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Documenting Death Is a Gripping Ethnographic Account of the Deaths of Preg ANTHROPOLOGY STRONG Documenting Death is a gripping ethnographic account of the deaths of preg- nant women in a hospital in a low-resource setting in Tanzania. Through an DEATH DOCUMENTING exploration of everyday ethics and care practices on a local maternity ward, anthropologist Adrienne E. Strong untangles the reasons Tanzania has achieved so little sustainable success in reducing maternal mortality rates, despite global development support. Growing administrative pressures to document good care serve to preclude good care in practice while placing frontline healthcare workers in moral and ethical peril. Maternal health emer- gencies expose the precarity of hospital social relations and accountability systems, which, together, continue to lead to the deaths of pregnant women. “This powerful and compelling analysis of maternal mortality in rural Tanzania is a groundbreaking addition to scholarship on Africa and its public health challenges. Adrienne E. Strong presents a rich ethnography of hospital func- tion and dysfunction, to which the voices of patients and staff add poignant detail. The ways in which state and global health policy shape maternal health and well-being frame individual narratives in a memorable testimony.” Maternal Mortality and the Ethics of Care in Tanzania Maternal Mortality and the Ethics of Care Carolyn Sargent, Professor of Anthropology, Washington University in St. Louis “Documenting Death is an arresting tale of life and death on a busy maternity ward in rural Tanzania. Drawing on a remarkable period of ethnographic field- work, Strong evocatively details the predicament of nurse midwives caught in the ‘biobureaucracy’ of global health projects and their audit trails. A significant contribution to medical anthropology and critical global health scholarship.” Margaret MacDonald, Associate Professor of Anthropology, York University Adrienne E. Strong is Assistant Professor of Anthropology at the University of Florida. UNIVERSITY OF CALIFORNIA PRESS WWW.UCPRESS.EDU A free ebook version of this title is available through Luminos, University of California Press’s Open Access publishing pro- ISBN: 978-0-520-31070-4 gram for monographs. Visit www.luminosoa.org to learn more. Cover illustration: Kanga fabric showing the phrase Dunia si dunia bila mama (The world is not the world without mothers). Photo by the author. 9 7 8 0 5 2 0 3 1 0 7 0 4 Luminos is the Open Access monograph publishing program from UC Press. Luminos provides a framework for preserving and reinvigorating monograph publishing for the future and increases the reach and visibility of important scholarly work. Titles published in the UC Press Luminos model are published with the same high standards for selection, peer review, production, and marketing as those in our traditional program. www.luminosoa.org Documenting Death Documenting Death Maternal Mortality and the Ethics of Care in Tanzania Adrienne E. Strong UNIVERSITY OF CALIFORNIA PRESS University of California Press Oakland, California © 2020 by Adrienne E. Strong This work is licensed under a Creative Commons CC BY-NC-ND license. To view a copy of the license, visit http://creativecommons.org/licenses. Suggested citation: Strong, A. E. Documenting death: Maternal Mortality and the Ethics of Care in Tanzania. Oakland: University of California Press, 2020. DOI: https://doi.org/10.1525/luminos.93 Names: Strong, Adrienne E., 1988– author. Title: Documenting death : maternal mortality and the ethics of care in Tanzania / Adrienne E. Strong Description: Oakland, California : University of California Press, [2020] | Identifiers: LCCN 2020014517 (print) | LCCN 2020014518 (ebook) | ISBN 9780520310704 (paperback) | ISBN 9780520973916 (epub) Subjects: LCSH: Mawingu Regional Hospital (Rukwa Region, Tanzania) | Mothers—Mortality—Moral and ethical aspects—Tanzania Classification: LCC RG966.T34 S77 2020 (print) | LCC RG966.T34 (ebook) | DDC 362.1982009678—dc23 LC record available at https://lccn.loc.gov/2020014517 LC ebook record available at https://lccn.loc.gov/2020014518 Strong_CIP 29 28 27 26 25 24 23 22 21 20 10 9 8 7 6 5 4 3 2 1 To all the health care workers of the world in this, 2020, the first Year of the Nurse and Midwife Contents List of Illustrations ix Acknowledgments xi List of Abbreviations xv Prologue xvii Introduction 1 1. The Mawingu Regional Hospital Maternity Ward 22 2. Working in Scarcity 45 3. Protocols and Deviations: Good Enough Care 67 4. “Bad Luck,” Lost Babies, and the Structuring of Realities 91 5. Landscapes of Accountability in Care 110 6. The Stories We Tell about the Deaths We See 126 7. Already Dead 147 8. “Pregnancy Is Poison”: The Road to Maternal Death 165 9. The Meanings of Maternal Death 188 Epilogue 204 Appendix: Deaths Occurring during the Field Period 207 Glossary of Medical Terms 211 vii viii Contents Notes 215 References 225 Index 241 Illustrations FIGURES 1. View of Mawingu Hospital 24 2. Inside the maternity ward 26 3. Ward floor plan 27 4. Nurses’ break room 