Anthropologies of Global Maternal and Reproductive Health

Front matter

Global Maternal and Child Health Medical, Anthropological, and Public Health Perspectives Series Editor: David A. Schwartz

Lauren J. Wallace

Margaret E. MacDonald Katerini T. Storeng Editors

Foreword

One of the more important lessons I learned as a medical anthropologist came from work on maternal mortality that Oyuna Chuluundorj and I did in Mongolia. Oyuna, who had left her position as an Obstetrician Gynecologist in the Mongolian health system to study medical anthropology, was troubled by increases in maternal morbidity and mortality after Mongolia transitioned from Soviet-style socialism to neoliberal capitalism. As we began to investigate this problem it became increasingly clear that we were not simply dealing with a public health or health system problem, but with a complex set of linked social, economic, and political processes that were increasing the vulnerability of women, particularly those living in rural areas. We learned how fraught the policy-making process is in the domain of maternal and reproductive health given its entanglements with local social norms as well as global ideologies. In short, we learned, as the authors of this volume show clearly across multiple contexts, that a focus on maternal and reproductive health is a powerful and revealing lens through which one can investigate social changes, power, gender relations, political economy, and institutional dynamics within particular contexts. It throws into sharp relief the contested and error-prone terrain of global health policy as it is implemented in different places, and questions the conventional wisdom that maternal and reproductive health are simply the province of health (medical) care systems.

The contributors to this volume underscore the need to engage with “sites of practice,” local contexts, and lived experiences. They show how policies are created and implemented, questioning both the evidence base drawn upon in crafting policy and the problems that occur when policies travel globally without critical appraisal of variable relevance or implementation processes. Importantly, this volume moves medical anthropology in a useful new direction, showing how bridging and blending health policy and systems research with ethnography can yield useful insights about what works — or does not — to improve maternal and reproductive health, and why. It adds additional voices and perspectives on the policy process as it looks from “below.” Yet while we might hope for a world where local voices and lived experience comprise the primary evidence base for developing policy, in fact policymaking is far more complicated than this and requires both careful analysis and advocacy. This volume offers steps forward for doing this.

Precisely because ethnography has proven to be such a useful approach to understanding the “local” manifestations of health policy, medical anthropology has emerged as what I believe is the leading social science of global health. This volume

vu viii Foreword clearly advances this contribution. In order to understand the impact of health policies on maternal and reproductive health, the key features of a critical global health are identified and examined. These include careful considerations of the social patterning of risk and response; the global circulation of technologies, including pharmaceuticals; the politics of evidentiary processes — what evidence counts, why, and to what effects; exposure of how universal, global policies have uneven, unanticipated, and potentially harmful effects; and the many ethical concerns that emerge with any indiscriminate implementation of policy created in the absence of contextual grounding. The problems of rights, of fairness, and of socially and economically structured inequalities emerge again and again as obstacles to the development of accessible, effective, responsive, and salutogenic health systems.

Of concern, and despite decades of work exhibiting the importance of a biosocial approach, the authors demonstrate that the field of maternal and reproductive health remains prone to the continual and contested pull of technocratic, biomedical solutions. Although there is clear evidence that non-biomedical approaches to birth — for example, midwifery, “humanized” birth, baby-friendly hospitals, doula programs — contribute to better outcomes in terms of maternal and neonatal health, the biomedical imperative of many health systems persists in capturing and regulating reproductive processes. We continue to grapple with global health policies that mandate single-mindedly and uncritically skilled attendance at birth, even though this is only one means for safe and humane delivery, not to mention that what counts as “skill” can be questioned, particularly if there is little attention to other needs — safe, clean, and properly equipped facilities, for example.

Given the subject of inquiry and its centrality to health and, more broadly, the human condition, a focus on maternal and reproductive health is shot through with politics, ideologies, and moral judgments. Controversy emerges here and there: misoprostol, a life-saving drug when used to control postpartum bleeding, for example, may also be deployed as an abortifacient and subject to legal proscriptions; instances of maternal mortality may be used as instruments to discipline providers and government officials, as Oyuna and I found in Mongolia, leading to blame-shifting and underreporting rather than efforts to address causes and identify solutions.

