Documenting Death

Maternal Mortality and the Ethics of Care in Tanzania

Adrienne E. Strong

• Publisher: University of California Press
• Year: 2020
• Edition: 1
• eBook ISBN:
  9780520973916
• Topic: Ciencias sociales
• Subtopic: Ginecología, obstetricia y partería

A free open access ebook is available upon publication. Learn more at www.luminosoa.org. Documenting Death is a gripping ethnographic account of the deaths of pregnant women in a hospital in a low-resource setting in Tanzania. Through an 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 emergencies expose the precarity of hospital social relations and accountability systems, which, together, continue to lead to the deaths of pregnant women.

1

The Mawingu Regional Hospital Maternity Ward

The deep-blue walls of the Mawingu Regional Hospital compound usher people arriving on the main road into Sumbawanga Town, a town of some 150,000 ­residents, located on the Ufipa Plateau, approximately 1,200 kilometers from ­Tanzania’s economic center of Dar es Salaam. The hospital’s large plot of land is the same one on which the hospital has sat since at least the 1920s, when the ­facility numbered a few dilapidated buildings. According to the current staff’s ­collective memory, the oldest buildings still standing on the Mawingu Regional Hospital grounds date to the 1970s. Other wards have risen around this original core, ­fanning out on the hospital plot. The newest structures include the main operating theaters, the psychiatry unit, and, most importantly for the issues in this book, the maternity ward.

For an understanding of how a hospital can contribute to maintaining high rates of maternal mortality, some background information is necessary. ­Therefore, I begin by introducing the hospital and the institutional actors who will ­reappear throughout. These actors make up the characters in this story and include the nurses and doctors, yes, but also documents and paperwork and the physical spaces of care themselves. Situating these actors within the larger context of the Rukwa region and its medical infrastructure helps to draw attention to the ­importance of each. Additionally, scarcity’s influence on the current state and functioning of the health care system in Rukwa becomes clear. This scarcity foregrounds many of the ethical and care negotiations and exchanges that develop throughout the rest of the book.

The first glimpse of scarcity, if you knew how to look, would be visible as you rounded the blue wall’s corner and approached the hospital gates. Here you would pass the visitor’s waiting area. Relatives always occupied the waiting area: a cluster of concrete benches with an aluminum roof that provided shade during the dry season and shelter from the wet in the rainy season. Here relatives from outlying villages waited for their family members to heal or perish, waited to bring family members food or take away soiled clothes for washing, waited to be told to run to a private pharmacy for a critical medication unavailable inside. Clutching brightly colored plastic or woven baskets full of food the hospital did not provide, they waited for the hospital’s visiting hours, which happened three times per day for approximately one hour each. Some people, having come from a village and lacking a place to stay in town or any relatives with whom to pass the time when they were not allowed inside the hospital wards, spent the entire day in this waiting area. They waited, whiling away the long hours on the concrete benches worn smooth by many others who had passed the time similarly. This waiting area sometimes acted as a litmus test for the state of the hospital. If I passed relatives crying or if there was commotion in this area, I could expect to hear reports of a death or some other extraordinary event when I sat down in the morning clinical meeting.

Next to the visitors’ waiting area, security guards manned the hospital gate and occupied a guardhouse, its spare rooms consisting of a couple of broken chairs and a telephone. The guards were responsible for ensuring that relatives did not roam about the hospital at unsanctioned times. They also inspected all cars for stowaways, ensuring that no patients left the hospital without the proper receipts confirming payment and their discharge cards signed by a doctor. Though most of them knew me, they also subjected my car to search, particularly when I would leave in the middle of the night shift. The guards would ask me to turn on the interior light or open the door so they might look in the back seat and the trunk to ensure that I was not smuggling any patients out of the hospital.

Once I was past the guards, the hospital compound opened up in front (figure 1). A dusty turnaround-cum-parking area in the dry season, it turned into a muddy and cratered expanse during the region’s long rainy season. A sign ­listing the hospital departments greeted visitors to Mawingu’s compound. To the far-right side of the compound was a meeting hall, used for the morning clinical meetings, similar to the grand rounds that take place at many hospitals worldwide. In the course of these morning meetings, the hospital staff members gathered to hear reports on the state of the hospital from the previous twenty-four hours, including the number of patients, deaths, admissions, and discharges, as well as a report on the money collected and spent. They also discussed particularly difficult cases in order to decide on subsequent treatment and presented cases in which a patient had died. The medical officer in charge presided over the meeting. These meetings started every weekday morning and included nurses and clinicians from all the hospital departments. The meeting hall was a vital venue, often the only one, for sharing information about the state of the hospital.

FIGURE 1. View of Mawingu Hospital. Photo by author, 2014.

