Partial Stories: Maternal Death from Six Angles

By Claire L. Wendland

A close look at stories of maternal death in Malawi that considers their implications in the broader arena of medical knowledge.

By the early twenty-first century, about one woman in twelve could expect to die of a pregnancy or childbirth complication in Malawi. Specific deaths became object lessons. Explanatory stories circulated through hospitals and villages, proliferating among a range of practitioners: nurse-midwives, traditional birth attendants, doctors, epidemiologists, herbalists. Was biology to blame? Economic underdevelopment? Immoral behavior? Tradition? Were the dead themselves at fault? 

In Partial Stories, Claire L. Wendland considers these explanations for maternal death, showing how they reflect competing visions of the past and shared concerns about social change. Drawing on extended fieldwork, Wendland reveals how efforts to legitimate a single story as the authoritative version can render care more dangerous than it might otherwise be. Historical, biological, technological, ethical, statistical, and political perspectives on death usually circulate in different expert communities and different bodies of literature. Here, Wendland considers them together, illuminating dilemmas of maternity care in contexts of acute change, chronic scarcity, and endemic inequity within Malawi and beyond.

• Language: English
• Publisher: University of Chicago Press
• Release date: Apr 22, 2022
• ISBN: 9780226816876

Book preview

Cover Page for Partial Stories

Partial Stories

Partial Stories

Maternal Death from Six Angles

CLAIRE L. WENDLAND

The University of Chicago Press

Chicago and London

The University of Chicago Press, Chicago 60637

The University of Chicago Press, Ltd., London

© 2022 by The University of Chicago

All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations in critical articles and reviews. For more information, contact the University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637.

Published 2022

Printed in the United States of America

31 30 29 28 27 26 25 24 23 22     1 2 3 4 5

ISBN-13: 978-0-226-81686-9 (cloth)

ISBN-13: 978-0-226-81688-3 (paper)

ISBN-13: 978-0-226-81687-6 (e-book)

DOI: https://doi.org/10.7208/chicago/9780226816876.001.0001

Library of Congress Cataloging-in-Publication Data

Names: Wendland, Claire L., author.

Title: Partial stories : maternal death from six angles / Claire L. Wendland.

Description: Chicago : University of Chicago Press, 2021. | Includes bibliographical references.

Identifiers: LCCN 2021037139 | ISBN 9780226816869 (cloth) | ISBN 9780226816869 (paperback) | ISBN 9780226816876 (ebook)

Subjects: LCSH: Mothers—Mortality—Malawi. | Pregnancy—Complications—Social aspects—Malawi. | Pregnancy—Complications—Malawi—Case studies. | Childbirth—Complications—Malawi—Case studies.

Classification: LCC RG530.3.M3 w46 2021 | DDC 362.19820096897—dc23

LC record available at https://lccn.loc.gov/2021037139

This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper).

Out of Bounds (or Our Maternity Asylum), the epigraph to chapter 4, is from Jack Mapanje, The Last of the Sweet Bananas: New & Selected Poems (Tarset, Northumberland: Bloodaxe Books, 2004). Reproduced by permission from Bloodaxe Books, http://www.bloodaxebooks.com.

for the guardians, the witnesses, the givers of care

and for the mothers, especially mine

Contents

Introduction

BONNEX KAUNDA: There are too many goings-on these days.

1  Dangerous Modernities

AGNESI KUNJIRIMA: You can make your pregnancy safe.

2  Knowing Bodies

LILLIAN SISKA: I help them right here at home.

3  Ambivalent Technologies

CHIMWEMWE BRUCE: Changes, yes, but no development.

4  Abundant Scarcity

RHODA NANTONGWE: By the time she comes to the hospital, it is too late.

5  Countless Accountings

DYNA NG’ONG’OLA AND KETTIE PENSULO: Women in this community are very much concerned.

6  Fragile Authority

Conclusion

Glossary of Chichewa Terms

Key People and Places

Abbreviations

Acknowledgments

Notes

References

Index

Introduction

All I knew about her was that she was pregnant, almost at her due date, and that she’d been shot. An armed robbery at the place where she worked the night shift, the newspaper later reported. I didn’t learn her name until I read the article. She was pronounced dead in the emergency room. The chief resident and the attending physician on call had raced down the stairs when the call came, leaving us medical students behind. They had hoped to resuscitate her and to get the baby out. Doing both at the same time sounds like a bad idea, the chief resident explained afterward, but it isn’t. It’s nearly impossible to resuscitate a hemorrhaging pregnant woman who is still trying to send blood through her placenta to the fetus. Their efforts were futile. Neither mother nor child survived. Later, the chief resident wept quietly, her face turned away from us, at the nurses’ station. (She was cool, competent, a woman of steel: I was shocked to find her capable of tears.) The attending obstetrician put his hand on her shoulder tentatively. You couldn’t have done anything. She just bled out.

Why did she die?

At one level, it’s obvious: she bled to death.

