CRASSH

New Approaches to Maternal Mortality In Africa

Caroline Bledsoe (Melville J Herskovits Professor of African Studies in the Department of Anthropology, Northwestern University)

‘A drug of many uses’:  Misoprostol and the language of ambiguity in the ‘management’ of pregnancy and labour in the US and West Africa

This paper considers the complex international legal environments in which decisions are made about pregnancy and pregnancy termination in Africa. While maternal mortality rates are improving around the world, in Sub-Saharan Africa, birth itself remains a risky proposition (Hogan et al., 2011; Ross & Blanc, 2012). Of all the factors that contribute to this risk, haemorrhage remains the biggest killer.  Into this mix appeared Misoprostol, a drug developed and patented by the US pharmaceutical company Searle (later taken over by Pfizer), and approved by the US Food and Drug Administration (FDA) for treatment of gastric ulcers.  In the early 1990s Misoprostol was found to have uterotonic effects of great interest to obstetricians.  It could be used to dilate the cervix and to induce labour, qualities of special use when the life of the mother or baby is in danger, and to help expel the afterbirth.  As well, it could stop bleeding in a woman who was having a miscarriage or who was haemorrhaging after birth. It could even be used in the active management of the ‘third stage’ of labour, immediately after birth, to help prevent haemorrhage. It was soon found that the same uterotonic effects of the drug could also be used to induce an abortion. In many countries, Misoprostol is acquired by women who do not wish to proceed with a pregnancy, whether legally or otherwise. 

Misoprostol carries risks for mothers and children, and can cause side effects. Its abortifacient properties can produce consternation even in the most legally benign environments.  But the facts that it is so obstetrically effective – and, that it cheaper and easier to store than other similar drugs – have made a significant difference for the safety of birth in the poorest of settings, especially in Asia. Some health ministries, including that of Ghana, have even begun to dispense it as routinely in antenatal visits to pregnant women, with instructions for its use in the event that the women are unable to come to a clinic or receive help from a trained provider.  All this seems little short of miraculous in an era in which the cost for getting any new drug at all approved by the FDA is around one billion dollars, and in which research on drugs for the field of obstetrics – with its relatively low promise of lucrative payoff, in an aging population – has almost come to a standstill.

The oddity, however, is that for all the time that it has been around, across the world, Misoprostol has never been officially approved by the FDA for anything but the treatment of gastric ulcers (Chong et al, 2004).  All the obstetric prescriptions, programs, campaigns, and even statements by the manufacturer itself have recognized these uses, and the official drug approval agencies in a number of countries have approved it for use.  As far as the FDA is concerned, however, such uses are ‘off-label’:  not ‘illegal,’ but beyond its own regulatory domain. As far as the company is concerned, it might recommend certain uses, but the physician prescribes it at his/her own risk.

This paper explores an odd dialectic that has resulted in the case of Misoprostol. For places like Africa, the official voices express the language of obvious need – a drug with clear utility for saving lives and terminating unwanted pregnancies far more safely than before. On the US side, however, the language of ‘misuse’, ‘off-label’ use, and so on, seems to dominate, all in an environment in which there may be substantial benefits to major players in keeping the drug in legal limbo. Beyond that, the paper draws attention to the implications for pregnant and childbearing women in Africa, and their position in the high-stakes pharmaceutical industry.

Vincent De Brouwere (Professor of Public Health at the Institute of Tropical Medicine, Antwerp, Belgium)
Why and when did maternal mortality decline in modern societies?

From the 1930s onwards, maternal mortality sharply decreased in all western countries settling at a ratio of less than 10 per 100,000 live births in the 1970s and stabilising at this low level. The main explanation for such a decline is universal access to modern technology such as antibiotics, blood transfusion, anaesthesia and obstetric surgery.

Before 1937, maternal mortality levels displayed very different country-specific patterns. The reduction in maternal mortality paralleled increases in the intensity of the coverage by professional midwives with a clear contrast between the USA – with a staggering maternal mortality around 600-800 per 100,000 live births – and Sweden, Denmark, Norway and the Netherlands with a ratio around 250-300 per 100,000 live births. The sharp difference in the decline of maternal mortality can be attributed to a combination of several technical and political conditions that appear to have played a decisive role.

