Modernisation of Maternity Care in Malawi

Abstract

Low-income countries have by and large adopted antenatal programmes and policies regarding childbirth of high-income countries. The logic behind human rights and development interventions leads to increased regulation and homogenisation of what is considered the socially acceptable, safe and normal way to handle birth. In an effort to decrease maternal and neonatal deaths and to modernise and institutionalise childbirth, the Government of Malawi, in cooperation with donors and the international community, is creating new regulatory regimes regarding where, how and under whose care to give birth. The government has made out-of-facility births with traditional birth attendants (TBAs) illegal by banning TBAs from practising. Customary legal mechanisms have been used to compel women to seek skilled birth attendance (i.e., modern practices) and to penalise TBAs who continue to practice. The traditional birth culture embodied in TBAs is portrayed as conservative, unchanging, primitive and impossible to control and monitor due to the oral tradition it is based upon and the low literacy rate. The ban on TBAs applies as a contribution to social norms on childbirth and normalisation practices of facility-based birth. As theorised by Michel Foucault, biopolitical governance means governing people's conduct within a framework and making use of traditional legal mechanisms. In the present case, a post-colonial state employs these means in order to change people's behaviour in the area of childbirth. The purpose of this article is to analyse the modernisation process of maternity care from a biopolitical perspective, focusing on the normalising and rationalising aspects that seem to underpin the safety arguments behind the TBA ban. The starting point is that the customary law represents a political battle over what it means to be a modern state concerned with the female population; law is a discursive site, as theorised by Ratna Kapur.

Keywords:

• Hospitalisation of Childbirth
• Birth Politics
• Biopolitics
• Law as Discourse
• Human Rights in Childbirth
• Maternity Care in Malawi

Acknowledgements

Chisomo Kaufulu-Kumwenda's assistance before and during the research visit to Malawi was invaluable. Professor Jeremy Gould offered academic inspiration. This work was supported by the Academy of Finland through the research project “Integrating Human Rights and Development: Strategies, Impact and Emerging Issues” (2011–2013, grant number 131696).

Notes

¹ See T Kulmala, Maternal Health and Pregnancy Outcomes in Rural Malawi (Academic dissertation, University of Tampere, Tampere, 2000), 18. See also A Oakley, The Captured Womb: A History of the Medical Care of Pregnant Women (Basil Blackwell Publisher, New York 1984).

² A Zonal Health Officer in Lilongwe who had conducted a study on usage of SBA and TBA noted a decrease in SBA in Lilongwe, i.e., an urban area (meeting of September 2013, Lilongwe).

³ Malawi Growth and Development Strategy II 2011–2016. Also see Malawi Demographic Health Survey 2010.

⁴ C Bowie and E Geubbels, Epidemiology of Maternal Mortality in Malawi (College of Medicine, Malawi, 2nd ed, 2013), 8.

⁵ T Bisika, “The Effectiveness of the TBA Programme in Reducing Maternal Mortality and Morbidity in Malawi” (2008) 5 East African Journal of Public Health 103–.

⁶ This figure is presented in A Nove, “Midwifery in Malawi: In-depth Country Analysis” (State of the World's Midwifery 2011) 3. Available at http://www.unfpa.org/sowmy/resources/docs/country_info/in_depth/ Malawi_SoWMYInDepthAnalysis.pdf (accessed 20 March 2014).

⁷ A report by the Ministry of Health and WHO from 2006 gives the figure of 984 deaths per 100,000 live births and writes: “the situation has remained largely the same over the past decades”. See Ministry of Health, Final Report: Assessment of Future Roles of Traditional Birth Attendants (TBAs) in Maternal and Neonatal Health in Malawi (WHO Malawi, Lilongwe, August 2006), 7.

⁸ F Bustero and P Hunt, Women's and Children's Health: Evidence of Impact of Human Rights (WHO, Geneva, 2013), 42.

⁹ M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 276.

¹⁰ M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 284–85.

¹¹ C Bowie and E Geubbels, Epidemiology of Maternal Mortality in Malawi (College of Medicine, Malawi, 2nd ed, 2013), 6.

