MATERNAL MORTALITY IN INDONESIA

MATERNAL MORTALITY IN INDONESIA

In most undeveloped countries the joy of bringing a new life into the world is often replaced with the sorrows of a mother passing. Health officials have struggle in creating approaches to combat the staggering rates. Many of the approaches designed to lower rates focus heavily on biomedical care. Biomedical approaches improving these causes have not substantially lowered rates.  The problem lying heavily in its weak ability to connect the approach to the social reality of the people. In this review I will explore the ways in which cultural factors prohibit the use of biomedical care and the need to create a framework that addresses socio-cultural factors in Indonesia. Using the medical anthropology approach allows us to understand why strategies proven effectively in developed countries are falling short in undeveloped nations. Ethnographic research shows the areas in which biomedical approaches have failed in order to modify for a better solution.

Maternal mortality rates have produced serious public health concerns, over half a million women die every year from giving birth. An overwhelming 99 percent of those deaths happen in developing countries. The World Health Organization defines maternal mortality as, “the death of a woman while pregnant or within 42 days of termination or from any cause related to or aggravated by the pregnancy or its management. (2011).” The WHO states that causes are due to medical complications, health policies that affect availability, accessibility, quality of reproductive health services and underlying socio-legal conditions (Global Health Watch 125). Solutions include family planning and medically training midwives. Also, the Safe Motherhood Initiative that gives planned parenthood option like contraceptives to rural women. Global representative pose the issue as a human rights issue. It states that, “failure to address preventable causes of maternal death is a violation of women’s rights (Global Health Watch 130).” Although global health representatives do classify maternal death as a public health issue, little focus is given on why biomedical care alone isn’t making much of a difference as well as the underlining causes.

                My approach of this problem is stemmed from the article written by M. Cameron Hay. In the article, Dying mothers: Maternal mortality in rural Indonesia the author argues that the perception of death, cultural stigma and social relationships prevent individuals from utilizing biomedical care, ultimately leading to maternal death.  He also argues that simple biomedical fixes have not caused mortality rates to decrease. Hay conducted his ethnographic research by doing fieldwork in a rural village Pelocok in Indonesia where maternal mortality rates are high and through extensive interviews. He follows the journey of two mothers Inaq Hin and Inaq Marni who lose their life while giving birth.

DYING MOTHERS            

Cameron Hay, in his article, Dying mothers: Maternal mortality in rural Indonesia describes child delivery as a cultural event and shows how biomedical interventions made no impact on saving a mother’s life. In the Indonesian culture, midwives are responsible for the maternal health and delivery of a child. These midwives are women who are trained mainly through experience and little on science. After the delivery of Inaq Hin the midwives experienced problems on getting the “afterbirth” placenta to come out and immediately started to experience heavy bleeding. When asked to take her to the hospital the midwives refuted it saying it’s too far, no transportation, and little money. They stressed if Inaq Hin didn’t survive it was her Allah’s fate to let her go. In a panic with nothing else to resort to the midwives called upon Hay for guidance from his biomedical book, Where there is no Doctor (Werner 1992). Although Hay tried to apply various techniques from the book, Inaq Hin eventually passed away due to hemorrhage bleeding. After questioning the cause of her death the midwives answered, “her time was finished. It is certain if her time wasn’t gone the medicine would have been strong enough for her (Hay 254).” In the second delivery of Inaq Marni who lived easily accessible to a hospital decided to give birth in her hut at home. After giving birth to the first unborn child the midwives realized she had another child inside of her not wanting to come out. When Hay’s instructs to go to the doctor Inaq Marni says, “why would I want to die over there (Hay 261).” After the midwives pulled the unborn fetus out similar to Inaq Hin the placenta did not come out and experienced hemorrhage bleeding. Inaq Marni and her two children passed away. When asking the midwives about the cause of her death they placed the blame on the mother for taking contraceptive pill and the midwives for their delivery mistakes.

Hay then analyzes the Pelocok people’s perception of death and concludes the ways in which the biomedical approach needs improvement. He advocates the need for better government training, communication regarding midwives, increased access and cost, and the need for health care to be familiarized more within the community. Child delivery in Pelocok is a community event. He explain that it is important to make note of the way communication between community members influences the midwives decision on how to care for the mother. When creating an approach we must respect that some religions have social hierarchy positions try to work along it and not force them to assimilate to the biomedical culture we have in the U.S.

