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 UNIVERSIT Y 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 vii C ontents 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 2 04 Appendix: Deaths Occurring during the Field Period 207 Glossary of Medical Terms 211 viii Contents Notes 215 References 225 Index 241 ix Illustrations F IG U R E S 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 M A P S 1. Map highlighting the Rukwa region 11 2. Map of the Rukwa region showing the three main districts 12 x Illustrations TA B L E S 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 xi Acknowled gments 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 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. 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. xv Abbreviations AMO Assistant medical officer AMTSL/AMSTL Active management of the third stage of labor APGAR Appearance, pulse, grimace, activity, respiration (also named after Virginia Apgar) APH Antepartum hemorrhage BEmONC Basic emergency obstetric and neonatal care CCF Congestive cardiac failure CEmONC Comprehensive emergency obstetric and neonatal care CHFs Community Health Funds CO Clinical officer CPD Cephalopelvic disproportion DIC Disseminated intravascular coagulopathy DMO District medical officer DRCHCO District reproductive and child health coordinator EN Enrolled nurse HBB Helping Babies Breathe HIV/AIDS Human immunodeficiency virus /acquired immunodeficiency syndrome HMT Hospital Management Team ICU Intensive Care Unit 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 xvii Prol o gue Paulina was in her late twenties, and as she sat on the chair opposite the doctor, I took in her shining skin, nice clothes, and plump figure. She looked to be the picture of health now, in her third pregnancy. Dr. Deo was meeting with her because she had already had two Cesarean sections and knew from her last birth that she should report to the hospital early to plan the surgery before her contrac- tions began. In addition to looking in excellent health, Paulina was also what a Tanzanian nurse or doctor might consider to be the ideal patient. She had around her feet all the items health care providers told women to bring with them when they came to the hospital to give birth. In the absence of disposable bed coverings or sheets for the beds in the labor room, women brought brightly colored vitenge or khanga fabric to lay over the cracked or worn foam mattresses encased in vinyl on the metal frame beds. Paulina’s all-purpose plastic basin was also there next to her feet, brightly colored and waiting to function as bed pan, emesis basin, trash can, and dirty laundry basket. Peeking out of her purse were pairs of sterile surgical gloves in the paper packaging; deeper in the bulging bag were neatly folded clothes for the baby. Paulina and Dr. Deo discussed some of the particulars of her present pregnancy and the reasons she had had C-sections previously. They agreed that she would stay overnight and Dr. Deo would perform the operation the first thing the next morning. I passed by Paulina and Nurse Lucy around 8:30 a.m. the next day as they were on the way to the operating theater for the scheduled C-section. Paulina looked calm, a veteran of the C-section, as Lucy and the ward cleaner wheeled her across the bumpy concrete path between the maternity ward and the operating room on the other side of the hospital. By 1:30 p.m., back on the maternity ward, the