By Julianne Weis
If you follow the world of global health policy, particularly the debates surrounding maternal health and the ever-looming race to meet Millennium Development Goal number 5, it is easy to assume that the reason there are such poor indicators for maternal health across lower-income countries is that women are simply refusing care out of ignorance, cultural bias, and economic restrictions. This story is sounded repeatedly in regards Ethiopia, where less than 10% of women deliver with a medical assistant at hand. But the onus to change such indicators is often placed fully on the women, and we need to give them vouchers, get rid of their domineering husbands, and even pay them to attend ante-natal clinics and labour wards.
In some instances each of these solutions can work. However, they are by no means as universal fixes, as some in the development community often assumed. Not only does this narrative take away the agency of women, it also neglects the other side of the equation – the nature of care provided. It ignores what should be a fundamental question: why don’t we ensure that maternal health services are actually appealing to pregnant women?
In many cases, even in Ethiopia, with over 80% of the population living in rural areas, it is not mere financial stress or lengthy distance from a health clinic that prohibits women from attending. The care provided in clinics and hospitals is often so far divorced from the type of aid that women want that there is no incentive to attend unless a dire health emergency occurs, and all other options have been exhausted.
Childbirth is an excruciating process: a woman is placed in a position of incredible vulnerability, and the agonizing pain can be unrelenting and frightening. This is not a situation where you want to be in a strange environment with people talking down to you, often in a language you don’t understand, where your family is left outside and you are alone and subjected to seemingly alien procedures. Commentators are increasingly deriding the public health discourse for neglecting the importance of quality of care, but it’s not merely the quality that is at stake, yet also the appropriateness of care. Are we providing an environment of care that women actually want?
Even though so few women in Ethiopia give birth in a clinic/hospital setting, this is not without long effort: midwives and health extension workers have been trained and are now operating in 70% of kebeles nationwide – a legacy of a programme developed in the 1950s to train community health workers, nurses, and sanitarians at the Gondar Public Health College. So, for the last sixty years public health workers have campaigned for women in Ethiopia to attend ante-natal classes and deliver their babies in clinics and hospitals.
Why has this unrelenting effort mostly failed?
Concerns over economic constraints and distance from facilities are no doubt limiting factors, but this conclusion takes away the agency and responsibility of Ethiopian women. If the clinic-based care was an attractive option for women and perceived as a necessity, it would compete more evenly with the home-based model of birth that women overall prefer. Home births in Ethiopia vary vastly by region, from husbands and wives squatting together, to groups of women invoking the Virgin Mary in collective prayer at the parturient’s home. These types of interventions and models of birth are left out of the clinic. And, even though they are low-technology and cost-free, they are never included in the medical mode of delivery. But these are the interventions that women seek after for whilst vulnerable in the sways of birth pains.
Birth is not a mere biological process, and focusing solely on the physiological needs of Ethiopian women has limited the reach of clinics and hospitals to deliver what could be life-saving interventions. It is not a matter of convincing women to come to clinics through propaganda and cash transfers, but providing an environment that is actually amenable to women, where they can actually benefit from the care provided.