Many women in pregnancy receive advice from health workers, communities and public medical institutions. Despite efforts to improve maternal health in Zambia, rules governing the antenatal period for women can have a detrimental impact. Public health bodies should take note that the toll of being unable to follow the rules can lead to women’s social exclusion and stigmatisation.
My recent research shows that, in the Zambian context, health facility rules have inequitable consequences for women’s pregnancy and childbirth experiences. Evidence from other authors’ research suggests that these rules are the ‘unintended’ consequences of global and national safe motherhood targets.
In Zambia the rules for women include: not doing physical work in pregnancy, giving birth in a health facility, taking a taxi home after the birth, bringing the father of the baby to register the pregnancy, eating well, bringing materials to the delivery such as industrial disinfectant, a plastic sheet or a cord clamp, and many more. Women with fewer financial resources and social support struggle to follow these rules, often making financial sacrifices (borrowing on future wages to pay for transport to the facility), physical sacrifices (working hard in the fields to store food for the post-partum period) or relational sacrifices (going to the facility despite not having the right clothes).
Women who are unable to follow all the rules often feel guilty about putting their own or their baby’s health at risk, experience shame and may be stigmatised or punished by health workers. Punishments include fines, exclusion from accessing healthcare, being shouted at, threats to impose a C-section, and more.
For example, a rural respondent describes both the heavy work she had to undertake during pregnancy in order to follow the rule about eating well, and the shaming she endured from the midwife as a result of breaking the rule about only undertaking light work.
’I hated work, I just used to work because when I give birth I would stay a lot of days [not working] … eating in this village it is food from the bush [so no work means no food].’ … I got sick, I even went back to the clinic, at the clinic they asked me…
Midwife: ‘were you doing any work when you were pregnant?’
’Emukwai I was working,’
Midwife: ‘But we don’t allow you that’s what has caused you to get sick. Medicine, I will not give you any medicine, that is work paining, it has brought you sickness. We refuse [don’t allow] you [to work] when you are pregnant.’
The findings show that these women, as a result, are also likely to be stigmatised by other lay people at the facility or in their community. ‘Rule breakers’ are described by other women as lazy, careless, ignorant or disrespectful.
Public health rules as engines of social exclusion
The idea that moralised health discourses can contribute to social exclusion extends far beyond the Zambian context. In the UK, for example, a rule about breastfeeding is particularly fraught. There is currently a lot of debate about the mental health impact of messages that frame breastfeeding as ‘the only responsible choice’. Going beyond the maternal health field, recent articles make the same point around healthy eating among US teenagers and worldwide hygienic practices. In many cases, public health campaigns attempt to change people’s behaviour with moral arguments, without sufficient recognition of the structural barriers faced by some population groups. There is also a pervasive culture of coercing people ‘for their own good’, through soft (social control) or hard means (fines).
Implications for public health
So what is public health to do? In Zambia, district health officers were convinced that these rules helped to decrease health facility deliveries and maternal deaths, despite the national government’s condemnation of their coercive application. Whether in maternal health, nutrition or sanitation, the rules reveal an apparent tension between ‘saving lives’ and social justice. In reality this tension may not exist. Research should further investigate whether lower mental and social well-being in pregnancy and childbirth leads to worse health outcomes. Further, while the rules may improve average levels of access and outcomes, the most disadvantaged could lose out, thereby increasing inequities.
Even if the tension is real in a given context, it is not immutable. The rule about bringing materials to the health facility may save lives in a Zambian context where facilities lack the resources to provide these materials themselves. But while the health worker has no choice but to tax women in this way, the country (and donors) could decide that such a tax is regressive and materials should be paid for by the state. The ways in which rules are formulated and enforced can tell us more about prevailing power relations than morally neutral public health problems.
Photo: Woman preparing vegetables in Mongu, Zambia. Credit: Worldfish.