International Journal of
Sociology and Anthropology

  • Abbreviation: Int. J. Sociol. Anthropol.
  • Language: English
  • ISSN: 2006-988X
  • DOI: 10.5897/IJSA
  • Start Year: 2009
  • Published Articles: 309

Full Length Research Paper

Postpartum consultation attendance at the maternity ward in Sokoura, Côte d’Ivoire

Adou Serge Judicaël Anoua
  • Adou Serge Judicaël Anoua
  • Department of Anthropology and Sociology, Research and Training Unit Communication, Milieu and Society, Alassane Ouattara University, Bouaké, Côte d’Ivoire.
  • Google Scholar
Akissi Bernadette Kouadio
  • Akissi Bernadette Kouadio
  • Abobo-East Health District, Ministry of Health and Public Hygiene, Abidjan, Côte d’Ivoire.
  • Google Scholar
Kouamé Frédéric Signo
  • Kouamé Frédéric Signo
  • Laboratory of Studies and Research in Reproductive Health Care Transition, Alassane Ouattara University, Bouaké, Côte d’Ivoire.
  • Google Scholar
Yao Vincent Dibi
  • Yao Vincent Dibi
  • Department of Anthropology and Sociology, Research and Training Unit Communication, Milieu and Society, Alassane Ouattara University, Bouaké, Côte d’Ivoire.
  • Google Scholar


  •  Received: 06 February 2021
  •  Accepted: 31 March 2021
  •  Published: 30 April 2021

 ABSTRACT

This study investigates why postpartum women cannot or will not receive postpartum consultations at the maternity ward in Sokoura, Côte d’Ivoire. It aims to present the sociocultural, economic, infrastructural and organisational factors limiting new mothers’ access to postpartum care and to suggest ways to encourage them to seek out such care. A qualitative approach was adopted and data was collected from individual interviews with new mothers and midwives. The results have elucidated the factors hindering postpartum consultations at the maternity ward in Sokoura and the broader sociological context in which they need to be assessed. The relevant factors are deficient knowledge about the post-partum period, new mothers’ professional obligations, their spouses’ limited financial means, the distance of the maternity ward, unfavourable transport conditions, tensions between new mothers and midwives, and inadequate organisation and management of the postpartum consultation services at the maternity ward. These obstacles to postpartum care can be broadly categorised as insufficient education, scarce social support and unfavourable environmental and medical conditions. To remedy these issues, it is necessary to foster community action targeting new mothers and their spouses, to develop midwives’ cross-cultural skills, notably their capacity for anthropological observation, and to involve public authorities in the changes.

 

Key words: Postpartum women, accessibility, postpartum consultations, obstacles, social change, maternal and neonatal health.


 INTRODUCTION

Postpartum consultations are an essential aspect of reproductive health. WHO estimates a yearly maternal mortality rate of 289,000 worldwide and a corresponding infant mortality rate of 2.9 million (WHO, 2014). Almost all maternal   deaths   (99%)   are   recorded   in  developing countries, mostly in Sub-Saharan Africa, with almost a third occurring in South Asia (Alkema et al., 2016). In response to this alarming situation, one global strategy aims to redress unequal access to reproductive, maternal and neonatal healthcare services, as well as the variable quality of such services (UN, 2015). Despite international efforts, limited access to postpartum consultations is still a major concern in Côte d’Ivoire. According to official data, out of the 64.1% of mothers who had had an assisted delivery in 2018, only 28% received postpartum consultations. In the same year, 753 maternal deaths were routinely recorded, which corresponds to a ratio of 114.2 maternal deaths per 100,000 live births. Furthermore, there were 23,519 stillbirths out of a total of 659,225 births, which is equivalent to 3.7 stillbirths per 100 births in healthcare facilities (MSHP, 2019). Strategies aimed at improving these figures need to ensure high-quality healthcare services at a national level, so that adequate and ultimately optimal care can be provided to parturients and new-borns. The fifth strategic component of the National Health Development Plan for 2016-2020, aimed at improving the health of mothers and children and reducing mortality by 50% by 2020 (MSHP, 2016) represents an official national goal of this kind.
 
