Managing Motherhood, Managing Risk: Fertility and Danger in West Central Tanzania

by Denise Roth Allen

Overview

An investigation of the consequences resulting from fertility-related development interventions in Tanzania

Product Details

ISBN-13:	9780472022588
Publisher:	University of Michigan Press
Publication date:	10/22/2009
Format:	eBook
Pages:	328
File size:	2 MB

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Managing Motherhood, Managing Risk

Fertility and Danger in West Central Tanzania

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By Denise Roth Allen

University of Michigan Press

Copyright © 2004 Denise Roth Allen
All right reserved.
ISBN: 9780472030279

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CHAPTER 1
Motherhood as a Category of Risk

Mrs. X died in the hospital during labor. The attending physician certi‹ed that the death was from hemorrhage due to placenta previa. The consulting obstetrician said that the hemorrhage might not have been fatal if Mrs. X had not been anemic owing to parasitic infection and malnutrition. There was also concern because Mrs. X had only received 500 ml of whole blood, and because she died on the operating table while a caesarean section was being performed by a physician undergoing specialist training. The hospital administrator noted that Mrs. X had not arrived at the hospital until four hours after the onset of severe bleeding, and that she had several episodes of bleeding during the last month for which she did not seek medical attention. The sociologist observed that Mrs. X was 39 years old, with seven previous pregnancies and five living children. She had never used contraceptives and the last pregnancy was unwanted. In addition, she was poor, illiterate and lived in a rural area.

—World Health Organization,

"Helping Women off the Road toDeath"

The questions start with how people explain misfortune. For example, a woman dies; the mourners ask: why did she die? After observing a number of instances, the anthropologist notices that for any misfortune there is a fixed repertoire of possible causes among which a plausible explanation is chosen, and a fixed repertoire of obligatory actions follow on the choice. Communities tend to be organized on one or another dominant form of explanation.

