Managing Motherhood, Managing Risk

Fertility and Danger in West Central TanzaniaBy Denise Roth Allen

University of Michigan Press

Copyright © 2002 Denise Roth Allen
All right reserved.
ISBN: 0472112848
CHAPTER 1
Motherhood as a Category of Risk

Mrs. X died in the hospital during labor. The attending physician certied 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 five 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,

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 fixed repertoire of possible causes among which a plausible explanation is chosen, and a fixed 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 first 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 officer 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. 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 figures holding a stretcher on which lay a stick figure 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. Xs 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 Womens Health: The Action Agenda for the 90s, and Mrs. X was once again in the limelight. After presenting Mrs. Xs 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 first decade of the Safe Motherhood Initiative (198797). 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. 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 five living childrenwere hints to the audience that she didnt 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 first decade of the Safe Motherhood Initiative. Often shown in conjunction with the story of Mrs. X, the road served as a visual summary of the causes of and solutions to maternal mortality. Signposts along the road reminded the audience of the four main factors that contributed to Mrs. Xs death: life-threatening complications, excessive fertility, high-risk pregnancy, and poor socioeconomic development. Another set of signposts along the road indicated the policies and programs that would have enabled Mrs. X to exit that road. Those exits included curative and preventive measures such as first-referral-level obstetric service, community-based maternity services, family planning, and the implementation of social policies to raise the status of women.
Without question, Mrs. Xs death is a tragic one; I still remember how deeply her story moved me the first time I heard it in 1988. But since completing my own research on womens pregnancy-related experiences in a rural community of west central Tanzania, I have come to see the short account of her death in a different light: as a story that shapes and then freezes this unfortunate womans experiencesand thus, by extrapolation, the experiences of all women she is supposed to representinto a particular representation of facts. It is, ultimately, a story that conceals more than it reveals.
For example, although we are told that the social and demographic characteristics of Mrs. Xs lifeher unwanted pregnancy, her illiteracy, her poverty, her rural addresscontributed to her demise, we are not offered much insight into how they did so. Nor are we told anything about the context in which decisions that affected her survival were made. Instead, we are presented with a partial telling of the events that led to her death, one that seems crafted to suggest that the real solutions to the problem are, for the most part, biomedical.
But what if we asked different kinds of questions about Mrs. Xs death; would it change our perception of the problem? For example, by the title she is givenMrs. Xwe can assume this woman was married. What about unmarried women? Are their health issues different from or similar to those of the married Mrs. X? We also learn that Mrs. X was illiterate. If we limit our questions to what happened once she arrived at the hospital, had she been able to read, would she have gotten better care? Mrs. Xs story reveals that she came to the hospital four hours after the onset of bleeding. What was the cause of that specific delay? Her story notes that she hadnt sought medical attention for the bleeding during her pregnancy. Why hadnt she? Was her illiteracy the reason she had not sought medical care, or had she gone to her local clinic but been turned away by nurses? We learn that Mrs. X never used contraceptives. Do we know why? Could it be that she had tried several times, but the...