On Saturday “Mom,” one of the matrons at the clinic, invites us to attend a gathering in a very small village a few miles from Kafountine.  We all pack into a taxi and travel the dusty road that is flanked on both sides by rice fields. These fields are family owned, women worked, and the rice produced is not for commercial use. In times not far gone, the young girls would work these fields with their sisters, cousins, aunts, mothers and grand relatives—this is women’s work.  Now, here as practically everywhere in the world, young girls want to be and look cool.  The western media has re-shaped their mind to the liking of Beyonce and Sharika and Rhinnanna (no Jill Scott, Eryka Badu, and India Arie are known over here).   The older men and women are chiding the boys who, when the young girls go by, pull their pants down to their hip bones—NO Further Down.  Senegal—that was the home of the Senegal mini braids in the 70s and 80s, where sistas with money would fly over here to get an intricate braid creation with individuals and layers—is now the home of weaves and wigs…all ugly monstrous materials, with skin bleaching (aka skin burning) in true Black Face creations…reproductions of the symbols of beauty that are they are bombarded with through the media.

But in Kafountine and surrounding small villages of the Jolla People, on this Saturday, we are off to participate in something different but the same.  Weekly dance practice for the Initiation Ceremony for the boys and men who were not here when the last one was held.

In August 2010 the Jolla men-children and men who were not here for the last Initiation in 1978 will go through one week of rites of passage; these rites are sacred. The Initiation is held when it is called for; it is not set by calendar. In an Initiation Celebration in 2007 in a nearby village the Drums of The Forest decreed that it was time for one in Kafountine and its surrounding villages. This Celebration will cost the villages a tremendous amount of money for people who have so little; outfits to be made, food and drink to be made and provided to all, a cow to be sacrificed each day.

Each Saturday the men-children, young men, and young girls and their families leave behind the tarnished world of 2010 to come together teach and practice the old ways of manhood and womanhood.  To teach and practice the dances for the Ceremony:  for the older men-children to teach the younger; for the women to cheer on in dance and movement the men-children as they perfect their steps and stamina; for the older men to call the boys to step perfection as good drill sergeants would do; as the old women step out to dance once again as if a young woman in tandem with the men-children.   For the flow of support and protection and pride is here in this time and place to kiss and carry every mother’s son who is present.  Every man-child knows in his core that he is loved, protected and respected by everyone present; he belongs to this community; he is never alone and unloved. He belongs and is kept in the hearts of each person present—his self esteem is sealed by this Ceremony he will take part in soon.

The women are carried to some place with their singing and beating of sticks that women’s energy only gets to go to…you cannot stop yourself from singing at the top of your voice because your voice is not yours it belongs to the group.

The Ceremonial circle begins with the drums and women’s voices.  The older men, the elder do a slow step at the front of the processional similar to the ones I have seen at Native American Pow Wows; the Bounce step done by the old.  Then are the middle age men who were initiated at the last ceremony (they wear skirts over their pants as a sign of being initiated—once the initiation Ceremony is completed in August all of the new initiates will be required to wear a skirt over their pants for 1 year); then the men who have been further initiated and wear special neck jewelry which indicated that they can be cut but do not feel pain, they are mixed with the men who carry metal tubes that are loaded with gun powder and other things (these guns are set off periodically). Next, the men-children, by age groups join the processional doing their appropriate dance step; finally the group of the little men-children.  Every man-child is taking this with full-heart seriousness and obedience; no playing laughing, lolly gagging; eyes are on you (and the girls are watching too) you must do your best.

The men-children are then separated into smaller groups by age and practice their steps with the aid of the drumming and the support of the women’s voce and beating of sticks.  The gun powder guns are fired , the drums are constant, and everyone is in the moment.  You could not stop yourself from joining—it is a tsunami—and your body’s shared collective DNA from being from this home-place this gene pool; it claims you and you want to be one with this community; with this family.

See images of the initiation practices in my photos albums…

NO BOTTLE FED BABIES!  EVERYONE BREASTFEEDS THEIR BABIES!! THEY BREASTFEED IN PUBLIC WITH NO COVERING WHILE CARRYING ON THEIR REGULAR LIVES . THEY LIVE WHAT WE SAY—BREASTFEEDING IS TRULY NATURAL HERE.

