Capitals diminished, denied, mustered and deployed. A qualitative longitudinal study of women's four year trajectories after acute health crisis, Burkina Faso.

Accumulating evidence indicates that health crises can play a key role in precipitating or exacerbating poverty. For women of reproductive age in low-income countries, the complications of pregnancy are a common cause of acute health crisis, yet investigation of longer-term dynamics set in motion by such events, and their interactions with other aspects of social life, is rare. This article presents findings from longitudinal qualitative research conducted in Burkina Faso over 2004-2010. Guided by an analytic focus on patterns of continuity and change, and drawing on recent discussions on the notion of 'resilience', and the concepts of 'social capital' and 'bodily capital', we explore the trajectories of 16 women in the aftermath of costly acute healthcare episodes. The synthesis of case studies shows that, in conditions of structural inequity and great insecurity, an individual's social capital ebbs and flow over time, resulting in a trajectory of multiple adaptations. Women's capacity to harness or exploit bodily capital in its various forms (beauty, youthfulness, physical strength, fertility) to some extent determines their ability to confront and overcome adversities. With this, they are able to further mobilise social capital without incurring excessive debt, or to access and accumulate significant new social capital. Temporary self-displacement, often to the parental home, is also used as a weapon of negotiation in intra-household conflict and to remind others of the value of one's productive and domestic labour. Conversely, diminished bodily capital due to the physiological impact of an obstetric event or its complications can lead to reduced opportunities, and to further disadvantage.

Beyond body counts: a qualitative study of lives and loss in Burkina Faso after 'near-miss' obstetric complications.

Averting women's pregnancy-related death is today recognised as an international health and development priority. Maternal survival is, in this sense, a success story. There is, however, little research into what happens to the women who survive the severe obstetric complications that are the main causes of maternal mortality. This paper examines findings from repeated in-depth interviews with 64 women who survived a clinically defined 'near-miss.' These interviews were conducted as part of a prospective longitudinal study of women who 'nearly died' of pregnancy-related complications in Burkina Faso, a poor country in West Africa. Drawing on sociological and anthropological perspectives that consider the defining characteristics of 'loss' to be social as much as biomedical, the paper seeks to understand loss as disruption of familiar forms and patterns of life. Women's accounts of their lives in the year following the near-miss event show that such events are not only about blood loss, seizures or infections, but also about a household crisis for which all available resources were mobilised, with a train of physical, economic and social consequences. The paper argues that near-miss events are characterised by the near-loss of a woman's life, but also frequently by the loss of the baby and by further significant disruptions in three overlapping dimensions of women's lives. These include disruption of bodily integrity through injury, ongoing illness and loss of strength and stamina; disruption of the household economy through high expenditure, debts and loss of productive capacity; and disruption of social identity and social stability. Maternal health policy needs to be concerned not only with averting the loss of life, but also with preventing or ameliorating others losses set in motion by an obstetric crisis.

Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso.

Substantial healthcare expenses can impoverish households or push them further into poverty. In this paper, we examine the cost of obstetric care and the social and economic consequences associated with exposure to economic shocks up to a year following the end of pregnancy in Burkina Faso. Burkina Faso is a low-income country with poor health outcomes and a poorly functioning health system. We present an inter-disciplinary analysis of an ethnographic study of 82 women nested in a prospective cohort study of 1013 women. We compare the experiences of women who survived life-threatening obstetric complications ('near-miss' events) with women who delivered without complications in hospitals. The cost of emergency obstetric care was significantly higher than the cost of care for uncomplicated delivery. Compared with women who had uncomplicated deliveries, women who survived near-miss events experienced substantial difficulties meeting the costs of care, reflecting the high cost of emergency obstetric care and the low socioeconomic status of their households. They reported more frequent sale of assets, borrowing and slower repayment of debt in the year following the expenditure. Healthcare costs consumed a large part of households' resources and women who survived near-miss events continued to spend significantly more on healthcare in the year following the event, while at the same time experiencing continued cost barriers to accessing healthcare. In-depth interviews confirm that the economic burden of emergency obstetric care contributed to severe and long-lasting consequences for women and their households. The necessity of meeting unexpectedly high costs challenged social expectations and patterns of reciprocity between husbands, wives and wider social networks, placed enormous strain on everyday survival and shaped physical, social and economic well-being in the year that followed the event. In conclusion, we consider the implications of our findings for financing mechanisms for maternity care in low-income settings.