The trouble with maternal death narratives: Race, representation, and reproduction

ABSTRACT

The high risk of maternal death in Africa has cast a shadow over representations and experiences of pregnancy and childbirth. In the 1980s, amid new awareness of disparities in maternal mortality rates between high and low-income countries, tragic anecdotes of women dying during childbirth emerged as a tool to garner political and economic support for global health interventions aimed at women. While successfully raising public concern and billions of dollars in aid, given that these stories are some of the few stories of African women so widely circulated, it is important to ask: what else does the genre of maternal death narrative do? How might discursive practices around childbirth structure the care offered to African women? What power relations are revealed in this form of knowledge production and promotion? This article examines how maternal death narratives function, circulate, and structure potential solutions to the problem of maternal mortality. In focusing on the pathways to death, women’s bodies are foregrounded as sites of knowledge production over their experiences. I use fieldwork with pregnant and birthing women in southwest Nigeria to explore the ways that women piece together different sources of care in an effort to ensure successful deliveries amidst considerable uncertainty.

KEYWORDS:

• Maternal mortality
• race
• global health
• Africa
• religion

The birth of safe motherhood

In 1987, the World Bank, the World Health Organization (WHO), and the United Nations Fund for Population Activities (UNFPA) joined forces to convene the first-ever international conference focused solely on maternal mortality and morbidity. The International Safe Motherhood Conference in Nairobi would be only the first of a self-propagating series of national, regional, and international calls to action, conferences, task forces, congresses, programs, initiatives, and countdowns centered on the health of pregnant and birthing women and involving governments, donors, non-governmental organizations (NGOs), and technical assistance organizations. The seeds for such an occasion had been planted years earlier when the then director-general of the WHO, Halfden Mahler, revealed at the 32nd World Health Assembly that ‘half a million women die from maternal cause [sic] each year’ and that 99% of those deaths occurred in Africa, Asia, and South America (Mahler, 1979). Prompted by such alarming statistics and the disproportionate lack of action, six years later, Allan Rosenfield and Deborah Maine published a seminal paper to raise awareness for the ‘neglected tragedy’ (1985). In November of that same year, the WHO convened the Interregional Meeting on the Prevention of Maternal Mortality, where even more data confirming previous estimates was presented. By the end of this meeting, the attendees – 41 health professionals, researchers, and policymakers from 26 countries – were in agreement that ‘a major initiative to prevent maternal death should be mounted – and was, in fact, overdue’ (WHO, 1986). Thus, Safe Motherhood was born.

While interest in the health of mothers and children predates the 1987 conference (See AbouZahr, 2003), two innovations, one technical and the other ideological, mark Safe Motherhood as a break from past frameworks for addressing women’s health. First, new statistical techniques made it possible to produce the first estimates of the extent of the problem. Using data available from civil vital registries, hospital audits, and household surveys in a sample of low-income countries, the WHO was able to make numerically concrete a problem that had otherwise been speculative. The new numbers exposed disparities between low and high-income countries and also gave the movement a quantifiable goal toward which interventions could be aimed. Second, Safe Motherhood is marked by its paradoxical emergence in the wake of economic recession, structural adjustment, and the eventual abandonment of the 1978 Alma Ata Declaration. This original commitment made by the WHO to support ‘Health for All’ by strengthening primary health care and addressing underlying social, economic, and political determinants of health was never realised amid a shift toward a more selective primary care championed by the World Bank and its structural adjustment programs (Walsh & Warren, 1980; Tejada de Rivero, 2003). As a result, while most officials in public health would agree that successful deliveries require structural shifts including comprehensive primary health care systems to address underlying determinants of health, Safe Motherhood is more selective in its aims. Safe Motherhood interventions have remained narrowly focused on where women deliver or who attends their deliveries despite the growing consensus that ‘vertical’ approaches fall short in the face of the deep-seated complexities of the problem.

Transnational mass mobilisation, in which billions have been committed to reducing pregnancy-related deaths, enjoyed a second wave of heightened public interest in 2000 when improving maternal health was included as one of the eight Millennium Development Goals (MDGs). The fifth MDG was divided into two targets: 5A Reduce by three quarters, between 1990 and 2015 the maternal mortality ratio (MMR), and 5B achieve universal access to reproductive health. These targets were further narrowed by the indicators that would be used to measure success, which included the MMR, the proportion of deliveries attended by skilled birth attendants, the contraceptive prevalence rates, and adolescent birth rates.

This tendency toward the biomedical technofix (Lock & Nguyen, 2010) in the context of the racial and gendered imaginaries that informed the formation and propagation of Safe Motherhood, even as the significance of social, political, and economic factors to maternal health is repeatedly documented, is the subject of my investigation. Central to the rhetoric of Safe Motherhood are maternal death narratives. These detailed anecdotes of women dying during pregnancy or childbirth emerged as a tool to garner political and economic support for global health interventions aimed at women, or rather mothers. While successfully raising public concern and financial support, it is important to ask what else the genre of the maternal death narrative does. What happens when a focus on African death is the driving force of inquiry in global health? What possibilities are foreclosed? How might discursive practices around childbirth and motherhood structure the care offered to African women?

