Homebirth fines and health cards in rural Tanzania: On the push for numbers in maternal health

Over the last two decades, there has been a global push to improve maternal health by increasing numbers of facility births in low- and middle-income countries like Tanzania. While recent scholarship has interrogated the increasing hegemony of numbers and metrics in global health, few have ethnographically explored how this push for numbers and its accompanying technologies affect the lived experiences of parturients and those who care for them during pregnancy and childbirth in rural communities. Based on seven months of multi-sited ethnographic research conducted in three different rural communities in Mpwapwa District in 2016, this article explores how mothers and nurses in Tanzania experienced the push for numbers in maternal health, particularly as that push is enacted through homebirth fines and health cards. Intended to reduce maternal mortality, policies meant to increase facility births in rural Tanzania can inadvertently decrease access to care for the most marginalized community members, while simultaneously enticing under-resourced and over-burdened health workers to sanction non-compliant women while doing nothing to improve the wider health systems in which they work. Ethnographic interviews with mothers, nurses, and government leaders show how homebirth fines exacerbate structural inequalities in healthcare access, excluding some of the poorest women from the healthcare services they desire. Additionally, weekly participant-observation conducted at each of the community health dispensaries highlights the way female nurses engage in improvised and often punitive tactics with health cards, key documents for women to be able to access free national healthcare services. While the new sanctions can help lessen the heavy workloads of healthcare workers at rural dispensaries, they also lead to worsening relationships between nurses and the communities they serve. By prioritizing the perceptions and negotiations surrounding homebirth fines and health cards, this paper shows the unintended consequences of indicator-driven care, which most negatively affect the poor.