BY LIZZIE FISHER
During medical anthropologist Adrienne Strong’s second visit to Tanzania, she witnessed a harrowing scene: a doctor at Singida Regional Referral Hospital performing an autopsy on a woman who had died with her full-term baby still inside of her. In an interview with me, reflecting on her experience, Strong remarked, “It is truly the moment where I became overwhelmed with questions about why it was that a woman who had already reached the hospital–which many people could not do–still died. It really set off this quest to better understand the persistent nature of maternal mortality in lower-resource settings.”
Reproductive complications are tragically common in Tanzania. It was there Strong observed cases of obstetric fistulas (abnormal openings between the vagina and bladder caused by prolonged labor) and instances where newborns fell on the floor because of lack of personnel to catch them. While particularly acute in Tanzania, maternal mortality is not unique to the region. According to the CDC, a maternal death occurred almost every two minutes in 2020 [2]. Frustratedly, Strong stated, “We have so many things aiming to reduce [maternal] deaths, that surely we should have figured this out by now.”
Why then does the issue persist? In her ethnography, Documenting Death, Strong delves into this under-researched phenomenon. She differentiates “technical care,” the medical treatment clinicians provide to patients, from “affective care,” the emotional support offered–both of which are critical to saving lives [1]. Often, after receiving poor psychological care in hospitals, laboring women will opt to give birth at home, which can increase the risk of complications. Strong argues that the nurses in Tanzania lack resources to provide either type of care, making them victims of the same systemic failures harming their patients.
Due to material scarcity in Tanzania, much of the technical care necessary to save patients is not attainable. To quote Strong in our conversation, “You can be the best-trained person with the most book knowledge, but if you don’t have the infrastructure and equipment to do the things you know how to do, you are not going to be able to live up to the full potential of your training.” Furthermore, overworked and underappreciated nurses will struggle to provide patients with optimal care and empathetic treatment. Strong notes the existence of abusive care in Tanzania, but she cautions against simplistic blame of nurses and argues that this may even reinforce mistreatment of patients. As Strong explains, “Sometimes [nurses] are bad people, but sometimes they are just products of their circumstances.”
Throughout Documenting Death, Strong draws on Paul Brodwin’s term “everyday ethics,” which takes into consideration how one’s environment reshapes ethical norms [1]. From a Western perspective, it is hard to understand that what seems objectively right or wrong may be much more context-dependent and complex. Accepted ideas of best medical practices are not always possible and can even be harmful in lower-resource settings like Tanzania. For example, in her ethnography, Strong examines Tanzanian professionals’ use of the partograph, a visual representation of a woman’s cervical dilation that suggests if a laboring body needs intervention [1]. Strong observed that, though in theory a useful tool, the partograph was often falsified, misused, or missing altogether. Whether because of fear that the partograph would be physical proof of malpractice, miscommunication as to whose responsibility it was to fill out the document, or improper training on how to complete it, this “standard” is not pragmatic in every setting.
Thinking ahead, Strong referenced the World Health Organization’s position paper, “Transitioning to Midwifery Models of Care,” published just after our conversation. The document advocates for a more humanistic and midwifery-centered approach to childbirth. While WHO’s encouragement of such a birthing model is a step in the right direction, Strong questions, “What does that really mean for a place like Tanzania where big parts of midwifery models of care are patient choice and freedom of movement? When your infrastructure can’t support that, how are we supposed to raze all these hospitals and build new ones that can be midwifery model birthing centers?”
In the future, Strong hopes to see international healthcare prioritize nurses as human beings, as well as emphasize localized solutions. “What I have felt since working in Tanzania is that [global initiatives] mean such different things to people in different places,” says Strong. To effect meaningful change, policymakers must recognize the drastic differences between their own lifestyles and those of the people impacted by their decisions. Strong powerfully explains, “I see my role as a conduit for people outside Tanzania to understand what it is that [these nurses’] lives look like, and how these policies that are designed in far off places are playing out when we don’t tailor them to local settings the way they really ought to be.”
Lizzie Fisher is a first-year in Saybrook College.
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References
- Strong AE. Documenting Death: Maternal Mortality and the Ethics of Care in Tanzania. Berkeley, CA: University of California Press; 2021.
- World Health Organization. Maternal mortality [Internet]. World Health Organization. 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
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