EXPLAINING DEATH: MEDICAL ANTHROPOLOGY PERSPECTIVE

Medical anthropology allows us to frame maternal mortality from multiple perspectives. It analyzes the ways in which members of the community contribute and influence to maternal mortality. It shows the need for solutions beyond the quick fix of simply placing hospitals in rural towns. For example, in the suggestions implemented in the article, Hay’s makes account of how in both cases of the mother their death was perceived as fate or through error. Instead of dismissing their reasons as not logical because the lack of evidence in science, it is important that we develop an understanding of their cultural view and show where “fate” can be hope. Even when they did all they could possibly do the people of Pelocok didn’t consider taking the women to the hospital. Using medical anthropology concepts will allow us to see why midwives would watch the mother pass than commute to a hospital. Medical anthropologists surpass the excuse that fate determines ones death. Often times health officials perceive that the women deny biomedical care because of their distrust in it. In this case that was false, the midwives called upon Hay desperately to look up medical solutions in his book.  It is not that they are unsure of the science behind the medicine but rather the cultural factors that keep them at a distance. Medical anthropology shows us that the difference between the perceptions of the people from biomedical specialists is one the reasons why maternal mortality rates are increasing even more healthcare access. It also shows us that social relationships and cultural meaning play a significant role in maternal care. Through the medial anthropology perspective it is evident that frameworks need to address socio-cultural forces affecting women in Pelocok from receiving care.

COMPARING THE TWO

 When comparing the approach used by Hay to The Global Health Watch Report 3, I found several differences on the perception of what is causing the problem. In The Global Health Watch Report 3 it discussed the Safe Motherhood Initiative, which was designed to draw attention to important factors like women’s reproductive cyle, pre-pregnancy, antenatal, delivery and post-partum periods. The initiative however doesn’t provide a framework of how women can receive care for their cycles rather on increasing awareness (Global Health Watch 127). Another approach in the report included a framework for maternal mother health and family planning. The frameworks focus is on health systems and policies affecting the socio-political context of health (Global Health Watch 131). Suggesting that increased access, more contraceptive methods, and medical training would help decrease the rates of mortality. Interesting enough the ethnographer refutes these claims, stating increased biomedical antenatal care, trained caregivers, and increased access “do not effect whether or not a woman dies (Hay 246).” Unlike global health representatives he shifts the focus on how we can integrate biomedical care into the social reality of Pelocok. The ethnographer’s work shows that research is not just about results. Global health representatives are looking at the high rate of mortality in regards to how they can improve the healthcare system. Through medical anthropology we see that the people who do have access to the healthcare programs installed by the government are still not utilizing them due to socio-cultural reasoning’s.  Hay shows that a framework for trust is needed to shift people’s perception about death in order for them to use the biomedical care provided by the government. Rather than just training caregivers on medicine, more training is needed on communication and comfort. The medical anthropology approach differs from the Global Health approach, because it takes into account the cultures way of life and tries to connect biomedical care to them by emphasizing with their conditions.

MY THOUGHTS

                From a conceptual perspective, examining maternal mortality through medical anthropology concepts allowed me to see the ways in which socio-cultural factors contributed to the increased mortality rate. Prior to the concepts, when hearing about women dying in undeveloped countries from pregnancy my initial reaction would be similar to global health representatives. My frameworks would focus on advocating for more access to hospitals, healthcare policy reform, and better training. However, the medical anthropology approach allowed me to see the culture’s perspective of maternal care. It brought more focus on how maternal care is a social role of the community, extending far beyond a visit to the doctor like in the U.S. In the Pelocok culture, the midwives are given the responsibility of caring for the mothers using religious factors. Applying the medical anthropology concepts shows that in different societies where cultural factors are different, special frameworks are needed that cater to that culture’s beliefs.

