Local adaptations to a global health initiative: penalties for home births in Zambia

Abstract

Global health initiatives (GHIs) are implemented across a variety of geographies and cultures. Those targeting maternal health often prioritise increasing facility delivery rates. Pressure on local implementers to meet GHI goals may lead to unintended programme features that could negatively impact women. This study investigates penalties for home births imposed by traditional leaders on women during the implementation of Saving Mothers, Giving Life (SMGL) in Zambia. Forty focus group discussions (FGDs) were conducted across four rural districts to assess community experiences of SMGL at the conclusion of its first year. Participants included women who recently delivered at home (3 FGDs/district), women who recently delivered in a health facility (3 FGDs/district), community health workers (2 FGDs/district) and local leaders (2 FGDs/district). Findings indicate that community leaders in some districts-independently of formal programme directive-used fines to penalise women who delivered at home rather than in a facility. Participants in nearly all focus groups reported hearing about the imposition of penalties following programme implementation. Some women reported experiencing penalties firsthand, including cash and livestock fines, or fees for child health cards that are typically free. Many women who delivered at home reported their intention to deliver in a facility in the future to avoid penalties. While communities largely supported the use of penalties to promote facility delivery, the penalties effectively introduced a new tax on poor rural women and may have deterred their utilization of postnatal and child health care services. The imposition of penalties is thus a punitive adaptation that can impose new financial burdens on vulnerable women and contribute to widening health, economic and gender inequities in communities. Health initiatives that aim to increase demand for health services should monitor local efforts to achieve programme targets in order to better understand their impact on communities and on overall programme goals.

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

“…5,6,30,38 † Both home-birth fines and userfees place the burden on poor women and increase health system inequity, as confirmed by a longstanding and growing body of evidence on the negative implications of user-fees, 8,9 and the recent studies on home-birth fines. 40 We showed that different actors are frustrated about userfees and their impact on the poor, especially because in Malawi non-institutional deliveries have become strongly associated with maternal deaths. 6 Our analysis highlights issues of intersectionality, with different social locations, power relations and experiences converging to shape inequity.…”

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

“…Only when we analyse power relations from the global to the local level, and how these dynamically interact with policies, can we understand how inequities are shaped. Following other scholars, 7,11,36,43,44 we make a couple of suggestions towards more equitable health systems. First, utilising ethnography can generate a better understanding of the complex interactions between policy and dynamic power relations.…”

“…Reduced trust in health workers and the government might have broader consequences of trust in public services and society more generally. 43 Our analysis has shown the need for considering aspects of power, health systems functioning and financing at the global, national and local level 44 to understand how health policies are implemented and what the consequences may be. 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.…”

Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi

“…The successful reduction of the maternal mortality ratio in Malawi, from 957 deaths per 100,000 live births in 1990 to 634 deaths per 100,000 live births in 2015, is often attributed to the community involvement approach and in particular, the fine system used by local chiefs [ 11 ]. The application of fines for home births is not unique to Malawi; it is reported in Zambia [ 12 ], Burkina Faso [ 13 ] and Tanzania [ 14 ], among others. In an evaluation of strategies to increase health facility deliveries, Butrick et al [ 11 ] suggest that a fine-based system is generally considered appropriate because it is more affordable for a developing country like Malawi, than an incentive system (e.g.…”

“…Furthermore, it is assumed that, because fining within the chiefs system in Malawi is embedded in traditional ways of regulating social behaviours, fines for women in the field of maternal health are socially acceptable. Health system actors may also justify penalties as a fair response to home delivery as communities have been educated about the importance of facility delivery [ 12 ]. Some authors, however, raise critical questions about the use of penalties as incentives to influence health-seeking behaviour.…”