Meetings, Networking, and the Race to the Finish

It's been far too long since I've updated this. After I finished my data collection in the villages in Rukwa, I quickly rolled straight into conducting the interviews with the hospital staff members and administrators, as well as with regional and district administrators. I had about one week to breathe a little bit before packing up and moving to Dar es Salaam where the race then started to finish collecting data from the National Archives and to start (and hopefully finish) transcribing more than 58 individual meetings and interviews, in addition to the over 45 recordings my research assistant and I collected during our visits to eleven different villages. I now have almost exactly three weeks left here in Tanzania. 

Since moving to Dar, I have been feeling a diversity of emotions related to all of these transitions- the end of my time in the field, leaving behind beloved friends and colleagues, and, soon, reintegrating to a country and culture I haven't been a part of for nearly two years. Somewhere in there, as I try to process all of this, the words for writing about my research seem to have gotten stuck inside. I'm not going to attempt to relive the last three months since I last wrote, so you'll just have to be happy with what comes out. I will, eventually, write more about the experience of interviewing the nurses and other hospital staff because I think reflecting on that experience is an important part of thinking through not only my data, but my own subjectivity here. 

I wouldn't call it writer's block, but it seems to be something else. Currently, I'm sitting in a meeting discussing Respectful Maternity Care, which has become a (relatively) new initiative or target for intervention on the part of USAID and, subsequently, is being incorporated into new programs and being evaluated where it was a part of longer-standing projects. I am awash in a stream of numbers and P values. And I'm seriously wondering why these people don't get some social scientists (OK, to be fair, I haven't surveyed the crowd on their educational backgrounds, but they all talk like public health practitioners, clinicians, and monitoring and evaluation people). This was particularly apparent when I heard, once again, a question from the meeting attendees about why women are reporting more abuse that occurred when they were at the hospital to give birth when they are interviewed at home 4 to 6 weeks after the fact as compared to when they are asked 3-6 hours after giving birth, while still in the hospital. The one person's hypothesis was that women have had more time to reflect on the events; another person's interpretation was that women are relaxed at home and they were not relaxed at the hospital. What we're missing here is an admission that women are afraid of retribution and the chance that they would receive intentionally neglectful care if they return to the same facility another time. I think some of them, particularly the Tanzanians, know this but no one was particularly saying it in the straightforward manner I was hoping for. 

At our lunch break, one of the people wanted to know if I'd taken all of the health systems information from the hospital, too. She wanted to know if I'd collected all of the stats and all of the data entered into the health data system every month at the hospital. I said no, I hadn't, but I knew it was available if I needed to go back for it. She seemed a tad disappointed, exemplifying their love of quantitative data. One of the repeated refrains is that we need more information on the "contextual drivers in different environments" of abuse and needing more information on the perspectives and motivations of the health care providers, and all those working in the health care setting. And I just sat there and nodded and nodded and thought "Gee, that's exactly what my dissertation looks at; it will beautifully contextualize everything they're talking about." Now, hopefully these people present will all read some of the information I will on day eventually publish. Day 2 I did have two people talk to me enthusiastically about the work of Lynn Sibley at Emory and Stacey Langwick, the anthropologists they know. 

On the other hand, I did find it very interesting to hear about some of the implementation research and I really enjoyed the time we spent discussing issues in groups. On the second day, we spent time in groups trying to design a program to address one aspect of disrespect and abuse in a fictional district in Tanzania. Interestingly, all of the groups chose independently to focus on verbal abuse. My group had some very interesting conversation and we largely agreed on many of the factors influencing the presence or use of bad language or disrespectful language by providers. What we did not necessarily come to a consensus on was what might be done to most effectively address those factors and then reduce verbal abuse. I would have been happy to sit there and discuss the nitty gritty of planning interventions for several hours based on the information I've gotten from health care providers in Rukwa. I'm hoping that, at some point, it will be possible for them to really work on addressing respectful maternity care in all of Tanzania. 

