Global policies and the provision of birth care in Burkina Faso

Targets and indicators set at global level are powerful measures that influence health systems in low-income countries. Facility-based births have been promoted as the main strategy for reducing maternal and neonatal death risks on the global scale. Further, measurements of facility-based births are used as an important indicator for monitoring maternal mortality reduction worldwide. However, there is a need to explore how the policy of institutional birth is implemented and how it resonates with health systems characterised by extensive resource scarcity. In this PhD project, I aim to describe and analyse the links between the global policy of skilled attendance and actual practices of birth care provision in Burkinabè primary health care centres. Methods: The study is based on multi-sited ethnographic fieldwork over 4 months in 2011-2012 in 4 primary health centres in rural Burkina Faso. Observational data from the maternity units was supplemented by 14 in-depth interviews with health workers and a total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members. Paper I documented how health workers provided birth care in a context of limited financial resources, insufficient personnel and poorly equipped facilities; the quality of the birth care provided was severely compromised. Health workers tended to place the responsibility for poor quality of care on infrastructural limitations and patient behaviour. Health workers felt disempowered, had limited abilities to prevent and treat birth complications and resorted to alternative and potentially harmful care strategies. Paper II found that community members experienced strong pressure to give birth in health facilities. Women and their families reported being subjected to verbal, economic and administrative sanctions if they did not attend services or adhere to health workers’ recommendations. Women, who for social and economic reasons had limited access to health facilities, found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seeking skilled care at birth. Pressure to use facility care and sanctions experienced by women who do not comply with health worker instructions may compromise trust in the health system. It may further marginalise women who already have poor access to facility care and may contribute to worsened health outcomes. Paper III uncovers the magnitude of reporting demands that health workers experience and the pressure placed on them to provide the ‘right’ results, in line with global policy targets. The paper describes the way in which health workers document inaccurate accounts. One example is how they complete the labour surveillance tool partograph after birth, transforming it into a ‘postograph’, to adhere to the expectations of district health officers. The drive for the ‘right’ numbers might encourage inaccurate reporting practices and produce knowledge that feeds into policies that are incapable of addressing the realities experienced by frontline health workers and patients. The study has documented the unintended effects of global policies on institutional care in Burkinabe health facilities: The quality of care was severely compromised, health workers employed sanctions towards women to increase uptake of institutional care, and the focus on indicators affected reporting practices in primary health care facilities. Drawing on ethnographic fieldwork set in a context of extreme resource scarcity, this PhD thesis constitutes a case study of how indicators in the field of maternal health affect care provision and our knowledge about care

“Death audit is a fight” – provider perspectives on the ethics of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system in Ethiopia

Background Maternal and neonatal health are regarded as important indicators of health in most countries. Death auditing through, for example, the Maternal and Perinatal Death Surveillance and Response (MPDSR) is viewed as key to preventing maternal and newborn mortality. However, little is known about the implications of implementing perinatal auditing for healthcare professionals in low-income contexts. This study aimed to explore the ethical and practical consequences clinicians experience concerning MPDSR reporting practices in Ethiopia. Methods Qualitative semi-structured in-depth individual interviews were conducted with 16 healthcare workers across professions at selected facilities in Ethiopia. The interview questions were related to clinicians’ experiences with, and perceptions of, death auditing. Their strategies for coping with newborn losses and the related reporting practices were also explored. The material was analyzed following systematic text condensation, and the NVivo11 software was used for organizing and coding the data material. Results Participants experienced fear of punishment and blame in relation to the perinatal death auditing process. They found that auditing did not contribute to reducing perinatal deaths and that their motivation to stick to the obligation was negatively affected by this. Performing audits without available resources to provide optimal care or support in the current system was perceived as unfair. Some hid information or misreported information in order to avoid accusations of misconduct when they felt they were not to blame for the baby’s death. Coping strategies such as engaging in exceedingly larger work efforts, overtreating patients, or avoiding complicated medical cases were described. Conclusions Experiencing perinatal death and death reporting constitutes a double burden for the involved healthcare workers. The preventability of perinatal death is perceived as context-dependent, and both clinicians and the healthcare system would benefit from a safe and blame-free reporting environment. To support these healthcare workers in a challenging clinical reality, guidelines and action plans that are specific to the Ethiopian context are needed.publishedVersio

