Africa: Journey to the Motherland
by Astrid Grove
© 2006 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 78, Summer 2006.]
Photos provided by the author
Baby with Grandma and Author
My first memory of my African adventure is standing in the parking lot of the airport in Dakar, Senegal, and feeling like I was finally home. The sights, sounds and smells were unfamiliar…yet the pulsating beat of the earth beneath me was as familiar as the strands of DNA in my cells. I began to smile, and that smile still remains as a reminder of my extraordinary experience in Senegal, West Africa.
Eleven of us were there: three preceptors, the president of the board of Midwives on Missions of Service (MOMS), the husband of one of the preceptors and six interns. We stayed in a compound in a small fishing village that was a two-hour drive north of Dakar, the capital of Senegal. The town is called M'boro Sur Mer. The earth there is sand, the plants are tropical, the ocean is wild and salty and the weather is warm/hot and dry…yet I am home.
Sakor is the owner of the land where we stayed and husband of Kaya Skye, the founder of the African Birth Collective. He managed the trip and was our driver. Abi is the cousin of Sakor and a blessing on the earth. Her compassion, genuine generosity, keen sense of humor, honesty and beauty graced our trip and everyone on it. She kept us well-nourished in our bodies, minds and souls.
Breakfast in Senegal consists of white bread, margarine or butter, and Senegalese tea with white sugar and powdered milk. Within a few days we discovered we could get fresh peanut butter, yogurt and eggs to add to the meal. Lunch happens late, anywhere from 1 pm to 4 pm, depending on when the fish comes in off the boats. It usually consists of white rice, a protein like fish/egg/chicken/meat (sheep, goat or cow), and vegetables including potato/turnip/carrot/winter squash/okra/tomato/lettuce and delicious sauces. Dinner happens anywhere from 8 pm to 10 pm and usually is a lighter version of lunch. The food was absolutely delicious, though a little lacking in protein and vegetables. We all ate out of the same large bowl with our right hand or a spoon. Abi graciously taught us the etiquette and style of Senegalese eating. She explained that eating out of the same bowl teaches sharing and generosity. This is expressed by sharing whatever you have directly in front of you with the others by breaking it up and putting some in each person's spot in the bowl. Also, there is a special way of balling up the food in your hand and then popping it into your mouth. Eating was a very enlightening experience.
In the morning and afternoon we sometimes found a café that sells Café Touba, a delicious coffee with a Senegalese spice and lots of sugar. Going to the café is a social experience and a great way to meet the locals. After lunch one might find green tea as well. It is usually served in three rounds, the first round being the strongest, and each round thereafter becoming weaker and sweeter. This tea is high in caffeine, so beware. A favorite roadside treat is the beignet, a french-fried dough made with sweetened batter and fried in a vat of hot oil. Delicious. Sometimes we would also get a fried dough wrapped around fish paté with a spicy sauce. In the market you can find fresh fruit including papaya, bananas and watermelon, as well as fresh roasted peanuts, fresh yogurt and fresh ground peanut butter.
The Birth Room
Wolof is the language of Senegal, and many Senegalese also speak French. Some of the more "educated" Senegalese will also speak English. Many of the clinic's clientele did not speak English or French. My favorite saying in Wolof is "Ndank, ndank, moie jop golo chin yiey" which translates as "Slowly, slowly, the monkey comes out of the bush." This saying teaches us that by being in the moment and acting with intention, we will see that what we need will present itself. Whenever I was in a situation where little communication was occurring because of the language barrier, I would whip out this phrase and get a good laugh. Usually every Senegalese in the room would repeat the phrase over and over, laughing and saying "She knows Wolof!"
Revealing my "jell-jellies" was another communication technique I used. I first learned about them while on shift. The first mama I took care of was very sweet and we really connected. Her name is Fatou Diop. She gifted me a string of blue and yellow glass beads. Her mother then showed me that she was wearing some of these same beads around her waist so I put mine around my waist. When I put them around my waist, they both began to laugh hysterically and the grandma began dancing around the room, jiggling her beads, and proceeded to "moon" me. Well, I figured out that these beads are considered very sexy to the Senegalese and are worn by women to seduce men in bed. After this experience not a day passed that I did not wear my jell-jellies. I could get a whole room of women dancing and singing just by revealing my jell-jellies.
