Women who break the rules: Social exclusion and inequities in pregnancy and childbirth experiences in Zambia.

Health inequities are a growing concern in low- and middle-income countries, but reducing them requires a better understanding of underlying mechanisms. This study is based on 42 semi-structured interviews conducted in June 2018 with women who gave birth in the previous year, across rural and urban clinic sites in Mansa district, Zambia. Findings show that health facility rules regulating women's behaviour during pregnancy and childbirth create inequities in women's maternity experiences. The rules and their application can be understood as a form of social exclusion, discriminating against women with fewer financial and social resources. This study extends existing frameworks of social exclusion by demonstrating that the rules do not only originate in, but also reinforce, the structural processes that underpin inequitable social institutions. Legitimising the rules supports a moral order where women with fewer resources are constructed as "bad women", while efforts to follow the rules widen existing power differentials between socially excluded women and others. This study's findings have implications for the literature on reversed accountability and the unintended consequences of global and national safe motherhood targets, and for our understanding of disrespectful maternity care.


Introduction 24
The maternal health literature's excessive focus on individual-level barriers to maternal healthcare 25 access may have fuelled individual-level approaches to addressing maternal health inequities 26 (Gabrysch and Campbell, 2009;Moyer and Mustafa, 2013). Targeted behaviour change interventions, 27 abolishing user fees, or conditional cash transfers have been rolled out to increase access to care 28 among those shown to have least access: the uneducated, the poor, those who do not save, or older 29 women (Målqvist et al., 2013). Other studies have taken a more systemic perspective, investigating 30 whether some health facilities may simply be too far or too low quality for certain populations to 31 access them (Gabrysch et al., 2011). This line of enquiry has yielded its own set of interventions, such 32 as building more facilities, distributing transport vouchers or bicycle ambulances, or introducing 33 performance-based financing. Yet despite the growing prioritisation of health equity, intra-country 34 inequities in access to maternal healthcare services in Low-and Middle-Income Countries (LMICs) 35 remain larger and are reducing at slower rates than inequities in other primary healthcare areas 36 (Boerma et al., 2018). Given this comparative lack of progress, we need to better understand the 37 underlying mechanisms producing inequities in order to inform policy (Friedman and Gostin, 2017; 38 Krieger, 2001; Wainwright and Forbes, 2000). Understanding mechanisms may depend on including 39 power processes in our analyses, a rare occurrence in the LMIC health policy and disrespectful 40 maternity care literatures (Bradley et al., 2016;Sriram et al., 2018). 41 Also lacking is a broader understanding of maternal health inequities that includes the absence of 42 "unfair and avoidable" differences in "mental and social well-being" (Ramírez, 2016;Whitehead, 1991, 43 p. 219; World Health Organisation, 1946, p. 1). If we take this definition of health equity seriously, we 44 cannot reduce it solely to equitable healthcare access, healthcare quality, or even respectful maternity 45 care. According to Freedman et al's (2014) definition, disrespect and abuse of women in maternal 46 healthcare includes "specific provider behaviours experienced or intended as disrespectful and humiliating" as well as " systemic deficiencies that create a disrespectful or abusive environment" In order to explore the mechanisms behind inequitable pregnancy and childbirth experiences, this 66 study uses diverse women's perspectives on their own recent experiences and a theoretical approach 67 that explicitly acknowledges power, Naila Kabeer's (2000) social exclusion framework. Contrary to 68 much of the existing literatures on maternal health inequities and on disrespectful care, which focus 69 on women's characteristics or the health system's shortcomings, this study's findings illustrate that 70 inequities can be created and reinforced by routine institutions: health facility rules governing how 71 women should behave in pregnancy and childbirth. Adding to the literature on reversed accountability 72 and the use of by-laws in maternal healthcare, this study is the first to describe a broad set of health facility rules from women's perspectives and to analyse how these rules create inequities in maternal 74 healthcare. 75