I think I saw a small can of dry formula behind the counter in the Mini Marche near the light bulbs and batteries…..

Even the 13/15 year old moms are breastfeeding immediately.  New moms who are struggling with breastfeeding are immediately supported and given advice by all the women around them.

There are breastfeeding education posters throughout the prenatal clinic. Keep in mind this poor, rural agrarian setting does not have the economy to support a formula-based feeding style. And clean water, with which to mix the formula, is not readily available, another big issue here. Thank God for breasts!!!!!!!

NO STROLLERS OR FANCEY SLINGS; EVERYONE TIES THEIR BAIES ON THEIR BACK WITH A SIMPLE PIECE OF CLOTH.

Who are the women who birth at the Kafountine clinic? Kafountine has permanent residents who are Wolof, Jolla, Mandinka, Peuhl and the various regional sub-tribes of these major tribes. In addition, it has residents who have migrated, on a permanent or temporary basis, from the Gambia or Guinea Bissau.

If you were in labor and having a baby at the Kafountine clinic who and what do you bring with you?

When a laboring mother arrives at the clinic the women family members and or female friends bring a large plastic basket which contains numerous “pons”  (or large pieces of fabric that can be worn as a lapa or a head piece or a shawl or used as a pad or to tie around things to carry them) and fabric for the mom and baby to wear and any other birthing and post partum supplies.

It is the sole responsibility of the laboring and post partum mother’s family and friends to take care of her.

During labor, they labor sit the laboring mom; they provide her with food and drink throughout labor; they find one of the metal buckets for her to use as a bathroom. They watch over her and report to the sage femmes or matrones when the laboring mom needs help or they have questions. The concept of loving, gentle labor support by providing soft touch and words of gentle nurture and encouragement (warm fuzzies) is rarely done.  The women are more staunch in getting the laboring women to move and walk and work hard. Labor is hard work and the faster and harder, the sooner the baby will come. Laboring women do not make much noise; the shake their hands, tighten and beat their fists, compress their forehead, jaws and faces, hold heir lower backs; and first time mothers kneel to the ground; first time Peuhl mothers sometimes call out for their mothers.

Men do not attend birth!! They do visit the mother and baby after the birth and they have been placed in the Le Grand Salon. No women family members or friends are allowed to be present in the delivery room!

After the birth, they keep watch over the mother and her baby. They bring food and drinks, with the necessary glasses and dinnerware. They bring a blanket for the post partum bed.  They bring a mat for each person who intends to stay with the laboring mother upon which the women family members and friends can sleep on the floor near her bed. The clinic has 2 foam mattresses for family members to sleep on, but there are always more people than the 2 mattresses.  Family and friends simply sleep on the floor with a cloth over them—they do not have mosquito nets. They cook for the mom in the outside courtyard on the coals if they do not bring already prepared meals. They wash the mother’s and baby’s clothes. Most importantly, they let the sage femme or mattrone know if the post partum mother is having a problem, like a post partum hemorrhage, or the baby is having a problem.

When do laboring women arrive at the clinic?

Just like in the U.S., some first time mothers arrive when “they think they are in labor” and after a vaginal exam and timing and palpating contractions are found to be less than 3 cm. dilated and in very early labor. Some first time mothers do prodromal here too! They like all women who enter in any stage of labor are kept but are only admitted if they are 3 cms.

Once you enter the clinic in any stage of labor you are kept! The clinic would be fined if a laboring (even in early labor) mother left and later had her baby at home.  The women family members and friends are responsible for labor sitting her and the sage femme or matrone will do a vaginal exam every hour to see if she is progressing.

More seasoned mothers will arrive in active labor when they think birth is imminent; many walk in the door at 7-8 cms. and have their babies within 60 minutes. A sizeable number arrive when they are complete and ready to push.  And each week at least 1 woman arrives after her baby has been born at home to have the sage femmes or matrones deliver the placenta and examine the baby. Those women who birth at home go outside in the bush to birth their babies.  They do not want their families to see them in pain and it is important that their husbands and male children not be exposed to birth blood.