I also happened to be sitting next to the President of TANA, the Tanzania nurse's association and he and I had a wonderful conversation at the end of the meeting and over lunch. I was also geeking out a little bit because I was introduced to Dr. Mbaruku whose papers I have been citing for some time. They are looking at starting a project in Rukwa and I would be so thrilled to work with them in any way on that! I also had two of the USAID, Washington DC Senior Maternal Health Advisors tell me they were very much looking forward to reading my work and seeing the results. I was trying to rep anthropology these two days and I think, maybe, it worked! It was very interesting to be in a room with such quantitative people, though I did have one public health researcher tell me that he really respects anthropologists so much because of the depth of data we are able to collect. Fuzzy feelings for anthropology ensued. Overall, I was very pleased that I sort of fell into this meeting. I was invited by someone I have been in contact with due to the Wazazi na Mwana program that was going on in Rukwa but I was sort of the only unaffiliated person present, everyone else came from organizations and head offices in DC and the Ministry of Health and the like. It was great for networking and I hope I still have more business cards that I left somewhere in the U.S…. Look for another post soon on respectful maternity care in my "From the News" section where I'll write my thoughts on the new study that came out from the World Health Organization and that was covered in the NY Times at the end of June. Next up, my presentation for USAID and CDC on August 4th before I leave. Now, I just have to figure out how to present some things that will be useful and interesting to more public health people. Wish me luck!

Challenging the Conventional Thinking

This past week I successfully finished collecting data for my study's second and third sub-objectives, which involved work in communities outside the municipal district. I had originally had a smaller number of objectives for work in the communities but grant reviewers wanted to see more work in villages and among community members outside of health facilities. I had mixed feelings about revising my project to include these expanded community visits for a couple of reasons. Primarily because the barriers to care in communities are well known and well studied, and secondly, because it was really the facilities in these areas I wanted to look at, not necessarily the community dynamics. I also think this was one of the reasons another funding agency just was not having any of my grant. I submitted to them twice and didn't make it past the first round of reviews either time. They were looking for the conventional narrative, the line of thinking in anthropology that suggests we should be examining maternal death through the lens of the community and the subjectivity of those most at risk, the women themselves. I sought to break from this convention because this dialogue has sustained the Safe Motherhood movement since the 1980s and, unfortunately, in countries failing to make progress on significantly reducing maternal mortality, the problems that were challenging in the 1980s are still present. No point beating a dead goat (we don't have any horses around here) by continuing to repeatedly "discover" that transportation is a problem, education is a problem, bad roads are a problem, etc. And guess what I heard in all of these community meetings? You guessed it: still not enough education; transportation is still a challenge; people are still poor; the roads are still bad. 

When I started on this line of thinking-examining maternal deaths from inside the hospital, the social and institutional dynamics- I didn't think it was particularly radical, new maybe but that's what we all hope for our dissertations, right? By focusing on the health care providers and facilities, I was hoping to work most closely with those who also directly have the power to influence a woman's recovery or death. Sure, delays before she arrives at the hospital factor into it all, but, as I said above, these are well known. Where the ethnography has often stopped is at the doors of the hospital. If we do see inside a health facility in an ethnography, in so many cases, it is as the anthropologist accompanies a woman from the community and bears important witness to the ways in which (often minority) women are treated or discriminated against through overt or micro aggressions in the biomedical care setting. What we don't see as much-one chapter here or there- is the perspective of the health care providers themselves. How their personal lives, national or international policies, institutional rules and procedures, or social interactions with other providers and administrators deeply color the care they are able to provide. In my mind, this picture is crucial for filling in the blanks and moving forward. My work has also ended up shedding light on the ways in which the documents meant to represent a hospital (or dispensary or health center) and the daily practices often diverge. It is all well and good for a person in an office in Dar es Salaam to adamantly tell me what people are "supposed to do," but the real work, and the power of anthropology, is in discovering why it is that health care providers deviate from the protocols and guidelines. 