Global policies and the provision of birth care in Burkina Faso

Targets and indicators set at global level are powerful measures that influence health systems in low-income countries. Facility-based births have been promoted as the main strategy for reducing maternal and neonatal death risks on the global scale. Further, measurements of facility-based births are used as an important indicator for monitoring maternal mortality reduction worldwide. However, there is a need to explore how the policy of institutional birth is implemented and how it resonates with health systems characterised by extensive resource scarcity. In this PhD project, I aim to describe and analyse the links between the global policy of skilled attendance and actual practices of birth care provision in Burkinabè primary health care centres. Methods: The study is based on multi-sited ethnographic fieldwork over 4 months in 2011-2012 in 4 primary health centres in rural Burkina Faso. Observational data from the maternity units was supplemented by 14 in-depth interviews with health workers and a total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members. Paper I documented how health workers provided birth care in a context of limited financial resources, insufficient personnel and poorly equipped facilities; the quality of the birth care provided was severely compromised. Health workers tended to place the responsibility for poor quality of care on infrastructural limitations and patient behaviour. Health workers felt disempowered, had limited abilities to prevent and treat birth complications and resorted to alternative and potentially harmful care strategies. Paper II found that community members experienced strong pressure to give birth in health facilities. Women and their families reported being subjected to verbal, economic and administrative sanctions if they did not attend services or adhere to health workers’ recommendations. Women, who for social and economic reasons had limited access to health facilities, found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seeking skilled care at birth. Pressure to use facility care and sanctions experienced by women who do not comply with health worker instructions may compromise trust in the health system. It may further marginalise women who already have poor access to facility care and may contribute to worsened health outcomes. Paper III uncovers the magnitude of reporting demands that health workers experience and the pressure placed on them to provide the ‘right’ results, in line with global policy targets. The paper describes the way in which health workers document inaccurate accounts. One example is how they complete the labour surveillance tool partograph after birth, transforming it into a ‘postograph’, to adhere to the expectations of district health officers. The drive for the ‘right’ numbers might encourage inaccurate reporting practices and produce knowledge that feeds into policies that are incapable of addressing the realities experienced by frontline health workers and patients. The study has documented the unintended effects of global policies on institutional care in Burkinabe health facilities: The quality of care was severely compromised, health workers employed sanctions towards women to increase uptake of institutional care, and the focus on indicators affected reporting practices in primary health care facilities. Drawing on ethnographic fieldwork set in a context of extreme resource scarcity, this PhD thesis constitutes a case study of how indicators in the field of maternal health affect care provision and our knowledge about care

‘We saw she was in danger, but couldn’t do anything’: Missed opportunities and health worker disempowerment during birth care in rural Burkina Faso

Background: Facility-based births have been promoted as the main strategy to reduce maternal and neonatal death risks at global scale. To improve birth outcomes, it is critical that health facilities provide quality care. Using a framework to assess quality of care, this paper examines health workers’ perceptions about access to facility birth; the effectiveness of the care provided and obstacles to quality birth care in a rural area of Burkina Faso. Methods: A qualitative study was conducted in 2011 in the Banfora Region, Burkina Faso. Participant observations were carried out in four different health centres for a period of three months; more than 30 deliveries were observed. In-depth interviews were conducted with 12 frontline health workers providing birth care and with two staff of the local health district management team. Interview transcripts and field notes were analysed thematically. Results: Health workers in this rural area of Burkina Faso provided birth care in a context of limited financial resources, insufficient personnel and poorly equipped facilities; the quality of the birth care provided was severely compromised. Health workers tended to place the responsibility for poor quality of care on infrastructural limitations and patient behaviour, while our observational data also identified missed opportunities that would not demand additional resources throughout the process of care like early initiation of breastfeeding and skin-to-skin contact after birth. Health workers felt disempowered, having limited abilities to prevent and treat birth complications, and resorted to alternative and potentially harmful strategies. Conclusions: We found poor quality of care at birth, missed opportunities, and health worker disempowerment in rural health facilities of Banfora, Burkina Faso. There is an urgent need to provide health workers with the necessary tools to prevent and handle birth complications, and to ensure that existing low cost life-saving interventions in maternal and new-born health are appropriately used and integrated into the daily routines in maternity wards at all levels

Juridification of maternal deaths in Ethiopia: A study of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system

Juridification of maternal health care is on the rise globally, but little is known about its manifestations in resource constrained settings in sub-Saharan Africa. The Maternal and Perinatal Death Surveillance and Response (MPDSR) system is implemented in Ethiopia to record and review all maternal and perinatal deaths, but underreporting of deaths remains a major implementation challenge. Fear of blame and malpractice litigation among health workers are important factors in underreporting, suggestive of an increased juridification of birth care. By taking MPDSR implementation as an entry point, this article aims to explore the manifestations of juridification of birth care in Ethiopia. Based on multi-sited fieldwork involving interviews, document analysis and observations at different levels of the Ethiopian health system, we explore responses to maternal deaths at various levels of the health system. We found an increasing public notion of maternal deaths being caused by malpractice, and a tendency to perceive the juridical system as the only channel to claim accountability for maternal deaths. Conflicts over legal responsibility for deaths influenced birth care provision. Both health workers and health bureaucrats strived to balance conflicting concerns related to the MPDSR system: reporting all deaths vs revealing failures in service provision. This dilemma encouraged the development of strategies to avoid personalized accountability for deaths. In this context, increased juridification impacted both care and reporting practices. Our study demonstrates the need to create a system that secures legal protection of health professionals reporting maternal deaths as prescribed and provides the public with mechanisms to claim accountability and high-quality birth care services

