Midwives in Niger: an uncomfortable position between social behaviours and health care constraints.

Maternal mortality rates are very high in developing countries. In Niamey, the capital of Niger, maternal mortality rate is 280/100,000, in spite of a high concentration of health services and of health personnel. Several studies demonstrated that the efficiency of maternal health services was low, both because the quality and the quantity of work were insufficient. The usual response to the poor performances of health services in developing countries is mainly technical. If improvement of the training of health personnel and re-organization of health services are necessary, they are not sufficient. A good effectiveness of care cannot be achieved without a mutual confident relationship between providers and patients. Focus group discussions were held in Niamey with women users of maternal health services, with student midwives and experienced midwives. Sources of complaints between providers and patients appeared to be numerous. However, they are centered around two themes, delivery techniques and cultural requirements, which correspond to two types of constraints: technical constraints and social representations and practices of the population. A description of traditional practices and beliefs related to delivery were obtained through discussion groups with old women and traditional birth attendants (TBAs). Both women and midwives are tied up by the same social rules (e.g. linguistic taboos, respect and shame) but technical constraints force midwives to violate those rules, making the application of their technical skills very difficult. Thus, the mutual relationship between users and providers is source of dissatisfaction, which often degenerates into an open confrontation. Midwives must learn how to implement obstetrical techniques within specific cultural environments.