                In a practical perspective, frameworks for maternal mortality need to include the socio-cultural position and beliefs within a society. The global health approach of reforming healthcare and forcing biomedical care onto the people is proven effective in the United States however; the cultural differences between nonwestern societies are dramatic. Pushing for solutions that work in one society onto others without taking into consideration their difference in their social, economic/political, and cultural infrastructure will not decrease mortality rates. Through ethnographic research one can attest that in order to reduce maternal death we have to include factors like perception. We must look at the perspective of the individual, culture/community, and global health representatives. Viewing the problem from more than one standpoint will allow us to not only understand but make a more grounded solution. The medical anthropology perspective suggests that in addition to the global health approach more work is needed

CONCLUSION

                 Thousands of women are dying every year and in some cases leaving a newly born child behind. The skyrocketing mortality rate is extremely hard to face knowing that we have the resources and tools to help save the lives of these women. Only by creating frameworks that recognize socio-cultural factors that create a road block for women to receive the medical care they need, will the numbers start to decrease. In Cameron Hay’s work he shows that the government’s solutions of building more hospitals in rural towns did not help save mother Inaq Hin and Inaq Marni. The mothers refused to go to the hospital. Using medical anthropology we can break down conflicts regarding maternal care like different perceptions of death, cost/ access, and issues of trust. In this way, people in undeveloped countries will not feel like they are going out of their cultural, political/economic, and social comfort zones in order for them to receive maternal care. The medical anthropology approach does not dismiss the global health approach. It instead makes light of more socio-cultural areas of concern than biomedicine and calls for improvement on relating the approach to the social reality of people who live in rural environments.

Denden Embaye

 

WORKS CITED

"Maternal Mortality: Need for a Broad Framework of Intervention." Global Health Watch 3: An Alternative World Health Report. N.p.: Zed, 2011. 124-32. Print.

Hay, M. Cameron. "Dying Mothers: Maternal Mortality in Rural Indonesia." Medical Anthropology: Cross-Cultural Studies in Health and Illness 18.3 (1999): 243-79. Taylor & Francis Online. Web. 12 Dec. 2012.

Metastatic Cancer and Mothering

In this essay, I will explore the World Health Organization’s World Health Statistics for 2012, which highlighted the topic of noncommunicable diseases and how they are a growing threat. Of those noncommunicable diseases, I will focus specifically on cancer. I am addressing the topic of cancer from an anthropologist’s perspective by focusing on life with cancer, specifically women with metastasized cancer. I will then discuss Kirsten Bell and Svetlana Ristovski-Slijepcevic’s ethnography titled “Metastatic Cancer and Mothering: Being a Mother in the Face of a Contracted Future.” Kirsten Bell conducted the fieldwork for the ethnography by observing a support group for women with metastatic cancer held at a local cancer treatment center in western Canada between September 2007 and April 2008. I found this ethnography intriguing for it sheds light on the subjective experience of metastasized cancer, and how that reality is affected by factors such as mothering. A synthesis and juxtaposition of these two very different, yet similar works will then follow, for both works involve cancer, yet each work represents completely different views of cancer. The World Health Statistics represents cancer with figures that are completely decontextualized, whereas “Metastatic Cancer and Mothering: Being a Mother in the Face of a Contracted Future” represents cancer within a specific context.

The WHO’s World Health Statistics for 2012 included the highlighted topic of noncommunicable diseases and how they are a major health challenge for the twenty-first century. This problem is due to an increase in the population as well as a general increase in longevity. These two factors have lead to a shift of the dynamics of population ages, for there are now more middle-aged and older adults than there are children and young adults. The increase of middle-aged and older adults is directly correlated to rise of deaths due to noncommunicable diseases. “Of the estimated 57 million global deaths in 2008, 36 million (63%) were due to noncommunicable diseases (NCDs),” and the second largest portion of NCD deaths are due to cancer, a considerable twenty-one percent (WHO 2012:32). The World Health Statistics stated that the annual deaths due to cancer is projected to be 13 million in the year 2030, opposed to 7.5 million deaths that occurred in 2008 (2012:34).

