Meeting targets or saving lives: maternal health policy and Millennium Development Goal 5 in Nicaragua

Abstract

In support of maternal health, disease-specific and target-oriented global policy initiatives, such as in Millennium Development Goal 5, have led to a prioritisation of narrow indicators at the expense of more comprehensive approaches. In line with global policy, Nicaragua has made skilled attendants and institutionalised delivery central to its efforts to achieving MDG5 on maternal health. Drawing on ethnographic fieldwork in Nicaragua, involving participant observation and interviews with hospital and community health workers, and women and their families, this paper critically discusses how target-oriented maternal health strategies were manifested in local realities. It shows that Nicaragua’s brigadistas (community health workers) and parteras (traditional birth attendants) have been driven to narrowing their own roles to identifying pregnant women and advocating that they have an institutional delivery as one their most important tasks, making them agents of MDG 5 target achievement. This has engendered fear among brigadistas and parteras of being held individually responsible in the event of a maternal death, creating dissatisfaction with their role and reducing their motivation. While intended to improve maternal health, the pressure to reach targets has unintended negative implications for the relationship between women, the local volunteers and the formal health system, which needs to be addressed.

Résumé

À l’appui de la santé maternelle, des initiatives politiques internationales spécifiques à une maladie et axées sur des cibles, comme l’OMD 5, ont conduit à donner la priorité à des indicateurs étroits aux dépens d’approches plus globales. Conformément à la politique mondiale, le Nicaragua a mis les accoucheuses qualifiées et les naissances en institution au centre de ses activités pour réaliser l’OMD 5 sur la santé maternelle. Se fondant sur le travail ethnographique mené sur le terrain au Nicaragua, avec observation des participants et entretiens avec des agents de santé communautaires et hospitaliers, ainsi que des femmes et leur famille, cet article examine de manière critique comment les stratégies de santé maternelle axées sur les cibles se sont concrétisées dans les réalités locales. Il montre que les brigadistas (agents de santé communautaires) et les parteras (accoucheuses traditionnelles) du Nicaragua ont été amenés à restreindre leur rôle et à considérer que l’une de leurs principales tâches était d’identifier les femmes enceintes et de les encourager à accoucher en maternité, en faisant des agents de la réalisation de l’OMD 5. Cette évolution a engendré chez eux la crainte d’être tenus individuellement pour responsables en cas de décès maternel, ce qui les a rendus insatisfaits de leur rôle et a sapé leur motivation. Alors qu’elle est destinée à améliorer la santé maternelle, la pression pour parvenir aux objectifs a des conséquences négatives inattendues sur les relations entre les femmes, les bénévoles locaux et le système de santé officiel, qu’il convient de considérer.

Resumen

Por apoyar la salud materna, las iniciativas de políticas mundiales dirigidas a enfermedades y metas específicas, como el Objetivo de Desarrollo del Milenio 5, han llevado a la priorización de indicadores limitados a expensas de enfoques más integrales. En línea con las políticas internacionales, Nicaragua ha determinado que asistentes calificados y el parto institucionalizado son esenciales para sus esfuerzos por lograr el ODM 5 respecto a la salud materna. En este artículo, basado en el trabajo de campo etnográfico en Nicaragua, que consistió en observación participativa y entrevistas con personal hospitalario, trabajadores en salud comunitaria, mujeres y sus familiares, se trata con ojo crítico cómo las estrategias de salud materna orientadas hacia metas se manifestaron en realidades locales. Se muestra que los brigadistas (trabajadores en salud comunitaria) y las parteras de Nicaragua se han visto obligados a limitar sus propias funciones a identificar a mujeres embarazadas y a reconocer el parto institucional como una de sus tareas más importantes, por lo cual son agentes para lograr el ODM 5. Por ello, los brigadistas y las parteras temen que se les impute la responsabilidad de una defunción materna, lo cual ha creado descontento con su función y disminuido su motivación. Aunque su intención es mejorar la salud materna, la presión por alcanzar metas tiene implicaciones negativas no deseadas en cuanto a la relación entre las mujeres, voluntarios locales y el sistema de salud oficial, que deben ser abordadas.

