Ina Mae in Zambia

A Zambian Midwife and the baby bundle in Chipata.

In my last week here I have been reading Donna’s (my host) copy of Ina Mae Gaskins Spiritual Midwifery from 1977.  This book is groovy in the true Simon and Garfunkle late1960’s sort of way.  Besides being an integral component of the midwifery cannon of literature, it is a fierce, if not dated, reminder of the potential pleasures of having a baby – and the essential role that trust, sensuality, surrender has in birthing [this is an Ina Mae term as is Puss, Rush, groovy, heavy, loving, tantric, psychedelic, telepathic, get high with each rush, smooching….]  

I have really been enjoying it. The first half of the book is birthing stories, each about 2-3 pages, written by women and their partners about their birth experience with the midwives on The Farm – and before the farm existed when they all lived and traveled in a caravan of school buses. (Yes, I’m telling you, those were the groovy days.)  While the stories are full of breech deliveries, premature births, tight cords around necks, and even a stillbirth, the excerpts by the women convey such a sense of satisfaction with their birth experience – even when there are episiotomies and hospital deliveries involved. They talk about loving the midwives, loving their partners, and feeling blessed no matter what the outcome.

The farm midwives placed a lot of importance on working through psychological blocks and interpersonal dynamics between partners on the ability of the woman to both safely and fulfilling deliver the baby.  They tell the women often that ‘tight lips equals a tight bottom’ and encourage the mothers to ‘smooch’ their partners, and get out all of the psychological crap between them.  The men play an integral role in the process – and many women write about how they relied heavily on the energy given to them by the presence of their partner.  They create an environment of love and trust and sensuality – as they say, “a baby should come out in the same way that it was created…”

And then I sit up. And I’m in Zambia. And birthing in the clinics here could not be any more different than the loving, groovy rooms of Ina Mae’s farm (indeed – they are all home births – the rooms designed and created by the mothers themselves).  And I wonder – should this privilege of a fulfilling birth experience come only after basic sets of safety standards have been met? Is this the equivalent of Maslow’s hierarchy of needs? That only after the basics have been met (shelter, food, safety) can one actualize one’s self and experience true fulfillment?  Or is birthing opposite? Is it especially important to create a kind, loving, mother-friendly environment in low resource settings? Or is the question a completely mute point? Is it important for ALL women, regardless of financial status or geographical location or health status to have that kind of experience? 

Yes. To both.

Here is why I think this kind of experience is especially important in a place like Zambia – besides the fact that (I believe) it is a human right to have a humanizing birth experience. 

1) One of the reasons that maternal mortality is thought to be so high here is the low rate of facility births.  Many women deliver at home – with traditional birth attendants – and not in the hospital.  The government has made a big push for facility births because the staff is trained to handle complications and there are more resources than at home.  However, after describing the birthing practices here – including the occasional hitting of women, yelling at them that they are ‘uncooperative’ – and leaving them virtually alone until they grunt and push – my mom said it best: “Why would the women come to the facilities to have their babies?” Even if it is ‘safer’ – it is less pleasant – more isolating- less fulfilling – and therefore less chosen.  If more emphasis was placed on creating a pleasant birthing experience for the women – perhaps that would reduce the maternal mortality just by getting the complicated cases near the interventions that could save lives.

 2) There is physiologic and anecdotal evidence that decreased stress leads to fewer complications in birth.  Separating a woman from her family, her partner, her loved ones, and placing her with a care provider who she perhaps less than trusts increases her adrenaline, which blocks the oxytocin (the contraction, orgasm and breastfeeding hormone), which slows down labor and increases risk of complications. So make her happy and decrease complications.  Sounds easy, no?

But the other parts of me thinks- do all these niceties really matter? Or are they just that? Is it basic skills in safety that are at the crux of decreasing the number of women who die in or after childbirth?  

During my presentation to HSSP to update them on the preliminary results of the project – I talked about the ubiquitous ‘baby bundle’ – as I call it. After the baby is born, it is whisked away and wrapped in a cloth diaper, then a towel, then a crocheted blanket, then a huge fuzzy adult size blanket – so it looks like an overstuffed burrito baby – which is so large in diameter that it is tough for two adult arms to completely wrap around it.  I talked about how that baby bundle reduces any skin-to-skin contact that the mother-baby pair gets, and I included in my list of recommendations that more emphasis be put on the importance of skin-to-skin contact in the hours following birth. 

