Between orchestrated and organic: Accountability for loss and the moral landscape of childbearing in Malawi.

Abstract This paper explores loss in childbearing in Malawi (miscarriages, perinatal deaths and maternal mortality) as a lens to understand accountability and health system functioning. In low-income countries, maternal and perinatal mortality reflects poor health system functioning, to be improved in part through accountability. Understanding how accountability plays out on the ground requires examination of the existing, 'organic' accountability relationships and mechanisms. Thematic and discourse analysis of interviews and observations illuminates vocabularies of responsibility and practices of accountability concerning loss. Women are especially held accountable for loss, by a range of social actors. They use existing 'organic' accountability relationships and mechanisms to manage their own interests, but arguably also to care for pregnant women, even though negative birth experiences may ensue. Instances of disrespectful care appear a by-product of the convergence of organic and orchestrated, policy-driven accountability for numeric outcomes (deaths averted) rather than process (quality of care). Moreover, in the absence of essential physical resources, providers and relatives mobilize the social resources at their disposal to keep women and babies alive. Improving quality of care requires acknowledgment that providers' actions are both systemic and situational, and embedded in local moral landscapes and uneven webs of accountability. Highlights • Women are frequently held accountable for loss, by practitioners and communities. • Care is shaped by accountability relationships between a wide range of social actors. • Converging organic and orchestrated accountability may result in disrespectful care. • 'Disrespect and abuse' could be seen as care for the survival of women and babies. • Providers' actions are systemic and situational, and embedded in accountability webs. [ABSTRACT FROM AUTHOR]