Two years ago the UNFPA issued a State of the World’s Midwifery report 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 the evangelical organization World Vision 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 World Vision 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.
We 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 or bad. 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.
One day while we were acting out a birth scenario where a baby was extremely distressed at birth, we talked about how helpful it would be for the midwives to be able to count fetal heart tones. If a traditional midwife could determine in advance if a baby was in distress, she may be able to resolve the situation or have time to make a transfer. Without knowing how to count, how would a midwife learn to count heart tones? For those of us who learned to count diligently in elementary school, it is hard to imagine a world that is not ordered by numbers that correlate to days and times. The midwives shared that they track their menstrual cycles with a string of beads that is cycled to the moon. This way of knowing makes sense in an area where there is no electricity and women still bleed with the moon.
Midwife Olivia was with us at that meeting and she thought of the abacus. This is how the Heart String was conceived and born. We made a string of color-coded beads that midwives could use to assess fetal heart tones. For every heartbeat, the midwife ticks off a bead and then after 15 seconds (we use sand timers), look at what color bead they have landed on. White beads mean the FHT is too low. Green beads, FHT is in a range of normal. Red beads, the FHT is too high. We then developed protocols for what to do in instances where heart tones are too low or too high. The strings were almost immediately understood and used with great accuracy, because it is a way of understanding that correlates to traditional systems of knowledge. Over the last several years, we have used the Heart Strings with traditional midwives in several countries and have been overwhelmed with their success. Midwives who previously could not tell the difference between a high-risk mother and a low risk mother were able to make appropriate medical decisions prior to a bad outcome, thereby avoiding catastrophe and saving lives.
I still wonder if there is a way to honor ‘different ways of knowing’ when we think about education, especially in a community that is not our own? When we think critically about barriers to maternal and child health, we must understand the history and context of the places in which we stand and we must question methods that ‘bestow’ knowledge upon others. There is no one answer to the crisis that faces women around the world, but one thing I know for sure is that one on one care and support is not only achievable, it is imperative to good outcomes. We don’t need tons of money or fancy equipment. To stand with women, we must be ‘with women’. We need good old-fashioned, ‘hands on’ care. The kind that women give to other women. The kind that mothers give to their babies. The kind that nurtures and sustains. The kind that thrives on and in community.