Theory 76
This study draws on Naila Kabeer's framework of social exclusion (2000), applying it for the first time 77 to the analysis of maternal health inequities. According to this framework, social exclusion or inclusion 78 operates on the basis of different and overlapping forms of disadvantage attached to social groups. 79 Disadvantage can be economic but also cultural or representational. Economic and cultural 80 advantages translate to power, which groups can use, consciously or unconsciously, to further their 81 existing advantages through strategies of inclusion or exclusion. This framework is well suited to the 82 analysis of women's overall experiences of pregnancy and birth, and the inequities therein, by 83 including representational disadvantage in its definition of injustice: 84

Disrespectful behaviour does not represent an injustice solely because it constrains the subjects 85
in their freedom for action or does them harm. Rather, such behaviour is injurious because it 86 impairs these persons in their positive understanding of self -an understanding acquired by 87 inter-subjective means (Honneth, cited in Kabeer 2000, 84). 88 The framework also draws attention to how institutions (such as health facilities) operate as potential 89 agents of exclusion. Institutions are posited to govern the distribution of resources (such as access to 90 high quality and respectful maternal healthcare), according to rules that may or may not privilege 91 existing endowments or group belonging. The institutions and the rules do not themselves cause social 92 exclusion. Social interactions and power relations between groups result in the creation of institutions 93 that have the potential to exclude. 94 Kabeer identifies a range of practices through which groups can use institutions to exclude, in 95 conscious or unconscious ways. Two of them are relevant here. Firstly, 'mobilisation of institutional 96 bias' (Lukes, 1974), defined by Bachrach and Baratz as "a predominant set of values, beliefs, rituals and institutional procedures ('rules of the game') that operate systematically and consistently to the 98 benefit of certain persons and groups at the expense of others." (Kabeer, 2000, p. 91). For example, 99 institutional procedures such as health facility rules, which apply theoretically to everyone, may have 100 inequitable effects as a result of being easier to comply with for some social groups than others.
points over the 2008-2013 period (CSO et al 2014). The Government of Zambia has made it a priority 123 to reduce these inequities in its National Health Strategic Plans (Republic of Zambia MOH, 2017, 124 2005. Many health and health-related reforms have been initiated in Zambia over the past ten years 125 with inequity reduction in mind. 126 This study draws on data collected in Mansa district, Luapula Province, which was purposively selected 127 because it has one of the lowest averages for facility delivery in the country according to the last 128 available Annual Health Statistical Bulletin of 2013 (39%). Mansa district hosts the capital of Luapula 129 Province and was selected due to high levels of contrast between its urban and rural areas, both in 130 terms of distance to well-equipped health facilities and type of livelihood. Rural residents mostly make 131 a living from subsistence or small-scale farming as well as farming others' fields or selling goods such 132 as home-brewed beer. Urban residents typically either have informal jobs such as roadside sellers, or 133 service industry jobs such as bank clerks, police-women, and teachers. Mansa district has 56 facilities 134 (of which 1 hospital and 6 urban health centres) and 4 ambulances for approximately 258,800 people 135 (Worldpop, 2016 because the paper is grounded in a thick description of inequities as experienced by pregnant and 144 labouring women, data collection focused on women with diverse and overlapping characteristics 145 instead of comparing women's reports to that of their husbands, families or health workers. 146 The study is based on analyses of 42 semi-structured interviews with women aged 18 or older who 147 had given birth in the previous 12 months. Interviews were conducted in June 2018 and collected 148 information on women's experiences of their most recent pregnancy and birth, as well as their views 149 on which types of women were more likely to have negative or positive experiences. I also took notes 150 during (but did not audio-record) informal conversations with health workers, health volunteers, and 151 two district health officers. 152 The interview guide was initially drafted by the author and adapted in a pre-data collection workshop 153 with the interviewers, according to their understanding of the field site's context. It was progressively 154 modified during data collection in order to further explore themes raised by respondents (such as 155 home delivery, fines, finding money for the birth, etc.), based on daily discussions between the 156 interviewers and myself. The interviews were conducted in the Bemba language by two interviewers 157 from Lusaka whom I trained and supervised, with some respondents choosing to be interviewed in 158 English. I was always present at the data collection site, and present in 4/42 interviews. Interviews 159 lasted between 35 and 60 minutes and took place in an aurally private location, often outside and 160 always within the perimeter of the immunisation clinic. 161 Respondents were recruited from nine child immunisation clinics (including outreach clinics) in rural 162 and urban settings. Recruitment combined convenience and purposive sampling to compare women's 163 experiences from diverse and overlapping social locations (Table 1). Respondents were assigned 164 characteristics by self-reporting, except for the "visibly poor" category, which was determined by the 165 interviewers and myself, using their interview notes about the respondent's attire and appearance. 166 The intention was to capture visual clues indicating poverty relative to the study's context (e.g.: poor 167 quality of chitenge cloth typically used as clothing, torn shoes, un-groomed hair), as opposed to my or 168 the interviewers' relative wealth. While this categorisation cannot measure actual poverty, these 169 markers could have sparked processes of social exclusion. Written or oral informed consent was 170 obtained for all interviews. During the consent process, interviewers stressed that they were not working with the health facility but that the health workers and the Ministry of Health were aware of 172 All interviews were audio-recorded and were transcribed from the Bemba audio recording into English 178 by the interviewers and two additional research assistants. Names of people and places were redacted 179 in the quotes used in this paper and the respondents themselves are referred to with codes. Common Bemba expressions have not been translated from English -these include "Awe" ("no"/"nothing" or 181 used as an exclamation); "Emukwai" (an expression of agreement or positive emphasis); "Kaili" 182 ("because" or for negative emphasis); "Ba" Sarah (respectful manner of referring to Sarah). Costs are 183 given in Kwacha, the Zambian currency. In June 2018, 10 Kwacha was equivalent to 1 USD. 184 I analysed the interview data using a simplified grounded theory approach adapted from Corbin and 185 Strauss (2012). Specifically, some codes emerged from the transcripts, while others were informed by 186 the interview guide (which did not pre-suppose any mechanism for explaining inequities). In line with 187 grounded theory, I drafted memos to summarise the content of one or more codes, ask additional 188 questions of the data, and look for differences in coded content between categories, e.g. "married" 189 vs. "not married". I also explored analytical relationships between memos during the writing process. 190 Unlike a pure grounded theory approach, memos were not drafted for all codes but only for those 191 relevant to a salient mechanism that emerged during the coding process, and which is explored in-192 depth in this paper. The theoretical perspectives used in this paper did not emerge from this study but 193 neither were they anticipated prior to memo-writing; rather, they were applied during the write-up 194 phase in order to understand the implications of the findings. 195