The first element is information about the magnitude of the problem and an understanding that it was possible to prevent maternal deaths. From as early as 1751, Sweden started compiling national vital statistics and this permitted it to measure maternal mortality ratios and to identify avoidable maternal deaths. In other countries such as Belgium (1830), England and Wales (1838), and the USA (1920) information on levels of maternal mortality became available later. Political willingness was however essential and in Sweden this arose due to pressure from medical leaders. The role of public pressure exercised through committees and associations would appear later in the early twentieth century in the USA and England and Wales.

The second element was the professionalization of childbirth. Professionalization meant the training of competent, accountable and autonomous providers of care. The strategic choice in Sweden was to train midwives. In 1829, midwives were authorized ‘after an extended training period to use forceps, sharp hooks and perforators, in addition to their ability to perform manual removal of placenta and extraction in breech presentation’. In 1881, antiseptic techniques were universally implemented by all midwives. However, in England & Wales and the USA, for instance, the training of midwives in modern obstetrical techniques was delayed until the beginning of the twentieth century.

The third element was the implementation of a scaling-up strategy for access to professional care. Those countries that managed to provide professional obstetric care to cover the whole population, including poor and remote areas, attained a relatively low level of maternal mortality earlier than others, achieving this before the advent of the era of modern obstetrics in the second half of the twentieth century.

Vikki Chambers (Research Officer in Africa Power and Politics Programme, Overseas Development Institute)
A comparative perspective of the political factors which shape maternal health outcomes in Malawi, Niger, Rwanda and Uganda

Despite recent improvements (in some countries), progress towards reducing maternal mortality ratios in sub-Saharan Africa overall lags considerably behind what has been achieved in other developing country regions. These continent-wide figures, however, hide disparities within and between countries. While general trends remain poor, some countries are doing significantly better than others. Over the last past three years, the Africa Power and Politics Programme has examined factors which shape maternal health outcomes in Malawi, Niger, Rwanda and Uganda. Drawing on local field research, the programme has explored how actors, institutions and resources have combined to overcome key bottlenecks which otherwise undermine the provision of services which contribute to good maternal health outcomes.

Findings from Rwanda indicate that it has made particularly impressive progress in ensuring safe motherhood, particularly in rural locations. Three key institutional features seem to drive this progress. The coherence of the policy environment has been a key element. In addition to aiding in the definition of lines of responsibility, it has facilitated the avoidance of overlapping mandates which usually encourage actors to pass the buck for service delivery failures. Secondly, laxity in professional standards and related problems ensuing from lack of motivation have been overcome through the use of upward accountability mechanisms that serve as strong deterrents against misconduct by actors responsible for service provision. Accompanying performance pressures have been consistent, with rewards and sanctions that ensure that all actors work toward the same objective of providing high-quality services. Finally, a crucial element has been the facilitation of interactions through which different actors, including users, can work together to overcome key bottlenecks.

This presentation will explore these findings in more details, with specific reference to fieldwork in the rural districts of Nyamagabe and Musanze in Rwanda. It will also provide a comparative perspective by examining the Rwanda research findings alongside those from Malawi, Niger and Uganda.
 

Rachel Chapman (Associate Professor at the Department of Anthropology, University of Washington)
Maternal Mortality, HIV/AIDS and the New Counter-Geography of Survival in Central Mozambique

HIV played an unexpected role in causing an estimated 20% of maternal deaths in 2008.  Yet globally, few HIV-positive pregnant women and fewer HIV-exposed infants receive life-saving ARV treatment.  Hypotheses range from ‘service operations failure’ focusing on systems operation and provider-related barriers at clinic level, to behavioralist speculation about stigma and other socio-cultural factors in deterring women from accessing services.  Neither approach is adequate. Both ignore structural adjustment policies which erode social safety-nets and shift the cost of social service from the public sphere back to the domestic sphere through privatization, fees-for-services and removal of subsidies on basics. Scale-up of AIDS treatment exposes neoliberal policies and conditions that imperil women everywhere, especially food insecurity and inadequate top-down, disease-specific responses to HIV/AIDS.  I propose a ‘repoliticization’ of both frameworks to analyze AIDS-related maternal mortality, health systems collapse and AIDS-related stigma as tangible consequences of failed trickle-down economics.  Ethnography reveals economic austerity engenders significant micro-level changes, as individuals reorganize around depleted household resources.  This ‘counter-geography of survival’ includes birthing outside biomedical surveillance, defining health from embodied experience and participation in ‘face-to-face reciprocities’ of lively churches that decommodify healing in powerful ways. While churches may sometimes keep those who are sinking ‘barely floating’, they cannot substitute for the social security system of the modern welfare state. As unprecedented resources flow from the global-north to the global-south, urgent work must involve improving PMTCT/ART services and provision of all PMTCT/ART services as part of quality, comprehensive women’s health programs while strengthening overall public health-care systems.

