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Towards an anthropology of public health priorities: maternal mortality in four obstetric emergency services in West Africa

If epidemiological studies can define priorities for action, anthropological analyses are needed to clarify the conditions for the possibility of health problems. This article illustrates some of the ways in which public health and anthropological research may complement one another. Every year, 250,000 of the worlds 200 million pregnant women die in Sub-Saharan Africa. The medical causes of death are known and what should be done to avoid these unnecessary deaths is also known: quality caesareans, use of magnesium sulphate, hygiene during childbirth, tests and transfusion. So, concretely, the question is why sundry reforms fail or struggle for effective application. Drawing from a complex system of observation set up in four different services for 4-month periods, this article aims to specify the qualitative variables that are behind the deaths of parturients.

Key words public health, mortality, West Africa, emergency services

Introduction
Every year, 500,000 of the worlds 200 million pregnant women will die: 47.2% of these deaths occur in Sub-Saharan Africa, which means that globally although significant variations can be found depending on the countries, the urban or rural environments and the families socio-cultural status the risk of a woman dying of causes linked to pregnancy is around 1,000 per 100,000 live births (OMS 2004). In countries like Mali or Niger more than 3,000 maternal mortalities are expected per year (Ou draogo and e Bouvier-Colle 2002; Des Forts 1996). In response to this situation, prior preventive actions like family planning programmes attempt to erode the terrible rule of too many too many children, too early, too late and too close where mortality largely finds its origins. This work is undoubtedly vital. However, it is always difficult to intervene in social behaviours like fertility, nuptiality or abortion practices: sexuality always relates to complex adjustments and multiple variables of juridical, social, religious and emotional dimensions. As the European experience shows, it is often necessary to transform the larger economic, political and cultural dimensions in order to modify gender relations and promote fertility decrease (Perrot 1998; Cole and Thomas 2009).
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Other approaches, complementary to the preceding ones, have preferred to focus on access to health services and the quality of care dispensed. These works can at least appear simpler a priori. In fact, the medical causes of death are known haemorrhages 27%, infections 14%, gestational hypertension (HTA) 13%, dystocia 9%, and abortion 16%. And what should be done to avoid them is also known: quality caesareans, use of magnesium sulphate, hygiene during childbirth, tests and transfusion. Concretely, all these actions fit into specific cultural and socio-technical contexts that must be analysed if one wishes to understand how they are appropriated by local actors and why sundry reforms even when they are right on paper fail or struggle for effective application (Prual 2004, 2008; Witter et al. 2009). Globally, the question is simple. It involves explaining the gap between what should be done and what, most often, the personnel know should be done and what, unfortunately, is actually done. 1 Some studies place great emphasis on corruption practices linked to the health service teams social constraints or the importance of heavy determinants such as lack of finances and the absence of coherent local health policies (Jaffr and Prual 1994; Jewques et al. e 1998; Jaffr and Olivier de Sardan 2003) and have made an inventory of the questions. e But these studies are still too general for one who wishes to analyse the reasons behind implementing or not implementing certain medical gestures and the manifold ways in which these decisions blend with medical and social decisions. Certainly, since our investigations, various economic actions, such as the obstetric package (Renaudin et al. 2008), free caesareans (Dumont et al. 2001) or the mutualisation of risks (Ndiaye et al. 2008) have been implemented to render care economically accessible to a large number. However, even here, as Okonofua underlines, efforts aimed at increasing access should be complemented with improved quality of care, without which very little results can be achieved (2008: 12). Quality care and maternal mortality must be documented from below in order to understand them. Consequently, this involves moving from the why, (which) seems to call for a correct answer that suffers no weakness or logical incoherence ( . . . ) to the how, which invites people to include what they consider important for the story in their answer, whether I had thought of it myself or not (Becker 2002: 106). This study takes a rigorous qualitative scientific approach to examine how a set of socio-technical practices, a certain organisation of work and a specific manner of being in the social world construct maternal mortality from day to day in some model obstetric health services. 2