Keywords:

• maternal health
• health policy and programmes
• community health workers
• Millennium Development Goals
• Nicaragua

We live in a world that is, more than ever, shaped by global ideas. Policy decisions and programmes increasingly emanate from actors such as the World Bank, UN agencies, international NGOs, global health initiatives and foundations,¹ and national policy has been profoundly impacted by the proliferation of external policy expectations.² It is also argued that global health policies are limiting states’ capacity to govern and develop their own national health priorities and health systems, facing development-related expectations coming from the global scene.^3,4 Global goals like the Millennium Development Goals (MDGs) have been criticised for their “one size fits all” targets and for their reinforcement of a donor-centric view of development.⁵ MDG 5 on improving maternal health has been criticised for being just about skilled attendants at birth, and not about the comprehensive approach needed to fulfil its maternal and reproductive health agenda.⁶

Focusing on MDG 5, this paper draws on fieldwork from Nicaragua to provide an ethnographic perspective on how global and national maternal health policies are manifested in local realities. The analysis focuses on brigadistas (community health workers) and parteras (traditional birth attendants), and how the pressure to meet targets – justified by the imperative to save lives – has had a major impact on their work and roles. Nicaragua’s brigadistas and parteras have become central agents of target achievement, with their role focused heavily on facilitating the achievement of greater institutionalisation of birth.

Methodology and context

The data were collected from January–May 2012 in El Tuma-La Dalia, Matagalpa, in the northern mountainous areas of Nicaragua. Matagalpa province has among the highest rates of maternal mortality in Nicaragua. With around 67,000 inhabitants in about 180 communities, the poor, rural municipality of El Tuma-La Dalia struggles to obtain and uphold basic infrastructural necessities such as roads and bridges, telephone services, electricity and water supply. In addition to these systemic weaknesses, social challenges such as high rates of teenage pregnancy, domestic violence and men’s lack of responsibility for their children are widely present, issues often linked to machismo, a concept describing women’s subordination — and often assumed to be synonymous with male dominance.⁷

The research involved mapping the area by describing socio-cultural, historical and political contexts and unfolding local structures and institutional networks from the local to the global level. This provided essential background information about places and actors and the relations between them. Participant observation involved spending considerable time with local women, brigadistas and parteras in their own environment and participating in brigadista training sessions at health facilities to obtain a broader understanding.

The next step was to invite individuals encountered in this first stage for interviews. I conducted interviews with 15 brigadistas and parteras, and also followed seven more closely in their work. They were chosen at training sessions at the hospital, or I went to communities in the municipality or to the neighbourhoods of La Dalia (the main village where the hospital is located) asking for the brigadista or partera. The interviews were centred on their experiences of the health system and their role and work. In addition to visits at health facilities I conducted five interviews with local MINSA (Ministry of Health) personnel, four women working at a casa materna (maternity waiting home), 11 NGO representatives and four municipal politicians. They were chosen based on their position and knowledge about maternal health issues and strategies in the municipality. I also conducted interviews with 72 women and men from 28 different communities and neighbourhoods whom I met at health facilities, at the casa materna or when visiting communities or neighbourhoods where I went knocking on peoples’ doors, inviting pregnant women or women who had (recently) given birth for interview.

The central focus of the interviews was how and why women chose to give birth at home or at the hospital, and about their perceptions and experiences with the health care system. All interviews were open-ended and semi-structured, which allowed for further elaborating on issues each informant found important. I chose not to tape-record the interviews as I felt people were more comfortable and could speak more freely without. All interviews were conducted in Spanish, notes were taken throughout the interviews and translated by me and written up in full. Lastly, participating in everyday life allowed me to further understand pregnancy and birth-related experiences and how women and men perceived the health system.

Targeting maternal health

Nicaragua’s approach to maternal health is influenced by global maternal health policy, which has itself undergone several shifts during the past decades. The Safe Motherhood Initiative, launched in 1987, was rooted in a comprehensive approach to health, reflecting the Alma Ata Declaration of 1978. The comprehensive approach, which seeks to tackle the roots of ill-health, incorporating attention to social, economic and biomedical determinants, has constantly been critiqued for being unclear and even unrealistic for poor countries. Critics argued that major sources of mortality and morbidity should be targeted through cost-effective interventions that can be easily monitored.^4,8,9 As selective and disease-specific approaches gained prominence throughout the 1980s and 1990s, the comprehensive agenda did not materialise. Lack of improvement prompted efforts to revitalise the Safe Motherhood Initiative in 1997, in part by focusing on more targeted interventions for reducing deaths from obstetric complications. Two interlinked interventions were put forward: skilled birth attendance and emergency obstetric care at first-referral level (health facilities at district level). Only midwives, doctors and nurses with midwifery skills were recognised as skilled birth attendants, excluding traditional birth attendants and community health workers.^9,10