Findings 196
This study found that health facility rules form an important part of participants' experience of 197 pregnancy and childbirth and have inequitable effects. Women with fewer social and financial 198 resources are less able to follow the rules and are therefore more at risk of being subjected to 199 sanctions, or more likely to make significant sacrifices to follow the rules. The authoritative knowledge 200 legitimising the rules also strengthens the view that women with fewer resources are 'bad women', 201 while women's efforts to follow the rules and avoid sanctions reinforces inequitable power relations 202 within and beyond the health facility. 203 In section 3.1, I describe the health facility rules, as well as the sanctions women were subject to if 204 they broke the rules. I then explain how the rules can be understood as social exclusion processes 205 resulting in inequitable experiences of pregnancy and childbirth in section 3.2. In section 3.3, I explain 206 how the rules reinforce inequitable structural processes through their influence on the moral order 207 and power relations. 208

Rules and sanctions 209
In this section, I explain how I identified the "rules", the scope and nature of this study's evidence on 210 rules, and what the rules and sanctions are. I categorised guidelines for behaviour in pregnancy and 211 childbirth as "health facility rules" according to respondents' reports. In order to count as a rule, 212 respondents needed to say that this behaviour guideline had been communicated by health workers 213 or the health facility. It was not necessary for respondents to: mention any specific sanctions linked 214 to the rule; actively label it as a rule, a law or an order; or for the rule to be mandated by the health 215 system or a traditional authority. Rules mentioned frequently towards the beginning of the data 216 collection process were specifically asked about in subsequent iterations of the interview guide, 217 thereby increasing the likelihood of reporting. The list of rules should not be understood as exhaustive 218 or representative, but as evidence that a set of rules is highly relevant to women's pregnancy and birth 219 experiences in Mansa and, very likely, beyond (see Discussion). 220

