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