Maternal and reproductive health policy contends with a domain where health outcomes in terms of death and disability reveal astonishing and deeply troubling levels of inequity. It is well known that the risk to a woman in the global “south” of dying in childbirth or suffering a life-changing and stigmatizing disability such as obstetric fistula is many hundreds of times greater than the risk faced by a woman in Europe or North America. These epidemiologic facts reveal a level of social suffering that has no parallel in global health. While there has been some improvement over the past few decades, much more needs to be done. Questioning maternal and reproductive health policy is a critically important area of work. The contributions to this book reveal some of the paths we may take to move toward a healthier world.

Professor and Director Craig R. Janes School of Public Health Sciences

Waterloo, ON, Canada

Acknowledgments

The editors and authors thank participants in the “Ethnographic Examinations of Global Maternal and Child Health Policy and Practice” panel at the American Anthropological Association annual meeting in Washington, DC, in 2017, many of whom have contributed in various ways to this book. We extend our thanks to numerous anonymous chapter reviewers, and to Jean-Pierre Olivier de Sardan, D. Ann Herring, Philip B. Adongo, and Bregje de Kok for insightful comments. The editors would like to express their gratitude to their Springer Editor, Janet Kim, who patiently provided editorial expertise, and our energetic and sage Springer Series Editor, David Schwartz, who contributed kind advice without which the book would not have come to fruition. We would also like to thank our families for loving support during the preparation of this book.

We are grateful to York University; the Centre for Development and the Environment at the University of Oslo; the Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town; the University of Sussex; and the Wellcome Trust [105011/Z/14/Z], in addition to Ljiljana Pantović, Priscilla Magrath, Lauren J. Wallace, and Meredith G. Marten, who generously contributed funds to make this book open access.

Contents

Lauren J. Wallace, Margaret E. MacDonald, and Katerini T. Storeng

Part I Implementation Disconnects and Policy Rhetoric Baby (Not So) Friendly: Implementation of the

Ljiljana Pantović

The Promise and Neglect of Follow-up Care in

Bonnie Ruder and Alice Emasu

The Domestication of Misoprostol for Abortion in Burkina Faso:

Seydou Drabo

The “Sustainability Doctrine” in Donor-Driven Maternal Health

Meredith G. Marten

Part II Policy Ambivalence The Place of Traditional Birth Attendants in Global

Margaret E. MacDonald

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

Planning Policies... 42404 is05 a¢ceeuat sauces test E ied aes

Maya Unnithan xi

Part I Contesting Authoritative Knowledge and Practice

Regulating Midwives: Foreclosing Alternatives in the

Priscilla Magrath Making Space for Qualitative Evidence in Global Maternal

Christopher J. Colvin

PartIV The Rise of Evidence and Its Uses

The International Childbirth Initiative: An Applied

Anthropologist’s Account of Developing Global Guidelines. . . .

Robbie Davis-Floyd Selling Beautiful Births: The Use of Evidence by Brazil’s

Lucy C. Irvine

Contents

Editors and Contributors

About the Editors

Lauren J. Wallace, PhD, is a Senior Researcher at Dodowa Health Research Centre in Accra, Ghana. She is a medical anthropologist whose research critically examines the making and implementation of maternal and reproductive health policies at national and subnational levels. Her PhD (2017, McMaster University, Canada), funded by a Vanier Scholarship from the Canadian Institutes of Health Research, was an ethnographic study of family size and family planning in northern Ghana. She has since “studied up” to examine the dynamics of national priority setting for maternal and reproductive health in Ghana and Uganda ethnographically. Dr. Wallace is currently the Ghana