Women who have had one baby at the clinic tend to stay home as long as they can for any subsequent babies. Why? Some tribes do not trust medical interventions in birth and avoid the clinic for prenatals and birth as long as possible; some women cannot afford the cost of delivery (Senegalese $ 1,250) and need time to collect the money from friends and family.

In addition, the laboring mother and her family need to have money available to pay for any medications that are outside of the routine labor, birth and post partum medications (pitocin, methergine, iron pills, etc.).  For instance, IV fluids must be paid for by the laboring mother and they are not always available if the pharmacy is closed.

More costly is the transport to the hospital, usually the one in Ziguinchor which has a surgical team, can cost the laboring other and her family Senegalese $20,000.  As a result, medical interventions are made on three levels here with multiple delays:

• A medical determination;
• A family decisions that the recommended treatment is something they agree with and can pay for; and
• Effectuating the decision—collecting the money, getting the pharmacy to open and get the medicine, getting the ambulance here from Ziguinchor or a private taxi to Ziguinchor.

The issue of birth and the phrase “Trust Birth” has been a part of fabric of my life for the last 7 years. I have helped women find their way through the birth of their children and their own birth as mothers.  I began my journey in this world of birth as a hospital-based doula and birth center-based doula. I went to The Farm and my Sista-midwives-mentors guided me into my new safety zone of birth out of the hospital, then to home birth, and to become a midwife birth assistant.  I have grown in confidence and conviction that birth is natural and almost always safe and became a midwife birth assistant who loves home birth.

I have provided clients who thought they wanted a hospital birth, with information and emotional support and given them a safe haven in which to reflect upon that decision.  Many have re-evaluated their birth setting choices and chosen an out-of-hospital birth setting with a midwife; some have even helped catch their own babies.

I have shared my belief and faith that birth is a physical occurrence for a meta-physical change, and will be the best day of your life.

Yes, I have sometimes doubted the process of birth but never the outcome, not even in the face of babies who were not ready to be or stay with us.

I have studied everything I could get my hands on in my journey to midwifery but nothing has prepared me for what I have seen and felt here.

At Kafountine I have met women who trust birth and its outcomes without question. They trust birth because birth is.

I have met and worked with the sage femmes and matrones, collectively the Sista-midwives here, who routinely manage birth complications that many U.S. home birth midwives have little experience with, except to transfer. Here, even with the grossly limited resources available and the near impossibility of transfer, these Sista-midwives do not recognize our Western distrust and “what if” of the birthing process, of birth or birth complications—they just do what they can do, always prepared for whatever outcome God and nature dictate.

Kafountine clinic is a small clinic in a rural village in Senegal, West Africa. It treats every woman who enters, regardless of her medical condition. These clients are not risked out of this practice as with out-of-hospital birth practices. The client may have high blood pressure; diabetes; hypertension (all related to their diets of white rice, white bread, sugar and other starches); protein, calcium, and iron deficiencies; anemia; malnutrition;  dehydration; and other conditions that arise from often having children too close together.

I have witnessed and participated in the births with mothers who have partial placenta previa, pre-eclampsia, twins, breeches; babies with IUGR, oligohydramnios and polyhydramnios; numerous babies with thick meconium and several babies that needed resuscitation.  The Sista-midwives here managed these births on a routine basis, with no oxygen, no suturing skills, an ambu bag that is almost s old as I am and doesn’t work, and limited medications; IV fluids are only available when the pharmacy is open and must be paid for by the mother.  Just skills and experience and a trust in birth and acceptance of its outcome. Two clients have been transferred; one with a brow and nose presentation and one with a platypoid pelvis and an assynclytic presentation.

Their ways are clearly not the ways that are commonly used by midwives in the U.S., but we are not in the U.S. We are in what is called a “low resource setting” and that phrase is a great understatement for this setting.  The resources are severely limited – the skills and experiences of the Sista-midwives are its greatest resource, and a formidable one at that.  This is not a birth site where “nurturing and warm fuzzies” support is offered. “Tough Birth” is the protocol here.