At another level, it’s not so obvious. It was 1989. I was a medical student then, just beginning an obstetrics clerkship in a grim urban hospital in Saginaw, Michigan, one of the rustier parts of the Rust Belt. Massive unemployment had transformed the city as the auto industry withdrew. Saginaw was afflicted by an epidemic of violence that fed on instability, racism, inequality, and the drug trade. Some thirty to forty homicides occurred annually in a city of less than seventy thousand people. It is likely that this young woman would not have died in a place less flooded with guns and despair. A place like Blantyre, Malawi.

In Blantyre, fifteen months later and nine thousand miles away, I wrote in a journal:

Updates: The lady with the jaw and abdominal lymphoma died, as did the one with advanced Kaposi’s and the woman with tetanus. The woman from Mwanza who had a huge swollen abdomen post C-section, that we thought was abscess, bled out and died on the [operating room] table. The swelling was some kind of cystic blood-filled structure—?

Why did these four women die?

At one level, each of these four deaths had an obvious explanation. The cystic blood-filled structure was a huge hematoma, a collection of blood resulting from unrecognized vascular injury during her cesarean operation. Like the mother in Saginaw, this woman bled to death. The women with lymphoma, Kaposi’s sarcoma, and tetanus all died because they could no longer breathe.

At another level, the explanations are again less obvious. It was 1990. No plague of gun violence afflicted Blantyre, Malawi. But another slow inferno burned through the hospital wards and smoldered in neighborhoods throughout the city—this one, too, fueled by massive unemployment, racism, inequality, instability, and poverty. The human immunodeficiency virus (HIV) is strongly associated with both Kaposi’s sarcoma and adult Burkitt’s lymphoma. Both cancers respond to chemotherapy, where it is available—but a catastrophic deterioration in health care was also at work. It is rare for a woman to bleed to death from a surgical complication in a place where there is a robust blood bank. Anti–tetanus vaccination campaigns have been highly effective almost everywhere. It is likely that not one of these Malawian women would have died had their pregnancies and births happened someplace where medical infrastructure was stronger. A place like Saginaw, Michigan.

There is more than one way to tell the story of any of these deaths. We who construct explanations—whether we attribute death to hemorrhage, to HIV infection, to the proliferation of guns, to poverty sustained by racism or inequality fueled by capitalism—focus on particular scales of time (minutes, hours, years, decades) and of space (organs, bodies, communities, nations). Those scales of time and space in turn imply certain kinds of interventions while taking others off the table. Implicitly, our explanations determine who is responsible for intervening (clinicians, politicians, pharmaceutical companies, pregnant women themselves), and with which tools (blood transfusions, ambulances, chemotherapy, policies, economic development). Much is at stake in these stories, and for the storytellers.

This book examines stories about maternal death, especially those told in the southeastern African country of Malawi by people who attend to pregnant women in the course of their work. Maternal mortality rates are high there, despite decades of interventions by the state and by nonstate organizations. Stories of dead mothers circulate through hospitals and villages, told by many different experts: herbalists and nurses, chiefs and doctors, epidemiologists and the healers called asing’anga. These stories offer competing explanations, making sense of catastrophe and allocating responsibility. Many point the way to strategies for averting future deaths. Stories of maternal deaths are used by elders seeking to educate juniors. Those elders may be national policymakers, the anamkhungwi who preside over initiation rituals and counsel pregnant women about what to expect, or faculty obstetricians at Malawi’s College of Medicine. In the Malawian context, as in all contexts, explanations for death are structured from available evidence—evidence revealed through technologies that range from hematocrits to dreams to proverbs. Narratives are also built using available metaphors and rhetorical strategies. In making sense of loss, they reveal how people make sense of the world they inhabit.

People in many parts of the world understand pregnancy as unpredictable and perilous. Proverbs and metaphors across Africa emphasize the contradictions and dangers of pregnancy. A Hausa proverb has it that the world is a pregnant woman, meaning that one can never know what to expect in life or in pregnancy.¹ Malawians warn that a pregnancy isn’t something to boast about—you can’t know how it will turn out.² The anthropologist Jean Comaroff, working among Southern African Tswana people, has described human and agricultural reproduction there as liminal processes, midway between society and the wild.³ One Malawian expression for pregnancy, ali ndi pakati, indicates that a woman is in the middle.

In the chapters ahead, I explore how people charged with caring for pregnant Malawian women explained maternal death and danger. Such people included hospital-based nurse-midwives and doctors, as well as herbalists who treated infertility and overdue pregnancies. They included azamba who once attended births in many Malawian neighborhoods—and still did secretly in some, even after a law banning traditional birth attendants. Some of these experts had biomedical training, whether a little or a lot. Some called themselves, or were called by others, traditional. A few did not fit easily into either well-worn category. Their backgrounds did not fully predict how they made sense of maternal death: the same explanation could appear, for instance, in the testimonies of elders without formal schooling and the diagnoses of obstetrical specialists with extensive postgraduate training.

