Causes of death are mortality stories. Yet demographers and epidemiologists do not often think of them as stories. Mortality statistics come to our laptops as numbers—counts of a variety of causes of deaths assigned according to the International Classification of Diseases. Yet, as this book richly illustrates, the production of mortality data is inherently messy, and how this mess transforms into neatly categorized statistics about death matters. The production processes we select can reveal or obscure stories about why women, too often, die in childbirth; and these stories shape policy, drive interventions, and affect lives, for better or worse. Claire Wendland, the book's author, is an extraordinary mortality storyteller. Wendland is an obstetrician-gynecologist who draws on over 30 years of practice in the United States and Malawi. The book, set in Malawi, draws on Wendland's surgical and clinical observations and experiences, as well as analyses of de-identified medical records, giving us insight into how health practitioners identify causes of death that end up on death certificates. Wendland is also an epidemiologist who skillfully takes apart statistical models and examines exactly how maternal mortality indicators are produced. The book includes historical analysis, drawing on primary archival work at the WHO, as well as other collections in Europe and Malawi. Finally, Wendland is a medical anthropologist, who wrote extensive fieldnotes, engaged in ethnographic observation, and conducted over 100 interviews in Chichewa and English with doctors, clinical officers, nurses, midwives, traditional birth attendants, health surveillance assistants, traditional healers, politicians, family members, and community leaders, among others. This rich dataset adds an important complexity and nuance to our understanding of the places, lives, and deaths that are central characters in the stories of maternal mortality in the book. The book's title, Partial Stories, takes its inspiration from Chimamanda Ngozi Adichie's well-known essay on "the danger of a single story." The book examines the many partial stories that are told about the causes of maternal mortality: the structural adjustment and modernity story (Chapter 1), the medical story (Chapter 2), the technological story (Chapter 3), the abundance/scarcity story (Chapter 4), the statistical/epidemiological story (Chapter 5), and the political story (Chapter 6). These partial stories variously locate risk, and potential interventions, in modern lifestyles, within a woman's own body, in the health facility where she finds herself, in her community, in the national and global political economy of her country, and in its stage of development. Chapter 2, Knowing Bodies, examines medical stories of death. The first row of one such story reads: "RC 28 G3P2L0" (p. 69)—which Wendland translates for us as describing a 28-year-old woman "RC," who presented with her third pregnancy, had given birth twice, and had no living children. The ninth row completes the story: "HD#14→ incomplete ab," describing RC's death on the 14th day in hospital due to an ongoing miscarriage. These rows were distilled into a single definitive cause of death on the death review form—hemorrhage, one of the most common causes of maternal death. However, as Wendland details, in fact, many causes may have contributed to the death including delayed lab results; the patient's HIV-positive status and lack of clarity about whether she was on anti-retroviral therapy; lack of blood transfusion; underqualified staff given the seriousness of the case; and pneumonia (pp. 69–70). Thus, hemorrhage as a cause of death is a partial story, rendering invisible vital information that could be useful for future interventions. Chapter 3, Ambivalent Technologies, looks up from the pregnant woman to consider the health facility around her, bringing into sharp focus the many tools and technologies involved in childbirth and maternal mortality stories. These tools include basins, gourds, razor blades, syringes, automated analyzers to aid diagnoses, healing technologies such as cesarean sections, the misoprostol pill which aids labor contractions and controls postpartum bleeding, and "appropriate technologies," a euphemism for hacks used by healthcare workers in low- and middle-income countries when standard technologies are not available. These tools and technologies could help or harm, and the chapter illustrates how maternal deaths were often attributed by health workers to their presence, absence, or misuse. The book illustrates how the global health community in Malawi contributed to these presences and absences in Chapter 4, Abundant Scarcity. The chapter illuminates the contrast between medical enclaves such as Médecins Sans Frontières and Western-funded research projects which had many elite and expatriate staff, the latest tools and technologies, and plentiful supplies for patients lucky enough to be under their care. This abundance stood alongside everyday absences and scarcity in government-funded Malawian health facilities—with not enough staff and not enough supplies, both contributing to maternal death. Health facility scarcity was strikingly encapsulated in the description of what pregnant women were required to bring with them to some government-funded labor wards, including a new razor blade, a basin, two chitenje (African print wraps), one waterproof cloth, soap, and thread. With these items, a prospective mother would be able to use one chitenje to create a mattress for herself, the waterproof cloth to protect the delivery table from birth fluids, the razor blade for the health worker to cut her newborn's umbilical cord, and thread to tie it off. She would use the basin and soap to wash her clothes and infant, and the second chitenje to wrap her newborn (p. 175). Even if a woman brought all this, she still confronted scarcity at the health facility which could cause her death. As Wendland put it, scarcity meant that "maternal mortality is often produced passively; it is the product of actions not taken. The cause of death is the hospital not staffed…the clinic never built…the ambulance up on blocks not repaired or refueled, the sutures not restocked…the antibiotics not delivered to the health center" (p. 182). Contrasting Western abundance with local scarcity in the same district, or even within the same hospital, further