Principal Investigator of the COVID-19 in West and Central Africa (CATALYSE) study, in which she examines policy and systems responses to COVID-19 and their intended and unintended effects in Ghana, in collaboration with national policymakers. She has also worked on other large-scale, interdisciplinary global health studies. Presently, she is also a Researcher at the University of Ghana’s School of Public Health, where she examines responsive and effective primary health care programs in urban settlements in Accra, in collaboration with local governments. Dr. Wallace is presently an Adjunct Assistant Professor in the Department of Anthropology at McMaster University, where she has also held an appointment as an instructor in the Midwifery Education Program.

xiii xiv Editors and Contributors

Margaret E. MacDonald, PhD, is Associate Professor and Graduate Program Director in the Department of Anthropology at York University in Toronto, Canada. As a medical anthropologist, her interests lie in how cultures of biomedicine, science, and technology shape ideas, practices, and materialities of gender, health, and reproduction. She conducts research in a range of settings across the globe: with midwives and their clients in Canada; within a community of global maternal health advocates and policymakers; and in rural and remote Senegal where non-governmental organizations implement interventions to improve maternal health. Her work in the global health arena has focused on key debates and emerging tools in the campaigns to improve maternal health care and reduce maternal death in low-resource settings: the controversial place of traditional birth attendants in maternal health; the production and uses of photography, film, and infographics as affective, aesthetic information about sexual and reproductive health, and the emergence of new biomedical-technical solutions embedded in feminist politics. She currently leads a collaborative project looking at the work of midwives and the experiences of clients under COVID-19 with particular attention to the impacts of the pandemic on marginalized and racialized groups.

Katerini T. Storeng, PhD, MSc., is Associate Professor at the University of Oslo’s Centre for Development and the Environment, and Head of its interdisciplinary Global Health Politics research group. She is a medical anthropologist whose ethnographic research takes a critical perspective on how global norms, values, and power relations influence debates about evidence and health policy processes and prac- | tice. Her PhD (2010, University of London, UK) was an ethnographic study of the making of the global Safe Motherhood Initiative. She has since studied the social and political dynamic of global public-private partnerships in global health governance, including Gavi, the Vaccine Alliance, regarding how such partnerships engage civil society. Her current research, funded by the Research Council of Norway, examines new forms of partnerships between public health agencies and pharmaceutical and technology corporations established in response to COVID-19. As former staff and Honorary Associate Professor at the London School of Hygiene & Tropical Medicine, Dr. Storeng has also collaborated on several large-scale, interdisciplinary studies on maternal health, notably longitudinal research into the social consequences of pregnancy-related illness, unsafe abortion, and catastrophic healthcare expenditure in Burkina Faso.

Editors and Contributors XV Contributors

Christopher J. Colvin, PhD, MPH Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA

Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

Robbie Davis-Floyd, PhD Department of Anthropology, Rice University, Houston, TX, USA

Seydou Drabo, PhD, MPhil Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway

Alice Emasu, MSW, MBA TERREWODE, Soroti, Uganda

Lucy C. Irvine, PhD Institute for Global Health, University College London, London, UK

Craig R. Janes, PhD School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada

Margaret E. MacDonald, PhD Department of Anthropology, York University, Toronto, ON, Canada

Priscilla Magrath, PhD Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA

Meredith G. Marten, PhD Department of Anthropology, University of West Florida, Pensacola, FL, USA

Ljiljana Pantović, PhD Institute for Philosophy and Social Theory, University of Belgrade, Belgrade, Serbia

Bonnie Ruder, PhD, MPH, CPM Terrewode Women’s Fund, Eugene, OR, USA Katerini T. Storeng, PhD, MSc. Centre for Development and the Environment, University of Oslo, Oslo, Norway

Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK

Maya Unnithan, PhD Department of Anthropology, University of Sussex, Sussex, UK

Lauren J. Wallace, PhD Department of Anthropology, McMaster University, Hamilton, ON, Canada

Dodowa Health Research Centre, Research and Development Division, Ghana Health Service, Accra, Ghana