Reflections on the unintended consequences of the promotion of institutional pregnancy and birth care in Burkina Faso

The policy of institutional delivery has been the cornerstone of actions aimed at monitoring and achieving MDG 5. Efforts to increase institutional births have been implemented worldwide within different cultural and health systems settings. This paper explores how communities in rural Burkina Faso perceive the promotion and delivery of facility pregnancy and birth care, and how this promotion influences health-seeking behaviour. A qualitative study was conducted in South-Western Burkina Faso between September 2011 and January 2012. A total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members were conducted. The data were analyzed using qualitative content analysis and interpreted through Merton's concept of unintended consequences of purposive social action. The study found that community members experienced a strong pressure to give birth in a health facility and perceived health workers to define institutional birth as the only acceptable option. Women and their families experienced verbal, economic and administrative sanctions if they did not attend services and adhered to health worker recommendations, and reported that they felt incapable of questioning health workers' knowledge and practices. Women who for social and economic reasons had limited access to health facilities found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seek skilled care at birth. The study demonstrates how the global and national policy of skilled pregnancy and birth care can occur in unintentional ways in local settings. The promotion of institutional care during pregnancy and at birth in the study area compromised health system trust and equal access to care. The pressure to use facility care and the sanctions experienced by women not complying may further marginalize women with poor access to facility care and contribute to worsened health outcomes

Policy, paperwork and 'postographs': Global indicators and maternity care documentation in rural Burkina Faso

Targets and indicators set at the global level are powerful tools that govern health systems in low-income countries. Skilled birth attendance at a health facility is an important indicator for monitoring maternal mortality reduction worldwide. This paper examines how health workers negotiate policy implementation through the translation of clinical care into registries and reports. It does so by analysing the links between the global policy of institutional births and the role of documentation in the provision of birth care in primary health centres in Burkina Faso. Observations of health workers' practices in four primary maternity units (one urban, one semi-urban and two rural) conducted over a 12-week period in 2011–2012 are analysed alongside 14 in-depth interviews with midwives and other health workers. The findings uncover the magnitude of reporting demands that health workers experience and the pressure placed on them to provide the ‘right’ results, in line with global policy objectives. The paper describes the way in which they document inaccurate accounts, for example by completing the labour surveillance tool partograph after birth, thus transforming it into a ‘postograph’, to adhere to the expectations of health district officers. We argue that the drive for the ‘right’ numbers might encourage inaccurate reporting practices and it can feed into policies that are incapable of addressing the realities experienced by frontline health workers and patients. The focus on producing indicators of good care can divert attention from actual care, with profound implications for accountability at the health centre level

'Maternal deaths should simply be 0': Politicization of maternal death reporting and review processes in Ethiopia

The Maternal Death Surveillance and Response system (MDSR) was implemented in Ethiopia in 2013 to record and review maternal deaths. The overall aim of the system is to identify and address gaps in order to prevent future death but, to date, around 10% of the expected number of deaths are reported. This article examines practices and reasoning involved in maternal death reporting and review practices in Ethiopia, building on the concept of ‘practical norms’. The study is based on multi-sited fieldwork at different levels of the Ethiopian health system including interviews, document analysis and observations, and has documented the politicized nature of MDSR implementation. Death reporting and review are challenged by the fact that maternal mortality is a main indicator of health system performance. Health workers and bureaucrats strive to balance conflicting demands when implementing the MDSR system: to report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices but also the care given in the study sites. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control. The practical norms of how health workers report deaths perpetuate a skewed way of seeing problems and solutions in maternal health. On the basis of our findings, we argue that closer attention to the broader political context is needed to understand the implementation of MDSR and other surveillance systems

'Maternal deaths should simply be 0': Politicization of maternal death reporting and review processes in Ethiopia

The Maternal Death Surveillance and Response system (MDSR) was implemented in Ethiopia in 2013 to record and review maternal deaths. The overall aim of the system is to identify and address gaps in order to prevent future death but, to date, around 10% of the expected number of deaths are reported. This article examines practices and reasoning involved in maternal death reporting and review practices in Ethiopia, building on the concept of ‘practical norms’. The study is based on multi-sited fieldwork at different levels of the Ethiopian health system including interviews, document analysis and observations, and has documented the politicized nature of MDSR implementation. Death reporting and review are challenged by the fact that maternal mortality is a main indicator of health system performance. Health workers and bureaucrats strive to balance conflicting demands when implementing the MDSR system: to report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices but also the care given in the study sites. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control. The practical norms of how health workers report deaths perpetuate a skewed way of seeing problems and solutions in maternal health. On the basis of our findings, we argue that closer attention to the broader political context is needed to understand the implementation of MDSR and other surveillance systems