Maternal health is generally declining around the world (WHO, 2015). However, maternal health inequalities between rich and poor countries, and even within particularly poor countries persist. Côte d'Ivoire is one of the most problematic countries with high maternal mortality rates (679 deaths per 100,000 live births against an average of 230 in developing countries and 16 in developed ones), despite all the efforts at the national and international level (MDGs, targeted free care policies, SDGs, etc.). It seems that health studies and programs focus on the financial aspect of access to maternal health care and that they do not integrate contextual and institutional norms. Thus, we ask ourselves the question of knowing what the Social Determinants of Maternal Health (SDMH) in Côte d’Ivoire are. We have set out the following assumptions: In developing countries, health economics studies only focus on access to health care by limiting themselves to technical models and narrow criteria of the analysis of care behaviors. The Ivorian health system lacks of virtuous institutional complementarities. This lack of institutional complementarities is at the same time linked to the poor consideration of the social determinants of maternal health. Poor maternal health indicators in Côte d'Ivoire persist due to the poor consideration of SDH in studies and policies. This thesis is divided into three main parts.
The first part criticizes the economic literature focusing on the use of health services as the main channel of access to health and neglecting other important social factors. Most of these studies are confined to theoretical and technical models based on an absolute rationality of individuals. However, it is essential to consider the complexity of a limited rationality that is reinforced by the evolving nature of behaviors over time.
In the second part, our thesis therefore proposes a hybrid analysis framework of institutional complementarities which is intended to be global and systemic and which seems to us better suited to our problem. This framework takes into account this development and the social context of individuals. We jointly mobilize it with the SDH approach. In this SDH approach, we distinguish on the one hand access to maternal health services, of which we examine a multidimensional approach, and on the other hand, other SDMHs. First, the results of this part shows that in Côte d'Ivoire, there would be strong complementarities between the institutions interacting for the health of wealthy and/or educated women and employed by the formal sector and often having recourse to private health sector. Second, the Ivorian health system lacks of good institutional complementarities in favor of poor women who often consult in the public sector. This contributes to deteriorating the performance of the Ivorian health system.
The third part is an application of our analytical framework through a mixed method (quantitative and qualitative). A critical quantitative analysis allows us to confirm the weak consideration of the social determinants of maternal health in the studies. Most of the factors highlighted are the size of the household, the woman's level of education, financial barriers, the number of pregnancies, etc. Hence a qualitative survey in Côte d’Ivoire with pregnant women and those who have recently given birth, modern health professionals, traditional practitioners, NGOs, community relays was necessary, in order to collect the perception that individuals have of the health system and to find out any institutional deficiencies.
In one hand, it appears that maternal health in Côte d'Ivoire is also influenced by policies and institutions in other social fields such as housing, transport, environment, education of women and nursing staff, information, cultural norms, etc.).
On the other hand, the results of our interviews surmounted by a documentary review show that there is a dysfunction between health institutions in Côte d'Ivoire in the implementation of health policies aimed at maternal health. Among other things, it appears that contrary to the WHO standard recommending a postnatal observation of 72 hours, women who have given birth in the public sector spend between 8 and 24 hours in observation, due to a lack of reception beds. However, those going to the private sector pass the average 72-hour period well. Some women give birth at home because they live in small villages far from the nearest health center and have no transport available at certain times to get there. Public structures generally suffer from a weak technical platform. Regarding the targeted free health care policy, information conveyed by the media and administration is out of step with that received and transmitted by midwives, nurses and pharmacists (who are the closest of patients) in public structures. The latter often claim to receive incomplete delivery kits and are forced to charge patients for essential and expensive equipment while they think they have totally free care. This causes a lack of trust between the healthcare staff and the patients. Several women interviewed were not informed of the existence of this free policy. Traditional practitioners seem to be left out of the institutional arrangements within the health system while consulting by many women. These are the few social factors hindering the improvement of maternal health in Côte d'Ivoire. It is necessary to seek virtuous institutional complementarities in favor of women using public health services or in rural areas, if we wish to reduce maternal deaths in Côte d'Ivoire. Maternal Health should also be considered in the formulation of policies of other social sectors.