Kusum Gopal (UN expert for South Asia, East Africa and the MENA region)
A woman exists solely to give birth: understanding the culture of maternal health in Dodoma Tanzania

The Pilot  Ethnographic Project was specifically formulated and undertaken for UNESCO for DElLVERING AS ONE’ UN Joint Programme 2 to produce a reliable, gender-sensitive social cultural blueprint aimed to reduce maternal mortality and neonatal deaths. The health of ‘biological’ individuals in the context of their environments and indeed, social and cultural relationships therein - such details have thus far, often, been overlooked in biomedical research but, inevitably have a critical bearing on all forms of health; research and intervention need to be recognised as social and cultural processes. n formulating this pilot project we have sought to broaden the insights from these scholarly researches, as also, reflected upon the lessons from the many national and international agencies committed to community-based participatory programmes for over three decades  – because maternal and neonatal deaths have continued to rise. Hence, the exclusive reliance on models based upon statistical and demographical principles for measuring the human condition is not adequate. After all, human beings are not effects of molecular and neuronal causes of genetic determinism with fixed traits but, are formed from relationships which in their activities they create anew. Also, it must be borne in mind that human beings the subjects of statistical measurements are never cognitively imprisoned by pre-ordained, predetermining schemata especially, when operating in a world without guarantees. This paper discusses the diverse social and cultural influences that inform the lives of women, men, girls and boys. It examines in-depth all aspects of women’s health and status associated with pregnancy and childbirth and, neonatal care with a view to informing stakeholders both in communities and, among health practitioners about what local populations are doing, thinking and saying on maternal and neonatal care whilst recording the experiences of government health personnel, the condition of the health services and the interactions between the communities. It also explores the practice of medical care and, the training of health workers’ and their education. The health workers who were trained concentrated on the experiential weight of human understandings, in particular, those voiced by pregnant women, their families and, the various problems they encounter in their environments, as also their access to and, treatment at the health facilties as indeed, the anxieties and understandings of the health workers – all grades on levels of professional training, nature of health care – on what is possible and what is not possible in their administration of medical assistance.
 

Wendy J Graham (Professor of Obstetric Epidemiology at the School of Medicine and Dentistry, University of Aberdeen; Senior Research Advisor, Department for International Development)
Maternal mortality: evidence gaps and measurement traps

Since May 2010, four different sets of global and regional estimates of levels and trends in maternal mortality have been published by two different constituencies – the United Nations Inter‐agency group (WHO et al, 2010; WHO et al, 2012) and an academic group (Hogan et al, 2010; Lozano et al, 2011). The estimates are broadly consistent in terms of three headline messages: a decline in the overall magnitude since 1990, the recognition that MDG5 will not be met by 2015, and the disproportionate concentration of poor progress in the sub‐Saharan Africa (SSA). This consistency is reassuring given the different modelling approaches adopted to estimating levels and trends in countries with poor or no empirical data, also mostly in SSA (AbouZahr, 2011). However, such a macro‐perspective to measuring and reporting mortality continues to mask the marked and growing differences between and within countries, and distracts attention from strengthening local information sources most relevant to preventing further deaths (Byass, 2011).

'What you count is what you do' is a simple phrase which has long‐been applied to the field of maternal mortality, and captures the vicious cycle of poor data and poor action. This cycle was described over 20 years ago as the measurement trap (Graham & Campbell, 1992)– highlighting how limitations arising from the conceptualisation of maternal health, definitions, data sources and indicators, have major consequences for policy, programmatic and clinical interventions to help reduce the burden of preventable maternal deaths. This presentation will explore the modern day implications of the measurement trap, with particular reference to SSA. The aim will be to highlight key blind spots or evidence gaps with significance both to the emerging post‐2015 action agenda and for the engagement of the global academic community.