—Mary Douglas, Risk and Blame

I first heard the story of Mrs. X in February 1988 during an afternoon talk in the School of Public Health at the University of California, Los Angeles. The guest speaker, a senior medical officer from the World Health Organization (WHO), had come to speak to graduate students about the recently launched Safe Motherhood Initiative, an international effort to address the problem of maternal mortality in the "developing" world. "From the very beginning, even before labor began," the speaker told us, "Mrs. X was on the road to death." The challenge, as he put it that day, was getting her off that road. Projected onto the large overhead screen before us was a hand-drawn image of a downhill road. At the bottom of the road were two stick figures holding a stretcher on which lay a stick figure corpse, Mrs. X. And handwritten at several intervals along this downhill road were the various key dramatic points of the story: "placenta previa"; "anemia"; "several episodes of bleeding during pregnancy"; "39 years old"; "unwanted pregnancy"; "illiterate"; and so on. We were then asked as a group to determine the cause of Mrs. X's death.
Eight months later I again came across the story of Mrs. X as I was browsing through a WHO publication (1986). I had just begun doctoral studies in anthropology and was researching a paper for a class on health problems in Africa. Remembering the story of Mrs. X, I decided to focus my paper on maternal mortality.
I encountered Mrs. X a third time, three years later in June 1991, at the Eighteenth Annual National Council for International Health Conference in Arlington, Virginia. The theme of the conference was "Women's Health: The Action Agenda for the 90's," and Mrs. X was once again in the limelight. After presenting Mrs. X's medical and social history to the audience, the keynote speaker thoughtfully posed the following question: "Why did Mrs. X die?"
Mrs. X achieved a certain amount of notoriety during the first decade of the Safe Motherhood Initiative (1987–97). Versions of her story were recounted in international journals and conference keynote speeches, developed as the central theme in advocacy videos and classroom lectures, and used in training workshops to sensitize health-care workers to the multiple causes of preventable maternal deaths. Although we were not told what country she actually came from, certain key phrases— "poor, illiterate, and lived in a rural area," "anemic owing to parasitic infection and malnutrition," "seven previous pregnancies and five living children"—were hints to the audience that she didn't reside in any Western industrialized nation. She was a "developing country" woman, and through her story we came to understand the experiences of all pregnant women labeled as such.
The "road to maternal death" was another concept widely invoked during the first decade of the Safe Motherhood Initiative. Often shown in conjunction with the story of Mrs. X, the road served as a visual summary of the causes of and solutions to maternal mortality. Signposts along the road reminded the audience of the four main factors that contributed to Mrs. X's death: life-threatening complications, excessive fertility, high-risk pregnancy, and poor socioeconomic development. Another set of signposts along the road indicated the policies and programs that would have enabled Mrs. X to exit that road. Those exits included curative and preventive measures such as first-referral-level obstetric service, community-based maternity services, family planning, and the implementation of social policies to raise the status of women.
Without question, Mrs. X's death is a tragic one; I still remember how deeply her story moved me the first time I heard it in 1988. But since completing my own research on women's pregnancy-related experiences in a rural community of west central Tanzania, I have come to see the short account of her death in a different light: as a story that shapes and then freezes this unfortunate woman's experiences—and thus, by extrapolation, the experiences of all women she is supposed to represent—into a particular representation of facts. It is, ultimately, a story that conceals more than it reveals.
For example, although we are told that the social and demographic characteristics of Mrs. X's life—her unwanted pregnancy, her illiteracy, her poverty, her rural address—contributed to her demise, we are not offered much insight into how they did so. Nor are we told anything about the context in which decisions that affected her survival were made. Instead, we are presented with a partial telling of the events that led to her death, one that seems crafted to suggest that the "real" solutions to the problem are, for the most part, biomedical.
But what if we asked different kinds of questions about Mrs. X's death; would it change our perception of the problem? For example, by the title she is given—Mrs. X—we can assume this woman was married. What about unmarried women? Are their health issues different from or similar to those of the married Mrs. X? We also learn that Mrs. X was "illiterate." If we limit our questions to what happened once she arrived at the hospital, had she been able to read, would she have gotten better care? Mrs. X's story reveals that she came to the hospital four hours after the onset of bleeding. What was the cause of that specific delay? Her story notes that she hadn't sought medical attention for the bleeding during her pregnancy. Why hadn't she? Was her "illiteracy" the reason she had not sought medical care, or had she gone to her local clinic but been turned away by nurses? We learn that Mrs. X never used contraceptives. Do we know why? Could it be that she had tried several times, but the only method available at her local clinic always made her sick? We are told that this last pregnancy of hers was unwanted. How do we know that? We have already been told that she arrived at the hospital in serious condition and died on the operating table. When did anyone have time to ask her if she had wanted to be pregnant at all?
What if we learn that Mrs. X was actually from a rural part of northern India; would our understanding of the factors that contributed to her death begin to change? Or if we learn that she came from southern Sudan? From an urban setting in postwar Liberia? From a village in Tanzania? Would the causes of her death and thus the solutions to "the problem" be the same? What if we learn that she was actually from rural Kentucky, couldn't afford medical insurance, and that the "physician undergoing specialist training" was a resident working at the county hospital who had been working nonstop for the past thirty-two hours? Would the definition of the problem and thus the proposed solutions change?
In Writing Women's Worlds, Lila Abu-Lughod (1993:7) cautions against a homogenization of women's experiences, what she calls a "trafficking in generalizations." A language that abounds in generalizations, she notes, forms "part of a professional discourse of objectivity and expertise, [and thus] it is inevitably a language of power. It is the language of those who seem to stand apart from and outside of what they are describing" (8). Drawing from Dorothy Smith's (1987) critique of sociological discourse, Abu-Lughod continues:

This seemingly detached mode of reflecting on social life is actually located: it represents the perspective of those involved in professional, managerial, and administrative structures, and its origins lie in the management of internal social groups like workers, women, blacks, the poor, or prisoners. It is thus part of what [Smith] calls "the ruling apparatus of this society." (1993:8)