Many people believe that cancer is only a problem for the developed world, the high-income countries. This idea is completely false, for “more than two thirds of all cancer deaths occur in low- and middle-income countries, with lung, breast, colorectal, stomach and liver cancers causing the majority of such deaths” (WHO 2012:36). The World Health Statistics states that there are four key behavioral risk factors for cancer tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol (2012:35). However, there are other factors that can cause cancer, like “infections such as hepatitis B and hepatitis C (both associated with liver cancer), human papillomavirus (associated with cervical cancer) and Helicobacter pylori (associated with stomach cancer) [which] cause[d] 20% of cancer deaths in low- and middle-income countries, and 9% of cancer deaths in high-income countries” (WHO 2012:36). “In sub-Saharan Africa, for example, cervical cancer is the leading cause of cancer death among women due to a high prevalence of infection with human papillomavirus. In high-income countries, the leading causes of cancer deaths are lung cancer among men and breast cancer among women” (WHO 2012:36).

In a twenty-five minute film titled “Cervical Cancer: The Real Lady Killer,” produced by PATH and Rockhopper for the BBC World’s “Kill or Cure?” series, Sarah Nyombi, a Ugandan member of parliament, is talking to a young girl named who had just been vaccinated with the HPV vaccine. The young girl has had a first hand experience of cervical cancer, for it has left her motherless. Although her mother was never formally diagnosed with metastasized cervical cancer, the symptoms experienced by her mother match those related to cervical cancer. When her mother became ill, her father took her to a local herbalist. After multiple visits to the herbalist and while following his treatment, her mother’s condition quickly deteriorated. After her mother’s death, the family learned that the cause was cervical cancer, and the herbalist’s treatment could not have helped.    This example demonstrates how cancer affects low-, middle-, and high-income countries, and is therefore a growing global health issue.

The support group Kirsten Bell observed was “small, intimate, and relatively unstructured…[They] met for one and a half hours on a fortnightly basis,” and generally had between six and twelve women present (Bell, Ristovski-Slijepcevic 2011:631). Less than half the women who attended the drop-in support group had metastatic breast cancer; the remainder had blood, colorectal, ovarian, uterine, stomach, or lung cancer as their primary tumor sites. The majority of group members were in their fifties and sixties, and many had adult children as well as grandchildren, while four of the regular group members had nonadult children ranging in ages from four to eighteen (Bell, Ristovski-Slijepcevic 2011:631). To understand this ethnography, we must take into account the reality these women live with, the context of their diagnosis. Having a diagnosis of metastasized cancer has forced these women to come to grips with the knowledge that it is not “if” their cancer will result in their death, but “when”. With that in mind, we must acknowledge that these women are living with a limited amount of time. This idea will surface again when I discuss women in the support group who have dependent children.

While attending the support group, Bell notices how an unspoken, yet constantly acknowledged “hierarchy of suffering” had developed. By unspoken, I mean that none of the attendees blatantly refer to the hierarchy, yet it is constantly implied in multiple situations because the support group attendees constantly acknowledged how the four women with nonadult children were worse off. During a session, Lara voices her concern over Sara’s well being. Sara “has just found out that she will have to have chemotherapy and that she can’t face the thought of it at the moment. She sobs that her husband and 12-year-old daughter have ‘hit the roof’ about it and she doesn’t want to go through palliative chemo again (Bell, Ristovski-Slijepcevic 2011:630). Bell and Ristovski-Slijepcevic explain how “it was her [Sara’s] 12-year-old daughter that made her story so heartbreaking. For the assembled women, it seemed that the tragedy of metastatic cancer, where life is foreshortened by disease that is largely incurable, is multiplied when the person experiencing the cancer is a mother with dependent children” (Bell, Ristovski-Slijepcevic 2011:630). Bell notes how, “Time and time again, women with adult children echoed their relief that they had not been diagnosed with metastatic cancer until after their children had grown up” (Bell, Ristovski-Slijepcevic 2011:634-635), further solidifying the acknowledgement of the hierarchy present. Bell notes,

Women in the group shared an understanding that mothers with dependent children had a claim to suffering that ‘trumped’ all other claims women might have, including physical pain (a serious issue for women with bone metastases), disabilities such as blindness, or even not having children, although this latter state entailed its own special form of suffering for other younger women in the group. For example, Bridget, a woman in her early 40s, talked about how her diagnosis had forced the realization that time had run out to do the things she wanted to accomplish in her life: “Like, I’ll never be able to have children, and I’m limited to what I can, I think, have from now to the end of my life. And that is devastating.” [Bell, Ristovski-Slijepcevic 2011:635]

This hierarchy is further defined when Jane, a woman in her sixties who was diagnosed with uterine cancer that has metastasized, attends a meeting and explains how she is very upset because she “is really worried about her granddaughters who are 7 and 9—both of her own daughters are alcoholics and she wants to be there for her granddaughters” (Bell, Ristovski-Slijepcevic 2011:635).