For progress to be made in increasing postpartum consultation rates, several determinants of health, including poverty, geographical distance, lack of awareness, inadequate services, and cultural practices, must be taken into consideration (WHO, 2015). Factors such as these have received scientific attention in previous studies. The most notable ones which have been repeatedly identified by researchers include mothers’ age, number of prior births, socioeconomic status, level of education, living environment, beliefs about the post-partum period and postnatal care, and knowledge about maternal morbidity and mortality. For example, Somefun and Ibisomi (2016) argue that compared to primiparas, older women and multiparas are more likely to refrain from postpartum consultations in health centres, having enough experience with childbirth and consequently enough self-confidence to think them unnecessary. Similarly, the analysis carried out by Rwabufigiri et al. (2016) suggests that old age and poverty are significant obstacles to receiving postpartum consultations. Nkurunziza (2014), in turn, affirms that women with little to no education have not yet internalised the preventive rationale behind obstetric care and consequently believe that there is not much to be gained from postpartum consultations, especially in the apparent absence of health problems. Furthermore, Tarekegn et al. (2014) have concluded that women from rural zones, as well as less autonomous ones who are not in charge of their own finances, are particularly disinclined to have recourse to postpartum care. Finally, Zamawe et al. (2015) have established lack of knowledge about postpartum care, the long waiting periods before such care is provided, and the separation of maternal and neonatal care in clinics are among the main factors that deter postpartum women.
 
This brief overview of some of the literature suffices to reveal that the factors which negatively correlate with seeking postpartum care are manifold. Unfortunately, the analyses of the phenomenon published  in  the  cited studies cannot fully account for the low rates of postpartum consultation attendance or reliably predict any imminent negative consequences thereof. In the region of Gbêkê in Côte d’Ivoire too, a very small proportion of postpartum women is receiving postpartum consultations. Indeed, this region has recorded one of the lowest rates of postpartum consultation attendance in the country, 14.2% below the national target (27%) in 2018 (MSHP, 2019). These figures reflect the precarious and dysfunctional state of the postpartum consultation services at the Sokoura Maternity in particular. This healthcare facility recorded 797 live births between January and September 2020, according to the 2020 activity report of the Northeast Bouaké Health District. Although immediate postpartum care was received in all 797 cases (100%), there were only 200 early postpartum consultations (20%) and 61 late postpartum consultations (8%). It is thus apparent that new mothers are less inclined to seek postpartum consultations at the maternity ward as time goes by after their delivery.
 
In the study, the reasons for which postpartum women failed to attend postpartum consultations at the Sokoura Maternity in 2020 will be surveyed and possible explanations for their reticence with regard to this service will be considered. Potential strategies for improving this situation will likewise be proposed. The hypothesis that will be adopted here is that social resistance to postpartum consultations is determined by sociocultural, economic, infrastructural and organisational factors, which this study aims to explore in the context of the maternity ward at Sokoura. A socio-anthropological analysis of these obstacles is especially important given that their specificities vary between social groups and geographical areas. It will also be maintained that they require an intervention within a critical anthropological framework, serving to encourage new mothers to seek postpartum consultations, and that a dialectical approach would be especially pertinent.


 METHODOLOGY

Scope
 
The scope of the present study is the maternity ward of the urban health centre in Sokoura, Côte d’Ivoire, which is located in the north-central portion of the country, in a savannah zone. It was chosen for the epidemiological and ethical interest it offers. From an epidemiological point of view, morbidities such as umbilical infections, infantile colic and malaria in both new-borns and parturients were frequently recorded in this healthcare facility, and from an ethical point of view, the low rate of postpartum consultations was remarkable. Research was conducted over a period of two weeks, between the 28th of September and the 9th of October, 2020.
 
Participants and data collection
 
The present study is qualitative in character and adopts a descriptive and interpretative approach.
 
The study population consisted of postpartum women and midwives, selected through consecutive and convenience sampling based on preestablished criteria. In the case of postpartum women, the essential criteria were living within the limits of the healthcare network of Sokoura, which automatically excluded women who resided in other zones and did not necessarily frequent the Sokoura Maternity, and having given birth at most 42 days before participation in the study, to ensure that the information provided would be current. As for the midwives interviewed, they were professional practitioners of mainstream medicine with at least six months of work experience in the maternity ward. They were thus in a position to provide insight into how postpartum consultations are organised and how they proceed. In total, 25 postpartum women and 5 midwives were interviewed, which brings the study population to 30. This sample size was determined based on considerations of data saturation (Pires, 2007) and taking into account the overall rarity of postpartum women matching the selection criteria.
 