These Sista-midwives are not proponents of “mother the mother” and “warm fuzzies” in labor. Tough love is practiced here by the midwives and the female family members – the message is birth is hard work! Verbal harassment and chastisement and threatened slapping are a part of the standard protocol; fundal pressure was used only once in our presence.  These practices were discontinued in our presence when we remarked about it.  Also, no female family members or friends are allowed to attend the birth.

I have to make it clear that some practices used by the Sista-midwives as part of their protocol here are hard for me to hear and watch. These Sista-midwives are zealous proponents of the Western hospital delivery practices that flourished in the 1950’s and 1960’s. For instance:

1. Laboring mothers are required to birth lying flat on the delivery table with their hips resting on a large bed pan – if they attempt to birth in any other position they will be stopped, chastised, loudly hollered at with threats of potential adverse birth repercussions. Absolutely no squatting is allowed!
2. Fundal pressure and fundal tickling is done with most births;
3. Laboring mothers are required to keep their hands and arms folded on their chest – they are not allowed to touch their baby crowning or to have their baby placed on their chest. The Sista-midwives’ believe that the mother’s germy hands will infect her baby and their desire to perform the delivery and post partum care without the interference of the mother; and
4. All cords are cut immediately because they believe delayed cord cutting can lead to infection.

As one of the sage-femme’s commented when we lobbied for squatting, delayed cord cutting, skin-to-skin, “We used to do those things and then we got science.”  The Western Medical machine continues to spread its mis-information throughout the First World – the Home of Natural Birth.

As a result of these practices and protocols, these women continue to have their babies in a field behind their homes alone, or with a traditional home birth midwife.

The mothers, when they leave the clinic resume their working responsibilities immediately. They do not have any recuperation period post partum; when they return home they are immediately back in the full swing of their lives—cooking, cleaning, washing clothes, taking care of their husband children—hard women’s work (a perfect scenario for post partum hemorrhage).

The medical protocols established by the Senegal Dept. of Health, in their compliance with the World Health Organization and USAID guidelines, have developed protocols for its clinics throughout Senegal that were difficult for us to understand  and appreciate at first.  They are so far from the protocols used by home birth midwives in the U.S.  But the homebirth reality of the U.S. is of little relevance in the reality of Africa.  We had to set our home birth reality aside, but bring our skills, experiences and knowledge, and step into the reality of birth in Senegal with its problems; and its solutions to those problems.

The World Health Organization has stated that the biggest killer of women in birth and post partum hemorrhage; next, is infection.  It has recommended a more active management of both second and third stages of labor in order to reduce the risks of post partum hemorrhage.

In response Senegal has developed protocols to address the WHO concerns and reduce maternal mortality and the reality of the Senegalese women’s post partum life style:

1. Pregnant women routinely receive iron pills throughout their pregnancy;  and
2. Prenatal visits (4) focus on disease prevention by ensuring that pregnant women receive vaccinations;

When in labor, women:

1. Receive a vaginal exam every hour, even if their bags of water have released;
2. May receive an injection of pitocin, intra-venous without perfusion,  if labor stalls;
3. Receive an injection (IM) of pitocin when they are complete (cervix has completely dilated and effaced) in order to minimize time pushing;
4. Receive another infection of pitocin (IM) as soon as the baby is born, even before the placenta is delivered.  The cord is cut immediately;
5. May receive an injection of methergine and gauge curettage (for clot removal) after the delivery of the placenta. Methergine is not given if the woman’ blood pressure is high;
6. May receive antibiotics  during post partum stay;
7. Receive an injection of pitocin (IM) each day she is in the clinic’s post partum unit; and
8. Receive an injection of pitocin (IM) upon discharge along with iron pills.

In addition, the baby receives an oral dose of polio vaccine and tetanus shot upon discharge.

The liberal use of pitocin and several of the other practices here are ones that we would never do as out-of–hospital midwives.

As much s the liberal use of pitocin and methergine and frequent vaginal exams (even after rupture) troubles me in Senegal these are their first line of defense against post partum hemorrhage.  We are outside of the protocols we know and understand, in a reality that Senegalese believe necessitate these drastic measures.