In this discussion, Brenda stated how much more “difficult” cancer is when there are “children in the picture.” However, although people listening to Jane’s story (including KB) were sympathetic, and although it was clear to us that Jane had a fundamental role in mothering her granddaughters, it did not have the same heart-wrenching qualities as Sarah’s. The hierarchy of suffering therefore appears to intersect with the hierarchy of mothering mentioned earlier, whereby the most appropriate person to mother a child is the biological mother rather than another family member. [Bell, Ristovski-Slijepcevic 2011:636]

            The induced hierarchy of suffering embodied by the women in the support group illustrates the current social perception that the biological mother is the best caretaker for her child. Bell and Ristovski-Slijepcevic address the cultural conceptions of mothering. They discuss how mothering has been described as both a biological and moral activity of caring, but how women become mothers and live mothering is greatly determined by larger social and cultural forces (Bell and Ristovski-Slijepcevic 2011:631). Therefore “cultural idioms such as ‘motherly love’ and ‘maternal instincts’” (Bell and Ristovski-Slijepcevic 2011:632) enforce the social perception that mothering must be done by the biological mother. This is why the mothers in the support group who have dependent children are at the top of the hierarchy of suffering; they have to deal with the reality of how much time they have to live, how much time they have with their children to be their mother. They have to juggle the role of a mother while also having to deal with the symptoms and reality of their cancer. Some group members with adult children stated how they can just stay in bed all day when they are having a bad day, or do not feel like dealing with the world. However, the mothers with dependent children do not have that luxury; they have to get out of bed and “mother” their children.

Kirsten Bell and Ristovski-Slijepcevic state that they are not surprised at how “so much of the support literature about families dealing with cancer either ignores mothers or focuses exclusively on children” (2011:636). This is what makes Bell and Ristovski-Slijepcevic’s ethnography completely different from most literature, for the fieldwork focused specifically about mothers while also taking into account their offspring. Blachman suggested that there is a cultural confusion in conceptualizing motherhood and mortality, and at that intersection, “Blachman stated that ‘[i]f being sick is generally depressing and frightening, if cancer raises the specter of death, if death is to be avoided at all costs, then seriously ill mothers of young children strike an emotional chord on an altogether different scale’” (Bell and Ristovski-Slijepcevic 2011:636). The support group members voiced their frustration with the current self-help literature that was available to them. The literature echoed how the women must make time for themselves, which was “unrealistic admonitions which women in the support group were all too aware carried their own hegemonic tendencies” (Bell and Ristovski-Slijepcevic 2011:645).

While conducting fieldwork, Kirsten Bell attacks cancer with a different approach, an approach similar to that of Gooldin’s while conducting fieldwork with anorexics in Israel. Gooldin focused on how anorexics viewed their disease and their embodiment of a heroic moral subjectivity, rather than just the medical aspect of anorexia. Kirsten Bell focuses on the subjective experience of living with metastasized cancer while having dependent children, rather than just medical aspect of metastasized cancer. This approach highlights a completely different aspect of metastasized cancer that is not represented in the WHO’s World Health Statistics. WHO acknowledges how cancer is a problem, but they solely represent it with numbers and statistics, completely free of any human-like connections. Statistics are important tools that allow us to make comparisons that make sense, but it de-contextualizes social realities. Anthropologists such as Kirsten Bell bridge that gap and connect numbers with, what I believe, is true meaning. She humanizes those with metastasized cancer, attaches a persona to those numbers. She focuses on how life with cancer is, something that is overlooked by WHO, similarly to how life with anorexia was also overlooked. 