Borrowing from writer Chimamanda Adichie’s notion of the single story (2009), I demonstrate that the danger of the single story has implications for global health too. In order to explore the ways African women are discursively deployed in development schemes and the impact this has had on local programming in an urban African setting, I employed archival, ethnographic, and textual analysis methods. Ethical approval for this research was obtained from the University of California, San Francisco IRB. My archival research took place primarily at WHO headquarters, where I focused on communications related to the first Safe Motherhood conference and subsequent initiatives. Making my way through technical reports, speeches, conference agendas, correspondence with ministers of health, and newspaper clippings, I interrogate the configuration of hegemonic conceptualizations, transnational discursive practices, and biopolitical apparatuses around global maternal mortality since its conception as an international problem in the 1980s under the rhetoric of Safe Motherhood. Using a critical race studies analytic lens, I examine the texts promoted by the maternal health development regime with a focus on how maternal death narratives, by disseminating a caricature representation of African women as poor, uneducated, and suffering, bear on the projects that claim to address them.

My ethnographic research centers on one such project in Ondo, a state in southwestern Nigeria where most residents are of the Yorùbá ethnic group and Pentecostal Christianity prevails. Over the span of six years, I followed the development of Ondo’s maternal health campaign, Abiye, and the experiences of the pregnant women who were its targets. I interviewed government officials, physicians, health workers, community-based birth attendants, and pregnant women on my visits to government hospitals, private clinics, mission homes (church-based birthing centers), and countless other informal spaces where reproductive health services were accessed. All research participants participated voluntarily and provided informed oral consent in accordance with UCSF IRB standards for a study of this nature. Care was taken to de-identify all transcripts, documents, and other data collected in the course of the study in order to maintain the anonymity of the participants. Likewise, aside from well-known public figures, names of participants have been changed.

My research coincided with Dr. Olusegun Mimiko’s second and most ambitious term as governor of Ondo state. During his administration, Mimiko made the fifth MDG, to improve maternal health, into a state priority, taking cues on how to achieve this from global health and development agencies, which also provided the financial backing. However, in predominantly Christian Ondo, large numbers of women deliver outside the purview of the state in homes, churches, and other private spaces, where the spiritual is expected to have a direct bearing on the outcome of the pregnancy. I show how Ondo missed an opportunity to incorporate local priorities and resources, especially has they related to religious practice, in its programs because the solutions to the problem of maternal mortality were limited by racial and gendered imaginaries best exemplified by tropes of the ‘maternal death narrative.’

Moving away from these problematic narratives, African women’s literature and oral tradition offer a way of complicating representations of African women and taking seriously the role of religion in their lives. They open up space for us to ask questions that may not have answers, at least not to be found in dominant regimes of knowledge, problematising authoritative conceptualizations of motherhood, birth, care, and African women.

Mothers in development

The Safe Motherhood Conference took place over the course of four days in February of 1987. In addition to leadership of the convening organisations, in attendance were several African, Asian, and South American ministers of health including the minister of health of Nigeria at the time, Dr. Olikoye Ransome-Kuti, the son of prominent women’s rights activist Funmilayo Ransome-Kuti and brother to legendary musician and activist Fela Kuti. The WHO archive reveals much about how European Christian worldviews, Enlightenment thought and evolutionary theory extended into global health discourses, reinforcing specific conceptions of gender, sexuality, and reproduction. I focus on three quotes that summarise the sentiments of the moment.

First, the conference opened with remarks by Barber B. Conable, the then president of the World Bank. Setting the tone for the four days of sessions that would follow, Conable described the problem in economic terms:

Working for safe motherhood, we will be working for steady development on all fronts. Maternal health care … is an investment in development. It is an affordable and productive investment (Conable, 1987, p. 155).

Next, Mahler began his address by quoting the Book of Genesis:

In the Book of Genesis we may read these words: ‘Unto the woman He said, I will greatly multiply thy sorrow and thy conception; in sorrow shall thou bring forth children.’ But in the present time, neither the conception nor the sorrow is evenly distributed about the world. Surely the most striking fact about maternal health in the world today is the extraordinary difference in maternal death rates between industrialised and developing countries (Mahler, 1979).

And, finally, in the ‘Call to Action,’ adopted by consensus at the conference, it was noted:

We need to remember that the industrialised countries faced this challenge in the past. For some the change has taken place in our lifetime, through dedication and the reallocation of priorities (Starrs, 1987).