Material and method

A complex system of observation set up in four different services for 4 months allowed us to continuously and simultaneously follow the behaviour of the set of actors enacting the drama: the parturient, the accompanying family, the set of concerned
1 Thus an old study in a hospital environment underscores the fact that 85% of deaths would be avoidable at Donkas CHU (Keita et al. 1989: 84955). Similarly, the notion of avoidable maternal mortality permits (precisely) an accurate quantification of the gap between the possible and the realised (de Brouwere and Van Lerberghe 1998). These inquiries were conducted in 2006 in the framework of AQUASOU, a programme of the French Ministry of Foreign Affairs coordinated by Dr Alain Prual. I wish to thank him and Dr Luc de Bernis for their comments on a previous version of this text.
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health personnel and eventually the other apparently more peripheral actors such as administrative staff, sellers of pharmaceutical products or taxi drivers. 3 In practical terms, I remained permanently in the labour and delivery rooms. I could thus follow, register and sometimes chronometer medical behaviour unfolding there. At the same time, other investigators remained at the door so as to respect parturient modesty but also to observe their arrival in the service and the interactions occurring between those accompanying them and the carers. The task of questioning womens families and their near ones on their perception of care or their difficulties during this situation fell to this external team. Every evening, during a debriefing session, these various drama acts could be linked and built into a set of enacted case studies. Finally, we attended department meetings and taped them, which permitted us to observe how these human and medical events were scientifically commented. This allowed us to study how our observations were translated into medical language, what care workers considered as significant but also what these actors hid from their superiors and colleagues. In other words, what rules and finalities did this particular narrative of a medical case history obey? This qualitative approach corresponds to several theoretical models linking the sociological reasoning to its context (Passeron 2006). Suffice it to quote thick description that aims to describe and analyse linkages of actions and the significations their authors attribute to them (Geertz 1998) or micro-history committed to the identification of invisible structures according to which actors experiences are articulated (G. Levi 1989). Specifically, this stance of observing interactions in situ, between the parturient, their families and health personnel, allowed us to accede to the ordinary course of things (Farge 1994), to that which occurs precisely when nothing extraordinary seems to be happening from the point of view of care workers: life is unfolding in its routine and its regimes of low intensity (Veyne 1996, Passeron 1996). From an ethical point of view, we intervened in all these fields on the demand of department heads, with the explicit aim of helping practitioners to improve their practices. The reasons and modalities of the inquiry were presented to the entire department team before we intervened. The inquirys results were presented to care workers during restitution sessions that aimed to find solutions for the dysfunctions observed. All the words pronounced during childbirth deliveries, technical meetings or interviews with sundry actors were taped, translated and written in extenso.

The social and organisational dimensions of maternal mor tality

Certainly, one cannot easily grasp the legato of ordinary behaviour beneath the staccato imposed by concepts and discontinuous times of observation. Moreover, nothing is simple or linear and the sequences linking behaviours and determinations are always open and complex. However, a qualitative study of these medical services helps describe daily practical norms (Olivier de Sardan 1995) that characterise interactions between health professionals and parturients. Moreover, this anthropological approach
3 This article respects the rule no name, no blame for obvious ethical reasons. Hence, Western African countries, services and hospitals where we worked are not cited. But we have worked at their request and thank them for their hospitality.
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does not stop at this description. It also reveals how much these approaches to treatments are determined by the combination of heterogeneous variables social, technical and organisational composed of speeches, objects and architectural adjustments, etc. These qualitative variables, fitting as they do within specific contexts, can match up in various ways. But, in our study, three types of challenges emerged. These included (1) a form of articulation between social and technical dimensions, (2) effects of precariousness on health care and (3) a certain way of organising health units: the mechanism of maternal death within Obstetrical Intensive Care Units in West Africa. This is what we need to describe precisely.