“Metastatic Cancer and Mothering: Being a Mother in the Face of a Contracted Future” is an ethnography that unveils how having dependent children significantly affects a mother with metastasized cancer’s illness experience. It analyzes the cultural norms of mothering when applied to the biomedical diagnosis of metastasized cancer in our current time period when the context of how biological mothers are the best care takers of their children while also taking into account the subjective reality of living with metastasized cancer. Although this ethnography does not focus specifically on a better way with dealing with the global health issue of cancer, it does remind us how context is key, and how we cannot solely focus on statistics, for they “silence the experiences and voices of those with metastatic cancer—experiences and voices that require considerably more research and reflection” (Bell and Ristovski-Slijepcevic 2011:645). Statistics can also be misleading, for a large percentage of deaths are not reported, or countries do not have a system in place that allows an accurate report of statistics. For example, that young Ugandan girl whose mother died of cervical cancer was most likely not reported in the correct manner. Yet, that dependent young girl was still left motherless because of metastasized cancer. There needs to be a change in the current literature available to those living with cancer. More mothers are being diagnosed with cancer all throughout the world, and therefore there must be more alternative literature that recognizes the distinctiveness of life with metastatic cancer, as a mother with dependent children or otherwise. Because the current cultural context where motherhood is synonymous with self-sacrifice, the idea that “mothers with metastatic cancer must choose between mothering themselves and mothering their children paradigmatically connects this discourse with a much larger cultural trope on motherhood and the self: that ultimately women must make a choice between themselves (and their career) and their children” arises (Bell and Ristovski-Slijepcevic 2011:645). This ethnography further helped me to understand how cultural perceptions play a major role in our mentalities, and how although two people may be diagnosed with the same disease, their specific perception of their individual experience of suffering is subjective to other factors, such as having dependent children. 

Works Cited

Bell, Kirsten, and Svetlana Ristovski-Slijepcevic 2011 Metastatic Cancer and Mothering: Being a Mother in the Face of a Contracted Future. Medical Anthropology: Cross-Cultural Studies in Health and Illness, 30:6, 629-649

World Health Organization - World Health Statistics 2012

Prioritizing Risk

I worked with Annika Launiala and Marka-Liisa Hinkasalo’s article “Malaria, Danger and Risk Perception among the Yao in Rural Malawi.” I will discuss how these anthropologists are looking at the Yao community in Lungwena, Malawi and the medical anthropological perspective on their work analyzing risk perception. Describing pregnancy in Lungwena with medical anthropology means that one can assess various cultural and socioeconomic factors to reduce risks with pregnancy. The primary author, Annika Launiala, uses this perspective to look at risks to pregnancy holistically. Launiala’s study is a reminder that health is a culturally relative entity. Therefore, when trying to organize health care or aid it is vital that it addresses root issues of power. In practical use however, malaria in pregnancy as a global health issue stems from systemic problems regarding poverty and biopower.

Malaria in pregnancy:

The primary author, Launiala, initially aimed to focus on community perceptions of malaria risks during pregnancy. In actuality, however, the article mainly discusses perceptions of sociocultural risks being greater than perceptions of biological risks. The only time malaria as a health problem is really discussed is as such: an example of a biological risk. Launiala discusses gender dynamics when it comes to pregnancy and cultural perceptions of risk among this community. She also discusses how the community prioritized biological and sociocultural risks, like infidelity versus contracting an STI. As the author mentions, different biological risks defer to sociocultural risks because they are already part of everyday life. Biological risks like malaria can be dealt with to incur no social or biological adverse consequences The principle author ultimately concludes that malaria in pregnancy is not a major concern for the Yao because there are greater social and cultural risks than malaria. Even if a disease does not present much of a biological risk, like a curable STI,  it still has the power to generate huge social risk by raising questions of fidelity. This makes women vulnerable not because they are ill but because they may lose their financial support should their husbands chose to divorce them. Ultimately the danger with malaria in pregnancy is not the disease itself. The danger is the need for preventative care that accounts for “local vulnerabilities and perceived threats” rather than focusing on just curing malaria. Global health looks at straightforward cures for preventative care rather than holistic approaches that consider social and cultural effects on treatment. This article explores that topic using malaria in pregnancy as an example. While there are efforts to cure malaria and malaria in pregnancy, these efforts focus on the disease aspect. However, they do not deal with the cultural aspects of pregnancy. According the Launiala, dealing with malaria in pregnancy has been focused on treatment and prevention in specific cultural context.

