The Life and Work of a Rope Midwife in Darfur
by Ramona Denk
© 2009 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 89, Spring 2009.]
Photos provided by the author
This is a fictional composite account of the life and work of an imaginary traditional midwife in a Darfur village. It is based on multiple sources of information, including direct experience, observation, personal interviews and the research of others. In reality not all of these exact traditions and story details come from one place or one person, but each separately is based on at least one source.
My name is Fortunate and I am a traditional midwife. I live in a small village in rural Darfur, in the country of Sudan, in northeast Africa. I am a widow with seven grown children (now six, since one of my daughters died last year). I take care of her three children that she left behind. Besides my work as a midwife, I work our farmland. I grow millet and vegetables for us to eat. In good rain years, we can grow extra to sell, but in dry years, we eat one meal a day and really struggle. We grow hibiscus plants that we sell to get money for oil, tea, sugar and soap. We usually have a couple of goats and a few chickens around. We used to have a whole herd of sheep and three cows, but most of them were stolen during our regional conflict here, which is still going on. My grandchildren gather firewood for cooking and grass to feed our two donkeys. The oldest child takes one donkey to fill our four jerry cans with water from the well. This is an all-day job since it is so far away.
I have seen a lot of things in my many years, though now I have trouble seeing out of one of my eyes. I‘m not sure how old I am, since we usually don‘t keep track of birth dates, but I was married when I was about 15, and now I have two great-grandchildren.
I am what they call a “rope midwife,” because I follow our tradition of hanging a rope from the ceiling of the birth hut for the woman to hold onto during labor. I became a midwife on my own, without any training or mentoring. One day, after I already had a few children of my own, I was out in the fields by the well and a lady was giving birth with no one else to help her. So I helped deliver her baby, and that‘s how I became a midwife.
In the past, some traditional midwives got to be trained by the Ministry of Health in the nearest city for a few months. Other women go through the government midwifery school for a year and a half. I didn‘t get either of those chances. These days, anyone who wants to be a midwife has to go to the school, and be under age 30 when they start, and not be pregnant or breastfeeding. Usually a midwife candidate should know how to read and write, too, so that eliminates all but one or two women in the average village. The closest school-trained midwife to us is more than two hours away by donkey, so I deliver most of the babies in our area. I would like to receive training, but I just do the best I can.
Pre-marriage and Marriage Traditions
Getting married and having children is the most important desire, maybe the only goal, of most girls in our culture. If a woman is really blessed by God, she might have seven, eight, even 15 children. People often marry one of their cousins, and extended families are very important to us. Many men marry more than one wife; a few even take up to the four that Islam allows.
Sexual honor is an important value in our society. This is one reason that girls should get married within a few years after their first monthly cycle. This is also one reason that we circumcise, or “purify,” girls when they are between five and 12 years old. Some people call this female genital mutilation (FGM). It is a long-standing tradition with us. In many communities in Darfur, if a girl is not circumcised, no man will marry her because she is not “clean” and also she is more likely to run around and do bad things before marriage.
In the old days, the midwife doing the circumcision would cut out the clitoris and cut off the labia with a knife and then sew the sides together, leaving a very small hole for urine and blood to escape. This would ensure that the girl remained unviolated for her husband. (When a man married a girl, he would be responsible to open her up. He might use a knife, or he might use only his manhood.) After the circumcision, the girl would have to lie in bed recovering for two weeks. Many times the girl would get sick with a fever or grow weak from losing blood and die. Nowadays, the government of Sudan has made female circumcision illegal. But most people still do it, just in a milder form. Often the girl‘s grandmother or mother insists on it, even if her father doesn‘t want it done. The midwife will just take out the clitoris, or maybe just make a token cut, and the girl recovers very quickly. Then the crowd of people at her initiation party is satisfied that she was circumcised.
Women in Darfur are strong and work very hard. They are responsible to keep their household, raise their children, take care of their farms and animals, and make sure someone gets water from the well, which may be hours away by donkey. Their husbands help with the heavier work on the farm. When their children are three or four years old they start helping out too. Women usually carry their baby on their back, wrapped with a cloth, while they are working or going to the weekly market.
Usually when a woman is pregnant, she continues the same amount of work until the day the baby is born. We say that she shouldn‘t sleep too little or too much. We also don‘t eat eggs when we are pregnant because they cause swelling.
If women are breastfeeding a baby when they get pregnant, they should wean right away, because the milk will make the older baby sick.
Some pregnant ladies go to antenatal checkups at the clinic in the big town. They give out free iron pills and medicines if she needs them, and near the end of her pregnancy they give her a homebirth delivery kit with things like a plastic sheet, a razor and string for the baby‘s cord, and a bar of soap—if they have not run out of the kits. I don‘t do checkups for pregnant women except to estimate what month of pregnancy they‘re in, or to see what position the baby is in when they are nine months along.
Family Planning and Abortion
Sometimes women in the cities take pills so that they don‘t get pregnant for a while after they have a baby. We don‘t have much knowledge or availability of things like that, and anyway most of our women want to have as many children as God, the Great and Glorious, allows.
Sometimes a girl gets pregnant before she is married. Maybe she and her fiancé gave in to their passions, or maybe she was raped by the Janjaweed militias while she was gathering firewood in the savanna. Or a married woman may get pregnant when her husband is living in another city. In any case, of course, it is a huge shame, so a girl or woman in this situation will often do something to try to end the pregnancy. She may drink water with laundry bluing powder, get an injection of malaria medicine, or take a lot of aspirin. She might try hard physical activity like running. A traditional midwife might put something inside her, like a used urinary catheter or IV tubing or plant stem, or put certain herbs and seeds in her womb.
