Anthropological overview of kangaroo care in community settings in Madagascar.

The management of preterm births remains a major challenge in Madagascar, given the lack of equipped facilities in rural areas, and the absence of precise data concerning the incidence of such births. The World Health Organization (WHO) recommends the kangaroo method (skin-to-skin contact) for the management of preterm infants. In this article, we examine the conditions for success and the obstacles facing kangaroo care in community settings in Madagascar. We performed a qualitative research, collecting data from the districts of Antananarivo and Mahajanga in 2021. In total, 54 semi-structured interviews and two focus group sessions were conducted with the parents of preterm infants and healthcare professionals.The obstacles identified by the research included incomplete and inaccurate knowledge, leading to heterogeneity in the practice of kangaroo care: arbitrary duration, lack of kangaroo care at night, exclusive breastfeeding, and only partially practiced skin-to-skin contact. We found that the conditions for success depended on: (1) the healthcare system, (2) local interpretations of pregnancy, and (3) the structure of the infant's family. Failings of the medical system, cultural habits going against kangaroo care, and "nuclear" and/or "single parent" family structures undermine the application of this practice, jeopardizing upscaling efforts. We hope that the results of this research will guide community strategies for the management of preterm infants and kangaroo care.

Obstacles to routine immunization in Madagascar: Structural, relational and cultural constraints.

This article proposes an overview of anthropological studies concerning childhood immunization in Madagascar, where vaccine coverage still remains low. The COVID-19 epidemic has heightened the reticence of populations to be vaccinated in the public health centres of this country. It appears necessary to study the factors which may impact immunization practices and its representations. The principal results of these studies describe immunization from the perspective of parents of children under five years of age. The role that they attribute to a vaccine is essentially that of reinforcing the health of children against illness. There is a misunderstanding of combination vaccines, one vaccine generally being associated with one disease. The findings also show a complex relationship with immunization, injections and the health passport. Finally, uptake of immunization or not is motivated by the structural and local context such as the perceived frailness of the newborn baby, the practice of post-partum confinement, or the lack of knowledge about the vaccine. Lack of understanding of immunization and mistrust of it are signs of a fragile health system. An in-depth analysis of immunization and the impact of COVID-19 on its perception will provide a clearer view of the fragility of the immunization programmes implemented in Madagascar.

A qualitative analysis of obstetric violence in rural Madagascar.

In Madagascar, a country where maternal mortality remains high, the quality of obstetric care as perceived by users has been little explored. In this paper, we examine the perception of the quality of care in rural areas, by identifying women's experiences and expectations for basic and emergency obstetric care and how providers are meeting them. Data were collected in 2020, in three rural regions (Fenerive-Est, Manakara and Miandrivazo). 58 semi-structured interviews were conducted with women who had given birth in basic health centers or at home, and with other key informants including caregivers, birth attendants (known as matrones), grandmothers and community agents. 6 focus groups took place with mothers who had given birth at home and at a basic health centers and 6 observations took place during prenatal consultations. This article highlights the major dysfunctions perceived in the services offered and their influence on healthcare use. The women highlighted a lack of consideration of their expectations in obstetric care, with a defective caregiver/patient relationship, unforeseen costs and inadequate infrastructures incapable of guaranteeing intimacy. The women also complained of a lack of consideration of their fady (cultural prohibitions that can lead to misfortune) that surround pregnancy. These local practices conflict with the medical requirements of priority interventions in maternal care, and the respect of these practices by the women leads to reprimands and humiliation from caregivers. This obstetric violence, which emanates from the structure of society, gender relations and the biomedical practices governing pregnancy and childbirth in health facilities in Madagascar, constitutes an obstacle to the use of obstetric services. We hope that this description of the various dimensions of obstetric violence in Madagascar will make it possible to identify the structural obstacles limiting the capacity to provide quality care and to engender positive improvements in obstetric care in Madagascar.