My task in this book is not to debunk certain explanations while validating others. It is, instead, to explore how these explanations work: what they do and don’t do, and for whom. Exploring meaning-making about a single problem in a single place across a broad range of experts reveals unexpected commonalities, such as the moral messages embedded in accounts that appear to be purely technical. Experts’ narratives show how people make deaths into knowledge, how that knowledge becomes simple common sense, how alternative explanations—and a host of uncertainties—disappear along the way, and why those disappearances matter.

In exploring accounts of maternal death, we also come to understand some of the ways in which social, political, and economic inequalities shape societies and bodies, and constrain people’s chances of survival. Ali ndi pakati. She is in the middle between life and death, and the world around her may push her one way or the other.

Maternal Mortality Matters

Maternal death matters most for the women who die and for the people who live in relationship to them. Such a death is grievous and consequential for families; most dissolve after a mother’s death.

Maternal mortality matters politically too. National and regional leaders can be shamed over terrible statistics and applauded for improvements. Politicians attended more closely to maternal death during the early 2000s in many places, including Malawi, because of the fifth Millennium Development Goal: MDG-5 called for reducing maternal mortality by three-quarters from its 1990 levels. As 2015 approached, newspaper articles and public speeches often pitted one country’s achievements against another’s failures. Maternal mortality appears especially important for politics in southeastern Africa, where smooth processes of reproduction have long been read as testaments to legitimate leadership and a plague of deaths indicates a community gone badly astray. (You will read more about this connection in the book’s first chapter.)

A tight connection between strong medical care and safe pregnancy means that for epidemiologists, maternal mortality matters as a sensitive indicator of systemic health-sector dysfunction. Obstetrical emergencies are not always predictable. They happen—rarely, but catastrophically—even in healthy women with apparently normal pregnancies. They happen in out-of-the-way places, in any weather, at any time of day or night. To prevent death, skilled clinicians must respond swiftly with a range of tools, from blood transfusions to surgery to antihypertensive medications. Maternal mortality is typically low when health systems are strong: reliably supplied with essential tools and medicines; adequately staffed with well-trained and attentive workers; readily accessible 24/7/365; well integrated with effective referral systems. I have practiced obstetrics in two countries; neither meets all these criteria. In the United States, women can nearly always count on a well-supplied hospital, and usually on a reasonably staffed one. In Malawi, women cannot. In both countries, access and referrals are chronic problems.

Historians and physicians often quote a study suggesting that if healthy women were left alone with no medical care whatsoever, roughly nine hundred women would die for every hundred thousand births.⁴ Where pregnancy is safest, at this writing, three or four women die for every hundred thousand births. With high-quality medical care and good general health, maternal death is almost entirely preventable. The same cannot be said for cancer, stroke, heart attack, suicide, homicide, or many other common causes of death. Thus, even when maternal deaths are quite uncommon, they can be what some Malawians call the ears of the hippo: a small clue to a big problem. By one common estimate, for every woman who dies of pregnancy complications, seventy suffer serious long-term injuries. Where women die at greater rates, so do newborns, and far more often. Where the shortcomings of medical care allow high maternal death rates, other vulnerable people will suffer and die from that inadequacy too.

In addition to inadequate health care, at least two other underlying factors contribute to maternal mortality. First, overall well-being affects survival. Malnourished, anemic, immune-compromised, or addicted women face disproportionate perils in pregnancy. So do women beleaguered by racism, abuse, exploitation, and economic hardship. Second, too much obstetrical intervention can also be lethal. In the United States, many public health analysts believe that excess use of cesarean delivery is one factor behind a rising maternal mortality rate.

Maternal mortality matters as testament to injustice. Women’s health advocates understand high rates of maternal death to indicate both gender inequity and a widespread disregard for the lives of poor people. Health disparities between the poorest and the wealthiest nations in the world are greater in the realm of maternal mortality than in any other measure, including life expectancy or infectious disease burden. Globally, maternal deaths are concentrated in Africa south of the Sahara and in southern Asia, with hot spots elsewhere (Afghanistan, Central America). Within many nations, these deaths track with social marginalization. Aboriginal women in Australia have death rates much higher than those of non-Indigenous women. In the United States, black women—across educational levels—are far more likely to die than white women.⁵

A Changing World

This chapter opened with five deaths, all of black women: one in Saginaw, Michigan, four in Blantyre, Malawi. In the three decades since these five women died, much has changed.

In Malawi, estimated maternal mortality rates worsened substantially in the 1990s and early 2000s, reaching some of the highest levels anywhere in the world. For a time, these numbers suggested that giving birth by oneself in the middle of the forest would be safer than giving birth in Malawi. Terrible metrics and rankings hit the news regularly. Midwives, doctors, chiefs, and politicians weighed in with explanations and prescriptions. Legislators passed new laws. Activists began new initiatives. Health officials instituted new trainings and campaigns. Some of these new approaches were exemplary: for instance, Malawi pioneered methods for expanding antiretroviral treatment among pregnant HIV-infected women. Maternal mortality fell substantially, although perhaps not to the levels of neighboring countries. At the time of this writing, epidemiologists estimate that maternal mortality in Malawi is declining slowly. It is roughly back to its early 1980s levels.

