The Patient’s Perspective on Institutional Logics in Russian Maternity Care

Abstract

The interplay between different institutional logics is a vital topic in contemporary institutional analyses of healthcare. In this paper, we consider relations between professional, bureaucratic, market, and informal logics in the volatile and ever-transforming context of post-Soviet maternity care. We approach this issue from an unconventional angle and study how various logics are interpreted, enacted and manipulated by women-patients. Neo-institutional scholars commonly enlist patients as institutional actors that are involved both in maintaining and changing the institutional order. However, current research neglects the patients’ perspective instead focusing on the practices of healthcare providers. In order to fill this gap, we investigate how expectant mothers make sense of and navigate the complex institutional environment of Russian maternity care. In our analysis we rely on empirical data from fifty-nine qualitative interviews with recent mothers conducted in St. Petersburg in 2015–2017. This data allows us to conclude that the institutional dynamics of maternity care are powered mostly by the rivalry of two logics – one bureaucratic, the other market-driven. The professional logic, meanwhile, remains underrepresented and dominated by the other two. Unlike healthcare practitioners, women perceive the bureaucratic logic as chaotic and unpredictable, while wealthy clients employ a repertoire of actions offered by the market logic to exercise more control of their hospital routine. Different institutional logics compete for dominance, leaving areas of uncertainty in regard to institutional rules. In some cases, patients use informality to manage such ambivalence and challenge the formal order of healthcare facilities. The common character of this strategy prompts us to suggest that informality forms a distinctive fourth logic that frames some actions and interactions within Russian maternity care.