Par turients health care: between social and medical norms

For treatment in a precarious world where expert systems offering an equal space to all (Giddens 1994) do not exist, one has to succeed in acquiring a certain existence by oneself. Clearly, going unperceived represents a major risk. Hence, in health services, patients use sundry means of showing they exist. The use of money and some form of corruption is often indispensable to win favours from some of the staff. But globally, entry into services is made through acquaintances. One uses family or friends networks and thus the medical organisation is permanently duplicated by an interconnected system, 4 where for example one who has an eye complaint could approach a cousin who is an orthopaedist who would hand him over to one of his friends who is an ophthalmologist. 5 Chronic pathologies or continuous care gives patients and care workers time to weave links and happily moderate this function. But it cannot be the same for childbirth. In this situation, urgency and pain prevent any negotiation with the staff. Henceforth, depending on whether the parturient will be recommended or anonymous, the differences in treatment will be important and sometimes crucial for the health of mother and child. The extract below is from our research notes: An anonymous young girl arrives in the labour room. Her file mentions that she is highly anaemic. She is told to get up, remove her loincloth and lie down on the delivery table. She gets up moaning and manages on her own. The midwife says: Ah! What a smell! Intern: Serum, the baby is coming, Im going to give her the serum now! Quite violently, the labour rooms midwife tells him to slip the basin under her bottom: Come! The corridor door is wide open; electricians are entering and leaving the room. She is cleaned vigorously. The midwife pours a disinfectant liquid onto her and leaves the traditional cord hanging on the womans hips. The stillborn infants head is in the vulva, the woman pushes, she moans, no one is looking after her. She cries out: Help me!
4 5 Cell phones manifest and reinforce this. On this set of procedures see Jaffr and Olivier de Sardan (2003). e
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The midwife comes nearer, she presses the womans stomach and the woman catches hold of her hand. Midwife: you refuse to be helped, so do it on your own! She comes back and sits, washes her hands. Im hungry; Im going to get something to eat . . . At the same time a private childbirth is taking place. All the midwives are busy with that woman and so are the care workers: The parturient sighs, Mummy, as soon as someone goes near her. The midwife puts her on a drip. She says, Be brave, be brave, okay. . . . If you push it will be even worse. Breathe with your mouth open . . . This inequality with modes of recognition can couple itself with a sort of habit of misfortune. In fact, a number of texts devoted to corporate firms and to the sociology of organisations underline that workers who are assigned repetitive tasks see the unusual as a signal (Bagla-Gokalp 1998). But once again, this could be stated in simple terms. In reference obstetric departments where 5 deaths for 100 live childbirths can be counted (Ou draogo and Bouvier-Colle 2002), what is unusual and which event serves as a e signal? Paradoxically, repetitive dramas render one blind to the dramas unfolding and to their prevention. But let us return to our fieldnotes: We enter the delivery room at 9.20 a.m. Two parturients are under observation. One of them, Madam X, gives birth towards 9 a.m. The placenta delivery took place at 9.15 a.m. Application of a traditional diaper (rolled loincloth). (. . .) 1 p.m. Madam X has still not been examined. I again inquire about the blood pressure. Not answering me, she tells a student to make a vaginal tampon to diminish the haemorrhage. Meanwhile, in order to clean the blood that has flowed onto the ground, the student beginner midwives have assembled to find out who had washed the baby and ask her to clean the floor. 1.10 p.m. I ask that at least she be given some soup or glucose serum, since she seems to be very weak. 1.15 p.m. the doctor on duty arrives and the midwife talks to him about Madam X. The doctor confirms that she had been bleeding before the delivery but says he cant examine her as he himself is very tired and has spent the morning in the operating room. On the other hand, he will examine an external patient who had been recommended to him by a care worker and who presents gynaecological symptoms. We leave the delivery room towards 1.30 a.m. Madam X has still not been examined. Implacably, the routine of difficult situations combined with a certain social indifference modifies the medical signal and obliterates the perception of an emergency situation. Putting risk at a distance by a certain moral and emotive routine limits the technical gesture and consequently makes for an obstetric risk. 6