¹² Amnesty International, Deadly Deliveries: The Maternal Health Care Crises in the USA (Amnesty International, London, 2010).

¹³ See K Whitaker, “Is Sierra Leone Right to Ban Traditional Birth Attendants”, The Guardian (London, 17 January 2012). Available at http://www.theguardian.com/global-development/poverty-matters/2012/jan/17/traditional-birth-attendants-sierra-leone (accessed 15 October 2013) and “Why Traditional Birth Attendants Will Keep Thriving”, Daily Monitor, available at http://www.monitor.co.ug/artsculture/Reviews/Why-traditional-birth-attendants-will-keep-thriving/-/691232/1845284/-/12o3ca8z/-/index.html (accessed 15 October 2013).

¹⁴ World Health Organization, Traditional Birth Attendants: A Joint WHO/UNICEF/UNFPA Statement (WHO, Geneva, 1992).

¹⁵ A joint statement by WHO, ICM and FIGO, Making Pregnancy Safer: The Critical Role of the Skilled Attendant (WHO, Geneva, 2004).

¹⁶ A Nove, “Midwifery in Malawi: In-depth Country Analysis” (State of the World's Midwifery 2011) 3. Available at http://www.unfpa.org/sowmy/resources/docs/country_info/in_depth/Malawi_SoWMYInDepthAnalysis.pdf (accessed 20 March 2014).

¹⁷ R Kapur, Erotic Justice: Law and the New Politics of Postcolonialism (The Glass House Press, London, 2005), 23.

¹⁸ R Kapur, “The Citizen and the Migrant: Postcolonial Anxieties, Law, and the Politics of Exclusion/Inclusion”, (2007) 8 Theoretical Inq. L. 537–, 542.

¹⁹ R Kapur, Erotic Justice: Law and the New Politics of Postcolonialism (The Glass House Press, London, 2005), 50.

²⁰ E Declercq, R DeVries and K Viisainen et al, “Where to Give Birth: Politics and the Place of Birth”, in R DeVries & S Wrede et al (eds), Birth by Design (Routledge, New York, 2001), 7–9.

²¹ See Ternovszky v Hungary (App no 67545/09) (2010) ECHR 14 December 2010. The cases of Dubská and Krejzová v Czech Republic (App nos 28859/11 and 28473/12) are under review in the European Court of Human Rights. In Lithuania, the police has investigated 400 home births. See K Kunnas, “Epäilyttävä synnyttäjä”, Helsingin Sanomat (Helsinki, 20 May 2013).

²² See list provided at Our Sisters in Chains, available at http://www.sistersinchains.org/our-sisters-in-chains.html (accessed 10 October 2013).

²³ AF Cohen, “The Midwifery Stalemate and Childbirth Choice: Recognizing Mothers-to-Be as the Best Late Pregnancy Decisionmakers”, (2005) 80 Indiana Law Journal 850–71.

²⁴ M Foucault, The Birth of Biopolitics: Lectures at the Collège de France 1978–1979 (English translation, 2008; first published by Palgrave Macmillan, 1978–79), 317.

²⁵ M Foucault, Security, Territory and Population: Lectures at the Collège de France 1977–1978 (English translation, Palgrave Macmillan, 2007), 363.

²⁶ M Foucault, The Birth of Biopolitics: Lectures at the Collège de France 1978–1979 (English translation, 2008; first published by Palgrave Macmillan, 1978–79), 318.

²⁷ A Gupta, “Governing Population: The Integrated Child Development Services Program in India” in TB Hansen and F Stepputat (eds), States of Imagination: Ethnographic Explorations of the Postcolonial State (Duke University Press, Durham NC, 2001), 66–96, at 68–69.

²⁸ R DeVries, A Pleasing Birth: Midwives and Maternity Care in the Netherlands (Temple University Press, 2004), 15.

²⁹ C Pateman, The Disorder of Women (Polity Press, Cambridge, 1989), 11.