Resources rules
Bringing materials to the facility when giving birth, e.g.: soap, Jik, dish/tub/bucket, plastic sheet, gloves, nappies, chitenges, clothes for the mother, clothes for the baby 15 Taking a car or taxi to leave the facility after birth 2

Sexual and reproductive rules
Not having extramarital sexual relations 3 Not having 'too many' children 2 Should have sex with the husband during pregnancy 1

Maternal healthcare seeking rules
Giving birth at the facility 16 Bringing the father of the baby when registering the pregnancy 11 Not using traditional medicine "for opening the way" in pregnancy or childbirth, which is a mixture of herbs to hasten delivery 7 Going to the mother's waiting shelter in the last month of pregnancy 4 Attending ANC 3 Starting ANC at 2 or 3 months 3 Coming to the facility promptly when in labour 2 Taking facility medicine during pregnancy 2 Coming to the facility for delivery with the "SMAG" (community health worker) 1 Rules during labour at the facility "Being strong", i.e.: not making noise or crying, and successfully pushing the baby out 6 Being clean and shaving pubic hair prior to arrival for delivery 6 Lying down during labour and not moving around the delivery ward 4 Women's entourage not allowed in the labour ward 3 Using a bucket instead of the toilet for urine and faeces 3 Obeying instructions from healthcare workers 3 around rules included words translated as "must"; "should"; "told"; "have to"; "not allowed"; "not 227 supposed to"; "required"; and "taught". The level of coerciveness implied by respondents' language 228 varied from strong norms to laws (i.e. traditional authorities' by-laws), depending on the respondent 229 but mostly on the rule itself and associated sanctions, if any. 230

Lifestyle rules during pregnancy
Many of these rules were mentioned by less than five respondents, but three rules were mentioned 231 by 10 or more different respondents: giving birth at the health facility; bringing in-kind materials to 232 the health facility when giving birth; and bringing the father of the baby to the facility to register the 233 pregnancy. Most rules were mentioned across sites, with no specific rural-urban pattern, or whether 234 women had delivered in a health centre or the hospital. The exception is the rule about not having 235 extramarital sexual relations, which was only mentioned by 3 out of 6 respondents from one specific 236 site. 237 Many respondents described specific sanctions which they had experienced or which they expected 238 to incur if they broke the rules (INSERT LINK TO ONLINE FILE A). Fines up to K50 were charged for delivering from home, or up to K10 for registering the pregnancy late or not at all. These fines were 240 confirmed in informal conversations with community health workers ("SMAGs") from two sites and 241 with two district health officers. 242 Women coming without the father of the pregnancy to register at the health facility could be excluded 243 from antenatal registration, unless they received special dispensation from the SMAG or the chief. 244 One urban woman of low socio-economic status who had recently been left by her husband said she 245 was twice turned away from registering her pregnancy due to not having a husband. 246 Respondents also mentioned the possibility (or the experience of) being shouted at or scolded, being 247 beaten or slapped, or being shamed by health workers if they broke the rules. For example, a 248 respondent reported a situation during an antenatal clinic where women coming without husbands 249 were shamed by being made to sit separately, leading to an altercation with the health workers, who 250 accused them of sexual promiscuity ("meeting in the grass" Health workers might also make women feel responsible for negative health outcomes when they did 257 not follow the rules. In the quote below, the health worker tells the respondent that she has caused 258 her own illness as a result of not following the rule about doing only light chores during pregnancy: 259 "I got sick, I even went back to the clinic, at the clinic they asked me that, "were you doing any 260 work when you were pregnant?" "Emukwai I was working," "But we don ' Sanctions were not the only, or perhaps even the main reason women followed the rules. Both the 265 rules and the sanctions were legitimised by authoritative knowledge, to which health workers had 266 privileged access. Women believed following the rules was the best way to manage the risky event of 267 childbirth. This was partly because they saw the rules as inherently important for their health and their 268 baby, and because following the rules enabled access to health workers with the "right" knowledge 269 as well as drugs and equipment. 270 As is common in other settings, authoritative knowledge was constructed by framing information 271 exchanges during antenatal care as knowledgeable health workers teaching ignorant pregnant women 272 (Browner and Press, 1996 Simultaneously, the rules themselves reinforced authoritative knowledge by outlawing reliance on 277 competing forms of knowledge. For example, women were not allowed to take traditional medicine 278 during pregnancy or labour, or to rely on their own judgement of how far along their labour was when 279 deciding when to come to the health facility for birth. 280

