www.jogh.org Department of Anthropology, York University, Toronto, Canada Margaret MacDonald : Why ethnography matters in traditional birth attendant to solve pressing global health problems. multi-disciplinaryto andinter-sectoral efforts knowledgethat makes essential contributions reliable and robust produces Ethnography • doi:10.7189/jogh.07.020302 onlytheonunderstanding thatthese ‘cultural reasons’ laywith the foreign aidagency thatsuggested it say that trying to get TBAs in rural Malawi to distribute condoms did not work for sumption‘cultural about thereasons’ scope of practice– but of these specific TBAs in this particular setting. I would venture to distribute condoms; it was not a cultural barrier to be overcome by education or training but a faulty as SafeMotherhoodthe project whichincluded recommendation the thatpressedTBAsshouldbenot to a rethinking of the means by which to achieve project goals. I will never know. I wrote up my report on er courses, for example. Or the information I shared may have ponentbeen on takenthe asimportance new of‘evidence’ condom distributionthat provoked in the next round of TBArier’ trainingto achieving sessions the goalsand ofrefresh the project and become the object of a new set of topress strategiesforcommunity based condom– distributionadding abyTBAs. Itmaycom have been noted ‘culturalasa bar goneone ofthree ways. Itmay have been ignored and the HIV prevention project may have continued gochi – that TBAs were highly unlikely to ever distribute condoms within their communities – mayBut first have let me continue the ethnographic story. The information I shared in the meeting room in Man efforts to understand and address complex global health problems. ticle I will argue that ethnography matters in global health as an essential component of interdisciplinarygraphic data that, with proper context and analysis, constitute reliable and robust knowledge. In this ar in project reports to add texture or to illustrate a point, but anthropologists consider such stories ethno Many who work as practitioners in global health could recount similar stories. They might include them Their work was attending births. They did not fail to fit the bill, they refused it. ‘reproductiverealmoftheworking in foreignbe agency tosexualaid health’, and refused. theseTBAs doms still in their packages, closed the kits again and slid them carefully back into place. Imagined by a partof their training out from under beds or curtained closets, opened the lids to reveal lengths of con place to talk to men about that.” I had also watched as they slid the ‘Safe Birth Kits’ they had received as aboutfelttheydistributing condoms.invariablytheyno,”“Oh “We me. told don’tthat.It’s do ournot their homes to talk to them about their work and had asked them as politely as ittake isan ethnographicpossible approachto do to somy task.how I knew the TBAs wouldn’t distribute condoms. I had been to Motherhood project. I was also a graduate student in anthropology at the time and therefore inclined to projectsheworked for. hadbeenI working Monkeyin Bayforthepast three months evaluating Safea therethemeetingin discuss.to Sheenvisioned themidealascommunity actorstheHIV preventionin The case of the 1 in the MonkeytheinSafeBayMotherhood project werethatwe She was referring to the traditional birth attendants (TBAs) distributingbeshouldtributecondoms!”condoms? They banged her fist on the table. “How can we get them to dis T the small town of Mangochi in southern Malawi, Malawi, southern in Mangochi of town small the crossedhadwithwhomI pathsanseveral times in he representative from the foreign aid agency, a wom December 2017 •Vol. 7No. 2•020302 ------

