Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University and Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, the Netherlands.
VU University, Amsterdam, the Netherlands.
Int J Equity Health. 2018 Sep 24;17(1):131. doi: 10.1186/s12939-018-0848-3.
This 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.
Findings 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.
In 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.
The 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.
本文旨在探讨传统权威在马拉维北部两个母婴健康项目中的作用。在改善母婴健康的策略中，这些权威机构制定了附则：地方规则，以增加产前和分娩护理的利用率。本研究使用性别制度框架批判性地评估附则的内容、过程和影响，并了解责任和问责制是如何构建、协商和扭转的。
研究结果基于在马拉维北部五个卫生中心集水区进行的一项定性研究。使用会议观察和文件搜索、36 次半结构化个人访谈和 19 次焦点小组讨论收集数据，这些访谈和讨论对象是女性母婴健康服务使用者、男性社区成员、卫生工作者、传统领袖、地方官员和卫生委员会成员。进行了性别和权力敏感的主题分析，重点关注附则的制定、解释和执行过程及其对男女的影响。
在研究地区，传统领袖引入了三项附则，规定孕妇必须参加产前护理；带丈夫一起去；并在卫生中心分娩。如果妇女不遵守这些规定，她们有被罚款或被拒绝获得母婴健康服务的风险。研究结果表明，责任和问责是协商的，附则并非统一适用。虽然地方官员支持附则，但较低级别的卫生干部和一些社区成员对附则提出了质疑，特别是对个人责任和普遍性原则提出了质疑。
该研究为研究不足的附则现象提供了新的证据。从性别角度来看，附则存在问题，因为它们将孕产妇保健的责任个体化，并在制裁的定义和适用方面歧视妇女。通过附则，在国家政策和国际机构的支持下，妇女承担了孕产妇保健失败的全部责任，这表明妇女对全球孕产妇健康目标的责任出现了“反向问责”的形式。这可能会对妇女的生殖健康权利产生负面影响，并阻碍实现性别不平等和健康公平的目标。在卫生政策制定和规划以及问责制改革中进行有针对性的性别和权力分析，可以帮助发现这些挑战和潜在的意外影响。