Chapter 1 A Introduction Geek for

Lauren J. Wallace, Margaret E. MacDonald, and Katerini T. Storeng

This book treats policy as an ethnographic object. Its ten chapters examine global policies for improving maternal and reproductive health, tracking the processes and politics of their making, the mechanisms of their implementation in diverse contexts, and people’s intimate encounters with their consequences and effects. Doing so is timely since there is a growing appreciation that the success of health policies and interventions hinges on issues that are at the core of medical anthropological inquiry: the complexities of program implementation, the impact of socio-political contexts, and issues of local agency, equity and accessibility. Indeed, the burgeoning subfield of health policy and systems research views an interpretive and critical inquiry that draws on multiple disciplines, not least anthropology, as essential to understanding and informing effective policy (Gilson et al., 2011; Ghaffar et al., 2016).

The inspiration for this book was a double panel at the American Anthropological Association annual meeting in Washington, DC, in 2017 convened by Lauren

L. J. Wallace (%3)

Department of Anthropology, McMaster University, Hamilton, Ontario, Canada Dodowa Health Research Centre, Research and Development Division,

Ghana Health Service, Accra, Ghana

e-mail: wallalj @mcmaster.ca

M. E. MacDonald Department of Anthropology, York University, Toronto, Ontario, Canada e-mail: maggie@yorku.ca

K. T. Storeng Centre for Development and Environment, University of Oslo, Oslo, Norway

Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK e-mail: katerini.storeng@sum.uio.no

© The Author(s) 2022 1 L. J. Wallace et al. (eds.), Anthropologies of Global Maternal and Reproductive Health, Global Maternal and Child Health, https://doi.org/10.1007/978-3-030-84514-8_1

Wallace, entitled “Ethnographic Examinations of Global Maternal and Child Health Policy and Practice’, for which Maggie MacDonald and Katerini Storeng served as discussants. The panel sought to honour recent ground-breaking studies in which anthropologists had exposed the logic, values and practices of global health. As the book took shape, we sought to bring current medical anthropological research on global maternal and reproductive health into more direct conversation with anthropological studies of policy and with health policy and systems research. Our goal was for these conversations to produce more nuanced, more useful accounts of the making and implementation of global health policy than one field alone.

Reproduction is a unique entry point for anthropological analysis and critique of global health policy because it is a key site of social reproduction in every society. By focusing on reproduction, this book raises vital social and cultural concerns relevant to individuals, families, communities and nations: the meaning of life, personhood and death; moral regimes of gender and sexuality; the complexity of kinship and familial relations; and the intersectionality of gender, class and race. Reproduction is also a site of governance of women’s bodies and lives (Jordan, 1978; Ginsburg & Rapp, 1995; Locke & Schepher-Hughes, 1987; Morgan & Roberts, 2012). Policies and interventions designed to improve maternal and reproductive health connect intimately with all levels of health system functioning (Storeng & Béhague, 2017) and are entangled with some of the most fundamental and long-standing tensions in global health including how to balance community versus facility-based health services; targeted interventions versus health systems strengthening; selective versus comprehensive primary care; the distribution of scarce resources across competing actors and needs; and contestation over what constitutes evidence (McCoy et al., 2010). Not unlike other global health interventions, maternal and reproductive health policies are also often framed by perceived wisdom and evidence that has been generated by a narrow set of research methods, often making it difficult to derive solutions relevant to the local context (Béhague & Storeng, 2008; Olivier de Sardan, Diarra & Moha, 2017).

As this book goes to press, the global COVID-19 pandemic is in its second year. The pandemic has disrupted routine reproductive, maternal, newborn, and child health (RMNCH) services, especially in low resource settings, threatening hardwon gains in maternal mortality reduction (Robertson et al., 2020). The pandemic has also exacerbated larger social and economic challenges that underlie weak health systems and poor access to quality of care, laying bare the structural violence that creates vast inequities between nations and within nations along intersectional lines of race, class and gender. At the same time, the pandemic has reinforced the need for critical social science research on the workings of health policy and health systems to be part of the evidentiary mix upon which people-centred and equitable health policy and systems everywhere are built. It is a key moment of reckoning for maternal and reproductive health policy, and for global health more broadly.