VIEWPOINTS VIEWPOINTS December 2017 •Vol. 7No. 2•020302 fective interventions. datainthedesign andimplementation ofef trates the critical importance of ethnographic campaignsto reduce maternal mortality illus incorporation of traditional birth attendants in The history of global policy on the training and that is robust and reliable, if not reproducible. fromsecondary accounts, orfrom rapid appraisals. Bythis method, ethnographers produce knowledge ethnographyofferofbettertogoaldistance,accounts socialthe fromphenomenaisa ofcan one than cal ethnographers excel at illuminating the connections between the micro and macro levels. Ultimately, andactions of individuals and cultural groups, but not in isolation of history and politics. Indeed, criti The point I want to stress here is that ethnographers seeks to make visible the practical and moral worlds ated from within or without. communities and cultures as dynamic entities with the capacity to change – whether the change is initi ugee camps, epidemics – develops patterns and ways of being. At the issame the essencetime, of ethnography.ethnographers approach Even life in exceptional times and situations – conflict zones, prisons, ref ic sites for anthropologists. Though lives may be framed by big events and issues, it is the quotidian that busy urban health clinic, or a group of foreign aid workers in their field offices: these are all ethnographThe kinds of communities that anthropologists study are broader now than in the past. A rural village, a munities they seek to understand, learning local languages and living to a great extent peopleas localover peoplelong periodsdo. of time. Anthropologists immerse themselves for months and years in the com Ethnography is the hallmark of the discipline of anthropology. It involves following the everyday lives of of TBAsofhadnotbeen properly understood evaluatedor [ decisioncaused controversy at the time, with many practitioners and researchers arguing that the work failure,side–linedand favourinincreasingof numberthe‘skilledof birthattendants’ globally [ But a little more than a decade after its launch, the TBA component of the SMI was reviewed, deemed a knowledge traditional medical cultures and incorporate local practitioners in a more systematic way. otherorganisations trainingbeenhadappearedprogressiveit1970ssinceTBAs andthe a ac tomove birthscommunitytheat levelidentifytoand refer and healthwomenrisk toatfacilities. UNICEFand planning activities. One of the key interventions was the training of birth attendants to better cope with 2000,throughupgradesyearhealthpackagesystems,theoftoa personnel,by half familyby andber majority of deaths occurring in the global south.. The stated goal of the initiative was to reduce this num Fund (UNFPA).Fund globalmaternalthetimemortalitythat estimated At500 was rate at Worldtheby 1987 HealthOrganisation World(WHO),the UnitedNationstheBank,Populationand tive to address the problem of maternal mortality was the Safe Motherhood Initiative (SMI), launched in Attendant deployed in interventions. This requires a bit of history. The first globalTo initiaillustrate howethnography matters globalin health, willreturnI the casetotheTraditionalof Birth MATERNAL HEALTH THE CASE OF TRADITIONAL BIRTH ATTENDANTS IN GLOBAL WHY ETHNOGRAPHY MATTERS health projects. too: sets of assumptions, taxonomies, and rationales that just as surely contribute to the outcome of tionslocal to succeed is a staple of global development thinking. But global health communities have culturesas a strategy in the first place. The idea that cultural barriers to change must be combatted for interven to be shared descriptions and multiple perspectives, thus providing a distinctive understandingrapherpresencea– ofboth involved theanddetached, worldinscribed intheinstant thatandover time, allowing deservesprecise Ethnography matters for contemporary societies…This claim derives from the very activity of the ethnog [ 1 ].

- - 2 scribedineffective inappropriateand methodsthe usedin de had Jordan Brigitte anthropologist 1978 as early As TBAs to make a difference? designedand launched toappropriately train and support cerning and birth, could interventions have been the basis of such knowledge of local logic and practice con playing and what roles they could be expected to play? On alreadywere TBAsroles understoodwhatbetter have we dance had mattered in this effort from the beginning? Would 3 ]. Whatethnographic].if databirthonatten www.jogh.org • doi:10.7189/jogh.07.020302

000 a year – vast –year a 000 2 ]. The]. ------www.jogh.org Photo: from author’s own collection (used with permission). • doi:10.7189/jogh.07.020302 iourmost global health interventions seek [ able to capture the social relations of health care so fundamental to the changes in wardsknowledge accountabilityand behav metrics in global health is a factor, even though qualitativephy is methodologiesa question ripe arefor discussion.better Certainly, the dominance of quantitative research and the trendpressing to andpersistent global health problems. Whyglobal health culture hasnotembraced ethnogra edge that can contribute to the multi–disciplinary and inter–sectoral effort to create effective solutionssum,Inethnography mattersto globalin health because producesit distinctive, locally grounded knowl ceed. It can help identify modes of change that make sense not universally but in a given context. particularity, not in their global otherness. It can help explain why some caninterventions illuminate the faillogic andand rationale others of peoplesuc and communities at the local level and see them in their world rather than seeing them as locally made and isolated problems of underdevelopment or culture. It and history to the understanding of present day health challenges for people and populations aroundin research the and interventions continues to scale up, ethnography matters more than ever. It adds context canbe more important to women and their families than training in the choice of abirth attendant [ trained as TBAs did not consider the reality that factors such as ethnicity, language, religion and kinship care” [ equatehealth services and that “for many women forrange a ofreasons TBAs are preferable tohospital makes pragmatic sense given that so many women in low resource settings still do not have access to Arecent ad article in this journal has called for the ‘return of the traditional birth attendant’ arguing that it charged that TBAs had been scapegoated. tioninghealth caresystem many inplaces themidst HIVepidemic andinanof others. in Somecritics Significantly, she was also imagined as being able to improve maternal health without the aid of a func the local imagined by the SMI was paradoxically too general; the TBA was imagined as a universal type. The irony is that the SMI had tried to respect and incorporate local tradition rather than steamroll it. But Anthropologist Denise Roth Allen sums it up well: obstaclesto development for their failure to take on these new roles designated for them by SMI policy. onlyNotwereTBAsdeemed failures reductionthein maternalof deaths, seenas theybealso cameto insight into why. complicationshealthfacilities,refertothemand example. for Ethnographic providedcouldhavedata SMI policy. Yet in some places in some ways TBAs were working effectivelyMalawiIn observedI thatmany nurse–– able resented to being draftedidentify intothe role TBAofliaison women by with bor support when birth is imminent pregnant women residing in rural areas perceive some of these TBAs as risks rather than as sources of la not produced the results policy makers and program planners originally intended; nor is it surprising that tendants in the span of a ten–day training course, it is hardly surprising that TBA training Whenprograms women whohave have had no experience delivering babies are somehow turned into traditional birth at 8 ]. As maternal mortality remains high on the global health agenda and the search for innovation [ 6 ], p. 115. 3 9 , 10 ].There are several directions wemight take tochange well. Guidelines for identifying women to be be to women identifying for Guidelines well. as problems other identified Anthropologists never attended a birth before [ projectSMIhadlocal a byTBAs trainedas and relatives or alone. Some 30% of women identified wiferyandmanywomen gave birth with female munities,there wasdistinctno tradition midof [ TBAs had to be “invented” to fit into SMI activities no special experience or expertise with ; women who came forward to receiveThe TBA.training the of had equivalent local no was there example,forNepal, In universal TBA. a of tion pologistsbegan tocall into question the very no lems with training and supervision, some anthro [ ity by trainers towards rather hands–on learning, lack of cultural sensitiv training of Maya midwives in the Yucatan: didactic 4 5 ]. In addition to documenting pedagogical prob ]. Similarly,]. Tanzaniain amongSukuma com December 2017 •Vol. 7No. 2•020302 parteras, 6 ]. and no follow–up - - 7 ]. ------