Pregnancy as illness:

The principle author studied perceptions of risk of malaria relative to other risk factors. The population Launiala worked with was mainly Yao by ethnicity in the city of Lungwena, Malawi. Launiala states that “The purpose [of the study] was to gain a comprehensive understanding of the sociocultual context of managing pregnancy and malaria.” The author described how people perceived cultural relationships to the vulnerability of pregnant women. These relationships included those with witchcraft, infidelity from both partners, gender dynamics, diseases other than malaria, and poverty. Topics that were discussed in depth were perceptions of the severity of STIs and HIV/AIDS in particular. The author then discussed the effect of poverty in accessing treatment and sexual interactions. Launiala’s data supports that pregnancy induced certain behaviors from women who did not want to incite malevolent spirits or nearby witches. It also invoked cultural knowledge about certain marital behaviors. Infidelity from either partner is culturally believed to complicate or ultimately harm a pregnancy. However, the author points out that extramarital relationships on the husband’s part are common in Malawi but it is ultimately the woman’s responsibility to protect herself from sexually transmitted diseases. 

Medical anthropological perspective and WHO focus:

I thought this article was fairly well rounded from a medical anthropology perspective. Launiala already wrote it from one. She is focusing on a community and their relationship to a health problem. However, she looks at it from cultural as well as biomedical perspectives. She also doesn’t look at just access to biomedical treatment but attitudes towards risk management and societal factors to sickness. For anthropologists and care providers, the key to treating malaria in pregnancy seems to be treating changing its priority of risk relative to other diseases as well as giving pregnant women the agency to prioritize their health. According to the author, the WHO focuses on providing treatment for malaria and not much else. WHO’s focus, as well as other NGOs focus on providing treatment and prevention. While this is necessary, the author also stresses the need for anthropologists and all social scientists “to go beyond simplified measures of knowledge, attitudes and practices and incorporate sociocultural context, recognition of illness, perceived severity and susceptibility, perceived benefits, risks and capacity for action, and availability and accessibility” (414). Indeed, the WHO report focuses on malaria prevention throughout a population and in children under 5 years old. Even here, the data seems to focus on access to antimalarials and sleeping under an insecticide treated net (ITN). Though malaria is one of the most prioritized disease causes worldwide, there is no data in the WHO World Health Statistics regarding malaria risks in pregnancy. However, the WHO report does talk about poverty affecting areas that are geographically already prone to malaria. The WHO’s suggestion for dealing with this issue is by pushing international funding for these areas to increase awareness and provide access to health care. It addresses issues with healthcare that stem from economic access, but makes no mention of sociocultural perceptions of malaria. However, the report is also aware that funding should not be conflated with access:

“With very low levels of funding, countries cannot ensure universal access to even a very limited set of health services. On the other hand, higher levels of funding might not translate into better service coverage or improved health outcomes if the resources are not used efficiently or equitably.” (World Health Statistics Report 2012, 42)

Concptual analysis:

