Paper short abstract:

This study explores ways in which policies to reduce maternal mortality in Rwanda impacted on perceptions of risk and on behaviour, and how women and health workers negotiated biomedical and ‘traditional’ concepts within financial and organisational power relationships

Paper long abstract:

Rwanda reduced maternal mortality rates by two thirds in 10 years. This study explored how change occurred and how people made sense of it. Fieldwork was carried out with Health and community staff and local women in Western Rwanda. Government strategy was to increase services, community participation and uptake of health insurance, and to incentivise antenatal attendance and delivery in health centres. Punishment emerged as a key policy tool and a means by which health professionals exerted power; women were punished financially for home delivery and health staff displayed punishing attitudes to get people to use their services. These attitudes were resented by women and discouraged trust in staff and attendance at clinics. This is contrasted with empowering methods of a successful NGO-run maternity clinic. This punishment ethos combined with an increasing discourse of maternal risk and of modernity resulted in an increasing acceptance of using maternity delivery services. However, these co-existed with, and were often in conflict with, belief in magical causes of illness and use of traditional methods for protection against magic. High levels of mistrust extended to government such that health programmes, eg. contraception and HPV vaccination, intended to reduce risk, are seen as plots for further disempowerment and control. Themes of risk perception, empowerment and control are explored.