The Anthropology of Global Maternal and Reproductive Health Policy

Policy is a social and political construct. It is a window into larger processes of governance — the mechanisms of power, knowledge, values and vested interests that are used by social actors, including governments, and corporations, to conceptualise, organise and regulate human life and relationships. An anthropological approach to policy contrasts with the instrumental, linear-rational model of the policy process that is often seen in policy analyses rooted in political science. It entails taking on the often complex, ambiguous and messy nature of policy by studying through and across the multiplicity of actors and interests, locales of power and influence and cycles of policy proposal and revision. The anthropology of policy takes a capacious approach to what counts as policy, including documents and clinical guidelines, laws, position statements, political speeches and declarations. Ethnographic fieldwork is particularly well suited to following policies into their ‘implementation contexts’ where they are interpreted, adapted, worked around or ignored in the context of practical norms and professional cultures (Shore & Wright, 1997; Wedel & Feldman, 2005, p. 2; Olivier de Sardan, Diarra & Moha, 2017; Fassin, 2013).

Anthropological critique often reveals the local consequences of global health, countering the ‘master narratives’ and working assumptions of the global health enterprise including the dominance of biomedical approaches to understanding health and illness and technocratic approaches to organising care (Nichter, 2008; Whiteford & Manderson, 2000; Castro, 2004). Working in the political economy of health tradition, critical medical anthropologists have also sought to connect the macro-level politics of structural violence and inequality to the micro-level of embodied experience (Singer & Baer, 1995; Farmer, 2004). Such efforts have shifted anthropologists’ gaze beyond the local setting and its immediate context, towards an appreciation and analysis of the deeper economic, political and historical underpinnings of health and illness. This shift has involved looking directly at the ‘global health enterprise’ itself to unpack the complex assemblages of social networks, power relations, ideologies, funding flows, documents, things, knowledge claims and epistemic discourses that constitute it (Pfeiffer & Nichter, 2008, p. 413; Ong & Collier, 2005; Janes & Corbett, 2009). Most recently, the term ‘critical global health’ has emerged to capture the expansive approach taken by many anthropologists to understanding the ‘policy space’ of global health (Biehl & Petryna, 2013).

Some of the earliest work in the field of critical global health focused squarely on maternal health. Judith Justice’s detailed examination of the planning and implementation of a program to train and disperse Assistant Nurses Midwives throughout the Nepalese countryside (1989) and Brigitte Jordan’s classic critique of training courses for traditional birth attendants in Mexico (1978) both clearly illustrate the lack of consideration of local context in national-level policies meant to improve maternal health care. These studies and a small body of ethnographic work that followed explored the interface between the technical logics of global health policy and programs and the material and sociocultural realities that produce poor maternal health. In so doing, they pointed to stark disjunctures between global ‘safe motherhood’ policy and the lived experiences of women, health workers and their communities (Pigg, 1997; Allen, 2002; Foley, 2007; Berry, 2010; MacDonald, 2017; Olivier de Sardan, Diarra & Moha, 2017). The interest in policy as a site of ethnographic inquiry within medical anthropology and critical global health studies has expanded greatly over the past decade; attention to metrics and the datafication of global health playing no small part (Storeng & Béhague, 2014; Adams, 2016).

The chapters in this edited book contribute to a growing body of knowledge illuminating global maternal and reproductive health policies through close attention to their formation and implementation in particular contexts. This volume offers ethnographic insights into the mechanisms by which global maternal and reproductive health policies are formed and implemented in diverse locales around the world, from India to Burkina Faso, Tanzania and Uganda, Switzerland and Serbia, the United States and Brazil. They will be of interest to scholars working in the overlapping subject areas of critical global health, medical anthropology, and the anthropology of reproduction and health policy and systems research. It is our intention that these chapters also speak to and inform the work of global public health experts and the development of guidelines and interventions. In short, we hope that these chapters can contribute to improved knowledge as well as actual practice.