28 5. Ward notebooks 39 6. Supply trolleys 46 7. “Blood isn’t sold” poster 59 8. Labor and delivery room 70 9. Maternity ward operating theater 78 10. Post-Cesarean room 79 11. Partograph 94 12. Stillborn babies 124 13. Kizi dispensary 167 14. Women carrying firewood and water 176 15. Foundation of unfinished addition to Songambele dispensary 184 16. White Ribbon Alliance illustration of the Rukwa region 194 MAPS 1. Map highlighting the Rukwa region 11 2. Map of the Rukwa region showing the three main districts 12 ix x Illustrations TABLES 1. Example of an action plan 143 2. Number of deaths per district 207 3. Deaths at Mawingu Regional Hospital, January 2014–April 2015 207 Acknowledgments While so many people made this book, and the research on which it is based, possible, I must certainly first acknowledge my lasting thanks and debt of grati- tude to the hospital staff at Mawingu Regional Hospital, as well as to the health administrators of Rukwa region who courageously and, probably, without know- ing exactly what they were in for, granted me access and permission to the region and its health facilities. I learned so much from all those who were involved in this project in all ways, large and small. Special thanks go to my dear friend Dr. Samwel Marwa for his lasting support and interest in this work and all my work that has come after it. Likewise, I must thank Dr. John Gurisha for his assistance, support, insights, and interest as I conducted fieldwork. Ester Sanjala and her household have become family since she first picked me up at the Sumbawanga bus stand in 2012. Her hospitality, friendship, and gossip have sustained me during my work. Tumaini Mdapo, Edward Mwakasege, and their family have added so much both to my research and my life. From the fateful nighttime motorcycle ride when Mwakasege and I first met, he and his family have buoyed me up in countless ways, helping with logistics as well as laughter, shared food, and endless stories. Last, but certainly not least, I am grateful to Rebeca Matiku for her work as my research assistant through months of trips to remote villages on treacherous roads and in questionable guesthouses, as well as for her transcription help. Thanks, too, to Hussein Kandoro for his support, friendship, and connections throughout the fieldwork period and to Alida Fernhout, who arrived in my life in Tanzania at just the right moment. In my intellectual life, I want to thank, first and foremost, Carolyn Sargent for her unflagging support and confidence in my ideas and research direction, even xi xii Acknowledgments when it took some unanticipated deviations. Her guidance and friendship have led me to where I am currently in my career, and I am forever grateful. Many thanks to John Bowen, who helped to guide the ship home and facilitated and encouraged my connections with the University of Amsterdam and the Health, Care, and the Body group. Priscilla Song was always an enthusiastic cheerleader with incisive and stimulating comments and suggestions. To Shanti Parikh and Brad Stoner, my deepest thanks for support, encouragement, and feedback as committee members. Also from my time at Washington University in St. Louis, I especially thank Lauren Cubellis, Elyse Singer, Dick Powis, Anita Chary, Oğuz Alyanak, and Colleen Walsh-Lang. At the University of Amsterdam, though my time was short, I am so grateful to Anita Hardon, who first proposed the idea of a joint PhD and offered to be my supervisor. I benefited immensely from my interactions with Trudie Gerrits, Bregje de Kok, and Rene Gerrets. Eileen Moyer and her Becoming Men group have not only kept me company but drawn me into new and delightful conversations. To the beautiful people of room B5.16 who wel- comed me into their midst, I am so thankful for the care and fun you all showed me. Yvette Ruzibiza and Linda Chipatiso provided so much companionship and moral support. The Trans-Atlantic Forum program made these connections pos- sible and resulted in lasting friendships. The work for this book was supported by the National Science Foundation through a Graduate Research Fellowship, a Doctoral Dissertation Research Improvement Grant, and a Postdoctoral Research Fellowship. Fulbright-Hays, a PEO Scholar Award, and a Dissertation Writing Fellowship from Washington University in St. Louis also supported the research and writing. While it might seem as if most of the work was already done before I reached the University of Florida, the Department of Anthropology and the Center for African Studies welcomed me with warmth and enthusiasm and helped me bring this proj- ect home. My writing and I have both benefited from weekly writing sessions with Marit Østebo and the support of my other colleagues in the department, as well as wonderful grad students and the Center for the Humanities and the Public Sphere. Thanks to Megan Cogburn for long hours of conversation about Tanzania and mutual research topics of interest and to Rebecca Henderson for her enthusiasm and some assistance preparing the manuscript’s last bits and pieces.
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