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

Celebrating Successes and Confronting Our Weaknesses

I will be the first to admit, it is often easier to critique than it is to praise, particularly when the points for improvement seem to outnumber the successes and the points for congratulations. There is a balance that we must strike when working to improve any situation, particularly when trying to lead others towards a common goal. In my research, people often ask me what I have discovered and what I have noticed about how things are going in Rukwa in regards to efforts to reduce maternal deaths. Amidst the noise of the areas for improvement, the sounds of the success stories can easily get lost. 

I was just at a conference this past weekend and gave a presentation on maternal mortality globally, followed by a section on maternal mortality in Tanzania, and a little bit about my own research. I received a comment via email from a Tanzanian doctor in the audience who suggested I needed to do more to highlight the successes of the efforts to reduce maternal deaths and I shouldn't be airing the problems to an international audience. I've been thinking about that comment ever since I read it. Fundamentally, I believe praise and recognition is an incredibly important part of keeping people motivated and trying their best. However, with this, we must not shy away from openly and honestly discussing ways in which we have failed, fallen short, or made mistakes. It is only through an honest and thorough discussion of these instances and events that we can come to truly see the opportunities for improvement and the best ways to address them for future success. By being brave enough to discuss these challenges and shortcomings with mixed groups of people, we might just be able to share information and exchange ideas about what has worked or is not working in order to address similar concerns in disparate locations. 

One thing I have noticed (and you might recall from my previous post) is that Tanzanians seem to not like confrontation. Let's be honest. There are a lot of people (not just Tanzanians) who don't like confrontation for a lot of different reasons. It's uncomfortable. It opens the way for people to be embarrassed or angry or ashamed. People's feelings get hurt. There are good ways and bad ways to go into a confrontation that can determine the way the other party will react and how the relationship will move forward. However, without airing grievances and discussing issues, those issues can start to fester and no action is taken. I recently had lunch with a fellow anthropologist who has also worked in hospitals in Tanzania. She suggested that some of the desire to avoid confrontation in the hospital setting might be traced back to the Ujamaa period in Tanzania's history. This was the name for socialism under the country's first president, Julius Nyerere. Ujamaa fostered a sense of community and "ndugu," or brotherhood. This brotherhood concept was officially in use from 1975 through the end of the socialist period in 1985. Bech et al. (2013) (via the political scientist Michael Okema) write that ndugu as a concept was "used to create a separation from the harsh authority and fearful obedience of the colonial past… Okema pointed to several dangers: corruption, inefficiency, indifference, and lack of necessary authority and discipline." It makes me wonder whether or not some of the desire to avoid conflict, confrontation, and, by extension, disciplinary actions, might not be related to this time period. While there are plenty of younger health care providers who would have only been small children during this time period, it's possible the residual effects continue to permeate health care institutions and leadership philosophies. 

One of the respondents to my survey on the work environment at the hospital mentioned that they are never told any specifics about things to improve. For example, she said, they might be told that "staff members are using bad language" on the maternity ward, but there won't be any details about who or what exactly was said or in what circumstances. While this might save someone from disciplinary action, it makes it virtually impossible to improve interactions with clients or to get to the bottom of the issue through a discussion of motivating factors for using such language or more positive ways to interact with patients, etc. Because no action is taken, it continues to be seen as something that, if not accepted, is at the very least tolerated in daily practice on the maternity ward. One leader on the maternity ward explicitly mentioned that they feared not being liked by subordinates. This is understandable but shouldn't inhibit the hard decisions and conversations that need to be had.

While difficult, these conversations must be had in order to address areas for improvement and to move forward, towards the common goal of better care. Obviously, if there are complaints about a particular person's behavior or professionalism, they should not be publicly reprimanded or embarrassed but they should be talked to in a constructive manner that will also help them to grow and improve their skills and their practice. This though, brings me back to a common refrain of improving leadership and management capacities for providers. There are certainly some in Sumbawanga who are good at these things, just as good managers and leaders exist in other areas of the country, but we need to make sure that everyone gets some management and leadership training or mentoring in one form or another. It's hard being a leader and sometimes it's lonely, but it can also be unbelievably fulfilling and empowering when you see your team accomplishing more than they once thought possible. To get there, tough conversations and tough decisions have to be had and made. Not everyone is going to like you but hopefully they will respect you. Perhaps it would be helpful just to teach everyone some basic management techniques? I will be exploring what kind of leadership or management training or advice those in positions of authority have received and whether to not they feel this has met their needs.

I suspect that a desire to shy away from these conversations is inhibiting more open forms of communication that could lead to more creative and effective solutions to improving care. This connection between ndugu and discipline is a relatively new line of thought for my research, which I am looking forward to exploring more in the near future. Personally, I will be working on trying to highlight more of the successes when I give presentations or have discussions with people, but we can't rest on our laurels or avoid the work that still has to be done.

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