All of the participants were individually interviewed, so that analysable data could be collected (Bonnet, 2009), specifically data corresponding to this study’s objective of gaining a deeper understanding of the sociocultural, economic, infrastructural and organisational factors which limit new mothers’ access to postpartum care at the Sokoura Maternity. To this end, two interview guides were prepared in advance, one for postpartum women and another for midwives. The former centred on sociocultural, economic and healthcare factors such as primary healthcare needs, access to high-quality healthcare, healthcare costs, awareness of the warning signs of certain morbidities, and financial means, as well as additional factors such as geographical distance from the maternity ward, the time needed to reach it, and means of transport. The latter interview guide was in turn focused on infrastructural and organisational factors relating to the management of postpartum consultations and the services they consist of. Data was collected with verbal informed consent from all of the participants, recorded with a tape recorder and in the form of written notes, and anonymised. All participants were assigned numbers serving to identify them for the purposes of the ensuing analysis.
 
Data management and analysis
 
The collected data was manually processed. This involved a transcription of the audio recordings. A thematic content analysis was then performed (Paillé and Mucchielli, 2012), based upon the different sociocultural, economic, infrastructural and organisational elements that had come to light in the interviews, with the purpose of pinpointing the factors which limit postpartum women’s access to maternal and neonatal care. The fine-grained interpretation of the data from a dialectical perspective (N’da, 2015) enabled clearer identification of the obstacles that postpartum women face in this regard.


 RESULTS AND DISCUSSION

Factors affecting access to postpartum consultations in the Sokoura Maternity
 
This study revealed a multitude of factors which limit new mothers’ access to postpartum consultations in the Sokoura Maternity or deter them from such services. For the purposes of the analysis presented below, they have been roughly grouped into four general categories, namely sociocultural, economic, infrastructural, and organisational factors.
 
Sociocultural factors
 
The sociocultural factors which determine the extent to which new mothers can or will seek out postpartum consultations at the Sokoura Maternity mostly consist of beliefs, perceptions and social customs relating to postpartum care. For example, some of the postpartum women viewed postpartum consultations as an acute care service. They therefore refrained from visiting the maternity ward unless they or their new-borns were perceptibly ill, as the following testimony reveals: “I bring my baby to the maternity ward only when he’s sick and needs to be cared for. That aside, I haven’t had other appointments since I gave birth.” (mother no. 2). Other women associated postpartum care only with having their new-born’s navel tended to and having their perineal dressings cared for, in case they had undergone an episiotomy. One of the women reported: “They cut me up before I gave birth, so now I go to the maternity ward so they can clean my wound or clean my baby’s belly button” (mother no. 9).
 
In their study on postpartum consultations in the French department of Rhône, Agnès and Le Goaziou (2006) similarly found that new mothers sought postpartum care for medical problems, including emergencies. The intercurrent pathologies that most frequently motivated their decision to undergo a systematic postpartum check-up included fatigue, pain from their C-section scar and urinary incontinence. Another study by Landge et al. (2017), carried out in Mumbai, India, established that postpartum women refrained from postpartum care because they felt that they did not need it, because they did not have time, or because they were uninformed about postpartum care services. Furthermore, Akibu et al. (2018) state in their study on postpartum care in North Shoa, Ethiopia, that the main raison that women failed to attend their three recommended postpartum consultations was their belief that they were in good health. Workineh and Hailu (2014), in turn, report that in the Jabitena district of Ethiopia, mothers’ level of education and their ability to recognize at least one early indicator of a postpartum obstetrical pathology were significantly correlated to their inclination to seek postpartum care. Given this essential role of education in maternal health, Rodrigues et al. (2013), in their work on women’s social representation of pregnancy, the postpartum period and educational action in Brazil, proposed educational strategies aimed at deconstructing the traditional conception of reproduction and teaching scientific facts in lieu of traditional beliefs.
 