6 For a broader perspective on this question of social production of indifference see Herzfeld (1992) and Olivier de Sardans comments on the shift from a structural indifference linked to the advent of a bureaucracy to a behavioural indifference (2003: 274).
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These medical behaviours thus stem from multiple dimensions. It is not entirely a matter of dormant gestures or inert knowledge. Actors behaviour is only the visible part or the multiple factor result of a tectonic complex linking institutional or professional dimensions with a moral economy. These attitudes inextricably merge ethical values the social forms of recognising the other with more technique. They gather plural dimensions of social inequality, professional burn out, and watchfulness worn down by routine into a single observable behaviour. 7 Finally, the interweaving of these professional and social characteristics appears in the heart of health care. In the socio-linguistic field, code switching can be considered as different uses linked to contexts and as markers of stylistic choices (Gumperz 1989: 111). When transferred to the field of care, this notion allows us to identify this constant intricacy of social norms and techniques and the reciprocal influence of habitus of professional behaviours observed in all the departments. But let us be more specific. When a midwife argues with a parturient who is moaning, she is obeying more her cultural codes that encourage a woman in Sahel to master the pain of childbirth than acting as a professional attentive to the obstetric problem such a complaint might evoke (Jaffr and Prual 1993). e Admittedly, it is the same everywhere and the behaviours of health personnel always mix technical norms with habits and local customs. But in the contexts we are describing, the spill over of professional behaviours into more naturally popular attitudes is particularly important. Outside a situation of declared emergency that invites prompt medical and standardised action, gestures and care broadly correspond to daily behaviours. By accentuating this feature, one could say that only emergency serves as a technical reminder, inducing behaviours respectful of coded medical processes. To put it crudely, in maternities, the organisation of work is practically the same as in small informal restaurants of neighbourhood areas. Identical temporality: in one, action is taken only when an order is placed; in the other emergencies are not anticipated. Identical organisation: in one, the cutlery is not arranged; in the other, files are stacked up. Finally, in the two cases, places like objects are polythetic: the same object has uses and characteristics that vary depending on the combinations they enter into (de Certeau 1980: 115). 12.45 a.m. The woman arrives on a trolley. R R The specialist orders the purchase of a caesarean kit, Loxen and Valium . This is a primigravid administered for 35 weeks of amenorrhea and eclamptic crisis. Furthermore, she has drepanocytosis. 2.30 p.m. A midwife places a catheter in the parturient. R The specialist: The parents should be asked if they have found Loxen . 2.40 p.m. The blood pressure is taken. 2.45 p.m. The specialist leaves to eat. 3.12 p.m. The medicines arrive but the specialist is absent. 3.29 p.m. The tube for the blood type arrives (the blood test costs 3500 Cfa). The tube for the blood type is taken by the hospital assistant. But the assistant hasnt gone back to look for it.
7 More broadly, it would no doubt be necessary to go back to the mental and moving criminal courts that profoundly transformed our relations with our fellow creatures with the advent of modernity (Revault dAllonnes 2008: 9). Ethics is political. In many historical contexts the notion of citizenship was critical to build a political equivalence between people and therefore an equivalence of care regardless of social status of the patient.
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4.20 p.m. We ask for the blood type but it still hasnt arrived. 4.40 p.m. The blood type arrives. Specialist Its Rh negative! He thinks its noted in Ss file but in fact its entered in As. 4.45 p.m. Another doctor: Is the blood type done? Specialist: Well also prescribe a syntho for post operation. The specialist looks for Ss file to note the blood group. He doesnt find it. The file has disappeared. The DES and the midwife argue about the file. (. . .) 5.20 p.m. Departure towards the operation hall. This observation underlines how professional spaces are not governed by a professional order. The hospital does not delimit a specific cognitive and normative behavioural space. One behaves largely as one does outside, which leads to hierarchical interference, technical inconsistencies and explains once more the importance of weak links such as a tired assistant or a missing stretcher. . . . The combination of these apparently modest and therefore barely considered errors leads to womens deaths.