Taken together, these three quotes are both representative of the larger Safe Motherhood agenda and illuminating of how Enlightenment constructions of blackness, gender, and sexuality continue to pervade discourses of Safe Motherhood. They marry the economic, the religious, and progress in ways that are eerily reminiscent of an imperialism that never quite expired. As Michel-Rolph Trouillot writes, ‘modernity is necessarily plural … it requires an alterity, a referent outside itself – a pre- or nonmodern in relation to which the modern takes its full meaning. It is historically plural’ (2002, p. 222). This plurality is produced through the management and imaginary projection of populations external to what he calls the North Atlantic. Celebrated German philosopher, G. W. F. Hegel theorised that Africa, unlike Europe, was yet to develop a spirit or consciousness of freedom, and thus outside the ‘theatre of History'¹ (1837). The ‘Call to Action’ places countries like Nigeria in this Hegelian racialised teleology. The global story of maternal health is often told in this way²: The countries of western Europe and the United States contended with high rates of maternal mortality until the advent of certain technologies, antibiotics, and standards of obstetric care. They serve as the models from which African countries should take lessons. Often, political will and gender equality are highlighted as making the crucial difference. These narratives, of course, leave out the centuries of racialised violence and exploitation that made such uneven industrialisation possible.

What is significant about Mahler’s bible reference is the simultaneous gesture to the Christian influence on the WHO and, relatedly and not in contradiction, its secular mission. Christianity played an important role in the civilising mission of Frederick Lugard’s ‘dual mandate,’ just as religious justifications for intervention lie at the core of WHO’s mission. The Christian Medical Commission (CMC), ‘born out of a belief that there is something peculiarly Christian about the business of health and healing’ (Smith, 1998, p. 16) as the medical outreach arm of the World Council of Churches (WCC), was the first major NGO to partner with WHO.³ CMC stimulated discussion at WHO about the then radical approach of community-oriented primary health care well before it was presented at Alma Ata (Smith, 1998; Litsios, 2004). Alma Ata’s ‘Health for All’ was, however, never fully realised and CMC and WHO parted ways ideologically. Whereas CMC continued to be motivated by an idea of ‘wholeness,’ the WHO, increasingly beholden to economic forces, supported a selective primary health care model.

Finally, Conable’s speech brings capitalist motives into sharp relief. It is indicative of a trend, which started modestly in 1979 with the World Bank’s creation of the Health, Nutrition, and Population sector and has only accelerated in the last couple decades. It is what Devi Sridhar has called ‘the economic gaze,’ the latest in a line of organising principles for public health policy, from Michel Foucault’s clinical gaze (medicine) to David Armstrong’s community gaze (epidemiology), to the present moment in global health, which she suggests is dominated by economic concerns (Sridhar, 2011). The World Bank’s increasing involvement has impacted health policies and projects substantially. Sridhar notes how terms like ‘human capital’ and ‘cost effectiveness’ have become mainstays in global health, ordering how interventions are designed, assessed and funded, while DALYs⁴ are commonly used to estimate the burden of disease. These are innovations of the World Bank, which is now the largest funder of global health within the UN system and second overall only to the Global Fund⁵ (Sridhar et al., 2017).

Similarly, when, during the summer of 2013, a woman died at Mother and Child Hospital in Akure, the capital of Ondo, the chief medical director concluded a long discussion of her last hours in the hospital with this somber note: ‘This is a serious issue. A woman has just died. A mother has just died. A wife has just died. A daughter has just died. We don’t even know the economic contribution she was making to the family.’ The singular concern with economic productivity results in bodies that only have value in so much as they enhance the global economy. Target groups are created with this justification because it is their health that will have the greatest ramifications for the productivity of countries. Mothers became central development targets through Safe Motherhood, making claims to health care contingent on specific notions of economic productivity.

In emphasising the reproductive and productive capacities of women, Safe Motherhood constructs mothers as not only the main targets of global health programs, but as markers of development. That the previous millennium development goals and current sustainable development goals of the United Nations feature prominently the improvement of maternal health in this specific way is another suggestion of this. In her work, Clare Wendland (2016) describes why reproductive health indicators like maternal mortality matter to health policy makers beyond the deaths they represent. They interpret the significant gap in maternal mortality ratios between rich and poor regions in a time when most causes of maternal death are preventable to be a sign of gender and class inequity. Disruptions in reproduction also signify political illegitimacy and due to the complex planning and infrastructure necessary for safe deliveries, maternal mortality is used as an indicator of a system’s overall functioning. These numbers are, however, rarely interpreted as indicators of histories of dispossession.

Yet reproductive health is also historically linked to colonial racialisation. Africans were sexualised and racialised in ways that drove colonial intervention and placed women at the center of these interventions. In Curing Their Ills (1991), Megan Vaughan examines colonial medical discourse on Africa and finds that midwifery and childrearing were considered to be a locus for social, in addition to biological, reproduction. Missionaries, regarding certain birthing practices as African and therefore inferior, sought to reform childbirth and childcare as the most expedient way of reforming the African mind in favour of Christianity. Today, it is important to continue to examine race as it informs the global health programming that is disseminated across the globe to places like Ondo. I return to the originary moments of Safe Motherhood to examine how racialised stories told about African women can limit possibilities for intervention or worse yet, contribute to conditions that facilitate racialised violence.

