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Table 5 Case studies

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

Case 1: Home births and delays in arriving at health centres: individual versus collective responsibility.
There was disagreement among participants on whether it was appropriate to penalise individual women for home births and late arrivals at the health centre or whether families, chiefs and communities should be held accountable. According to two male councillors, the community, in particular the chiefs should be fined as “it is their job to save mothers” and they are the ones responsible for the promotion of institution-based deliveries. The anticipation of punishment for chiefs would allow them to increase their efforts and it would be a way to hold them accountable. Others, however, proposed the punishment should apply to the family of the woman, including the husband, as barriers to reach the health facility in time are most likely related to familial circumstances. Moreover, husbands are the ones who need to assist with potential blood transfusion and transport in case of complications and they are directly responsible for maternal survival. A clinician and a nurse did not want to blame the husbands as they usually are willing to release money and join their wives but it is guardians (a pregnant woman’s family member or elderly woman accompanying them to the clinic) who intentionally delay women, and who promote home births.
Case 2. Delay in arriving at the health centre: universality versus unique circumstances.
Health workers held nuanced views regarding the conditions under which women should be punished or not for arriving late for childbirth. For example, a male clinician and a female nurse argued that exceptions should be made for women living far away from the health centre. Other health workers were of the opinion that punishment should not be routine practice because “birth cannot be predicted” and “there can be miscalculations in due date”. Another female nurse argued that poor families compare the costs of coming early to the maternity waiting home and coming late and decide to come just before the delivery to save costs. She insists the task of a health worker is to understand the reasons for late arrivals of women before making a judgement. In two FGDs, health workers agreed that they should help women regardless of their timing to attend the facility. Hospital attendants and health surveillance assistants, but also some male and female nurses, emphasise that advising and counselling is better than punishing since this fits better the potential personal circumstances of women as well as facility circumstances, as explained by a male health worker: “The way it is here, the maternity ward is small, and many people also sleep on the floor, it’s your luck sometimes that a person comes when it’s already time to give birth. She has left the space for other women, others come from faraway places, so you see she lightens your burden in that she will give birth just three days and she is out” (male environmental officer HF1).