Implementation Disconnects and Policy Rhetoric

The disjuncture between policy ideals and their implementation in practice — a longstanding concern of anthropological critiques of global health — is taken up by several authors in this volume. The notion of a ‘travelling model’ whereby an intervention developed by international experts is introduced in a standardised format in many settings, without consideration for specific, local, implementation contexts, analytically captures this situation. Travelling models have long been taken to be intrinsically effective, and therefore universally applicable; yet in reality, they ignore or underestimate the particularities of social and cultural context, resulting in disconnect on the ground (Olivier de Sardan, Diarra & Moha, 2017; see also MacDonald, 2017).

The trouble with travelling models is illustrated in Ljiljana Pantovié’s chapter on the implementation of the international Baby Friendly Hospital Initiative (BFHD in a Serbian hospital. Pantovic shows how the social, political and economic conditions in Serbia — namely the devastating effects of the civil war, international sanctions in the 1990s and the deleterious effects of IMF policies on the Serbian healthcare system since the 2000s — have severely hindered the uptake of the BFHI by frontline health workers. The ten steps meant to foster the uptake of breastfeeding by new mothers, she observes, are both thinly learned and thinly applied by healthcare workers struggling to manage high workloads in understaffed hospitals, in combination with unsustainable national funds for implementation.

Bonnie Ruder and Alice Emasu’s chapter on the global push to bring surgical repair to obstetric fistula similarly reveals the failure of a travelling model to solve a complex problem. Their ethnography examines a donor-funded treatment model in Uganda that focusses on surgical camps but without follow-up or patient tracking. While the majority of women who receive the surgery experience its life-changing benefits, a sizeable minority experience residual incontinence and complications — something that the surgical camp model does not fund or even measure. Poor outcomes are underreported and thus women suffering from residual incontinence fade from view in the story of a global health intervention defined by its success. Consequently, limited attention and resources are dedicated to residual incontinence, leaving many women without alternative treatment options.

New drugs and devices are key features of health policies and projects as they circulate around the world. Getting them to have the effect that policymakers intended, however, is a process often met with roadblocks, gaps and diversions (Russel, Sobo & Thompson, 2000; Suh, 2015). This is starkly relayed in Seydou Drabo’s ethnographic fieldwork on access to a drug, misoprostol, for medical abortion in Ouagadougou, Burkina Faso, where abortion is illegal in most circumstances. Growing evidence for the safety and effectiveness of misoprostol for use in the prevention and treatment of postpartum haemorrhage and unsafe abortion — two major causes of maternal death worldwide — have persuaded global and national level institutions to recommend its use. As Drabo explains, women seeking abortions in Ouagadougou are able to access misoprostol through unofficial channels, including intermediaries such as health workers and drug sellers, sex workers and friends. However, he describes a landscape of deeply unequal and frequently unsafe access to the drug depending on one’s social position. Drabo concludes that even as global policy hails misoprostol as a revolution in terms of its safe and effective biochemical effects on the body and simple and low cost features, the matter of safe access to safe abortion for all women in settings like Burkina Faso has not been addressed.

Like travelling models, the ‘key social representations’ and ‘master narratives’ in global health that surround them often frame problems in ways that limit thinking about potential solutions, leading to implementation gaps and distortions, unintended consequences and failed projects (Nichter, 2008; Inhorn, 2006). Meredith Marten’s chapter examines the impact of the circulation of buzzwords, master narratives and policy rhetoric — in her case the push amongst global donors to implement ‘sustainable’ maternal health programs and projects in Tanzania. By describing programmes focused on prevention of mother-to-child transmission of HIV, (PMTCT), Basic Emergency Obstetric and Newborn Care (BEmONC) and Respectful Maternity Care (RMC), she reveals how donors’ unrealistic yet frequently replicated ‘doctrine of sustainability’ paradoxically seems to undermine the strength of the health systems that donors claim to support. Marten argues that the sustainability doctrine fails to challenge neoliberal and philanthrocapitalist models of health care, advancing funding and implementation models more accountable to donors than to the public health systems providing care.