Inequitable effects of rules 281
While respondents typically presented the rules as legitimate, the rules resulted in inequitable 282 pregnancy and birth experiences. This is because not all women had access to the financial and social 283 resources needed to meet the rules, and because the rules were unevenly applied. Inequities in the 284 experience of pregnancy and childbirth were structured according to socio-economic status, rural vs. 285 urban residence, marital status, age, number of children, and how much support could be expected from one's husband/father of the child or relatives. Respondents' overall vulnerability resulted from 287 the intersection of these characteristics, with extensive links between financial and social resources. 288

Mobilisation of institutional bias 289
Women with insufficient resources could either break the rules, believing they were endangering their 290 and their baby's health and risking sanctions, or follow the rules by making costly financial and 291 relational sacrifices. In line with Kabeer's framework (2000), the rules can be understood as a form of 292 institutional bias. While the exclusion is unconscious, the rules are designed to serve an "ideal" 293 patient, excluding women who do not conform to that ideal. 294 Respondents with limited financial resources described making sacrifices to raise the required funds. 295 One urban respondent in her 20s with two children did piecework in order to survive, often in 296 exchange for food, and did not make enough to "keep money" (save). In order to pay for transport to 297 the health facility (around 20K, equivalent to payment for weeding a field), she took out a loan from 298 the woman she sells fritters for, who deducted it from her future earnings. She also accepted in-kind 299 help in the form of baby clothes and nappies from the sister of her baby's father, even though he 300 denied responsibility for the pregnancy. Despite these financial and relational sacrifices, she knew she 301 would not be able to pass as a financially comfortable married woman when she reached the facility: 302 to make these sacrifices and face potential shame because she was worried about childbirth 305 complications and being made to pay a fine she could not afford for home delivery. 306 For rural women, gathering sufficient financial resources to follow the rules could require sacrifices 307 taxing their physical resources. A rural married woman in her 20s explained she had to shoulder a 308 heavy workload during her pregnancy in order to store enough food for the post-partum period, which 309 was also, ironically, against the rules:

01] 313
Other facility rules required women to be embedded within specific social relationships. Eleven 314 respondents were unmarried or separated at the time of pregnancy and birth, which made it more 315 difficult to follow the rule about bringing the father of the baby to register the pregnancy. While it is 316 feasible for the father to fulfil this duty even if he is not married to the mother, unmarried fathers 317 refused responsibility in 3 out of 11 of these cases. 318 The rule about doing only light chores when pregnant also assumes women can draw on social 319 relationships. Being single would make it harder to follow this rule: 320 Women's access to financial resources depended heavily on their social network, particularly their 325 parents if they were unmarried or their husband if they were married. 326 327

Unruly practices 328
The ways in which the rules were applied varied according to women's characteristics. One rural 329 respondent said women "with names" (important women), are not punished for delivering at home. 330 An urban respondent of a higher socio-economic status who delivered from home due to a fast labour 331 did not report paying a fine, although health workers "were not happy because I gave birth at home 332 so they had to say a lot 'why didn't you come, you knew that you were in labour…' then I had to explain 333 what happened." [03-03-01]. Another urban woman, who was educated but poorer, delivered from home due to her husband not being there at the start of labour, and did not mention incurring a fine 335 either. She was delivered by her neighbour, a retired nurse who after delivery went with her and the 336 baby to the facility to explain the situation. The advocacy of the retired health worker likely helped 337 her to avoid a fine or a confrontation with the health workers. 338 Sanctions also depended on socially constructed expectations about women's level of responsibility 339 and vulnerability. For example, young women were thought to be less able to give birth. As a result, 340 health workers were perceived to be more patient with them during labour. While this flexibility in 341 the application of the rules appears to address underlying inequities, it might impair "a positive 342 This ignores the situation of several respondents who said their husbands cannot or will not provide 354 support, despite the gendered norms prescribing that they should. While other respondents said the 355 husbands would be sanctioned as a result, the final responsibility was often constructed as the wife's:

