Paper short abstract:

Hopes invested today in community health workers echo those once invested in “traditional birth attendants.” In Malawi, TBAs once treated as stop-gap extensions of the modern state are now often vilified as dangerous non-moderns. Their experience raises cautions about health work at the boundary.

Paper long abstract:

"Global health" schemes today often place high hopes on community health workers, imagined to extend sensitive, appropriate, and inexpensive care to people in poor countries and remote places. These hopes are not novel. From the early twentieth century to the mid-1990s, so-called traditional birth attendants (TBAs) were imagined as agents who might extend safe motherhood practices beyond the reach of doctors and nurses. Programs to teach TBAs the rudiments of biomedical obstetric care proliferated. The rise and fall of TBA programs raises cautions about today's focus on CHWs.

In Malawi, birth attendants were registered (although never entirely), trained (although never at large scale), and supervised (although never consistently) for decades. Training programs largely ended by 2005; in 2007 TBA practice was outlawed. Although the ban was later reversed, the legal status of these attendants now varies among districts and is often unclear. In the aftermath, those who still work as TBAs are largely cut off from relations with government health workers and facilities.

How did these birth workers go from saviors to scoundrels? Drawing on ethnographic and archival research, and on interviews with birth attendants in Malawi, I argue that a managerial biomedical imaginary stabilized and homogenized a remarkably heterogeneous set of practitioners. TBAs were not just at the boundary between traditional and biomedical: the whole category was a product of bureaucratic boundary-drawing that never matched up with what was actually happening in practice. This imaginary made the hopes invested in TBAs possible—and their disappointment inevitable.