This focus on health care facilities has been largely well-received here in Tanzania, in theory, but I have encountered times when I am 100% convinced that people don't think the problem lies within their own house and therefore proceed to make judgments about what kind of data I should be collecting and what is relevant or not to my study of maternal death. Like the time when two top regional health administrators denied my request to attend a regional meeting on the basis that they thought it had nothing to do with my work and was just "internal business." Unbeknownst to them, I had already been privy to the major discussion of the meeting due to my relationships with other people. I was only interested in hearing how they were proposing to redistribute funds to help the regional hospital sustain its care for pregnant women in a more financially stable way. I wasn't necessarily interested in other dirty laundry, so to speak. Nevertheless, these administrators closed the proverbial gates squarely in my face with a suggestion that I head back to the ward, presumably where they thought I belonged. Again, I was struck by the idea that many people still need to broaden their conceptions of the causes of maternal death. These administrative issues undeniably affect maternal health outcomes because they affect supply availability and distribution, staff salaries and extra duty pay, district referral procedures, and communication; how could they not see the meeting was directly relevant to my research? It reminded me of my very first day on the maternity ward when one of the nurses basically told me I was barking up the wrong tree if I thought the nurses and doctors had anything to do with women's deaths or serious morbidity; malpractice was not in the question, she said. By the way, it is perfectly within the administrators' rights to deny me access to the meeting, I was mostly upset by what seemed like a disappointing lack of understanding of the goals of my research, even after having been at the hospital for a year.

So here I am, on the other side of the community portion of my study. I am glad I did it, it strengthens the overall study, but nothing earth-shattering was discovered. Each village had some specific issues but, overall, the threads were the same- not enough medications, need providers with more expertise, transportation is a major cost when trying to reach health services. What I may not have anticipated was that this portion of the study has provided further ways to connect health care service provision with broader political policies and reforms. From this portion of the study though, I am going to have to challenge everyone in the next maternal death audit meeting if they try to keep saying there was "delayed decision making in the family" in nearly every case, as in the past. Most of these community members try their best to reach health care services and the decision is often made early enough; it's other challenges down the line that often derail their attempts to arrive in a timely fashion. Relatives arrive at the dispensary with a woman in labor in the middle of the night. One relative stays with the woman while the other runs to the health care provider's house because there's no security guard or anyone else there at night. The nurse says she's tired and refuses to come out of her house, telling the family to go to the other provider's house. That one says the same thing and so the local "traditional" birth attendant helps the woman give birth on the porch of the dispensary. Where does this scenario fit in the three delays model? Is this a delay before reaching the hospital? At the hospital? Where does the responsibility lie then for carrying out some disciplinary action against the provider who refused to help the woman and her relatives? Will the family or community be empowered enough to even know that they can complain about this? If so, to whom do they complain, and will that person listen? There is also a blatant lack of connection and communication between facilities and communities, which, in my professional opinion, further exacerbates many of the challenges currently present and leads to bad will towards providers on the part of community members. 

In the village in which I was working this past week, the medical attendants were telling me that they no longer even bother to call the district ambulance because they know from experience that it will most likely not arrive. Instead, they choose to advise family members to find a motorcycle or private car to transport them in the hopes that it will be faster than waiting for the district ambulance to travel the short 29km from its supposed parking spot. This means families sell cows or tracts of land in order to pay a business man nearly $100 USD to take them and their sick relative to the nearest health center, which doesn't even do operations. Some choose to use motorcycles as their means of transport but this has led to the community members being familiar with the ways in which to transport dead bodies on the back of motorcycles. It's still prohibitively expensive for most people to even use a motorcycle and by the time the money is collected, the patient's condition can have significantly worsened to the point where they die on the way to the next level of care. It's tragic and macabre that they can tell me their strategies for returning these dead bodies back to the village and it's due not to the road quality, but to poor organization and communication at the district health level and due to a lack of some kind of price regulation for transportation for sick people. It's perfectly within the means of the village government's authority to make a rule saying it is illegal to increase the price of transportation for sick people. If you would use 20,000 TSH worth of fuel to go and come back, then you want a profit, so maybe you charge 40,000 TSH or 50,000 TSH. There is no reason to charge 100,000 TSH or 150,000 TSH for a one way trip.   

The next month will be my last here in Sumbawanga before I move to Dar for two months before the end of my project. The remaining time will be for finishing interviews with nurses, doctors, and administrators, as well as those providers who have been working in the region since the 1980s or before. I am also currently trying my darnedest to collect data for a social network analysis but that is going slowly and can most accurately be described as herding cats. We shall see how it turns out, I think it will be extremely interesting if I can collect high quality data for it. Wish me luck! 

"Are your hands pregnant?"

