Documenting Death

Front matter

DOCUMENTINGS

Maternal Mortality and the Ethics of Care in Tanzania

ADRIENNE E. STRONG Wess We

Introduction

3. Protocols and Deviations: Good Enough Care

4. “Bad Luck,” Lost Babies, and the Structuring of Realities 5. Landscapes of Accountability in Care

8. “Pregnancy Is Poison”: The Road to Maternal Death

9. The Meanings of Maternal Death Epilogue

Appendix: Deaths Occurring during the Field Period

Glossary of Medical Terms

Notes 215 References 225 Index 241

ILLUSTRATIONS

FIGURES

View of Mawingu Hospital 24 Inside the maternity ward 26

Ward floor plan 27

Nurses break room 28

Ward notebooks 39

Supply trolleys 46

“Blood isn't sold” poster 59

Labor and delivery room 70 Maternity ward operating theater 78 Post-Cesarean room 79

. Partograph 94

Stillborn babies 124

. Kizi dispensary 167

Women carrying firewood and water 176

Foundation of unfinished addition to Songambele dispensary . White Ribbon Alliance illustration of the Rukwa region

MAPS

Map highlighting the Rukwa region 11

Map of the Rukwa region showing the three main districts 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 gratitude to the hospital staff at Mawingu Regional Hospital, as well as to the health administrators of Rukwa region who courageously and, probably, without knowing 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 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, Oguz 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 Bs.16 who welcomed 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 possible 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 project 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. Through funds from the Center for African Studies, I was able workshop my manuscript with Luise White and Claire Wendland. To all of you, thank you for your time and energy and for engaging seriously with my work. Additional special thanks are due to Claire Wendland, a fellow scholar of maternal mortality, for her support and encouragement from this project's earliest stages. Likewise, many thanks to Emma Varley, who never fails to leave me inspired for the road ahead. I am also most grateful for the thoughtful comments from Ellen Foley, Maggie MacDonald, and an anonymous reviewer who read the manuscript for the University of California

ACKNOWLEDGMENTS xiii

Press. The final product is that much better because of your engagement and the potential you saw in it.

In more recent days, all my thanks to Jyoti, who puts up with my stress and anxieties about this, and all my work, with grace, silliness, and love. Last (because, really, they're first), my family’s support, encouragement, and patience have made all of this possible throughout the years.

AMO AMTSL/AMSTL APGAR

APH BEmONC CCF CEmONC

CHFs

CO

CPD

DIC

DMO DRCHCO EN

HBB HIV/AIDS

HMT ICU

ABBREVIATIONS

Assistant medical officer Active management of the third stage of labor

Appearance, pulse, grimace, activity, respiration (also named after Virginia Apgar)

Antepartum hemorrhage Basic emergency obstetric and neonatal care Congestive cardiac failure

Comprehensive emergency obstetric and neonatal care

Community Health Funds

Clinical officer

Cephalopelvic disproportion

Disseminated intravascular coagulopathy

District medical officer

District reproductive and child health coordinator Enrolled nurse

Helping Babies Breathe

Hospital Management Team

Intensive Care Unit XV xvi ABBREVIATIONS

IMF International Monetary Fund

IUFD Intrauterine fetal death

IV Intravenous, short for intravenous fluids in most instances

MDGs Millennium Development Goals

MMR Maternal mortality ratio

MO Medical officer

MoH Ministry of Health

MoHSW Ministry of Health and Social Welfare

MSD Medical Stores Department

MTUHA Mfumo wa Taarifa za Uendeshaji wa Huduma za Afya (Health Management Information System or HMIS)

NASG Nonpneumatic antishock garment

NG Nasogastric

NGO Nongovernmental organization

NO Nursing officer

OPD Outpatient Department

PPH Postpartum hemorrhage

PV Per vagina

QIT Quality Improvement Team

RAS Regional administrative secretary

RHMT Regional Health Management Team

RMO Regional medical officer

RN Registered nurse

RRCHCO Regional reproduction and child health coordinator

SBMR Standards-Based Management and Recognition for Improving Quality in Maternal and Newborn Care

SDGs Sustainable Development Goals

TB Tuberculosis

TBA Traditional birth attendant

UNFPA United Nations Population Fund, formally United Nations Fund for Population Activities

UNICEF United Nations International Children’s Emergency Relief Fund

USAID United States Agency for International Development

WHO World Health Organization