What is it like to publish a book open-access with our Luminos program? Adrienne Strong, Associate Professor of Anthropology at the University of Florida and author of Documenting Death: Maternal Mortality and the Ethics of Care in Tanzania, discusses her award-winning book and her experience publishing open-access.

Documenting Death is a gripping ethnographic account of the deaths of pregnant women in a hospital in a low-resource setting in Tanzania. Through an exploration of everyday ethics and care practices on a local maternity ward, anthropologist Adrienne E. Strong untangles the reasons Tanzania has achieved so little sustainable success in reducing maternal mortality rates, despite global development support. Growing administrative pressures to document good care serve to preclude good care in practice while placing frontline healthcare workers in moral and ethical peril. Maternal health emergencies expose the precarity of hospital social relations and accountability systems, which, together, continue to lead to the deaths of pregnant women.

The book is also a multiple award-winner of the following prizes:

  • Leah M. Ashe Prize for the Anthropology of Medically–Induced Harm 2022 Honorable Mention, Society for Medical Anthropology
  • Adele E. Clarke Book Award 2021 Honorable Mention, ReproNetwork
  • Eileen Basker Memorial Prize 2021, Society for Medical Anthropology

What motivated you to focus the book on this topic?

When I was 19 years old, I visited Tanzania for the second time. I spent most of my time at a regional hospital with a few other pre-med and global health American students. At the time, I was planning to go to medical school to specialize in infectious diseases.

Some of the clinicians who spoke English let us follow them around the hospital, including a doctor working on the obstetrics and gynecology ward. One morning he explained that a woman had died on the maternity ward and invited us to observe the post-mortem exam to help determine her cause of death. It turned out that the woman had been in labor, waiting to give birth to her full-term baby who had also died in utero. As he started the post-mortem, I was struck by the fact that his first incision mirrored that of a C-section, which might have saved her life and that of her baby. I was profoundly touched by the irony that while she had made it to the hospital, it was not enough to save her and her child.

Afterward, I continued to ruminate on the global inequities that led that woman, along with too many others, to die in lower resource settings like Tanzania. I realized that my training in basic sciences like biology and chemistry could do very little to help explain the deeper structural reasons that made her more likely to die than women in my home country. I have been pursuing the answers to that question essentially ever since. Through more time in Tanzania, I realized that hospital and healthcare workers had stories to tell as they sought to improve maternal healthcare services and prevent the deaths of pregnant women. So, when it came time to do the research for my PhD, I decided to work with healthcare workers to try to understand how hospital function and health sector dynamics were related to interpersonal interactions, power dynamics, and historical constraints all affecting maternal health outcomes.

What is one of the most compelling insights from your research?

Perhaps it seems obvious, but I think one of the most compelling insights is that healthcare workers are people, too. The COVID-19 pandemic brought light to this issue globally as healthcare providers across settings worked so hard to care for people without all the necessary personnel and materials they needed. Healthcare workers in lower resource settings, like Tanzania, are used to working in similar environments day in and day out. They often lack personal protective equipment, they are dealing with chronic staffing shortages, and they are overworked and underappreciated. And yet, policies expect them to do more and more. In the context of maternal mortality, I tried to ask “at what cost”?

As both an anthropologist and a doula, how have people reacted to how you ended up learning to deliver babies?

First and foremost, what I always want people to know is that I didn’t set out to help deliver babies. It wasn’t a method, it wasn’t a part of the plan. I pursued training as a doula because I wanted to be able to provide some comfort measures and support to the women in labor at the hospital. Doulas, as a rule, don’t help deliver babies.

On my first visit to Mawingu, the nurse in charge took a break from some administrative duties to give me a brief tour of the ward, explaining the different rooms and what happened where on the ward. As we passed through the delivery room, we saw that a woman silently standing near her bed was pushing. The other nurse-midwives were occupied with other patients and the nurse in charge couldn’t get to the woman fast enough. She continued pushing and the baby fell on the floor in a pool of amniotic fluid and blood from the umbilical cord that had broken as the baby fell the couple of feet to the floor. Even in the hospital women were giving birth alone.