While there we worked 24-hour shifts every other day and we all had Sundays off. We split into two teams of three interns and one preceptor each. Some nights we would have time to sleep a bit between births. We all found very interesting positions and places to sleep in the clinic. I am not sure of the exact numbers, but I believe that at least 40 births occurred during our shifts, including one maternal death and four neonatal/fetal deaths.
The clinic where we worked is in the town of M'boro, a 20-minute car ride away from our compound. Ami is the sage-femme of this clinic. She had her 20th anniversary of being a midwife while we were there. She also has been the midwife at this clinic for 20 years, which in and of itself is a huge undertaking and accomplishment. In Senegal a sage-femme is distinguished from a matron. A sage-femme is a university-trained midwife who has undergone formal education and clinical education. A matron has gone through a six-month clinical training.
At the clinic the matrons handle the births when all is normal and call upon Ami when something strays out of the range of normal. Five matrons work at the clinic: Hadi, Absa, Lependa, Astu (student) and Julie (student). Ami does the prenatals while the matrons do the postpartums. Aisha is a specialist in family planning and is very busy working with women. She prescribes Depo, Norplant, IUDs, male and female condoms, and birth control pills. Apparently the young men will use condoms, but getting the married men to use them is more challenging. Ami inserts the Norplant and IUDs, while Aisha handles the other methods.
The predominant religion in Senegal is Islam although some people there are Christians. The Muslim women come in to the clinic with prayer ties on their heads, their arms, around their bellies and their legs. They are called "gree-grees." The matrons remove them when the women present to the clinic in labor. They are a considered protective to mom and baby. I believe that passages from the Q'uran are sewn inside the bundles. During labor the women pray almost constantly and we commonly heard a phrase, "yaletif," which is a birthing prayer to Allah. At one birth the laboring woman called for holy water and her mother walked in bearing this gift. It gave her the strength she needed. Also, each family I helped care for took their placenta home. Apparently the father buries it the next day with prayers.
After being in the clinic just a short while, we realized what skills we could offer to the women and to the matrons and sage-femme. First, the women labor lying down, they have no labor support and they push their babies out while lying on their backs. We brought in poster boards with pictures of different laboring positions. I sat with a few women who enjoyed hands and knees, supported squat and slow dancing. The women responded beautifully to us. News got around town fast that really nice American sages-femmes were at the "Poste de Santé de Mboro" and they had "cadeaux," which means "presents" in French. The cadeaux they spoke of were gallon-size Ziploc bags filled with essentials like toothbrush and toothpaste, baby hat, socks, onesie, blanket, shampoo and soap.
The women do not have childbirth education classes and the matrons and sage-femme thought the idea was pretty ridiculous. They said that all of the women learn about pregnancy and childbirth from their mothers and other women relatives. Well, that is great—except these women all expect to labor lying down and give birth on their backs. I wonder when this type of birthing became the norm for the Senegalese women.
We noticed that the matrons were very hands-on in an aggressive way. They were yelling at the mommas to push, doing fundal pressure, finger forceps, really intense perineal massage and catheterization for nearly every woman. Also, immediately postpartum the matrons would go into the uterus after membranes and clots without sterile gloves. As we started to feel more comfortable with our roles there, we basically took over the births. I think that being able to see hands-off birthing was a huge gift for them. They asked a lot of questions and showed true interest.
Now, in retrospect, I can see how their method of aggressive birth practices works for them and the women. Within a half hour to 45 minutes after the women have their babies in the labor room, they are whisked away into a postpartum room where they receive little or no postpartum care. At least that was my perception. What I perceived as an aggressive tactic ensures that the woman does not have retained placental parts or membranes or clots and makes sure her bladder is empty so that the risk of a 4th stage hemorrhage is reduced.
We also began to see that the matrons and the sage-femme were not adequately trained in neonatal resuscitation. They did not have an infant bag and mask and instead used a pinard horn and simply blew into the baby's mouth and nose. They said that this helps to bring up mucus, and it did. It did not increase heart rate.
The Postpartum Room
They also slapped the babies really hard on their buttocks to bring them around, which worked, too. I saw many babies brought around this way. Unfortunately the experience is very intense and violent for the baby. One afternoon we taught neonatal resuscitation with a few of the matrons and practiced with a baby doll. It went really well. During this lesson we noticed that the matrons and sage-femme were not using the bulb syringe correctly. Instead of letting the air out of the syringe and putting it in the baby's mouth and nose to draw out the mucus, they were pushing air into the baby's mouth and nose. We showed them the correct way and they were thankful. They really enjoyed the lesson. Luckily, they now have two infant bag and masks and are using them. I hope that they have fewer neonatal deaths now.
