International Scholarly Research Network
ISRN Obstetrics and Gynecology
Volume 2012, Article ID 649412, 8 pages
Qualificationof Staff, Organizationof Services,and
Management of Pregnant WomeninRural Settings: The
Case of Diema and KayesDistricts (Mali)
1Department of Public Health, Faculty of Medicine, University of Montreal, 1420 Mont-Royal Boulevard, Montreal,
QC, Canada H2V 4P3
2International Health Unit, Research Center of the Centre Hospitalier de l’Universit´ e de Montr´ eal (CRCHUM),
3875 Saint-Urbain Street, Montreal, QC, Canada H2W 1V13
3Direction R´ egionale de la Sant´ e, P.O. Box 231, Kayes, Mali
Correspondence should be addressed to Maman Dogba, email@example.com
Received 11 January 2012; Accepted 14 February 2012
Academic Editors: I. Figa-Talamanca and J. Sundby
Copyright © 2012 Maman Dogba et al.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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
[1–4]. In Mali, referral-evacuation systems (RESs) are one
strategy in the fight against maternal and perinatal mortality,
where the implementation has had to cope with shortages
of staff, particularly of midwives in rural settings. An RES
looks after the upgrading of emergency obstetric services,
the financial coverage of patients by community cost-sharing
schemes, and the transfer of patients, as needed, to better
equipped facilities . It closely links peripheral healthcare
structures (community health centres (CHCs))), district
care system . Its interventions are concentrated on the
intrapartum period, during which most maternal deaths
occur . It includes a functional referral and allows for
simultaneous action on the demand and supply sides.
Indeed, the RES ensures rapid management of obstetric
complications in Mali’s context, which is characterized by
low rates of institutional delivery, especially in rural settings.
In 2006, the rates of facility-based deliveries were 45% in
Mali, 34% in Kayes, and 90.3% in Bamako, the national
Mali, a low-income West African country, has eight
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 ob-
stetric complications, whose occurrence is most often unpre-
dictable, all deliveries should be carefully monitored by staff
qualified for deliveries—essentially either midwives or other
comparably skilled professionals [9–11, 32]. Thus, in Kayes
be required to implement the RESs, in addition to those
2ISRN Obstetrics and Gynecology
at the DHCs and the regional hospital. However, in 2005,
there were only seven midwives at the CHC level, and, in
2006 and 2009, only eleven. In the face of these shortages
of qualified personnel, two strategies were implemented.
One that took immediate effect was to extend obstetric
services coverage in CHCs by using matrons. They are much
less qualified than midwives but are more easily trained,
recruited and, especially, retained in rural areas because they
come most often from the local communities that train and
employ them. Midwives complete three years of study after
their baccalaureate degree, whereas matrons undergo a few
months of internship and some theoretical training in a
maternity unit. The content of the matrons’ training varies
depending on the maternity unit they attend. Moreover, no
particular level of schooling is required for this training,
although most matrons have at least completed primary
school. In 2005, Kayes region had 196 matrons in CHCs
and 222 in 2006. Another strategy was to train obstetric
nurses, who are less qualified than midwives but more than
matrons. They are considered qualified to do deliveries [12,
13]. They receive three years of theoretical and practical
training in competencies similar to midwifery skills, after
a basic teaching diploma (six years of primary and four
years of secondary schooling). In the CHCs of Kayes region,
there were eight in 2005 and 14 in 2006. Despite these
had access to obstetric care and reduced by half their risk of
dying from obstetric complications. These results were made
possible through the combined action of all components of
the RES .
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 [6, 14]. Kayes region is the
largest source of Malian emigrants to France , and
the ASACOs enjoy the financial support of Malian citizens
from Kayes who are living abroad. Healthcare projects are
sometimes funded as much as 80% by emigrants from the
Kayes region, which represents 30% of the combined total
contributions to the region’s development . Thus, while
some CHCs might have only three professionals—a nurse,
a matron and a pharmacy manager—others might have as
many as eight professionals. In addition, around 10% of the
CHCs in the Kayes region have physicians. In CHCs where
there is a physician, that person is automatically the centre’s
manager: the physician-in-charge (m´ edecin chef de poste, or
MCP). Otherwise, it is the most qualified staff, often the
nurse, who is the manager: the nurse-in-charge (infirmier
chef de poste, or ICP).