Mrs. X and the maternal death narrative

In the first session following the opening ceremony of the Safe Motherhood Conference in Nairobi, Dr. Mahmoud Fathalla presented the story of ‘Mrs. X,’ who dies during labour. The account is, for Fathalla, ‘a typical profile for one of those unfortunate half a million mothers who die every year,’ (1987, p. 1). The immediate cause of death had been documented as excessive bleeding secondary to placenta previa, a condition in which the placenta sits too low in the womb. Fathalla explained that this condition is not fatal on its own. In a series of death reviews conducted sequentially by the hospital, a WHO-supported community-based study, a Family Health International study, and finally a study supported by the Population Council, several other causes of Mrs. X’s death were uncovered. These included: the four hours it took Mrs. X to get to the hospital due to a lack of emergency transport; the initial absence of the clinician upon Mrs. X’s arrival delaying the start of the necessary surgical procedure by three hours; the lack of readily available blood for transfusion; unmet need in antenatal services as Mrs. X had severe anemia and a few minor bleeding episodes earlier in pregnancy; Mrs. X’s socioeconomic status as the ‘illiterate wife of a poor farmer’ (p. 2); and the idea that Mrs. X, at 39 years old with seven children, three of whom were boys, did not really want any more children.’ (p. 2) Fathalla made clear that this last ‘cause’ was meant to drive home the point that the entire saga would not have taken place had Mrs. X. had access to contraception to prevent her from getting pregnant in the first place. All of these factors keep Mrs. X on the perilous ‘road to maternal death’ (p. 4).

This case, while illustrative of several ‘lessons,’ tells us one story as if it is the only story: ‘There is a Mrs. X dying because of pregnancy and childbirth every minute somewhere in the developing world’ (p. 1). Mrs. X, since immortalised in a short film (2012) in which the narrator reports plainly, ‘Mrs. X represents a universal mother,’ is not given a proper pseudonym. Even this amount of specificity would have presumably detracted from the universality of her experience. Her story serves as meta-narrative for the maternal death narrative.

Told in global health conferences, classrooms, and publications, maternal death narratives tend to follow the same course. Taking place in an often rural, unhygienic setting, an impoverished, uneducated woman who is on either extreme of the reproductive life-span – ‘hyper-fertile’ or barely pubescent – does not make it to the hospital in time to save her own life. The stories always feature a barely functioning health care system and almost always include a bad guy – the misogynistic husband or male figure, who is curiously at odds with the health of his wife and child (often the source of the delay in seeking care).

The women in these stories uniformly live miles and miles from the closest licensed health care provider and, despite sometimes having multiple previous pregnancies, have no plan in place for their deliveries. They fall into labour alone and scared, and strangely, they have no idea about any of the danger signs of pregnancy, often ignoring extremely concerning symptoms (Mrs. X ignored two episodes of bleeding earlier in her pregnancy). The maternal death narrative is not only demeaning in the way women are portrayed as ignorant, unclean, powerless victims of circumstance. It leaves key aspects of the story out. Where are Mrs. X’s relatives and friends? Who delivered her first seven children? How did she explain the early episodes of bleeding?

In her TED talk, ‘Danger of a Single Story’ (2009), novelist Chimamanda Adichie contends, ‘Show a people as one thing, as only one thing over and over again, and that is what they become.’ The single story of Africa comes from ‘Western literature’ portraying it as ‘a place of negation, of difference, of darkness.’ She explains how she was shocked to visit the home of the domestic worker that her family had employed: ‘It was impossible for me to see them as anything else but poor. Their poverty was my single story of them.’ She, then, describes an encounter with her American college roommate, who had made similar assumptions about her before they met: ‘She had felt sorry for me even before she met me. My roommate had a single story for me. A single story of Africa.’ Taken together, these two vignettes are illuminating in a way that does more than expose stereotypes. The point is subtle, personal as well as political. Adichie, a Nigerian woman, is guilty of having the same oversimplified image of maids as her roommate has of all Africans. Yes, Africa is more diverse than Western literature presents it to be, but it is also important to affirm that this diversity is not harmonious. There are imbalances of power within the continent, just as they exist between continents. Adichie concludes, ‘Power is the ability not just to tell the story of another person but to make it the definitive story of that person’ (2009).

