Background
At the end of the Millennium Development Goal era, maternal and neonatal mortality rates remain unacceptably high in many countries in sub-Saharan Africa. In Burkina Faso, the lifetime risk of maternal death is one in 55, and about one in ten children will not survive their fifth birthday [
1]. Whereas under five mortality has been declining during the last decades, neonatal mortality remains unchanged [
2]. The time around birth is critical for both mothers and new-borns [
3,
4]. Timely access to care at and around the time of birth is one of the main strategies to reduce maternal and neonatal morbidity and mortality [
5,
6], as important is the quality of the care provided in health facilities [
7]. Low quality facility birth care represents a missed opportunity to improve birth outcomes and increase the demand for facility birth care.
There is a unanimous call for improved quality care to prevent maternal and child deaths, but little consensus on how quality in healthcare should be defined [
8]. Campbell et al. divide quality of care into
accessibility of services and
effectiveness of the services provided [
9]
. Accessibility is ensured when users can access the health structures and processes of care which they need. Effectiveness is divided into clinical and inter-personal care and involves different dimensions of the health system such as the structure or organisation of the services, the process of care, and the outcome of the care provided [
9]. These dimensions are interlinked; for example, in order to achieve desired outcomes such as decreased infection rates in a facility, the availability of structures such as water and soap for hand washing is a prerequisite, but does not by itself ensure that birth attendants wash their hands.
Since most women and new-borns are well, and only some develop complications, quality of birth care should be considered differently from other areas of care provision [
10]. As it is difficult to predict birth complications, it is an expressed goal in the global health community that all women should give birth assisted by skilled birth attendants [
5]. This implies giving birth with a provider with midwifery skills, trained in the management of normal deliveries and the detection and management of complications during birth with the ability to refer to a higher level of care when needed [
5]. At all primary health care facilities, basic emergency obstetric and neonatal care (BEmONC) should be made available to treat complications. This includes the possibility to carry out the following six key functions: providing parenteral antibiotics, anticonvulsants, oxytocic drugs, removal of placenta and retained products of conception, assisted vaginal delivery and resuscitation of new-borns [
11]. Effective transportation systems to facilities with comprehensive care, including competence to carry out caesarean sections and blood transfusions, are essential for timely treatment of complications [
12].
Given the numerous definitions of quality birth care, a variety of frameworks have been suggested to assess this outcome [
8]. Many focus on outcomes such as case-fatality rate and caesarean section rate, some focus on structure such as equipment and personnel available, fewer focus on the process of care. One reason for this could be that the gold standard for assessing process is direct observations of the provision of care, which is costly and time-consuming [
8]. The meaning of quality of care also depends on the assessor’s viewpoint. Users of health care would, for example, emphasize inter-personal aspects of care when evaluating the quality, whereas cost-effectiveness is a typical concern for managers [
9,
13]. To gain knowledge about quality of care, the providers’ perspective plays an important role since they are situated at the point of service delivery and are able to technically evaluate the quality of clinical care more accurately than users of services.
In Burkina Faso, it is estimated that 66 % of births take place in a health facility with a skilled attendant [
1]. Out of pocket costs for delivery care have previously been reported to impoverish patients and their families and to constitute an important access barrier [
14]. A national subsidiary policy for deliveries and emergency obstetric care was implemented in 2006, subsidising 80 % of the costs of care and providing free emergency transportation [
15]. Other reported barriers to facility birth have been distance to health facilities and women’s limited decision-making power within households [
16].
The great majority of facility births in Burkina Faso take place in primary health centres (Centres de Santé et de Promotion Sociale). The data on outcomes of these facility births are suggestive of poor quality care; few are able to provide BEmONC and one prospective study found no difference in perinatal death risk between home-based and institutional deliveries [
17,
18]. Studies of the quality of care provided in health centres have shown limited knowledge and compliance with guidelines among health personnel, unavailability of necessary drugs and diagnostic tests, delayed provision of care and inadequate counselling about danger signs during pregnancy and childbirth [
18‐
21]. Even so, women giving birth in these health centres report a high degree of satisfaction with the services provided [
22].
We conducted an exploratory qualitative study in four primary health care centres. In line with Campbell et al.’s framework we focused on access to care and the effectiveness of clinical and interpersonal care. We explored health workers’ perspectives on women’s access to facility birth and safe birthing, the strategies health workers employed to provide quality care; and what they experienced as obstacles to the provision of quality birth care.
