Partial Stories: Maternal Death from Six Angles By Claire Wendland, Chicago: University of Chicago Press. 2022. pp. 356.
Partial Stories is a collection of ethnographic accounts of maternal death told by people who care for pregnant people in Malawi, a country known for its high maternal mortality rates. Taken as a whole, the stories add depth to a Malawian expression for pregnancy: ali ndi pakati (she is “in the middle”). These stories act as diverse, competing, and always interested hypotheses about how a woman may be pushed “one way or the other,” toward life or death (4). While the book focuses on Malawi, Wendland weaves in brief reflections on births she attended in the United States to demonstrate how the danger and liminality that characterize birth everywhere become sites of meaning-making, struggles for authority over bodies, and diagnosis.
The premise of the book is that all stories—whether told by epidemiologists, politicians, activists, medical professionals, or traditional birth attendants—are partial, incomplete and inclined toward the stakes of the teller (14). One major strength of the book, resulting from Wendland’s perspective as a physician and a medical anthropologist, is its ability to interweave biomedical and nonmedical analyses of maternal death without naming one “story” as superior to another. Interviews with traditional birth attendants (TBAs), traditional healers, initiation counsellors, community health nurses, herbalists, doctors, clinical officers, and health surveillance assistants (HSAs) are complemented by ethnographic observation and participation as a doctor on the wards of a public hospital. Each of the book’s six chapters provides an in-depth glimpse at familiar tropes around the issues of maternal risk and danger in Malawi: “harmful cultural practices,” vulnerable bodies, magic-bullet technologies, portable “best practices,” statistics, and policy. Any of these chapters could be assigned as a standalone piece in an undergraduate or graduate course in medical anthropology or global health.
Each chapter is prefaced by a brief vignette in which a person who cares for pregnant women explains why women face danger, prefiguring Wendland’s extended analysis of the “story” in the chapter. Early on, we meet a sing’anga, or traditional healer, who explains that pregnancy is dangerous these days—in contrast to a romanticized (62) golden past of being “born easily”—because women become pregnant too early, have lax morals, and are promiscuous or greedy for gifts from male partners. Rather than dismiss these stories, however, Wendland traces regional economic and social changes resulting from the nineteenth-century trade in goods and people, the twentieth-century growing cash economy and rising male labor migration, and the post-1980s consequences of austerity measures to provide a backdrop for his interpretation. This historical view deepens our understanding of how stories about “then” and “now” become “diagnostic narratives with therapeutic implications” (57) and captures how such changes “shaped landscapes in which disproportionate numbers of black and brown women die today” (32).
The chapter “Knowing Bodies” explores how people trained in biomedical ways of knowing construct stories of maternal danger. Drawing from textbooks that Malawian medical students and nurses studied and showing how reporting forms delimit what stories can be told about any given death, Wendland demonstrates how doctors can come to see health and justice as separate matters (82). Moving across the multiple scales that (pregnant) women navigate, Wendland shows how medical shorthand, whose lexicon is cells and molecules, narrows doctors’ ability to know or see etiologies of danger that lie outside the body proper: poor roads and unreliable public transportation that delayed a deceased mother’s arrival to a health care facility or a pregnant woman’s anemia caused by overlapping pathways of malnutrition, malaria, hookworm, and schistosomiasis, for example. When medically trained people read truths from bodies, they attend to “certain scales of time and space over others” (97). Later, in an analysis of the death audit tool called verbal autopsy, where an interviewer asks people close to a deceased mother about the cause of death, Wendland shows how newly automated versions of the death review rely on yes/no questions that enable a software program to assign a single underlying cause of death. While this ensures that every verbal autopsy of a maternal death in any country results in a single diagnosis drawn from among eight standardized and mutually exclusive causes, it leaves out the social, economic, and moral complexities of women’s situations and obscures many other causes of death such as negligence, incompetence, lack of supplies, bad roads, or lack of public transportation (199).
I recommend the chapter “Ambivalent Technologies” for any undergraduate course interested in divesting students of assumptions about how best to help people in the Global South. Moving away from celebratory discourse around “appropriate technologies,” Wendland reminds us that all technologies embed the potential to help and harm. So, too, does the term appropriate technology obscure the conditions that make tools acceptable to use in one place but not in another. For instance, the textbook used by medical trainees in Malawi presents two approaches to obstructed labor—symphysiotomy and destructive delivery—in contexts where women may not have access to operating theaters (these “appropriate technologies” are not mentioned in Global North textbooks). Yet, these potentially lifesaving procedures are not practiced because doctors see them as “gruesome embarrassments” or “inhumane relics of the past”—even if they might end obstructed labor, they wounded the mother or destroyed the fetus in the process (134). Wendland demonstrates how the concept of appropriateness can serve as a “bureaucratic mask for injustice” (143) wherein the absence of gold standard practices, medicines, or treatments is taken for granted rather than seen as cumulatively produced by racial capitalism and histories of colonial extraction. Building on this insight, Wendland tracks how stories of maternal and infant deaths in labor wards center absences, uncertainties, and poor substitutions as constitutive of care in Malawi. Yet, rather than dwell in the frustrations experienced by clinicians who lack even the most basic tools needed to do their work, Wendland highlights how they refuse to accept such conditions as ordinary; in some cases, they talk as if they were working in contexts of abundance, invoking “dreams of care” and aspiring to the ordinary that clinicians in other parts of the world take for granted (177).
The final chapter tracks the rise and fall of TBAs, hailed in the 1970s as a solution to weak health infrastructure and inadequate health personnel, particularly in rural areas. Wendland shows how speculation about the quality of maternal care delivered by various agents marks certain people and practices as moral/immoral, safe/risky, or modern/backwards; such stories inform national policies. While Malawi was the first African nation to train TBAs, in 2007, the country suddenly imposed a ban on TBA practice and coded it as “harmful cultural practice.” The vilification of TBAs allowed governments and multinational organizations to “do something” about unsafe birth without spending much money (253). Wendland shows how the ban garnered support among diverse actors ranging from male chiefs to medical doctors who latched on to the figure of the dangerous TBA to shore up their own authority over birth even as maternal mortality rates did not change as a result of the policy.
Partial Stories offers a new narrative about maternal death in Africa by undermining “the notion that any of the single stories we already think we know is definitive” (13). At times, the book features graphic, bloody, and tragic instances of maternal death, but the care Wendland put into thinking about how to tell the stories she shares is evident throughout. I can only assume that attending to Malawian women giving birth in contexts of “abundant scarcity” drove home the fact that, as she puts it, policies, histories, and metrics are not as bloodless as they seem. I appreciate that the book’s protagonists are all Malawian: this isn’t a book about global health as typically imagined. So, too, does Wendland make clear the internal diversity of opinions, perspectives, and stories told by categories of people too often homogenized in the global imaginary (doctors or traditional healers, for instance). One comes away from this book with an awareness that stories are the real currency in the economy of evidence-based interventions that characterize maternal health policy and practice today.