Grace Bantebya Kyomuhendo (Professor at School of Women and Gender Studies, Makerere University)
Why Interventions so often Fail: Fractures and Continuities in Cultural and Gender Drivers of Maternal Health in Africa

Jean Michel Massing (Professor of Art History in the Department of History of Art, University of Cambridge)
From Birth to Death in Africa: 16th to 18th Century Testimonies

In this paper, I will consider how a Dutch traveller, Pieter de Marees, in his ‘Description and Historical Account of the Gold Kingdom of Guinea’ of 1602, described the life of women from the coastal area of Ghana, from birth to death, including childbirth and maternity mortality, but also what interested him more, the nature of the skin colour of Africans, from birth to old age. This will be followed by later discussions, especially of the importance of semen for skin colour. This euro-centrist argument will be followed by an account of African visual testimonies, through sculptures of women and of mothers and child from the Dogon of Mali, and a funeral group from Sierra Leone, all from the same time span. The first example will show the difficulty of the task, partly because of the highly secret array of practices, especially in the women's sphere; the second example, however, shows that the historian can sometimes recover the original meaning of a work without immediate context by looking at later traditions.
 

Godfrey Mbaruku (Deputy Director of the Ifakara Health Institute, Tanzania)
Health Systems/ policy towards reduction of maternal and neonatal deaths

Maternal mortality in most sub-saharan countries remains obstinately high. In Malawi, for example, the maternal mortality ratio is 1000 whereas in the United Kingdom it is 13 per 100,000 live births. Whereas there has been a steady decline in maternal mortality in Europe over the past 60 years, in Africa even long periods of stability and increases in health spending have had little apparent effects. Incidentally, in countries with civil strife or immediately afterwards, the maternal and neonatal mortalities are exceedingly high. Also, it is a well-known fact that 99% of all these deaths occur in low income countries and Sub-Saharan Africa contributes to the largest share. Furthermore, for each maternal death, morbidities are estimated to be more than 40 times.

The UN has set a target for maternal case fatality rate of less than 1%. Less than 50% of women in low-income countries are attended by skilled personnel, yet life-threatening complications that require emergency care will arise for around 15%. Neonatal mortality is 12 times higher than maternal mortality and accounts for 7 million deaths; about 3 million babies are stillborn and 4 million die in the neonatal period. The major causes of deaths in mothers are haemorrhage, sepsis, obstructed labour and hypertensive disorders and in newborns infection, pretem births and asphyxia.

Models of healthcare that have been developed in Europe, based on highly trained specialists using complex technology and an abundance of other healthcare workers, are unlikely to be a practical way forward or sustainable in sub-saharan Africa. Hence, alternatives forms of care, such as the utilization of middle level cadres must be sought. Also, the interventions to manage almost all of the major causes which have been known for years, is not rocket science. However it seems that the persistence of this problem has tasked mankind for many years.

Most of the programs geared towards reduction of the burden apart from being too few have nearly always been at most in individual countries or projects. The successes recorded have not been translated into other sites and hence their total effects remain at most insignificant. Priorities shifting have been the order of the day, ranging from the emphasis in antenatal care, use of traditional birth attendants to skilled healthworkers but to no avail. Furthermore, it seems that there exist other contextual factors which are specific to individual areas which are responsible for this lack of wider applicability.

While there has been a significant gain towards the achievements of the millennium development goals 4 and 5, the major effects have been in child mortality while maternal mortality has remained insurmountable. At any rate, the prospects of achieving the Millennium development targets is beyond the reach of the majority of high burden countries and even the progress towards this goal has been slow and may take many years to come by. Fingers have been pointed to poverty with concomitant poor health systems as the major underlying causes, although there are examples of few countries which in spite of being poor, have demonstrated tremendous gains in this aspect. This finding brings the confusion as to what is actually needed or works in reducing this dilemma. It seems likely that while there is no crystal ball (or magic bullet), efforts must continue at all fronts in order to reach a stage where the relentless loss of lives will be a thing of the past.

Ashley Moffett (Professor of Reproductive Immunology at the Department of Pathology and Centre for Trophoblast Research, University of Cambridge)
How does the mother’s immune system affect the outcome of pregnancy?

The immune system is important in pregnancy because the mother and her baby are genetically different individuals; the baby has inherited half of its genes from the father. Our immune systems function by recognizing non-self or anything different from a healthy self cell including the non-self paternal genes present in both the baby and its placenta, also formed from fetal cells.

