The “Sustainability Doctrine” in Donor-Driven Maternal Health Programs in Tanzania

Strengthening health systems to provide equitable, sustainable health care has been identified as essential for improving maternal and reproductive health. Many donors and non-governmental organizations (NGOs) have contributed to undermining health system strengthening, however, through adhering to what Swidler and Watkins call the “sustainability doctrine,” policies that prioritize time-limited, targeted interventions best suited for short-term funding streams, rather than the long-term needs of local populations. This chapter presents ethnographic data from semi-structured and key informant interviews with 16 policymakers and NGO directors in Dar es Salaam, Tanzania from 2011 to 2012. I illustrate how sustainability doctrine policies were put into practice, and how they have persisted, despite their shortcomings, using examples of donor-prioritized maternal healthcare initiatives in Tanzania rolled-out several years apart: prevention of mother-to-child transmission of HIV (PMTCT) and basic emergency obstetric and newborn care (BEmONC) programs in the late 2000s, and more recent efforts to implement respectful maternity care (RMC) programs. I focus on several issues informants identified as crippling efforts to build strong health systems, particularly the internal brain drain of healthcare workers from the public sector to higher-paying NGO jobs, and the prioritization of types of programs donors believed could be sustained after the funding period ended, specifically trainings and workshops. I describe how despite these issues, international organizations still design and implement less effective programs that often fail to account for local circumstances in their efforts to solve some of the more intractable health issues facing Tanzania today, in particular, the country’s stagnating maternal mortality rate. In this chapter, I argue that practices promoted and implemented under the guise of “sustainability” in policy papers and reports generated by donors paradoxically contribute to health system precarity in Tanzania.

Introduction

This edited volume treats policy as an ethnographic object. Examining both policy spaces and sites of practice, the chapters illuminate both professionals’ and lay people’s intimate encounters with health policies. By ‘studying up’ and considering the multiplicity of actors and interests involved in global policies for improving maternal and reproductive health, the ten chapters in this volume track the processes and politics of policymaking and the mechanisms of their implementation in diverse contexts in Asia, Africa, Europe and South America. The chapters provide in-depth analyses of the complexities of policy formulation and implementation, the impact of socio-political contexts, as well as issues of local agency, equity and accessibility. Together, they demonstrate the value of ethnography as well as reproduction as a unique site for the generation of rich insights into the working of global health policies and their impacts. Such critical social science research is increasingly recognised as a crucial part of the evidentiary basis upon which people-centred and equitable health policy and systems everywhere are built. This volume will be of interest to scholars working at the intersection of critical global health, medical anthropology, and health policy and systems research, as well as to global public health practitioners.

The International Childbirth Initiative: An Applied Anthropologist’s Account of Developing Global Guidelines

This chapter describes my personal experiences as an applied anthropologist serving as the lead editor in the development of a set of international guidelines focused on improving quality of maternity care: the International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care (2018). The ICI’s purpose is to encourage global awareness and local implementation of the MotherBaby-Family Model of Care. This is a model based on women’s rights and humane, respectful, family-centered care. The ICI’s creation story is continuous with global movements to improve the quality of maternity care and with a deep history of birth activism by practitioners, public health advocates, and social scientists aimed at decreasing unnecessary medical intervention in childbirth. This narrative is widely relevant for understanding how to develop and implement global guidelines that can flexibly adapt to local contexts. The ICI was developed by the merging of the 2015 FIGO Guidelines to Mother-Baby Friendly Birthing Facilities with the pre-existing International MotherBaby Childbirth Initiative (IMBCI) in an intense and rewarding group process. The chapter discusses factors that contributed to the successful development of clear global guidelines for high-quality maternity care. These include attention to process, alignment with key values of the women’s health and midwifery movements, multilevel collaboration and networking around a clear vision, garnering input from many people with diverse voices and perspectives, and patience with and commitment to the tasks at hand.