³⁰ M Foucault, The Birth of Biopolitics: Lectures at the Collège de France 1978–1979 (English translation, 2008; first published by Palgrave Macmillan, 1978–79), 62.

³¹ M Dean, “‘Demonic Societies’: Liberalism, Biopolitics and Sovereignty”, in TH Hansen and F Stepputat (eds), States of Imagination: Ethnographic Explorations of the Postcolonial State (Duke University Press, Durham, NC, 2001), 51.

³² M Dean, “‘Demonic Societies’: Liberalism, Biopolitics and Sovereignty”, in TH Hansen and F Stepputat (eds), States of Imagination: Ethnographic Explorations of the Postcolonial State (Duke University Press, Durham, NC, 2001), at 50.

³³ M Dean, “‘Demonic Societies’: Liberalism, Biopolitics and Sovereignty”, in TH Hansen and F Stepputat (eds), States of Imagination: Ethnographic Explorations of the Postcolonial State (Duke University Press, Durham, NC, 2001), 51.

³⁴ P Rabinow, “Introduction” in P Rabinow (ed), The Foucault Reader (Penguin Books, London, 1984), 3–29, at 17. Originally in M Foucault, The History of Sexuality, Vol. 1 (Pantheon Books, New York, 1978), 143.

³⁵ See U Paananen, S Pietiläinen et al (eds), Kätilöntyö [The work of the midwife] (Edita Publishing, Helsinki, 2007), 17.

³⁶ H Helsti, Kotisynnytysten aikaan [At the time of home birth] (Suomalaisen kirjallisuuden seura, Helsinki, 2000), 14.

³⁷ E Declercq, R DeVries and K Viisainen et al, “Where to Give Birth: Politics and the Place of Birth”, in R DeVries & S Wrede et al (eds), Birth by Design (Routledge, New York, 2001), 15.

³⁸ See H Helsti, Kotisynnytysten aikaan [At the time of home birth] (Suomalaisen kirjallisuuden seura, Helsinki, 2000), 63.

³⁹ S Wrede, Decentering Care for Mothers: The Politics of Midwifery and the Design of Finnish Maternity Services (Åbo Akademi University Press, Turku, 2001), 17.

⁴⁰ S Wrede, Decentering Care for Mothers: The Politics of Midwifery and the Design of Finnish Maternity Services (Åbo Akademi University Press, Turku, 2001), 87, 89.

⁴¹ H Helsti, Kotisynnytysten aikaan [At the time of home birth] (Suomalaisen kirjallisuuden seura, Helsinki, 2000), 14.

⁴² E Declercq, R DeVries and K Viisainen et al, “Where to Give Birth: Politics and the Place of Birth”, in R DeVries & S Wrede et al (eds), Birth by Design (Routledge, New York, 2001), 13.

⁴³ G Abalu et al, “Comparative Analysis of Structural Adjustment Programmes in Southern Africa” (SD Publications Series, 1996), 11–14. Available at http://www.afr-sd.org/publications/23souafr.pdf (accessed 17 February 2014).

⁴⁴ H Englund, Human Rights and African Airwaves: Mediating Equality on the Chichewa Radio (Indiana University Press, Bloomington, 2011), 5–7.

⁴⁵ See F Bustero and P Hunt, Women's and Children's Health: Evidence of Impact of Human Rights (WHO, Geneva, 2013), 43.

⁴⁶ M Foucault, The History of Sexuality, Vol. 1: An introduction (originally published in 1976); Vintage, 1990), 23.

⁴⁷ D Korpela, The Nyau Masquerade: An Examination of HIV/AIDS, Power and Influence in Malawi (Tampere University Press, Tampere, 2011), 48.

⁴⁸ D Korpela, The Nyau Masquerade: An Examination of HIV/AIDS, Power and Influence in Malawi (Tampere University Press, Tampere, 2011), 50.

⁴⁹ D Korpela, The Nyau Masquerade: An Examination of HIV/AIDS, Power and Influence in Malawi (Tampere University Press, Tampere, 2011), 50–51.