The hypothesis we are testing is that maternal recognition of the paternal non-self on the placenta by the uterine immune system regulates placentation and, in particular, blood flow to the placenta and fetus, and thus birth weight.
Pivotal to this idea is the placenta and the key role that placental cells (trophoblast) play in tapping into the maternal blood supply and transforming the uterine arteries.  Balanced placental trophoblast invasion is crucial in achieving the optimum maternal blood supply so that babies are big enough to be healthy at birth, but not too big to pass through the birth canal.  Pregnancies at the extremes where trophoblast invasion is either too vigorous or too limited are responsible for much of the maternal mortality seen in sub-Saharan Africa; where the blood flow is severely reduced, the mother is at risk of pre-eclampsia and, if the baby is very large, obstructed labour and post-partum haemorrhage occur. 

How does the immune system regulate placental trophoblast invasion so that the baby grows to a good size but not too large to pass through the birth canal?  

Uterine immune cells known as Natural Killer (NK) cells have receptors capable of recognizing paternal non-self molecules (known as HLA) present on the invading trophoblast cells.  This is maternal immune recognition of the fetal placenta.

Of interest is that both the genes encoding the maternal NK receptors and their HLA binding partners on the ‘non-self’ placenta, are highly variable.  Each woman inherits her own particular variants of the NK receptors and the baby inherits just one of a range of potential non-self HLA genes from the father.  Thus, the combination of maternal NK receptors and their HLA fetal ligands potentially differs in each pregnancy.  Our results show that there are particular maternal/fetal genetic combinations associated with high-risk pregnancies.

Because of the great diversity of these NK receptor and HLA genes, the study of these genetic variants can inform past history of migrations and evolution of human populations. The question arises, therefore, whether the high frequency of maternal and neonatal mortality in sub-Saharan Africa due to pre-eclampsia and obstructed labour (and their complications) is reflected in particular African variants of NK receptor and HLA genes? 
 

Annettee Nakimuli (Obstetrician; Lecturer and PhD student in the Department of Obstetrics and Gynaecology, Makerere University)
Maternal Mortality in Africa: Experiences of a Ugandan Obstetrician

I am an Obstetrician working at Mulago Hospital in Kampala. This is the largest Hospital in Uganda with 32,000 deliveries a year. Of the 80-100 deliveries every day, normally 20 are delivered by caesarian section. There are generally 4 maternal deaths in a week and the main causes are post partum haemorrhage, pre-eclampsia/eclampsia, puerperal sepsis and complications of abortion. A quarter of these women are under 18 years of age. Obstetric fistula following obstructed labour is common among those who survive death. The reasons for performing caesarean delivery are numerous but the common ones are: prolonged/obstructed labour, repeat caesarean sections, preeclampsia/eclampsia and fetal distress.

The hospital facilities are completely inadequate for this work load. Insufficient beds means that women are normally on the floor mattresses and all the corridors are lined up with women waiting. The theatres are always in operation meaning that sick women experience delays in essential surgery. Our day starts at 8:00 am with an audit meeting followed by a ward round in the labour ward that usually lasts 4 hours. Our aim at these rounds is to review clinical progress of the admitted mothers and to prioritize those on the theatre list for emergency surgery. There are four doctors, including one obstetrician, and one anesthetist available in each 12 hour shift to perform difficult deliveries and caesarian sections. The antenatal clinics also have heavy loads of mothers which makes it difficult to prioritize those who are high risk for pregnancy complications.

A common and frustrating occurrence is that women present too late due to transport and financial problems. There is also little understanding that the early mild symptoms of pre-eclampsia herald a life threatening disorder that is only prevented by urgent delivery. The large number of women requiring blood transfusion is also a problem. Shortage of midwives means that patients are reviewed infrequently over the critical delivery period. Significant progress has been made in combating malaria and HIV/AIDS, which have in the past been major causes of maternal mortality.

Balancing patient care, training of medical students and research is very challenging. I am doing a doctoral research on the immune-genetics of pre-eclampsia. My research has highlighted areas that we should focus on to understand the causes of this maternal mortality and morbidity. Records are poor and epidemiological data are lacking. It was difficult to find out basic obstetric data such as the birth weight distribution and the pre-eclampsia/still birth rates. In Uganda as a whole only 30% of births are registered. Maternal and perinatal death reviews have been instigated and these should highlight preventable causes and how practice can be changed.
 