Although aggressive and lacking in skills in some areas, the matrons and sage-femme were very skilled in many areas and I learned a lot from them. They taught me a really important aspect of midwifery that I had not yet experienced. They taught me how to get by with what I have on hand. They are masters at this and I am amazed at the intense volume that these women are managing with so few supplies.
The situation was difficult when a baby or momma needed more medical care than any of us at the clinic could offer. Usually the families could not even afford a taxi, never mind medical care. We were told that some sort of financial assistance was available, yet the families still seemed to choose not to transport for financial reasons. Women are transported from the clinic to the hospital for three reasons: fetal heart tones lower than 120 or higher than 160, meconium in the amniotic fluid after rupture and inadequate dilation and descent. No one appeared to recommend transport for babies who were not doing well.
One night we had a woman come in who was in early labor, bleeding vaginally, the fetus was not alive and her blood pressure was 70/40. The woman's husband and I carried her out to a taxi. She did not look good. I never heard of this woman's outcome. My heart is heavy over this.
Another problem we noticed was the immediate cold water baths given to the babies by some of the matrons. The babies' temperatures were dropping and some were even showing signs of respiratory distress from being so cold. So, we began implementing a strategy to "protect" these babies. As soon as the baby was born, we wiped her off to clean her up. We tied off her cord with cord tape and put on a hat and an outfit from the cadeaux. This way the matrons would not need to bathe the baby in the cold water. It worked like a charm.
The matrons and sage-femme used oversized plastic gloves with only two fingers to check the mama's dilation. They seemed to check every two hours. I also noticed that sometimes up to three different women would check a mother two or three times in a thirty-minute period. To counteract this I would stay with my mamas nearly the entire time they were in labor. Because I tend to be hands-off, I often would not even check. The matrons would come in and ask me how dilated the mama was. I would say that I didn't check her but she appears to be 6–7 cm and is doing great, progressing, etc. They would give me a funny look and proceed to glove up to check her. I would tell them that it was not necessary, and they would more often than not honor my request. Sometimes they would really want to check, so I stepped aside to keep the energy positive.
Generally the women labored in the labor rooms. Often two or three women would be laboring in the same room with their mothers and sisters and their children. The matrons would come in every two hours and bring the laboring mama into the delivery room to check her. If she wasn't fully dilated she would be sent back to the laboring room. Her female relatives would comfort her by saying "masa" which is translated as "be strong."
The women pretty much stayed on their backs for most of the labor. The families would bring in a warm grain mush to feed the laboring mamas and offer them tea. When they were ready to push, they moved to the delivery room.
No one is allowed in the delivery room with the mama; she must enter alone, without her family. I had difficulty supporting this practice. When I questioned the matrons they said that this was their way, the way of the Senegalese. Some women would be crying out for their mothers, with their mothers standing on the other side of the door sending their silent support.
I realized that if I stayed with the mamas and rubbed their backs and legs and gave them water and showed them different positions, they were very receptive. I feel that the women genuinely appreciated the care and attention they received from us. In general the labors progressed very smoothly and quickly. The women were so strong. They were so close to their instincts that they just did it. Beautifully. The first baby I caught, I instinctively handed up to her mama. Apparently, this is not done in Senegal. The mama did not know what to do with her bloody baby and gave her back to me.
As soon as the birth was imminent, the matron would put a plastic bed pan under the mother's pelvis to help collect fecal matter and blood. This was very uncomfortable for the laboring mothers, but very helpful for cleaning up the space. We worked really hard to get rid of the bed pan, but the bottom line was cleanliness. If we didn't use the bed pan we would have more blood to clean up and more chance of infection in the clinic. It's a hard call at best. I more often than not ditched the bed pan and did a really good clean-up job. The matrons were helped by having us around. We were more sets of hands to do the tremendous amount of work for which they were responsible.