highlights the preventability of maternal death, with abundant staff and supplies a few steps but many worlds away. Local scarcity was in part produced by Malawian debt and structural adjustment policies in the 1980s and 1990s to address the debt. As described in Chapter 1, Dangerous Modernities, the country had turned to global agencies for assistance, and in exchange, the agencies' demands resulted in a reduced national healthcare budget and subsequent healthcare shortages. The subsequent era of the last two decades was seen as bringing poverty and hunger; rising inequality and associated jealousies which led to a rise in witchcraft; and a range of modern diseases such as diabetes, hypertension, and HIV/AIDS which created dangerous complications for pregnancy. In this story of maternal death, all these problems of modernity combined to make contemporary pregnancy dangerous and deadly compared to the past. Chapter 5, Countless Accountings, highlights how "the goals of quantifying death and explaining deaths were in tension" (p. 202). Malawi did not have a complete vital registration system, requiring the use of verbal autopsies (VA)—interviews with relatives which were transcribed and distilled to come up with a single cause of death. Describing one such interview, Wendland shows how what was left on the cutting floor in the service of producing "clean data" was critical for crafting effective interventions to prevent maternal death. The three delays framework (delays in deciding to get care, accessing care, and receiving adequate care) enables practitioners to identify failure and intervention points. In this case, the VA interview revealed the critical role of transportation delays in the woman's death, but the listed cause of death was hemorrhage. The chapter then examines how the VA data were transformed into Malawian maternal mortality indicators and trends. Wendland compares and contrasts the differential modeling strategies and methodological choices of the Institute for Health Metrics and Evaluation (IHME), which produces the Global Burden of Disease studies, and the UN/World Bank/WHO group (UNWW). The chapter illustrates how models and the indicators they produce are also a form of storytelling; they "conceal many uncertainties, build in many assumptions, and obscure many human decisions about what and whom to count" (p. 189). IHME and UNWW told different stories of maternal mortality, in part due to different covariates: IHME focused on national development and included GDP, neonatal mortality, HIV seroprevalence, and women's education as covariates, while UNWW focused on the presence or absence of skilled birth attendants (pp. 205–217). It was the UNWW group estimates that entered Malawian politics, in part because the group had consulted with national epidemiologists. The book then examines the lives these estimates took on in Malawi, how they were employed by President Joyce Banda during her administration (2012–2014), and how they motivated interventions, all without access to the rich information available in the raw VA data. In Malawi, as around the world, reproduction is political, and the final substantive Chapter 6, Fragile Authority, tells the reproductive governance story of maternal death. Both historically and currently, many policies have been enacted to regulate how births occur, including who is permitted to help pregnant women (spirit healers, nurses, midwives?), who can attend a birth (traditional birth attendants or clinicians?), and where births can occur (inside or outside of health facilities?). On the ground in Malawi, these decisions had life-and-death consequences. "Skilled birth attendants" (SBAs) were the WHO gold standard, yet while newly trained nurses were SBAs, traditional birth attendants who might have attended hundreds of births were not and were banned between 2007 and 2010 and again from 2012 onwards. Meanwhile, many untrained individuals, such as cleaners and ward attendants, attended births in health facilities due to task shifting because of a limited number of nurses available to work in wards (p. 238). The chapter also describes problematic attempts to involve men, both at the level of male chiefs (who imposed fines on women who gave birth at home) and at facilities where some women "rented husbands" (p. 263) to ensure they were seen or at least not sent to the back of the line. Partial Stories is dense and long (almost 300 pages, not including notes and bibliography). This is in part because the book often privileges granularity and comprehensiveness over being succinct and deft. The book would have benefited from more clarification of the key arguments, less repetition, and more sifting through the many different explanations within chapters for the reader. It is easy to get lost in the forests and thickets of this book. And by the end of the book, when the adventure is over, the reader is left with an extensive understanding of the causes of maternal mortality in Malawi, but no clear way forward. The policy implications are immense, but it is hard to know what to do next, beyond just being better informed, while carrying on with our favored form of story reading or telling. Yet this book makes clear the necessity of more fully integrated storytelling, and multisectoral actors at policymaking tables. Could there be national policies around resource-sharing between the many Western-funded health projects in the country and local hospitals? Should there be a return to fully equipping and integrating traditional birth attendants and healers into the national healthcare system? Could VA interviews include checkboxes for the three delays, to enable data-driven interventions as significant as the HIV treatment cascade (% diagnosed, % on treatment, % virally suppressed)? A robust section on policy implications would have helped readers better translate these important findings into transformative actions. Nevertheless, Partial Stories is an extraordinary accomplishment. It is that rare book that comes along and forever transforms how a perennial social problem is seen and thought about. The study is unmatched in its sheer breadth, and complex and nuanced depth, reflecting the rich experience, expertise, and empathetic knowledge brought to bear by Wendland. This book is a must-read for mortality scholars and maternal health policymakers.
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