How can natural birth be optimal with so many dying in Africa?

SYLVIE DONNA REPORTS ON SOME SURPRISING FACTS ABOUT BIRTH IN SUB-SAHARAN AFRICA...

Many people dismiss natural birth – of any kind – because of the outrageously high mortality rates in sub-Saharan Africa. Women there have to go natural… look where it leaves them! But is it true that ‘natural’ inevitably means ‘unsafe’?

You could be forgiven for not wanting to be like women in other countries. If you’ve ever been away on holiday somewhere further than Calais, you might have found members of your own sex a little different. At the very least, you may be momentarily surprised by women you see away from home.

Personally, I remember noticing superficial differences when I first went to the Continent: the apparently effortless chic in France and Italy, the tendency of all women over a certain age to wear black in Spain and Portugal… Then, in Morocco, I found myself fascinated by women who were going about their business with babies tied to their backs. (Often I would linger behind a woman as she leant forward to retie her shawl, while her baby clung on obligingly.) In Korea I saw a woman running a fast food café entirely single-handed with a three-month-old baby strapped to her back. That, I felt, could never be me.

The feeling of non-identification with women is one I revisited when I attended the Women Deliver conference in October 2007 in London. That weekend was also a time when I found myself repeatedly thinking through safety issues and at last understanding why… In all the sessions I attended I heard about experiences which were far, far from my own. Although I’d given birth three times myself (entirely naturally, without drugs or interventions), I never had to contend with the health hazards which seem commonplace to most women in developing countries. My lifetime mortality risk of 1 in 8,200 compares very favourably with a woman in Sierra Leone, whose risk is 1 in 8. I had the luxury of fast and efficient emergency care, should things have gone wrong, unlike my counterparts overseas. Their fate might be determined by non-existent telephones, poor road surfaces and ill-functioning or unowned vehicles. Oh, and I also started my child-bearing career with a healthy and unmutilated body…

Female mutilation is in fact 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…

Even women who have not been ‘cut’ are exposed to risks we can barely comprehend, simply because of lack of health care facilities. Many live too far away from hospitals or clinics and those that are accessible locally are often inadequately stocked and staffed. Not surprising then that an estimated 536,000 women died in childbirth in 2005, many of 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 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. All these answers seemed unsatisfactory to me as a woman who has experienced natural birth.

While I can accept the reasons these men suggest to some extent, I think there might be another one 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?

Having said all this, I must admit my view changed somewhat after I’d read a book, which I’d also found at the conference, on one of the exhibitors' stands. 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. I do, after all, remember an old English colleague’s experience in Casablanca when she became pregnant. Her husband, a relatively poor Moroccan school teacher, was loathe to spend money on either antenatal care or birthing facilities. The planned trip back to England for the birth was eventually cancelled… a private hospital in Muscat would do fine; a few weeks later my friend shrugged as she told me it would be a private hospital in Casablanca after all. Then, with only a couple of weeks to go, it became a government hospital and finally she gave birth with no professional support, electricity or running water in the city’s old medina… She was one of the lucky ones who was able to laugh about it afterwards.

I feel very, very fortunate to have had the best that birth has to offer for the births of all three of my daughters. For my first birth I was in Sri Lanka and as a private patient at a cottage hospital I had access to the very best of medical care. I was also fortunate to have the support of an excellent obstetrician there, who had agreed to support me in my wish not to have electronic fetal monitoring or any drugs or unnecessary interventions. The second time I gave birth, Dr Michel Odent was in attendance. If you know anything about him at all, you will know that he is the last person to disturb a birth unnecessarily! (It was interesting to experience a real fetus ejection reflex…) For the third time I decided to stick with the NHS. After finding a supportive midwife and booking a homebirth, I gave birth to my third child with minimal disturbance. A far cry from what I might have experienced 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 (Doubleday 2002), which was commissioned by the charity CARE International. Here’s an extract:

To step into Kibera is to be lost at once in a random, seemingly endless warren of rank, narrow passageways wandering between rows of frail, dirt-floored hovels made of tin and mud and twigs and holes. Each shanty, on average, is ten feet by ten and home to five or six people. Down the centre of each lane runs a shallow trench filled with a trickle of water and things you don’t want to see or step in. There are no services 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

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 Care International 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 Save The Mothers

Advice for preparing for a safe, developed-world style of natural birth is included in the book, Birth: Countdown to Optimal. Note that a companion edition for caregivers is also available, Optimal Birth: What, Why & How This book provides material for discussion in the form of accounts, interviews and reflective questions.