After the presentation, the deputy director, an American woman, expressed her dismay in this reduced skin-to-skin time due to the baby-bundle, to which her Zambian colleague responded "everyone in this room was born into a baby bundle. We all survived."  Which is true.  It’s a good point.  And it calls into question that, which I think, from my midwifery background, is ‘essential.’

So what is the answer? Should each clinic around the world strive to create the groovy experiences as Ina Mae and her team does? Or should it be a strictly safely first approach? Or is it an obvious combination of the two that is important? 

It is this question of mother-friendly services that brought me into midwifery in the first place, back in 2002 in Tanzaniza, inspired by Mary Kroeger. I think it is this question that will keep me active and passionate about this profession.  I think one thing is clear – there is no harm in providing mother-friendly-fulfilling birth experiences. So why not include it?  We could all use a bit more Ina Mae. 

[There is an international effort to improve the friendliness of birthing practices. It came out of the work done by Mary Kroeger and her wonderful colleagues:  International MotherBaby Childbirth Initiative - www.imbci.org]

 

land of plenty

The past few days I have been feeling really ready to go home. However, after a day of feeling sorry for myself on Monday, I decided to make the most of this last week: to get as much work done as possible, to continue explore Lusaka, and to continue to learn about what it means to be Zambian. 

 Today I decided to my walk back to the HSSP office (my hosting organization) from the hospital instead of hopping on a ubiquitous minibus or jumping in a cab.  I wasn't in a hurry to get back in front of my computer, and have started to relish each moment

 here (a self monologue "why not walk back? when will be the next time you have the luxury of walking down a red-dusty street in africa?").  While I moseyed down Nationalist Avenue, a large wide street past some embassies but without many pedestrians, I found myself walking almost in tandem with a thin Zambian man in a dirty white baseball cap, dirty white pants and a dark green sweater.  He was walking at almost the same pace as me, and after a while like this, I realized that we were alone.  My inner monologue, as ashamed of it as I am, started something like this "I have a computer and digital SLR

 camera in my bag. We're alone on this street... it's broad daylight, and I've never heard of anything like this in Zambia.. but should I switch to the other side of the street?"  It didn't take long before he interrupted my monologue with his voice.  It was obvious that his inner-monologue was very different from my own: "Madame.  I am looking for employment," he said. "Do you have any employment for me?"  

He looked in my eyes. His were sad. His clothes hung on his bony frame and the baseball cap was shading a wasting face.  "I am sorry," I said. "I am leaving on Saturday to go home to America." The minute that came out of my mouth I regretted it: what kind of answer was this? What was I saying? "I am sorry you are desperately poor. I am rich. I am getting on an airplane that cost close to 2000 dollars to buy and heading home to the land of plenty."  I don't think he took it like that - instead he feigned a smile and walked ahead of me.  

I welled up with tears. I have been asked for employment here before - women have shoved their numbers at me, asking if I know of anyone who needs a housekeeper. Men constantly ask me if I want a cab - cars drive by honking as if to say "need a ride?"  I don't know why this man caught me so off guard. I know life here is hard. 

Even I complain that the grocery store is more expensive than at home - gas is almost at $12 a gallon - and even a small beaded key chain runs about $2-3 dollars.  But the statistics say that people here live on $1 a day.  How can that be? It is true however.  The manager of the compound where I live, Vin, makes 200,000 kwacha a month. That's about $75. He supports a family of five.  And there you are, less than a dollar a day per person.  He struggles every day and lives literally hand to mouth.  

(Vin's family in front of my house here)

His wife is pregnant with their fourth child - and has been having unusual pains that prompted him to bring her to a clinic.  The cost of an ultra-sound was about $20 - more than a quarter of his monthly salary- and figuring out what was going wrong was nearly impossible. When he told me his story, I gave him the money - but it is only a small band aid for a huge problem. The next week her tooth was aching so badly she couldn't eat.  Another $20 needed.   Last night, while we were talking, he said "I hate it. I hate only working for millie meal.  Life is worth more than that."  His words rang so true.  The struggle for the poor here is truly heart breaking.

