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Many people dismiss the idea that birth can proceed normally and safely because
of the outrageously high mortality rates in sub-Saharan Africa. Women there have
to go without medical management and intervention… and look where it leaves
them! But is it true that avoiding medical management inevitably results in an
unsafe birth?
There was a lot of information provided on this very topic at the
Women Deliver conference in October 2007 in London. The many sessions which
took place made it clear that we in Britain (and America) never have to contend
with health hazards which are commonplace to most women in developing countries.
A British woman's lifetime mortality risk of 1 in 8,200 compares very favourably
with a woman in Sierra Leone, whose risk is 1 in 8. We have the luxury of fast
and efficient emergency care, should things have gone wrong, unlike our
counterparts overseas. Their fate might be determined by non-existent
telephones, poor road surfaces and ill-functioning or unowned vehicles. And we
also start having children much later than women in Africa, with a healthy and
unmutilated body… In far too many places there and elsewhere around the world,
young girls of 7 or 8 have their genitals cut, supposedly so as to prepare them
for marriage.
Female mutilation is shockingly widespread in some 28 countries in Africa and
the Middle East. It has even been reported as occurring in some communities in
India, Indonesia and Malaysia. In a country such as Niger ‘only’ 5% of women are
affected, while 99% come under the knife in Guinea. (Surprisingly perhaps, 97%
of women are affected in Egypt.) How can this be? Even in places where it’s
officially illegal (for example, in Tanzania) girls continue to have their
clitoris and labia cut out at the age of 7 or 8.
After being sewn together so as to leave a tiny hole, it’s hardly surprising
that most of them later suffer pain when menstruating and having sex, then
tearing and haemorrhage when they give birth. Tears which present no major
consequences for wealthy First World women become a life sentence for a woman
with scar tissue, who has no access to health care. Not only does she often
become completely incontinent (unable to control any of her bodily functions),
she also inevitably becomes a social outcast who can only shuffle along and beg.
The shame, the stink and the stigma are simply too much for family and friends
to bear… them literally bleeding to death.
In other cases, women do theoretically have access
to health care facilities. However, although they
are happy to trek along to clinics for a few
antenatal appointments (perhaps on foot, by bus, or
on the back of a moped or truck), they don’t often
visit them when they’re actually in labour. In one
of the conference plenaries, Dr Q Monir Islam–Head
of the
World Health Organization unit for Making
Pregnancy Safer–invited the floor to offer views on
why this was so. (The ‘floor’ incidentally consisted
of over 1,800 people with access to a floating
microphone.) Dr Islam’s question got responses from
four or five male representatives of sub-Saharan
African countries, as well as one from Afghanistan.
One man said that while attendance at antenatal
appointments in his country guaranteed maternity
leave, giving birth at the local clinic did not
‘add’ anything to a woman’s unit for Making Pregnancy Safer–invited the floor
to offer views on why this was so. (The ‘floor’ incidentally consisted of over
1,800 people with access to a floating microphone.) Responses came from four or
five male representatives of sub-Saharan African countries, as well as one from
Afghanistan. One man said that while attendance at antenatal appointments in his
country guaranteed maternity leave, giving birth at the local clinic did not
‘add’ anything to a woman’s practical or financial status; another man seemed to
think it was a question of education; yet another mentioned lack of support from
husbands (who may not agree to pay medical fees), while another mentioned
mistrust of healthcare providers. There might be another reasons too, which goes
far deeper: perhaps women shy away from hospitals and clinics at this vulnerable
time because they know about the joy and empowerment possible when birth is
natural, healthy and safe. Birth at the local clinic, on the other hand, might
induce feelings of fear, loneliness or frustration. This view is echoed by the
author of
Monique and the Mango Rains (Waveland Press 2006), Kris Holloway, who lived
in Mali for two years as a Peace Corps volunteer. After working alongside a
traditional labour attendant there–the ‘Monique’ of the title–Kris chose to give
birth at home herself when she later gave birth to her two sons in the USA. “I
experienced birth in Mali first,” she explained, “and that became my yardstick.