In 2000, maternal health was incorporated into the MDGs. MDG 5 aims to reduce maternal mortality by 75% of 1990 levels by 2015, and considerable pressure from a variety of global actors exists on countries to reduce maternal mortality quickly as the deadline approaches.¹¹ The emphasis on measurable targets and the use of indicators in the MDG era have meant that interventions such as skilled attendance at birth have been prioritised as proxy indicators for maternal health.⁶ Despite a return of attention to social determinants of health and comprehensive models in recent years, from the Commission on Social Determinants of Health to published articles about the rebirth of Alma Ata for instance,^12,13 many countries have adopted the more narrow focus on skilled birth attendants in their safe motherhood programmes. This narrowing of focus applies to the MDGs more broadly which, according to Vandemoortele, has failed to shift the focus of the development discourse from a narrow growth paradigm to a broader human-centred perspective of sustainable and equitable well-being.⁵

A comprehensive vision of health care

Partly mirroring these global shifts, Nicaragua’s health politics have also changed over the years. After over 40 years of dictatorship and a revolution in 1979, the Sandinista government started to implement socialist programmes in the 1980s, focusing on education and health, which had not been accessible to the poor and marginalised areas during the dictatorship.¹⁴ One of the earliest MINSA (Ministry of Health) programmes trained volunteer health aides called brigadistas. They received some months of training and were sent to improve health in isolated rural areas, a task which they succeeded in accomplishing.¹⁵ This was important for a government seeking to front the political significance of health.

During the 1980s the work of these health volunteers developed into more permanent activities,¹⁵ and even today local people are trained to become brigadistas in their own community. Although not every community has brigadistas, this structure has prevailed during the change towards a neoliberal government in 1990 and been reinforced after the Sandinistas or FSLN (Sandinista National Liberation Front) won the presidential election in 2006. In contrast to the “pay for performance” arrangements with health workers currently being implemented in many countries,¹⁶ the importance of free health care and the principles of solidarity, love and voluntarism are frequently communicated to the brigadistas. This ideology builds on ideas of citizen participation, socialism, Christianity and solidarity, which are concepts the government uses to describe itself. Working alongside parteras, brigadistas were responsible for other primary health care concerns. Maternal health has been part of government strategy for a long time, but was reinforced when the FSLN came back into power as part of its emphasis on rural, poor communities.

In response to the downsizing of the public health sector under structural adjustment in the 1990s,¹⁴, the government removed user fees in public health facilities in 2007, added a significant community outreach component,¹⁷ and presented a new Family and Community Health Care Model, a more comprehensive approach than the individualistic, fragmented and curative approach of the former government.¹⁷

Improvements and involvements in health

Nicaragua has shown overall improvements in health status since the revolution, but still struggles with inequalities in access and quality of care. The Pan American Health Organisation estimates that about 40% of the population still lack adequate access to health care, and the 60% that do have access often find the care to be of poor quality.¹⁸ The maternal mortality ratio (MMR) has been reduced during the last couple of decades, now estimated by WHO to be 95 per 100,000 live births.¹⁹ In the 1980s the revolution brought health services to people that were previously lacking, and both maternal and child health were priority areas.^14,15 However, between 1992 and 2005 the MMR fluctuated, reaching its highest levels in 1996, 1997 and 1999,^18,20 alongside the downsizing of the public health sector and structural adjustment.

Since about 2006, a decline in the MMR has again been discernible,²⁰ concurrently as community outreach and skilled attendance at birth began to be further emphasised. However, despite overall improvements, the poor, rural populations in the north-central and eastern provinces still suffer from disproportionately high maternal mortality. MMR estimates in these areas range from 180 to 214.¹⁸ Paradoxically, in 2006, during the elections, a law making all abortions illegal, even to save a woman’s life, was signed. The World Bank considers maternal mortality the most worrisome of the health-related MDGs in Nicaragua, and reaching the MDG target MMR of 22 is highly unlikely.²¹ Even so, Nicaragua is committed to the MDGs and incorporated them into the National Development Plan in 2003.²² Apart from reducing deaths from unsafe abortions, reducing maternal mortality has become one of the government’s main strategic aims in relation to health.

As part of an effort to increase the level of deliveries at health institutions, parteras, who had previously played an important role in providing delivery assistance at the community level, were discredited as birth attendants in the middle of the year 2000. University-educated obstetric nurses have been placed in regions with the highest rates of maternal mortality as part of an initiative to train and deploy nurses with midwifery skills to isolated areas.²³ Yet parteras are still expected to visit women during pregnancy and encourage antenatal check-ups and hospital delivery, while at the same time they are banned from charging for their services on the principle that people should not pay for health services. However, some still attend births. Many parteras also work as brigadistas, leading to a conflation of their roles.

