Reinforcing marginality? Maternal health interventions in rural Nicaragua

Abstract

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.

Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua

“…Creating health services that are culturally sensitive and adapted to population needs should be a priority to encourage in-facility deliveries [ 33 ]. Because perceptions and beliefs about the capacity of health facilities can affect care-seeking for delivery services, the need to reduce cultural barriers that affect the utilization of delivery services may persist, as has been suggested by other studies in the region [ 34 ]. Furthermore, the decision to give birth in a health facility is not necessarily individualized: the woman’s partner, family and others in her community may also play a role [ 35 ].…”

Towards renewed commitment to prevent maternal mortality and morbidity: learning from 30 years of maternal health priorities

“… 40 Women desiring home births were reluctant and expressed concerns about inattention and neglect from hospital personnel and assessed these health facilities as incapable of providing good and appropriate care. 40 , 41 In response to women preferring home births despite the government emphasising facility births, public health officials referred to these women as ignorant and troublesome. Forced implementation of the policy disregarded the social, cultural, and economic accessibility for the most marginalised populations, engendering resistance to facility-based birth, and making women hide their pregnancies from local health facilities, 41 which may have contributed to delays in care-seeking, even in the case of complications.…”

Inner peripheries: dealing with peripherality and marginality issues within the European policy framework

“…the 1st and 2nd Cohesion Thematic Objectives and 6th Rural Development Priority funds). Indeed, nowadays the information and communication technology are essential to improve the smallholders' competitiveness (Townsend, Wallace, & Fairhurst, 2015), and services such as the telemedicine (Whitacre, Wheeler, & Landgraf, 2017), and finally guarantee a prompt and continuous health care interventions (Balestrieri et al, 2019;Kvernflaten, 2019).…”