In Mali, a poor sub-Saharan country, maternity referral systems were implemented to combat the still-high rates of maternal mortality. This qualitative study was aimed at understanding the relationships between the qualification of staff in community health centres, the organization of services, and the management of pregnant women in the maternity referral system in Kayes, a rural region of Mali. Physicians who managed CHCs actively or passively modified work organization, the level of technology, their obstetric skills, and staffing. They also created a competitive environment and developed relationships of trust with patients and with the district health centre. These findings are helpful in orienting decision-making for better personnel management.
The human resources crisis created by personnel shortages is currently the greatest impediment to generalizing proven strategies for improving maternal and perinatal mortality [
Mali, a low-income West African country, has eight administrative regions. RESs have been implemented in all of them, with considerable variation in the levels of inter- and intraregional functionality. In Kayes region, where this study was conducted, the seven districts’ RESs were set up between 2002 and 2005. They are supposed to facilitate normal deliveries in the CHCs and the referral of complicated cases to the DHCs. For early screening and referral of obstetric complications, whose occurrence is most often unpredictable, all deliveries should be carefully monitored by staff qualified for deliveries—essentially either midwives or other comparably skilled professionals [
In addition to the shortages of midwives, the numbers and qualifications of staff in the CHCs’ healthcare teams vary considerably. In Kayes region, as everywhere in Mali, CHC management falls under the responsibility of local communities and is conducted through community health associations (ASACO) that can take the initiative in staff recruitment and remuneration [
A quantitative evaluative study looked at the relationships between professional teams and care outcomes. It showed that the joint mother-newborn survival is significantly influenced in the Kayes maternal referral system by combined effects of the skill configuration of CHC personnel and distance traveled. Thus, women referred from a CHC where there was a physician were six times more likely to survive from an obstetric complication than were those transferred from a CHC without a physician, based on comparable morbidity and controlling for distance travelled and other cofactors [
We conducted a multiple-case study in the districts of Kayes and Diema. Using purposive and stratified sampling, we selected, in two stages, 25 CHCs from the districts’ total of 67 CHCs as units of analysis. First, we selected 13 CHCs headed by physicians (MCPs), taking into account the number of healthcare personnel and the distance between each CHC and the DHC, to maximize variability in the care environment. Then, we selected 12 other CHCs headed by nurses (ICPs); these were comparable to the MCP-managed CHCs in every respect except for the qualification of the manager in charge.
We carried out semistructured interviews with the personnel involved in maternal care: matrons, nurses, obstetric nurses, midwives, and physicians. In each CHC we visited, participants were invited to freely elaborate about the organization of maternal services in their centre and about what they did to improve the outcome of care for the women. This enabled us to develop a picture of the centre’s functioning and to validate it with the staff. Through nonparticipant observations, we were able to observe professional interactions in the teams and to verify whether the organizational modalities corresponded to what was stated in the interviews. The interviews were carried out by the first author and a sociologist from the region. On average, the interviews lasted 60 minutes (between 45 and 90 minutes). We interviewed ICPs (
Characteristics of the CHCs and the respondents.
Kayes district | Diema district | Total | Grand total | |
---|---|---|---|---|
Distribution of CHCs by manager | ||||
CHC with MCP | 11 | 2 | 13 | 25 CHCs |
CHC with ICP | 8 | 4 | 12 | |
Distribution of CHCs by distance between CHC and DHC | ||||
50 km or less | 7 | 5 | 12 | |
More than 50 km | 11 | 2 | 13 | |
Distribution of CHCs by staff levels | ||||
3 staff or less | 8 | 4 | 12 | 25 CHCs |
More than 3 staff | 11 | 2 | 13 | |
Distribution of respondents by staff category | ||||
Physicians | 9 | 2 | 11 | 56 |
Midwives | 5 | 0 | 5 | respondents |
Nurse managers | 7 | 3 | 10 | |
Other nurses | 3 | 0 | 2 | |
Matrons | 19 | 4 | 23 | |
Obstetric nurses | 4 | 0 | 4 |
The interviews were recorded with the respondents’ consent and then transcribed. The coding and analysis of the transcribed material were done using QSR International’s NVivo 8 software. We developed the coding plan from a list of codes inspired by the literature on human resources in healthcare services and on quality of services [
This project received ethical approval from the Research Centre of the University of Montreal Hospital Centre, from Mali’s National Department of Health, and from the Kayes Regional Department of Health. In accordance with local practices, verbal informed consent was obtained from the ASACO managers and health personnel for the interviews as well as for their recording. To maintain respondents’ anonymity, extracts from the interviews are reported using identification numbers.