Rules as social exclusion? 360
In order for the rules to be understood as a strategy of social exclusion, it is important to show that 361 they originate in unequal power structures. While underlying power structures were not investigated 362 by this study, it is suggestive that women with fewer financial and social resources faced 363 discrimination beyond the health facility as well. For example, women reported being excluded from 364 community groups organised through the church, either as a result of having a non-marital pregnancy 365 or because they lacked financial resources: 366 Unmarried pregnant women were also likely to experience sanctions from their relatives. Relatives' 375 reactions to their pregnancy included shouting and scolding, chasing their daughter from the house, 376 not speaking to her, and denying her financial support. 377

"Now, kaili the meetings at Dorcas they see how a person is, that is when they pay attention
These social sanctions were underpinned by a moralised discourse of personal responsibility. 378 Respondents who did not identify themselves as lacking resources emphasised women could always 379 save some money, e.g. from braiding hair, or could ask friends for help, perhaps in exchange for some work. They perceived women lacking financial resources in pregnancy as lazy or irresponsible. 381 Unmarried pregnant women were described as being sinful, stupid, or too proud. 382

Structural effects of rules 383
Health facility rules not only exclude women with insufficient financial and social resources, but also 384 reinforce the structural processes that underpin inequitable social institutions such as the rules 385 themselves. The moralised discourse around rules provides an additional rationale for community 386 members to label women with insufficient financial and social resources as "bad women", while the 387 imperative to follow the rules puts pressure on socially excluded women to further disempower 388 themselves, thereby widening existing power differentials. 389

Reinforcing the moral order 390
Women who struggled to follow facility rules were often constructed as bad women by other 391 respondents, specifically as a result of them breaking the rules. From the perspective of authoritative 392 knowledge, this is not surprising, as those who do not align themselves with authoritative knowledge 393 are frequently constructed as immoral (Jordan, 1997, p. 56 The rule about bringing the father to register the pregnancy reinforces inequitable power relations 422 between men and women by making women dependent on men's willingness to assume paternity. 423 The rules also reinforce inequitable power relations between unmarried mothers and their relatives. 424 Unmarried mothers had to face severe social sanctions and perform their guilt in order to reconcile 425 with their families, upon which they relied to meet facility rules: 426

Limitations 443
The following aspects of the research design may have led respondents to more actively legitimise 444 rules and sanctions, and to avoid mentioning their own "transgressions" and the sanctions they 445 experienced as a result: interviews were held within the health facility compound or outreach location; 446 interviewers often had a higher social status than interviewees with respect to their education, fluency 447 in spoken English, material wealth signalled in terms of clothing, and having a formal, white-collar job; 448 some respondents believed the interviewers were health workers and I was a Peace Corps volunteer, 449 a position of potential authority (despite the information and consent process stating the contrary). 450 The recruitment strategy de facto excluded women whose experiences resulted in the loss of their 451 baby or their life. The study also excluded women younger than 18 years, despite adolescent pregnancy being relatively common in Zambia (CSO et al 2014), for practical reasons linked to getting 453 parental consent. While the experiences of the <18 age group should be explored in future research, 454 most of the respondents aged 18-20 years old self-identified as being "too young" to give birth. 455 Interviewees were assigned the "visibly poor" category at the time of the interview, which may have 456 differed from their appearance at the time of the birth. Furthermore, it is not known whether health 457 workers or people in the community use the same visual cues as the interviewers to determine 458 whether someone lacks financial resources. The "visibly poor" category was used along with many 459 other categories to inform small-n purposive sample selection, and for the initial structuring of 460 analytical comparisons. I identified respondents as "lacking financial resources" in the final analysis 461 solely according to their own accounts. 462 While I attempted to interview both women who had and had not delivered at a health facility, only 463 4 out of 42 respondents did not deliver in a health facility. This may be due to respondents being 464 unwilling to reveal a home birth, women delivering at home being unwilling to speak with us, or to a 465 contact with the health system is very likely to have been structured by health facility rules. 475