Karen Rosenberg (Professor and Chair at the Department of Anthropology, University of Delaware)
The evolutionary background to modern human birth constraints and maternal mortality

The high rates of maternal mortality that we see today in Africa and other parts of the world, have a number of causes, many of which undoubtedly are the outgrowth of various aspects of the range of modern lifestyles and economic inequality. Some of these probably arose about ten thousand years ago when humans began to practice agriculture and some are even more recent developments. However, at least some of the causes of maternal mortality have much deeper roots in our evolutionary heritage. We know that childbirth in humans and our ancestors is more complicated than in other apes and that these complications are associated with greater risks to both mothers and infants.  In this paper, I will explore the deep evolutionary origins of the constraints imposed on human form (for both mothers and infants) during the birth process in order to understand when, how and why humans began to give birth to large-bodied, large-brained but helpless babies in the complicated, risky, awkward and uncomfortable way that we do. That is, I will provide the evolutionary context for our current pattern of childbirth, including high levels of maternal (and infant) mortality but also including the typically human habit of attendance during birth. Some of the most common causes of maternal and infant mortality and morbidity, such as cephalopelvic disproportion, post-partum hemorrhage, shoulder dystocia, pre-eclampsia or fetal oxygen deprivation are direct consequences of the balancing of constraints that simultaneously act on human female anatomy, the mechanism of childbirth and on human infant development and anatomy. 
 

Philip Steer (Emeritus Professor in Obstetrics and Gynaecology at the Faculty of Medicine, Imperial College London)
What are the influences of maternal ethnic background on obstetric outcomes in London Hospitals today?

‘Ethnicity’ relates to factors such as culture, language and beliefs. It is different to ‘race’, which refers to differences in physical characteristics associated with distinct populations identified by heritable phenotype or geographic ancestry. The race/ethnicity mismatch hypothesis suggests that nutrition and the environment (‘ethnicity’) have a long-term influence on racial evolution, and rapid changes in ethnicity can disadvantage some racial groups.

Between 1988 and 2000 we collected detailed obstetric data from all women delivering in 17 maternity units in the old North West Thames region. They included 362,630 white Europeans, 17,095 black Africans, 14,557 black Caribbeans, and 66,409 South Asians. The perinatal mortality was 50% higher in the South Asians compared with the white Europeans, and almost doubled in the black Africans and Caribbeans. Social and cultural factors were not sufficient to explain these differences.

We know that some genetic conditions vary substantially between races, for example sickle disease is particularly common in West Africans. We and others have shown that the fetuses of black African and South Asian mothers mature more quickly and that the physiological duration of their pregnancies is approximately 1 week shorter than in white Europeans. The very high rate of passage of meconium (fetal bowel contents) into the amniotic fluid in black African fetuses is a phenomenon associated with earlier maturation of the bowel. Different growth rates result in important variations in the gestation at which perinatal mortality associated with postmaturity starts to rise. Earlier maturation of the fetal lungs in blacks and South Asians means that elective Caesarean sections should probably be carried out at least a week earlier in black Africans and South Asians than in white Europeans.

The narrower pelvis in black Africans aids stability when running, and probably accounts for some of the success of black Africans in athletics, particularly sprinting. However, this leads to more difficult childbirth and much higher rates of maternal birth trauma, such as obstetric fistula. This is reflected in the higher Caesarean section rates seen in black Africans in developed countries, compared with white Europeans.

White Europeans have on average the largest babies, with those of black Africans being almost 200 g smaller, black Caribbean's 250 g smaller, and South Asians 300 g smaller, despite correction for gestational age at birth, and the size of the mother. The incidence of gestational diabetes increases much more rapidly with advancing maternal age in black Africans and South Asians than in white Europeans, and with increasing body mass index in South Asians. The association of high BMIs with overweight babies is particularly marked in South Asian women with gestational diabetes.