No, I didn’t want to die in childbirth, but yes, I wanted a midwife! I think the
biggest thing that I learned was how strong I was as a woman, what power my body
had, and what beauty there was in birth as a community event, a women-centred
event. I knew that I wouldn’t get any of that in a hospital.” Is it possible
that some women in Africa prefer the risk of death, to the rational relative
safety of the local clinic?
There might also be plenty of other reasons... In
Where Have All The Mothers Gone? (Epic Press 204) Dr Jean Chamberlain Froese
recounts twenty heart-rending stories of death or disaster, or at best
near-misses, experienced by women living in sub-Saharan Africa. Perhaps roads
(or lack of), communications (or lack of) and husbandly support (or… er, lack
thereof) were a bigger reason for these women.
What we experience in the UK is a far cry from what women might experience in
Kibera, the slum in Kenya, which you might have heard from recently in the news…
Consider how different your lifestyle is—in terms of hygiene and health—from
that of a woman in the Third World. Bill Bryson, the American travel writer,
reported on the conditions that many women experience in his book
African Diary in Kibera—no running
water, no rubbish collection, virtually no
electricity, not a single flush toilet. In one
section of Kibera called Laini Saba until recently
there were just ten pit latrines for 40,000 people.
Especially at night when it is unsafe to venture
out, many residents rely on what are known as
‘flying toilets’, which is to say they go into a
plastic bag, then open their door and throw it as
far as possible. In the rainy season, the whole
becomes a liquid ooze. In the dry season it has the
charm and healthfulness of a rubbish tip. In all
seasons it smells of rot. It’s a little like
wandering through a privy. Whatever is the most
awful place you have ever experienced, Kibera is
worse. Kibera is only one of about a hundred slums
in Nairobi, and it is by no means the worst.
Altogether more than half of Nairobi’s three million
people are packed into these immensely squalid
zones, which together occupy only about 1.5 per cent
of the city’s land. In wonder I asked David
Sanderson what made Kibera superior. [David is CARE
International’s regional manager for southern and
western Africa.] “There are a lot of factories
around here,” he said, “so there’s work, though
nearly all of it is casual. If you’re lucky you
might make a few dollars a day, enough to buy a
little food and a jerry can of water and to put
something aside for your rent.” “How much is rent?”
“Oh, not much. Ten or twelve dollars a month. But
the average annual income in Kenya is $280, so $120
or $140 in rent every year is a big slice of your
income. And nearly everything else is expensive
here, too, even water. The average person in a slum
like Kibera pays five times what people in the
developed world pay for the same volume of water
piped to their homes.” That’s amazing,” I said. He
nodded. “Every time you flush a toilet you use more
water than the average person in the developing
world has for all purposes in a day—cooking,
cleaning drinking, everything. It’s very tough. For
a lot of people Kibera is essentially a life
sentence. Unless you are exceptionally lucky with
employment, it’s very, very difficult to get ahead.”
Every day around the world 180,000 people fetch up
in or are born into cities like Nairobi, mostly into
slums like Kibera. Ninety per cent of the world’s
population growth in the twenty-first century will
be in cities.
Bill Bryson
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Is it surprising, given this environment, that the
developing world has such poor birth statistics?
If you would like to support the work going on to
improve living conditions for people in places like
this, go to
www.careinternational.org.uk.
If you’d like to support some of the women who aren’t so
lucky, the ones who have to suffer the consequences of
their birthplace, please send a donation by logging on
to
www.maternityworldwide.org or
www.savethemothers.org.
If you would like to help Fresh Heart develop a manual
for traditional and/or skilled birth attendants in
sub-Saharan Africa, South Asia and other undeveloped or
developing parts of the world, please email
help@freshheart.co.uk.
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