The World Bank, Inter-American Development Bank, USAID and various UN agencies are heavily involved in strategies, planning and implementation of health policy in Nicaragua.¹⁸ The government is dependent on external resources, with almost half the health budget coming from grants, loans and debt relief.²⁴ The Inter-American Development Bank granted Nicaragua a $30 million performance-driven loan (2005–2010) to reduce maternal and infant mortality by improving access to antenatal care and births in institutions, to accelerate progress towards the health MDGs.^25,26 A new $20 million Inter-American Development Bank loan was given in 2011 to further reduce maternal and child mortality in three of the most vulnerable provinces, among them Matagalpa. Only care that comes with agreed best practice will be recognised as qualifying for funding. The indicators related to maternal mortality are family planning use, women staying at the casa materna (maternity waiting home) – a strategy for ensuring access to institutional delivery for women living in remote areas – and births attended in health units that offer emergency obstetric care.²⁷

Meeting targets through institutionalising birth

Reflecting recent global policy trends in maternal health and donors’ emphasis on skilled birth attendance as a main performance indicator, Nicaragua’s efforts to reduce maternal deaths now focus heavily on institutionalising all births. Implicitly, however, this policy equates institutional delivery with skilled birth attendants. In the municipality where I did my fieldwork, a primary hospital opened in 2011 became the only recognised place for giving birth, replacing the old health centre and – in theory – home births. The municipality’s eight health posts provide antenatal care. At the time of my fieldwork, MINSA was trying to increase the number of specialists in the hospital. They had obstetric nurses, but the presence of an obstetrician was irregular, and confined to weekdays. The obstetrician performed C-sections, but as the hospital did not yet have a blood bank, severe emergency cases had to be referred to the regional hospital, located about 1.5 hours’ drive away. Despite these limitations, an increase in institutional births since the hospital opened has been claimed but the percentage remains unclear and about 40% of women still deliver at home, either with a partera, a family member or alone (Personal communication, local hospital doctor, April 2012). Women delivered at home as they did not trust the health facilities or were embarrassed to expose themselves in front of others, or they saw home birth as risk free. Others emphasised limited access or other barriers such as the husband refusing to allow it or problems leaving children behind while going to the hospital.

Despite a new hospital and an increase in personnel, the health system is totally dependent on the work of brigadistas and parteras in local communities, as they are the hospital’s main link to the communities. Once a month the hospital and its two health educators have training sessions with the brigadistas and parteras, either at the hospital or the health posts they belong to. Brigadistas are recognised as the people who should promote the “basic health package”, such as child health and sanitation, but one of their main tasks is to identify and report statistics about pregnant women in their communities, which many of the brigadistas are thus focusing on. They too, along with parteras, are expected to visit all women through their pregnancy, motivate and refer to antenatal care, invite them to use the casa materna and advocate for institutional deliveries, all of which is without any financial compensation. Parteras, though, often still receive some compensation from families, called a gift rather than payment.

Although Nicaragua’s health plans and programmes echo a more comprehensive agenda on paper, in reality this more “selective” approach, focusing on delivery care, is emphasised. According to a doctor working for the regional Ministry of Health, the government’s determination to reduce the MMR reflects how important it has become for them as an indicator not only of health, but also of development. Moreover, according to an NGO representative in Matagalpa, the government wants to control all the statistics on maternal mortality and has banned the NGO from analyzing maternal deaths in the area since 2010 (Personal communication, February 2012). Nevertheless, NGO representatives believe that the statistics as presented by the government may not be complete. Moreover, the complete ban on legal abortions also creates doubts about the extent to which maternal mortality has in fact decreased (Personal communication, February 2012).

Saving life – fearing deaths

The government’s overarching policy, that maternal deaths are unacceptable, is manifest at every layer in the health system; MINSA holds regional Ministries of Health responsible for averting maternal deaths, who in turn put pressure on local health facilities. Ultimately, the brigadistas, parteras and women themselves are expected to comply with the imperative to institutionalise birth. Several of the brigadistas and parteras I interviewed expressed concern not only about the pressure to get women to seek antenatal care and to deliver at the hospital, but also about being blamed in the event of any maternal death in the community.