Biopower is at play here. The men in this society have disciplinary biopower in the sense that the patriarchal societal norms remove a woman’s ability to protect her body from STIs. According to Launiala, AIDS is considered a bigger threat in Malawi because AIDS has no cure. Yet regardless of this, condom use within a marriage is societally discouraged because its implications in female infidelity. For the sake of financial and community support, women were willing to put themselves at risk for the disease they considered the most severe and dangerous. Here, it is where the men of Lungwena have the power to constrain the agency of their wives, both over her body and her means of living. It is also interesting to remember that participants in this study also included malaria as one of the most dangerous diseases to contract in a biological sense. In fact, some respondents to the study said that all the discussed diseases in the study were just as dangerous to one another. However, intersections of societal risks and ability to cure a disease created higher perceptions of overall risks in diseases like HIV/AIDS and STI’s in general. Though malaria was certainly considered a dangerous disease, it was only considered a high risk disease if untreated. Then there was the notion of vulnerability in regards to witchcraft and extramarital relationships. It is believed that witchcraft or malevolent spirits can be dangerous for the mother and unborn child. It is also believed that infidelity from either side of the relationship can harm or terminate the pregnancy. These beliefs enforce a set of proper behavior needed to avoid danger from malevolent magic. Here, biopower is wielded in its regulatory model. By the cultural politics of Lungwena, men are not supposed to be having extramarital sex. This is for the interest of the wife and baby and out of expectations as a  husband to help produce children.  The women listed STIs and HIV/AIDS as most dangerous to a pregnant woman. It was interesting because the assessed these dangers bacsd on the ability to cure the disease, severity of the disease, and treatment. Malaria exposes the pregnant woman to biological risks that she can control by going to a clinic. However, when it comes to STIs and HIV/AIDS her agency is limited because challenging how she contracted these diseases is a social risk that is greater than the biological risks. She can get antimalarial drugs if she needs to with no social repercussions. She cannot divorce a husband because of financial needs. This is because it suggests infidelity on the mother’s side and could risk divorce. “Although it may not be a conscious choice made by women in Lungwena, this ethnography depicts how a pregnant woman ends up accepting immediate disease ans medical risks…rather than placing herself at social risk of being divorced by her husband, losing support, and even being cast out by her family and relatives because of  HIV- related stigma” (412)

Practical changes to risk:

I don’t know how much could change in this medical system without first making huge changes to political, financial, and health system infrastructure. According to the WHO report, Malawians pay very little out of pocket for their health care expenditures. Launiala’s data seems to echo this. The main cost is usually that of acquiring transportation. So while it’s good that the Yao don’t have to pay for necessary health costs that they couldn’t afford anyway but not all that helpful if they cannot access those resources when necessary. Part of medical anthropology is understanding how power affects the health and healthcare systems that affect communities. Here it is the effect of poverty on biopower. Women in this community need to get married and have children in order to cement social capital and to support themselves with husbands. However, because of prohibitive transport costs, most of these women cannot access emergency healthcare when necessary. Then there is further restriction of agency when it comes to protecting the health of the mother. Though there are cultural restrictions regarding infidelity, it is generally understood that it happens anyway, usually with the husband of a relationship. Therefore, women can’t even protect themselves from STIs in this community because their husbands cheat, contract the infections, and women are culturally expected to have sex with their husbands. However, to ask the husband to use protection isn’t even an option because it raises suspicions that the woman is the promiscuous party. Then it puts the women at risk of divorce, which in this community, carries too high a risk of financial ruin. All these factors need to be considered instead of just throwing money at these communities. Again, the problem here is not actually malaria, it is risks associated with pregnancy.

Solutions in agency:

The primary author, Launiala, initially aimed to focus on community perceptions of malaria risks during pregnancy. In actuality, however, the article mainly discusses perceptions of sociocultural risks being greater than perceptions of biological risks. While I thought this was a unique article to address malaria specifically in pregnant women, I didn’t think it was a very effective article explaining what it set out to do. From an anthropological standpoint, I don’t think there was anything very new about this article; many cultures practice cultural restrictions to protect pregnancy. People in many cultures go through pregnancy in extreme poverty. However, Launiala’s work was a good reminder of why holistic approaches to medical anthropology are necessary. What seems to be a specific problem in a community is actually one that reflects holes in systems of healthcare. Knowledge of cultural practices is absolutely necessary when dealing with global health issues. However, that knowledge cannot be used without also considering socioeconomic factors that are affecting a community. Giving communities financial aid to soothe economic problems will only help so far as communities have the social impetus to use it effectively.

- G James Keum

Works Cited

Global Heath Watch, comp. Global Health Watch 3: An Alternative World Health Report. London: Zed, 2011. Print.

Launiala, Annika, and Marja-Liisa Honksalo. "Malaria, Danger, and Risk Perceptions among the Yao in Rural Malawi." Medical Anthropology Quarterly 24.3 (2010): 399-420. Print.

WHO. World Health Statistics 2012. Rep. N.p.: WHO, 2012. Print.