Despite that experience, I still had absolutely no intention of becoming involved in clinical care because I’m not trained. However, when I returned to the hospital, one of the very experienced nurse-midwives, who is a nationally certified trainer of trainers for basic emergency obstetric and neonatal care, decided she was fed up with me scribbling in my notebook, just watching events unfold. Despite my insistence that I wasn’t trained, she decided that I needed to be more useful if I was going to spend time there. She then taught me how to help conduct safe deliveries and supervised me as I helped. In this way, I learned how to conduct only uncomplicated deliveries and I would help only when one of the nurses or doctors was not available, similar to the way the cleaners sometimes helped or the medical attendants, though I had received more instruction than they had.

There are definitely ethical questions that arise around my participation, like “would you be allowed to do the same thing in the United States?” This really gets at the heart of power imbalances and dynamics that mean foreigners might not be questioned or that my whiteness enabled me to escape further scrutiny. I wouldn’t be qualified to deliver babies in a hospital in the U.S. However, I was not delivering babies as a matter of course but when it was an urgent question of me versus no assistance.

I also do not have any certificates or official qualifications. However, my training was essentially via apprenticeship, a method anthropologists of reproduction have long argued is a valid mode of knowledge transmission for birth and reproduction. Whenever I did assist in or conduct a delivery, I always did so only until someone else was available to take over and I always maintained the highest respect for women’s bodily autonomy, comfort, and reproductive rights.

In the end, the healthcare workers working in this setting raised the ethical question of my presence without the ability to help. What would have been the ethical implications of simply watching as more babies fell on the floor or more women gave birth alone? This is what drove me to learn more. I don’t anticipate I will ever engage in my research in this way again. Mawingu also now has a much more sustainable ratio of providers to patients due to several changes in the last few years, which is a very positive development.

What is the main message you hope readers take away from your book?

It sounds simplistic but I hope one of the key takeaways is that without engaging with complexity we’re never going to be able to address the problem of maternal mortality in any setting, let alone lower resource ones resource. I also hope people appreciate the impossible situation nurse-midwives and physicians are in with expanding bureaucratic requirements, high caseloads, and only the most basic resources. The result is that good people make mistakes or pregnant women get lost in the institutional shuffle due to competing demands. Nobody wants pregnant women to keep dying but systems are not currently set up to effectively and consistently prevent their deaths in many lower resource settings.

Why did you decide to publish your book open-access (OA)?

My hope was that making the book open-access would significantly increase access to those working in places like Tanzania, and have a far greater reach and impact. Likewise, OA publishing makes it much easier to teach at a variety of institutions where students may not have the economic resources to purchase several books per semester. Instructors can also teach one or two chapters of the book without worrying about cost.

How did publishing OA impact the audience for your book?

The book undoubtedly has traveled much further as an OA publication. Tanzanians and others working in similar locations have contacted me via email to let me know they’ve read the book. I love that I can also just send a link to the Luminos site if anyone wants a copy. That has made it so much easier to share with people, especially in Tanzania.

What I appreciate the most is hearing from these audiences—clinicians, global health practitioners—that they feel the book is a faithful, accurate, and compassionate, representation of their work environments. I also know for a fact that people are teaching with the book more frequently than would have been possible if students had to purchase copies. I’ve heard from several colleagues at colleges and universities across the country who have told me that the book is so much more accessible to their student population this way. Finally, as of Spring 2024, the book has been viewed or downloaded close to 4,000 times via the Luminos site alone. People in more than 72 countries have accessed it. Seeing that data was probably the coolest part of the OA publishing journey!

What would you tell another author who is considering publishing open-access?

I would tell them they should absolutely do it! Publishing open-access has been a great experience and has led to connections and potential collaborations that I am certain would not have arisen without OA. I have only received positive feedback from people and still, almost 5 years later, would make the same choice again in a heartbeat! If you’re considering OA publishing, think about including funds to support this in grant proposals or start-up funding.