As maternal death rates fell in Malawi, they rose in the United States. For a long time, few people took notice. National vital statistics centers and the Centers for Disease Control published few official metrics.⁶ The topic rarely arose in journal articles or professional meetings, although obstetricians and epidemiologists occasionally noted that pregnancy-related complications and deaths were disproportionately affecting black women. California public health officials began to pay more serious attention when statewide statistics indicated that maternal death rates had more than doubled from 1999 to 2006. Nationally, it was not until 2016 that the problem of maternal death in America really hit the news and aroused public consternation. At the time of this writing, epidemiologists estimate that maternal mortality in the United States continues to rise. Rates of death are about a twentieth of those in Malawi, but the numbers trouble many people. They tell a story in which the United States is a more dangerous place to be pregnant than all other wealthy countries and many middle-income ones: in 2019, childbirth was safer in Kazakhstan or Turkey than in the US.⁷

Ratios and rankings like these are usually treated as facts. There are compelling reasons to believe that the trends they describe reflect real dangers to real women. Quantifying maternal mortality is not easy, however. Even in the places where maternal deaths are most common, they are still sporadic events. Many American physicians have never seen one. Even the highest estimates of maternal death in Malawi calculated sixty live births for every maternal death; in the great majority of cases, birth goes well. To calculate reliable rates thus requires either accurate recording of deaths among large numbers of people or accurate recording of deaths among smaller numbers over a long time span. Definitions—what counts as a maternal death? what counts as a pregnancy-related death?—have changed over time and vary from one place to another.⁸ Deaths related to pregnancy are easily misreported or misclassified. Almost any given death, as you will see, can be explained in many ways. These uncertainties and ambiguities do not stop people from coming up with explanations, or from proposing interventions.

On Methods

While this book touches on experience in the United States and on scholarship from other places, it mostly explores how people in Malawi have responded to the problem of maternal death. I became interested in this question during an earlier research project. Between 2001 and 2003 I studied the experiences of doctors-in-training at the University of Malawi’s College of Medicine, as a lens on the larger phenomenon of African biomedicine. Because I am an obstetrician as well as an anthropologist, I also volunteered a couple of days each week at the teaching hospital, Queen Elizabeth Central Hospital (or Queens).

That project was not about maternal death or danger. Still, I observed many more maternal deaths in those months spent at Queens than in years as a doctor in the United States. I listened as my colleagues and our students analyzed particular cases, interpreting some deaths in order to prevent others. The American obstetricians I knew located risk within pregnant women’s bodies. Our professional journals featured algorithms designed to calculate just how at-risk any given pregnant woman was by weighting factors such as age, weight, race, or blood pressure. Malawian clinicians also sometimes located risk in the bodies of women—especially women pregnant for the first time or chronically ill, a euphemism for HIV infected—although I did not see them using algorithms. Often, they located risk in traditional practices and traditional birth attendants (TBAs), or in government neglect and political malfeasance.

Both Malawian and American approaches seemed to downplay iatrogenesis: the damage we ourselves inflict.⁹ In both places, iatrogenic injuries stemmed from hospital-caused delays in care, complications of unnecessary operations, or blunders made by inexperienced and poorly supervised trainees. In Malawi, additional dangers included high postoperative infection rates related to limited access to soap and water on the postpartum wards; in the US they included complications of elective labor inductions.

I wondered how expert discourse on maternal risk changed in a place where childbirth appeared—to me—so full of danger. What led biomedical providers in Malawi to see traditional practices as major threats to pregnant women, and their own practices as benign? And what about the TBAs and other nonbiomedical healers—what were their explanations for maternal death?

SOURCES

I have recorded many stories of maternal deaths in field notes and journals since my first journey to Malawi in 1990. Intensive work on this project began in 2007.¹⁰ I returned for shorter visits in 2010/11, 2013, 2014, 2015, and 2017. Beginning in 2007 I gathered narratives in English and Chichewa from well over a hundred people consulted as experts by pregnant women. Twenty-six were azamba, or traditional birth attendants (TBAs); twenty-four were nurse-midwives; nineteen were asing’anga, or traditional healers; fourteen were alangizi or anamkhungwi, counselors involved in initiations into adulthood or motherhood; the remainder were community health nurses, herbalists, doctors, health extension workers called health surveillance assistants (HSAs), and midlevel clinicians called clinical officers. Twenty-six fit more than one category; for instance, two-thirds of TBAs were also herbalists, asing’anga, or anamkhungwi. Ninety-two interviewees allowed me to digitally record our conversations. I also spoke with officials who tracked maternal health problems, and with community leaders who mobilized popular support for safe motherhood.

