Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda.

BACKGROUND: The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249-584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda. METHODS: Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities. RESULTS: Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery. CONCLUSIONS: The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.

Chaucer and the Disconsolations of Philosophy: Boethius, Agency, and Literary Form in Late Medieval Literature

This study argues that Chaucer's poetry belongs to a far-reaching conversation about the forms of consolation (philosophical, theological, and poetic) that are available to human persons. Chaucer's entry point to this conversation was Boethius's Consolation of Philosophy, a sixth-century dialogue that tried to show how the Stoic ideals of autonomy and self-possession are not simply normative for human beings but remain within the grasp of every individual. Drawing on biblical commentary, consolation literature, and political theory, this study contends that Chaucer's interrogation of the moral and intellectual ideals of the Consolation took the form of philosophical disconsolations: scenes of profound poetic rupture in which a character, sometimes even Chaucer himself, turns to philosophy for solace and yet fails to be consoled. Indeed, philosophy itself becomes a source of despair. In staging these disconsolations, I contend that Chaucer asks his readers to consider the moral dimensions of the aspirations internal to ancient philosophy and the assumptions about the self that must be true if its insights are to console and instruct. For Chaucer, the self must be seen as a gift that flowers through reciprocity (both human and divine) and not as an object to be disciplined and regulated.

Chapter one focuses on the Consolation of Philosophy. I argue that recent attempts to characterize Chaucer's relationship to this text as skeptical fail to engage the Consolation on its own terms. The allegory of Lady Philosophy's revelation to a disconsolate Boethius enables philosophy to become both an agent and an object of inquiry. I argue that Boethius's initial skepticism about the pretentions of philosophy is in part what Philosophy's therapies are meant to respond to. The pressures that Chaucer's poetry exerts on the ideals of autonomy and self-possession sharpen one of the major absences of the Consolation: viz., the unanswered question of whether Philosophy's therapies have actually consoled Boethius. Chapter two considers one of the Consolation's fascinating and paradoxical afterlives: Robert Holcot's Postilla super librum sapientiae (1340-43). I argue that Holcot's Stoic conception of wisdom, a conception he explicitly links with Boethius's Consolation, relies on a model of agency that is strikingly similar to the powers of self-knowledge that Philosophy argues Boethius to posses. Chapter three examines Chaucer's fullest exploration of the Boethian model of selfhood and his ultimate rejection of it in Troilus and Criseyde. The poem, which Chaucer called his "tragedy," belonged to a genre of classical writing he knew of only from Philosophy's brief mention of it in the Consolation. Chaucer appropriates the genre to explore and recover mourning as a meaningful act. In Chapter four, I turn to Dante and the House of Fame to consider Chaucer's self-reflections about his ambitions as a poet and the demands of truth-telling.

The Land of the Savior: Óscar Romero and the Reform of Agriculture

This study approaches Óscar Romero by attending to his intimate involvement in and concern for the problematic surrounding the reform of Salvadoran agriculture and the conflict over property and possession underlying it. In this study, I situate Romero in relation to the concentration of landholding and the production of landlessness in El Salvador over the course of the twentieth century, and I examine his participation in the longstanding societal and ecclesial debate about agrarian reform provoked by these realities. I try to show how close attention to agrarian reform and what was at stake in it can illumine not only the conflict that occasioned Romero’s martyrdom but the meaning of the martyrdom itself.

Understanding Romero’s involvement in the debate about agrarian reform requires sustained attention to how it takes its bearings from the line of thinking about property and possession for which Pope Leo XIII’s 1891 encyclical Rerum novarum stands as a new beginning. The enclyclical tradition developing out of Leo’s pontificate is commonly referred to as Catholic social doctrine or Catholic social teaching. Romero’s and the Church’s participation in the debate about agrarian reform in El Salvador is unintelligible apart from it.

What Romero and the encyclical tradition share, I argue, is an understanding of creation as a common gift, from which follows a distinctive construal of property and the demands of justice with respect to possessing it. On this view, property does not name, as it is often taken to mean, the enclosure of what is common for the exclusive use of its possessors—something to be held by them over and against others. Rather, property and everything related to its holding derive from the claim that creation is a gift given to human creatures in common. The acknowledgement of creation as a common gift gives rise to what I describe in this study as a politics of common use, of which agrarian reform is one expression.

In Romero’s El Salvador, those who took the truth of creation as common gift seriously—those who spoke out against or opposed the ubiquity of the concentration of land and who clamored for agrarian reform so that the landless and land-poor could have access to land to cultivate for subsistence—suffered greatly as a consequence. I argue that, among other things, their suffering shows how, under the conditions of sin and violence, those who work to ensure that others have access to what is theirs in justice often risk laying down their lives in charity. In other words, they witness to the way that God’s work to restore creation has a cruciform shape. Therefore, while the advocacy for agrarian reform begins with the understanding of creation as common gift, the testimony to this truth in word and in deed points to the telos of the gift and the common life in the crucified and risen Lord in which it participates