In the 13 CHCs with ICPs, the distribution of tasks for the clinical management of pregnant women followed a homogeneous model, while those with MCPs showed a variety of profiles.
The ICPs looked after general consultations, oversaw the proper functioning of the CHC, and delegated responsibility for maternity activities to the matrons. The matrons organized prenatal consultations and did the deliveries; they sought technical advice from the ICPs for complicated cases. The ICPs also coordinated patient transfers to DHCs. In these CHCs, the ICP rarely took the initiative to monitor simple deliveries. The following excerpt illustrates this work organization, which was nearly uniform in all CHCs headed by nurses:
“When there is no complication, the matron is in charge, but under my supervision.” (ICP_10).
In some CHCs managed by ICPs, this division of tasks, which was sometimes associated with a physical separation between the maternity unit and other buildings, led to the perception that the CHC was made up of two distinct entities:
“the first matron is our boss… and the ICP is the boss of everyone… She (the matron) is the person that the women listen to and are influenced by the most.” (Matron_44).
Analysis of the organization of work in CHCs with MCPs shows three models of service organization.
The first model is comparable to CHCs managed by ICPs and was found in five CHCs with MCPs. Matrons managed deliveries and only called on the MCP in serious cases. Despite only being directly involved in a selective and limited way with the serious cases, the MCPs did systematic telephone followup of patients with the matrons.
In the second model, seen in three CHCs, the MCP’s involvement with pregnant women was more frequent and involved both simple and complicated cases. This model was characterized by two complementary measures: the systematic examination of women by at least two members of the personnel, and the organization of weekly staff meetings and presentations where the week’s difficult cases were discussed. Two of these MCPs said they implemented these measures to improve the knowledge of their team members and to provide patients with appropriate management of complicated cases.
“…we divide the work; the nurse looks after the prenatal consultation, and in real time, if a woman arrives, the matron can look after her. (Even) if she is very busy, the nurse sees the woman,
The third model of work distribution seen in three MCPs was characterized by their very strong involvement in the management of pregnant women. They conducted the first examinations of many women and sometimes did deliveries, even for simple cases.
“Yes, I’m there for all the deliveries. Often at night I do not wake the matron, I do the deliveries myself. I am the “gynecologist.” (MCP_48).
In a context in which CHCs are managed autonomously by the ASACOs, the possibility of having MCPs with obstetric skills was accompanied by the purchase of ultrasound equipment in three of the CHCs that had physicians. In addition, with the support of some Kayes emigrants, two CHCs were fitted with operating suites and were in negotiations with the Regional Department of Health to obtain authorization for interventions. Expertise in the use of ultrasound was one of the recruitment criteria for staff in these facilities and was helpful for the early diagnosis of certain pathologies, as this physician explained.
“When a patient arrives who has had no prenatal visits, I quickly do an ultrasound, and this lets me know if it is a case of twins, or of placenta praevia, and we can make decisions quickly.” (MCP_18).
While no ICPs envisioned raising the level of technology in their centres—since according to them, the complicated cases should be referred to the DHCs—the MCPs were preparing development plans for their CHCs. In these development plans, the MCPs envisioned raising the levels of emergency obstetric care (EmOC) competency in their teams, setting up a functional laboratory in addition to ultrasound, installing internet connections, promoting the use of solar energy, and, in the longer term, creating functional operating suites.