Selling Beautiful Births: The Use of Evidence by Brazil’s Humanised Birth Movement

Maternal health care continues to be excessively medicalised in many national health systems. Global, national, and local level policy initiatives seek to normalise low-risk birth and optimise the use of clinical interventions, informed by strong evidence supporting care that is centred on women’s preferences and needs. Challenges remain in translating evidence into practice in settings where care is primarily clinician-led and hospital-based, such as in Brazil.I conducted an ethnography of the movement for humanised care in childbirth in São Paulo between 2015 and 2018. I draw on interviews and focus groups with movement members (including mothers, doulas, midwives, obstetricians, politicians, programme leads, and researchers), and observations in health facilities implementing humanised protocols, state health council meetings, and key policy fora (including conferences, campaigning events, and social media). Key actors in this movement have been involved in the development and implementation of evidence-based policy programmes to “humanise” childbirth. Scientific evidence is used strategically alongside rights-based language, such as “obstetric violence”, to legitimise moral and ideological aims. When faced with resistance from pro-c-section doctors, movement members make use of other strategies to improve access to quality care, such as stimulating demand for humanised birth in the private health sector. In Brazil, this has led to a greater public awareness of the risks of the excessive medicalisation of birth but can reinforce existing inequalities in access to high-quality maternity care. Lessons might be drawn that have wider relevance in settings where policymakers are trying to reduce iatrogenic harm from unnecessary interventions in childbirth and for supporters of normal birth working to reduce barriers to access to midwifery-led, woman-centred care.

Making Space for Qualitative Evidence in Global Maternal and Child Health Policymaking

The success of health interventions often hinges on complex processes of implementation, the impact of sociopolitical and cultural contexts, resource constraints and opportunity costs, and issues of equity and accountability. Qualitative research offers critical insights for understanding these issues. “Qualitative evidence syntheses” (or QES)—modeled on quantitative systematic reviews—have recently emerged as an important vehicle for integrating insights from qualitative evidence into global health policy. However, it is challenging to integrate QES into policymaking in ways that are both acceptable to the often-conservative health policy world and consonant with social science’s distinctive methodologies and paradigms. Based on my experiences participating in and observing numerous guideline working group meetings and interviews with key informants, this chapter offers an auto-ethnographic account of an effort to integrate QES into the World Health Organization’s global OptimizeMNH guidelines for task shifting in maternal and newborn health (MNH). It is based on my experiences participating in and observing numerous guideline working group meetings as well as interviews with several key informants. Advocates of QES were successful in helping to make a place for qualitative evidence in this global guideline. Their work, however, required a delicate balance between adopting quantitatively inspired methods for evidence synthesis and innovating new methods that would both suit the project needs and be seen as legitimate by qualitative researchers. This case study of the development of one WHO guideline does not signal a revolution in knowledge production, but it does show there remains room—perhaps growing room—for a more expansive vision of what forms of knowledge need to be on the table when developing global health policy.

The Promise and Neglect of Follow-up Care in Obstetric Fistula Treatment in Uganda

Considered the most severe of maternal morbidities, obstetric fistula is a debilitating childbirth injury that results in complete incontinence with severe physical and psychosocial consequences.The primary intervention for women with obstetric fistula is surgical repair, and success rates for repair are reported between 80% and 97%. However, successful treatment is commonly defined solely by the closure of the fistula defect and often fails to capture women who continue to experience urinary incontinence after repair. Residual incontinence post-fistula repair is both underreported and under-examined in the literature. Through a novel mixed-method study that examined clinical, quantitative, and qualitative aspects of residual incontinence post-repair, this chapter draws on in-depth interviews with women suffering with residual incontinence and fistula surgeons, participant observation, and a desk review of fistula policies and guidelines to argue that an inadequate model of fistula treatment that neglects follow-up care exists. We found that obstetric fistula policy has been determined in large part over the years by international development agencies and funding organizations, such as international nongovernmental organizations (INGOs). We argue that the neglect in follow-up care is evident in fistula policy and can be traced to a donor-funded treatment model that fails to prioritize and fund follow-up care as an essential component of fistula treatment, instead focusing on a “narrative of success” in fistula treatment. As a result, poor outcomes are underreported and women who experience poor outcomes are largely erased from the fistula narrative. This erasure has limited the attention, resources, research, and dedicated to residual incontinence, leaving out women suffering from residual incontinence largely without alternative treatment options.

Regulating Midwives: Foreclosing Alternatives in the Policymaking Process in West Java, Indonesia

