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CHAPTER 1 Motherhood as a Category of Risk 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” The questions start with how people explain misfortune. For example, a woman dies; the mourners ask: why did she die? After observing a number of instances, the anthropologist notices that for any misfortune there is a ‹xed repertoire of possible causes among which a plausible explanation is chosen, and a ‹xed repertoire of obligatory actions follow on the choice. Communities tend to be organized on one or another dominant form of explanation. —Mary Douglas, Risk and Blame I ‹rst heard the story of Mrs. X in February 1988 during an afternoon talk in the School of Public Health at the University of California, Los Angeles . The guest speaker, a senior medical of‹cer from the World Health Organization (WHO), had come to speak to graduate students about the recently launched Safe Motherhood Initiative, an international effort to address the problem of maternal mortality in the “developing” world.1 “From the very beginning, even before labor began,” the speaker told us, “Mrs. X was on the road to death.” The challenge, as he put it that day, was getting her off that road. Projected onto the large overhead screen before us was a hand-drawn image of a downhill road. At the bottom of the road were two stick ‹gures holding a stretcher on which lay a stick ‹gure corpse, Mrs. X. And handwritten at several intervals along this downhill road were the various key dramatic points of the story: “placenta previa”; “anemia”; “several episodes of bleeding during pregnancy”; “39 years old”; “unwanted pregnancy”; “illiterate”; and so on. We were then asked as a group to determine the cause of Mrs. X’s death. Eight months later I again came across the story of Mrs. X as I was browsing through a WHO publication (1986). I had just begun doctoral studies in anthropology and was researching a paper for a class on health problems in Africa. Remembering the story of Mrs. X, I decided to focus my paper on maternal mortality. I encountered Mrs. X a third time, three years later in June 1991, at the Eighteenth Annual National Council for International Health Conference in Arlington, Virginia. The theme of the conference was “Women’s Health: The Action Agenda for the 90’s,” and Mrs. X was once again in the limelight. After presenting Mrs. X’s medical and social history to the audience, the keynote speaker thoughtfully posed the following question: “Why did Mrs. X die?” Mrs. X achieved a certain amount of notoriety during the ‹rst decade of the Safe Motherhood Initiative (1987–97). Versions of her story were recounted in international journals and conference keynote speeches, developed as the central theme in advocacy videos and classroom lectures, and used in training workshops to sensitize health-care workers to the multiple causes of preventable maternal deaths (see ‹g. 2). Although we were not told what country she actually came from, certain key phrases— “poor, illiterate, and lived in a rural area,” “anemic owing to parasitic infection and malnutrition,” “seven previous pregnancies and ‹ve living children”—were hints to the audience that she didn’t reside in any Western industrialized nation. She was a “developing country” woman, and through her story we came to understand the experiences of all pregnant women labeled as such. The “road to maternal death” was another concept widely invoked during the ‹rst decade of the Safe Motherhood Initiative...

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