My research assistant and I arrived in village 1 on Monday this past week. On the drive there (an adventure in and of itself the first time), I was expressing my concern about how we might be perceived and what kind of reception we might expect. Being the first village, I had nothing to compare it to and wasn't about to blame anyone for being suspicious of me. However, we pulled up to a small cluster of people and asked them if we had reached the right village and where we might find the village leaders. They pointed us to a cluster of people trickling out of one of the primary school classrooms, saying the village leaders were just not getting out of a community meeting. The second person we met was the Village Chairman. I began to explain to him what we were here to do and what I study. I told him we were there to learn about life in their community, the challenges they face, and how they view the quality of their health care services. He was extremely receptive and, in fact, very happy to hear that I had chosen them as a site for my research and the first village, at that. 

He took us over to the village dispensary and we went on a brief tour of the village. I explained how we would like to go about things and asked for his help in arranging some meetings. On Day 1, we met with members of the village's Community Health Committee and interviewed the two health providers who were present. For Day 2, we set up a group discussion with the community leaders in the morning and then a men's focus group discussion in the afternoon. On Day 3, we did a women's focus group discussion in the morning and a group discussion with older women, particularly those who, in the past, had been working as community ("traditional") birth attendants. 

I loved the conversations we had and the exchanges that took place. I learned a great deal and I hope I was able to help them at least a little bit with some health education and some answers about the ways in which the health care system operates. I was also able to help the health care providers assemble and start using some of the equipment they had been given several months earlier. One of my objectives with the providers was simply to listen to them about the challenges they face and the difficulties they have in their work in the community. They seemed grateful to simply have someone interested in listening to their problems. They told me "inatia moyo," basically it was encouraging. There is also a Swahili saying that when the visitor arrives, the local benefits. They were saying it, but I hope it was true, at least a bit!

Unsurprisingly, the opinions we heard from the men and the women were pretty opposing, in some instances. We asked a general question about the responsibilities of men and the responsibilities of women. Women told us stories about the hard work they do, telling us things like "You'll see a woman going to the field. In one hand she has her hoe, on her back a young child, on her head firewood, and she's probably even pregnant." They also told us that many women continue with this hard work even while they are pregnant and if they don't, if they ask for a rest or tell their husband they were too tired to finish all the work at home, their husbands will ask them, "Why can't you work? What, are you hands pregnant?" This can be dangerous for women and can, in some cases, even lead to pregnancy complications and possible miscarriage. The women told us that the men like to drink and some even get drunk in the mid morning. They do this instead of contributing more to the family, but the men are the ones who make the plans for the family and women are simply the receivers; on this account both the men and women agreed. 

On the topic of men's participation in reproductive health care, the women told us their husbands will accompany them to the dispensary if they are in labor, but only at night when they know no one else will see them doing this. Men said they thought it was important to accompany their wives to the prenatal clinic but, when the chips were down, only three of about twelve participants said they'd actually ever gone with their wives and out of nearly fifteen women, only three said their husbands had ever gone with them. There was also an issue, brought up by the women, of the men not believing their wives when they told them what they had learned at the prenatal clinic. Everyone generally agreed that this idea of men participating in women's health was a new thing and hadn't yet really caught on. 

We also learned about how the poor corn prices and the poor market last year had effectively stalled the community's effort to build a new, larger dispensary building specifically for reproductive and child health issues. We heard about bureaucratic difficulties, poor communication, and poor support from the district. We heard stories about past witchcraft and the difficulties women had giving birth in the community before the presence of the dispensary. We heard about how this thing called "human rights" had made children the children of the state and not their parents. Men perceived the concept of human rights as detrimental to their ability to effectively discipline their children, it has "taken away the strength of parents." 

Some of these issues are already well known and some of them are specific to this community, but I can already tell that this work in the villages will add necessary and beautiful background color to the work I've been doing in the regional hospital. I already had questions for the communities based on my time in the hospital and I have returned to the hospital with more questions for them based on what I've heard in the village. I think this iterative process is going to be very fruitful and will highlight further issues related to the health care system and how everyday people interact with it in times of crisis.  

