Institutional Ethnography Texts Organizing Maternity Care in Northern Uganda: From Global Goals to Local Practices and Back Again

Drawing on a study of the social organization of maternity care and birth in northern Uganda, this talk traces the activation of two ‘local’ texts, a letter and a form. I identify their role in coordinating activities translocally on a micro-scale - between a rural health centre and patients’ rural homes - as well as on a global scale - between global health paradigms formalized in the Millennium Development Goals and rural women’s everyday experiences of care. I trace how despite global health norms around human rights, gender equity, and health care accessibility, a coercive approach to health care that developed in a remote rural northern Uganda setting can be traced via texts to the Millennium Development Goals. Consequences of the coercive approach include violence, barriers to health care, and added ‘work’ for women accessing care. Beyond a narrative of unexpected outcomes of well-intentioned interventions that is repeated in development circles, I suggest that poor outcomes are in fact predictable. Poor outcomes result from, among others, “vertical” implementation that places health outcomes on different issues or among different population groups in competition with each other, universal and technical approaches that ignore local social and political contexts, and framings of maternal health problems as primarily rooted in culture or tradition. Both the improvised local texts and the highly formalized international texts play a role in ruling relations. In trying to face in two directions at once, towards global health goals and patients, local health care providers fail both in particular ways. I suggest ways in which local social relations could be made more visible to global health governance, resulting in better translations of intentions to outcomes.