Methods
Study site
The study was conducted in the Banfora and Mangodara health districts in the South-western part of Burkina Faso with an estimated population of around 500 000 inhabitants. Situated in West-Africa, Burkina Faso is among the world’s poorest countries, ranking 181
th of 187 on the Human Development Index 2011 [
23]. In the study area, cotton production, subsistence farming and animal husbandry remain the main economic activities. With annual rainfalls of over 900 mm, the region of Banfora is amongst the most fertile and the least poor in the country [
24]. Literacy is low in the region, 80 % of the adult population in the two health districts is considered illiterate. The main spoken language is Dioula; French is the official language, but is only spoken by those who have attended school.
The annual number of expected deliveries in the study area was 24 500 in 2011 [
25]. At the time of the study, Banfora and Mangodara health districts had 39 primary health centres, usually with one dispensary and one maternity unit. Primary health centres referred women with obstetric emergencies to the regional referral hospital in Banfora town. The driving time from the health centres participating in the study to the regional hospital varied from five to 150 minutes. Not all health centres had access to an ambulance; some had to rely on private transportation.
Data collection
The fieldwork lasted from September 2011 to January 2012 and the data collection took place in four primary health centres in the Banfora region, combining participatory observations and in-depth interviews.
As we assumed that working conditions would differ between urban and rural areas and depending on the monthly number of births, one urban, one semi-urban and two rural facilities were chosen. The number of health workers in the health centres varied from two to 12. The number of births per month varied from three to 100. The infrastructure of the health centres also varied substantially. Some had electricity and running water, while in others health workers had to rely on their personal torches as the only light source and on water from wells situated up to one kilometre from the health centre.
The two rural health centres were relatively large units situated approximately 65 km from the Banfora regional referral hospital. No smaller rural health centres were chosen due to practical concerns such as availability of housing and transport during data collection.
The first author, at the time a third-year medical student, carried out the participatory observations, both day and night for 12 weeks; three weeks in each of the four primary maternity units. The researcher was present at the health centres from two to eight hours every day, and during 14 night shifts. During this period, more than 30 deliveries were observed, 21 deliveries during daytime and 13 at night. The observations were non-structured; the researcher followed the health workers at work, asking questions and helping out with small tasks like getting the necessary drugs and equipment ready for the health workers. She did not work autonomously, nor did she provide direct patient care. Observations and reflections were noted daily in a field diary, providing information about health worker-patient interactions; health workers’ practices related to routine care such as pre- and postnatal consultations, reception and follow-up of women through first, second and third stage of labour as well as providers’ perspectives about working conditions, access to and quality of care.
In addition, the first author conducted 12 in-depth interviews with health workers providing obstetric care. Health workers were purposively selected for in-depth interviews on the basis of informal conversations and caregiving during observations in the health facilities, as well as their levels of experience and training, to represent different views. Two of the interviewees did not work in the study health centres, but were selected to represent the view of health workers in small rural health centres where, for practical reasons, observations could not be carried out. The 12 interviewees were two registered midwives, three registered nurses, one enrolled midwife, four auxiliary midwives, and two outreach health workers. Three of the interviewees were male. The recruitment of participants was ended at the point of data saturation when little new information emerged from the interviews. In addition, two medical doctors in the health district management team were interviewed about policy implementation at the centre level. The interviews included open-ended questions about access to facility pregnancy and birth care, the quality of care provided, working conditions, and health worker performance. All co-authors contributed to the making of the interview guide, which was piloted for its suitability in facilities not participating in the study, the interview guides were modified in the course of data collection based on observational data. The interviews were conducted in French in a separate room at the interviewees’ workplace, and lasted from 45 to 90 minutes. The interviews were recorded and transcribed verbatim.
Data analysis
After initial analysis during fieldwork, interview transcripts and field notes were analysed thematically. NVivo 9 software was used to code and organize the data (
http://www.qsrinternational.com). Firstly, after being familiarized with the datasets, initial codes were generated. These codes were grouped into categories and subsequently into themes. For instance, having a single blood pressure measurement device at the maternity ward was coded as
shortage of equipment. This code was grouped with other codes to form the category
insufficient infrastructure as a barrier to routine care. This, and others were then again grouped into the theme
Barriers to quality routine maternal and new-born care. The combination of participant observations and interviews allowed for methodological triangulation, cross-checking the observational and interview data during analysis for improved validity [
26].