Labor and Birth Traditions
When it comes time for a woman to give birth, one of her family will come and get me. Many of her women relatives and neighbors will also come in and out of the hut to observe and support. This also provides the opportunity for women to see and carry on our traditions. In our culture, woman should not cry or yell too much in labor, but should bear it stoically. I hang a rope from the thatch roof of one of the mud-walled huts in her family compound, so she will have something to hold onto when she kneels for the birth. In villages that have a trained midwife, some women still prefer to call the traditional midwife because the trained midwife will make them lie on their back to deliver, and women are afraid that this will make a hole in their back.
One important technique that we traditional midwives use is to repeatedly sweep our hands one after the other from the back of a woman‘s private parts to the front. This helps bring the baby out.
When the baby‘s head is showing, I cut the woman‘s circumcision open on both sides with my razor. After the birth the woman keeps her legs together and puts salt on it to help it heal. Or a trained midwife may sew her up.
After the birth, I hold the baby out to the mother, then take it back, then give it to her again, then take it back—three times for a baby boy, and four times for a girl.
Traditions after the Birth
After a woman has a baby, all her relatives and friends come to visit her and congratulate her and her husband. If she has enough relatives nearby to help with housework, she will not go out of the family compound for 40 days. At first she will just stay in bed and breastfeed the baby. When I attend a birth, I usually stay with her for a few days to give help and advice. We feed the mother a special porridge drink with sorghum and sugar and milk. On the eighth day, the family holds a feast to celebrate the naming of the baby.
I don‘t charge for my services, but the family will usually give me some money or some food or supplies. I know that in the Day of Resurrection my good deeds will bring me favor with God, so I don‘t mind.
We have traditional ways of dealing with problems during pregnancy or birth. If the baby is breech or in a bad position, people may hold the mother upside down by her feet and shake her. For fevers, they may send someone to the clinic to bring a penicillin injection. If the baby doesn‘t breathe, they may suck out its nose with a syringe (with no needle). If the mother has bleeding or swelling, they may put fire on her forehead.
I have been instructed by the doctors and nurse practitioners to send or bring the women and babies to the hospital if there are certain problems. If there is too much bleeding, or the labor takes too long, or the water breaks and the baby doesn‘t come soon, or the baby is not in a good position to be born, or other problems arise, she needs to go to see a doctor. So I try to do this, though at times it is not easy, as the story below shows.
Story of a Transport
Last year a lady named Fatna who lives in a village near ours developed a fever four or five days after she gave birth to a baby boy. Her mother-in-law had attended her birth because it was a quick labor and they didn‘t have time to come get me. I thought the fever might be malaria, because it was during the rainy season. We gave her malaria medicine but she got worse. So the next day I told her husband that we should take her to the clinic in the big town.
At first he didn‘t want to, because they are very poor and don‘t have money for the transportation. Also the family was busy with the harvest and would have a hard time sparing someone to camp out on the hospital grounds to take care of Fatna. But I convinced him that it was important.
So he took his donkey and went to another village where a man owns an old pickup truck. He was somewhere out in his field, so Fatna‘s husband waited for a boy to go fetch him. By the time they got back to Fatna‘s village, it was almost dark and not safe to drive to the city because of bandits and the conflict that we in Darfur have been suffering from the last few years. Also this man‘s truck headlights didn‘t work.
We started out early the next morning. Fatna‘s husband and a neighbor rode in the cab with the driver, and her mother and sister and I rode with her in the back of the truck on a couple of blankets. Her family had bought some extra charms with Quran verses in them from a holy man, and put them around Fatna‘s neck for protection. We left Fatna‘s new baby with another lady in the village who could breastfeed him. Usually it takes about an hour to travel the sandy tracks through the desert to the big town, but this time it took about three hours because of getting stuck in the mud and having a flat tire.
The truck owner wanted to be paid 600 Sudanese pounds ($300 US dollars) for the trip but the husband negotiated it down to 500 pounds. When it is not the rainy season, the truck owners only ask for 300 pounds because the riverbeds are dry instead of flooded. The owner agreed that they could pay their savings of 100 pounds now, and pay the rest later when they could gather money from relatives and neighbors. Fatna‘s brother has a construction job in the city earning 250 pounds a month, so he will be able to help them.
We got to the clinic, and the medical assistant and registered midwife checked Fatna and said she had an infection.
They gave her an IV drip with medicine in it, and scooped some bad-smelling blood clots out of her. They said that we should take her to the hospital in the city because she was very sick. They said she was also thin and had poor blood because of malnutrition.
The truck owner agreed to drive us to the city. We brought Fatna to the maternity hospital, which is the only one in our state. The doctor scolded us for not bringing her in earlier. They continued giving her medicine in the IV drip, and cleaned out her womb. But Fatna died in the night. Sometimes the fate God gives us is hard to bear, but we must accept it.
I am thankful that most of the mothers and babies that I serve end up healthy and fine. I don‘t have fancy instruments and equipment and gloves like the trained midwives, but I have my mind, my heart, my courage, my experience and my two work-worn hands.
Ramona Denk is a midwife from the US who works for a humanitarian organization in Darfur, Sudan. She is responsible for overseeing and starting reproductive health programs in their rural project areas. She has a passion for reproducible midwifery training.
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