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To achieve Millennium Development Goal 5 on maternal health, many countries have focused on marginalized women who lack access to care. Promoting facility-based deliveries to ensure skilled birth attendance and emergency obstetric care has become a main measure for preventing maternal deaths, so women who opt for home births are often considered 'marginal' and in need of targeted intervention. Drawing upon ethnographic data from Nicaragua, this paper critically examines the concept of marginality in the context of official efforts to increase institutional delivery amongst the rural poor, and discusses lack of access to health services among women living in peripheral areas as a process of marginalization. The promotion of facility birth as the new norm, in turn, generates a process of 're-marginalization', whereby public health officials morally disapprove of women who give birth at home, viewing them as non-compliers and a problem to the system. In rural Nicaragua, there is a discrepancy between the public health norm and women's own preferences and desires for home birth. These women live at the margins also in spatial and societal terms, and must relate to a health system they find incapable of providing good, appropriate care. Strong public pressure for institutional delivery makes them feel distressed and pressured. Paradoxically then, the aim of including marginal groups in maternal health programmes engenders resistance to facility birth.

Word count: 10238 Birgit Kvernflaten is a PhD candidate at the Centre for Development and the Environment (SUM), at the University of Oslo, Norway. Her research has focused on reproductive health and maternal health in Guatemala and Nicaragua, exploring local perspectives in the context of policies and interventions. Her current PhD research concerns maternal health among rural women in Nicaragua, in particular the policies and practices in relation to maternal healthcare, and how maternal health interventions encounter local socio-cultural realities. Abstract Nicaragua has a long history of health activism and government policies aimed at achieving various models of participation in health. Drawing on ethnographic research in rural Nicaragua, this article situates contemporary participation within this larger historical and political context and critically explores how participation in health is understood and practised. Contemporary health interventions focus on compliance in their endeavour to improve maternal health. This focus, I argue, creates a productive tension between health seekers' and health workers' understanding of themselves as citizens and the government's attempt at achieving public health aims. My empirical focus is on the brigadistas (community health workers), women, and expectant mothers. I describe how brigadistas work as interlocutors between the government and the people. In this relation, women and brigadistas express expectations of and dissatisfaction with the healthcare services offered. Drawing upon an extensive literature on participation, I suggest that within this particular relational space a new political space may appear where demands for improved healthcare services can be articulated and recognized.

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