Others have called attention to the use of trauma stories in the popular media and development literature (Kleinman and Kleinman 1996). Kleinman and Kleinman point out that such stories, although usually based on real-life events, homogenize human experience, reducing the complexity of people's everyday experiences to "a core cultural image of victimization," an image that is then used to "rewrite social experience in medical terms" (1996:10; Scheper-Hughes and Lock 1987).
Within the international health and development literature specifically, "third world" or "developing country" women as a category are often depicted as thinking, feeling, believing, and responding in similar ways (Kabeer 1994; Mohanty 1991; Parpart 1993; Sen and Grown 1987). This homogenization of experience also has practical consequences: it can lead to the development of generic policies and programs in the belief that what works in one third world locale will surely work in another.
The Safe Motherhood Initiative: Unfulfilled Expectations
Maternal mortality reemerged as an issue of international public health concern in the mid-1980s with the publication of the article "Maternal Mortality—A Neglected Tragedy: Where Is the M in MCH" (Rosenfield and Maine 1985). In that article, maternal health advocates Allan Rosenfield and Deborah Maine from the Center of Population and Family Health at Columbia University called health professionals, policymakers, and politicians to task for neglecting mothers in maternal and child health programming:

It is difficult to understand why maternal mortality receives so little serious attention from health professionals, policy makers, and politicians. The world's obstetricians are particularly neglectful of their duty in this regard. Instead of drawing attention to the problem and lobbying for major programmes and changes in priorities, most obstetricians concentrate on subspecialities that puts [sic] emphasis on high technology. By reviewing the issue here we hope to stimulate those concerned with international health and doctors and policy makers in developing countries to make reduction of maternal mortality one of their priorities. (Rosenfield and Maine 1985:83)

