Managing Motherhood, Managing Risk: Fertility and Danger in West Central Tanzania

12. Risk and Maternal Health

CHAPTER 12 Risk and Maternal Health A reprise: Mrs. X died in the hospital during labor. The attending physician certi‹ed that the death was from hemorrhage due to placenta previa. The consulting obstetrician said that the hemorrhage might not have been fatal if Mrs. X had not been anemic owing to parasitic infection and malnutrition. There was also concern because Mrs. X had only received 500 ml of whole blood, and because she died on the operating table while a caesarean section was being performed by a physician undergoing specialist training. The hospital administrator noted that Mrs. X had not arrived at the hospital until four hours after the onset of severe bleeding, and that she had several episodes of bleeding during the last month for which she did not seek medical attention. The sociologist observed that Mrs. X was 39 years old, with seven previous pregnancies and ‹ve living children. She had never used contraceptives and the last pregnancy was unwanted. In addition, she was poor, illiterate and lived in a rural area. —World Health Organization, “Maternal Mortality: Helping Women off the Road to Death” I bring this account of women’s pregnancy-related experiences to a close by returning once again to the story of Mrs. X. In light of the other women’s stories we have examined in the preceding pages, how well does her story capture the complexity of maternal health issues in the community of Bulangwa? Although Anna’s miscarriage in the marketplace, Njile’s pregnancy that “turned to the back,” the death of Milembe’s “eleven-month-old” fetus, Sayi’s prolonged labor, and Ndalu’s postpartum hemorrhage all involved risk, in the latter stories we were able to see the diverse ways the risks those women faced went beyond the individual women themselves. One of the things that repeatedly struck me over the course of my ‹eldwork in Tanzania was how often the stories women shared with me or 226 the events I witnessed de‹ed the boundaries laid out in the story of Mrs. X. Sometimes the factors that contributed to women’s pregnancy complications were similar to the ones identi‹ed in Mrs. X’s story. Other times the risks those women encountered were very different. One thing all of their stories had in common, however, was that their experiences would have been misunderstood or misrepresented if put into one small paragraph, consisting of fifteen lines of text. If the details of their experiences are dif‹cult to summarize so as to be relevant for all, what implications does this have for the success of a maternal health initiative that recommended a standard set of solutions be implemented everywhere, irrespective of the context? Although the accounts of women’s pregnancy-related experiences in the preceding pages were diverse and not easily summarized, there are nevertheless some general lessons to be learned from such stories. These lessons can be characterized as suggestions about how to approach the design and implementation of maternal health programs rather than as a blueprint for speci‹c interventions per se. Delineate the Context of Maternal Health Although the direct medical causes of poor maternal health outcomes are the same worldwide, beliefs and practices associated with the management of maternal health risk vary considerably between and within societies. We saw examples of this throughout this book. In some cases, local practices surrounding pregnancy and childbirth are directly related to the cultural beliefs or norms shared by those belonging to a speci‹c ethnicity or among people living within a particular setting. In others, people’s responses to maternal health risk are a direct result of the socioeconomic status of particular individuals or groups of people, while in still other cases the practices surrounding the management of pregnancy and birth complications may be a re›ection of how past and present international recommendations have played out within health facilities at the local level. Given this diversity, delineating the context of maternal health requires gaining an understanding of how risks to maternal health are de‹ned in particular settings and the various strategies that women, men, healers, and healthcare workers alike are using to address or counteract them. For example, attention to local practices related to pregnancy and childbirth in Bulangwa revealed that many women were using biomedical and nonbioRisk and Maternal Health 227 medical sources of maternal health care simultaneously. A closer look at the reasons...