The present study also found that some women saw postpartum consultations as an occasion for midwives at the Sokoura Maternity to impose contraceptive methods on  them,  in  order  to prevent them from having another child. One of the women related: “The day when I gave birth, the midwife talked to me about an injection and a pill that women take so they won’t conceive again for some time. So if I go back there, she’s going to give me an injection so I won’t have another child.” (mother no. 14). This is another unfavourable association which predisposed postpartum women to refrain from seeking postpartum consultations at the Sokoura Maternity. On this subject, Robin et al. (2008) emphasised that it is essential for postpartum women to have access to postpartum contraception. They suggest that every postpartum woman, if she so wishes, should be prescribed effective contraceptives before being discharged from the maternity ward, within an appropriate time frame to prevent an unwanted, immediately succeeding pregnancy. However, postpartum contraception is not always a priority for healthcare staff, as Fatima et al. (2018) showed in the context of Bangladesh, where religious convictions deter women from using contraceptives following childbirth and where women and their family members are often insufficiently informed. Furthermore, Mon et al. (2018) pointed out that in Myanmar, misconceptions regarding postpartum and postnatal care services are a significant obstacle to using them optimally. The same conclusion has been reached by Dapaah and Nachinaab (2019), who revealed that sociocultural factors such as age, faith, traditional belief systems, level of education, and marital status affect women’s tendency to seek maternal health services in the postpartum period in the Talensi district of Ghana. Additionally, in their study carried out in Melbourne, Australia, McCallum et al. (2011) ascertained that use of postpartum care services was more frequent among mothers with mental health issues and those with unsettled infants that were prone to persistent crying, displayed a resistance to soothing and suffered from poor sleep.
 
In addition to the perceptions of postpartum care explained and illustrated above, certain social practices constitute an additional hindrance preventing new mothers from seeking postpartum consultations for themselves or their new-borns. Indeed, the community imposes many restrictions on new mothers and new-borns, which are intended to ensure their well-being. One such restriction is the postpartum confinement of new mothers and their new-borns to their home for several days, during which the mother enjoys full rest and receives highly important visits from guests bearing bountiful gifts, as one of the interviewed women explained: “When a woman gives birth, she must not go out because guests come with presents and the baby’s future depends on the aura of some of these people. If the baby is not there when they arrive, bad luck will follow him.” (mother no. 1). This domestic confinement also serves to shield the mother and her newborn from malevolent individuals who are perceived as a threat to their health or their lives. In this function, it is regarded as an indispensable preventive measure. It was brought up by some of the interviewed mothers, who explained that for the first seven days of its life, the newborn must not be seen by certain individuals. One mother clarified: “Before the baby is ready to go out, my husband and some other people cannot see him, otherwise his head will crack. This means that I can’t go to the hospital with him. For me too, this is a time when I’m not supposed to spend too much time outdoors” (mother no. 12).
 
Besides these perceived risks, a mother and her new-born’s emergence from domestic confinement must be preceded by appropriate rituals, as some of the interviewed women mentioned. Before these rituals have been completed, the mothers do not allow themselves to visit the maternity ward. In the words of one of the mothers: “Before my baby leaves the house for the first time, preparations need to be made. An animal is burned, the baby’s hair is combed, and he’s given a name. Without this, neither the baby nor the mother can leave their home, even if there’s an emergency.” (mother no. 6). Chasles (2009) discusses comparable practices in the context of rural India, where new mothers must submit to constraints such as isolation and dietary restrictions for their purification; only then can they can resume their day-to-day lives in the community without potentially contaminating it. Additionally, White et al. (2014) established that in Mali, seeking postpartum care services is conditioned by prior observance of traditional practices and the approval of postpartum women’s mothers-in-law. Lastly, Alemayeh et al. (2014) concluded from their research in Abiy Addi, Ethiopia, that educating mothers about the importance of postpartum care is crucial to increasing the use of postpartum care services, and Bayot (2019) states that greater awareness of the specificities of the postpartum period would enable women to be better cared for and supported.
 
The cited literature and extracts from the interviews presented so far clearly show that beliefs and social practices prevent or deter new mothers from seeking postnatal consultations, at the Sokoura Maternity and across the globe. Such sociocultural factors play a different role than the economic ones examined below.
 
