An MSF midwife in Somalia

She has seen pregnant women brought to the clinic in wheelbarrows and crawled into mud huts to check on the well being of new borns. Within the Somali culture, expectant mothers are not concerned about their due date. And she has seen more sick and dying mothers and babies in eight months than seen in 20 years in the USA.

After 22 years of working as a midwife in the United States, mostly in home births settings, I have come to Somalia to continue my midwifery. Since my young adulthood, I have wanted to do some kind of service in a high-need area. I have a daughter who is now 22. When she was little, I needed to take care of her. But when she went to college I started to think more seriously about being able to do some kind of international service. Two years ago I decided to apply to MSF. I chose this organisation because I liked what I heard about them. I liked their philosophy and what I was aware of them doing. MSF is an organisation that is committed to serving the most vulnerable populations in the world. They often go into problem areas in the world that other do not. Before I worked with MSF I had a private midwifery practice in Lancaster county Pennsylvania, USA. Before that I worked for two years on the Navajo reservation in Arizona, USA. My work with the Amish and the Navajo Indians has shown me what a blessing it is to be an intimate part of another culture. How much I can gain personally from seeing others strengths. Working with the Amish has also given me a comfort level with simplicity. I can work without electricity and have it seem normal. I also have the confidence that, if I do my best to be sensitive, I can be accepted even by people who are different from me in some ways. And I can figure out how to be helpful. Working with the Amish taught me many things about how much potential people have for goodness. How to live by your own convictions. How to care for and feel blessed by the dependent members of your community. These values can be carried in to the global community as well. The MSF people are the only non-Somalis living in Galcayo. We consist of a midwife, nurse, doctor, trainer and non medical manager - all living together in one compound. Most of our work focuses on the hospital but we also do some health related activities in the community. MSF is supporting the regional hospital, which is in Galcayo, in a partnership with the local health authority. MSF was supplying medicine and basic emergency equipment to the hospital maternity floor and antenatal clinic before I arrived. I am the first outside midwife to try to give support to the local people as they develop a system for safe and nurturing care of women and newborns during the childbearing year. My job includes on the job support and training in the antenatal clinic in the hospital, the in-patient maternity, the maternal child health clinic in the community and with the midwives and Traditional Birth Attendents (TBAs) doing home births in the community. Our hope is to support the initiatives of the local health community in building sustainable health care. We are hands off. All care is given by a local health care provider. The expats role is to guide, support and encourage when needed. All decisions and initiatives made in the hospital are a combined effort between the local people and MSF. It is a 60 bed hospital with maternity, paediatric and medicine wards as well as an emergency department, antenatal clinic and surgery department. The surgery department is supported the International committee of the Red Cross (ICRC). We are also involved with the Maternal Child Health Clinic, cholera preparedness, training of the midwives and traditional birth attendants in the community - and we are continuing to look in to female genital cutting advocacy in the community. The hospital sees up to 850 people a month in the outpatient dept of which 75 are antenatal. Overall monthly inpatient admissions are around 80. The midwives here have no standardised education and no continuing education. The midwives have a lot of practical knowledge and skills and they work hard, although the care they give is far less comprehensive then what we see in the United States. There are no professional books written in their language and very limited resources for them to give care. Many of the things we take for granted in the Western world, such as ultrasound and fetal heart monitoring, and routine lab work, are simply prohibitively expensive for women here. One of the places I spend time is in the antenatal clinics. Routine prenatal care as we know it is not practised here. Women mostly come for care if they are worried about something. The maternal mortality rate in Somalia is estimated to be 1,600/100,000 - one of the highest in the world. In Somalia, it is estimated that one in seven women will die from a pregnancy related complication, so there is reason to be concerned if you are pregnant. Women's gestational ages were not calculated here before I arrived. People are not interested in their due date. No management was done of pregnancies under stress. The local midwives have almost no equipment - not even gloves or blood pressure cuffs. Eclampsia is common. MSF supplies basic equipment and medicines to the antenatal clinic. We have made prenatal vitamins, folic acid and ferrous sulphate available for free as anaemia is a serious problem here. At the hospital antenatal clinic the average haemoglobin is between eight and nine. I also spend a few days a week giving on-the-job support and training in the hospital. It is a challenging, and often sad, place. Most women give birth at home many deliveries are fine. However because of women's poor nutritional status, many complications do happen. Referrals are often delayed. There are many reasons for this including lack