Heart Strings: Lessons in Being With Women

by Rachel Zaslow, Mother Health International

Two years ago the UNFPA issued a [State of the World’s Midwifery report](http://www.unfpa.org/sowmy/report/home.html) that called for investment in trained midwives as the single most important response to the global crisis in maternal health. “Every year approximately 350,000 women die while pregnant or giving birth — almost 1,000 a day,” states the report. “Of these women, 99 percent die in developing countries”. The World Health Organization reports estimate that close to 80% of babies born in these rural areas are received into the hands of traditional midwives; women who practice midwifery as it has been handed down to them from generation to generation. An important question for those of us invested in international midwifery work must be, what happens when traditional midwives intersect with western models of training and obstetrics? Can issues of power and privilege be transcended such that the two work together in harmony?

NGOs, charitable organizations and government models of education in
Africa have historically approached the training of traditional midwives with a ‘West is
best’ model. While the training of traditional midwives in western style obstetrics may
have had some successes, ripple effects of this model can be traced to unintended
consequences that ultimately harm the very population organizations are attempting to
serve. For example, for over 10 years an evangelical organization based in the U.S.
implemented a series of workshops for traditional midwives around the world. These
trainings, meant to lower infant and maternal mortality by providing rural midwives with
western style basic birth emergency skills, almost eradicated use of ‘traditional’
midwifery, yet failed to offer sustained access to education or resources that make
replacing traditional methods with western practice a reality.

Midwives in Uganda were told not to use a local blade of very sharp grass to cut umbilical cords after birth, but instead to use razor blades. When the donated razor blades ran out the midwives did not return to using blades of grass, instead they used rusty or unsterile razors and unintentionally exposed infants to infection. These same midwives were given training
manuals and practice protocols written in English when most of them have never learned
to read or write, let alone speak English. At the end of the U.S. based trainings, traditional midwives had integrated key aspects of the lessons; women pushed babies out while laying flat on their backs; umbilical cords were clamped and cut before babies were breathing; when a hemorrhage occurred, midwives searched for drugs that were not there rather than risk using local remedies. In direct correlation to the end of these trainings maternal and perinatal mortality skyrocketed in rural areas. The Ugandan Government responded in 2006 by requiring traditional midwives to refer all clients to the nearest hospital, in many cases over 50 miles away. It would be impossible to expect women to walk miles in labor to receive support and most cannot afford even public transportation. Local hospitals did not (and still do not) have infrastructure to serve the number of women that would come to birth there if the traditional midwives actually made all of these referrals. The result is a confusing and dangerous set of messages and services for both laboring women and health care providers.

I began working with traditional midwives in Northern Uganda in 2007. They were just coming out of a 23 year-long civil war where most of them had been displaced and were living in internally displaced persons camps. The women they served had every risk factor imaginable for a complication, and yet they were served with the most limited of resources, sometimes without gloves, and in exchange for a bar of soap or a small bag of sugar. One thing that became immediately clear to me as I sat in circle with these women was how often they have been told that their knowledge is wrong. The midwives and I talked. We ate meals together. We shared stories. We acted them out. We swapped advice. The beginning stages of what would later become a fully integrated birth clinic, were about midwives doing what they do best: building community. I believe that when we remove midwifery from community, we risk losing midwifery altogether.

(A second blog post--soon to follow-- will include one of the innovations emerging from Mother Health International).