We are not arrogant or neo-colonialist enough to carry ourselves as if we are here to bring our view of midwifery to Africa. We are here to bring our skills and information and assistance to our Sista-midwives and to help the women who are birthing. We teach and learn from each other.

Given the above basic information, in the future I will write about the birthing women here.

Yaseem has asked us to let her know what we would like to eat for lunch and dinner. Since everything we eat is locally grown and fresh, we decide to visit the open air market to see what vegetables and fruits are available. Since Jessica’s luggage has yet to arrive she will be shopping for a few outfits to wear until her luggage arrives.  I am going along as the photographer.

We concentrate on the village to the left of the clinic; to the right is the section of Kafountine that houses the European hippie, eco-green hotel, restaurants and stores—the tourist section.

On the corner of the clinic is the Mini Marche, which is a very small version of your corner store. It has the things that a small urban corner store has, but with sodas (Cokes made with sugar!) and beers that are not quite cold and no frozen foods. It sells French wines and liquor; the half pints of hard liquor are kept on a low shelf out of the eyes of customers.  There is WI FI access here and the owner never has change; a good way to get you to spend more money.

Downtown Kafountine consists of dusty, pot-holed roads just like the ones upon which we traveled to get here. They are lined with corrugated metal roofed stalls, most without electricity; and each stall has a specialty. There are larger one-room, one-level, brick stores, usually selling hardware or home supplies. Oh, there are numerous coiffeur stalls featuring hair weaves and wigs, barber shops and butcher shops.  Kafountine does not have a bank or ATM; the Western Union is open 5 days a week for a few hours, but it closes at noon on Friday and does not open again until Monday morning.

Most businesses close down for part of Friday, the Muslim Holy day; many businesses are open on Sunday.

We walk down the dusty main street with a stream of onlookers; we are considered “Toubab,” politely translated as “tourist” but also meaning a person of European ancestry; we are not reviewed as the “returning African sistas.” Their knowledge of who we are and how we got to be is practically nonexistent except for those who have seen a part or all of the “Roots” series. Makeda with her waist length locks and African centric clothing, Jessica with her light skin, me with my hair cut short; we are not recognizable as being one of Africa’s children by our folks Back Home.  A question soon asked of us is, how did we get such light skin (did we bleach it?) and are our parents white.

We make our way to the open air vegetable and fruit market. These stands are set up just like the ones all over the world, except the vendors are all women! One vendor has her section and displays her produce; the vendors work together referring you to other vendors if they do not have what you want and making change for each other. Getting change is a big challenge in Kafountine!

What fresh produce do they have?  Eggplant, tomatoes, onions, many types of potatoes, lettuce, sweet potatoes, string beans, papaya, oranges, limes, mandarins, bananas, cassava, and avocado. There is no okra. EVERYTHING INVOLVES BARTERING—only the things in the Mini Marche are a fixed price.

Jessica buys an outfit from a woman who has a street stand. I visit the 3 stalls of fabric and plan my next shopping adventure. Much of the fabric is made in Senegal, Gambia and Nigeria; the lesser quality items are made in China; the prized bissan riche fabric is made in some place I do not remember.  There are very few stalls that sell ready-made clothes. The influx of ready-made clothes has had a substantial adverse impact on Senegal’s economy.  Until recently everyone had their clothes made at the neighborhood tailor.  Now the young folks want to dress like the people on TV and in the movies and like the Europeans who visit here. You see a few older teenage boys walking around in second- hand European and American clothes; a broke-down brimmed hat and long coat, trudging down the back roads of sand.

Since I have the camera I accumulate an army of children who want their photos taken and then to see themselves in the camera.  Every one of them has a snotty nose and many a low cough. Remember, whooping cough is still a problem in Africa.

I treat myself to a luke warm Corona beer and head back to the compound to deposit the groceries and get back to the clinic.

See my photo albums for some images of our shopping trip.

Today has been set aside for getting to know the family compound and how things are done here.