of transport, fear of hospital procedures, women's low status, and midwife's lack of training and equipment. Many of the women are very sick when they arrive at the hospital. About one in every 30 or 40 women admitted to the hospital dies. Transportation is a serious problem even for people living in town. None of the midwives and few of the patients have cars. The price to hire a car is prohibitive for many. I have seen women come in on wheel barrows. Also the hospital is just north of the line dividing the clans. Women who are south of the line have to come to an area where they feel their safety may be in danger. Although the hospital is outspoken about its neutrality, this political situation means very late transfers. I have seen more sick and dying mothers and babies here in eight months then I had seen in 20 years in the United States. Again the resources in the hospital are very limited, but basic emergency medicine, blood and equipment is provided. The problems include, Eclampsia, severe anaemia, malaria, prolonged labour, haemorrhage and infection. The maternity floor is predominately run by midwives. The local doctors are busy and overstressed but do sometimes come to see very sick patients. There are no pagers, so it is hard to find doctors in an emergency. There are about 20 deliveries a month in the hospital and another 20 sick pregnant or post partum women. There is limited electricity in the hospital so dealing with emergencies at night is difficult. I have spent time teaching very basic things like daily rounding and vital signs and management of both normal and problem cases. Caesarean sections can be done but not always and not quickly. There are no IV pumps so medicines given by IVs cannot be closely monitored and so their use is limited. There are few provisions for new-born care. A lot of babies die both before and soon after they are born. The necessary resources for neonatal intensive care are not available. The families feel sad about losing their babies but don't have the privilege to feel the sadness as fully as we do in the Western world where death is so rare. Since I have been here, between one quarter and one third of the women giving birth in the hospital have lost babies - mostly from stillbirths and less from early neonatal deaths. The midwives here work very hard. It is amasing to see their strength as they face very difficult situations with very limited resources. I have seen many improvements in the care given in the hospital. The head midwife on the maternity floor is named Mahuba, she is a beautiful, 30 year woman who is raising one baby daughter. Her husband lives in Minneapolis, USA. She works every morning untill mid-afternoon. In the evenings and nights, she deliveries babies in the community. She is very wise and patient. It takes a lot of strengh to face the difficult situation she encounters. She always has a warm smile for everyone and has taught me a lot about giving care in this environment. I share with her what is written in the literature and my experience from the West. Because she only reads Somali, she is glad for me to share my reading with her. In Somalia, childbirth is viewed as a woman's domain. Men are not involved - not even the husband. But people have very good female support. Women generally see childbirth as hard and impossible without aggressive management by the midwives. They believe that female circumcision prevents births from happening spontaneously. There is a lot of active pushing and cutting done by the midwives. Part of this is learned by the western influence. I continue to try to assure them that women can give birth with gentle encouragement and support. I have been told that the nomadic people who live in the rural areas tie a rope to the ceiling and the women holds it while she squats to give birth. When I suggested we get a rope for the hospital they laughed. They keep people up and active during labour. I have informal discussions with the midwives from the antenatal clinics and inpatient maternity floor once or twice a week. They pick a topic they want to talk about, I read about it and we all discuss it. They are very eager to participate. This week we talked about hormonal contraceptives and what is the significance of bacteria and viruses and how to avoid spreading them. The next time we plan a PP haemorrhage board game. They love to look at pictures and have written information given to them. I also have regular meeting with the midwives and traditional birth attendants who deliver babies in the home. I am meeting with them biweekly to do continuing education, give some basic supplies and hopefully show them the strengths of a professional midwife organisation. We hope to facilitate a link between them and the hospital so emergency obstetric cases can be dealt with efficiently. As these meetings have evolved, I have found them to be a delightful group. One of the midwives meets with me before the class and I share with her what the books tell us about the topic we will be covering. She then presents the topic to the group both from her experience and from book learning. Today three midwives sang songs about the importance of woman and mothers and there willingness to help promote their health. It was very touching. They have taken me with them when they do their work. I have crawled into homes made of sticks to see baby twins who are having trouble breast feeding. These women do such important work. They care for the majority of the birthing women and often are not paid because the women have no money. I have decided to stay for another six months. I need more time to be part of the process of supporting a community while it finds its way to giving safe and nurturing maternal and newborn care in the best way possible given the resources. I feel like it is a gift to try.