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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.
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 181th 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. 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. 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]. 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.
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