In November 1985, four months after the publication of Rosenfield and Maine's article, WHO hosted the Interregional Meeting on the Prevention of Maternal Mortality at WHO headquarters in Geneva, Switzerland. The meeting brought maternal health professionals, researchers, and policymakers from twenty-six countries and agencies together to review factors that contribute to maternal mortality in developing country settings (WHO 1986). From the perspective of the various experts attending the meeting, risks to maternal health were defined in terms of the medical, reproductive, and socioeconomic factors that contribute to the high rates of maternal mortality in many of the world's poorer countries. They noted that a woman's age, her physical health, the number of her previous pregnancies, her socioeconomic status, and her desire to be pregnant all had a bearing on whether or not she would survive a given pregnancy. The physical distance from a woman's home to a health center or hospital was also identified as an important factor that affected whether or not she would survive a given pregnancy should complications arise.
In response to the issues raised at the 1985 meeting, WHO, in collaboration with the World Bank and the United Nations Population Fund (UNFPA), formulated a set of curative and preventive measures to help ensure that motherhood became a safe aspect of women's lives. Billed as the "Safe Motherhood Initiative" and launched at an international conference in Nairobi in February 1987, this joint international effort set out to reduce by half by the year 2000 the then estimated 500,000 annual maternal deaths associated with complications during pregnancy, childbirth, and the postpartum period (Starrs 1987). As noted already above, a standard set of preventive and curative interventions were seen as key to achieving this goal. These included, but were not limited to, the establishment of emergency obstetric and community maternal health services, the promotion of family planning, and the implementation of social policies to raise the status of women.
Despite the Initiative's efforts, revised global estimates of maternal mortality reveal that the number of annual maternal deaths is now estimated at 585,000, an upward revision of 85,000 deaths per year since the Initiative was first launched in 1987 (WHO and UNICEF 1996). In terms of the impact of maternal health interventions during the first decade of the Initiative in Africa specifically, a recent article notes that sub-Saharan Africa is the only region in the developing world where maternal health standards have actually declined (Harrison 1997). Clearly, something is not working as intended.
This book offers insight into why efforts to "make motherhood safe" have not always worked as intended in "Bulangwa," the pseudonym for a small, rural community in the Shinyanga Region of west central Tanzania. Drawing upon twenty-two months of ethnographic research that explored women's pregnancy-related concerns, my intention is to examine the processes by which a set of seemingly well-intentioned international recommendations go awry when they are implemented at the local level. My analysis of some of the Initiative's effects in this small, rural setting is focused on a particular period of time: from July 1992, when my fieldwork in Tanzania began, up until July 1994 when my research in Bulangwa came to an end. My discussion of the Safe Motherhood Initiative is also limited to a particular period of time: from the mid-1980s when the issue of maternal mortality began receiving more international attention, until the late 1990s when the first decade of the Initiative drew to a close.
Post–first decade assessments of the Safe Motherhood Initiative acknowledge that some of the recommended strategies to reduce maternal mortality were not as effective as originally hoped (Nowak 1995; Maine and Rosenfield 1999; Starrs 1998). According to an article that appeared in a 1995 issue of the journal Science, the failure of the Initiative to reach the goal of reducing maternal mortality by half by the year 2000 is now seen as a result of some of the recommended strategies themselves, "especially those selected initially by key organizations such as WHO, UNFPA, and UNICEF" (Nowak 1995:781). Despite such acknowledgments, many of the post–first decade assessments of the Initiative's impact on maternal health outcomes still provide very limited insight into the context in which such failures occurred.
This book provides that context. Central to my analysis is the notion of official and unofficial definitions of maternal health risk. I define as official the various factors that have been identified by international and national policymakers as posing risks to women's survival during pregnancy and childbirth. I define as unofficial those risks that, although valid for community members at the local level, did not become part of any official policy. I argue more specifically that official definitions of risk do not always accurately reflect the realities of women's experiences of pregnancy and childbirth; that these incomplete or inaccurate definitions of risk have sometimes led to the development of inadequate solutions for reducing maternal mortality in Tanzania; and that some of the solutions proposed as a result of relying exclusively on official definitions are, in turn, perceived as risks themselves by local community members.
Situating Motherhood and Risk
The Fieldwork Setting