This family compound is the home of Monjara’s family; we are living with Jolla people and Wolof is not their language. Here as elsewhere in the world, the extended family still lives under one roof, or in this case in one compound. I am not sure who all of the folks are yet. Monjara, the gracious matriarch; her daughter Yaseem our hostess and cultural anthropology guide; Zuzu (Augustine) who is a nephew and his wife who keeps a watchful eye on our safety and is our DJ ,with a huge Boom Box and complete collection of reggae and African music. There are others who visit and spend the night—all are welcome.

The compound consists of:

A garden where food is grown for family consumption;

An outhouse with 2 showers—one for men and one for women;

A large main living quarters with several bedrooms; this is Monjara’s and Yaseem’s house;

4-5 small bedrooms in a row;

An outdoor cooking shed;

An indoor kitchen with a stove, refrigerator and freezer –most of the cooking is done on a free-standing burner;

Our section consists of 3 bungalows with 2 of us in each one.  They are very nice! There are 2 windows with fabric curtains and a door to close if you wish. Why close and lock this door—our windows are open and we are just stuck in our city living minds; everyone is family here, with our best wishes at heart.  Plus the bats are no big deal and stay outside.  We have mattresses on the floor, upon which we put our own sleeping bags, with mosquito nets over them.  We have one light source with the latest environmental light bulbs. Each bungalow has a plastic chamber pot;

An outdoor shower and #1 for our section only;

The well.  All of the water used on the compound is drawn from the well; and

There are 3 goats, 2 dogs, and numerous chickens running around; plus birds in the day and bats at night.

What is a day on the compound like?

The house wakes at close to 6:00 a.m. and it is till pitch black. The animals are let out of their confines, the ground of the compound is swept with brooms to remove any leaves or debris; water is drawn with which to water all of the plants;  the well water is put on the stove is boiled in preparation for a warm morning bucket showers. Other chores are done and our breakfast is placed on the table in our bungalow section. Or breakfast is pretty much like continental breakfast—hot water for coffee or tea, fresh French-type bread with butter and cheese, all kinds of jelly and jams; the fruits are fresh!!!! Papaya, oranges, mandarins.  We brought our own cereals and oatmeals, dried fruits and nuts and teas.

We arise at about 8:00 am.  We awake with a plan in mind for getting to the outhouse. Makeda and I have made good use of the chamber pot during the night.  It is one thing getting down to the ground to sleep on the floor on a mattress when your are  awake, but getting up in the  pitch black dark, flashlight in one hands searching for the chamber pot is another.  You know how we tell our clients not to sit straight up all at once but to roll to their side before getting up? That is pretty much my way of getting up from my bed. And getting down to bed is like the old dog circling its mat at night. Bad knees, old bladder, and the floor is so much lower now than it used to be.

We each draw own well water and take either a cold or warm shower.  I love drawing the water from the well!!!!!!  We straighten our rooms and settle in for breakfast together. We eat and plan our day at the clinic.  Yaseem joins us to discuss what we would like for lunch (about 2:30) and dinner (about 7:30/ 8:00). She will bring us lunch to the clinic. Her core muscles are so strong and her posture so perfect, she carries our lunch on her head the 1  1/2 miles to the clinic.  Sometimes she joins us her for lunch and helps with language translations.

Lunch and dinner can consist of: rice or couscous; fish with an onion sauce; lentils with vegetables (carrots, potatoes, cassava, and eggplant) a red sauce or palm oil sauce; salad with lettuce and tomatoes, onions, hard boiled eggs and bread and fruit. I beg for byysop (hibiscus with ginger drink) and Makeda begs for “Super Konja” something with okra (my most hated food and hard to find this time of year in Casamance). The diet of Senegal is a starch based diet, with a high sugar consumption; it helps explains its very high rate of diabetes and high blood pressure.

We head off to the clinic around 9:30 am.  While we are gone Yaseem cleans out rooms and washes any dirty clothes… I want to be her best friend!!!!!

On our slow nights we return home from the clinic around 6:00 pm.   We relax, take a cold shower, and eat dinner.  Then it is talk some and go the bed, awaiting the call from the clinic. We are on call after that and when the clinic calls and there is someone in labor, we put our clothes back on and head there as fast as possible down the road.  Some nights we do not return home until 1:00 am or later.  Zuzu has kept the compound gate unlocked and is dozing in a chair outside, waiting to make sure we get in safely (what a wonderful man).

