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

Abstract

BackgroundThis paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws: local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed.MethodsFindings are based on a qualitative study in five health centre catchment areas in Northern Malawi. Data were collected using meeting observations and document search, 36 semi-structured individual interviews and 19 focus group discussions with female maternal health service users, male community members, health workers, traditional leaders, local officials and health committee members. A gender and power sensitive thematic analysis was performed focusing on the formulation, interpretation and implementation process of the by-laws as well as its effects on women and men.ResultsIn the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres’ and some community members contest them, in particular, the principles of individual responsibility and universality.ConclusionsThe study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, women bear the full responsibility for failures in maternal health care, suggesting a form of ‘reversed accountability’ of women towards global maternal health goals. This can negatively impact on women’s reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. Contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.Electronic supplementary materialThe online version of this article (10.1186/s12939-018-0848-3) contains supplementary material, which is available to authorized users.

Increasing male engagement in the prevention of vertical transmission of HIV: what works in sub-Saharan Africa?

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“…These effects could have unintended consequences on uptake of maternal services and overall maternal and child health. In extreme cases, denying antenatal care services to women who present without male partners (whether by protocol or by overzealous practitioners) can discourage uptake and hinder access to early initiation of maternal care 912 13…”

“…Allowing women to define the role(s) they want their partner to have in vertical transmission prevention9 13 21…”

Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study

“…Socio-cultural norms and gender stereotypes have been known to influence the uptake and utilization of maternal health services [1][2][3]. This is thought to be through the effect of gendered social roles, the dynamics of vulnerability inherent in existing social structures, as well as negative socio-cultural norms [4,5]. The resultant outcome is attitudes and behaviors that affect, among others, pregnancy intention and attendant uptake of contraceptive services; as well as perceptions of what constitutes a normal birthing process, and the eventual decision-making regarding choice of place of delivery [6].…”