Megan Vaughan (Smuts Professor of Commonwealth History and Director of the Centre of African Studies, University of Cambridge)
Moral responsibility, accountability and maternal death in Central Africa: a historical approach

Historically, Central African societies recognised the dangers involved in childbirth and attempted to mitigate these. Though the learned practical skills of ‘traditional’ midwives  and birth attendants were no doubt effective in a proportion of cases, we know from the historical and comparative literature that in the absence of specific technologies and techniques, maternal death rates were almost certainly high. Ongoing biomedical research may reveal that the incidence of conditions such as eclampsia, was in fact higher than we have assumed. But maternal deaths were not regarded as inevitable. Powerful moral discourses operated that linked personal conduct, and particularly sexual transgression on the part of women and sometimes of their husbands, to maternal and infant deaths.  Midwives played a part in extracting ‘confessions’ from women experiencing complications of labour, and deaths were frequently explained in terms of a woman’s refusal to confess adequately. In practice, this system of assigning responsibility was more flexible and more ‘forgiving’ than this narrative implies, but childbirth was, nevertheless, a process imbued with moral as well as physical dangers.

In this paper I briefly examine the workings of these moral discourses around childbirth and discuss them in relation to both the on-going debate around the role of traditional birth attendants in present-day Africa, and the systems of professional accountability to which medical personnel are now, in theory, subject. In the process I am trying to explore how longstanding narratives of guilt and moral responsibility around childbirth reappear in new forms. 
 

Jonathan Wells (Professor of Anthropology and Pediatric Nutrition at Institute of Child Health, UCL)
The obstetric dilemma: an ancient game of Russian Roulette, or another fine mess that agriculture got us into?

The difficult birth process of humans, often described as the obstetric dilemma¹ is commonly assumed to reflect antagonistic selective pressures favoring neonatal encephalization and maternal bipedal locomotion. However, the dilemma is not exclusive to humans, and is present in some primate species of smaller body size. The fossil record indicates mosaic evolution of the obstetric dilemma, involving a number of different evolutionary processes. The dilemma appears to ease between Australopithecus and Pleistocene Homo, only to increase again in recent human populations. Most attention to date has focused on its generic nature, rather than on its variability between populations. We re-evaluate the nature of the human obstetric dilemma using updated hominin and primate literature, and then consider the contribution of phenotypic plasticity to variability in its magnitude. Both maternal pelvic dimensions and fetal growth patterns are sensitive to ecological factors such as diet and the thermal environment. Neonatal head girth has low plasticity, whereas neonatal mass and maternal stature have higher plasticity. Secular trends in body size may therefore exacerbate or decrease the obstetric dilemma. The emergence of agriculture may have exacerbated the dilemma, by decreasing maternal stature and increasing neonatal growth and adiposity due to dietary shifts. Paleodemographic comparisons between foragers and agriculturalists suggest that foragers have considerably lower rates of perinatal mortality. In contemporary populations, maternal stature remains strongly associated with perinatal mortality in many populations. Long-term improvements in nutrition across future generations may relieve the dilemma, but in the meantime, variability in its magnitude is likely to persist.

Claire Wendland (Associate Professor at Departments of Anthropology, Obstetrics & Gynecology, and Medical History and Bioethics, University of Wisconsin-Madison)
Explanations and uncertainties surrounding unsafe motherhood in Malawi

In much of southeastern Africa, including Malawi, numbers of maternal deaths appear to be unusually high despite decades of monitoring and programmatic intervention – both by states and by non-state organizations. The problem is broadly recognized both in scholarly literature and in the word on the street. However, clinical, epidemiological, policy and epistemological uncertainties mean there is no single widely accepted explanation for it. In that gulf, explanatory narratives proliferate among those charged with caring for pregnant women. 

My research uses those narratives to consider what constitutes reliable evidence on maternal death, what makes certain kinds of knowledge count as expert, how various experts weave stories out of what they do and do not know, how those stories are then put to work: how imaginative worlds lead to certain kinds of pragmatic action. I draw from interviews and from ethnographic observations at hospitals, health centres, and the dense peri-urban settlements where the magnitude of maternal death appears to be worst in Malawi. Several case studies of maternal deaths help to illuminate how various scales of uncertainty may interact to allow many different plausible explanations of the same problem – or even of the same individual’s death. This work explores the explanatory narratives put forth in response. I examine narratives by a wide range of people considered experts in various communities, including traditional healers who provide treatments that make pregnancies ‘stay’, birth attendants (azamba), nurse-midwives, clinical officers, policy makers and others. 

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