This part of the compound, before one entered the hospital proper, also housed offices for both hospital administrators and regional health ­administrators. In this area, doctors also had offices for consultations and their weekly specialty clinics, such as diabetes and gynecology. Opposite this, the regional administrative block housed the open registry, home to all hospital personnel files; the regional medical officer, the highest-ranking medical official in the region; the regional health ­secretary; the regional nursing officer; the hospital accountant; and the regional environmental health officer. Next to this building was the Dental Department. Finally, back near the guardhouse, was the Medical Records Department, in a small two-room building with an office and with shelf upon crooked shelf of medical charts and files numbering in the thousands.

The point of entry for nearly all patients, except those going straight to the laboratory or the maternity ward, was the Outpatient Department (OPD). Passing through the main door into the OPD, I had to pass the cash office where often a line of patients or relatives waited to pay the fees required at various steps of the hospital visit or stay. Chipping paint in the uniform colors of government health facilities in Tanzania—pale yellow on top and bright blue from waist level to the cement floors—spotted the walls of the OPD. The OPD itself was a narrow waiting room with several wooden slat benches on which patients and those who accompanied them waited. This area of the hospital could be particularly crowded and hectic but was also supposed to be the first stop for any emergency cases because the hospital lacked an emergency department. I sometimes saw semiconscious people lying on dilapidated gurneys or slumped over in a wheelchair parked near the doctor’s door.

Throughout my time at the hospital, the administration changed their ideas about the ideal method of arrival for pregnant women, convinced at one time that they should all pass through the OPD to be triaged and receive a file, and at another that the best course of action was sending them straight to the maternity ward without any paperwork or notion of their condition. The maternity ward provided the single biggest administrative challenge to hospital management because the number of women coming to give birth routinely eclipsed the number of all other patients two, three, or even four times over.

At the end of the OPD was the pharmacy. A painted iron lattice separated the pharmacy worker from the waiting patients, relatives, or hospital staff members. Papers and medications were passed between these parties through the lattice or via a small opening at the level of a wooden ledge that served as a counter, worn shiny by elbows and hands. A doorway near the pharmacy led out into the hospital compound. From this vantage point, I could look out over the yard, the district medical administrative offices, and then, past a large and flamboyant poinsettia, to the hospital kitchens and, behind that, the laundry and the mortuary.

At the opposite end of the OPD was the doorway to the rest of wards. Mawingu Hospital, like many other hospitals in tropical countries, was built in a style derived from colonial hospital plans, meant to facilitate the flow of air and patients, ­preventing dangerous miasmas.1 The different wards were offshoots of the main walkway.

THE MATERNITY WARD

The maternity ward was toward the back of the hospital, the furthest point from the entrance. Pregnant women arriving in labor usually proceeded directly to the maternity ward, navigating their uncertainty about both hospital procedures and its layout as they followed the smooth concrete walkway around various corners and the open mouths of the other wards. Upon arriving at the doors to the maternity ward, the pregnant woman generally entered with a female relative or friend who had accompanied her to the facility. Often the relative balanced on her head a plastic basin full of clothes and birth supplies (gloves, a plastic tarp, sometimes an umbilical cord clamp) wrapped up in a colorful kitenge cloth to keep everything contained. They passed through the first set of doors to the ward, then through an anteroom, to enter the ward proper (figure 2).

FIGURE 2. Inside the maternity ward. Photo by author, 2014.

Several rooms with unique purposes formed the ward. These included the ­Kangaroo Care Room for premature babies; the antenatal room for women admitted on the ward, perhaps because of health problems or a history of C-­sections, but not in active labor; the labor room; the delivery room; the operating theater; the post–Cesarean section room; the postnatal room; and the small room for women readmitted with their babies after birth because of the baby’s health ­condition. In the center of this square was a freestanding, smaller building that contained the offices of the managers of the ward: the ward nurse in charge and the ward medical officer in charge (figure 3).

FIGURE 3. Ward floor plan, 2019.

Interspersed throughout these rooms to which women had access was a parallel but prohibited set of rooms that were solely for medical personnel. These spaces included the nurses’ changing and break room, staff toilets, a main storeroom for the ward medical supplies, and a storeroom for cleaning supplies, which the male nurses also used as their changing room. The changing room was the most important social location on the ward for the nurses. They used this small room for tea breaks during the workday and as a place to exchange gossip, money, and wedding invitation cards, to conduct side business (such as selling water, snacks, or secondhand clothes), or to discuss private issues (figure 4).

FIGURE 4. View of the break room with boxes of nurses’ personal belongings, teacups on the table, disposable protective gowns draped over the cupboard. Photo by author, 2015.

