AN ABSTRACT OF THE THESIS OF Bonnie J. Ruder for the degree of Master of Arts in Applied Anthropology presented on November 28, 2012 Title: Shattered Lives: Understanding Obstetric Fistula in Uganda Abstract approved: Melissa J. Cheyney In Uganda, there are an estimated 200,000 women suffering from obstetric fistula, with 1,900 new cases expected annually. These figures, combined with a persistently high maternal mortality rate, have led to an international discourse that claims the solution to improving maternal health outcomes is facility-based delivery with a skilled birth attendant. In accord with this discourse, the Ugandan government criminalized traditional birth attendants in 2010. In this study, I examine the lived experience of traditional birth attendants and women who have suffered from an obstetric fistula in eastern Uganda. Using data collected from open-ended, semi-structured interviews, focus groups, and participant-observation, I describe the biocultural determinants of obstetric fistula. Based on findings, I argue that although emergency obstetric care is critical to prevent obstetric fistula in cases of obstructed labor, the criminalization of the locally constructed system of care, TBAs, serves as yet another layer of structural violence in the lives of rural, poor women. Results demonstrate how political-economic and cultural determinants of obstetric fistula are minimized in favor of a Western prescribed, bio-medical solution, which is heavily resource dependent. This solution is promoted through a political economy of hope fueled by the obstetric imaginary, or the enthusiastic belief in Western- style biomedical obstetric care’s ability to deliver positive health outcomes for women and infants regardless of local context and constraints. Recommendations include increased obstetric fistula treatment facilities with improved communication from medical staff, decriminalization of traditional birth attendants and renewed training programs, and engaging local populations in maternal health discourse to ensure culturally competent programs. ©Copyright by Bonnie J. Ruder November 28, 2012 All Rights Reserved Shattered Lives: Understanding Obstetric Fistula in Uganda by Bonnie J. Ruder A THESIS submitted to Oregon State University in partial fulfillment of the requirements for the degree of Master of Arts Presented November 28, 2012 Commencement June 2013 Master of Arts thesis of Bonnie J. Ruder Presented on November 28, 2012. APPROVED: Major Professor, representing Applied Anthropology Director of the School of Language, Culture, and Society Dean of the Graduate School I understand that my thesis will become part of the permanent collection of Oregon State University libraries. My signature below authorizes release of my thesis to any reader upon request. Bonnie J. Ruder, Author ACKNOWLEDGEMENTS I am deeply grateful for all the advice, support, and encouragement from my advisor, Dr. Melissa Cheyney. From the initial MAP meeting through the completion of this project, she has guided, challenged, and inspired me in countless ways. I am also grateful for my committee members, Dr. Kenneth Maes, Dr. Larry Roper, and especially Dr. Chi, my advisor in the IH program. I would like to thank Oregon State University Anthropology Department, the President’s Commission on the Status of Women, and the School of Language, Culture, and Society for financial support of this project. Special thanks to Dr. Susan Shaw, Karen Mills, and Loretta Whip. I am especially grateful for my cohort in the Reproductive Health Lab. There I have found scholarly support, constructive advice, friendly suggestions, and most importantly good listeners and lifelong friends. Even in the most stressful times, we managed to find something to laugh about. I am forever grateful to Alice Emasu, Apio Stella, and the staff and volunteers at TERREWODE. Thank you for the generosity, patience, and kindness you extended to my family and me during my fieldwork. I couldn’t have completed this project without your support, guidance, and invaluable knowledge. Your dedication to fistula advocacy, awareness, and treatment is truly inspiring. I feel a deep gratitude for the women, both obstetric fistula survivors and traditional birth attendants, who shared intimate and painful stories with me. Your stories are with me forever and I hope I have represented them faithfully here. I have been incredibly blessed with a wonderful community that has supported my family and me throughout my graduate school experience. I have often joked that it takes a village for a mom to go to grad school, and I’ve been lucky to have an amazing village. Friends and family have helped us in countless and immeasurable ways. Special thanks to my family for all their love throughout the years ~ my mom, my dad, Karen, Stacie & Kevin, and Ryan & Danielle - without your belief in me, none of this would have been possible. A special shout out to my dad and Ryan for bringing emergency supplies to Uganda! Finally, I am especially thankful for the love and support from my husband, Eric, and our sons, Soren & Lucas. Eric has believed in me from day one and encouraged me in the most challenging times. Through the years he has become an expert in homebirth, midwifery, and now obstetric fistula as well. He’s my late night editor, in addition to gracefully picking up the slack whenever I needed a hand. Eric, Soren & Lucas accompanied me to Uganda and were the best companions and research assistants ever. Thanks for standing by my side and hanging in there when things were tough. I am forever grateful and will cherish the memories we made in Africa. TABLE OF CONTENTS Page Chapter 1 Introduction ……………………………………………………………….. 