And so my heart I ached for this man who was honestly asking me for employment. And for the cab drivers who sleep in their cabs, and drive me to the hospital at the wee hours in the morning with dust still in their eyes. And for the women who leave their own children alone to care for someone else's for less than $100 a month.   While here the roads are often good, and on the surface this country sometimes looks together, there is true hardship when you just lightly scratch the surface.... I don't know that I've done a darn thing to help this summer.  I don't even know what I could do.  

So I will leave Zambia with love for this country - but with sadness too.  Knowing that as I board my plane to the land of plenty, the people who have touched me will be here. Every day. Hungry. Struggling.  Asking the next white girl who walks down the street if she can give them  job.

Lusaka again

Midwife in Kanyama with her thank you eye glasses

Looking through the window of the train...

Toasting our big night

Adorableness in Zanzibar

Two weeks with no blogging translates into the fact that I was having too much fun...

Where to begin?

Caleb and I took a canoe safari for 4 days on the Zambezi river.... paddling and floating our way down the river with Zimbabwe on our right and Zambia to our left. We camped on 'neutral territory' islands in between - so as to not have to avoid elephants on our camp site (hippos and crocodiles do travel to the islands, so swimming was sadly prohibited...) Our guide, Kambol (he said his parents tried to name him after the soup brand, but that the person who wrote out the birth certificate misspelled it and the name stuck) was fantastic. He was a one man show, as neither Caleb nor I are particularly expert at canoeing and camping 4 course dinners over a fire) and knew so much about the land and the foliage and the animals that surrounded us.

To the midwives among you - we learned about a type of antelope that can retain their fetus and stop themselves from giving birth for months and months during a drought - and that when born, the baby is not any worse for the extra months inside.... He told me the name, but I've forgotten now.

After we returned from the trip, we spent a few days in Lusaka, and I handed out my thank you gifts to the midwives that participated in my study - safety eye glasses to prevent against transmission of HIV if there are any 'splashes' of bodily fluids. I spent a fun and santa-clause-esque day driving around to all of the compounds in which I worked, dropping off three pairs per clinic. The midwives were very appreciative, and it felt like great closure. I will try to post a picture if the internet cooperates.

Then we left on a trip into Tanzania with some friends. As a train lover, and an over-night-train-lover especially, I had planned for us all to take the train from an industrial town about 4 hrs north of Lusaka (Kapiri Mposhi) to Dar es Saalam. It was supposed to be 44 hours (2 nights)- but ended up being 52 - and the ride became VERY long and greuling. It perhaps was my fault, as somehow I thought that Africa would magically transform into India, and we would be served hot chai by the chai-wallas in the morning and indian food for lunch. Instead, it was chips (french fries) and pink sausage on the menue. Yuck. Ok, sometimes chips are delicious.... but enough was enough after 3 days of fries.

Dar captured my heart in a surprising way in an India-meets-Africa sort of experience. We did get chai there from a local shop, and Caleb managed to put down a whole plate of curry and chapati before 9am, which impressed me. I was content eating a half of a papaya drizzled with lime juice with a spoon - trying to recover from french-fry-overload. The markets were full of colors and energy and men on bikes and mosques and cows and - well - it made my heart soar. If I can say this only once without getting in trouble - it made me wish I had picked a different city to base this study. Ok. That's out. Moving on...

Zanzibar was just pure love. And our lodging for a few days was called "Paradise beach bungalows" - a name that could not have been more fitting. I could go on an on about the turquoise water, the Swahili culture and food, and the joy of relaxing, but I'll spare you.

I'm back in Lusaka now. I have a week to tie things up here: present preliminary results of my project to my hosting organization, finish handing out eye glasses, buy last minute gifts, and say my goodbyes.

People keep asking if I'm ready to go home - and I think I am. I am sad to leave Africa. But at this point I feel like if I was to stay longer without another project or mandate I would be spinning wheels.

And, to continue with the food theme, I can't WAIT for a huge salad.