“MINSA will blame the partera or the brigadista if a women dies in the community, so we are afraid if it will happen. It is not fair that we will be blamed as it is not our fault that the woman does not go. Even though we tell her to go, she does not always listen to us. Some just do not want to or cannot go.” (Brigadista)

An older partera also working as a brigadista stressed that a maternal death in the community would trigger investigation. She sent or went with all pregnant women in her community to the hospital to make sure she did not have to attend their births. NGOs also felt pressured to get women to attend health institutions. A representative from a women’s organisation said that although people are appalled by any maternal death, they are nevertheless relieved when they hear it did not happen in their own community.

“We shiver at the thought of a maternal death in our province”.

The fear of being held responsible for a maternal death was revealed at all levels. The local health facilities were also scared that maternal deaths will occur in their municipality. There is a notion that all maternal deaths are preventable, and that the failure to prevent any deaths reflects poorly on the job performed by health workers. These pressures increasingly resulted in women being sought out and brought in to health facilities.

“If we hear about a pregnant woman who is at risk, we go out into the community to get her. We will not have maternal deaths this year. Sometimes we even trick her into coming if that is what it takes.” (Local hospital doctor)

Health personnel at the hospital emphasised the importance of institutional birth as the only acceptable (and safe) birth. This became apparent in the way they worked with the brigadistas and parteras and behaved towards women in the community. In the monthly meetings the brigadistas and the parteras were reminded of the importance of bringing women to the health facility, while the health educator often stressed the danger of the continued practice of home birth with a partera. In a meeting I attended, he talked about a woman bleeding to death in the arms of a partera because she did not go to hospital and rejected the idea that a partera could be an appropriate birth attendant:

“There is no such thing as a ‘super partera’. A ‘modern partera’ does not attend births. Their attending births is a crime.” (Health educator)

Rejecting parteras as birth attendants reflects global and national policy. It is not, however, a “crime” in Nicaragua, even though the health educator presented it as such in the meeting.

Although health personnel at facilities felt pressured from the central level, the responsibility for getting women to the health institution was placed most directly on the brigadistas and parteras. If they do good work in the communities, maternal death can be avoided. In another meeting I attended, poor community organisation was blamed for a maternal death. The brigadista is taught to be responsible for organising transport in emergency cases. As such, the responsibility for institutionalising births is removed from the health system and the health facilities, and instead placed on the individuals at community level. In the process, weaknesses in the formal health system are downplayed and allowed to persist.

Quality of care and health workers

The policy focus on institutionalised birth to some extent obscures what actually goes on within health facilities. Women and families were often dissatisfied with the care received. Their complaints focused on poor treatment, long waiting lines and unpleasant personnel. Brigadistas and parteras also felt that hospital personnel did not take their decision to send women to the hospital seriously, resulting in women waiting long hours or being sent home without being seen, with the brigadista and partera feeling inferior and disrespected.

“The government prioritises maternal health, and they do not want any maternal deaths in the country. But we have gone from one extreme to another. Now they look for women in the communities and almost drag them to the health facilities, but when they get there the attention and care is bad. The personnel are not considering why people are there. They are just focusing on numbers and nervous about maternal deaths.” (Women’s organisation doctor)

This same doctor was also worried that the local health facilities recognised for birth had already exceeded their capacity. She questioned how they could possibly cope with the 40% of women still delivering at home, given their circumstances.

A woman living in a neighbourhood close to the hospital had given birth to her son at home only a few weeks earlier, and attributed her decision to concerns about hospital practice. She described this as an assault (grosería):

“You lay there exposed in front of many people, they cut you and even stitch you after birth. It is discriminating. I would not go.”

Although this woman perceived hospital-based delivery as a violation, the fact that she did not want to go made her problematic to the health system, which sometimes denounced women who did not comply as naïve or troublesome.²⁸ Although women’s worries did not necessarily equal poor quality of care, some of their comments were indicative of a widespread lack of trust in the health facilities. Some women also felt pressured to stay at the casa materna for a long time, leaving their families behind. One woman had even been told at the health post that she was obliged to stay there. However, after hearing that they might die if they chose to give birth at home, many women also wanted hospital delivery, although they simultaneously expressed concerns about poor treatment, long waiting lines and unpleasant personnel.

Due to their own experiences and stories from women, many brigadistas and parteras expressed dissatisfaction with hospital care, placing them in a difficult position, given MINSA’s expectation that they would encourage women to go. But simultaneously they agreed home births were risky and that women should go to the hospital. This situation can be summed up as follows: Hospital care is perceived as poor, but staying home is even worse.