⁵⁰ Ministry of Health, National Sexual and Reproductive Health and Rights (SRHR) Policy (August 2009), 10.

⁵¹ Meeting with TBAs, Southern District of Malawi (14 September 2013). This was confirmed in meetings with health professionals.

⁵² Meeting with TBAs, Southern District of Malawi (14 September 2013).

⁵³ M Longwe, Growing Up: A Chewa Girl's Initiation (Kachere Series, Malawi, 2006), 68.

⁵⁴ This fine system was confirmed in several meetings and is also used in Sierra Leone where TBAs have been banned.

⁵⁵ Meeting with group of mothers, Southern District of Malawi (14 September 2013). The commonality of this problem was confirmed in other meetings.

⁵⁶ RE Kapindu, “Malawi: Legal System and Research Resources”, GlobaLex 2009, 19. Available at http://www.nyulawglobal.org/globalex/malawi.htm (accessed 8 October 2013).

⁵⁷ Ministry of Health, Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (October 2005), 5.

⁵⁸ Ministry of Health, Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (October 2005), at 33.

⁵⁹ See BA Levandowski et al., “The Incidence of Induced Abortions in Malawi”, (2013) 39 Int Perspectives on Sexual and Reproductive Health 88–96. The authors refer to VM Lema et al., “Maternal Mortality at the Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi”, (2005) 82 East African Medical J 3–9.

⁶⁰ World Bank, “Reproductive health at a glance: Malawi” (April 2011). Available at http://siteresources.worldbank.org/INTPRH/Resources/376374-1303736328719/Malawi42211web.pdf (accessed 17 February 2014).

⁶¹ See M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 304.

⁶² A Kumar, The Examination of Traditional Birth Attendant Practices and their Role in Maternal Health Services in Mwandama Village Cluster (College of Medicine Master's Thesis in Public Health, Blantyre, Malawi, 2007), 1.

⁶³ Ministry of Health, Final Report: Assessment of Future Roles of Traditional Birth Attendants (TBAs) in Maternal and Neonatal Health in Malawi (WHO Malawi, August 2006).

⁶⁴ K Fahy, “An Australian History of the Subordination of Midwifery”, (2007) 4(1) Women and Birth 25–29.

⁶⁵ K Fahy, “An Australian History of the Subordination of Midwifery”, (2007) 4(1) Women and Birth 25–29.

⁶⁶ World Health Organization, Traditional Birth Attendants: A Joint WHO/UNICEF/UNFPA statement (WHO, Geneva, 1992).

⁶⁷ Ministry of Health, Final Report: Assessment of Future Roles of Traditional Birth Attendants (TBAs) in Maternal and Neonatal Health in Malawi (WHO Malawi, August 2006), 16; A Kumar, The Examination of Traditional Birth Attendant Practices and their Role in Maternal Health Services in Mwandama Village Cluster (College of Medicine Master's Thesis in Public Health, Blantyre, Malawi, 2007), 1.

⁶⁸ T Bisika, “The Effectiveness of the TBA Programme in Reducing Maternal Mortality and Morbidity in Malawi” (2008) 5 East African Journal of Public Health 103–, 105, 109.

⁶⁹ S Gloyd, et al, “Impact of Traditional Birth Attendant Training in Mozambique: A Controlled Study”, (2001) 46 Journal of Midwifery & Women's Health 210–16.

⁷⁰ Bergström and Goodburn have reviewed studies on training of TBAs and conclude: “None of these studies leads to a conclusion that TBA training as a single intervention can have a significant impact on maternal mortality.” S Bergström and E Goodburn, The Role of Traditional Birth Attendants in the Reduction of Maternal Mortality, available at www.jsieurope.org/safem/collect/safem/pdf/s2933e/s2933e.pdf (accessed 14 October 2013), 10.

⁷¹ Ministry of Health, Final Report: Assessment of Future Roles of Traditional Birth Attendants (TBAs) in Maternal and Neonatal Health in Malawi (WHO Malawi, August 2006), 20.

