When In Need of Discipline: Women’s Agency and Almeria’s Ban on Home Birth
Manguni, Grachel Lloren; De Herdt, Tom (2014). 'When In Need of Discipline: Women's Agency and Almeria's Ban on Home Birth' Paper presented at the annual conference of the HDCA, 2-5 September 2014, Athens, Greece.
Sen famously argues that a person should be free to do or be whatever it is that she has reason to value. However, he concedes that a person's agency may sometimes be in need of discipline. While children and mentally-ill persons are obvious examples, adults, whom Sen argues to be viewed as responsible agents, are, in some situations, disputatiously considered by others to require discipline as well. The controversy, however, does not end in the identification of whose agency requires discipline; it extends, and more contentiously so, to how discipline ought to be meted out.
In theory and in practice, agency is viewed either with full trust and confidence or with doubts in varying degrees. Depending on the view adopted, public action may take the form of letting a person's agency alone, enhancing it, manipulating it, or suppressing it.
In this paper, we analyze the case of the Municipality of Almeria which casted doubt on the agency of its pregnant women and, as a consequence, issued the first local ban on home birth in the Philippines. Before the ban, Almeria was a poor municipality with a very high rate of maternal mortality. At that time, public health service delivery was substandard and home birth with the aid of a traditional birth attendant, locally known as a 'hilot', was the norm. In 2006, the agreement that granted assistance to Almeria for the enhancement of its maternal and child health services was signed; and, in 2007, the resolution that banned home birth was issued. Almeria soon saw remarkable improvements in maternal health; and, in 2008, the Department of Health issued an administrative order which the press, later, dubbed as the No Home Birthing Policy. Since Almeria's ban was advertized in strongly positive terms, it became a source of inspiration for other local governments who later imposed their own bans on home birth. However, as the ban spreads further in the country and reaches national consciousness, it meets serious opposition from various groups who express their open condemnation of it as a strategy for safer live birth delivery.
From reviews of pertinent documents and interviews with officials, health workers, and women in Almeria in June 2013, we reconstruct the argument that Almeria had which started the imposition of bans on home birth in the country. We explain why the ban may not be absolutely necessary in reducing mortality; and, we argue that another strategy, which Almeria also employed, better responds to the alleged need of its pregnant women for discipline.
Officials and health workers of Almeria argue that even after public health services are improved–which would then make facility-based delivery much safer than home-based delivery–the pregnant women were unlikely to avail themselves of those services. This expectation stemmed from their perception of women as being so used to home birth and hilot that they have become 'obstinate' and 'resistant to change'. To officials and health workers, they were faced with a seemingly chicken-and-egg problem. Pregnant women were likely to switch to facility-based delivery once they have experienced it. However, they will only experience it if they will give it a try. But, women, to begin with, were deemed unlikely to even give facility-based delivery a try. Without giving it a try, though, they would not have the experience on which to draw the motivation to make the switch. So, officials and health workers realized they needed an impetus for experiential learning. The impetus, they soon concluded, was the ban.
However, we beg to differ. In light of better alternatives, we find Almeria's ban on home birth as an uncalled-for takeover of pregnant women's agency which may not be the best long-term strategy in pursuit of their human development.
The pregnant women in Almeria had three reasons for opting for home birth: poor public health service delivery; straitened circumstances; and divergent conceptions of what is safe. Since the ban does not seem to be a sensible solution to the first two problems, the pregnant women's divergent ideas of safety most likely triggered the imposition of the ban. On this subject, interview responses offer two important insights. First, for many women in Almeria, neither medical nor statistical suggestions work quite as well as experience in illustrating what is safe. Second, and more importantly, many of them gain confidence or get traumatized not only from their own experience but also from the experience of people whom they can easily identify themselves with. Indeed, it was for this reason that health workers in Almeria employed agency-enhancing measures like the 'burod-tabang-burod' or the 'pregnant-helping-pregnant' strategy. The strategy was developed so that expectant mothers can learn about the value of accessing appropriate health services from their fellow pregnant women, and even from post-partum women. Logically, both the ban and the burod-tabang-burod may have tied the loose ends from divergences in conceptions of safety. However, whereas the ban addressed the problem by suppressing the pregnant women's agency, the burod-tabang-burod addressed the same problem by engaging their agency.
And there are at least three reasons that make agency enhancement a better long-term strategy in promoting the pregnant women's human development. First, agency enhancement helps them make better choices and thereby bridges the gap between capabilities and achieved functionings. It therefore enables them to actually live lives they have reason to value. Second, agency enhancement equips them with analytical models or skills which may be applicable in other situations that they may face. It therefore enables them to become better decision makers even in other aspects of their lives. And third, agency enhancement leaves them with greater latitude to think through and act on their circumstances and values, and thereby accords them with better insulation from occasional ill-designed or ill-motivated public policies.
In view of these reasons, we argue for the reconsideration of the ban on home birth in Almeria and everywhere else in the country. Moreover, in general, when people's agency is found in need of discipline, we support strategies that enhance their agency over others.