduced in summary form.
From the guideline
Verbatim
“Recognizing the different realities of women (including their values and cultural traditions) is a good starting point for promoting joint efforts among relevant actors to develop health policies that are inclusive, geared to user satisfaction, and based on appropriate and compassionate quality care.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia, I see this PAHO tool as directly relevant to our multiethnic regions where maternal mortality disparities persist among Azeri, Armenian, and other minority populations facing language and cultural barriers to facility-based delivery. The dimension on women's autonomy—respecting choice of birth position, accompaniment, and traditional practices—addresses specific complaints documented in our 2019 maternal mortality review where minority women cited lack of cultural accommodation as a deterrent to institutional delivery. The traffic-light rating system provides a pragmatic monitoring framework compatible with our hospital accreditation cycles. The implementation caveat for Georgia is that successful rollout requires upfront investment in minority-language interviewer training, community engagement with minority councils to validate the 43 indicators culturally, and political commitment to act on red-priority findings, which may reveal uncomfortable gaps in regions where minority maternal outcomes lag national averages.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s multiethnic composition—including Azeri, Armenian, Ossetian, and other minorities—and its primary health care reforms under the Universal Health Care programme make culturally adapted maternal care highly relevant. While the tool was validated in Latin American settings, the five-dimension framework and traffic-light rating system are directly applicable to assessing and improving maternity services in Adjara, Kvemo Kartli, Samtskhe-Javakheti, and other regions with ethnic-minority populations. National adaptation would require translation of materials, training of interviewers in local minority languages, engagement of minority community representatives in knowledge dialogues, and baseline assessment in at least 10–15 first-level facilities and regional hospitals. The tool’s annual monitoring cycle aligns with Georgia’s quality-improvement cycles under hospital accreditation standards. Implementation would need coordination between the Ministry of Health, the Public Health Institute, the National Centre for Disease Control and Public Health, and minority affairs offices to ensure community participation and cultural validation of indicators before rollout.
Questions this guideline answers
Quick answers
How is this tool different from standard quality-of-care assessments?
It evaluates cultural adaptation of care specifically for indigenous and ethnic-minority women, assessing dimensions like women's autonomy, community participation, and respect for traditional practices (use of medicinal plants, placenta management, birth position choice) that standard tools do not capture. It also triangulates three perspectives—health workers, women users, and outside observers—rather than relying on provider self-assessment alone.
Who should conduct the assessment and how long does it take?
Trained interviewers or observers administer the tool through direct interviews, observation, or self-completion by health workers. Participation of indigenous community organizations and health facility authorities is required. Annual assessment of at least 10 women and 10 health workers per facility is recommended. Training, fieldwork, and reporting typically require 2–4 weeks per site depending on facility size.
What does the traffic-light rating system mean for action?
Red (<40% standard application) indicates urgent priority for improvement; orange (40–60%) suggests partial implementation needing strengthening; yellow (60–80%) reflects acceptable practice with room for enhancement; green (>80%) indicates high-quality culturally safe care. The tool generates a priorities analysis identifying all red-rated practices for inclusion in the facility improvement plan.
Can the tool be adapted for non-indigenous ethnic minorities?
Yes. While designed for indigenous populations in the Americas, the manual explicitly states the tool can be tailored to Afro-descendant women or women of any other ethnicity. Adaptation requires cultural validation of the 43 practices and indicators through knowledge dialogues with the target ethnic community to ensure indicators reflect their values, traditions, and care preferences.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 2023
- Status
- Current
- Published
- 2023-01-01
- Languages
- English, Spanish
- Scope
- Assessment tool for cultural adaptation of pregnancy, childbirth, and postpartum care services for indigenous and ethnic-minority women
- Audience
- Maternal health service managers, quality-improvement teams, midwives, obstetricians, public-health professionals, indigenous health programme coordinators
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12569-4 (PDF)
- Evidence
- Consensus-based good practices; validated through technical missions in Argentina, Bolivia, Colombia, Ecuador, Guatemala, Honduras, Paraguay, and Peru
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
Pan American Health Organization. Tool for Promoting Culturally Safe Childbirth: Basic Manual. Washington, D.C.: PAHO; 2023. 22 p. Available from: https://doi.org/10.37774/9789275125694GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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