These issues left many brigadistas and parteras dissatisfied with their relationship to the formal health system. Furthermore, because they felt their responsibilities and workload did not correspond with the compensation they received, some brigadistas stopped working or were seriously considering it, potentially leaving their communities without a health volunteer. Others wanted to form a union so as to be heard and acknowledged. They understood that payment in terms of money was unattainable, but they felt that an identity card as brigadistas, or even a backpack or a t-shirt to wear when they visited families, would make them feel more respected and appreciated. Health educators at the hospital were aware of the lack of motivation among many brigadistas, and regretted the absence of resources to pay them or provide them with practical support.

Discussion and conclusions

This study has shown the unintended negative consequences of Nicaragua’s current maternal health policy for the relationship between the formal health system, local health volunteers and pregnant women. As the whole maternal health care system is dependent on the health volunteers, they cannot avoid being involved in the national imperative to reach targets, but the relationship with them, their satisfaction with their work and their motivation could be improved through simple measures that make them feel they are an important part of the health system. It takes a long time to build health systems. The health volunteers are a good way to reach women in the communities; keeping a good relationship with them should be a priority.

The anxiety generated by the pressure to avoid maternal deaths is not easy to deal with, as this is situated within a system of targets and of performance measurement, where government performance also is rewarded or criticised by global actors. Although the pursuit of the goal of reducing maternal mortality is laudable, the pressure on everyone increases when the health system is not able to respond adequately to reach such an ambitious goal. The drive to reach targets and institutionalised deliveries has not been matched by equivalent improvements in quality of care, making many brigadistas, parteras and women ambivalent about hospital birth. In a study of neonatal and under-five mortality in a Nicaraguan community from 1970–2005, Perez and colleagues even showed an increase in neonatal deaths in the latest study period despite good coverage of skilled assistance at delivery,²⁹ and it has also been shown elsewhere that institutional delivery does not necessarily mean that care is of good quality.³⁰

The goal of institutional delivery was not questioned by health care providers at the hospital, which was in the process of improving delivery care with skilled assistance and emergency obstetric care during this study. But a narrow agenda which excludes important issues — quality of care, how people are received at the hospital, infrastructure and reducing socioeconomic barriers that keep people from seeking and getting good care — will continue to put many women off. Narrowing the agenda to selective “magic bullets” can also divert funds away from long-term health systems development,^3,9 which is crucial both for achieving and sustaining low maternal mortality.

Target-oriented initiatives also have implications for Nicaragua’s vision of a comprehensive health care model and ideology of solidarity and voluntarism. The health workers of the formal health system in the study area seemed to be trying to avoid maternal deaths, and were open about deaths they had experienced the previous year. At this writing, although they do not receive performance-based payment, the health system itself is becoming increasingly performance-based, driven both by external, performance-based health sector assistance and by the culture of targets and indicator achievement, spurred by the MDGs. The need to show progress has led Nicaragua to focus heavily on institutionalising births, with negative consequences for the relationship between the health system and the much needed health volunteers. Lastly, the legitimacy of the FSLN government’s aim to support maternal health and reduce maternal deaths is undermined by their making all abortions illegal, since deaths from complications of unsafe abortions represent a substantial proportion of total maternal deaths,³¹ including in Nicaragua.

Nicaragua is highly dependent on external aid and will do its best to perform on the global targets set. Increasing births with skilled attendants can reduce maternal mortality, but as Spangler argues, to declare victory just because health workers with the right titles attend most births can be negligent in under-resourced settings where training, regulation and technical support may be inconsistent.³⁰ The target- and indicator-oriented initiatives coming from the global scene should be much more informed and take account of local conditions. Although the MDGs and other initiatives to improve maternal health did not set out to be narrow, as shown by both Vandemoortele⁵ and Austveg,⁶ the choice of skilled birth attendants alone as an indicator of progress assumes good quality of care to be otherwise in place.¹⁰ At local level, the focus on targets and indicators has led to inappropriately narrow strategies, which has ultimately placed responsibility on achieving MDG 5 on individual local volunteers. While the intention to improve maternal health is unquestionable, the pressure to reach targets has had unintended, negative implications for the relationship between women, the local volunteers and the formal health system, and needs to be addressed.

Acknowledgements

Thanks to the health workers, women and families I interviewed in Nicaragua, and to Katerini Storeng, Sidsel Roalkvam, and Jagrati Jani-Bølstad for valuable comments. This study was supported by the Centre for Development and the Environment (SUM), University of Oslo, Norway, as part of my PhD thesis.