Adrienne Strong

Medical anthropology, maternal mortality, hospital ethnography, and dignity in women's health care

I am a medical anthropologist and Assistant Professor of Anthropology at the University of Florida with a joint Ph.D. from Washington University in St. Louis, USA and the Universiteit van Amsterdam in the Netherlands. I study maternal mortality and women's health in Tanzania, currently in the Kigoma region on a birth companionship program and the notions of ideal comfort, care, and support for pregnant women in labor. Before my current position, I was a National Science Foundation Postdoctoral Research Fellow with Columbia University's Mailman School of Health, in the Averting Maternal Death and Disability (AMDD) Program in the Heilbrunn Department of Population and Family Health and a Fellow at the Columbia Population Research Center.

My current book project, Documenting Death: Maternal Mortality and the Ethics of Care in Tanzania, under contract with University of California Press, focuses on the inner workings of a government regional referral hospital in Tanzania, examining how institutional structures related to hierarchy, bureaucracy, historical precedents, communication and other factors, may influence the capacity of the institution to provide effective maternal healthcare during times of obstetric crisis. My research focuses on biomedical healthcare providers and administrators, groups that are often overlooked in the context of medical anthropology in sub-Saharan Africa. I contextualize the hospital ethnography with interviews, participant observation, and focus group discussions in communities throughout the region, as well as through the use of primary archival sources from the colonial and post-independence eras. This is the first ethnography to examine the issue of maternal mortality in a low resource setting from this perspective and in the setting of a biomedical facility, complementing the existing work of anthropologists of reproduction who have worked at the community level.

I worked in the Rukwa Region for my PhD fieldwork, which I conducted from January 2014- August 2015. From September 2010 through July 2011, I conducted research on access to healthcare services during pregnancy, birth, and the postpartum period in the Singida Region of Tanzania. My most recent project was about a birth companion pilot program in the Kigoma region of Tanzania from January through December 2018, which focused on the ways in which companions impact the social dynamics of health center maternity wards and the care provided in those settings. This project also included an 80-question cultural consensus survey and analysis around the cultural domain of care and support for pregnant women.

This is my personal website, which includes updates on my research, collaborations, conference presentations and papers, publications, teaching, and critical responses to current events related to women's health and reproduction.

Mentions and Public Anthropology

Paper Prize

Washington University Feature

Feature on Anthropology Department Website

Research Report on Global Health Hub

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Mention on Anthrodendum

Mention on Anthrodendum for fieldwork blog

The Uniqueness of Maternity Work

Let me first say that lots and lots has been going on lately, taking me out to villages and back to the hospital and all around. Since September, I've been to Dodoma, Iringa, Dar es Salaam, Wampembe village, Sumbawanga, and all around the Nkasi District. In between, I've been filling out loads of paperwork for my two(!!) grants that I've now be awarded for my research and trying to pin down people for interviews (a bit like herding cats), as well as thinking ahead to residency permit renewal time, research clearance renewal (anyone thinking of doing research in Tanzania, I have lots of tips on these topics if you're interested…), and the holidays. When I'm not doing all of that, I will be either passed out on my bed or training for the Kilimanjaro Half Marathon in Moshi on March 1st. Wow. Now, onto the research.

The hospital has recently implemented a new accounting system, which now involves computers and printed receipts for medications and services provided. As with any big change, this one has been accompanied by a number of growing pains all around. I think there seem to be a number of new benefits of the system, including more accurate accounting and an increase in hospital revenue, always a good thing when government support is sometimes unpredictable, more predictable patient flow, and better record keeping. However, the nurses, in particular, have raised a number of concerns about the new system. These concerns have come from all sides, all wards, and a number of different nurses. However, the maternity ward staff have arguably had more changes to deal with than most of the rest of the hospital.

Only one month into this new system, there have already been reversals of policy and more changes. Maternity seems to be considered the problem child these days. First, we were problematic because we weren't using patient files, women just reported directly to the ward, bypassing the records department and payment window because all care for pregnant women is subsidized by the government. Then, we were a problem because we effectively used up the entire hospital's store of paper files for starting new patient records. Think about it. The maternity ward sees between three and six hundred deliveries each month, EACH MONTH! Of course we're using a lot of files. Personally, I thought the files were nice and were helping keep women's paperwork together and more organized. However, now, we have gone back to no files or charts. As another consequence of this new system, the nurses have to record the exact number of each supply used in the care of a patient. That means writing down the number of pairs of gloves you use, the number of syringes, IV fluids, uterotonics, etc. Now, this wouldn't be too terrible (though still onerous) if there was a systematic way in which to do it and then compile the info for the end of the day report. However, no such system exists and the nurses have been complaining loudly and often that this has drastically increased their workload on a ward where they are already overburdened and frequently extremely busy. The hospital, particularly the pharmacy and main store, will now no longer disperse supplies without the specific names of patients and a daily head count. This means that we did not have any gauze on the maternity ward, not a single piece, for nearly two weeks. It would be impossible to take the name of every woman who comes to give birth to the pharmacy in order to beg for some gauze. The baby would be out already before you even found the pharmacy person to talk to about the issue!

I see one of the major problems here as being located firmly with some of the hospital administration. There are several among them who have never worked on a maternity ward and therefore are unfamiliar with what it's like in the trenches, so to speak. They makes these plans with a broad brush and then expect maternity to adhere to the same protocols as the medical medical ward, which as one of my interviewees once said, "doesn't have any emergencies. What kind of emergency does medical medical have? Maybe someone is having diarrhea but it's not an emergency like on the maternity ward." We can't be running back and forth to the pharmacy to ask for gauze every time a baby is born. How is that supposed to work? Even the opening of a new file for every woman was drastically different for maternity than the rest of the hospital, not just because of the high volume of patients. It's time that the administration get it firmly in their heads that maternity will not be able to fall in line behind all the other wards, it is a uniquely complicated ward that should be treated differently and probably with more flexibility and inventiveness in order to address its unique issues. It's a daily struggle. I think these recent developments will probably be reflected in the questionnaire about to give to all of them. We'll see if it shows in how they rate their levels of satisfaction and empowerment...

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