Although the Shinyanga Region is located in a part of Tanzania that is often referred to as the home of the Sukuma people, the cultural and ethnic diversity that characterized the community of Bulangwa belies this generalization. Whereas the Sukuma people constituted the largest ethnic group in the community, people from a variety of other ethnicities also counted among its members. The result was a fluidity in social interactions, a fluidity that often transcended specific ethnic, cultural, or religious boundaries (Abrahams 1981). When placed within the historical context of the Shinyanga Region, this aspect of the community's social relations is hardly surprising. From the Bantu migrations into this area several centuries ago, to the nineteenth-century trade caravans that passed through neighboring areas with their cargoes of slaves and ivory, to the movement of Arab traders into the interior in the 1850s, to the impact of colonial rule, west central Tanzania has long been a site for a coming together of different peoples, for a fluidity in social and cultural interactions, for incorporation and assimilation, but for resilience as well (Abrahams 1967; Alpers 1968; Bennett 1968; Holmes and Austen 1972; Roberts 1968a, 1970; Koponen 1988).
Social interactions related to the management of maternal health risk in the contemporary setting were also notable for their fluidity. For example, many of the Muslim women living in the community, both Arab and African, tended to speak about risks during pregnancy, childbirth, and the postpartum period in relation to Islam (Good 1980), while spiritual ties to ancestors and perceived threats of sorcery were some of the key risk factors for maternal health mentioned by non-Muslim women (Sargent 1982, 1989). But these distinctions themselves were often blurred. Some Muslim women in the community consulted non-Islamic healers for medicines to safeguard against sorcery or for herbal remedies to prevent miscarriage, while non-Muslim women might use Islamic medicine to prevent miscarriage or "cure" their infertility. In addition, most of the women who sought care from local healers also visited the local government prenatal clinic when pregnant. A closer look at the reasons why reveals that these two very different systems of maternal health care, the biomedical and the nonbiomedical, were addressing and responding to two very different perspectives on maternal risk: risks of motherhood (as articulated in the government's Safe Motherhood strategy) and risks to motherhood (as articulated through the healing strategies adopted by women in the community).
Given these two different framings of motherhood and risk, how are some of the concepts and assumptions of the Safe Motherhood Initiative perceived and interpreted by women at the local level? To what extent were people in the community even aware of these latter definitions of risk, and if they were aware of them, to what extent did they acknowledge them as risks? Over the course of my fieldwork I learned that while some women may have heard about the biomedical risk factors associated with pregnancy through health education lessons at government prenatal clinics and hospitals, there was oftentimes a radically different perception of what the actual dangers might be, or even how they were prioritized in the community.
For example, in contrast to the Initiative's emphasis on the risks of "excessive fertility" (a risk of motherhood), many of the women I spoke with seemed much more concerned with the risk of "unsuccessful fertility" (a risk to motherhood). As a result, many had used local herbal or spiritual remedies at some point in their lives, either to become pregnant or ensure that their pregnancies would be carried to term (Feldman-Savelsberg 1999; Inhorn 1994a). Similarly, most of the women I interviewed were not using any family planning methods, and when I asked them why not, it soon became clear that concerns about the harmful side effects of birth control methods expressed by women in many Western countries mirror some of those raised by women living in Bulangwa. Irregular periods, fears of getting kansa (cancer), and threats to their future fertility were some of the reasons women gave for either deciding to discontinue use of a chosen birth control method or for avoiding the use of family planning methods altogether.
In addition to the physical risks women associated with pregnancy and childbirth, they also acknowledged a spiritual set of risk factors, such as ancestral displeasures or sorcery practiced by family members or neighbors. As a result of these perceived spiritual risks, local healers' advice on the prevention of spiritual risks was often followed more closely than the advice handed out by health personnel in hospitals and clinics.
Even the seemingly straightforward issue of access to maternal health care takes on new meaning when looked at from the perspective of women living in Bulangwa. In addition to physical distance, one must also consider the concept of "social distance." In other words, who are the women who actually make it to the hospital on time, and, once there, who are the women who receive immediate, competent treatment? In some cases, a lack of essential supplies resulted in a delay in treatment, but at other times the delay was a result of negative interaction between the woman, her family members, and hospital or clinic personnel. Although some of the maternal health literature dating from the early 1990s makes the point that how women are treated by health personnel within biomedical institutions has a bearing on their access to care, this crucial aspect of care was not alluded to in Mrs. X's story, nor was it stressed at the time the Initiative was launched in 1987 (Fonn et al. 1998; Okafor and Rizzuto 1994; Sargent and Rawlins 1991; Sundari 1992; Thaddeus and Maine 1990).
The Literature
Contrasting Perspectives on Risk