Economic factors
 
The economic factors influencing new mothers’ ability or willingness to receive postpartum consultations were their household chores, their professional obligations and their spouses’ financial means. Regarding the former, many of the interviewed mothers lamented that in addition to caring for and breastfeeding their infant, they had to continue keeping up the household by performing chores and feeding, nursing, and educating other members of their families. With so many duties, they found it difficult to attend postpartum consultations. One mother reported:
 
“with all the work around the house, we do not have time to go to the maternity ward, or we are too tired to do so” (mother no. 16). In his doctoral dissertation on maternal healthcare in Mali, Cisse (2018) similarly finds that women’s freedom to seek maternal healthcare services is restricted by their families’ chronic poverty and their own limited autonomy. It is noteworthy that the interviewed mothers who worked as saleswomen were even less available for postpartum consultations. They had to resume their commercial activities as soon as possible in order to not default on their credits. One mother stated: “If my newborn is not sick, I do not go to the hospital. I go the marketplace to sell instead, so that I can pay off my credit.” (mother no. 19). Additionally, some of the mothers had to return to work in the early postpartum partum period before their merchandise spoiled, as the following testimony clarifies: “I go back to work soon after giving birth because if I’m all alone and I do not go to the marketplace to sell my merchandise, it’ll go bad.” (mother no. 25). This situation is reminiscent of the one observed by Tesfahun et al. (2004) in the Gondar Zuria district of Ethiopia, where the most commonly cited reasons for not using postpartum care services were a shortage of time, the geographical distance of healthcare providers, a lack of childminders, and a simple unavailability of such services.
 
The limited financial means of the mothers’ spouses also account for the low rates of postpartum consultation attendance at the Sokoura Maternity, since their spouses were the ones who generally motivated them to seek out postpartum consultations as long as they could afford it. One mother revealed: “My husband is the one who buys the medication that I take. If he doesn’t have enough money, I can’t have postpartum consultations.” (mother no. 23). Even for the mothers who enjoyed professional stability themselves, obtaining postpartum care and advice at the maternity ward could prove to be a financial burden, as well as an administrative one. As one mother put it: “It takes a lot of effort and courage to buy medication, get a check-up and ask for medical care in general after you’ve given birth. With my baby, I have to go through a procedure at the insurance company so that I can pay for our medical needs.” (mother no. 21). One can consequently surmise that there is a significant correlation between families’ monthly income and the use of postpartum care services (Wudineh et al., 2018). It should be evident by this point that economic factors too can prevent new mothers from seeking postpartum consultations, including at the Sokoura Maternity. Sharma et al. (2014) underscored that in order to encourage greater use of postpartum care services, improving mothers’ economic status, educating them, and increasing their autonomy so that they can make decisions independently are essential measures.
 
The relevance of infrastructural factors to postpartum consultation attendance at the Sokoura Maternity will subsequently be presented in the study.
 
Infrastructural factors
 
The infrastructural factors that the present study identified involve the physical distance of the Sokoura Maternity, the means of transport used by the mothers, and the physical condition of the roads. Specifically, some of the mothers resided far away from the maternity ward, the means of transport which they used were rarely available or even exposed them to the risk of road accidents, and the roads themselves were sometimes in a state of disrepair and difficult to traverse. One mother summarised this state of affairs as follows: “To get to the maternity ward after having a baby, you have to go on foot or take a motorcycle taxi with your baby, but the road is in poor condition. It’s extremely dangerous because people drive recklessly around here. That’s why mothers prefer to buy medicine from midwives from their neighbourhood when they need to protect themselves or their babies from illnesses. That’s why we’re not interested in hospital medication and care when we have a baby.” (mother no. 7). Similar data is reported by Hordofa et al. (2015) for Dembecha, North-western Ethiopia, where transport problems and the remoteness of healthcare facilities were likewise sufficiently grave impediments to prevent the use of postpartum care services. Along the same lines, Gebrehiwot et al. (2020) have determined that geographical distance is a significant factor hindering use of postpartum care services in Adigrat, northern Ethiopia.
 
Finally, there are organisational factors which influence postpartum women’s decision to seek postpartum consultations, which will be discussed next.
 