A quantitative evaluative study looked at the relation-
ships between professional teams and care outcomes. It
showed that the joint mother-newborn survival is signifi-
cantly influenced in the Kayes maternal referral system by
combined effectsof the skill configurationof 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 . Pregnancies complications were
not managed at the CHC, but, at the DHC, the protective
role of physicians’ presence in CHCs was therefore attributed
to a better management of complicated cases before their
evacuation [18, 19], or to earlier screening of women poten-
tially at risk of obstetric complications, or to the beneficial
effects of ambulance transport. Despite those hypotheses, a
more rigorous understanding is needed of the mechanisms
staff, and the organization of services at the first level of care
provision, especially at a time when shortages of qualified
personnel lead to the adoption of task-delegation strategies
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 per-
sonnel involved in maternal care: matrons, nurses, obstetric
nurses, midwives, and physicians. In each CHC we visited,
participants were invited to freely elaborate about the orga-
nization 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 interac-
tions in the teams and to verify whether the organizational
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 (n = 10) (two ICPs were absent from their posts and
problems with the recording), nurses (n = 3), matrons
(n = 23), midwives (n = 5), obstetric nurses (n = 4), and
MCPs (n = 11) (one MCP had just been named to his post
and was not interviewed). In all, we conducted 56 interviews
and observed for 10 days. Table 1 shows the characteristics of
The interviews were recorded with the respondents’
consent and then transcribed. The coding and analysis of
NVivo 8 software. We developed the coding plan from a list
of codes inspired by the literature on human resources in
ISRN Obstetrics and Gynecology3
Table 1: Characteristics of the CHCs and the respondents.
Distribution of CHCs by manager
Distribution of CHCs by distance between CHC and DHC
Distribution of CHCs by staff levels
Distribution of respondents by staff category
CHC with MCP
CHC with ICP
50km or less
More than 50km
3 staff or less
More than 3 staff
healthcare services and on quality of services . The list
was combined with an open coding to allow the emergence
of new themes. Units of meaning were identified according
to the predefined or emergent themes. We then compared
the units of meaning between professional categories and
withineachcategory.Comparisons between MCPsand ICPs,
reported in this study, allowed us to identify points in
common as well as differences.
2.1. Ethical Considerations. 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.
Variations in the care environment include how work is
organized, the level of technology, the skill and numbers
of staff in the CHC, and the creation of a competitive
3.1. Variations in Work Organization. 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 responsi-
bility 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
“When there is no complication, the matron is
in charge, but under my supervision.” (ICP 10).
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 system-
atic 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
4 ISRN Obstetrics and Gynecology
and to provide patients with appropriate management of
“...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, systematically, even if she has to let the
matron continue.” (MCP 35).
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.”
3.2. Variations in Levels of Technology. In a context in which
CHCs are managed autonomously by the ASACOs, the
possibility of having MCPs with obstetric skills was accom-
panied 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
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.”
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
sound, installing internet connections, promoting the use
of solar energy, and, in the longer term, creating functional
“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).
3.3. Variations in the Skills and Numbers of Staff. 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 gynae-
cology-obstetric service, and the other three had undergone
supplementary training in EmONC or in obstetric ultra-
sound, most often at their own expense. All of them were
more deeply involved (model 2 or 3) in the management of
“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
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 recruit-
ment. 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 regret-
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
“But the only problem is the instability of the
and three weeks in Bamako” (Nurse 36 in an
ISRN Obstetrics and Gynecology5
3.4. Creation of a Competitive Environment. The presence of
physicians in the CHCs of Kayes Region created a compet-
itive 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.”
To develop the relational and interpersonal aspects of care, the
MCPs paid particular attention to relations with the profes-
sionals of the DHCs and with the patients.
3.5. Relations with the Professionals of the DHCs. The ICPs
see interactions between the CHCs and the DHCs as admin-
istrative 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
managementof referredpatients. Some MCPsnurtured rela-
tionships with the higher level of care that were sometimes
“... 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 have to work together to get results...
with regard to the women who are evacuated,
generally they give us feedback...” (MCP 35).
“...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
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.