“I would like to see it transformed into a referral health centre (DHC) someday, since, as you can see for yourself, it’s far to refer a patient; God knows what could happen. This is why I am doubling my efforts to evacuate less. We already have ultrasound; I’m looking into how we can also set up a lab so I can do the initial analyses here.” (MCP_48).
Six MCPs had a particular interest in obstetrics which led them to acquire skills in emergency obstetric and neonatal care (EmONC). Three of them had done a thesis in a gynaecology-obstetric service, and the other three had undergone supplementary training in EmONC or in obstetric ultrasound, most often at their own expense. All of them were more deeply involved (model 2 or 3) in the management of pregnant women.
“I got my training over the Internet. When I go to France, I use my vacations to do applied training sessions with my colleagues, but it’s really a personal choice.” (MCP_23).
Aside from training offered by the Regional Department of Health to upgrade their EmOC skills, the ICPs were unable to obtain any other supplementary training in obstetrics. Either they did not satisfy the conditions required for acceptance into these training programs, or they were unwilling to pay for the training themselves. None of the ICPs we interviewed had recently been able to update their EmOC skills. These training sessions competed with several others; also, they were held in the regional capital, such that the ICPs would have to travel. Staff who went for training were expected to brief the rest of the personnel. So the ICPs, knowing that the matrons would brief them and the other staff on the maternal care training they received, and wishing to limit their own absences from their posts, preferred instead to attend training sessions on HIV-AIDS and on policies, standards, and procedures.
In addition to the acquisition of additional skills, the presence of MCPs in CHCs was associated with staff recruitment. Nursing students preferred doing training internships in CHCs where there was an MCP in order to learn more. In addition, with the support of the MCP, these trainees were able to negotiate a contract as volunteers at the end of their studies. This ability to attract personnel changed the staffing levels in the CHCs, the workloads, and the combination of skills available for maternal services.
We encountered only one midwife in an ICP-managed CHC. All the other midwives and obstetric nurses were in CHCs managed by MCPs. However, they asserted that they preferred these centres, not because of the presence of a physician, but because they were high-volume centres, so they would not risk losing their skills. Some midwives regretted never having had the opportunity in the CHCs to practise even the simplest emergency procedures. The presence of midwives and obstetric nurses in the team improved the combination of skills available for maternal care; however, having female staff whose families did not live in the CHC’s village complicated human resources management because of absences due to family reasons, as illustrated by the following excerpt.
“But the only problem is the instability of the ON (obstetric nurse), who spends one week here and three weeks in Bamako” (Nurse_36 in an MCP-managed CHC).
The presence of physicians in the CHCs of Kayes Region created a competitive services environment that could, directly or indirectly, provide incentives for professionals’ performance.
“…since, as you know, in this district there are a lot of physicians, there’s competition; if you’re not competent, the villagers will go elsewhere for their care.” (MCP_18).
The MCPs reported benchmarking practices. To improve their performance, they compared themselves against best practices in healthcare in the region. On their own initiative, some arranged informally to take introductory courses on ultrasound from other colleagues in the region. Some collective initiatives were also mentioned.
“We even went to K… with the members of the ASACO, to exchange ideas and experiences in the context of advancing the CHC. Because K… is a CHC that does a lot. So, within the framework of exchanging ideas, we went there.” (MCP_57).
The ICPs see interactions between the CHCs and the DHCs as administrative relations that should be maintained but should not influence the management of referred patients. In fact, the DHC was “the trustee organization” (ICP_1) and “the decider” (ICP_24); “it ensures the proper functioning of the CHCs through the supply of vaccines and other materials and it receives quarterly reports from the health information system.” (ICP_1)
Only one MCP stated that relations between the two levels of care had no influence at all on the management of pregnant women. All the other MCPs considered it crucial to maintain good relations with the DHC to ensure better management of referred patients. Some MCPs nurtured relationships with the higher level of care that were sometimes already preferential.