Organisational factors
 
The organisational factors are the inadequacies that can be noted at the level of the organisation and management of the postpartum consultations at the Sokoura Maternity, which are compounded by interpersonal issues between midwives and postpartum women. On the whole, midwives who provide postpartum care were not held in a particularly high regard. Some of the interviewed mothers expressed a preference for older midwives when seeking postpartum care. One mother justified her attitude as follows: “When the midwife is older, I’m happy to receive postpartum consultations from her. If you’re attended to by a younger midwife, it’s hard to trust her and place yourself in her hands.” (mother no. 15). Furthermore, the indelicate and unwelcoming demeanour which some of the midwives displayed when receiving or counselling new mothers made the latter averse to the postpartum services offered by the maternity ward. Some of the midwives’ improper remarks were perceived as outrightly contemptuous. In this regard, one of the mothers stated: “When you go to the maternity ward after having a baby, not all of the midwives are welcoming. Some treat us very poorly. They might not even say hello and they often show no consideration for us. One time I was next in line on the bench but the midwife skipped me to attend to the next woman. My postpartum consultation was automatically  cancelled.” (mother  no.  5).  Razurel  et al. (2010) noted that such issues are a source of disappointment for mothers in the early postpartum period, who expect emotional support and respect. The long delays before the provision of postpartum care or consultations at the Sokoura Maternity were also remarked upon by the interviewed mothers, for instance, in the following comment: “Some of the midwives dally before getting to work. Even when they’re serving you, they’re flippant and chat with their co-workers. This discourages us from coming for postpartum consultations. At home, everyone waits hand and foot on a new mother.” (mother no. 10). On this subject, Elkhoudri and Baali (2007) finds that in Morocco too, unmannerly treatment at the hands of healthcare staff is an important factor discouraging postpartum consultation attendance.
 
Besides these hostile relations with some of the midwives, certain mothers were deterred from postpartum consultations by organisational and infrastructural deficits within the Sokoura Maternity, such as the shortage of consultation rooms and beds for inpatients. In fact, the room used for postpartum consultations was also used for family planning, as one of the interviewed mothers reported: “Postpartum care and consultations take place in the same room as family planning sessions. If there is need for hospitalisation, postpartum mothers share the rooms and beds.” (midwife no. 3). Not only was there no separate consultation room, the room where ultrasound scans are performed was overly crowded. One of the midwives revealed that: “mothers sometimes come with their babies because of an issue which requires an ultrasound scan, but when the scan is offered to them, they do not come back because there are too many people in the room.” (midwife no. 5). Assarag et al. (2014) have described a similar situation in Skhirat-Témara, Morocco, where in addition to long waiting hours, healthcare staff’s comportment, and the way postpartum consultations were conducted, the absence of continuous training and supervision for healthcare staff as well as excessive workloads contributed to the poor quality of the postpartum consultations and thus discouraged postpartum women from attending. It should also be noted that the lack of space at the Sokoura Maternity was compounded by the deficient or altogether lacking medical equipment and supplies. One of the midwives reported: “We are a peripheral facility and we are unable to perform some emergency care procedures. Equipment and supplies such as oxygen and electric aspirators are not within our reach, and the blood pressure monitor and scales are in poor condition.” (midwife no. 1). These deficiencies can be likened to those identified by Singh et al. (2014) in India, where the availability of proper healthcare infrastructure negatively influenced the rate of use of postpartum care services.
 
Now that the various sociocultural, economic, infrastructural and organisational factors which consistently prevent or deter new mothers from seeking postpartum consultations at the Sokoura Maternity have been examined, a discussion of the underlying sociological context of the observed state of affairs is in order.
 
Sociological context of the factors affecting postpartum consultation attendance at the Sokoura Maternity
 
