Background

In Ecuador, access to maternity services remains signifi-cantly lower amongst indigenous women compared with non-indigenous women partly due to cultural barriers [1]. A hospital in Ecuador where the indigenous rights move-ment is particularly strong implemented the Vertical Birth (VB) policy to increase indigenous womens ’ access to maternity services by adapting services to the local culture. This included conducting upright deliveries, introducing Traditional Birth Attendants (TBAs) and making physical adaptations to hospital facilities. Materials and methods This qualitative study explored the delivery of maternity services for indigenous women in an Ecuadorian hospital. Data was collected through observation, in-depth inter-views, a focus group discussion, and documentation review (e.g. hospital routine data). 40 interviews were conducted with Health Workers (HWs), managers, and policy-makers involved in maternal health at the field hospital. Data analysis was guided by grounded theory and drew heavily on concepts of “street-level bureau-cracy ” to explore implementation. Results Actors ’ values motivated their support or opposition to the VB policy and conflict ensued. Managers, policy-makers, indigenous actors and a minority of HWs sup-ported the VB policy. For this group, improving HWs’ attitudes towards indigenous women, widely perceived as discriminatory, was key to promote equitable access to services. Most HWs initially resisted the VB policy because they were concerned about the clinical implica-tions they attributed to the VB policy (e.g. postpartum haemorrhage and vaginal tears) and the tensions that stem from working alongside TBAs (e.g. conflicting advice given to patients). Nonetheless, TBAs played a crucial role in the VB implementation; they became women’s advocates and helped improve HWs ’ attitudes towards indigenous women. HWs effectively modified the VB policy and developed coping strategies to deal with their concerns. Managers accepted these as a com-promise to enable implementation. Implementation also succeeded because those supporting the VB policy were more powerful and because HWs concerns over clinical complications subsided