Doctoral Dissertation Research: An Institutional Ethnography of the Social Dynamics of a Bureaucracy in Historical Context

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All institutions display social and bureaucratic dynamics that affect how the institutions function. In the United States, health care provisioning institutions are particularly important because they comprise the majority of care facilities for the American public. The goal of the research funded by this award is to identify organizational factors that affect health care provisioning outcomes but are not necessarily directly related to technical expertise. The research will be undertaken by Adrienne Strong, a doctoral student at Washington University St. Louis, who works under the guidance of medical anthropologist, Dr. Carolyn Sargent. Strong has chosen to focus on the bureaucratic, institutional, and social dynamics that contribute to maternal deaths in biomedical care settings, because this is an area where the United States is known to lag behind other Western nations. She will conduct the research as an in-depth institutional ethnography of a hospital in the Rukwa region of Tanzania. Because the region has high rates of maternal mortality, the links between outcomes on the one hand and institutional structures and processes on the other will be easier to identify than they would in the United States where a single institution would provide too few events to study. In addition, understanding the social and bureaucratic dynamics of health care facilities in Africa is important for being able to stem the rising tide of globally significant infectious disease epidemics.Strong will collect data on sequences of events at the hospital, and on historical, institutional, and political economic structures that shape maternal risk. She will employ a variety of qualitative research methods, including in-depth interviews with government officials, health administrators, nurses and doctors, traditional birth attendants, and pregnant women and their families. She also will observe at the hospital; hold group discussions with women and community leaders; and conduct a work empowerment survey of health care providers. She will concentrate on four topics: 1) How institutional factors and strategies of health care providers shape obstetric emergencies; 2) Sequences of events preceding a woman's arrival at the hospital during an obstetric emergency; 3) How life events, social relations, and other community factors influence maternal health; and 4) Connections between historical processes and the current functioning of the health care system. Similar methods can be used in the United States to identify new sites for intervention to interrupt the pathway to maternal death once the underlying processes are identified. Strong's data will allow her to analyze communication (among medical professionals, between staff and patients, between women and their families or communities); health care provider morale and motivation; and administrator strategies and goals. Understanding these factors will complement the extensive previous research on the clinical and community causes of maternal death. This will contribute to social scientific understanding of the workings of bureaucratic institutions in general as well as low-cost solutions for improving health care in particular. Public health policies everywhere encourage women to give birth in biomedical care facilities. Strong's research will generate novel insight into the sequences of events leading to deaths in these settings from the unique perspectives of the providers, administrators, patients, and their communities. Understanding the social and organizational workings of health care institutions will help to develop avenues for improving their quality and efficiency.