⁷² Meeting with a perinatal nurse specialist (Blantyre, 13 September 2013); Meeting with nurse midwife and PhD student (Lilongwe 12 September 2013); Meeting with human rights lawyer (Lilongwe 9 September 2013). The use of herbs was also raised in the group meeting with TBAs.

⁷³ H Goer and A Romano, Optimal Care in Childbirth: The Case for a Physiological Approach (Pinter & Martin Ltd, London, 2013; first published in the USA by Classic Day Publishing, 2012) 327, 345, 365–372.

⁷⁴ See HJ Baker, “‘We Don't Want to Scare the Ladies’: An Investigation of Maternal Rights and Informed Consent Throughout the Birth Process”, (2010) 31 Women's Rights Law Reporter 538–93. Baker calls the episiotomy “a medically sanctioned female genital mutilation” (at 575).

⁷⁵ See N Wolf, Vagina: A New Biography (HarperCollins Publisher, New York, 2012), 24 and 88.

⁷⁶ A study reported that only one third of all of the American College of Obstetricians and Gynecologists guidelines, which form the basis of practice of obstetrics in the US, are based on scientifically sound evidence. See JD Wright et al., “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists Practice Bulletins”, (2011) 118 Obstet & Gynecol 505–12.

⁷⁷ M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 7.

⁷⁸ See examples from the USA and England between the period of 1778 and 1890, provided in M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 271.

⁷⁹ As a parallel, one can refer to a study about trends in maternal mortality in England in which the author finds no evidence for hospitalisation of birth being associated with lower mortality. If anything, hospitalisation was associated with higher mortality: the regions with more hospital births being the regions with higher mortality. See M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 298.

⁸⁰ T Bisika, “The Effectiveness of the TBA Programme in Reducing Maternal Mortality and Morbidity in Malawi” (2008) 5 East African Journal of Public Health 103–, 104.

⁸¹ T Bisika, “The Effectiveness of the TBA Programme in Reducing Maternal Mortality and Morbidity in Malawi” (2008) 5 East African Journal of Public Health 103–.

⁸² T Bisika, “The Effectiveness of the TBA Programme in Reducing Maternal Mortality and Morbidity in Malawi” (2008) 5 East African Journal of Public Health 103–, at 107–9.

⁸³ J James and T Collins, Achieving Equity in Skilled Birth Attendance: Malawi (Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All, 2012), 9.

⁸⁴ Meeting with CHAM (Lilongwe, 16 September 2013).

⁸⁵ A Nove, “Midwifery in Malawi: In-depth Country Analysis” (State of the World's Midwifery 2011) 3. Available at http://www.unfpa.org/sowmy/resources/docs/country_info/in_depth/Malawi_SoWMYInDepthAnalysis.pdf (accessed 20 March 2014), 15.

⁸⁶ T Bisika, “The Effectiveness of the TBA Programme in Reducing Maternal Mortality and Morbidity in Malawi” (2008) 5 East African Journal of Public Health 103–, 104.

⁸⁷ Ministry of Health, Malawi Health Sector Strategic Plan 2011–2016: Moving Towards Equity and Quality (Government of Malawi, September 2011), 15.

⁸⁸ A Nove, “Midwifery in Malawi: In-depth Country Analysis” (State of the World's Midwifery 2011) 3. Available at http://www.unfpa.org/sowmy/resources/docs/country_info/in_depth/Malawi_SoWMYInDepthAnalysis.pdf (accessed 20 March 2014), 6.

⁸⁹ J James and T Collins, Achieving Equity in Skilled Birth Attendance: Malawi (Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All, 2012), 9 and 16.

⁹⁰ A Nove, “Midwifery in Malawi: In-depth Country Analysis” (State of the World's Midwifery 2011), 3. Available at http://www.unfpa.org/sowmy/resources/docs/country_info/in_depth/Malawi_SoWMYInDepthAnalysis.pdf (accessed 20 March 2014), 5.

⁹¹ Meeting with perinatal nurse specialist (Blantyre, 13 September 2013).

