Being a midwife in West Africa: Between sensory experiences, moral standards, socio-technical violence and affective constraints.

Despite a long history of maternal health programs, the quality of obstetric care and access to facility services remain inadequate in West Africa. Although several qualitative studies have described human resource and facility constraints impacting pregnancy care and the violent or disrespectful care of women during labor, the reasons behind these behaviors have not been elucidated. In order to understand midwives' experiences with caregiving, in 2017-2018 we conducted interviews with 24 professional midwives in Benin and Burkina Faso and examined their perspectives on their profession, obstetric practices and personal lives. By including emotional, sensorial, linguistic and social elements, this paper shows important discordances between the proposals made by programs (such as rural postings and financial disbursement projects) and midwives' socio-emotional duties and economic roles. The study also shows that midwives' attitudes towards their patients are linked to their considering childbirth to be a moral act. Midwives' mistreatment of women in labor corresponds to constant shifts between technical obstetric skills and value judgements concerning expressions of pain, sexuality and desire. In addition, midwives justify their violent practices through the urgency of the situation, especially during crowning. The provision of care and the effective implementation of maternal programs cannot be improved without taking these justifications into account and without constructing dialogues enabling midwives to reflect on their social and emotional constraints, their relationship to the sexuality of childbirth, and the reasons for their practices. We advocate for more methodical research and for midwifery training to include in-depth case studies such as this one which start from the practical difficulties midwives face, making it possible to improve the midwifery profession as it is lived and not as it is imagined by fragmented, ungrounded programs.

[What sociotechnical arrangement is responsible for newborn deaths in West Africa?] / De quel agencement sociotechnique meurent les nouveau-nés d'Afrique de l'Ouest ?

INTRODUCTION: In Sub-Saharan Africa, despite the establishment of many health care programs, neonatal mortality rates remain extremely high. From a medical point of view, the main causes are obstetric, along with diarrhea and pneumonia. Understanding how these risks and pathogenic situations are constructed cannot be achieved without observing, analyzing, and understanding the underlying gestures and meaning systems. METHOD: Rather than describing obvious inequalities in the access to health care, our study aimed at questioning the different actors' operational capacities and at considering what is actually possible to improve in the most common healthcare situations. More specifically, how are births, neonatal care, and popular practices carried out in the first days of the lives of these newborns? In five countries of West Africa, a "multi-sited" anthropological study was carried out to observe the first weeks of newborns. This study not only allowed for the methodical identification of care interactions at and around childbirth in peripheral health care services, but also the popular practices related to the socialization of the child in family settings. RESULTS: Our fieldwork investigations show that neonatal risk corresponds to the combination of several sets of behavior. In obstetric services, for reasons linked to the symbolic status of the child as much as to a certain idea of the obstetric profession, the newborn remains marginal in the preoccupations of the midwives. This results in many dysfunctions (not warming the child, leaving the child in a drafty area, not feeding the child…) which constitute discontinuous risk factors.In the village and in the family, the newborn is at the center of many social practices - baths, rituals, ingestions of various "protective" products, period of seclusion, baptism… - which not only aim at conferring an identity and including the infant in the social group, but also build a set of infectious risks.Finally, while health actions build a translation space, no preventive dialogue has been established by healthcare personnel to inform people about the risks associated with certain social practices.Overall, these longitudinal follow-ups of newborns, as well as precise observations and interviews conducted with the actors on their reasons for acting, have made it possible to analyze the attitudes, gestures and social behaviors that constitute the concrete causes of neonatal risk. DISCUSSION: Describing the practices that newborns "benefit from" during their first days is essential to concretely identify and analyze the risks and reasons for high neonatal mortality. The empirical and documented approach of anthropology is essential to carry out these studies. But, more importantly, this qualitative approach must be implemented in vivo and in situ in the health services and during the training of health personnel to create a reflexivity of the caregivers and to initiate professional practices concerned with newborns. In the same way, our studies open the way for precise and documented dialogues with families which will enable the indispensable follow-up care for the newborns and ensure adapted preventive care and coherence in the care provided by the healthcare structures, the families, and the collectivities.

[Introduction]. / Ce que les sages-femmes disent de leurs vies, de leur métier et de leurs pratiques de soin.

INTRODUCTION: This paper is based on two observations. First, despite multiple health programmes, access to services and quality of obstetric care remain inadequate in Africa. Secondly, although several qualitative studies have described the poor quality of admission facilities, violence during delivery and neglect of the poorest women, the reasons behind these behaviours have not been elucidated.This survey, conducted in Benin and Burkina Faso, examined midwives' experiences of their job, their obstetric practices and their lives.By including the emotional, sensorial, linguistic and social elements, this paper shows important discordances between the proposals made by programmes (installation in rural areas, strict financial management) and midwives' social and emotional duties and economic roles. It highlights the importance of gender relations in the careers of these professionals.The study also shows that the attitudes of midwives are related to the fact that childbirth is considered to be a moral act and their mistreatment behaviour corresponds to constant shifts between technical skills (fertility) and value judgements concerning expression of pain, sexuality and desire. On the other hand, midwives justify their violent practices by the urgency of the situation, especially during childbirth.The provision of care and effective implementation of programmes cannot be improved without taking into account these forms of justification and without constructing dialogues enabling midwives to develop a reflection about their social and emotional constraints, their relation to sexuality, and the reasons for their actions.