Interviews with biomedical personnel were all in English, save the occasional Chichewa phrase. All but one of the interviews with people who worked outside the formal medical sector were in Chichewa, augmented by an occasional English word or phrase; the exception was an interview in Tumbuka, with an interviewee who was not comfortable in Chichewa. My Chichewa is slow and mediocre. The language is rich in euphemisms, allusions, metaphors, and oblique references to folktales, most of which elude me. Bilingual research assistants helped with all Chichewa-language interviews and double-checked all transcriptions and translations.

Ethnographic observations flesh out this work. During prolonged stays in Malawi in 2002/3 and 2007 I was a participant observer, working part time as a doctor on the wards and in the operating theaters of a large public hospital, welcomed to the meetings at which maternal deaths were discussed. In later years—mostly in connection with other projects—I spent time in district hospitals and health centers, at rural healing ceremonies, and in the workplaces of traditional birth attendants in densely settled urban slums. Observations and conversations in these contexts add to the analysis.

Malawians who spoke with me were extraordinarily heterogeneous. Their ethnic backgrounds were varied and often mixed; they spoke eight different first languages. Those who knew their ages ranged from twenty-three to seventy-four years old at the time of the first interview. A few, like the TBA Loveness Mandawala, provided birth years instead: I was born in 1935, so I think I now have so, so many years. Do your own sums; then you will be able to know how old this is. About a quarter of those who worked outside the formal medical sector were unsure of their ages.

Educational experiences varied. Most TBAs, asing’anga, and counselors had completed three or fewer total years of schooling. Those who worked in the biomedical sector, in contrast, had all finished secondary school; many had college or postgraduate educations. Some held medical degrees, including a few with specialty training. Others had completed doctoral studies. They had trained in Cuba, Canada, the United Kingdom, Russia, Norway, China, Germany, and South Africa. They were multilingual, cosmopolitan, urbane.

Even people with little or no formal education had sometimes lived abroad for work, or with migrant relatives, or through marriage to a foreigner. Yet others—often, people with rich insight into the complexities of social life and the dangers of childbirth—had little geographical exposure beyond their own villages. I remember walking several kilometers from the road down a footpath to a leafy rural compound, to talk with a mzamba then in her seventies wearing a neatly pressed housedress and a string of plastic pearls. She explained how herbal treatments and marital precautions could safeguard pregnancy, and how one needed to be flexible about these strategies in the face of the many social changes in the community over the preceding fifty years. When our conversation wound down, she brought a little tray of delicious roasted groundnuts for us to share and asked me to replay the interview on my digital voice recorder. We sat for an hour with our recorded voices in the air around us as—with evident delight—she called friends and neighbors over to listen.

Experiences with birth ranged widely. Some interviewees had delivered thousands of babies. Others had attended only a few births. Several men who treated pregnant women had never seen a child born. Almost everyone I interviewed had children of their own, although not all had children living.

One does not stop being an anthropologist outside the moments officially marked as research, any more than one stops being a doctor outside the clinic. Whenever I interviewed someone or recorded a discussion, I asked permission, explained the purpose of the project, and answered questions before proceeding. Many observations from Malawi and all observations from the United States, however, happened outside the formal context of research. So did casual conversations that provided insights. These were times and places where people knew me as a friend or student or colleague rather than—or in addition to—a researcher. In all cases, I have taken pains to keep identities untraceable.¹¹

Everyone I interviewed—whether in Chichewa on reed mats under a tree or in English on a wooden bench in a clinic room—knew that they were speaking to a mzungu doctor, and that this project was about death and danger in pregnancy. That knowledge unquestionably shaped the stories that they told. I present the full range of explanations people gave, but I have given particular weight to discussions with people I knew over several years and observed in action. Their accounts seemed less likely to be produced solely for an audience of one.

The experiences of people who provide maternity care were my focus; I learned only a little about the experiences of people who seek it. While I have often spoken informally with pregnant women and their kinfolk, these conversations were never systematic. Other books will be much better sources for readers who wish to understand how women and their families make decisions about care, evaluate danger, and cope with loss.¹²

In this introduction, I am quite present. That is deliberate: you should know what perspectives and limitations an ethnographer brings to her project. For the most part, in subsequent chapters, I will recede from the page—but readers should keep these methods and caveats in mind. Other researchers would have learned somewhat different things, and would have arranged those things into somewhat different stories.

