The New York Times has an article on the obstacles to safe childbirth in Tanzania.

I worked in two other African countries thirty years ago, and it doesn’t look like much has changed in these isolated and poor rural areas.

… Only 20 percent of women in the area give birth at the hospital, and many do so only when they need Caesareans. Many women say they simply cannot afford the hospital. More than 50 percent stay home to give birth, and the rest go to local clinics that cannot handle emergencies or perform Caesareans….

Our 120 bed hospital got electricity when I was there., and it was a big help. But before then, our hospitals used  a generator,  which is turned on in the evenings or for emergencies. Usually our midwives delivered  using a kerosene lantern. If you are lucky, you have an airconditioner or operate early in the morning when it’s still cool.

After I left, our nurses did the Cesarean sections, as described in the article. But we didn’t use ether. At one hospital, we had a nurse anesthetist or I gave spinal anesthesia. But at another hospital, we gave a Ketamine drip, controlled by the guy who usually cleaned the floors.

When I worked in Africa, just as described in the article, lots of women delivered at home with semi trained “birth attendants”, or at small midwife run clinics with limited resources.

The article says that patients had to supply a birthing kit; we were luckier:  we got funds from Europe, and our clinics were run either by churches or local authorities who helped fund supplies.
But in those days before HIV, friends in the US or Europe would wash up the latex gloves and send them on.

Our area had three clinics run by nurses, and all had access to cars for emergencies (usually a priest or a businessman). But in rainy season, the bridges might be under water or washed out, and even in the dry season it took an hour to drive to the clinics, all of which were less than twenty miles away.

Since our hospital had been there for years, the nuns were trusted, and since our tribe’s tradition was for moms to deliver with their own mothers, a lot of them would come with a relative to cook their own food (usually mom or little sister) and stay for free until they went into labor.

But some still delivered at home, with traditional midwives. Often the traditional midwives want to make labor faster, and give herbs. The result is sometimes a dead baby or a ruptured uterus. Depending on their experience, they might or might not recognize problems.

So when I worked in Liberia, before the civil war the government has programs to “certify” these midwives, who study for three to six months and learn hygiene, how to recognize common problems, and how to use simple medicines.

So how do you improve the safety of childbirth?

The obstacles are often not easily overcome.

You are often fighting the mother in law, or traditions. There is little or no money for things like hospitals, and sometimes the immans or local tribal shamans, and even some indigenous Christian churches forbid using the local hospital, which in rural areas is often run by a Christian church or may be run by another tribe.

If you live miles from the hospital, unless you stay there during your ninth month, you won’t make it in time for a delivery. And often women have other children to care for, and can’t afford the time off or the fee to stay there.

If you work in a town, or in the countries of southern Africa, you have more access to cash. Many of our women had relative working in the mines or cities of South Africa so they did have a small amount of “cash” to pay the fees. (We allowed the truly indigent to send a relative to work off the fee, which was the same price as the mother would give a traditional birth attendant).

Then there are the medical reasons for death in childbirth.

The African women have an oval pelvis, so that if the head “sticks” in the hole, the pressure on the tissue will cause it to rip, causing a hole where urine leaks continuously. The best and easiest treatment to prevent this is a Cesarean section, although forceps/suction delivery sometimes would be enough.

Sometimes mom would refuse a Cesarean section (local beliefs was that if mom require surgery, it meant she had committed adultery and was being punished). I know doctors who were forced to do the risky version and extraction, sometimes with a symphysiotomy (don’t ask) for these ladies…

The Times article is a good summary of some of the problems medical personnel face.

So how do you start to improve the safety of childbirth?

Money helps. Give to your local church, since many churches support mission hospitals and clinics that are in the most isolated areas. The UN is also a big help, as are many NGO’s.

Locals who are doctors or nurses often will stay in the area if they receive a good salary. Many help support and pay school fees for many relatives, so when I hear the clueless condemn the “brain drain” I get annoyed.

Another major obstacle is lack of ordinary infrastructure: roads, electricity, clean water, safety measures against criminals and stray animals such as baboons that can destroy a village’s crop. in one night.

Here in the Philippines, death in childbirth is rare in our area (although alas too common in poorer rural areas), because nearly every village has a midwife, and often the towns have ambulances and district hospitals. Yet even here, one of our neighboring farmers lost his wife from Toxemia, because she didn’t realize the need for prenatal care, and only went to the midwife when she “swelled up” and got sick.

As for “Family planning”, the favorite idol of the rich and famous, well, most African tribes have used traditional methods to space children for generations (prolonged breastfeeding, non vaginal intercourse, withdrawal, polygamy, and abstinence).

The real obstacle is the danger of death. If a mother knows that her children will survive, she will have fewer children, and carefully space them so that they can be cared for. If the mother knows that a measles epidemic will wipe out half her kids, she will have more kids. No kids, no one to care for you when you are old. It’s as simple as that.

Finally, when you read about Africa–or Asia for that matter–, you need to know that development is spotty.

You can find up to date cities, but down the road and off the main road it changes back to the past.

So read the Times article, and remember it the next time you hear or read someone who praises the good old days or points to people in the third world who live in simple huts and seem not to need all the “stuff” we do.

Then thank the Lord that you live in a country where death in childbirth is rare, and most kids live to grow up.

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Nancy Reyes is a retired physician living in the rural Philippines. Her webpage is Finest Kind Clinic and Fishmarket. 

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