Weighing the options for delivery care in rural Malawi: community actors' perceptions of the 2007 policy guidelines and redefined traditional birth attendants roles

Abstract

Despite significant recent improvements, maternal mortality remains high in Malawi. To address this, the Government prioritised strategies promoting skilled birth attendance. However, in a country where 80% of the population resides in rural areas, there are tremendous barriers to institutional deliveries. Historically rural women have been supported in childbirth by Traditional Birth Attendants (TBAs), and by skilled birth attendants (SBAs) at the health facility. In the past, TBAs were trained to help bridge the gaps in provision and accessibility of care but in the 1990's, the WHO recommended halting their training because it was perceived as ineffective for maternal mortality reduction. In 2007, the Government of Malawi issued Community Guidelines to promote skilled birth attendance and banned TBA utilization for routine deliveries. This grounded theory qualitative study used interviews and focus groups to explore community actors' perceptions of the 2007 Policy Guidelines and their implementation, and how the Policy affected the decisions and actions of rural women regarding their delivery care. Findings from this study indicate that although all actors may agree that delivering at facilities is safest when complications occur, this does not necessarily ensure their compliance. Women, men and TBAs particularly, perceived the Policy as prescriptive. Furthermore, the implementation of the policy aggravated some of the barriers women already faced. Issues of disrespectful and neglectful care at facilities also partly led women towards non-compliance. Furthermore, a view from the ground demonstrated that the Policy had led to a rupture of linkages between TBAs and SBAs, which have had a detrimental effect on the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation analysis in LICs, by focusing on the perceptions of those at the receiving end of policy change, and on their needs, and aspirations.