⁹² R DeVries, A Pleasing Birth: Midwives and Maternity Care in the Netherlands (Temple University Press, 2004), 62.

⁹³ J James and T Collins, Achieving Equity in Skilled Birth Attendance: Malawi (Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All, 2012), 15.

⁹⁴ F Bustero and P Hunt, Women's and Children's Health: Evidence of Impact of Human Rights (WHO, Geneva, 2013), 46.

⁹⁵ J James and T Collins, Achieving Equity in Skilled Birth Attendance: Malawi (Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All, 2012), 15.

⁹⁶ J James and T Collins, Achieving Equity in Skilled Birth Attendance: Malawi (Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All, 2012), at 16.

⁹⁷ F Bustero and P Hunt, Women's and Children's Health: Evidence of Impact of Human Rights (WHO, Geneva, 2013), 46.

⁹⁸ Quoted in P Rabinow, “Introduction” in P Rabinow (ed), The Foucault Reader (Penguin Books, London, 1984), 3–29, at 17. Originally in M Foucault, The History of Sexuality, Vol. 1 (Pantheon Books, New York, 1978), 17. Originally from M Foucault, Discipline and Punish (1975; English translation Vintage Books, 1979), 198.

⁹⁹ R DeVries, A Pleasing Birth: Midwives and Maternity Care in the Netherlands (Temple University Press, 2004), 15.

¹⁰⁰ D Korpela, The Nyau Masquerade: An Examination of HIV/AIDS, Power and Influence in Malawi (Tampere University Press, Tampere, 2011), 32.

¹⁰¹ M Longwe, Growing up: A Chewa Girl's Initiation (Kachere Series, Malawi, 2006), 19.

¹⁰² NL Aniekwu, “Converging Constructions: A Historical Perspective on Sexuality and Feminism in Post-Colonial Africa”, Africa Sociological Review 10 (2006), 143–60, at 146.

¹⁰³ M Longwe, Growing up: A Chewa Girl's Initiation (Kachere Series, Malawi, 2006), 20.

¹⁰⁴ Aniekwu (n 102 above) 146.

¹⁰⁵ M Longwe, Growing up: A Chewa Girl's Initiation (Kachere Series, Malawi, 2006), 27.

¹⁰⁶ M Longwe, Growing up: A Chewa Girl's Initiation (Kachere Series, Malawi, 2006), 34–35.

¹⁰⁷ NL Aniekwu, “Converging Constructions: A Historical Perspective on Sexuality and Feminism in Post-Colonial Africa”, Africa Sociological Review 10 (2006), 143–60, 147.

¹⁰⁸ NL Aniekwu, “Converging Constructions: A Historical Perspective on Sexuality and Feminism in Post-Colonial Africa”, Africa Sociological Review 10 (2006), 143–60, 143

¹⁰⁹ NL Aniekwu, “Converging Constructions: A Historical Perspective on Sexuality and Feminism in Post-Colonial Africa”, Africa Sociological Review 10 (2006), 143–60, 145.

¹¹⁰ M Longwe, Growing up: A Chewa Girl's Initiation (Kachere Series, Malawi, 2006), 79–81.

¹¹¹ The White Ribbon Alliance for Safe Motherhood, 2013. Respectful Maternity Care - The Universal Rights of Childbearing Women, 2013. http://www.healthpolicyproject.com/pubs/46_FinalRespectfulCareCharter.pdf (accessed 11 September 2014).

¹¹² Meeting with TBAs 2013; this was confirmed in other meetings.

¹¹³ Meeting with group of mothers, southern district of Malawi, 14 September 2013.

¹¹⁴ Meeting with group of mothers, southern district of Malawi, 14 September 2014.

¹¹⁵ See C Bowie and E Geubbels, Epidemiology of Maternal Mortality in Malawi (College of Medicine, Malawi, 2nd ed, 2013), 19.

¹¹⁶ Meeting with perinatal nurse specialist (Blantyre, 13 September 2013) and Malawi Human Rights Commission (Lilongwe, 11 September 2013). Cleaners were also mentioned in group meetings with mothers and TBAs.