Effects of precariousness in health care and treatments

Considering the example of the far crueller context of extermination camps which obviously cannot be compared with the one evoked here Primo Levi (1989) narrates how a mans life could depend on the cooks gesture of doling out soup. A few centimetres determined whether the prisoner would survive or weaken until he died, depending on whether the ladle brought up liquid to the surface or reached down to some heavier and nutritious food. This description highlights how much the value of gestures is therefore not in itself but depends on the contexts in which they are accomplished. And in these worlds of precariousness what appears as a detail reveals itself to be decisive in these contexts of urgency. One single example taken from our corpus could illustrate our words. A woman arrives in the hospital. The staff members tell her that she is not going to deliver immediately, her contractions being symptomatic of false labour. She is advised to return home and wait. This is what she does. But she doesnt have the money for another taxi. She will therefore deliver near her home, in a tailors house. She arrives bleeding at the hospital at night, and will be saved only in extremis, adding to the number of those who were lucky: near miss or lucky escape as public health terms it. Medically no error was committed. Simply, precariousness transformed an academic truth into a practical risk. The prescription is right only with respect to the context. Additional examples could be presented. Thus, is it good medical gesture to write a script while well aware that the patient will be unable to buy the prescription? Medical competencies are applied within specific contexts. Therefore the relevance of care practice must be evaluated with respect to the situations where they are being used. If one agrees on this point, it means that practitioners must be accustomed to reason not only from their theoretical knowledge but also from the cognitive and economical universe of his or her interlocutors. In addition, the effects of precariousness are observable in the heart of care-taking and consist of some sort of expurgating of clinical data.
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In newspaper jargon, expurgating an article consists of cutting out passages, more often for reasons of censorship. In our language, it is obviously only a metaphor. But let us go along with this image and all that it reveals in these maternities that often resemble these ravaged texts. Indeed, in the two cases, there are blanks. Just as the lack of words renders these stories comprehensible, the lack of objects makes these services appear as coherent technical wholes. Firstly, there is a lack of objects for flexible guidance (Dodier 1993), objects that accompany technical gestures and permit therapeutic decisions to be taken. In the obstetric field, this consists chiefly of partograms. But these follow-up notes that must forecast risks and accompany the delivery of parturients are not or too rarely filled in. Obviously, this is because a certain routine and an oral organisational memory or lack of time precludes the use of the written word. Also because the personnel do not evaluate their skills according to epidemiological norms, emphasising what could have been avoided (de Brouwere and Van Lerberghe 1998), but on the contrary play down failures in favour of daily successful deliveries. This biased reasoning presents the consideration of what should have been anticipated as preventive gestures and too easily exonerates those who did not do what they should have done. These partograms are also voluntarily neglected because writing is memory and unfolding and underlining an anomaly or an error in the delivery runs the risk of revealing a mistake for which one could be held responsible. On the contrary, filling in this partogram after the delivery permits reality to be rewritten to ones advantage. The question is then of a deficiency of cognitive objects. Indeed, in the medical world, decisions and cognitive processes underlying them are very largely linked to artefacts: data temperature, blood pressure, etc. assembled thanks to the use of an instrument. The body is medically articulated only through the measurement of constants and their inclusion in clinical tables of diagnostic trees. Thinking medically therefore requires material records. Hence, in concrete terms, a broken thermometer implies that infections cannot be surveyed. The disappearance of a tensiometer implies that women presenting with risk of eclampsia are no longer identified. In quite a few cases, when a single instrument is lacking, an indispensable technical gesture can no longer be made and this reduces the clinical approach to a follow-up by guesswork, as in the case of the woman presenting an infection whose temperature was taken only very approximately with the back of the hand. For various reasons, most of these cognitive objects or intermediary objects, though indispensable for building a medical observation, are lacking in these maternities (Vinck and Jeantet 1995). Every patient has his thermometer. For the blood pressure machine, there is the department kit, theres one kit for four rooms (. . .) When one finishes in one room, it goes to another. If theres a very serious case and if our kit is spoilt, we go get the duty doctors kit. But sometimes he too finds himself without a kit (laughs) . . . Because when it is spoilt, it is taken to the maintenance service, that takes time (. . .) Before the problem of AIDS, it could be lent to another patient, but since AIDS, all the patients have to buy their thermometer. . . (Midwife) Finally, other than this truly cognitive tool, other objects whose function consists of building an indispensable technical link are also lacking. In fact, in every industrial or sanitary undertaking, the production of knowledge more than a kind of discontinuous
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juxtaposition of individual talents corresponds to a collective process and to networks of cooperation, to a shared thought (Vinck 1999). Everywhere, the consistency of facts is linked to corresponding socio-technical networks (Latour 1994). In practical terms, this association is built and maintained thanks to the circulation of a set of intermediary objects or commissioners, of scripts deposited in the objects (Akrich 1990) that like files, health notebooks or attendance registers move from one to the other. As modest mobile memorials they are co-extensive with the acts accomplished, orienting reflection and supporting the entire cognitive process. Unfortunately, in the sanitary spaces described here there is nothing of the kind. And indeed, there is neither a follow-up nor thought of structure at all. In fact, all the patients are not surveyed; there are no monitoring notes. A number of documents are not filled in. A lot of information is missing in the files. Blood pressure is not taken regularly. When there is a change of shift, there is no communication between the outgoing team and the incoming team. In short, roles are not defined. There is no armband to take blood pressure; students dont have gloves. There are no needles for the blood test . . . (Intern)

