Weighing the options for delivery care in rural Malawi: community perceptions of a policy promoting exclusive skilled birth attendance and banning traditional birth attendants

To address its persistently high maternal mortality, the Malawi government has prioritized strategies promoting skilled birth attendance and institutional delivery. However, in a country where 80% of the population resides in rural areas, the barriers to institutional deliveries are considerable. As a response, Malawi issued Community Guidelines in 2007 that both promoted skilled birth attendance and banned the utilization of traditional birth attendants for routine deliveries. This grounded theory study used interviews and focus groups to explore community actors' perceptions regarding the implementation of this policy and the related affects that arose from its implementation. The results revealed the complexity of decision-making and delivery care-seeking behaviours in rural areas of Malawi in the context of this policy. Although women and other actors seemed to agree that institutional deliveries were safer when complications occurred, this did not necessarily ensure their compliance. Furthermore, implementation of the 2007 Community Policy aggravated some of the barriers women already faced. This innovative bottom-up analysis of policy implementation showed that the policy had further ruptured linkages between community and health facilities, which were ultimately detrimental to the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation in Low and middle income countries (LMICs), by focusing on the perceptions of those at the receiving end of policy change. It highlights the need for globally promoted policies and strategies to take better account of local realities.