Nolwazi Mkhwanazi (2016) locates the tendency to tell a single story in medical anthropology concerning sub-Saharan Africa. She identifies three parts to the single story in medical anthropology: first, ‘the state’s lack of or inadequate involvement in the provision of health care’ (2016, p. 195); second, ‘suspicion and distrust’ between Africans and Euro American countries, between Africans and their state government, or among Africans (p. 196); and third, ‘the creative crafting of knowledge, meaning and action’ (p. 197) in order to emphasise that Africans are not victim. While these stories might illuminate a pressing set of issues, the danger is that even as they attempt to highlight local agency, they run the risk of othering Africans. Noting that medical anthropological accounts seem to singularly focus on tragedy, she asks, ‘Where are the other stories – the stories that do not look into Africa but start from Africa and look out?’ (p. 195) For Mkhwanazi, the single story is ‘the antithesis to anthropology, which strives to study people and their engagement with the world around them’ and ‘endeavours to document the complexity, richness, and diversity of lives lived’ (p. 194). But I contend that the single story may actually accurately capture an essence of an anthropology which was born within the context of colonialism, an anthropology which seeks to capture, simplify, reduce, and render manageable (albeit now for scholarly consumption and global health intervention instead of colonial administration).

To be clear, it isn’t that anthropological literature is devoid of beautifully written, critical analyses exploring the social, political, and economic in relation to pregnancy-related death in Africa (see: Strong, 2020; Suh, 2021). Rather, even as this literature becomes increasingly nuanced, the centering of death is evident and the dependency on ‘the fix’ predominates. While anthropologist give us an arguably more ‘complete’ story, there remains a ‘case for letting anthropology burn,’ as anthropologist and social critic, Ryan Jobson contends in his 2020 review article. In line with Jobson, I am making ‘a call [for anthropology] to abandon its liberal suppositions’ (2020, p. 261) – that is, the epistemological orientation that ‘maintains the myth of perfectibility through progressive incorporation of historically subordinated peoples into the comforts and privileges of property and citizenship’ (p. 265). Maternal death narratives and ethnographies alike rely on the coherency of the state and the universal liberal subject to make their claims, but this grounding has insufficient in the face of the maternal health crisis time and time again. How do maternal death narratives constrain possibilities for care?

Delays

‘Too Far to Walk’ (1994), another landmark paper by Deborah Maine and Sereen Thaddeus, is an example of how narrative, not only what story is told but how it is presented, shapes proposed solutions to problems. By reviewing the existing literature on maternal mortality with ‘an emphasis on Africa,’ Maine and Thaddeus produced ‘a conceptual framework – three phases of delay – that identifies obstacles to the provision and utilisation of high quality, timely, obstetric care’ (1994, p. 1092). The fact that they limited their review scope to more immediate causes of maternal death, from the onset of an obstetric complication to the outcome, should not be overlooked as what they found informed their ‘three phases of delay’ model, now commonly used to structure entire maternal health programs. Ondo’s Safe Motherhood program, for example, is explicitly modeled on this approach.

The three delays described are: (1) delay in deciding to seek care; (2) delay in reaching an adequate health care facility; and (3) delay in receiving adequate care at that facility. Maine and Thaddeus offer programmatic interventions to counter the factors identified as contributing to the three phases of delay. All of the proposed interventions increase a specific type of access highlighted as missing in maternal death narratives. For example, ‘distance’ was identified as a barrier to reaching care. The options identified to address distance included having women live in maternity waiting homes near hospitals during their last weeks of pregnancy. The idea that women, some of whom have other children to care for, some of whom are in school, and some of whom are the primary breadwinners for their families, will spend the last few weeks of their pregnancy living potentially hours away from where they normally live and work seems farfetched. When women are painted only as victims, the solutions proposed by global health agencies do not account for the possibility that they may of their own volition say, ‘No.’ And the idea that the women may propose their own otherwise solutions is also overlooked.

Disregarding the agentive power of African women, the single tragic, victim-based narrative operationalises the need for state-based intervention, bureaucratic surveillance, and security apparatuses to ensure the safety of women and the future citizens they carry. In 2009, under the leadership of the then newly elected physician-governor Dr. Mimiko, Ondo state introduced a health program with the stated goal of making progress toward the fifth millennium development goals, one of which was to decrease maternal mortality rates by 75% between 1990 and 2015. In a presentation given by the former governor of Ondo state, ‘Mobilising Resources For Achieving MDG 5: The Ondo State Example,’⁶ Olusegun Mimiko summarised the phases of delays in a slide entitled, ‘Predisposing factors to maternal and child death.’ In the subsequent four slides, he described the measures that he had set in place in order to attend to these delays in Abiye, (loosely translated as Safe Motherhood), the state’s maternal health program, which launched on October 28, 2009. In order to prevent delays in seeking care, ‘health rangers’ were hired, trained, and assigned twenty-five pregnant women each to monitor with a customised checklist. In response to delays in reaching care, an ambulance referral system would be set in place. Finally, delays in receiving adequate care were countered with improved facilities and the recruitment and training of health personnel.