This past week, a plethora of new experiences

I've now been hanging out here in Dar es Salaam for the last week and it has been alternately very busy and full of boring downtime. I started out, last Sunday, with the determined plan to work on some analysis of a questionnaire I'd had the nurses all finish before I left Sumbawanga and then I thought I'd catch up on typing up all my field notes since last June. Well, I'm happy to report I did manage to do the analysis, I have not yet typed even a single sentence of old notes. It's one of those jobs that seems to become intimidatingly huge the longer I let it go and, of course, I don't keep up with it on a daily basis because after 8+ hours at the hospital and interacting with people, the last thing this "outgoing introvert" wants to do is rehash it all through hours of typing up the handwritten scribbles of the day. I did, however, have several productive and fun meetings. I have been giving a Tanzanian friend some tips on developing a research proposal for his application to some PhD programs abroad and we met for a couple hours to discuss research design and methods, which I really do love. I then did some shopping for things I can only buy in Dar or for those that are about half as expensive here as they are in Sumbawanga due to the distance. I was also searching for an elusive A4 size side spiral bound notebook of more than 100 pages. It felt sort of like searching for a unicorn. A very nice Indian guy, whose company sources what sounded like pretty much all the office supplies in the country, told me people here don't like spiral notebooks because they get too hot in the sun. Hmm… but they are commonly used in India. I was hoping to find a more durable replacement for the maternity ward's admission book, which has been in use for over a year now and currently looks like this: OK, never mind, I'm not seeing at the moment how I add a picture in here. I guess that means I should include pictures more often so I don't forget how… Suffice it to say, the book is literally falling apart and has created some big problems on the ward. The ward Nurse In Charge was asked to collect data on a number of things from throughout the whole year and the state of this notebook meant she was unable to find data from whole months because all the pages had fallen out and been irreparably lost. 

So, at any rate, the notebook needs to be replaced, badly, and is nearly full. The In Charge sent one of the medical attendants from the ward to request a new notebook for this purpose, approximately two weeks ago. Therein ensued a long quest that was, ultimately, unsuccessful. I tried to help out by taking this old notebook to the supply office and the hospital's Assistant Matron to plead the case for a new notebook. Well, the Asst. Matron decided that we didn't deserve a new notebook because we had proven ourselves unable to "take care of the data," as she put it. First, before being granted a new notebook (which costs about 2000 TSH or less than $1.50), we had to prove we could "take care of the data" and preserve it for future use. She wanted us to somehow repair this dilapidated notebook before she would be willing to give us a new one. Yeah, right. First of all, there is no tape or glue that can sufficiently accomplish this task. Second of all, who the heck is supposed to use their valuable work time trying to put Humpty Dumpty back together again? I asked, nicely, if perhaps she had some clear tape that we might use for the purposes of reconstruction? She sent me to her office to ask the young woman assisting there to give me some. What does this woman come back with? Masking tape. Definitely not going to be able to read any data through that stuff! So I gave up. While I was in the office, I saw an entire box of unused AA batteries, like the ones we requested more than 2 months ago for the purposes of the fetal doppler/heart monitor and the wall clock. I'm willing to bet that while we wait for batteries, the ones in that box will be expiring, unused. Such is the state of things. That is all to say, if anyone has a creative idea of how to keep this notebook in better order, please do let me know. A ring binder with loose leaf that gets changed every month? That's what the guy at the stationary store suggested. Maybe we might just try it. We handwrite every patient's name, along with a variety of other info, for each person who is admitted to the ward, which amounts to somewhere between 300 and 600 women per month. Just think of how much use that means that notebook gets! Another case of the hospital administration not being willing to adjust existing parameters and bureaucratic guidelines to accommodate the reality of the maternity ward.