One of the defining differences between expert and lay perceptions of risk, according to Mary Douglas, can be found in their respective approaches to the individual subject (1992:11). The expert, she notes, has a commitment to methodological individualism: "To start with the individual and to stay with the individual to the bitter end, is their chosen escape route to objectivity" (11). The problem with the objective approach of the expert, Douglas suggests, is that it says nothing at all about subjectivities, nor about the influence of a person's social support network. Nor does the expert acknowledge that "anger, hope and fear are part of most risky situations" and that a decision that involves cost also involves consultations with neighbors, family, and work friends (12).
The distinction Douglas makes between expert and lay perceptions of risk is similar in many ways to how biomedical and nonbiomedical approaches to health and healing have been characterized in the medical anthropological literature. It has been noted, for example, that within the biomedical context, sickness and ill health are seen in terms of how disease affects the individual person, and as a result, the focus of treatment is on the individual (Good 1995; DiGiacomo 1987; Lock and Gordon 1988). Some have suggested that this approach reflects the values of Western, industrialized countries, wherein individualism and an emphasis on high-tech treatment figure significantly (Davis-Floyd 1987, 1992; Martin 1987; Scheper-Hughes and Lock 1987). Nonbiomedical approaches to ill health, in contrast, often include a focus on the social and symbolic aspects of sickness and ill health and, in doing so, call into play a wider set of relationships external to the individual (Hepburn 1988:62; Young 1982). As we will see at various points throughout this book, differences between expert and lay perspectives on risk and biomedical and nonbiomedical approaches to health and healing matter in the context of women's fertility-related experiences in Bulangwa as well.
The Context of Risk: Past and Present Considerations
Appadurai's (1996) reflections on the production and meaning of locality in an increasingly globalized world offer some useful ways of thinking about how past and present social relations both within and outside of Tanzania have shaped the management of motherhood and risk in the contemporary setting of Bulangwa. For Appadurai, locality has a phenomenological, albeit inherently fragile, quality. He describes it as a "structure of feeling" that is actively produced and carefully maintained "against various kinds of odds" (179). He is careful to point out, however, that this structure of feeling is related to actual settings or "neighborhoods," noting at the same time that there is a historical and dialectical relationship between how local subjects and local neighborhoods are "produced, named, and empowered to act socially" (181).
As Appadurai's work suggests, and as Ginsburg and Rapp (1995) have noted elsewhere, global processes can have an impact on everyday experiences at the local level, affecting how local culture is both produced and contested. These authors' observations are important to keep in mind as we explore the cultural context of maternal health risk in Bulangwa. In what ways has the history of social relations in west central Tanzania shaped women's pregnancy-related experiences in the ethnographic present? To what extent is the "structure of feeling" that surrounds the management of maternal health risk in contemporary Bulangwa a reflection of how motherhood and risk were managed during Tanzania's colonial past? And in what ways, if any, do the discourses and practices related to the management of motherhood and risk continue to be actively produced and carefully maintained at the international, national, and local levels today?
Discourses of Development
Critical assessments of the impact of colonial and contemporary development interventions in African, Latin American, and Asian settings focus attention on how the languages and practices associated with development produce particular kinds of truths about societies or groups of people and on the power relations and unintended consequences related to the production of that knowledge (Escobar 1985, 1995; Ferguson 1990; Pigg 1993, 1995; Vaughan 1991; Wood 1985). Recent analyses of colonial maternal health policies, for example, note that the maternal body often served as the starting point from which British colonial interventions to modernize and transform native populations were launched (Jolly 1998a; Manderson 1998; Sargent and Rawlins 1992; Vaughan 1991). These "interventions in mothering," as the anthropologist Margaret Jolly refers to them (1998a:5), were articulated through policies and practices that involved the surveillance and supervision of pregnant and birthing women, mothers, and wives.