PATIENT FLOWS IN TIME AND SPACE

Pregnant women, their relatives, and health care workers flowed through these spaces in different ways but along specific tracks. Upon arrival, the patient and her companion reported first to the admission room. This large room was divided into two sections by a chest-height tiled wall. To the left were a number of beds occupied by women in active labor but not ready to give birth, as well as the more critically ill patients or those who needed close monitoring. Women who came to the ward with malaria in pregnancy, severe anemia, infections, preeclampsia, or eclampsia slept in these beds, where the nurses could easily monitor their ­condition without being far from the labor room, which was adjoining. To the right of the wall in the same room was the admission area. This area housed a large desk for filling out paperwork, a wooden bench for arriving women, a waist-high examination bed, a trolley with necessary supplies (gloves, cotton swabs, antiseptic, urine dipsticks), and a handwashing station made out of a plastic bucket with a spigot and a plastic basin on the floor. All women started at this point, in the admission room of the ward. Nurses then funneled them into the appropriate other rooms, sorted and marked out depending on which stage of labor they were in or what other health problems they did or did not have.

While those women who lived in the areas surrounding the hospital were familiar with the procedures on the maternity ward and in the hospital more ­generally because of previous interactions with the system either as patients or as visitors, women who came from outside the district were often confused about how they were supposed to move through these spaces. Nowhere was it written that women in labor could go directly to the maternity ward, and waiting in line in the OPD could cost valuable time. Additionally, when women or their accompanying ­relatives asked for instructions, they often received gruff responses from harried hospital ­personnel. Sometimes it was the security guards at the front gate who were most useful in navigating the flows of the hospital. More than once, I witnessed maternity ward nurses harshly telling women they had skipped some portion of the designated procedures and instructing them to return again after they had done it properly—getting the appropriate paperwork, for example, once the hospital had implemented a new accounting and file system.

Ultimately, this confusion about procedures and these difficulties navigating the hospital spaces resulted in much consternation as women in the midst of contractions or a painful pregnancy complication were forced to traverse the hospital, sometimes more than once, in search of the prescribed piece of paper, stamp, or receipt. Delays and bureaucratic procedures that, to women and relatives unfamiliar with the hospital, seemed opaque and unintuitive could produce dissatisfaction with care but also reinforce a woman’s sense that she was not in control and would do best to simply be quiet and listen to the instructions of the nurses. This instantiation of a woman’s lack of power within the epistemological structure and ­hierarchy of the hospital served to silence her voice, figuratively and literally, as when she did not tell a nurse she was experiencing a problem she thought was abnormal. In this way, the hospital hierarchy and bureaucratic processes produced in women a sense of uncertainty about when, and how, they could ask for attention from the nurses or doctors. These experiences paved the way for women who remained silent as they began to hemorrhage or felt a change inside their bodies, which later the nurses and doctors might identify as the cause of the woman’s death: infection, embolism, shock, life-threatening high blood pressure, cardiomyopathy, or uterine rupture. Women lacked the authoritative knowledge about their own bodies in labor;2 this authority was conferred only upon hospital staff members by their affiliation with biomedicine and their training in this system. Women often told me they did not know how to assert their needs, questions, or desires in this hierarchical, power-laden setting in which they were interlopers. The result, in some cases, was stillbirth or the woman’s death.

THE NURSES

The nurses, all of whom had trained in midwifery, did the bulk of the work on the maternity ward. While other groups of hospital staff members had more defined boundaries around their responsibilities, very little was outside the realm of ­nursing work. However, nurses were dependent upon the doctors for the ultimate decisions related to diagnoses and care plans. Within the nursing field in Tanzania were three main categories of nurses, distinguished by their levels of education and training. Enrolled nurses (ENs), in accordance with recent training changes enacted around 2011, went to school for two years to receive a certificate and primarily learned how to conduct uncomplicated deliveries. The older ENs had had around four years of training. Registered nurses (RNs) had either diplomas or degrees. RNs could subsequently continue schooling to become nursing officers (NOs) with university degrees in nursing. Many of the ENs were Fipa and had grown up in Rukwa, often doing their training at one of the nursing schools in the region. The higher levels of nurses often came from other parts of the country and were assigned to the Rukwa region via the government posting mechanisms. Occasionally, some of the Fipa nurses would complain that the hospital administration was favoring nurses from other ethnic groups, particularly those from the neighboring Mbeya region who were Nyakyusa, the same as the hospital’s top nursing manager, the patron.

When I first visited Mawingu Regional Hospital in 2012, all of the nurses on the maternity ward were female. In the middle of 2014, the ward received a handful of new nurses, two of whom were male, both ENs. Later, in early 2015, we received another set of new nurses, primarily ENs, three of whom were male. In the end, approximately three-quarters of all the nurses were female. In other parts of ­Tanzania where I have worked, men ha...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Illustrations
• Acknowledgments
• List of Abbreviations
• Prologue
• Introduction
• 1. The Mawingu Regional Hospital Maternity Ward
• 2. Working in Scarcity
• 3. Protocols and Deviations: Good Enough Care
• 4. “Bad Luck,” Lost Babies, and the Structuring of Realities
• 5. Landscapes of Accountability in Care
• 6. The Stories We Tell about the Deaths We See
• 7. Already Dead
• 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
• References