Enforcing ‘Progress’: A Story of an MDG 5 Indicator and Maternal Health in Malawi

Abstract

Considering the importance of metrics in current systems of global health accountability, this article analyses the dynamics behind a maternal health indicator. To achieve the target of Millennium Development Goal 5 (MDG 5) and increase the proportion of births attended by 'skilled health personnel', some districts in Malawi in 2010 introduced information campaigns to promote births in hospitals and a fine to punish mothers who delivered outside of biomedical health institutions. The study is based on ethnographic research in one Malawian village. While many mothers described the ill treatment and bad conditions in maternity wards, most women still started to publicly sanction institutional births. This apparent contradiction can be understood by looking at the positions and motivations of the various actors who participated in the performance of MDG 5 in the village and how their projects became tied to the focus on improving the indicator. Rather than expressing a demand for the existing maternal health services as such, the ethnography suggests that the actors' practices expressed hopes and claims to wider material improvements in a context of inequality. The article highlights dynamics that are concealed if we restrict the analysis to one of biopower, and expands the purview of the study of metrics into the spaces which indicators are intended to represent.

Public Servants as Development Brokers: The Shaping of INGOs’ Reducing Teenage Pregnancy Projects in Malawi’s Primary Education Sector

“…We have shown how actors' priorities play a role in the "falling apart" of services, starting with the discontinuation of donor funding and the (de)prioritisation of Safe Motherhood at the national level. In attempts to manage and "fix" the "falling apart" of services, dynamic responses are informed by actors' different priorities and constrained by limited power within a constantly † See also 39 for how financial incentives as part of results-based financing for maternal and newborn health affect Malawian women.…”

“Satanism is witchcraft’s younger sibling”: Changing perceptions of natural and supernatural anaemia causality in Malawian children

“…This would not only contribute to morbidity, but also possibly diminish the trust towards formal healthcare and enhance the caregivers’ reliance on traditional and complementary medicine. For example, a study performed in a rural village of Malawi found that pregnant women “resisted hospital births, not because they disliked biomedicine, but because the childbirth services were considered to be of such poor quality” and the maternity ward was described as a “place of hostility and lack of care” [ 37 ].…”

The Use of Ethnography in Maternity Care

“…• To understand the culture of an organization or setting, or understand a phenomenon within its cultural context (Goodwin et al, 2018;Higginbottom et al, 2013Higginbottom et al, , 2015Logsdon & Smith-Morris, 2017;Newnham et al, 2015Newnham et al, , 2017aNewnham et al, , 2017bTaylor et al, 2009;Véras & Traverso-Yépez, 2011;Yeh et al, 2014) • To understand how people give meaning to their experiences (Goodwin et al, 2018;Hunter, 2010;Hunter & Segrott, 2010) • To study the forces (rules, activities, discourses) that shape a person's world or setting (Grassley et al, 2015;Kennedy et al, 2010Kennedy et al, , 2013 • To describe "real life" experiences (Chen et al, 2015;Hugill et al, 2013;Hunter, 2010;Hunter & Segrott, 2010) • To gain an insider perspective (Taylor et al, 2009) • To include observation as a method (Harte et al, 2016; O'Boyle, 2013) • To allow for data triangulation (O'Boyle, 2013) • To provide a holistic or in-depth understanding (Hugill et al, 2013;Kemp & Sandall, 2010;Logsdon & Smith-Morris, 2017) • To allow the researcher's identity as a midwife and researcher to be reflexively incorporated into the process of data collection and analysis (Spendlove, 2018) • Because of the linguistic, cultural, and social diversities of the populations examined (Gagnon et al, 2013) Of the 20 studies that did not stipulate a reason for using ethnography, most (15/20) were relevant to ethnography to the extent that they either regarded the study of a culture or specific setting (Allen et al, 2015;Danielsen, 2017;Dove & Muir-Cochrane, 2014;Finlay & Sandall, 2009;…”