After that unicorn quest, I bought some new sandals at Woolworth's and ruminated on the cost of baby clothes that include locally (from South Africa) sourced cotton and how much better they looked and felt than all the super cheap stuff flooding the market from China. I then walked for several kilometers, eventually found the right daladala (hurray!) and made it to Muhimbili National Hospital to visit my friend who works in the Safe Motherhood Division of the Ministry of Health and Social Welfare and whose office is on the Muhimbili campus. We had a good conversation about several issues related to women's health and I got to see some of the upcoming things they are working on with other partners. Then is was the bus odyssey back to the hotel. I sat next to a very chatty guy who told me I could call him Pastor David and is looking for someone to help him grow his ministry outside of Tanzania. Any takers? Boy was he a talker. But he did have some interesting things to say about how women are treated when they go to the hospitals to give birth and why he felt nurses don't treat patients well. He told me what several other community members have, which is that nurses sometimes had few other career options and therefore do not really have a heart for their work but just do it for the salary. I can't even tell you the number of times I've heard this as a reason for the lack of compassion and caring on the part of nurses. I'm not convinced it's entirely true, though. Another friend, Canadian, told me she thinks the nurses who were trained during the Nyerere era have a much better attitude and work ethic because, back in those days, being in the health professions was valued and brought benefits with the position that no longer exist. People in those days entered into the profession because they felt called to do that work. I certainly think there's something interesting in that statement. We'll see if my upcoming interviews might lend any more credibility to that thought.

On Wednesday, I went to the US Embassy for my security briefing (don't go on Toure drive at night, you WILL be robbed, 100%) and to talk to the Fulbright coordinator and Public Affairs section people. I was also able to meet with the USAID contact I've been exchanging emails with for months. In the end, I came out with my security ID, a Fulbright Tanzania t-shirt (that everyone really likes, for some reason), a plan to join the American Club just for the use of the lovely, lap-size swimming pool, an invitation to dinner, and another for sundowners at the Dar es Salaam yacht club. Oh and a possible contact for someone who might want to rent my car while I'm not around. Great conversations all around and some good possibilities for future presentations and information sharing. And next time I'm allowed to bring my phone and my purse inside. I was caught entirely off guard when the security woman asked me if I needed anything from my purse. Fortunately I grabbed a pen. 

Thursday I hung out, went shopping for unnecessary things like a muffin tin and then ate gelato and watched a movie in a movie theater for the first time since the end of July. It was nice. And Hussein was back from Egypt, finally. Now, I am just waiting for my car from Japan to be ready to go. I certainly would have been drowning in this whole car extraction process if it hadn't been for Hussein and his friend Ally. It's overwhelming enough as is! Today we are trying to scramble around and get temporary plates, the registration card, insurance, and a once-over by the mechanic. Sounds overly ambitious for one day in Tanzania even to me, but fingers crossed I'll be on the road tomorrow for the 2015 cross-country road trip! Too bad I've already eaten most of the snacks I bought for the road… probably have to make another stop for some more of those. 

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...

General Life Update (because it's been too long since I last wrote)

Lots of things have been happening around here lately! In order to cover something in depth, I'm going to do a shorter, general update today and get back to a longer post, hopefully in the next week or so.

First, I am happy to report I have been awarded a Fulbright-Hays Doctoral Dissertation Abroad grant for this research! I found out last week and couldn't be more thrilled and grateful for the money and recognition. I am incredibly thankful for all my letter writers, proof readers, moral supporters and idea exchangers! Hopefully the money will start within the next month.

Second of all, for anyone who knows about my travails at the office of the Tanzania National Institutes for Medical Research, you will know how happy I am to have gotten the news today that my ethical clearance renewal certificate has finally been signed and is ready for pick up. This means, hopefully, that I won't have to deal with them again for quite some time! Hallelujah! They are my favorite bureaucracy to hate but I think they are trying to get themselves in order and I've seen some improvements in their communication and website of late. If anyone reading this ever needs advice on working with them to conduct medical research in Tanzania, let me know, I'm kind of an expert these days.

Third, one of my very good friends here and his wife just welcomed into this world a beautiful baby boy on Saturday. I'm so happy for them! Their three year old daughter seems to be excited about her role as a big sister, though she was dismayed when she was told she couldn't try to teach the baby how to read just yet.

I just finished writing the draft of a chapter for a textbook on maternal mortality which is set to come out next year sometime. I'm waiting for comments from the editor and reviewers but am very happy to have that off the docket for the moment. I am still working with the Medical Officer In Charge of the hospital to write a second chapter for the same book, which presents three case studies of maternal deaths that have occurred in the last year and offers some of our insights about how we might have prevented these deaths and what we need in the region in order to prevent similar deaths in the future. 

