Conceptualizing Pregnancy Loss in the Tanzanian Context

“Our national White Ribbon Day was first proposed by HE Ali Hassan Mwinyi, the second President of the United Republic of Tanzania, in 2006. We remember annually the terrible loss of mothers and newborns, and we discuss with our political leaders how to join forces in preventing further deaths. On this day we wear the White Ribbon as a symbol of mourning, but also as a sign of hope that this tragedy will soon end. Two women from this very community have died recently while giving birth. One was a teacher. She died due to lack of safe blood transfusion. The other died because her uterus ruptured while she was giving birth at home; she was brought to this centre too late. 

The deaths of mothers and newborns requires action from all of us! Women, husbands, and communities must speak out if things are not right, and they must work hard to save money for the birth and to avoid delays. Health workers must deliver quality services. The government must ensure budgets, infrastructure and qualified health workers in place."- Rose Mlay, National Coordinator White Ribbon Alliance for Safe Motherhood, Tanzania (WRATZ) http://whiteribbonalliance.org/national-alliances/tanzania/

I have been in Tanzania since the middle of January this year, 2014, and started my research in the Rukwa region in the middle of February. Though my research is not primarily concerned with pregnancy loss, this is topic which I feels deserves more attention. The numbers are there for all to see and within Tanzania there are a number of organizations and campaigns addressing neonatal mortality. Most recently, on White Ribbon Day (March 15th), I was part of a health center opening in which a number of organizations and government leaders spoke about continuing high rates of maternal and neonatal mortality. However, one aspect of these losses that rarely seems to be discussed is the emotional impact on the mother and how many women might possibly struggle with grief or depression following a pregnancy loss. A common response to a stillbirth or neonatal death is that it was caused by "bad luck" or that the baby or pregnancy wasn't meant to be. This has most likely come to be the standard response because neonatal death is still relatively common. I have witnessed women being told not to cry following a stillbirth and others being told repeatedly by nurses that they, the women themselves, were responsible for their baby's death because surely they had taken local herbal medicines, even when they had not.

I once asked a physician whether or not he thought maybe a woman who had recently lost her baby and developed a vesico-vaginal fistula due to prolonged obstructed labor was perhaps developing symptoms of depression. He told me he thought she was just being lazy and was surely going to develop bedsores if she did not start exercising and get out of bed. I told him I thought perhaps she was sad about losing her baby, the second child she had lost in such a way, within just a short three year period. He told me that he thought most women who came to the hospital with obstructed labor were tired of the pain and just wanted to the ordeal to be over and the baby to be out, regardless of the outcome. When I spoke with this woman and others who had had similar experiences, they told me they often thought about and remembered the babies they had lost but they tried not to dwell on it. 

I recently became friends with another woman who experienced a stillbirth after her uterus ruptured and she had to have an emergency Cesarean section. Her aunt confided in me and told me the woman had not even been given the chance to see the baby's face and was inconsolable. She regularly asked her relatives to bring her baby son to her so she could see him and hold him. This was impossible because they had already had the funeral for the baby. The woman was nearing depression, uninterested in many activities, only wanting to stay home  during the day and often crying for long periods of time.

It is my feeling that support for dealing with these losses should commence in the hospital setting. Women should be helped to understand what might have happened to cause the death (if a cause is known) and how they might prevent such a loss in the future, if it was even anything within their control. Sometimes it is and sometimes it is not. Health care providers should be sensitive to the emotional needs of women and how each individual may express grief in a different way. Being allowed to see the baby and know the child's gender may be helpful for some women or it may not be for others, but the choice should be presented to the woman before the tiny bundle is taken away. 

Nearly every morning I walk into the maternity ward and am greeted by tiny bundles wrapped in bright khangas or kitenge fabric. A silent and grim reminder that there is still much work to be done in improving health care and still more work to be done in order to understand how women cope with their "bad luck" that resulted in their child's death. On the part of health care providers, it should be an on-going goal to reduce the number of "fresh" stillbirths, those in which the baby was alive until very shortly before birth. These types of stillbirths often might be prevented with closer or faster attention. While I acknowledge that it's easy to say we should be able to reduce these types of stillbirths but it's harder to do, I am tired of excuses from providers that these deaths are simply "bad luck."