Reviewed Book
Documenting Death: Maternal Mortality and the Ethics of Care in Tanzania. Adrienne E. Strong, Berkeley: University of California Press, 2020, 270 pp.
Kathleen Rice
McGill University
Drawing on research in the maternity ward of a rural Tanzanian district hospital, Adrienne E. Strong’s Documenting Death: Maternal Mortality and the Ethics of Care in Tanzania shows how and why care practices deviate from nationally and internationally established protocols and guidelines aimed at reducing rates of maternal and infant death. Centering her ethnography on obstetric nursing practices, she draws on long-term observant participation (p. 18), focus groups, in-depth interviews, and document analysis to demonstrate that these guidelines and protocols accomplish a great deal that is well outside the scope of—indeed, sometimes directly counter to—their intended purpose.
Although biomedical facilities have been heavily promoted as the only safe place for birth, Strong shows that in rural Tanzania this messaging combined with a heightened emphasis on the documentation of guideline-sanctioned care practices has led to a demand for hospital-based obstetric services that is deeply misaligned with availability of resources—material, temporal, and affective. This misalignment opens the door for error, mistreatment, and sometimes death. The book makes important, substantive, and novel contributions to theory and knowledge in the anthropology of bureaucracy, social theories of care, and social studies of pregnancy and childbirth. It also contributes to scholarship on power, status, and nursing in sub-Saharan Africa, although in this respect it serves primarily as a regional example that resonates with prior research elsewhere, notably South Africa. Scarcity on many levels provides an overarching context that haunts the entire book.
Strong’s discussion of biobureaucracy is outstanding. Grounding her analysis in specific examples of maternal deaths and stillbirths that occurred and were documented during her fieldwork, Strong shows that in an environment where optimal care is impossible to provide due to chronic shortages of basic supplies, funding, and medical staff, the documentation of good care becomes more important than what was actually done. Besides creating additional work that draws nurses and doctors away from patients’ often-acute needs, she shows that biobureaucratic processes create new ways of concealing, normalizing, and/or explaining the fatalities that guidelines are intended to prevent.
The book also makes valuable contributions to the anthropology of care. Strong shows, for instance, how the increasing reliance on technology eclipses the centrality of affective care for nursing work. She also expands analyses of the intersubjectivity of care to include not only intersubjectivity between nurses and the patients in their care, but also between nurses and other health care providers. This discussion resonates in important ways with her discussion of biobureaucracy, where she shows how modifying care-related documents (e.g., partographs, audit reports) is instrumental to intersubjective care between nurses who are insufficiently supported by hospital administrators, the health care system, and the state. Although not a major focus, Strong also brings together notions care and African personhood by arguing that care that is kin centered rather than patient centered can be appropriate in local context.
Perhaps most striking is the analytic distinction that Strong draws between “fierce care” and “abusive care.” Fierce care is defined as nurses hitting and yelling at women in labor as a means of compelling them to find the strength to give birth; it is also used by nurses to protect themselves from allegations of negligent care through the performative effort of violent encouragement. While abusive care is not explicitly defined, it seems that these same actions would be deemed abusive if the laboring woman was deemed undeserving of this treatment—i.e., if she were already quiet, compliant with nurses’ instructions, and perceived to be making a concerted effort to deliver quickly. Strong argues that in the environment of the rural Tanzanian hospital, “the borders and boundaries of care versus abuse are not always clear-cut, and the recipient of care not always perceptible” (p.16). Moreover, she correctly notes that most anthropological studies of obstetrics and childbirth have focused on birthing women rather than care providers, and have, as she puts it, “separated these providers from their social connections and their broader political economic milieu, even while working hard to explicate these very factors and their influences on the lives of pregnant women” (p. 199). She aptly calls on researchers to recognize care providers as embedded within networks and systems that impact maternal mortality.
However, in centering nurses in her ethnography and analysis, Strong centers their role in perpetuating these deaths and abuses as well, thus setting herself up for the challenging task of showing and analyzing nurses’ role in maternal abuse and mortality while treating them with the compassion and understanding that is a cornerstone of ethical ethnographic practice. It is here that the book would have been strengthened with deeper ethnographic richness and narrative description of nurses’ lives. As Strong herself acknowledges in the Preface, the book deals with difficult topics that may elicit strong emotional reactions in many readers: preventable maternal deaths and stillbirths and the abuse of laboring women. Yet the reader does not end up feeling that they know the nurses, let alone care much about them, making it harder to empathize when their actions cause grievous harm.
The sometimes-distant tone of the writing may be a reflection of Strong’s own ongoing need to separate herself emotionally from the death and fierce care that she witnessed and analyzed. As she notes in the Preface, “the work of close, nuanced, and full analysis to try to uncover the reasons why these deaths continue to occur in health facilities required that I put my feelings (temporarily) on a shelf” (xix; emphasis in original). This is understandable and is arguably an acceptable price for accomplishing the important analytic work that Strong’s book achieves. However, scholars of reproduction and obstetric abuse and violence may have hoped for a stronger framing that calls on nurses to recognize their embeddedness in a harmful system and to amend their role in perpetuating death and abuse.
For these reasons, the book would be more appropriate for advanced students and scholars of reproduction than for early undergraduate teaching. The book succeeds commendably in showing that, contrary to established health messaging, “the institutionalization of birth is not, in and of itself, the solution to reducing maternal death in any setting” (p. 192). I thus recommend this book highly to critical scholars of bureaucracy, care, childbirth, and global health metrics, and to policymakers involved with developing guidelines and protocols for perinatal care.