VIEWPOINTS VIEWPOINTS December 2017 •Vol. 7No. 2•020302 REFERENCES 11 10 9 8 7 6 5 4 3 2 1 dm V Nvty , ele . lbl elh ilmc. e Atrpl 2008;27:315. Anthropol. Med diplomacy. health doi:10.1080/01459740802427067 Global H. Leslie T, Novotny V, Adams doi:10.7189/jogh.06.020302 2016;6:020302. Health. Glob J attendant. birth traditional the of return The J. Garrod K, Lane 1989;28:941. Med. 9536(89)90322-5 Sci Soc midwives. traditional of training the and Status C. MacCormack versity of Michigan Press, 1994;111. AllenDR.Managing motherhood, managing risk.Fertility anddangerwest inCentral Tanzania. AnnArbor, MI:Uni and Sargent C (eds), Childbirth and Authoritative Knowledge. Berkeley: University of California Press. 1997; 233. Pigg SL. Authority in translation: finding, knowing and naming traditional birth attendants in Nepal. In Davis–FloydMedline:2711228 R Jordan B. Cosmopolitan : some insights from the training of traditional midwives. Soc Sci Med. 1989;28:925.plications? A review of the evidence. SibleySoc L, SciSipe TA,Med. Koblinsky2004;59:1757. M. Does traditional birth attendant thetraining Inter–Agency improve Group for Safereferral Motherhood, 1988.for women with obstetric com StarrsA. The safe motherhood action agenda: Priorities for the next decade. New York: Family Care International and Fassin D. Why ethnography matters: On anthropology and its publics. Cult Anthropol. 2016;284:642. pology Theory. 2017;4:1. Elliott D, Thomas TK. Lost in translation? On collaboration between anthropology and Adamsepidemiology. V, editor. Medicine Metrics. Anthro What counts in global health. Chapel Hill, NC: Duke University Press, 2016. cross–disciplinary communication in both the conduct of research and writing [ pressuresCollaborativeabide.challengesmustthetheyofforward, research anotheron takingway is communities’knowledgefiscal,the valuestheshareideologicaltheyandtermsof in political and criticalethnographic studies ofglobal health policy–making circles tooffer insight into these ‘epistemic the marginal status of ethnographic knowledge in global health. Anthropologists can continue to conduct tice today. nography is an important part of the work of anthropologists engaged in global healthinatethe results researchof our research and to new pracaudiences. However we move forward, making the case for eth disclosure.pdf (available on request from the corresponding author) and declares no competing interests. Competinginterests: Authorship contributions: Funding: ing on earlier drafts of this article. Acknowledgements: None.

doi:10.1016/0277-9536(89)90317-1 I am grateful to Todd Foglesong and Sandra Widmer for reading and helpfully comment

Theauthor hascompleted theUnified Competing Interest form www.icmje.org/coi_at MM is the sole author of this article. 4 Medline:15279931 [email protected] Toronto, Canada 4700 Keele St, Toronto, ON M3J 1P3 Department of Anthropology, York University Margaret MacDonald, PhD Correspondence to:

doi:10.1016/j.socscimed.2004.02.009 www.jogh.org 11 • doi:10.7189/jogh.07.020302 ]. We can also dissem Medline:18958783 Medline:27606054 doi:10.1016/0277------