Policy Ambivalence

Global health has been characterised by several enduring debates about how best to deliver health care and improve health outcomes in low resource settings — comprehensive versus selective primary health care, community versus facility-based health, targeted interventions versus health systems strengthening (McCoy et al., 2010). Several authors in this book trace the arc of interventions intended to address major maternal and reproductive health challenges back to the 1970s, showing how they have played out against this backdrop over time. These authors reflect upon and illuminate the retreat, ambivalence, and in some cases, return, of previously contested policy approaches.

The theme of policy ambivalence surrounding community and facility-based approaches to care is taken up in Maggie MacDonald’s chapter, which follows the story of the traditional birth attendant (TBA) in global maternal health from the launch of the Safe Motherhood Initiative (SMI) in 1987 to the present. MacDonald argues that the original shift away from training TBAs within safe motherhood programs and their subsequent loss of legitimacy in global health was influenced by weak and inconclusive evidence, flawed conceptualizations of TBAs and the lack of consideration for the role of the larger political and economic context in which they worked — all of which was shaped by the re-organisation of the safe motherhood movement at the global level. MacDonald discusses how the recent repositioning of TBAs in maternal health policies and guidelines as potentially useful providers has been informed by a growing evidence base pointing to the effectiveness of TBAs, as well as the advent of high tech, cost effective, point of use technologies, which have led to the decentring of health facilities and professional health providers as the sole locus of clinical care.

Policy ambivalence is also illustrated in Maya Unnithan’s account of the conflicting approaches to reproductive health that have played out in India since the 1990s. On the surface, India’s family planning program seems to have undergone radical shifts from a population control model implemented through ‘targets’, to the abolition of targets and an integrated reproductive and child health model that upholds the rights of women to contraceptive choice. Yet, looking deeper, policy documents themselves offer clear indications of a return to state-promoted sterilisation, including cash incentives to clients to enhance contraceptive uptake and the introduction of new metrics to evaluate health worker performance. Unnithan shows how on the ground, these metrics are still perceived by Auxiliary Nurse Midwives as ‘targets’. Pressure on these community-level health workers from state directives to fulfil targets, and their experiences and perceptions of the lack of safety of reversible forms of contraception, combine to create a contraceptive bias towards sterilisation, even as Indian family planning takes on a new rights-based discourse.

Contesting Authoritative Knowledge and Practice

An enduring theme in critical anthropological studies of global health policy and implementation has been how the dominance of biomedicine tends to discredit local health knowledge and practitioners (Davis-Floyd & Sargent, 1997). In maternal and reproductive healthcare, this trend has been characterised by the consolidation of power away from traditional birth attendants and other lay healers and towards biomedical health facilities as the only safe place to give birth. Contestations around the professionalisation of maternity care are contests about authoritative knowledge and practice; that is, whose knowledge and authority counts and what counts as care. Global health interventions into maternal and reproductive health care are typically accompanied by the medicalisation and technocratic management of birth, with myriad and complex consequences for quality of care in underfunded, under-resourced healthcare systems.

Extending the discussion of the role of community-level birth attendants, Priscilla Magrath analyses Indonesia’s national policy to improve maternal health by promoting an official partnership between ‘skilled birth attendants’ (SBAs) and ‘traditional birth attendants’. In West Java, where she conducted ethnographic fieldwork, the local district health office engaged in ‘policy entrepreneurship’ to resolve enduring contests over the professionalisation of maternity care and promoted the partnership regulation throughout the region. Taking the local district as her starting point, Magrath maps the dense networks of national and global policies and pressures that exert themselves in local health governance and clinical practice: global policies promoting SBAs and sidelining TBAs; pressure on individual nations to reach the Millennium Development Goal on reducing maternal mortality; and the limited financial power and decision space afforded to districts under decentralisation in Indonesia. She concludes that by spotlighting the relationship between SBAs and TBAs as a key strategy to improve maternal health, attention was diverted from other health system challenges including under-resourced medical facilities and a weak referral system.