Claire Wendland is an anthropologist with training as an obstetrician, which positions her to understand both the social and medical dimensions of maternal deaths. I recently heard Wendland present findings from her extensive field research in Malawi, which explores different narratives or explanations for why women die from pregnancy and birth-related causes in a specific geographic context. Through interviews with workers in the health care industry in Malawi, Wendland has found that a high maternal mortality rate coupled with a lack of clarity around the exact causes of these deaths give rise to multiple and varying explanations for why they happen. Diverse experts advance divergent, often contradictory explanations for deaths that reveal competing social or political agendas. The explanations are used to understand risk, assign blame, teach biomedical concepts, present moral lessons, and critique Malawian society.

Wendland shared the stories of two young women’s deaths to illustrate how this process happens. In her first example, a 15-year-old Malawian girl gave birth to a live infant but began having seizures after the delivery. The facility she gave birth at had no way to control the seizures and the teenager died before there could be additional medical interventions. Following her death, some of the bio-medically trained staff speculated that eclampsia could have caused the seizures, while others suggested that it was cerebral malaria, in which case the pregnancy and birth did not contribute directly to her death. (This distinction matters, Wendland noted, for data purposes – if the death is not attributed to a pregnancy- or birth-related cause, it is not classified as a “maternal death.”) Meanwhile, Wendland noticed that when she explained the case to traditional birth attendants (TBAs), they attributed this very young mother’s death to an “unready path,” suggesting that her physical immaturity made her vulnerable to complications. Still others cited the girl’s lifelong experience with poverty and the ineffective medical transport system.

Wendland’s second story of maternal death was a 28-year-old woman at the end of her eighth pregnancy. The woman gave birth alone, outside, and experienced prolonged bleeding. She was found and carried by family members to the nearest medical facility. Her placenta was stuck to her uterine wall (perhaps it fused to scar tissue from previous pregnancies), likely causing the extended bleeding, but the facility lacked the capability to surgically correct the problem. She needed to be transferred to a hospital but died before that could happen. The primary medical explanation for her death was the hours-long hemorrhage and associated blood loss. However, Wendland’s interviewees also identified the inadequacy of the supplies and transportation system, the woman’s unwanted/uncontrolled fertility, and the possibility that a jealous person in her community had bewitched her.

The registration of deaths is not compulsory or common in Malawi, Wendland explained, and neither women’s deaths were included in official statistics. The limitations of data in this context mean that public health statistics themselves (for example, the attempts at estimating country-wide maternal mortality) are subject to varying interpretations, just like individual deaths.

Wendland then transitioned to the history of Malawian medical tradition. This is shaped by the country’s experience with European colonizers and racist, sexist labor markets. For example, in the late 1800s, European women shut out of job opportunities in Europe sought out midwifery training so they could provide care in missionary settings in colonized parts of Africa. For many reasons, including the racism of white missionaries, there was less resistance to white, European women getting formal training and entering medical professions than to black, African women doing the same.

Today, there are diverse care providers attending to childbearing Malawian women and all have numerous and competing explanations for the high maternal death rate, estimated by the CIA World Factbook to be 460 deaths per 100,000 live births, or 24th highest on a list of 184 countries. A woman’s lifetime risk of dying of a maternal cause in Malawi is one out of 34 (the United States is one out of 1,900). Wendland encountered the following potential explanations: HIV, pregnancy at a young age, close spacing of pregnancies, poverty, lack of information, the potential safety risks of traditional birth care practices, and more. During Wendland’s interviews, she noticed tensions in her interviewees’ descriptions of the past, present and future of Malawi. Some interviewees idealized the past, suggesting birth was historically safer than it is today, while simultaneously advocating for Malawi to move toward a modern future, with closer adherence to biomedical advice and interventions during pregnancy and birth. The narratives explaining maternal deaths may say more about how people view the dynamics and pace of societal change than about what is actually happening in the lives of individual woman who die.

Globally, the deaths of childbearing women are frightening and horrifying, but despite an abundance of plausible explanations for why maternal deaths happen, there isn’t agreement on where to focus resources. Nevertheless, understanding both the context and significance of experts’ explanations for why some women die can help in both the development and uptake of effective, culturally relevant solutions.