Analysis of the empirical data collected in this study reveals that lack of education constitutes a major cultural obstacle to receiving postpartum consultations at the Sokoura Maternity. Local women’s understanding of the postpartum period and the norms and practices attached to it are contrary to the facts of reproductive health and official policies regarding it. Thus, the interviewed mothers failed to appreciate that postpartum consultations serve to prevent maternal and neonatal morbidities and complications or detect them early on so that timely treatment can be started, in addition to being an opportunity to offer mothers advice regarding family planning, vaccinations, breastfeeding, and weighing their new-born. Instead, their behaviour in the postpartum period was guided by religious or mystical beliefs, as well as principles from traditional African medicine, and they were afraid of deviating from the long-rooted cultural norms of their community. This phenomenon has been noted by Kouanda et al. (2007), who highlighted the importance of persistent cultural practices related to childbirth as factors which deter mothers from seeking out postpartum consultations. The cited authors report that postpartum women provide reasons for refraining from the latter which range from lack of information to forgetfulness or lack of interest, since they already enjoy traditional care at home once they are discharged from the maternity ward. Similarly, Zaouaq (2017) pointed out that low levels of education among women, their lack of awareness regarding the postpartum period, and the burden of the patriarchal culture and social structure have fundamental implications for the extent to which they seek out reproductive health services. Sebbani et al. (2016), in turn, highlight ignorance of possible complications as a key factor in mothers’ avoidance of postpartum consultations. The precarious social and community support offered to postpartum women in Sokoura is an additional obstacle preventing them from receiving postpartum consultations. As explained above, new mothers’ professional and domestic workload is not lightened after childbirth. Consequently, the interviewed mothers were hardly in a position to seek out postpartum consultations. They were further hindered by their spouses’ meagre income, considering that postpartum care is quite expensive. All of these factors dictate individual women’s behaviour during the postpartum period and impact postpartum consultation attendance rates. On this subject, Rinfret (2007) underscores that mothers from traditional communities need continuous family care during the postpartum period, more than their spouses can provide on their own. She argues that reinforcing community support is therefore essential.
 
Along the same lines, Bayot (2018) points out that a postpartum woman is always surrounded by friends and family, who are there for her for better or for worse.
 
The present study has also brought to light infrastructural and organisational obstacles which prevent postpartum women from seeking postpartum consultations at the Sokoura Maternity. Above all, their physical access to the maternity ward is limited by the poor maintenance of much of the road network. The primary means of transport at their disposition is the motorcycle, but many of the mothers do not see it in a good light. This decreases the likelihood of their seeking postpartum consultations for themselves or their new-borns if they live in more remote parts of Sokoura. These findings concur with those of Messi and Yaye (2017), who indicate that difficulties related to transport and the geographical distance between patients’ place of residence and the nearest healthcare facility significantly impede access to the latter. In the context of the present study, they hinder the treatment of postpartum women and the satisfaction of their healthcare needs.
 
Finally, the relationship between postpartum women and medical staff and the limited facilities of the maternity ward compromise postpartum and postnatal care. The conditions at the maternity ward are on the whole highly unfavourable, as evidenced by the lack of a designated postpartum consultation room and medical supplies. These deficiencies inevitably contribute to the tension between mothers and midwives, causing the former to avoid postpartum consultations and leading to discontent on both sides. In their study on postpartum consultation in northern Benin, Ogoudjobi et al. (2016) have similarly noted that the poor organisation of the service, the shortage of rooms and the unavailability of other medical services such as vaccination negatively impact attendance rates. Additionally, Hatem et al. (2018) have shown that in Guinea-Conakry and Togo, healthcare providers’ skills and the duration and continuity of the postpartum services they provide are unsatisfactory. They therefore advocate further training for healthcare providers and the adoption of norms regarding their professional duties and their work conditions which would improve the quality of the care provided to postpartum women and new-borns in maternity wards in the two aforementioned countries.
 
The underlying educational, social, and infrastructural issues discussed above are all responsible to varying degrees for the low rates of postpartum consultation attendance in Sokoura. It is necessary to implement measures that would address these factors, encourage new mothers to seek out postpartum consultations more often, and thus improve the current state of affairs.
 
Further sociological perspectives and potential avenues for improvement
 
The discussion so far has highlighted   three  general categories of underlying sociological issues relevant to postpartum consultations, namely educational, social and infrastructural ones. The educational issues boil down to ethnological and medical ignorance. In particular, there is a significant rift between the way postpartum women on the one hand and biomedical sciences on the other conceive the postpartum period. Yet in the current state of affairs, postpartum consultations, as well as family planning sessions, fail to take into account postpartum women’s misconceptions about the postpartum period and the potentially dangerous cultural practices they observe. To remedy this situation, it is necessary to educate both postpartum women and midwives. As regards the former, they need to learn about preventive measures relevant to the postpartum period and make efforts to understand the basic biomedical reasoning behind them. In this way, they could come to appreciate the role of postpartum consultations and to view them as a source of further information and training. They would then be more inclined to seek out postpartum consultations as well as postpartum and postnatal care in general. This applies to the Sokoura Maternity and elsewhere too. As for midwives, they need to learn to understand postpartum women better and take into account the diversity of their cultural perceptions of pregnancy, childbirth and the postpartum period, as well as the attitudes and behaviours that stem from such perceptions. This awareness would enable them to counsel postpartum women in a less prejudiced manner and adapt to their needs and expectations. As a result, postpartum women would be less likely to avoid postpartum consultations at the Sokoura Maternity.
 