A complex and specic organisation of ser vices and human resources

In medicine, the term pain evoked denotes symptoms characterised by their manifestation far from their root cause. Thus a cardiac problem will be expressed by pain in the arm or in the hands. The hospital provides such sequences where the greater the distance from the cause such as the well-known butterfly effect the more its outcome is expressed in clinical action. Once again, an example taken from our fieldnotes illustrates this: The hospital assistant is absent and there is no oxygen. The oxygen circuit is inadequate. The staff dont know how to connect the bottle . . . all this drags on and at the end the caesarean is done, but as the mother couldnt be given oxygen, the child is dead. The next day, the staff members are informed: Foetal hypoxia in an eclamptic case: perinatal death. But our observations show that the caesarean was done only three hours after the decision was taken and there was no oxygen. The absence of hospital assistants means that life often hangs by a thread. Thus, another woman has died because the blood bank patrol had left for a break, taking the keys with them, or dangerous caesareans are postponed because the washing machine had broken down and overalls and the operating room could not be prepared. Anthropological research enlightens us and applies a principle of equivalence in the study of factors responsible for deaths and thus underscores how the most modest and distant of technical links can be the breaking point of a life. Reducing maternal mortality must eventually be accomplished by better management of hospital assistants and attendants. In a broader way, these difficulties also concern the way in which the relationship with other services is managed. This is how, in order to function, these maternities must be related to other structures like blood banks or neonatology units. They are closely dependent upon
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them, whether beforehand for reasons of supply or subsequently for directions. Consequently, besides mechanisms internal to obstetric services, other dysfunctions also arise in the most routine and ordinary practices, corresponding to relations between diverse specialisations and medical structures. For example, referring once again to our corpus, it could be a question of asking a woman to go to the city for confirmation of a diagnostic hypothesis but with some risk of haemorrhage. Here, it all ended well. But on the other hand, this collapse of responsibilities is particularly cruel and crucial in the field of transfusion emergencies. It was a Thursday and my sister-in-law had begun contractions. She called me and I went to see her. Usually, she delivers at dispensary A. This is her fourth delivery. I took her to the dispensary; we spent 6 hours there. Nothing was done. All the conditions seemed right for her delivery. Then the midwife decided to vacate us to the CHU. I called her husband who took us there with his car. By the time we got to the CHU, my sister-in-law had lost consciousness. It was 9 p.m. when she was admitted. Some time later, we were told that she had regained consciousness. At 2 in the morning, they told us they had decided to do a caesarean. (. . .) Early morning, around 5.30 a.m., we were informed that a boy was born. When we were delighted (. . .) a few minutes later we were told that the woman was bleeding heavily. A midwife came out with a prescription and asked us to quickly go and get blood. Our hearts were panicking. The husband ran to get blood, finding it with difficulty. He came back at 7 a.m. in the morning but it was too late, the woman had already died (Madame A A) Naturally, every department organises its work according to its own constraints. For example, ensuring that blood is available implies good management and reimbursement of material by the numerous applicant departments. This step is justified. Similarly, wanting blood urgently is equally justifiable when a woman is in the process of dying of haemorrhage during childbirth. The departments are linked but have conflicting constraints. In several cases, not having thought out all the socio-technical connections in their transversality, the sanitary administration finds itself caught in these multiple double binds where various medical and management constraints enter into conflict. And in the meantime quite a few parturiants like the newborn die when responsibility, rather than being shared, is on the contrary, in doubt. Death is constructed in-between. Between segments of reciprocal actions like the bank and the obstetric service or between obstetrics and neonatology. Once again, what is missing is a comprehensive view elaborated according to the practical constraints of care that would enable the shift from a kind of contradictory transaction to a harmonious interface. In reality, the organisation of work always corresponds to a kind of negotiation between a formal organisation of tasks and a set of experiences built day-to-day. It is always a question of relations between different professional segments and an unstable combination of technical constraints and actors wishes. 8 But in the departments where
8 On this question, see the observations in Yves Clots (1998) book.
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we work, use and invention always precede a certain reflexivity. Everywhere, to put it simply, one makes-do as one can. Admittedly, all this corresponds to a certain style of work management and to types of national traditions (dIribarne 1989). But here too, it is important to forcefully underline how these social techniques and economic situations determine a certain moral economy. Indeed, in the absence of a State that could guarantee means and resources, solutions are only individual and this political deficit engenders at least two kinds of consequences. First of all, before concrete difficulties and a real precariousness, actors find themselves forced to enact a kind of ethics of lesser evil whose motto could be one does what one can for a few. But one cant do it for everyone. How could it be otherwise in situations of precariousness? But here, as elsewhere, the lines between indispensable compromises and various dangerous adjustments are always frail. Moreover, as each initiative does not involve an organised group, whatever its intrinsic value, it can only add to a certain degree of disorganisation. But once again, let us go back to the field. Thus, as one of the nurses among the departments most useful and most courageous underlines: As for the kits, I buy them in the market (officially prohibited black market, but economically flourishing). I have to buy myself because if I buy at the central pharmacy it will be too expensive and I wont be able to sell at 10.7 euro. Actually, I have problems because I cant find wires. Some doctors dont care. They take the material in the kits and they dont put it back. They dont give a damn, its for their prot g s and later they leave. (Madam D. . ., nurse) e e It is therefore the illicit private sector the street pharmaciesthat permit the public sector to function. Paradoxically, with competition and the informal system, the devotion of these care workers allows patients to illegally avail of products at a relatively accessible price. This is an ethical solution to emergency but one that increases the technical disorganisation of the service and the hospital. This non-standardising process can also work in the other sense: patients can be recruited from the public to help run ones own private sector. Thus, in a public service, parturients were forced to pay a doctor for a private ultrasound since he had bought the equipment during a mission. Is this then the other negative side of the same situation? At the very least, this is a concrete result of a political situation since the collective use of a simple technical object would imply a public space governed by rules respected by all and benefiting all equally. In fact, daily and practically, all the activities are governed by this triple constraint system: work must be done correctly according to service norms but inadequacies of public institutions must be compensated and moreover, means of personal survival found in a difficult social environment. These few observations from the bottom correspond to experiences lived by practitioners. However, though these events have been experienced does not mean they have been analysed. Department team meetings should occupy a deliberative function. In fact, they are actually presented as moments of discussions around cases, but have become humdrum and automatic. Therefore, more than an analysis of situations along with their complex variables, some kind of expurgated facts are sought that permit the confirmation and illustration of clinical knowledge. Consequently, rather
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than permitting an analysis of facts, this use of medical knowledge encourages questions raised by a death to be dismissed thanks to tautological reasoning: Madam X died from eclampsia, her blood pressure was high or Madam Y died of haemorrhage because of lack of blood. . . The rest the waiting time, lack of organisation or absence of an assistant is forgotten. Technical and organisational dysfunctions are suppressed, as they are not supposed to concern the medical field. Consequently, these meetings appear somewhat as moments of exoneration rather than as occasions for analysing cases and what could have been avoided. Maybe it is up to anthropology to help out with the indispensable reflective function?