After the baby was cleaned up and dressed, we would bring the babe to the grandma while the momma was attended to and moved to the postpartum room. We would wash her off and make a pad out of the traditional Senegalese fabric. Then grandma would take all of the dirtied cloth, wash it in back of the clinic and hang it up to dry. They don't use chux pads either. They use the bright and beautiful traditional Senegalese fabric. Every mama brings in a tub with cloth for her to give birth on, cloth to wrap the baby, cloth for her pad and cloth for her to wear for her skirt after the birth.
When we arrived at the clinic they were washing their gloves and re-using supplies in a non-sterile way. They were using out-of-date lidocaine and needle and thread to suture perineal tears. Thankfully our group had a hefty donation of suture material and lidocaine so we left them in better shape. They did not have the same approach to suturing that we are taught here in the US. Instead of keeping the sutures inside of the tear, they sutured externally as well. The mom experiences more pain this way. Many times the matrons and sage-femme looked over my shoulder in admiration at the suturing techniques I used. We spent time showing them some of the stitches we use; they then practiced on foam that we brought for this purpose.
Placental abruption seemed to occur at a high rate. We believe that it is directly related to the diet, which is low in protein (although the protein is good quality) and high in simple carbohydrates. On my shift one mama with a placental abruption lost her baby in utero. The other shift experienced a maternal death (her baby died in utero) due to disseminated intravascular coagulopathy (DIC) from an abruption.
Preterm labor also occurred frequently, which we think is due to the extremely high incidence of malaria among pregnant women. Often the clinic would be overflowing with pregnant women receiving care for malaria or other pregnancy-related problems such as high blood pressure or threatened preterm birth. Conversely, the amniotic sacs were incredibly strong. I link that to the fresh ocean fish they eat on a daily basis. The fish is good quality protein and high in zinc. In many of the births, the water bag did not break until the head was born or even after the head was born. Not one of the 20 or so births I attended did a woman present to the clinic with ruptured membranes. Fascinating.
We also noticed a few true cases of fetopelvic disproportion (FPD). Although the babies were not that big, they were not able to fit into the mamas' contracted pelvises. After doing some research, I read in Anne Frye's Holistic Midwifery Volume II that women who hold heavy loads on their heads at a young age can actually develop android pelvises from the weight of the load pressing the femur into the pelvis. I believe that this might be the case for some of the women in Senegal. Frye also speaks about chronic malnutrition causing deformities in the pelvis. This also may be true for some of the women we saw.
I feel so thankful to have experienced low-tech births. I have really fine-tuned my skill of listening to fetal heart tones during first and second stage with a fetoscope instead of a Doppler. We also did not have the luxury of oxygen tanks and used room air to resuscitate babies. I saw that it works well. The babies didn't perk up as fast, but they were getting what they needed.
I found the morning after the last shift to be very emotional. The shift had been difficult and I left with a deep feeling of sadness for the state of medical care in Africa. One birth in particular was hard for me. The woman presented to the clinic already pushing. I found fetal heart tones right away. About 10 minutes later we could not find heart tones. After about 10 more minutes we again found them and they sounded great. She pushed out her baby and he just wasn't coming around. After thirty-five minutes of resuscitation, the baby was breathing on his own, although still presenting with chest retractions and nasal flaring. We checked on him throughout the night. In the hour before dawn, his family brought him to us. He was dead.
In the US we would have transported, but it is different here. As I was walking out of the clinic I began to hear the Muslim morning prayer booming out of the loudspeaker of the mosque that is on the same side of the street as the clinic. People began to flock to the mosque and in this moment I realized within myself the depth of the faith of the people here. The trust in the divine and the love of God. In sha allah. Il hamdou li lahi.
I have difficulty articulating why I went to Africa. I traveled there with the African Birth Collective to experience maternity care in Africa, to offer what I could and to finish my requirements for graduation from midwifery school. Yet, all along I knew that I had a greater, deeper reason for the journey. The reason is now, only one week after my return to the States, being revealed. Right now I am recognizing that I feel different inside. I have a sense of inner peace and joy in the simple pleasures of life that I feel almost 100% of the time. It feels like a sparkle in my soul. I also have a greater sense of purpose. This trip was an initiation for me. I walked through a gateway. I stepped into myself and into the role of midwife, and I feel wonderful.
For more information about the African Birth Collective, contact Kaya Skye at www.africanbirthcollective.org.
Astrid Grove, LM, CPM currently lives in central Vermont where she serves as a community midwife, maya abdominal massage practitioner, and herbalist. To learn more visit her Web site at www.birthrootmidwife.com.
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