The underlying social issue, in turn, is the lack of social support offered to postpartum women. Specifically, postpartum women and their spouses do not receive enough attention and assistance from their community in Sokoura, which makes it difficult for postpartum women to attend postpartum consultations. Further social integration of postpartum women and their spouses is therefore imperative. Without social cohesion between peers, there can be no social interactions which could enable or encourage new mothers to seek out postpartum consultations. Postpartum women and their spouses themselves must facilitate their social integration by observing the social dynamics within their community more closely, both between peers and more generally, and by reacting to it accordingly. The relationships which they could forge or consolidate in this way could ultimately help postpartum women to attend postpartum consultations and their spouses to deal with their increased expenses following the birth of their child.
 
Finally, there are underlying problems at the level of transport to the maternity ward and the facilities available at the latter, which require institutional intervention. As explained above, the means of transport which could take postpartum women and their new-borns to the maternity ward are unsafe, and the lack of equipment and supplies at  the  maternity  ward  render quality postpartum care impossible. The conditions are unfavourable from the point of view of both postpartum women and the midwives working at the maternity ward, and they have a negative impact on postpartum consultation attendance rates. It is essential for public authorities to set aside adequate resources for repairing the roads and equipping and supplying the Sokoura Maternity, with the purpose of improving its accessibility and the quality of the postpartum consultations. Finally, it should be emphasised that midwives must desist from value judgments regardless of postpartum women’s level of education, physical appearance and ways of expressing their emotions, including their possible anguish. They must remain composed, heedful and objective at all times in order to gain postpartum women’s trust. This would lead to increased satisfaction on both sides during postpartum consultations and care in general at the Sokoura Maternity.


 CONCLUSION

This study has shown that postpartum women’s ability or willingness to receive postpartum consultations at the Sokoura Maternity is negatively affected by multiple sociocultural, economic, infrastructural and organisational factors. In particular, postpartum women have divergent and uninformed perceptions of the postpartum period, they are overwhelmed by domestic and professional obligations, their spouses sometimes lack the financial means to cover the costs of postpartum consultations, the maternity ward is too far away from some mothers’ place of residence, the availability of means of transport is limited, the quality of much of the road network is unsatisfactory, the interpersonal relations between midwives and postpartum women are sometimes tense, and the postpartum consultations themselves are poorly managed and executed. A sociological analysis has highlighted three main categories of underlying issues: educational, social, and infrastructural ones. They cannot be apprehended fully without regard for the sociocultural and socioeconomic reality in which they exist. Human behaviour is also an essential factor which must be taken into account.
 
For appropriate and effective long-term solutions which would increase the postpartum consultation attendance rate at the Sokoura Maternity, social and institutional action is needed. First of all, it is necessary to raise awareness within the community and change the way postpartum women and their spouses are treated. Communication with them must have realistic goals and be adapted to their sociocultural reality. The involvement of the whole community is necessary to ensure that the social change in progress does not come to a standstill and to combat individual resistance to change. Secondly, midwives’ cross-cultural knowledge and skills must be reinforced so that they can treat postpartum women more appropriately and satisfy their expectations. Increasing their capacity for anthropological observation would be especially effective in the present context. Lastly, petitions and efficient community action could urge public authorities to get involved and improve the road network, the means of transport and the maternity ward itself. All of the solutions proposed here have the common fundamental goal of protecting the health of mothers and their children.


 CONFLICT OF INTERESTS

The authors have not declared any conflict of interests.


 ACKNOWLEDGEMENTS

The authors are grateful to the mothers and midwives for the many hours that they devoted to this study, and to the Head of the Sokoura Maternity for his availability and collaboration during the data collection period.



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