Ethical considerations
The study was approved by the national health research ethics committee of the Ministry of Health, Ouagadougou, Burkina Faso (Comité d’éthique pour la Recherche en Santé, CERS, No2011-9-57). Administrative clearance was granted by the regional health authorities in Banfora. Written informed consent was obtained from all interviewees. Verbal consent to participate at the care provision was granted by health workers for all observations. Health workers were asked to inform and ask all women in labour to consent to the researcher’s presence. To ensure the informants’ confidentiality, they are only referred to by their level of training throughout this paper.
Discussion
Disempowerment of health workers
In resource poor settings, where comprehensive emergency obstetric and neonatal care is inaccessible, primary care is used as a strategy to provide birth care to all [
8]. One of the main roles of primary care at birth is to detect and refer complications when these occur. The accounts of birth care providers in rural Burkina Faso reveal how health workers’ ability to assure timely detection and management of birth complications is severely limited. It has previously been documented that few of the primary health centres in Burkina Faso are capable of assuring BEmONC functions, especially assisted vaginal deliveries and removal of retained products [
20]. In this study, health workers reported that women prefer staying in primary centres rather than being referred to the regional hospital for fear of unmanageable out-of-pocket costs. To prevent maternal and new-born morbidity and mortality and limit the number of referrals, all BEmONC services need to be provided at the health centre level.
Even though emergency transportation should be provided free of charge according to the subsidy policy, this was not the case in the study area. Access to emergency transport has also been a concern in other regions [
22]. The combination of limited possibilities to manage complications at the health centre and little or no access to emergency transport made health workers into disempowered bystanders when life-threatening emergencies occurred. We argue that the despair of health workers faced with obstetric emergencies made them resort to alternative and potentially harmful strategies.
Missed opportunities in the process of care
Clinical care
Previous studies have shown that users’ of institutional deliveries in Burkina Faso evaluate the clinical care provided as of good quality [
22,
27], but patients have a limited ability to evaluate technical performance, and great discrepancies between reported and observed birth care have been shown [
18]. Health workers in this study reported severe technical weaknesses in the surveillance of women in labour, routine hygiene and the management of complications. There was a continuous lack of material supplies, staffing and competences of staff within the health centres. These findings are not new nor unique for Burkina Faso [
7,
28,
29], and are in line with the findings reported from the QUALMAT study conducted in the North-western part of the country [
20,
30].
Health workers perceived several clinical standards and protocols available in the health centres as not relevant for their particular contexts, but as something you would do in an ‘ideal world’. This is in line with previous findings from Burkinabè primary health centres [
30]. This non-compliance with set guidelines could be interpreted as a ‘know-do’ gap, but it may be more fruitful to discuss health workers’ ability to follow basic quality-promoting guidelines within a health system that is severely constrained in terms of both material and human resources. It has been shown that frontline health workers in Burkina Faso have limited access to clinical practice guidelines for maternal health, and that these are found to be of limited use [
31]. Successful implementation of clinical guidelines depends on the guidelines themselves, their implementation as well as health worker, patient and environmental characteristics [
32]. In a setting where health worker competences are seen as limited, there is an even larger need for clinical practical guidelines that are adapted to local realities.
It is important to note that certain aspects of sub-standard clinical care were not directly explained by insufficient infrastructure. Interventions that did not require additional costs such as skin-to-skin contact after birth to avoid hypothermia and early initiation of breastfeeding were not being routinely practiced in the health centres. Such low- or no-cost interventions constitute missed low-hanging fruits to substantially improve new-born health [
18,
33]. In the study setting, we believe that the limited training of auxiliary midwives and outreach health workers practicing in the maternity units contribute to a limited knowledge of the importance of such interventions. In resource-poor settings such as the study area, there is a particular need for continuous training of health workers with a focus on interventions that do not require additional cost, time or resources.
Inter-personal care
Although health workers acknowledged that access to facility birth care depended on geographical factors, inter-personal care and structure of facilities, the health centre was presented as the only responsible place for a woman to give birth. Women who give birth at home were seen as less invested in the well-being of their babies. Similar attitudes among health personnel have been described elsewhere [
34]. Such attitudes could be linked to the practice of blaming women for poor pregnancy outcomes [
30]. These findings resonate with Douglas’ writings about risk and blame. According to her, risk is inevitably moral, and every poor outcome chargeable to someone’s account. This implies a ‘combination of moralistic condemning the victim and an opportunistic condemning [of] the victim’s incompetence’ [
35].