When you arrive with a referral letter, they take
care of you faster, they do not just leave you
hanging.” (Midwife 32).
3.6. Relations with Patients. According to the MCPs, estab-
sible 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,
I say something, they do it...” (MCP 35).
ronment were sometimes deliberate and actively induced—
changes in the way work was organized, the level of technol-
ogy, and the qualifications of the personnel—and sometimes
they arose passively and unintentionally. The results of this
analysis are summarized in Table 2.
Analysis of the functioning of CHCs shows that MCPs,
depending on their interests in obstetrics, had varying levels
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 , and, as this study shows, the MCPs with
the greatest involvement were those who had supplementary
training in obstetrics. Still, an interest in obstetrics alone
does not explain the development of diverse models. In
fact, even when they organized the work like the ICPs did,
leaving matrons in charge of deliveries, the MCPs put in
place systems such as systematic phone call followup and
management of patients by several professionals, to ensure
complicated cases were properly managed. In this way, they
were not restricted to the traditional care model of the RES
used by nurses.
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 [26, 27]; never-
theless, further studies are needed to document better the
consequences for patient care of the relations between the
two levels of care. The MCPs also developed relationships
6 ISRN Obstetrics and Gynecology
Table 2: Summary of variations in the environment and in work organization under MCPs.
Technical and organization aspects
Relational and interpersonal aspects
Level of technology
Relations with the
Closer involvement in
Plans to raise the level of
training in obstetrics
Support for trainees
Acquisition of their
provided by the ASACOs
with expatriate support
Attractive to trainees
Midwives and obstetric
nurses in centres with
for more qualified
ISRN Obstetrics and Gynecology7
of trust with patients, while the ICPs did not mention
this. Yet, in the case of a referral system, social interactions
with patients are recognized as being beneficial to patients
. Although giving preferential treatment to patients
referred by a physician might be criticized from an ethical
standpoint, in the context of a network where final outcomes
depend on a succession of prior actions, an interdependent
team collaboration with information exchange between the
different levels is more effective than working independently,
and even more effective than consultation referral .
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
, cervical smears , first-trimester abortions , or
surgical interventions . However, these acts are usually
carried out in the district level centers. At the peripheral
level, often the responsibilities of the healthcare personnel,
beyond technical interventions, include relational activities
such as accompaniment and social support . It would
seem appropriate, therefore, to wonder whether the tasks to
be delegated, especially in the health centres and in a referral
system, should not also include relational and interpersonal
skills. Moreover, unintentional mechanisms that improve
performance, such as the capacity to attract personnel and
especially to create a competitive environment , should
be identified and maintained.
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 difficul-
ties of retaining midwives and obstetric nurses in rural areas
continue, while filling these positions would have a long-
term positive impact on maternal care [11, 33, 34]. Also, the
environmental variations produced by physician managers
veer away from the logic underlying the RES. Initially, only
simple deliveries were supposed to be handled in the CHCs.
However, the present study shows that, with management
autonomy and support from expatriates, some CHCs have
acquired increasingly qualified staff and sophisticated equip-
ment, including operating wards. With no governmental
regulation of what acts are to be done in CHCs, MCPs with
obstetric competencies could take over the management of
displacement would not be cost-effective and the number of
interventions would most certainly be too small to maintain
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
region, of the complexity and diversity of care organization
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 . A significant proportion of
This profoundly changes the organization of care, because
physicians bring a development model to their CHCs that
is centred on clinical practices and closely linked to their
personal and professional development. When nurses are
in charge of first-line health centres in rural areas, their
approach is more administrative; they tend to adopt a more
hierarchical than clinical perspective in their relations with
the higher district level and a work organization model in
which they delegate obstetric responsibilities to matrons. In
the referral-evacuation system of Kayes region, the presence
of physician managers in the CHCs created more opportu-
nities to improve patient care outcomes. An analysis of the
CHCs’ models of care organization reveals organizational,
relational, and interpersonal mechanisms that can improve
their performance. Still, this should be an ad hoc and
temporary strategy, as the problem of shortages of staff
qualified for delivery—particularly midwives and obstetric
nurses—continues, and there is a real risk that the referral
system’s operating principles would be modified in this
context of autonomous management of CHCs.
Conflict of Interests
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
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