Since finishing the book chapter, I am back to collecting data again full force. Lots of good conversations in the last week and I've nailed down a research assistant who is diligently working to help me transcribe hours of recorded meetings, group discussions, and interviews. We're planning on going to some villages to talk with peripheral health care providers and community members starting within the next month. We have to get some trips in before the rains start again in November! 

My favorite unfolding line of inquiry at the moment has to do with uniforms. The maternity staff has been reprimanded by the hospital Patron (who is in charge of all the nurses) for not wearing proper uniforms. I think this deserves its own post so look for that later. It might not sound exciting but I think it actually encapsulates many of the challenges the nurses face, speaks to issues of provider morale and motivation, and the disconnect between maternity and the hospital administration. So, I'll leave you with that until next time! Back to the emails and transcriptions!

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.

Moving Targets and Frontline Care

“The system in place is almost stabilized and then they change everything again. It’s discouraging. You’ve already encouraged [the providers] and then tomorrow you do something else and then the day after something else.”

- Edina, Monitoring and Evaluation officer for an NGO working on maternal and child health

I was recently with Edina* and a team of others from the same organization in the Rukwa district of Kalambo while they were working on various parts of a maternal and child health improvement project. Edina was talking with one of the project’s program officers after we’d spent several days visiting small dispensaries in remote areas of the district. These dispensaries are part of the project and therefore are the recipients of what they call “supportive supervision” visits. I asked to tag along to see what supportive supervision is all about and if it might actually have a chance of helping improve services, given that those two words make it onto many action plans created during reviews of maternal deaths. We had two doctors, who are also basic emergency obstetric and neonatal care (BEmONC) teachers, a regional nursing officer, one program officer who is also a physician, and two district health administrators, including one district reproductive and child health coordinator, and me, the local anthropologist. We broke into two teams of three to four people and spent two days at a facility. The idea is to evaluate the facility in terms of equipment, infrastructure, support systems (pharmacy, lab, ambulance if available, etc.), and personnel knowledge. We had an evaluation “tool” or book, which had a number of standards, each with a number of sub-standards, broken down by topics such as normal labor and delivery, management of complications, post-natal care, and infrastructure. The facility then gets a score based on the number of “yes” answers they get when they meet the sub-standards. Missing just one sub-standard earns you a zero for the entire standard.

These dispensaries are the first line of care for hundreds of thousands of people throughout Tanzania. Each village dispensary that we visited serves between about 2,000 and 6,000 people, depending on if it serves more than one individual village. Many of these facilities are staffed almost exclusively by medical attendants, who are not generally considered skilled personnel. To give you an idea, the medical attendant on the maternity ward at the hospital largely assists in picking up supplies from the main pharmacy, preparing equipment for sterilization, and doing things like folding gauze to be used in delivery packs. She does not administer drugs, help deliver babies, or generally have much direct contact with the care of the women who come to give birth. In the village dispensaries, these same people are responsible for evaluating patient conditions, prescribing medications, ordering supplies, keeping a clean and organized facility, making decisions about referring cases to higher levels of care, and helping women give birth.

We did not visit one dispensary that scored higher than 10% on their evaluation and most scores were around 5%. The challenges in these locations are many and some staff members at the regional hospital like to blame maternal deaths on these providers. While in some cases this may be true, the situation is far more complex. The death of a woman who lives in town and dies in the hospital after giving birth surely cannot be blamed on these front-line care providers in the most remote settings. However, many women in the villages these dispensaries serve may see the poor quality of care and choose to give birth at home with the assistance of a local midwife or relatives and neighbors.

I spent two days at one facility that only has one staff member working although there are supposed to be three. One of the others has been away from her post for nearly a year claiming she has numbness in her hands that causes her to not be able to work. She has not yet been replaced. The other absent provider seems to spend his time in town waiting for the next opportunity to attend a training or seminar at which he will be paid a handsome per diem and have nearly all his meals provided for free. The only working staff person is a medical attendant. While she clearly tries extremely hard, running this type of facility would be a nearly impossible task for one person. The morning we arrived she hadn’t yet shown up for work and it was after 9am. Government health providers are supposed to start work at 7:30 am everyday. The one evaluator immediately noted the woman’s absent and the line of waiting clients. Soon the provider, Salome*, arrived explaining that a woman had given birth at 10pm the night before and she had spent most of the night attending her. That was why she was late arriving at the dispensary to start work for the day. It seemed reasonable to me. The evaluator was not impressed and urged Salome to be sure to get to work by 7:30am. We started with the evaluation process. The organization is particularly interested to see how much knowledge providers have retained after attending BEmONC training (Basic emergency obstetric and neonatal care), which is very comprehensive and generally is conducted over the course of 2 intensive weeks, 6 days per week. Initially, the organization had not included medical attendants in these trainings but then decided to open the trainings up to this lowest cadre in recognition of the fact that these are often the only type of provider at dispensaries.

