Adrienne Strong

Medical anthropology, maternal mortality, hospital ethnography, and dignity in women's health care

I am a medical anthropologist with a joint Ph.D. from Washington University in St. Louis, USA and the Universiteit van Amsterdam in the Netherlands. I study maternal mortality and women's health in Tanzania, currently in the Kigoma region on a birth companionship program and the notions of ideal comfort, care, and support for pregnant women in labor. I am an Assistant Professor in the Department of Anthropology at the University of Florida. Before my current position, I was a National Science Foundation Postdoctoral Research Fellow with Columbia University's Mailman School of Health, in the Averting Maternal Death and Disability (AMDD) Program in the Heilbrunn Department of Population and Family Health and a Fellow at the Columbia Population Research Center.

I worked in the Rukwa Region for my dissertation fieldwork, which I conducted from January 2014- August 2015. From September 2010 through July 2011, I conducted research on access to healthcare services during pregnancy, birth, and the postpartum period in the Singida Region of Tanzania. My doctoral dissertation project focused on the inner workings of a government regional referral hospital, examining how institutional structures related to hierarchy, bureaucracy, historical precedents, communication and other factors, may influence the capacity of the institution to provide effective maternal healthcare during times of obstetric crisis. My research focused on biomedical healthcare providers and administrators, groups that are often overlooked in the context of medical anthropology in sub-Saharan Africa. I contextualize the hospital ethnography with interviews, participant observation, and focus group discussions in communities throughout the region, as well as through the use of primary archival sources from the colonial and post-independence eras.

This is my personal website, which includes updates on my research, collaborations, conference presentations and papers, publications, teaching, and critical responses to current events related to women's health and reproduction.

Mentions and Public Anthropology

Paper Prize

Washington University Feature

Feature on Anthropology Department Website

Research Report on Global Health Hub

Photoessay on SAPIENS.org

Mention on Anthrodendum

Mention on Anthrodendum for fieldwork blog

Publications

Welcome to my publications page. This includes citations of my works that have been accepted for publication, as well as brief mention of those in the pipeline i.e. in preparation or currently under review. When possible, I have provided links to the full work or the pertinent website for more information. 

