Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso

The policy of institutional delivery has been the cornerstone of actions aimed at monitoring and achieving MDG 5. Efforts to increase institutional births have been implemented worldwide within different cultural and health systems settings. This paper explores how communities in rural Burkina Faso perceive the promotion and delivery of facility pregnancy and birth care, and how this promotion influences health-seeking behaviour. A qualitative study was conducted in South-Western Burkina Faso between September 2011 and January 2012. A total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members were conducted. The data were analyzed using qualitative content analysis and interpreted through Merton’s concept of unintended consequences of purposive social action. The study found that community members experienced a strong pressure to give birth in a health facility and perceived health workers to define institutional birth as the only acceptable option. Women and their families experienced verbal, economic and administrative sanctions if they did not attend services and adhered to health worker recommendations, and reported that they felt incapable of questioning health workers’ knowledge and practices. Women who for social and economic reasons had limited access to health facilities found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seek skilled care at birth. The study demonstrates how the global and national policy of skilled pregnancy and birth care can occur in unintentional ways in local settings. The promotion of institutional care during pregnancy and at birth in the study area compromised health system trust and equal access to care. The pressure to use facility care and the sanctions experienced by women not complying may further marginalize women with poor access to facility care and contribute to worsened health outcomes.住院分娩政策一直是监测并实现千年发展目标5（Millennium Development Goal 5）的核心举措。全球范围内不同文化与卫生体系场景下，均已推行提升住院分娩率的相关工作。本研究探讨布基纳法索农村社区对医疗机构孕期与分娩护理推广及服务提供的认知，以及该推广如何影响民众的就医行为。 研究于2011年9月至2012年1月期间，在布基纳法索西南部开展定性研究。共对近期分娩女性及社区成员完成21次深入访谈与8场焦点小组讨论。数据采用定性内容分析法进行处理，并借助默顿的有目的社会行动意外后果理论开展阐释。 研究结果显示，社区成员面临强烈的住院分娩压力，且认为医护人员将住院分娩视为唯一可接受的分娩选择。若女性及其家属未遵从医护人员的建议接受相关服务，则会面临口头指责、经济处罚与行政惩戒；受访者同时表示，自身无力质疑医护人员的专业认知与执业行为。对于因社会与经济因素难以获取医疗机构服务的女性而言，惩戒措施不仅推高了医疗服务成本，还带来了社会污名，进一步成为寻求分娩时专业护理的额外障碍。 本研究揭示了全球与国家层面的产科专业护理政策，在本地场景中可能以意想不到的方式落地。研究区域内推行的孕期与住院分娩护理推广举措，损害了民众对卫生系统的信任，也削弱了医疗服务的公平可及性。强制使用医疗机构分娩的压力，以及未遵从要求的女性所遭受的惩戒，可能进一步加剧就医条件有限女性的边缘化处境，并导致健康结局恶化。