Sunday, January 29, 2012

Maternal Health Reflection

On the evening before the final academic presentations at the Makerere University School of Public Health, we led a discussion on Ugandan and American perceptions of fertility, relationships, love and maternal health. We also sought to engage a broader culminating discussion to provide a sense of closure on the last Sunday at Ndere Center in Kampala. We sensed a slightly more somber mood: the days of independent fieldwork had come to a close and groups were mentally gearing up to articulate in fifteen brief minutes the very complex experiences and issues they had encountered over three weeks in Kampala and Rakai.

Our first goal was to rekindle some of the energy and dynamism that has characterized so much of this trip. We held two simple physical games, both requiring closeness and non-verbal communication. We wanted to harness some of the palpable restless energy, and the games did restore a sense of spirit, even after we had gorged ourselves on soup, Luwambo and all the classics — matoke, rice, yams, Irish potatoes, beans, etc. The competitive element allowed people to refocus after a minimally structured day in Kampala, first challenging three bodies to fit on a two-foot square leaf of newspaper, and then rearranging groups along a line without speaking.

Rather than structure a didactic conversation on the nature and scope of maternal health issues in Uganda, we opted to sensitize the group to the diversity of our own experiences (i.e. number of siblings, aunts/uncles, one's birth location, and anticipated number of children). Interestingly, we did not find a stark delineation between Hopkins and Makerere students. For instance, of the two people who reported having been born in a maternity center, one was American and the other Ugandan. The only universal perception was that of a uniquely rewarding MU-JHU collaboration, which students described as  successful due to the group's cohesion, dynamism, openness, and diversity. Many cited preexisting anxieties that the group might gradually fragment into numerous cliques, but such a scenario never materialized in Uganda. Instead, the group was notable for its absence of "weird group dynamics", as well as its acceptance and receptiveness to individuals' needs.

The Social Context for Maternal Health in Africa
Social dynamics and relationship norms provide a contextual landscape for maternal health, both in terms of a woman's access to care and her health outcomes. We wanted to gauge whether the American and Ugandan students had encountered any surprising dynamics or behaviors, at the rural home-stay or in urban Kampala, that had informed their understanding of relationship norms (either American or Ugandan). Patience (MU) noted the seemingly inseparable nature of romantic relationships between Americans. She described love as pervasive and passionate, specifically noting the long distances over which relationships played out. She also noted, however, that divergences in academic or career paths were often enough sever ties between young couples. Both of her observations provide insight into how Ugandans might perceive American relationships.

The Americans were struck by the affection, generosity and intensity of platonic relationships between Ugandans. Jacques described contrasts between Ugandan and American social norms, noting that Americans are rhetorically "progressive," but in fact "very guarded about our space." In contrast, Ugandans more openly hug, hold hands and tolerate temporarily close quarters, on public taxis or Kampala's streets. Paradoxically, public displays of romantic love are rare and widely construed as inappropriate. As one MU student put it, "We don't have a kissing culture." The American students appreciated Ugandans' heightened sensitivity to physical well being and aberrations of the body. A bandaged knee, unnoticed in the U.S., had elicited Ugandans' concern (Joyce). Similarly, a conductor on a taxi had repeatedly asked Henry whether he was comfortable in the cramped space. The general mood of empathetic concern is perhaps best encapsulated by the typical Ugandan opening question in conversation: "How is your life?"

American and Ugandan Experiences: Birth and Fertility
Both MU and JHU students documented lower fertility rates among their generations, relative to their parents'. Of course, our results are not necessarily applicable to Uganda as a whole, for we were working with a highly educated group of students attending Makerere University. Nonetheless, these data do give a rough portrait of changes in contemporary reproductive norms across the life course and generations. Most students had 3-5 maternal aunts/uncles (45%), and roughly equal numbers had 1-2 (26%) and  >6 maternal aunts/uncles (30%). The proportions of students reporting 1-2, 3-5 and >6 paternal aunts/uncles were roughly equal (~33%). The majority of students had 1-2 siblings (65%), with five students reporting 3-5 siblings. With respect to future fertility, most envisioned having 1-2 (48%) or 3-5 (39%) children. Of the three students who desired >6 children, all were Ugandan.

Adelina observed a qualitative correlation between a student's number of siblings and desirable future fertility rates. Henry noticed less of a contrast between Ugandans and Americans than the literature might lead us to anticipate. Indeed, we found some flexibility and variability in perceptions of the appropriate family size, and never encountered unrelenting perceptions of "normality" in fertility.

We also posed questions related to anticipated choice of delivery site for expectant American and Ugandan mothers. Americans generally believed that Ugandans gave birth at home, citing barriers such as transportation and cost of hospitalization, as well as cultural norms, perceptions of safety, and limited education as determinants of home birth. Brynn recollected a lecture by Gilbert Burnham, in which he mentioned that the majority of Ugandans live in secluded rural areas. Frank proposed that more Ugandan women might give birth in the presence of a traditional birthing attendant (TBA), due to lower cost and proximity to the village. In contrast, Ugandan students assumed that Americans gave birth in hospital settings, as access to health care was perceived to be high. Interestingly, Patience expected technology to be "so high" in the U.S. that some women might give birth in their own kitchens.

In fact, 83% of all (Ugandan and American) students had been born in a hospital, potentially reflective of the prominence of health facilities in the course of pregnancy and delivery in both countries. Only one Ugandan student had been born at home. This finding might offer an interesting starting point for further discussion related to the medicalization of childbirth, both in the U.S. and Uganda.

In Kampala with No Agenda
During reflections on the free day spent in Kampala, students echoed earlier positive impressions of the group dynamic as whole. The MU students relished in seeing JHU students respond to taxis, crowds and vendors on the streets. MU students also felt directly responsible for the experience of their American counterparts. JHU students sensed and appreciated the generosity and patience of their MU counterparts, and benefited from their guidance and the opportunity to independently explore the city. There was a general consensus that MU students would benefit from a future program in Baltimore, and that it would enable the Americans to reciprocate in some small way. Marie alluded to potential parallels between Baltimore and Uganda in terms of health and education. Adelina emphasized the necessity of experiential learning to good global health practice, and reasserted the need for travel and direct interactions between students in developing countries and the developed world. The desire to integrate Ugandan hospitality, work ethic and resilience into our lives in the U.S. was reiterated. For many, this program has revealed or reconfirmed academic and career paths, and that process has continually drawn from the invaluable aid (linguistic, cultural and social) of our Makerere collaborators.

The true extent of the program's impact on our spiritual, service and professional lives will reveal itself only gradually. But individual growth is also already evident. The candid nature of our discussions has enabled us to break through superficial impressions of place and people to tease out motivations, interests, and structural factors that influence health outcomes. I am hopeful that the group dynamics we cultivated were not the result of some arbitrary collection of complementary personalites, but rather the result of purposeful conversation, openness and engagement, qualities that can be replicated with future groups in Uganda, Africa, and throughout the world.


  1. Great health articles given us on Ugandan and American perceptions of fertility. Before reading this blog I really didn’t know the importance of this issue. I am glad you shared this thank you.

  2. This was a very insightful article. Though provoking...It dashed a lot of stereotypes that I had about how and where most rural women delivered their babies.