CEPED, IRD, Université Paris Descartes, INSERM, équipe SAGESUD, Paris, France.
Museum National d'Histoire Naturelle, Paris, France.
Soc Sci Med. 2018 Dec;218:52-61. doi: 10.1016/j.socscimed.2018.10.002. Epub 2018 Oct 9.
In Madagascar, a country where over 60% of deliveries are not attended by a healthcare professional, late or inadequate responses to complications during childbirth account for a great number of maternal deaths. In this article, we analyse local perceptions of birth-related risks and strategies used to avoid these risks or manage complications of childbirth. We conduct this analysis in light of the social meanings of childbirth and the social expectations placed upon women in a context of socio-economic vulnerability and a challenged public health system. We conducted two separate studies in the district of Morondava (Menabe region) in June 2014 and March 2015, comprising semi-directive interviews with 111 people (59 mothers, 18 members of their immediate entourage and 34 institutional or healthcare stakeholders), and eight focus groups discussions - two with community leaders, and six with fathers. The results show that the social pressure exerted on women to give birth without complications leads them to practices aimed at avoiding a "big" baby including dietary restrictions, physical activity, and refusal of iron supplementation intake. During pregnancy, women are usually accompanied by a traditional birth attendant or matron (reninjaza). Further, they use the public health system by attending antenatal consultations. However, women are reluctant to deliver in a health facility, where the practices of health professionals are in discordance with the social realities of women and local beliefs around childbirth. If complications arise, they are explained by social causes. The parturient woman is only taken to a healthcare facility after carrying out rituals and if the problems do not resolve themselves. These findings support recommendations to reduce the cultural distance between health workers and childbearing women, strengthen the collaborations with reninjazas, and inform women and their decision makers (mother, reninjaza, spouse) about nutrition during pregnancy and signs of complications.
在马达加斯加，超过 60%的分娩没有医疗专业人员在场，分娩过程中出现的并发症如果不能得到及时或适当的处理，会导致大量产妇死亡。本文分析了当地对分娩相关风险的认知，以及为避免这些风险或处理分娩并发症而采取的策略。我们根据分娩的社会意义，以及在社会经济脆弱和公共卫生系统面临挑战的背景下，对妇女的社会期望，对这些内容进行了分析。我们于 2014 年 6 月和 2015 年 3 月在莫隆达瓦区（梅纳贝地区）进行了两项独立的研究，包括对 111 人（59 名产妇、18 名产妇的近亲及 34 名机构或医疗保健利益相关者）进行半结构化访谈，以及八次焦点小组讨论，其中两次是与社区领袖进行的，六次是与父亲进行的。研究结果表明，社会对产妇无并发症分娩的压力迫使她们采取各种措施来避免“大”婴儿的出生，包括限制饮食、减少体力活动和拒绝摄入铁补充剂。怀孕期间，产妇通常由传统的接生员或护士长（reninjaza）陪同。此外，她们会参加产前咨询以利用公共卫生系统。然而，产妇不愿意在医疗机构分娩，因为医疗机构的医疗行为与女性的社会现实和当地的分娩观念相冲突。如果出现并发症，她们会将其归因于社会原因。只有在进行了仪式并且问题没有自行解决的情况下，产妇才会被送往医疗机构。这些发现支持了减少卫生工作者与产妇之间文化隔阂、加强与 reninjazas 合作、以及向妇女及其决策者（母亲、reninjaza、配偶）提供关于孕期营养和并发症迹象的建议。