Aside from the fact that many of these initiatives were not fully realised once Abiye was scaled up to the entire state, even in the pilot phase, the program left out a significant aspect of the problem of maternal mortality in Nigeria. Focused on the ‘three phases of delays,’ the program did not initially account for the fact that a large percentage of women (84% according to the state’s own baseline survey) did not deliver in government facilities. Many of these women delivered in mission homes. These are birthing centers, which are often housed both ideologically and physically in Pentecostal churches, most notably the Redeemed Christian Church of God and Christ Apostolic Church. While most mission homes allow their members to seek pregnancy care outside of the church, the legacy of these church’s founding principles are evident in the strong aversion to biomedical interventions among many congregations (Oni-Orisan, 2017). Abiye could not respond to the deeply religious, mainly Pentecostal, concerns that motivate many women in their quest for successful deliveries. There was no framework, based on the stories told and models for intervention proposed, for understanding how women piece together maternal health care using multiple sources. It was not until an initial evaluation of the program showed that women were still delivering outside of government facilities in large numbers despite renovations that Agbebiye, a program which specifically addressed deliveries at home and in churches by criminalising them, was added to Abiye. The narratives that informed the three delays models and thus, Ondo’s Safe Motherhood programming, overdetermine the response to the problems they propose.

With conditions as described in maternal death narratives, it is a wonder any African woman is able to give birth successfully. Rarely do informal birth attendants make it into these stories. If they do, they are at best supporting characters with no lines and at worst, the very reason for the delay in seeking care. Maternal death narratives do not show communities coming together or sisters, mothers-in-law, and church congregations pooling their resources to ensure a safe delivery. They don’t discuss university students visiting mission homes, or how a woman who has been deemed infertile might take over-the-counter hormones to improve her chances of getting pregnant. Where are the stories of women who successfully abort using pills given to them by a friend of the family – women who use the wisdom in their networks to manage happy and healthy pregnancies?

In the remake of Fathalla’s original video, ‘Why did Mrs. X die (Retold)’ (2012)⁷, the narrator introduces the film by explaining that since Fathalla’s original lecture in 1987, ‘in some places, things have hardly changed. Women and their babies are still dying needlessly. This is why the story of Mrs. X must be retold.’ Rather than looking for new ways to illuminate the problem of maternal mortality, the same stories are literally retold again and again. In light of the lack of progress made since 1987, it is time to tell new stories that reflect the diversity and depth of African women’s experiences in relation to childbirth.

A balance of stories

What are the alternatives to the single story of maternal death narratives? Chinua Achebe called for ‘a balance of stories, where every people will be able to contribute to a definition of themselves, where we are not victims of other people's accounts’ (Fetters, 2013). African women’s literature and literary criticism offer a new methodological and analytical lens through which we might ‘bear witness’ (Thomas, 2019) free of the violent premise that we can and should be able to know all. For Jobson, ‘a commitment to bearing witness … does not prescribe a sentimental empiricism that rehearses narratives of violence and resilience for an audience of liberal observers and interventionists.’

To this end, I offer parallel excerpts. The first is from Nigerian novelist, Flora Nwapa’s Efuru (1966/1966/2014), the first full-length novel to be written in English by an African woman. The second comes from an interview I conducted with Itunu, a birth attendant I met during my fieldwork in Odo-Owa, a town in Kwara, Nigeria, known for being the birthplace of the father of the Christ Apostolic Church (CAC)⁸ and home to the CAC Faith Home, one of two trainings site for faith-based birth attendants within the church.⁹

Efuru, the eponymous protagonist, having lost her mother at a young age, yearns to be a mother. But after two failed marriages, an infant death, and a lifetime of unsuccessful attempts to have children, she ultimately finds both solace and power in her relationship with Uhamiri, the water goddess of the lake in her village. Uhamiri is a version of the mythic mammywata, a figure born from the colonial era transformation of indigenous Nigerian water deities worshipped for their ability to ensure fertility, health, and wealth. A product of cultural confluence, the elusive mammywata, disrupts the modern/traditional binary by maintaining relevance in vastly different times and places (Drewal, 1988). Uhamiri, like the figuration of mammywata, is beautiful, wealthy, independent, and though she is childless, she is the symbol of motherhood. Efuru dreams of Uhamiri at the end of the novel. Her dream prophesies a future of wealth, beauty, and happiness:

I was swimming in the lake, when a fish raised its head and asked me to follow it. Foolishly I swam out to follow it. It dived and I dived too. I got to the bottom of the lake and to my surprise, I saw an elegant woman, very beautiful, combing her long black hair with a golden comb. When she saw me, she stopped combing her hair and smiled at me and asked me to come in.

I went in. She offered me kola, I refused to take, she laughed and did not persuade me. She beckoned to me to follow her. I followed her like a woman possessed. We went to the place she called her kitchen. She used different kinds of fish as fire wood, big fish like asa, echim, aja and ifuru. Then she showed me all her riches. As I was about to leave her house under the water, I got up from my sleep. (Nwapa, 1966/1966/2014, p. 146)

Despite many obstacles, Efuru has, through her own efforts, found a desirable place for herself in her community.