Promotion of “skilled birth attendants” (SBAs) in global maternal health policy has prompted a range of policy responses to “traditional birth attendants” (TBAs). In Indonesia the response has been to develop a national policy of partnership between SBAs (bidan) and TBAs (dukun bayi). This policy aims to ensure the presence of an SBA at every birth yet offers a role for TBAs. In this chapter I examine the development of a district regulation on partnership, promoted within the context of decentralization policies enacted in Indonesia from 1999. The district regulation aimed to strengthen the national policy in a location in West Java where TBAs remain popular. Drawing on 10 months of fieldwork from 2012 to 2013 at a district health office and on observations of its outreach programs, I elucidate how the regulation on partnership was promoted through the policy entrepreneurship of certain key figures in the district health office. They argued that the partnership regulation was the fastest means to improve maternal health. But casting a spotlight on the relationship between SBAs and TBAs diverted attention away from other health system challenges including under-resourced medical facilities and a weak referral system. Three contexts played into this process of bringing the partnership issue to the fore: global policies promoting SBAs and sidelining TBAs; pressure to achieve the Millennium Development Goal (MDG) on maternal mortality; and the limited financial power and decision space afforded to districts under decentralization in Indonesia. In this context, the regulation offered a viable path for demonstrating commitment to improving maternal health outcomes, yet one that failed to address broader constraints in the health system that contribute to persistent high maternal mortality rates.

Conflicted Reproductive Governance: The Co-existence of Rights-Based Approaches and Coercion in India’s Family Planning Policies

India’s current population policy is situated between two conflicting discourses of population management, one that is governed by a demographic rationale advocating strict State regulation of fertility, and the other that is delineated by a rights-based framework that promotes individual reproductive choice and bodily autonomy. In this chapter, I show how this conflicted policy discourse becomes supportive of processes that empower the State, rather than facilitate reproductive autonomy among claimants on the ground. The chapter draws on textual analysis of policy and programme documents and discussions with health providers, users and policy makers during long-term fieldwork in the state of Rajasthan. I show that, in their role in promoting regional state directives on reproductive health policies, health workers are at once agents and subjects of State policy processes and of their community’s ideologies, preferences and practices related to childbirth and reproductive care. It is in their work and embodied practice of family planning that we most clearly evidence the implications of ‘conflicted reproductive governance’. When health workers struggle for their own remuneration and recognition, the State’s rights-based health policy objectives will remain unreachable.

The Domestication of Misoprostol for Abortion in Burkina Faso: Interactions Between Caregivers, Drug Vendors and Women

Misoprostol has been hailed as a revolution within global maternal health research and policy communities because of its potential to reduce maternal mortality from post-partum haemorrhage and unsafe abortion, allowing relatively safe abortion in legal and illegal settings. However, we know little about how women who want to use misoprostol access it to induce abortion. Based on 15 months of ethnographic fieldwork in Ouagadougou, Burkina Faso, this chapter describes and analyses how women gain access to misoprostol to induce abortion within a setting where induced abortion is legally restrictive and where the legal use of misoprostol is limited to post-abortion care and post-partum haemorrhage. The findings show that women seeking abortions in Ouagadougou are able to access misoprostol through unofficial channels, specifically through health workers and drug vendors. While this unofficial use of misoprostol is relatively safer, and more affordable than other options, access is not equally distributed and the cost women pay for the drug varies significantly. While women with strong social networks and financial resources can access misoprostol easily, other women who do not have money to buy misoprostol may become victims of sexual violence from men from whom they seek abortion services. In Ouagadougou, access to abortion with misoprostol is shaped by health workers and the social and economic conditions of the women who seek it. The study uses the concepts of ‘pharmaceutical diversion’ and ‘domestication’ as adjacent analytical frameworks to emphasize the changing pattern of access to misoprostol. The chapter introduces the importance of looking at safe access to safe abortion.

Baby (Not So) Friendly: Implementation of the Baby-Friendly Hospital Initiative in Serbia

The WHO and UNICEF launched The Baby-Friendly Hospital Initiative (BFHI) in 1991 with the goal of promoting breastfeeding. Four years later, this initiative was adopted in Serbia (then Yugoslavia). Although Serbia has officially been a part of the BFHI for over 26 years, less than 13% of children are currently exclusively breastfed for the first 6 months of life. Drawing on interviews, observations and document review, this chapter offers ethnographic insight into why the BFHI in Serbia has met with little success. I argue that the principles and practices of the initiative to promote breastfeeding have been both thinly learned and thinly applied by healthcare workers and therefore have had little positive impact on women’s empowerment to breastfeed or the rates of breastfeeding in the country. I show how the global Baby-Friendly Hospital Initiative implemented in Serbia in the early 1990s and the national level policies which renewed it in 2018 were severely constrained by social, political and economic conditions that hindered the uptake of the program by frontline health workers – namely the devastating effects of the civil war and international sanctions in the 1990s, and the deleterious effects of IMF policies on the Serbian healthcare system since the 2000s. The pressure of time due to high workloads, and understaffed hospitals, in combination with unsustainable national funds for implementation may contribute to the reality of the thin implementation of BFHI.