When we were done evaluating Salome, we sat down with her to create an “action plan.” This action plan is meant to be created by her for her so she can set goals for herself to improve the care she provides. Instead, the evaluators were primarily responsible for generating the action points and the entire plan was written in English, a language Salome does not know. We spent more time debating the dates to put down on the “time line” for bureaucratic purposes than we spent on actually constructing a useful plan and enabling Salome to carry it out. Each short action point took nearly an hour to accomplish as we debated the English wording, the numbering, whether or not I should include the page numbers the action points referred to, what a viable “intervention” was, and what date we should write. I was writing because, I thought, given English is my first language it would be fastest if I took down the notes. I was sorely mistaken. In actuality, we were constructing a document for use by bureaucrats, meant to adhere to a cookie cutter form not sufficiently flexible to be adapted to the needs of each facility and its personnel. The one program officer refused to use Salome’s own words in the plan and insisted on re-wording her statements. One intervention was listed as reviewing support materials in order to better remember the treatment and signs of severe pre-eclampsia and eclampsia. We had a lengthy debate about the date to be indicated on the “timeline.” I argued we ought to say “immediate and continuous review” while the program officer ended up calling some other person in order to confirm that no, we MUST put down one single date. So we chose an arbitrary date two weeks later. It made no sense. Clearly this time line was not for Salome, as we told her, “you know what we really mean, you have to do this every day but we have to write a date, you understand.” This was a time line for the people in the office.

At the very end, Salome thanked us and said she just had two things she wanted to say. First, she asked that the leaders (meaning the district health administrators) receive her requests for support and her efforts to follow-up requests when she makes them. She said often she is met with people who do not care and act as though they don’t have time for her. Her second request was that the BEmONC training materials be made available in Swahili. All of the books, the checklists, the evaluation tool, all given to her in order to help support her and improve the care she provides, are in English, a language she does not understand. I told one of the doctors on the team I was surprised the materials weren’t available in Swahili. He and the program officer both said, “Swahili is hard! How would you say ‘complications of labor and delivery’ in Swahili? It takes up too much room!” So the shorter, more concise English has been used for these complex and crucial clinical and patient care techniques and guidelines. I said, “Yes but wouldn’t it be better if they were in Swahili, so everyone could understand them?” The doctor said, “So you think now they should spend the money to translate these materials all into Swahili and reprint them?” In my mind, that money would be well spent because it’s a one-time cost. Paying for BEmONC trainings for hundreds of people, per diems for the participants and the instructors, accommodations, food, transportation, stationary, all of these costs are repeated again and again. Then, many of these providers go back to their posts and 6 months or a year later score 3% or 5% on the assessment criteria, indicating they’ve retained virtually none of the information they were taught. Perhaps they were simply staring out the window or counting their per diem cash, letting the English float past their eyes and in one ear and out the other. There are deep flaws in the ways these programs are constructed. Despite excellent intentions, solid clinical grounding, and relatively good follow-up, these training programs don’t appear to be doing much good, at least in the facilities we visited over the last two weeks. It’s almost impossible to know if these programs have reduced maternal and neonatal mortality, as they were intended, because the data on these deaths, complications, and outcomes, are also deeply flawed and likely corrupted to the point of uselessness, but that’s a story for another time. The techniques for conducting best-practices and even accounting for and documenting deaths are constantly being changed by the national and local governments, as well as non-governmental organizations. Providers get used to one system and the next day a new person shows up to tell them about another way to do everything. These shifting targets are made more difficult to deal with due to poor organization, leadership, and communication at the level of district health administration and between the districts and higher levels.

*Names have been changed to protect the privacy of the research participants.