Pergamon Sot. .Sci. Merl. Vol. 38. No. 8, 1069-1073. pp. 1994 Copyright i_: 1994 Elsevier Science Ltd Printed in Great Bntain. All rights reserved 0277-9536194 $6.00 + 0.00 zyxwvutsr MIDWIVES IN NIGER: AN UNCOMFORTABLE POSITION BETW EEN SOCIAL BEHAVIOURS AND HEALTH CARE CONSTRAINTS zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPO YANNICK JAFFRE’ and ALAIN PRUAL~ ‘Division de I’Education pour la Sante, Ministere de la Sante Publique, BP 12078 Niamey, Niger and *Departement de Sante Publique, Facuht de Sciences de la Sante, Niamey, Niger Abstract-Maternal mortality rates are very high in developing countries. In Niamey, the capital of Niger, maternal mortality rate is 280/100,000, in spite of a high concentration of health services and of health personnel. Several studies demonstrated that the efficiency of maternal health services was low, both because the quality and the quantity of work were insufficient. The usual response to the poor performances of health services in developing countries is mainly technical. If improvement of the training of health personnel and re-organization of health services are necessary, they are not sufficient. A good effectiveness of care cannot be achieved without a mutual confident relationship between providers and patients. Focus group discussions were held in Niamey with women users of maternal health services, with student midwives and experienced midwives. Sources of complaints between providers and patients appeared to be numerous. However, they are centered around two themes, delivery techniques and cultural requirements, which correspond to two types of constraints: technical constraints and social represen- tations and practices of the population. A description of traditional practices and beliefs related to delivery were obtained through discussion groups with old women and traditional birth attendants (TBAs). Both women and midwives are tied up by the same social rules (e.g. linguistic taboos, respect and shame) but technical constraints force midwives to violate those rules, making the application of their technical skills very difficult. Thus, the mutual relationship between users and providers is source of dissatisfaction, which often degenerates into an open confrontation. Midwives must learn how to implement obstetrical techniques within specific cultural environments. Key naords-midwives, developing countries, userrprovider relationship, dissatisfaction, cultural con- straints, traditional delivery INTRODUCTION In spite of a fast growing number of health personnel and of health services, maternal mortality remains a major public health problem in developing countries. The magnitude of the problem in the world was compared to the crash of an airplane, full of 250 pregnant or just delivered women, every 4 hr [I]. The World Health Organisation’s estimates of maternal mortality rates (MMR) for sub-Saharan Africa range from 270 maternal deaths per 100,000 thousands live births in Southern Africa to 760/100,000 in West Africa [2]. In comparison, the rate in North America is 12/100,000 [2]. A survey carried out in 9 countries under the supervision of WHO, showed that 88-98% of maternal deaths could have been avoided by appropriate care [I]. The determinants of maternal mortality can be classified into four main groups: direct medical causes (e.g. toxemia, hemorrhage, infections); reproductive behaviour (e.g. age at first marriage, parity, child spacing); socio-economic factors (e.g. GNP, literacy rate, social status of women); health care delivery (e.g. coverage, shortages of essential drugs, lack of qualified personnel, efficacy of health services). Safe Motherhood programs have essentially focused on reproductive behaviour (family planning programs) and on the delivery of health services (training of Traditional Birth Attendants (TBA), of midwives and of obstetricians). Because of their position in the health system, midwives play a key role: they are the persons initially responsible for antenatal care, for delivery services, for postnatal care, for family planning and for supervision of obstetrical teams at the peripheral levels. The second International Conference on Safe Motherhood held in Niamey in 1989 aimed at raising concerns of governments and funders about the importance of the problem, thus leading to actions that should make maternal mortality and morbidity rates decrease. The workshops and training programs that have been organized in Niger for midwives ever since do not seem to have produced the expected results: an improvement of maternal health services and, as a result, a decrease of maternal and infant mortality and morbidity rates [3,4]. In order to better understand the reasons for the relative failure of those programs, anthropological studies were carried out among the population of women and midwives.