While we were at the Kafountine clinic, two laboring patients were transferred to the Ziguinchor Hospital for complications that were beyond the clinic’s ability to handle.  One pediatric patient (7 months) was also sent to Ziguinchor.

The first illustrates the reality of working in a “low resource setting” and it was through this client, my first client, that the full meaning of a working in a low resource setting became fully clear to me.

Mrs. B, a short, petite, 16 year old, was here to have her second baby; she has the smallest feet. Her first baby died within a few hours of its birth and weighed less than 3 ½ pounds. When she arrived at 9:00 a.m. she is 3-4 cms dilated and the baby is very high and the mother has a very narrow pelvic inlet.

She is frightened, dehydrated and hungry, but does not want to eat or drink because she has been vomiting. Throughout the day her family brings her food and with constant coaxing she eats and drinks a little. Her female family members are practicing the “tough love” form of labor support that so characterizes birth here. We walk her and give her breaks to doze—she has no energy; a tired and pacing mother. We have ORS available for dehydration, but keeping it down is still an issue.

Throughout the day we have discussed and tried various options to get this labor to progress and for the baby to descend. We have used a wide variety of the comfort techniques and strategies to move the baby lower into the pelvis, but her pelvic inlet is very small and narrow.  Her contraction pattern remains irregular all day. We have focused our attention and commitment on changing the baby’s position in the uterus (yes, I took my rebozo and “Happy Puppy” glute moves to Senegal).

We have no IV with dextrose to give her some energy. The clinic does not carry dextrose IV and it would have to be purchased at the pharmacy.  The pharmacy is closed and the client does not have the money with which to purchase and IV. We volunteer to pay for it but with the pharmacy closed the issue is moot.

We have no Benadryl to give her a nap.

The baby is still too high for a safe rupture of the bags of water.

We have no homeopathics or herbals except for parsley tea for contraction stimulation.

By 7:00 p.m., her cervix has dilated only 3 cms. —to 7 cms. The baby is still very high, the heart tones no longer reassuring and the baby, and scalp stimulation is only a temporary improvement method. Despite our day-long rigorous activities to get the baby to descend and to re-position itself, the baby has not done so.

We discuss options for getting this baby out now. Recommendation—immediate transfer.

But as I was to learn, the decision to transfer involves three levels of decisions:

• The medical recommendation that a transfer is the only available solution in this situation;
• The family’s agreement on this recommendation—which involves getting a complicated set of approvals from various family members and money with which to pay for the transfer; and
• Access to transfer—collecting  money to pay for the ambulance and the ability to get the ambulance here from Ziguinchor

The matrone is not convinced that all available options have been tried yet and takes management of this client.  Her solution—pitocin by intra-venous injection and internal version. When this failed she recommended transfer to the hospital in Ziguinchor to the family.

We were unaware (and naïve) that in making this decision, the issue of money was the pivotal factor. It was not until the next morning that the ambulance arrived.

In Ziguinchor, Mrs. B. had a c-section and her second fetal demise.

From this event we took the issue of money out of decisions to be made by the family members of the clinic’s clients. We paid for ambulance rides, formula, water, food, etc. —life or death would not turn on the issue of money for our Sisters while we are here.

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On Thursday Feb. 4 we were called to check on a mother. We arrived to find a mother who is 6–7 cms., dilated, with the baby entering the pelvis in an assynclitic position, with a deflexed head, and a brow and nose presentation.

There is universal agreement to immediately transfer this mother to the hospital in Ziguinchor.  The family agrees to the transfer and we agree to pay for the ambulance (Senegal $20,000).  An IV is placed while the ambulance makes the drive from Ziguinchor; one of the midwives accompanies the mother on the ride.

As the ambulance arrives, the mother’s family members and some of the clinic’s post partum mothers come out to wish her good luck.

We sit down to give ourselves a “Job Well Done” pat on the back and a taxi cab speeds up to the clinic door, with a home birth mom and her twin girls.

