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Between orchestrated and organic: Accountability for loss and the moral landscape of childbearing in Malawi

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  • de Kok, B.C.

Abstract

This paper explores loss in childbearing in Malawi (miscarriages, perinatal deaths and maternal mortality) as a lens to understand accountability and health system functioning. In low-income countries, maternal and perinatal mortality reflects poor health system functioning, to be improved in part through accountability. Understanding how accountability plays out on the ground requires examination of the existing, ‘organic’ accountability relationships and mechanisms. Thematic and discourse analysis of interviews and observations illuminates vocabularies of responsibility and practices of accountability concerning loss. Women are especially held accountable for loss, by a range of social actors. They use existing ‘organic’ accountability relationships and mechanisms to manage their own interests, but arguably also to care for pregnant women, even though negative birth experiences may ensue. Instances of disrespectful care appear a by-product of the convergence of organic and orchestrated, policy-driven accountability for numeric outcomes (deaths averted) rather than process (quality of care). Moreover, in the absence of essential physical resources, providers and relatives mobilize the social resources at their disposal to keep women and babies alive. Improving quality of care requires acknowledgment that providers' actions are both systemic and situational, and embedded in local moral landscapes and uneven webs of accountability.

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  • de Kok, B.C., 2019. "Between orchestrated and organic: Accountability for loss and the moral landscape of childbearing in Malawi," Social Science & Medicine, Elsevier, vol. 220(C), pages 441-449.
  • Handle: RePEc:eee:socmed:v:220:y:2019:i:c:p:441-449
    DOI: 10.1016/j.socscimed.2018.09.036
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    References listed on IDEAS

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    1. de Kok, Bregje & Hussein, Julia & Jeffery, Patricia, 2010. "Joining-up thinking: Loss in childbearing from inter-disciplinary perspectives," Social Science & Medicine, Elsevier, vol. 71(10), pages 1703-1710, November.
    2. Haws, Rachel A. & Mashasi, Irene & Mrisho, Mwifadhi & Schellenberg, Joanna Armstrong & Darmstadt, Gary L. & Winch, Peter J., 2010. ""These are not good things for other people to know": How rural Tanzanian women's experiences of pregnancy loss and early neonatal death may impact survey data quality," Social Science & Medicine, Elsevier, vol. 71(10), pages 1764-1772, November.
    3. World Health Organization & UNICEF & UNFPA & World Bank Group & United Nations, 2015. "Trends in Maternal Mortality," World Bank Publications - Books, The World Bank Group, number 23550.
    4. van der Sijpt, Erica, 2010. "Marginal matters: Pregnancy loss as a social event," Social Science & Medicine, Elsevier, vol. 71(10), pages 1773-1779, November.
    5. Storeng, Katerini Tagmatarchi & Murray, Susan F. & Akoum, Mélanie S. & Ouattara, Fatoumata & Filippi, Véronique, 2010. "Beyond body counts: A qualitative study of lives and loss in Burkina Faso after 'near-miss' obstetric complications," Social Science & Medicine, Elsevier, vol. 71(10), pages 1749-1756, November.
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    Cited by:

    1. Sochas, Laura, 2019. "Women who break the rules: Social exclusion and inequities in pregnancy and childbirth experiences in Zambia," Social Science & Medicine, Elsevier, vol. 232(C), pages 278-288.
    2. Vestering, Asra & de Kok, Bregje C. & Browne, Joyce L. & Adu-Bonsaffoh, Kwame, 2021. "Navigating with logics: Care for women with hypertensive disorders of pregnancy in a tertiary hospital in Ghana," Social Science & Medicine, Elsevier, vol. 289(C).
    3. Das, Priya & Newton-Lewis, Tom & Khalil, Karima & Rajadhyaksha, Madhavi & Nagpal, Phalasha, 2022. "How performance targets can ingrain a culture of ‘performing out’: An ethnography of two Indian primary healthcare facilities," Social Science & Medicine, Elsevier, vol. 300(C).

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