1 Chapter 2 Literature Review………………………………………………………….. 13 Obstetric Fistula: Epidemiology, Evolutionary Predictors, and Treatment…… 13 Political-Economic Determinants of Obstetric Fistula……………………….. 17 Socio-cultural Determinants of Obstetric Fistula…………………………….. 22 Embodied Experience………………………………………………………… 23 Chapter 3 Methods …………………………………………………………………… 27 Phase 1: Qualitative Interviews with Obstetric Fistula Survivors……………. 27 Phase II: Qualitative Interviews with Traditional Birth Attendants………….. 30 Phase III: Reciprocal Ethnography.…………………………………………... 32 Participant Observation………………………………………………………. 34 Limitations……………………………………………………………………. 35 Chapter 4 Results ~ The Four Delays………………………………………………… 38 Delay One: The Delay in Seeking Care; Acha Josephine’s Story ………….... 39 Delay Two: The Delay in Accessing Care; Andira Nadine’s Story…..……… 45 Delay Three: The Delay in Receiving Care at the Health Facility; Aria Mary’s Story………………………………………………………………….. 49 The Fourth Delay: The Delay in Receiving Treatment for Fistulas; Anna Margaret’s Story………………………………………………………………. 57 Chapter 5 Results ~ Gendered Inequality & the Obstetric Imaginary………………… 63 A Girl-Child Bride: Apio Helen’s Story………………………………………. 63 Keeping Her in the Dark: Stella Amujo’s Story……………………………….. 70 TABLE OF CONTENTS (Continued) Page Faith in the Obstetric Imaginary: Mirembe Rosie’s Story…………………… 76 Chapter 6 Discussion………………………………………………………………… 84 Structural Violence and the Four-Delays……………………………………. 84 “Emergency” Maternity Care and Blame……………………………………. 88 Political Economy of Hope and the Obstetric Imaginary……………………. 93 Chapter 7 Conclusion………………………………………………………………... 95 Future Studies………………………………………………………………… 98 Recommendations……………………………………………………………. 99 Bibliography…………………………………………………………………………. 102 Appendices…………………………………………………………………………… 113 Shattered Lives: Understanding Obstetric Fistula in Uganda Chapter 1: Introduction After our morning rounds, I was invited into the doctor’s room to observe 1 antenatal care with Dr. Chipeta , the head obstetrician, and Winnie, a resident currently on the maternity ward. Around mid-day, we took a short break and began discussing medical school and doctor’s pay when the conversation turned to traditional birth attendants (TBAs). I told them I’m doing a study with local TBAs and with women who have suffered from obstetric fistula. Dr. Chipeta said he doesn’t think TBAs should be trained because then women will keep using them. “We just need to be done with them”. If the TBAs aren’t there, he explained, then all the women will come to the clinics or hospitals for delivery. I pointed out all the other obstacles women face -- poverty, lack of transportation, and especially the overcrowding at the hospitals. It was just 12:30 in the afternoon and all the maternity ward beds were full. Already women were lying on mats on the floor just outside his door. Dr. Chipeta agreed with my points, yet this didn’t seem to change his mind on TBAs. I asked Winnie her opinion. She said she didn’t really know about obstetric fistula, but she thinks the TBAs could still be of some use: “I think training might still be helpful in the meantime, until things improve at the hospitals.” I asked her if she thought she would go on and train as an obstetrician. She said probably not. It’s three more years of school and the pay is so little. In fact, none of the residents I talked to were planning to specialize in obstetrics. (Field notes, hospital maternity ward, Soroti, Uganda, December 2011) In Uganda, a persistently high maternal mortality rate, combined with one of the highest obstetric fistula rates in the world (Murk 2009), has led to the adoption of an international discourse that constructs institutional births with skilled birth attendants as imperative to improving maternal health. Dr. Chipeta’s comments illustrate how this discourse has permeated local, reproductive health fields despite tangible evidence of the difficulties associated with implementing this heavily resource dependent system. This maternal health discourse around the superiority of institutional deliveries originates in the global north and is based on a biomedical, technocratic model of birth. Adoption of U.S-style, biomedical models of obstetric care, that are imported and often uncritically embraced by those least able to implement them, has contributed to the rejection of