The historian Megan Vaughan's analysis of colonial biomedical discourse in eastern and southern Africa is also important in this regard. Her aim is to treat biomedicine as an "exotic system of healing" (not unlike past analyses of indigenous healing systems, she notes) and in doing so to highlight "the humiliating rituals of biomedicine in the colonial context" (1991:11; see also Comaroff 1993; Hunt 1999). She pays particular attention to how African women as a category became an object of knowledge, and thus concern, for colonial administrators and health officials. According to Vaughan, Christian missionaries saw African women as the "repository of all that was dark and evil in African culture and social practices" (1991:23), and therefore regarded with suspicion many of the local practices surrounding midwifery, initiation, and fertility cults (23). As we will see later in this book, African women in colonial Tanganyika (present-day Tanzania) were also constructed as objects in colonial and missionary discourse. Tanzanian archival documents reveal that older African women were perceived as particularly dangerous to society in that they were, in the words of one missionary doctor working in the Shinyanga District in the 1920s, "contaminated by native customs" and thus bypassed in government programs to train native midwives. Native mothers were also constituted as a distinct category of dangerous women, and, as a result, education programs geared to transforming native mothers into useful mothers were launched throughout the territory. My examination of the British colonial discourse on development in general and the role of native women in Tanganyika in particular sets the stage for my discussion of international and national approaches to managing maternal health risk in the contemporary context.
James Ferguson's analysis of the unintended effects of a World Bank-sponsored rural development project in Lesotho focuses on contemporary discourses of development and in so doing "takes as its primary object not the people to be 'developed,' but the apparatus that is to do the 'developing' " (1990:17; Justice 1986). Ferguson's study illustrates what can happen when development planners hold "certain kinds of ideas" about third world countries without taking into account the specific historical, political, and cultural contexts in which a particular country's "development problem" emerged. According to Ferguson, many of the planned economic interventions in Lesotho failed precisely because they were based on ideas that had no counterpart to the reality of how Lesotho's economy was actually structured. Instead, the Lesotho project interacted with what Ferguson refers to as "unacknowledged structures," an interaction that produced, in turn, a set of "unintended outcomes" (20). It is precisely because interventions are planned and implemented on the basis of such generic definitions, he suggests, that standardized development interventions more often than not fail. Ferguson is careful to point out, however, that the failure of a project does not necessarily mean that the project did nothing at all: the failure may simply mean that the project did "something else" not quite intended by development planners (276).
Ferguson's notions of unacknowledged structures and unintended outcomes are important to keep in mind as we examine the "something elses" that emerge when generic Safe Motherhood policies were implemented in a west central Tanzanian community. Much of the international and national attention in the early years of the Initiative was focused on the direct and indirect medical causes of maternal mortality. When mention of social and cultural factors was made, very little attention was paid to how power relations between providers of health care and their clients affected women's access to care. Nor was much attention paid to how economic hardships affected the quality of care that healthcare workers provided (Bassett 1997; Ruck 1996; Walraven 1996). Instead, attention to social and cultural factors was focused on eliminating "harmful cultural practices" and "traditional attitudes" that were assumed to be common to all third world country settings. As we will see later in this book, some of these assumptions about the widespread applicability of traditional practices resulted in the implementation of programs and recommendations that were not always relevant to women's pregnancy and childbearing experiences in Bulangwa.
Stacy Pigg's analysis of the discourse associated with UN-sponsored training programs for "traditional" healers in the Nepalese context explores similar issues (1995). Like Ferguson, Pigg is interested in highlighting both the intended as well as unintended consequences of development interventions, and like Ferguson and Vaughan, she grounds her analysis in Foucault's work on the relation between discourse, knowledge, and power (Foucault 1979, 1980). Pigg notes, for example, that the language used by development agencies is not neutral. This "moral discourse of saving lives," as she refers to it, presents particular versions of reality as truth and fact and, in the process, "reasserts the inevitability of institutional practices" (Pigg 1995:48). Following Foucault, Pigg suggests that studies of interventions implemented in the name of development pay attention to how particular definitions of problems "enable particular techniques for managing, organizing and disciplining people" (48). As we will see at various points throughout this book, techniques for managing, organizing, and disciplining Tanzanian mothers have been employed both within and outside of the biomedical setting. We will also see that techniques for managing rural women were present during the period of British colonial rule in Tanganyika as well.




Continues...

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Table of Contents

Contents List of Tables Preface Acknowledgments List of Abbreviations 1. Motherhood as a Category of Risk 2. The Colonial Community: Managing Native Motherhood 3. The International Community: Making Motherhood Safe from Afar 4. The National Community: Making Motherhood Safe in Tanzania 5. Situating the Fieldwork Setting: The Shinyanga Region in Historical Perspective 6. The Community of Bulangwa 7. Risk and Tradition 8. The Prenatal Period, Part 1: The Risk of Infertility 9. The Prenatal Period, Part 2: Risks during Pregnancy 10. Risks during Childbirth 11. Risks during the Postpartum Period 12. Risk and Maternal Health Notes References Index