The labor, delivery and post partum section of the Kafountine clinic is a small building, badly in need of every kind of repair that sits at the end of the clinic compound.  It consists of 5 rooms:

1.)   The large post partum room which is known as “Le Grand Salon.”  It has 10 twin sized beds for the post partum moms. A post partum mom normally stays for 2 days or longer if she had a medical complication;

2.)   The small laboring room which is just big enough for 1 twin bed and a foam mattress for a  family member;

3.)   A small delivery room which has 2 delivery tables and a place for 3 people to stand. Family members, not even the women, attend the birth;

4.)   A large office with a twin bed for a laboring mom or a post partum mom if the post partum;

5.)   A small room with 2 twin beds which can be used as another spare post partum room or a sleeping room for the visiting midwives;

6.)   And an outhouse with no shower; and

7.)   A water faucet for washing clothes or getting water to bathe or drink.

The building is in critical need of renovation and repair. The cement floor has pits and holes, the windows and doors have no screens; the rooms are poorly lit—with one 60 watt light bulb per room, even in Le Grand Salon. Each bed has a mosquito net hanging over it (USAID makes these available for about $3.00 for pregnant women and children under 5 years old).  There are only 12 fitted twin sheets and no top sheets for 14 beds; many of the foam mattresses have sheets with big holes in them. The walls have not be cleaned or painted in years and cob webs and spider webs adorn the ceilings and corners of almost every room.  There is evidence of mice in the visiting midwives room. The floor of Le Grand Salon is swept and mopped only twice a week.  The outhouse is horrendous and there are no showers or bathing facility.

When we arrive, the midwives are out of exam and sterile gloves and vitamin K and almost out of erythromycin and methergine. Thank goodness for the supplies I collected and Jessica bought with her!

We meet with the staff and get our first taste of midwifery care in Senegal. Awa, the lead sage femme, has been stationed here for over 4 years. After a few days of working with her we have the utmost respect for her professionalism, grace and caring.  Rose, the second sage femme has been here for 1 year. The sage femmes are assigned by the government to a clinic site and are paid by the government. The midwives do prenatals and other OB care, work 12-hour shifts and are on call for emergencies that are beyond the skill or resources of the matrones.

The 2 matrones, Mom and CheCha, are the backbone and foundation of this clinic. They deliver twins, breeches and other births that are not commonly managed by non-nurse midwives in the U.S. They also teach a once-a-week class to the young women on family health and women’s health issues.

What is a matrone? She is a woman who leaves her village and family for a term of 1-2 years to study midwifery; she is not a nurse. She then returns to her village and works full time doing labor and delivery in tandem with the sage femme or by herself. She has a room at the clinic in which she lives for her 2-days-on, 1-day-off schedule.

Her salary is paid from the proceeds from the women’s prenatal visits; the matrones and pharmacy staff (6 people) share 25% of the proceeds of the prenatal visits. The Senegal $1,250 birthing fee is given to the village—the village decides how that money is to be spent, but it is not used to pay the salaries of the matrones. The matrones have 2 gardens on the clinic premises and the money from the gardens’ produce provides them with money for themselves and their family.

For the last few months the clinic is averaging about 60 births a month.  By the time we had arrived they had had over 30 births so far in January. There is a high incidence (over 20%) of fraternal twins in Senegal as elsewhere in western Africa.  The common belief that this high incidence is a result of the consumption of African yams and sweet potatoes.

During my first day I assist with prenatal visits. The prenatal clinic building is in a separate wonderfully kept building.  It is bright, clean, tiled, and the walls are covered in wonderful information posters.  There is a lab for blood work and exam rooms.

The visit is much the same as in the U.S. except that there is a vaginal exam at each visit and there is practically no lab work done.

A routine prenatal schedule consist of 4 visits; one during each trimester. These visits focus on prevention issues–typing blood, testing for HIV, and vaccinations. Clients are routinely given iron pills for anemia.  There is no free medical care here so the clients are responsible for paying for these visits.  Because the clients do not know the date of their last menstrual period, the estimated due date is simply indicated by a month, not a specific date.

Tomorrow I will begin working in the labor and delivery section of the clinic!