Published works

  • Strong, A. 2017. Bureaucratic Proliferation, Surveillance, and Care Practices: The Partograph as Technology and Bureaucratic Document. Under review, American Ethnologist
    • Abstract: The partograph, graphical representation of a pregnant woman’s labor, is a simple technology meant to help healthcare providers detect serious problems for the mother or her baby before she gives birth. The partograph, as a document connected to a global health system, acts on healthcare providers, influencing their actions. Despite its presence in many low resource settings, providers often do not use it in the ways in which technical experts and policy makers imagine. Instead, the nurses and doctors on a Tanzanian maternity ward used the partograph to accomplish social goals of accountability or protection, and in bids for care on behalf of patients. Insight from the producers of these global/local documents contributes to understanding how local actors produce new meanings in a system that does not consider their productive capabilities, which transform the document’s original meanings. 
  • Strong, A. 2018. Causes and effects of occupational risk for healthcare workers on the maternity ward of a Tanzanian hospital. Accepted, Human Organization. Winner in the Peter K. New Student Research Paper Prize competition. 
    • Abstract: In this paper, the author introduces the concept of “institutional care” as a key component of mitigating healthcare workers’ occupational risk from their exposure to bodily fluids. In the Rukwa region of Tanzania, healthcare providers often work in very low resource environments that lack equipment and the tools needed for patient care. Additionally, resources for protecting the healthcare workers from occupational exposure to infectious diseases is also often lacking. Against the background of the 2014-2015 Ebola outbreak in West Africa and continued resource scarcity in the Mawingu Regional Hospital, healthcare workers explained the effects of a lack of certainty about women’s HIV status and a lack of personal protective equipment. On the maternity ward, the nurse-midwives worked in an environment that was high risk but also nearly entirely outside their control. When health administrators at the institutional level did not demonstrate care for their employees—what I term institutional care—the nurses reported higher levels of concern and fatalism regarding their potential to contract HIV or Hepatitis. The article concludes with recommendations for how to operationalize institutional care to mitigate occupational risk in this environment to care for hospital staff members so they can most effectively care for patients and minimize abusive interactions.
  • Strong, A., M. Cogburn, and S. Wood. 2018. A Facility Birth for All?: Homebirth, Hospital Birth, and Birth Registration in Tanzania in Birth in 8 Cultures, Robbie Davis-Floyd, Melissa Cheyney, and Carolyn Sargent, eds. Forthcoming.
  • Strong, A. and D.A. Schwartz. 2017. "Effects of the Ebola epidemic on health care of pregnant women- Stigmatization with and without infection" in Pregnant in the Time of Ebola, D.A. Schwartz, S. Abramowitz, J. Anoko, Eds., forthcoming
    • Abstract: By now, after the end of the Ebola virus outbreak in West Africa, we have begun to see the lingering effects of stigma on Ebola survivors, as well as children orphaned by the disease. However, there has been little scholarly attention to stigma in relation to its particularities while the outbreak was still active. Therefore, in this chapter we explore the effects of stigmatization on the health care services pregnant women—with and without Ebola—were able to access and receive during the outbreak. We propose three primary ways in which stigma operated to reduce pregnant women’s access to health care services during the outbreak: 1) Women and their relatives were afraid to go to health facilities for fear of being infected with Ebola while there, i.e. stigmatization of healthcare facilities; 2) Healthcare workers frequently died due to their occupational exposure to EVD while caring for others, i.e. they were stigmatized as carriers or transmitters of Ebola; and 3) Pregnant women themselves were refused services at health facilities due to fears that they were infected with Ebola, i.e. the physiological processes of birth, which involve high levels of potential for exposure to bodily fluids, led to health care workers’ stigmatization of these women when they sought services during pregnancy or, particularly, at the time of giving birth. In several of the countries that experienced the worst of the outbreak, women already faced some of the world’s highest rates of pregnancy-related death. We argue that the high fatality rate for pregnant women with Ebola, the drastic effects of the epidemic on countries’ health care workforce, and the inherent messiness of birth, all coalesced to create heightened discrimination and stigma around seeking care during pregnancy and birth. 
  • Strong, A. 2017. Working in Scarcity: Effects on social interactions and biomedical care in a Tanzanian hospital. Social Science & Medicine 172: 217-224. http://dx.doi.org/10.1016/j.socscimed.2017.02.010 
    • Until September 5, 2017 use this link for free access: https://authors.elsevier.com/a/1VOfj-CmUduse
    • Abstract: Based on mixed-methods, ethnographic research in government health facilities conducted in Rukwa, Tanzania over 23 months between 2012 and 2015, this paper explores the social implications of budget shortfalls in the healthcare system at the level of a regional hospital. Budget crises resulted from the late disbursal of funds and the failure of outside donors to meet aid commitments needed to subsidize healthcare at the national level. Healthcare administrators recounted specific donors who pulled out of commitments as a direct result of foreign government austerity measures enacted after the global financial crisis of 2008. In this environment of scarcity, partially due to years of reduced donor funds in the region, regional healthcare administrators circumvented bureaucratic fiscal procedures to ensure the continued functioning of facilities, and healthcare personnel struggled to provide pregnant women with high quality care in times of emergencies. Providers cited low morale and demotivation due to deteri- orating physical infrastructure, lack of supplies, and poor relations with the community as key factors inhibiting their ability to care for the women who came to their facilities. 
  • Strong, A. and D.A. Schwartz. 2016. “Anthropological aspects of risk to pregnant women during the 2013-2015 multinational Ebola virus outbreak in West Africa.” Health Care for Women International  
    • http://www.tandfonline.com/doi/abs/10.1080/07399332.2016.1167896?journalCode=uhcw20
    • Abstract: Researchers reflect on sociocultural aspects of the Ebola outbreak in West Africa and critically analyze the epidemic's effects on pregnant mothers and their babies. We address structural inequalities contributing to poor maternal health in lower-income countries, while reflecting on how the Ebola outbreak highlights the still-marginalized role of pregnant women. Drawing on prior research in West and East Africa, we discuss health care providers’ responses to risk of infection during maternity work under normal circumstances and in times of crisis. We end with recommendations for preventing such detrimental effects on the health of pregnant women in the case of another epidemic.
  •  Strong, A. 2015. “The convergence of social and institutional dynamics resulting in maternal death in Rukwa, Tanzania” in Maternal Mortality: Risk Factors, Anthropological Perspectives, Prevalence in Developing Countries and Preventative Strategies for Pregnancy- Related Death. Ed. David Schwartz. Nova Science Publishers
    • https://www.novapublishers.com/catalog/product_info.php?products_id=54695&osCsid=
  •  Marwa, S and A. Strong. 2015. “Three case studies and experiences of maternal death at a regional referral hospital in Rukwa, Tanzania” in Maternal Mortality: Risk Factors, Anthropological Perspectives, Prevalence in Developing Countries and Preventative Strategies for Pregnancy-Related Death. Ed. David Schwartz. Nova Science Publishers
    • https://www.novapublishers.com/catalog/product_info.php?products_id=54695&osCsid=

Works in Progress

  • Special section in Medical Anthropology, co-edited with Elyse Singer (Brown University), on obstetric violence. 
    • Strong, A. 2018. Ambiguous Caring in Tanzanian Maternity Services: What the Term “Obstetric Violence” Obscures
      • Abstract: Researchers have documented the widespread occurrence of disrespect and abuse on maternity wards throughout sub-Saharan Africa. Unlike in Latin America, the language of obstetric violence is relatively new in this region but, many of the documented behaviors fall within the conventional use of the term. While the term can be politically useful, non-specific use elides the nuances of varying forms of care—and violence—in many settings, thereby hobbling efforts to reduce these behaviors. Based on 23 months of ethnographic research on a Tanzanian government regional referral hospital’s maternity ward, I argue that using obstetric violence as a blunt tool disallows some possible solutions for improving maternity services for women in these settings. Within the Mawingu regional hospital’s maternity ward, nurses did engage in clear instances of violence—physical, verbal, emotional—or exacerbate women’s vulnerability to structural violence during parturition. However, there were other interactions that, on the surface, appeared to be violent but must be re-examined in light of local interpretations of valued and respected forms of caring, particularly in the context of a resource-poor healthcare environment. Refusing to engage in these ethically uncomfortable re-readings does a disservice to the healthcare providers on the front-line of care and perpetuates ethnocentric, paternalist ideas of “good” or “appropriate” care that we often export from high-income countries via guidelines and policies. Seriously engaging with nurses’ discourses of certain forms of violence as care does not excuse these behaviors but will enable researchers and policy makers to develop more nuanced tools and programs that enable behavior changes and improved care, as well as moving forward theoretical insights into care, violence, and birth. 
  • Strong, A. "Jumping the Red Tape:" Administrative Workarounds, Improvisation, and the Social World of Rumors in a Tanzanian Hospital (in preparation for submission to Journal of the Royal Anthropological Institute)

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