Community Cadres and Clinical Care: An Ethnographic Study of Local Agency in Maternal Health Initiatives in Chad

Maternal health initiatives in West Africa frequently depend on externally designed programmes. In Chad, where maternal mortality remains persistently high, the use of local community cadres—villagers trained as volunteers—is a common intervention. The lived experience and agency of these cadres within the formal healthcare system are not well documented. This ethnographic study explored the role and agency of local community cadres within maternal health initiatives in Chad. It aimed to understand how cadres navigate between community norms and clinical protocols, and how this intermediary position shapes programme delivery. A longitudinal ethnographic approach was employed, involving 18 months of fieldwork in two Chadian districts. Data collection included participant observation with 24 community cadres and clinical staff, in-depth interviews, and focus group discussions with community members. Cadres exercised significant, yet often unacknowledged, agency by adapting clinical messages to local cultural contexts. A central finding was their role as cultural translators, beyond mere linguistic interpretation. For instance, a majority of observed cadres creatively reframed the concept of 'birth planning' to align with local kinship decision-making structures, which improved its uptake. Community cadres are not passive implementers but active agents who mediate between biomedical systems and local realities. Their agency is crucial for the cultural legitimisation and practical effectiveness of maternal health programmes. Programme designers should formally recognise and support the adaptive work of cadres through more flexible training. Monitoring and evaluation frameworks should move beyond simple output metrics to capture the nuanced brokerage role cadres perform. maternal health, community health workers, ethnography, Chad, agency, cultural brokerage, programme implementation This study provides an in-depth, emic perspective on the critical intermediary role of community cadres, highlighting their agency as cultural translators essential for contextualising maternal healthcare.