Abstract
Health inequities are a growing concern in low- and middle-income countries, but reducing them requires a better understanding of underlying mechanisms. This study is based on 42 semi-structured interviews conducted in June 2018 with women who gave birth in the previous year, across rural and urban clinic sites in Mansa district, Zambia. Findings show that health facility rules regulating women's behaviour during pregnancy and childbirth create inequities in women's maternity experiences. The rules and their application can be understood as a form of social exclusion, discriminating against women with fewer financial and social resources. This study extends existing frameworks of social exclusion by demonstrating that the rules do not only originate in, but also reinforce, the structural processes that underpin inequitable social institutions. Legitimising the rules supports a moral order where women with fewer resources are constructed as “bad women”, while efforts to follow the rules widen existing power differentials between socially excluded women and others. This study's findings have implications for the literature on reversed accountability and the unintended consequences of global and national safe motherhood targets, and for our understanding of disrespectful maternity care.
Highlights
The maternal health literature’s excessive focus on individual-level barriers to maternal healthcare access may have fuelled individual-level approaches to addressing maternal health inequities (Gabrysch and Campbell, 2009; Moyer and Mustafa, 2013)
Understanding mechanisms may depend on including power processes in our analyses, a rare occurrence in the Low- and Middle-Income Countries (LMICs) health policy and disrespectful maternity care literatures (Bradley et al, 2016; Sriram et al, 2018)
This study found that health facility rules form an important part of participants’ experience of pregnancy and childbirth and have inequitable effects
Summary
The maternal health literature’s excessive focus on individual-level barriers to maternal healthcare access may have fuelled individual-level approaches to addressing maternal health inequities (Gabrysch and Campbell, 2009; Moyer and Mustafa, 2013). Despite the growing prioritisation of health equity, intra-country inequities in access to maternal healthcare services in Low- and Middle-Income Countries (LMICs) remain larger and are reducing at slower rates than inequities in other primary healthcare areas (Boerma et al, 2018). Given this comparative lack of progress, we need to better understand the underlying mechanisms producing inequities in order to inform policy (Friedman and Gostin, 2017; Krieger, 2001; Wainwright and Forbes, 2000). Understanding mechanisms may depend on including power processes in our analyses, a rare occurrence in the LMIC health policy and disrespectful maternity care literatures (Bradley et al, 2016; Sriram et al, 2018)
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