In her reading of Efuru, literary critic, Chikewenye Ogunyemi offers that in her turn to Uhamiri, Efuru ‘unleashes the secrets of a creative motherhood, a creative life’ (1996, p. 153, my emphasis). As her relationship with Uhamiri intensifies (she becomes a devotee), Efuru continues to prosper economically and socially, transforming into a self-actualised maternal figure, herself, for her community. Ogunyemi maintains that Efuru’s reproductive potential exceeds her capacity to give birth. Through the mythic representation of (creative) motherhood, Uhamiri, Efuru realises her inner desire to ‘mother’ others. In Igbo (and Yorùbá) conceptions of motherhood honour the spiritual and material elements of the procreative role and connect motherhood to leadership and societal wellbeing. Across Nigerian folklore, motherhood remains associated with the divine. Representations of motherhood, fertility, and childbearing are common in the ancient stories of Yorùbá òrìṣà or deities for example. Many of these strong associations between fertility, water, and personal exchanges with God(s), although somewhat transformed, have significance in contemporary forms of Christianity in Nigeria. Efuru’s story reflects these ancient and repurposed associations in a way that is unexpectedly resonant with a contemporary experience.

Efuru serves as a future text (but not the Text) that allows us to meaningfully bear witness to the experience of Itunu, a birth attendant-in-training at the CAC Faith Home in Odo-Owa. The notion of the ‘future text’ is discussed by Alondra Nelson in the introduction to her special issue on Afrofuturism (2002). Nelson describes, a future text as ‘a vision of the future that is purposely inflected with tradition’ in her analysis of Ishmael Reed’s Mumbo Jumbo, in which the capital ‘T’ Text, representing ‘the opportunity to encode African diasporic vernacular culture and create a tangible repository of black experience,’ is appropriately missing (2002, p. 7). A future text holds in tension the impossibility of its own existence and its creative potential. The story of Efuru/Uhamiri/mammywata is both a reflection of ancient cosmologies and a by-product of cultural transformation and technological innovation; thus, having the Afrofuturist quality of being a blueprint for understanding the present as it is inflected by the past and providing visions of the future.

The story Itunu told me about her path to becoming a birth attendant tracks that of Efuru in many ways. Itunu had spent several years working in a salon, unsuccessfully trying to train to be a hairdresser when she received a calling. The Holy Spirit took hold of someone in the salon and instructed her to go fast for three days in ‘the bush.’

Inside the bush where I was, I saw eight birds. They came to me. They came in front of me. Small, small birds … Ah! Inside the bush, me, alone at midnight! How will I survive? I tried to pray. I was crying. I was praying. I had a fearful mind and with it I was praying … I said, ‘Jesus, save me! … I spent the three days in the bush. The birds did not leave the place where they perched until I finished fasting for three days. When I finished, I was going and the birds were following … So I went first to the house of the pastor that told me to fast … The pastor asked me what I saw. I said, ‘I saw birds.’ He said, ‘Yes.’ He said those birds that I saw represent the babies that I was supposed to have delivered, that they told me about, but I refused. He said that God turned them into birds so that they can stay with me … He said that I wouldn’t be able to find my way back. He said that those children would not allow me to find my way until I do the work that I was supposed to do.

Itunu experienced attending births as answering a call from God. During the time she ignored it, there was no harmony in her life. It is only after a retreat to nature that she returns reborn into the world. She will guide women into motherhood, protect their fertility, and foster wellness. The fit with the myth of Uhamiri is not perfect, but here, again, is the creative motherhood, that comes as result of Efuru’s turn toward Uhamiri. Efuru’s story unlocks a grid of significance that is just as grounded in local spiritual tradition as it sheds light on the future.

While the unheard stories of African motherhood are diverse, I center the question of religion and secularity in my work because the act of labeling a practice religious has come to have the effect of delegitimization. Thus, of the experiences of pregnancy in Nigeria, those that are considered to be religious are most illegible to global health communities and least likely to be included in the dominant discourse unless otherwise ascribed to more legible political economic concerns. Efuru’s dreams and Pentecostal mission homes are unintelligible to many in global health. Not simply because of their spiritual content. This is not in itself the problem. Think, for example, of all the ways that the religious infused Safe Motherhood campaigns and colonial maternal health campaigns before them. These experiences as conveyed through dreamscapes do not make it into global health narratives because of their creative content and, ultimately, their incoherency. Global health, as a unidirectional structure of power, cannot envision Africa as a space of possibility.

Conclusion

What both Adichie and Mkwanazi bring to light is that the problem with the single story is not that it is necessarily untrue, but that it is incomplete. However, if Jobson is to be taken seriously, even this liberal quest for ‘complete’ is premised on conceptual and methodological preoccupations with a universal coherent human subject. The maternal death narratives (and even their richer ethnographical counterparts) characterise the problem of maternal mortality in such a way that the solutions are confined to state-driven fixes in a world where access to the state (or citizenship) is neither evenly distributed nor equally sought after and where spirituality disrupts boundaries between human and nature.