MY PATH TO MALAWI

Why study maternal death in Malawi? By the turn of the twenty-first century, the odds of death there were reported to be among the highest in the world. The most commonly used public health metric for maternal risk is the maternal mortality ratio, or MMR: the number of maternal deaths per hundred thousand live births. One widely disseminated article estimated Malawi’s maternal mortality ratio in 2000 to be 1,662:100,000, more than three hundred times greater than the world’s lowest ratios. Lifetime risk is probably easier to grasp: where birth was safest, epidemiologists calculated a woman’s lifetime risk of dying from a pregnancy-related complication at roughly one in thirteen thousand; in Malawi it was one in ten.¹³

Epistemology was as compelling as epidemiology. In southeastern Africa, bodies in general—and maternal bodies in particular—had long been linked with the harmonious functioning of society and with the fertility of land. Treatments for infertility, for recurrent pregnancy loss, and for crop failure could involve similar processes of divination and therapy. Songs and proverbs in several local languages used farming images for sex and pregnancy: the hoe used to plant potatoes in the anthill was the penis used to sow semen in the womb. During the course of this project, I would learn that people often explained sexual practices around pregnancy in agricultural terms. Couples must have regular sex in the early part of pregnancy, for instance, just as growing maize fields need frequent applications of rain. In later months they must stop having sex so that the child can ripen and dry in the womb.

Biomedical interventions into reproduction also had long histories here. Many early written accounts from the region came from Scottish missionary doctors, who carried forceps and ergot-derived medicines in their bags, and whose journals and letters referred to mothers lost to—or saved from—pregnancy complications. The Scots soon began training African assistants. Africans learned, taught, practiced, and adapted biomedicine for nearly a century and a half in Malawi, since well before the country had that name. This book uses some primary source materials from archives at the World Health Organization, the Malawiana collection of Chancellor College, and several European collections of materials on mission and colonial medicine in the British Nyasaland Protectorate—later, Malawi. It also draws on an exceptionally rich body of historical and social science scholarship grounded in this place.

Malawi had practical attractions too. I’d spent time there. Trusted colleagues could help me understand puzzling issues. I already spoke some Chichewa, the local lingua franca, and could deepen my knowledge of it rather than starting from scratch with a new language. Previous local experience allowed me to live comfortably in a dense city neighborhood where few expatriates came, and to get around by foot and by minibus to a wide range of people who dealt with pregnant women professionally.

Once, I would have characterized my long connection with Malawi as random: as a nerdy medical student interested in parasite life cycles, I had jumped at an opportunity to go to Blantyre in 1990 in the company of a generous and well-known malaria researcher. I’d never been on the African continent, knew little regional and no national history, and spoke not a word of any local language. At a big public hospital, I did not ultimately learn much about parasites other than malaria. But I learned a great deal about scarcity, injustice, political repression, grief, and my own appalling ignorance and ineffectiveness. Later I understood that I had been following paths trodden by colonial medics, missionaries, and researchers—including ethnographers—for more than a century. I wore those paths a little deeper, and others have since followed my own footsteps.

Wounds, Scars, and Partial Stories

Why pay attention to people’s stories about maternal death? Don’t medical science and epidemiological evidence explain what we need to know? If you are asking yourself this question, consider three points.

• First, the question introduces a misleading dichotomy between stories and medical scholarship. Medicine is full of stories, and even a statistical model can be usefully analyzed as a narrative. Unearthing the claims about truth embedded in these diverse stories allows us to explore why some kinds of interventions come to seem self-evidently valuable even though they repeatedly fail, and why others are never considered.

• Second, what we need to know to support maternal health intervention depends on what we want to do—or put off doing. Narratives authorize action, but desired actions also authorize particular narratives. Social scientists have gathered compelling evidence to show that neoliberalism, racism, and misogyny kill an inordinate number of women. Efforts to act against these powerful social forces have tended to find less institutional backing than efforts to educate the poor or to distribute pharmaceuticals.

• Third, stories do cultural work simply by being told. Even a narrative that many listeners find implausible may have real material consequences. Careful examination of many different narratives provides insight not only into maternal death but also into the ways people navigate the changing world around them.

The power of stories to remake the world and our experience of it is reason to pay attention to them. It is also reason for caution.

Over the years, as I read about maternal death in Malawi, I began to notice a recurring metaphor: calls for intervention in Africa made by powerful outsiders often used the image of a wound or a scar. In the 1850s, the explorer Dr. David Livingstone, urging European missionaries to come to the southern end of the Rift Valley to blot out slavery there, referred to it as the open sore of the world.¹⁴ In 2001, Tony Blair, then prime minister of the United Kingdom, claimed in a speech that the state of Africa is a scar on the conscience of the world.¹⁵ In 2010, Richard Horton, editor of the Lancet, called the lack of progress in reducing maternal mortality, particularly pronounced on the African continent, one of the most deforming scars on the body of global health.

Africa as scarred, deformed, bearing a wound that outsiders must heal. The metaphor is remarkable not only for its repetition over more than a century; it is remarkable because the image itself is wounding, its repetition a scar. Chimamanda Ngozi Adichie has famously warned about the danger of a single story.¹⁶ The representation of Africa in a way that calls for pity—a representation Adichie identifies as recurrent in Western literature—is a single story that characterizes the continent again and again as a place of catastrophe, poverty, disease, and suffering. Yes, catastrophe, poverty, disease, and suffering are abundant in Africa, as they are on every continent where human societies proliferate. So are innovation, complexity, and intellectual ferocity. The problem with stereotypes is not that they are untrue, Adichie says, but that they are incomplete. To create a single story is the privilege of those in power, who can tell the definitive story about less powerful others, while in turn having diverse stories told about themselves.