The blaming of women for poor pregnancy outcomes can also be seen as a way for health workers to justify the mistreatment of women reported in this paper. Threats of poor outcomes for women and their babies, lack of confidentiality, neglect of women in labour, unwelcoming and poorly trained health workers, are all part of the larger problem of the mistreatment of women during labour [
36]. It is evident that a health system deprived of resources may contribute to health worker behaviour, but it also seems reasonable to suggest that health workers utilize coercive methods deliberately to gain compliance from women, as reported from South-Africa [
37].
Being blamed and mistreated for not using the services as prescribed by health workers, has implications for the utilisation of services and the overall trust in the health system [
38]. The practice of sending a family member to find out who is on call, indicates that patients place their trust in individual health workers rather than in the health care institution, in this case the government health centre and its referral system [
39]. In this setting, the high turnover of health workers may partly explain the problem of trust and may represent a barrier to the accessibility of care. Keeping health personnel in rural areas is a challenge for most countries’ health systems [
40]. Although not explored in our findings, gifts of satisfaction to health workers have elsewhere been linked to the expectation of better treatment in the future, and thus interpreted as an element of bribery [
41]. The practice of gift giving implies an additional cost for women and their families and is thus perceived as a threat to equal access to facility care. At the same time, such informal payments constitute an important source of income for health workers in low resource settings, and contribute to the retention of health workers [
42]. In Burkina Faso, it has been shown that it is particularly hard to keep female health workers in rural areas because of lack of basic infrastructure such as water, electricity and schooling opportunities for their children [
30].
Methodological concerns
This study reports from four health centres in a rural part of Burkina Faso. Although substandard quality of care in primary health facilities in Burkina Faso previously has been documented [
18,
19], the emphasis on frontline health workers’ and managers’ perspectives provides additional insight into the dynamics within primary health facilities providing birth care. Through observations and interviews with providers, we gained knowledge of providers’ perspectives on accessibility of services and the three components of health care effectiveness: the structure of care, the process of care and the outcomes of the care provided [
9], and how these dimensions interact. This paper explored only providers’ perspectives; when users’ perspectives are presented, they are only seen through the lens of the providers of care.
As a young female student, the observer was perceived as a subordinate to the staff and was accepted in the ward, which facilitated participatory observation. However, social desirability bias may have influenced study participants both to describe and to perform best practices in the researcher’s presence. With no prior clinical experience from her home university and not having completed courses in obstetrics or paediatrics, she was only able to assess the health workers’ performance based on limited theoretical knowledge and nationally established guidelines as communicated to local health workers and was not able to provide advice on patient care. As the researcher experienced and developed an understanding of the practical constraints to the provision of quality care experienced by health workers, such as lack of water, electricity, referral possibilities and necessary drugs, her presence at the health centres may positively have influenced the interpretation of health worker actions in the findings. Staying for several weeks in each health centre, the health workers may have forgotten the observer’s role as a researcher and disclosed issues that they may not have revealed during formal interviews.
The observer did not understand the local language. This was a limitation when observing the patient/provider interaction and when the interaction between health workers took place in Dioula. When needed, the researcher asked health workers to explain to her in French what was happening.
The findings are limited to four health centres in the Banfora area and cannot be generalised beyond these study sites. However, the health centres in the study are subjected to the same health policy and the same health system culture and resource scarcity as health centres in other parts of Burkina Faso. Furthermore the services are provided in a socio-economic context with high levels of poverty and illiteracy which are not much different from other rural areas in the country. There is therefore reason to believe that the findings are relevant also in other rural health care settings in Burkina Faso.
Acknowledgements
We would like to address our sincere thanks to all participants in this study for their patience during observations and interviews. The authors of this paper would like to thank Ms Catherine Koné for her efforts during the data collection, Dr Abdramane Berthé for his contribution to design of the interview guides as well as Dr Nicolas Meda for his continuous support. We would also like to acknowledge the contribution of representatives from the Regional Health Directorate of Cascades, Banfora Health District and Mangodara Health District during the data collection period of this study.