If we are asked routinely to think with a certain African death, through global health calls, through media representations, through some critical theory, perhaps we make a ‘darkness’ that has only one register, making the multiplicity (and ambivalence) of existing alternate modes of life unthinkable. In relying on maternal death narratives to motivate global health campaigns around maternal health, policymakers obscure the plethora of ways that African people have, in fact, survived and the lengths that they go to in order to ensure safety for themselves and their children. In doing so, they build racialised and gendered imaginaries that overdetermine the international response.

The three-delays model, while certainly insightful and effective in addressing some of the issues related to childbirth, is a single story, which in focusing on preventing death alone fails to attend to the diversity of local realities. Ondo state missed an opportunity to respond directly to the needs and desires of its pregnant women in modeling its programming around the three delays instead of focusing on the results of their own needs assessment, which signaled that women preferred to deliver outside of hospitals. As a result, other potential solutions, working collaboratively with mission homes, for example, were foreclosed. This is important not only for saving lives, but also respecting their choices and the idea that they make choices based on reasonable concerns for their health and future. I find that moving toward a recognition of how singular narratives blind us to other possibilities will get us closer to recognition of solutions. As representations of motherhood and African women are complicated so too are possibilities for maternal health care.

African literature allows for pause to reflect on desire, anxiety, morality, and power in the context of notions and experiences of motherhood in a moment where we are all too concerned with population control and indices of development. The interruption creates refuge for creative potential to flourish and come to fruition. It makes space for the plurality of alternate modes of living that a concentration on death renders into singularity. In coupling artistic expression with scholarly inquiry, much like the Afrofuturist project, I hope to destabilise the normative matrix of binaries around blackness as oppositional to progress and futurity, making possible a different type of future making, new paths to achieve Abiye.

Acknowledgements

Many thanks to Vincanne Adams, Ian Whitmarsh, and Ugo Nwokeji who offered comments on different versions of this article. I am also indebted to Dr. Friday Okonofua, Dr. Dayo Adeyanju, Dr. Kayode Adegbehingbe, and Seye Olajide for helping me to contextualise and physically navigate the complex network of maternal health care in Ondo state. Finally, I am deeply grateful for the Nigerian women of Ondo state who shared their lives with me and allowed me to accompany them on a journey that is often filled with vulnerability and uncertainty. This article forms part of a special issue on the theme of ‘African Voices in Global Health: Knowledge, Creativity and Accountability’ edited by Mandisa Mbali and Jessica Rucell.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Research in Nigeria was supported financially by the Fulbright-Hays Program, which is sponsored by the U.S. Department of State. Archival research at WHO headquarters was supported by the Brocher Foundation.

Notes

1 In ‘Geographical Basis of History’ in his Lectures on the Philosophy of History (1837), Hegel maps culture on to geography, producing a theory of historical agency that ties the progress of world history to the ‘Spirit’ of a people. He contends that, while in zones of extreme climates (cold, heat, elevation), nature was ‘too powerful to allow Spirit to build up a world for itself … the true theatre of History [was] therefore the temperate zone; or, rather, its northern half’ (p. 3). Hegel elaborates on this view in his (only) analysis of Africa, which he describes as ‘the land of childhood … lying beyond the day of self-conscious history.’ (p. 11)

2 See, for example Van Lerbergheand and De Brouwere (2001).

3 The WCC administrative office was and still is a short five minute walk from the WHO headquarters in Geneva, allowing for easy communication between the two organizations. Soon after Mahler was elected to director-general, he began to follow closely the activities of the CMC, which were driven by a rights based, social justice framework. Impressed with their community-centered, ‘whole person’ approach to health promotion in rural areas, Mahler strengthened the WHO’s already informal relationship with CMC through a series of conversations and meetings with the CMC leadership. WHO’s principles of primary care emerged from these conversations and CMC had a significant presence at Alma Ata (Smith, 1998; Litsios, 2004).

4 A DALY or diability-adjusted life-year is a time-based statistical measure that accounts for both years of life lost due to premature mortality (YLLs) and years of healthy life lost due to disability (YLDs).

5 However, Sridhar et al. (2017) note that Global Fund is financed by trust funds held at the World Bank.

6 Based on an undated copy of the former Governor Mimiko’s Power Point presentation, which was sent to me by email communication in June, 2013.

7 The short film was produced and funded by Hands On for Mothers and Babies, and subsequently promoted by numerous organization including FIGO and WHO.

8 Joseph Ayo Babalola was a prophet and founding leader of the Christ Apostolic Church. Odo-Owa is not only where he was born, but where, after receiving a call from God, he began attracting large crowds for prayer meetings and to witness his miraculous acts of divine healing and prophecy before joining members of the Faith Tabernacle to later establish the CAC church in 1941 (Peel, 1968).

9 When CAC was established, one of Babalola’s first acts was to establish a space for maternity care and midwifery training in order to address the large proportion of reproductive concerns that brought people to the church (CAC, 1968). Today, there are two CAC Faith Home Maternities, where aspiring birth attendants are trained in maternity care.