“… our connections with the referral centre (DHC) are excellent because, as I said, these are colleagues, friends; they’re civil servants like me, and we
“…when I evacuate someone to …, where I have good connections, and I’m in contact with everyone, so then I just make a phone call to get whoever is on call to refer my patient, who is quickly taken on. I refer my people and they take care of them. I think it’s very important to be on good terms with them.” (MCP_18).
The advantages to patients of privileged relations with the higher level of care were confirmed by a midwife who had previously worked in a DHC.
“…it will be better if women go first to the CHC. When you arrive with a referral letter, they take care of you faster, they do not just leave you hanging.” (Midwife_32).
According to the MCPs, establishing a relationship of trust with the population made it possible to mobilize all the resources of the village and facilitated women’s acceptance of medical recommendations, such as transfers to DHCs. Unlike the ICPs, who did not mention the importance of this relational aspect, the MCPs reported that they made an effort to gain people’s confidence.
“If the population is not informed and aware, we won’t have good results…I’ve gained people’s confidence, we understand each other, and when I say something, they do it…” (MCP_35).
In summary, the variations identified in the MCPs’ care environment were sometimes deliberate and actively induced—changes in the way work was organized, the level of technology, and the qualifications of the personnel—and sometimes they arose passively and unintentionally. The results of this analysis are summarized in Table
Summary of variations in the environment and in work organization under MCPs.
Technical and organization aspects | Relational and interpersonal aspects | ||||||
---|---|---|---|---|---|---|---|
Work organization | Level of technology | Staff skills | Staffing levels | Competitive environment | Relations with the DHC | Relations with patients | |
Intentional variations | Closer involvement in patient management | Plans to raise the level of technology | Supplementary training in obstetrics | Support for trainees | Individual or collective benchmarking | Maintained | Acquisition of their population’s confidence |
Unintentional variations | Equipment (operating suites, ultrasound) provided by the ASACOs with expatriate support | Attractive to trainees Midwives and obstetric nurses in centres with MCPs | Competition that stimulates performance | Patients’ preference for more qualified staff |
Analysis of the functioning of CHCs shows that MCPs, depending on their interests in obstetrics, had varying levels of involvement in the management of deliveries. On the other hand, in CHCs with ICPs, the organization of work was uniform and conformed to the official model provided in the RES. More frequent, direct involvement of a physician in the management of pregnant women improved the combination of skills applied in maternal services. It is true that people perform better in contexts that correspond to their personal preferences [
Also, in the present study, the ICPs spoke only about the administrative aspects of their relations with the DHC, while MCPs nurtured their relations with those working at the higher levels with whom they established personal contacts to accelerate the handover of their patients. A quick management of obstetric complications is a factor in improving the quality of obstetric care [
In addition to going beyond the traditional model of care and developing the relational and interpersonal aspects of care, the presence of MCPs can raise the level of technology in CHCs and create a competitive environment that helps to improve performance. In a context of staff shortages where the general trend is to use less-qualified staff, the tasks, roles and responsibilities of qualified staff that are usually delegated are technical ones, such as anesthesia [
The presence of MCPs with an interest in obstetrics may improve the quality of care, but it does not resolve the problem of shortages of staff qualified to assist during women’s deliveries. In fact, as this study shows, the difficulties of retaining midwives and obstetric nurses in rural areas continue, while filling these positions would have a long-term positive impact on maternal care [
Through the study, we were able to explore relations between the qualifications of the staff heading up the CHCs, the organization of care, and the management of pregnant and child birthing women’s care in rural settings. While its generalizability to other contexts is limited, this study provides some understanding, in the specific context of Kayes region, of the complexity and diversity of care organization in CHCs.
Kayes region (districts of Kayes and Diema) is a specific context in which innovations in service provision can be studied. Significant levels of emigration and the flow of resources back to the emigrants’ communities of origin have allowed these communities to acquire a service offer that exceeds national standards [
The authors declare that they have no conflict of interests.
This research is funded by the Bill and Melinda Gates Foundation, the Global Health Research Initiative of the International Development Research Centre in Ottawa, Ontario, Canada, and the Canadian Coalition for Global Health Research.