¹¹⁷ This issue was taken up in all meetings both with nurse midwives, human rights activists, and ordinary mothers, and also in the group meeting with TBAs.

¹¹⁸ The dissatisfaction with nurses’ behaviour is raised also in newspapers, see E Shawa, “On Quality Nursing Care and Patients Needs” The Nation (Lilongwe, 9 September 2013).

¹¹⁹ C Bowie and E Geubbels, Epidemiology of Maternal Mortality in Malawi (College of Medicine, Malawi, 2nd ed, 2013), 19.

¹²⁰ Meeting with pregnant woman and mother of two (Lilongwe, 10 September 2013).

¹²¹ D Browser and K Hill, Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth (USAID-TRAction project, Harvard School of Public Health, 2010), 3. See also LP Freedman, “Human Rights, Constructive Accountability and Maternal Mortality in the Dominican Republic: A Commentary”, (2003) 82 Int J of Gynecology and Obstetrics 111–14.

¹²² Meeting with mother of four, Lilongwe, September 2013.

¹²³ PM Fenton, “Caesarean Section in Malawi: Prospective Study of Early Maternal and Perinatal Mortality”, (2003) BMJ 327–, at 587.

¹²⁴ P Mpaso, “Demystifying C-section Birth” (Weekend Nation, 7 September 2013).

¹²⁵ 2009, 6.

¹²⁶ This was raised in meeting with a perinatal nurse specialist who has been actively involved in midwifery associations (Blantyre, 13 September 2013) and by Malawi Human Rights Commission (Lilongwe, 11 September 2013).

¹²⁷ J Balaskas, Active Birth: The New Approach to Giving Birth Naturally (Revised edition of 1992, first edition published in 1983, The Harvard Common Press), 11. Balaskas refers to Dr GJ Engelmann's famous book Labour Among Primitive Peoples from 1883.

¹²⁸ T Kopare, Att rida stormen ut: Förlossningsberättelser i Finnmark and Sámpi [Birthstories from Finnmark and Sámpi] (Akademisk avhandling, Göteborgs universitet, 1999), 18.

¹²⁹ A Kumar, The Examination of Traditional Birth Attendant Practices and their Role in Maternal Health Services in Mwandama Village Cluster (College of Medicine Master's Thesis in Public Health, Blantyre, Malawi, 2007), 1.

¹³⁰ R Kapur, Erotic Justice: Law and the New Politics of Postcolonialism (The Glass House Press, London, 2005), 26.

¹³¹ Quote from J James and T Collins, Achieving Equity in Skilled Birth Attendance: Malawi (Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All, 2012), 18.

¹³² M Foucault, The History of Sexuality, Vol. 1: An Introduction (Originally published in 1976; Vintage, 1990), 144.

¹³³ M Dean, Governmentality: Power and Rule in Modern Society (SAGE Publications, 1999), 118.

¹³⁴ V Plumwood, Feminism and the Mastery of Nature (Routledge, London, 1993), 3.

¹³⁵ R Kapur, Erotic Justice: Law and the New Politics of Postcolonialism (The Glass House Press, London, 2005), 43.

¹³⁶ JA Nall, “Mother Beware: Perilous Scholarly and News Media Discourse around Homebirth”, 2 Int J of Communication and Health (2013), 46–.

¹³⁷ JA Nall, “Mother Beware: Perilous Scholarly and News Media Discourse around Homebirth”, 2 Int J of Communication and Health (2013), 46–, 38.

¹³⁸ C Bowie and E Geubbels, Epidemiology of Maternal Mortality in Malawi (College of Medicine, Malawi, 2nd ed, 2013), 18.

¹³⁹ Ministry of Health, National Sexual and Reproductive Health and Rights (SRHR) Policy (August 2009) 9.

¹⁴⁰ M Tew, Safer Childbirth? A Critical History of Maternity Care (Chapman & Hall, London, 2nd ed, 1995), 307.

¹⁴¹ See K Kielos, Det enda könet [The only sex] (Bonniers förlag, Stockholm, 2012).