title: Local adaptations to a global health initiative: penalties for home births in Zambia.
abstract: Global health initiatives (GHIs) are implemented across a variety of geographies and cultures. Those targeting maternal health often prioritise increasing facility delivery rates. Pressure on local implementers to meet GHI goals may lead to unintended programme features that could negatively impact women. This study investigates penalties for home births imposed by traditional leaders on women during the implementation of Saving Mothers, Giving Life (SMGL) in Zambia. Forty focus group discussions (FGDs) were conducted across four rural districts to assess community experiences of SMGL at the conclusion of its first year. Participants included women who recently delivered at home (3 FGDs/district), women who recently delivered in a health facility (3 FGDs/district), community health workers (2 FGDs/district) and local leaders (2 FGDs/district). Findings indicate that community leaders in some districts-independently of formal programme directive-used fines to penalise women who delivered at home rather than in a facility. Participants in nearly all focus groups reported hearing about the imposition of penalties following programme implementation. Some women reported experiencing penalties firsthand, including cash and livestock fines, or fees for child health cards that are typically free. Many women who delivered at home reported their intention to deliver in a facility in the future to avoid penalties. While communities largely supported the use of penalties to promote facility delivery, the penalties effectively introduced a new tax on poor rural women and may have deterred their utilization of postnatal and child health care services. The imposition of penalties is thus a punitive adaptation that can impose new financial burdens on vulnerable women and contribute to widening health, economic and gender inequities in communities. Health initiatives that aim to increase demand for health services should monitor local efforts to achieve programme targets in order to better understand their impact on communities and on overall programme goals.
authors.affiliation: Epidemiology Department, Mailman School of Public Health, Columbia University, New York, NY 10032, USA danagreeson@gmail.com.
authors.forename: Dana
authors.initials: D
authors.lastname: Greeson
authors.affiliation: Epidemiology Department, Mailman School of Public Health, Columbia University, New York, NY 10032, USA USAID Maternal and Child Survival Program (MCSP)/ICF International, Washington, DC 20036, USA.
authors.forename: Emma
authors.initials: E
authors.lastname: Sacks
authors.affiliation: Visiting Lecturer, Department of Sociology and Anthropology, College of the Holy Cross, Worcester, MA 01610, USA.
authors.forename: Tsitsi B
authors.initials: TB
authors.lastname: Masvawure
authors.affiliation: Epidemiology Department, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Austin-Evelyn
authors.affiliation: Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA.
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Kruk
authors.affiliation: The Institute of Economic and Social Research, University of Zambia, PO Box 32379, Zambia.
authors.forename: Mubiana
authors.initials: M
authors.lastname: Macwan'gi
authors.affiliation: Robert F Wagner Graduate School of Public Service, New York University, New York, NY 10012, USA.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Grépin
mesh_terms: D000328:Adult; D003150:Community Health Workers; D036861:Delivery, Obstetric; D005260:Female; D017144:Focus Groups; D014943:Global Health; D006268:Health Facilities / Q000706:statistics & numerical data; D006300:Health Services Misuse; D006700:Home Childbirth / Q000191:economics*; D006801:Humans; D008297:Male; D008427:Maternal Health Services / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D009042:Motivation; D011247:Pregnancy; D036301:Qualitative Research; D012424:Rural Population; D015024:Zambia
keywords: Global health initiative; Zambia; local adaptation; maternal health; penalties; traditional leader