A single story of African suffering does damage. It reinforces a long history of black pain as spectacle.¹⁷ It positions the story’s listeners as witnesses and voyeurs, producing an enjoyable righteousness—or a righteous enjoyment. Such a story renders its subjects abject. It undermines their dignity and conceals their heterogeneity. Yet the invisibility of black pain also does damage. Founding figures in obstetrics and gynecology learned on black women’s bodies, their fame resting on black suffering that disappeared from the journal articles they wrote. Founding figures in anthropology produced research made possible by violent colonial conquest, extracting theory while obscuring African oppression. As the inheritor of two disciplines still struggling with the consequences of these concealments, I am attentive to the harm done by telling single stories, and the harm done by hiding stories.

This book does not present a single story. In writing of maternal deaths I have tried, even when the text becomes graphic, to be wary of the abject, the grotesque, and the sensational. No righteous intervention is demanded. No white-savior expatriates rescue African women. I am sometimes visible in these stories, but only because concealing my presence would be a deceptive distortion. Nearly all the protagonists are African, and black. Among them are committed advocates for women’s health, disgruntled clinicians going through the motions of work, frightened young women, and scolding elders. Not one of them is reducible to the stereotypes these brief descriptions suggest. The whole point of the book is to undermine the notion that any of the single stories we already think we know is definitive. All stories are partial, meaning they are all incomplete. And all stories are partial in the other sense of that word: they reflect preference; they incline to a particular sort of explanation because something is at stake for the teller. Partial in both senses applies no less to my stories than to anyone else’s.

The Path Ahead

Global health literature on safe motherhood includes six familiar tropes that also came up during my interviews: dangerous traditions, vulnerable bodies, magic-bullet technologies, portable best practices, explanatory statistics, and sound policy. Spiraling roughly outward from particular bodies and stories to national metrics and international policies, each chapter ahead opens up one of these six ideas for examination. Each can stand more or less alone. Readers well versed in regional history could skip chapter 1; mathophobes could skip chapter 5. The unique contribution of this book, however, is less in any one chapter than in the layering of them all, providing multiple perspectives on a single problem in a single place and weaving biomedical and nonmedical analyses together.

Chapter 1, Dangerous Modernities, shows how explanations for maternal death reflect visions of the past and express concerns about social change. Some stories are exhortations to be more modern. Many are indictments of modern times. When a traditional birth attendant recalled a golden age of easy birth, or a nurse-midwife grumbled that times have changed, or a sing’anga explained a mother’s death by saying our women have become pompous, or an urban obstetrician and a rural chief both linked teen mothers’ deaths to democracy, they illuminated longstanding linkages between problematic modernities and problematic pregnancies. This chapter interrogates tradition while situating the problem of maternal death in time—both in linear history, and in the circular time in which each generation succeeds the last.

Biomedically trained people typically look for the secrets of an individual’s body by investigating ever-smaller parts of its interior. Chapter 2, Knowing Bodies, considers bodies as clinicians learn to interpret them, and also as biosocial phenomena shaped from before birth by history and social inequality. The chapter introduces readers to aspects of ordinary life in a large Malawian city and its surrounds, and ordinary medical care in the hospitals and health centers where formal-sector health workers labor. Building on the first chapter’s examination of time, this chapter grapples with space. Vulnerability and resilience manifest at scales from the molecular to the global, with cells, organs, neighborhoods, and nations in between. A close investigation of a single death reveals how these scales of injury and healing matter for the individual.

Prescriptions for safer motherhood often require essential technologies. Chapter 3, Ambivalent Technologies, examines tools used to ward off the dreaded pregnancy complication of obstructed labor—among them abortifacients, measuring sticks, and labor charts called partographs. Some technologies are powerful social actors, marking people who use them as either backward or modern. Even magic bullets presented as safe, inexpensive, and material are often also dangerous, expensive, and social. Discussions of the drug misoprostol and of cesarean section show how tools can be lifesaving and lethal, and how these tools get caught up in disputes over appropriate technologies—second-best measures intended to reduce deaths in resource-strapped places.

Absent technologies also act: broken blood pressure cuffs, on-call doctors who cannot be reached, powerful medicinal roots that are now impossible to find—all figure in stories about maternal death. Chapter 4, Abundant Scarcity, describes the power of what is not there. Some therapeutic possibilities exist nowhere within Malawi’s borders except in the pages of textbooks. Others are out of reach for most but available to a few, in enclaves such as private clinics or research projects. In this uneven landscape, experts protest, improvise, and dream. Their improvised practices of care, like the ambivalent technologies of the previous chapter, require a reconsideration of the best practice dogmas of global health and global bioethics.

