Loss in childbearing (maternal mortality; induced and spontaneous abortions; perinatal mortality) is an important problem in sub-Saharan Africa (SSA), specifically, in Malawi. Regardless of sustained global initiatives, maternal mortality (MM) and pregnancy loss are unacceptably common. In Malawi, life-time risk of maternal death is 1 in 18 (UK: 1 in 8200). Delays in seeking and receiving care are important contributors to the burden. They are not fully explained by practical (e.g. costs, distance) and cognitive (lack of knowledge) barriers. We need more insight into how local rationales affect use and provision of care, in particular interpretations of responsibility, blame and women’s entitlement to care. For instance, in Malawi, some interpret obstructed labour as signalling a woman’s infidelity, who is kept at home until she confesses. Practitioners’ moral judgements matter too; they seem to underpin substandard maternal care in SSA. In various African contexts, practitioners have been found to verbally and physically abuse especially ‘deviant’ clients (those not attending antenatal care, teenage mothers).

Using an innovative analytic approach –discourse analysis (DA)- this project will document how communities and practitioners interpret loss of the (unborn) child and mother and care provided; how these interpretations assign responsibility, blame, and entitlement to care and how they may affect use and provision of care. Interpretations will be elicited in interviews and focus groups. Acknowledging that accounts are never neutral, DA will be used to examine statements’ functions (e.g. justifying actions, allocating blame). Observations elucidate how interpretations of blame and entitlement to care may affect provider- client interactions. This study is theoretically and methodologically innovative. Going beyond the usual assessment of the content of accounts of loss and maternity care, it examines how such accounts produce moral judgements, evoke local interpretations of human rights and how judgements may affect maternity care. It includes providers and men, whose views have been neglected. Moreover, use of DA elucidates methodological issues affecting the validity of maternal death audits, increasingly used in resource-poor settings to infer cause of maternal death from practitioners’ and relatives’ accounts. However, they neglect how interpersonal issues at stake (responsibility, blame) for all parties concerned colour these accounts.