Discussion 476
While this study did not set out to gather evidence on how the rules affected maternal healthcare 477 access and outcomes, district health officers believed the rules helped to avoid home deliveries and 478 led to fewer maternal deaths. However, this study's findings imply that what works to meet average 479 health targets may not work to reverse health inequities. This is particularly true when health 480 inequities are understood to include wellbeing. This study focussed on women's perceptions of the rules, as well as the actual and expected 498 consequences of these rules for women. Generating evidence on the origin, formulation and 499 application of the rules would require analysis of policy-making and enactment at various levels. In 500 terms of the origin of rules, it is important to note that the rules are not necessarily evidence-based.
For example, the rule about "lying down" during delivery has a long history in former colonial powers 502 (e.g.: Oakley 1984) but is not be supported by available evidence (Gupta et al., 2017). There also 503 appears to be contradictions between official policies at the national-level, and the rules implemented 504 at the facility level. There is no national policy on fining mothers who deliver at home or requiring 505 them to bring specific items for delivery, and Ministry-level officials have condemned these practices higher levels of governance condemn the use of rules and sanctions to achieve safe motherhood 529 objectives, there seems to be cross-country similarities in the accountability contract. Specifically, 530 lower levels are given the freedom to choose strategies best suited to meet the objective, but typically 531 only insufficient (or no additional) resources to achieve the objective. This is reminiscent of Walker 532 and Gilson's (2004) analysis of nurses as street-level bureaucrats, i.e. workers who enact public policy 533 in the form of routinized practices, in a context that combines discretion over how to accomplish tasks 534 with insufficient resources (Lipsky, 1980;Reckwitz, 2003). 535 This study's findings also have implications for how we understand disrespectful maternity care. The 536 majority of respondents in this study understood sanctions as deserved punishment for breaking the 537 rules, and only rarely mentioned nurses' personalities or moods as driving factors. Findings also 538 highlight the important role of "institutional bias", which, contrary to "unruly practices", emphasises 539 the inequitable potential of "the rules of the game" themselves, as opposed to their discriminatory or 540 deficient application. In contrast, the current global framing of disrespectful care only includes health 541 system deficiencies and instances of provider behaviours that are identified as disrespectful by victims 542 and others. While Freedman et al (2014) convincingly argue that an initially restricted focus on these 543 aspects of disrespectful care will facilitate progress, we should evaluate whether such a focus is able 544 to address inequitable experiences of disrespectful care. 545

Conclusion 546
Health facility rules regulating women's behaviour in pregnancy and childbirth result in inequitable 547 pregnancy and birth experiences in Zambia. Women with fewer social and financial resources struggle 548 to meet the rules and must either suffer sanctions if they are unable to follow them, or make costly 549 sacrifices in order to comply. The rules also strengthen social exclusion processes beyond the facility by reinforcing inequitable power relations and a moral order where a lack of financial and social 551 resources is believed to result from personal shortcomings. 552 These findings highlight inequities in women's experience and identify an important mechanism 553 behind maternal health inequities. Policy-makers should develop responses that actively seek to 554 interrupt cycles of social exclusion. 555 The law, I know the way the law is, they don't allow giving birth in the village. All these 3 children

Rules during labour
Being clean and shaving pubic hair 6 They said when you come here, mothers should look clean. If you look clean, even the child inside will be clean, the baby movements will be okay. [03-06-02] Disrespectful treatment, e.g. shouting and shaming "Being strong", i.e.: not making noise or crying, and successfully pushing the baby out 6 They would ask, "have you had a child before?" I said no, she said you should be strong; motherhood is like this and like that. So, you should be strong, if you are not strong you can kill the child so you should be strong; you shouldn't be afraid of anything