The system of maternal mor tality

Sharing significations by no means implies being conditioned by these significations. The analysis of actors practices cannot therefore be confined to a kind of simple succession of group behaviours, nor can it implicitly suppose homogeneity of the health personnel. If there exists a common sensory base of moral values and tastes, and if the subject is not constituent (but) constituted (. . .), he is no less free to react thanks to his freedom and (can) take a distance thanks to his own reflection (Veyne 2008:144). Professionals can always exercise some kind of freedom. Some refuse what others accept. Some reform structures that others exploit. 9 But our anthropological study of hospital construction of maternal mortality permits us to identify regularities and invites reflection on three central points. First, it shows straight away that women do not simply die of an obstetric pathology but of a configuration articulating a set of discontinuous variables. Parturiants suffer from a complex system that links medical causes with social and organisational dimensions. No doubt these flexible categories are difficult to grasp, diversely shared and specifically transformed by each institution. But they function in a background of social inequality; globally, womens mortality finds its origins in this heterogeneous assembly of a set of discontinuous variables which we have grouped, in our study, in a set of three wide specific malfunctions that make up the system of maternal mortality. Some of these variables like the importance of being acknowledged before being treated are constant for wide socioeconomic landscapes. Others like the linkage between diverse services can be more specific. But to effectively understand how maternal mortality is built requires the analysis of the mechanism as a whole. Meaning, the description and analysis of a heterogeneous ensemble of institutional practices, moral values, professional practices that come together to create these deaths within these specific contexts. 10 Secondly, the methodological choices we applied give a practical meaning to broad notions often used in public health system failure, delayed care, ignorance of populations, maladjusted surveillance and propose relevant solutions in this precise context. Which concrete acts construct these failures, which powers run through
We have specified this in an article dealing with these questions of historicity and social variations of moral and affective categories (Jaffr 2006). e 10 Van der Geest and Finkler (2004) highlight the fact that hospitals reflect and reinforce the dominant socio-cultural configurations of the societies in which they are situated.
C

