Multi-layered risk management in under-resourced antenatal clinics: a scientific-bureaucratic approach versus street-level bureaucracy

In this article we contribute to critical risk approaches to studying pregnancy and childbirth in the global South. Following Sarah Rudrum’s work, our approach focusses on sociocultural inequalities amid the regulation of individuals. We draw on data from our Foucauldian-inspired ethnography of two antenatal clinics in an under-resourced area of South Africa to illustrate how multi-layered risk management operates in these spaces. These data were collected over a period of six months in the form of semi-structured interviews, observations of consultations and waiting room interactions, documents used in the clinic, and posters appearing on the clinic walls. Our findings show how a scientific-bureaucratic approach to pregnancy risk management, as encoded in international, national and institutional guidelines, is well known, highly visible, and practised through surveillance and reporting mechanisms in clinics. This approach incites healthcare practitioners to achieve particular performance standards and to monitor their professional agency. Managing pregnancy risk thus entails regulating the healthcare practitioners themselves. In implementing approved pregnancy risk management strategies in an over-subscribed and under-resourced public healthcare setting, however, healthcare practitioners face potential risk to their professional reputation and integrity. In managing this risk, they resist the scientific-bureaucratic approach through: depicting themselves as victims of unfair institutional arrangements or unreasonable patients; instituting street-level bureaucracy to control access to the clinics; and controlling patients’ actions in authoritarian ways. Our research shows that without engagement with the on-the-ground realities of the antenatal clinic in resource-poor environments, a scientific-bureaucratic approach to pregnancy risk management is inevitably limited in its effectiveness.