Chapter 5, Countless Accountings, considers analytical schemata used in Malawi to generate abstract knowledge about maternal death: a verbal-autopsy tool for assigning cause of death; the three-delays framework for evaluating access to care; an influential model for estimating maternal mortality. Building on a burgeoning scholarship on metrics, I show that a statistical way of knowing death, while appearing to promise an objective certainty, is as partial a narrative as those offered by people who bear witness to actual deaths in their workplaces. The chapter also shows how maternal mortality metrics shore up political claims, and how—and why—these claims became particularly important when Malawi’s first woman president briefly held power.

Practitioners’ narratives about death frequently bolster their own authority by depicting other kinds of expertise as dangerous: corporeally, socially, or spiritually. Women seeking safe paths to motherhood must navigate these claims and counterclaims. Meanwhile, policies intended to make motherhood safer sometimes can intensify patriarchal authority over women. Chapter 6, Fragile Authority, extends scholarship on reproductive governance and authoritative knowledge by showing how strategies that people use to legitimate their expertise can render care more dangerous and knowledge more partial (in both senses of that word) than it might otherwise be.

People looking for a study of how Malawian women navigate reproductive choices will not find it here. Other books provide more complex histories,¹⁸ clearer pictures of community life and gender relations,¹⁹ broader analysis of the political life of data,²⁰ richer hospital ethnography,²¹ closer study of healing practices,²² and subtler analysis of technologies.²³ My debt to many of these authors is evident, and deep. This book’s theoretical innovation is its synthesis of explanations for maternal death that usually circulate in different bodies of literature, different epistemic communities, and even different parts of the world. Considering them together allows new questions. Which approaches to a terrible problem are overdetermined by multiple interests? Who benefits and who is hurt? Why are some debates intractable, some wheels repeatedly reinvented? What possibilities never gain traction? Whose perspectives repeatedly disappear?

Each chapter includes observations and interview excerpts that illustrate key arguments. I’ve tried to be scrupulous about selecting materials that represent common patterns while also revealing the wide variation among Malawians. The brevity of these snippets of primary data comes at a cost. They give little sense of the texture of ordinary life, the cadences of people’s speech, the complexities and contradictions in any given person’s reflections on maternal health, or the peculiarities of the interview context. To provide readers with a better feeling for these matters, I have introduced each chapter by describing a specific person. For a few pages each, you will encounter a sing’anga, a maternal-child health coordinator, two azamba, a vimbuza healer, a nurse-midwife, and a clinical officer. Each of these experts told a story about maternal health in Malawi. Each took up positions in other stories: of the nation, of expertise, of danger. Some also spoke as daughters, mothers, friends, spouses, or community elders. A few accounts may be uncomfortable to read. In the one just ahead, for instance, the sing’anga Bonnex Kaunda attributed maternal death to the morals of our women today in ways that echo racist stereotypes about African promiscuity—but that also reflect longstanding indigenous connections between reproductive danger and a troubled society.

Chakufa sichilankhula. What is dead cannot speak.

Medical anthropology is a second career for me. The first, as an obstetrician-gynecologist, immersed me in medical ways of knowing for two decades before I became an anthropologist. I learned my trade in public hospitals at the rough edges of two poor states, and practiced for years in rural hospitals in two of America’s poorest counties. Women died in those places too—albeit in much, much smaller numbers. The conditions leading to their deaths never seemed adequately captured in our mortality-review meetings, or in medical journal reports. Some of these women’s stories appear briefly in the book. The minimal material from the United States and the much more extensive and systematic analysis from Malawi is not in balance. Moreover, the contexts of US deaths are quite different from those of the Malawian women who are at the book’s heart: the specific ways that injustice has been justified and racialized differ, although the damage that injustice inflicts on bodies can be similar. My intent in including material from the United States is to show that some of the processes at work—such as the ways policies can make women vulnerable, or the analytical practices experts use to draw lessons from deaths—are not so different. Maternal death is not a problem only over there.

Each of the book’s six chapters includes at some point a narrative of at least one maternal death. Some of these cases are skeletal, told in three or four sentences. Others are more fleshed out. Woven throughout the manuscript is a single more-detailed account, drawn from field notes, letters, and the recollections of clinicians involved. This story of Faith Chisoni—this story, not the story, because many could be told—shows how unstable any single story is. It also draws attention to an absence haunting the book: the inevitable and troubling absence of the voices of the dead women themselves.

The first mention of Faith Chisoni I found anywhere took up seven short lines. I’ve added translations beneath each one.

23 G3P1 29 wks

she was twenty-three years old, in her third pregnancy, and had already had one child; she was about seven months pregnant

previa, abruption

her placenta was covering the opening to her uterus; it had begun to tear away from the uterine wall and was bleeding

clinical DIC

her blood was no longer clotting