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these groups, which failures lead to delays, etc.? By giving substance to these large aggregates and permitting a precise analysis of effective causes of womens mortality, the qualitative inquiry permits us to think locally, to define actions anchored in the course of real lives and propose appropriate and applicable actions to improve factors that lead parturients to a fatal end. 11 Thirdly, and more broadly, the modest gestures and modes of organisation of professional spaces that we have just described are linked to larger dimensions that research or development programmes often refer to as the cultural context. This is a lazy term, since far from recalling a vague environment, it in fact designates a set of variables that are not integrated and included in the field of analysis, thus appearing only on the margins of the study. In short, the context is simply that which we have not yet taken the time to study. And yet, what is thus barred from reflections and calculations often determines actors behaviours far more than our fleeting and fragile projects. For instance, it is impossible to speak of maternal mortality without evoking broad simultaneities, such as a certain relationship to life known to be harsh and fragile or a religious universe that offers hope and the impression of a stable order in the face of a disorderly social world. In one of the capitals where we worked, the hospital surroundings were occupied by makers of coffins whose forms, colours, gilt and decorations evoked the deceased persons tastes or profession: guitars, fish or sparkling boats for eternity. These funerary shops permanently transmitted religious songs that resounded in the services; in some maternities midwives sang these same hymns during the deliveries. On Islamic soil, families carried dead bodies enveloped in white across the care rooms. No doubt, all this is difficult to measure. But this presence of a dramatised (perhaps one could even say tamed?) death and this co-penetration of technical and religious worlds must have some effects. Prayers and care mingle everywhere and far from being a mere local atmosphere, these cultural dimensions of technical spaces of care orient actions according to a shared sensitivity. The second socio-historical dimension is more technical. Indeed, since our examples attest to constant file errors, the transformation of contemporary societies by a paper revolution in Europe must be emphasised also in terms of the close links between the question of classifying and a certain organisation of space. Moreover, there is the manner in which facilities of systematic treatment of information work through a work of hygienic and rational organisation of space (Gardey 2008: 14). This standardisation of procedures produced a new moral economy where confidence, generally delegated to humans, and in particular to qualified workers, is increasingly deposited in artefacts and systems and rendered mechanical (Gardey 2008: 16). 12 The file is a result of this history of techniques and appears as an efficient social construct rendering all the cases socially homogenous and ensuring continuity of care. Besides the importance of the file and writing just evoked, 13 there must also be a certain manner of tidying up that is more than simple stacking and piling up. A process confirmed for
11 Cf. OMS/WHO (2004). On works in the African context see, among others, two articles representative of current practices of audits, one dealing with Tunisia (Tej Dellagi et al. 2001), the other with the Ivory Coast (Horo et al. 2008). Cf. also Howel (1995). These are the questions Chartier (2000) raises: the importance of literacy in the construction of modernity. A modern State thus calls for a certain degree of literacy, of familiarization with rules and written procedures (Gardey 2008: 281).

12 13

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example by the cognitive revolution that for Europe implied the shift from the chest to the cupboard in the 16th to 17th centuries (Milliot 1996: 83). Finally, the modern organisation of work basically consists of an appropriation of the employees time and his management by the factory (Thompson 1979) and corresponds to an invention of speed (Studeny 1995) that globally transformed Northern societies and was behind the definition of a quick and calculated time that would then engender the notion of urgency. In the language of educationists, have these crucial pre-requirements these pedestals of technical spaces of care made up of technical uses of time, 14 or the management of bodies linked to written records and habits of efficient tidying up been achieved? If one agrees with the above, a few actions aimed at improving the offer of health logically flows from our study.

Understanding better to act better

In order to realise the millennium targets in this field of maternal health other than those we indicated as crucial to the economic and medical base aimed at realising technical actions (obstetric contracts, free caesareans, financial anticipation of care) the improvement of quality care involves the application of three types of actions. Firstly, it is crucial to set up bodies for a qualitative analysis of work. This type of anthropological study could take the form of audits realised by the staff in their own services (Jaffr 2003) or providing important reviews of maternal mortality. These e approaches share the introduction of an indispensable reflexive dimension of care behaviours in services that, as we hope to have shown, can in no way be confused with medical or epidemiological analyses of cases. Secondly, the roots of action are never exclusively cognitive. One would have to be affected by complaints, want to help, feel concerned or responsible, fear a failure, suffer from a death . . . . A very concrete work of ethics around the theme of forms of engagement (Th venot 2006), e local modalities of recognising the other and medical risks of indifference are essential (Jaffr 2009). Finally, a real reflection on the organisation of enacting care, from the e most simple task of tidying up files to the most complex task of relating to operating time and to the interactions between different structures especially blood banks that make up the hospital, would underscore the necessity but equally the difficulties of constructing a coherent professional hospital space.
Yannick Jaffr e CNRS-UMI 3189 Anthropology Marseille 13006, France yannick.jaffre@univmed.fr

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For a broader reflection on the experiences and social constructions of time, see Hartogs (2003) excellent book.

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