The Maasai Midwife!

So I spent 3 days living with a Maasai tribe in a mudhut, peeing in a long-drop that was dug specifically for us mzungu visitors, trekking 6km in blistering heat to the dispensary each day, then home again, learning some of the Maasai language, about their traditions, history and observing a goat slaughter - then eating some. I loved my time there so much I arranged to go back for another 3 days after all the other students had headed back to the UK. I will write another post about life at Maasai, and working at the isolated dispensary but first I want to share the experience I had meeting the Maasai midwife.
The basics that you need to know is our Maasai guide was a warrior named Alais, the day I met the midwife his brother Festo took over his duties. Their village has over 800 inhabitants but the village is spanned over 50+km. Each family lives at a Boma, a small collection of mudhuts and an enclosure or two for the livestock.
So after my last day at the dispensary, we went back to our Boma, had some food then trekked about 2km to a nearby Boma to see the midwife. As well as being a shorter walk, it was mostly flat and much more pleasant...also due to the fact it was a cooler day so I didn't feel as though I was melting!
When Festo, Fred and I arrived we were greeted and shown to some small 3 legged stools in the shade of one of the huts - they took a little concentration to keep balanced on them! Then a girl aged about 10 guided an elderly woman around to us with a pole and assisted her to her seat. This was the midwife; aged 72 and blind. Yes. Blind!

Me and the Maasai Midwife

When she sat down she spoke at some length to Festo, then he spoke at length to her. This was how Maasai greet one another, after saying hello one person would give an in depth update of how they and their family is, and then the second person would do the same. Shortly after, Fred then gave his update to the midwife. Then I was introduced and told to ask anything I wanted.
I started by asking how long she'd been a midwife, how she became a midwife and how many women she'd cared for. Fred translated my questions to Festo in Swahili, who then translated them to Maasai for the midwife, and her answers were translated back along this route to me. I was told that when she was in her late teens she began attending births with other women of her village, a relative of her's was midwife at the time and she began asking questions and developed an interest. This relative encouraged her to get involved; palpating the uterus, supporting women, observing what was done during a birth. She then had her first baby and said she now understood birth better. She continued to learn the knowledge and skills her relative shared and as time went on got more involved then began taking on the role herself. She told me she's delivered thousands of babies and has no idea of a specific number as it's been too long!
I asked how she copes without her eyesight, especially in situations where I for one would completely depend on my vision such as external signs of descent of the fetus, observing for signs of placental separation, and assessing blood loss for hemorrhage. Her response was that birth has little to do with sight, she uses touch and sound. I continued to ask how she deals with emergency situations without her sight, to which she replied she has never had a woman hemorrhage, a shoulder dystocia, a cord prolapse or abruption. I asked if with her experience she's able to identify signs of any of these emergency situations and transfer the women to the dispensary or district hospital before they advance, she told me no, there has never been an emergency situation and no woman or infant has died in her care!

Inside a hut, the little doorways are sleeping areas, which almost
completely prevent a woman from being cared for in bed

She talked me through a typical birth, that when a woman is in labour a warrior from her Boma will go to the midwife's Boma and escort her back, guiding her with the pole that was used earlier to guide her to us. She said that this could be up to a 30km walk in the dark. This means she has to put so much trust in the warrior leading her, with it being dark he may not see as many obstacles in her path as he may in daylight...add to that the added risk of lions and other predators and wildlife freely wandering about the Savannah! She told me that the hut will be kept extremely warm for when the baby arrives, there will be other women there supporting the labouring woman and offering assistance to the midwife.
She palpates to check the contractions and presentation and sometimes does vaginal examinations - but not always. The woman's body then leads the birth, the midwife gives no time limits to birth but her experience tells her that things are progressing. Sweet chai is given to the woman to give her energy and positions including kneeling and squatting are encouraged to help fetal descent. She told me how the head is delivered, she waits for the head to turn and with the next contraction the baby arrives. She told this all in 1 long explanation and I kind of felt for Festo and Fred for having to remember everything she was saying before translating. However, as she spoke, she gestured and used her hands and knees as props...as she was talking Fred spotted me nodding knowingly in agreement. He quietly asked if I understood her and I told him what I thought she was saying. When Festo translated to Fred he kept smiling at me and said I was right. He then told Festo and the midwife that I'd understood without the translation. She said that midwifery doesn't need words just like it doesn't need eyes.
I asked what she does once the baby is born, when does she cut the cord and what is done with the placenta? Again, from her movements I figured out most of her response :) The baby has immediate skin to skin and is encouraged to breastfeed ASAP. The cord is tied when it has stopped pulsating and cut. Then she waits until the mother has a contraction and the urge to push and deliver the placenta. In retrospect I wish I'd have asked what's the longest time she's waited for third stage to be completed. Then the placenta is buried near to the Boma. This made me a bit nervous as not too long before this meeting I was being told about the lions and other predators that wander around...and they're putting 'bait' near their homes...reallllly hope they're buried very deep lol! I told them how some people consume the placenta either by cooking it, having it made into a type of smoothie or reduced into capsules...Fred couldn't believe what I was telling him...Festo's face suggested shock and the midwife began spitting and waving in disgust. Her view is that the placenta was part of the baby and part of the mother, if someone can eat that then what's to stop them eating their baby! That topic didn't go much further.
Out of curiosity I later asked what were her reasons for waiting for the cord to cease pulsating, as I assumed her practice wasn't based on current evidence. I was told that it's how she was shown when she was younger, she's always done that, as did the midwife before her...and why would you cut the cord when it's still doing a job? If the cord has a pulse then it has life running through it. I must admit I adore the simplicity in her reasoning and I really love that for her and the midwife before her, they have complete faith in Mother Nature and the ability of a woman's body.
This midwife provides some antenatal care too, if women are unwell during pregnancy she will advise them on traditional Maasai herbal remedies. Still dubious about her saying she's never had a woman with any complications I asked what does she do in situations such as malpresentation or premature labour. With the latter I was told that labour happens but nothing further was discussed regarding the wellbeing of the infant. Again with gestures that I understood, she told me that she turns babies that are the wrong way - basically performing External Cephalic Version (ECV). I said that where I am training it's only obstetric consultants who perform this procedure while the mother has pain relief (entonox) and a ultrasound scanner is used throughout the procedure to ensure the fetus is well, and if the procedure is unsuccessful then most women opt for a cesarean section. "If it doesn't work? Why wouldn't it work? It's easy? Why don't midwives do it? It's basic. Just need hands and grease." Again, a very frank response which focused on the hands on skills surrounding childbirth.
The three of them told me about some of the tradition surrounding childbirth; when a woman is at approximately 12 weeks gestation a large bombfire is built outside the hut. This is basically the pregnancy announcement and a way of telling family and friends that they are welcome to come and give their well-wishes. I'm not sure at what stage the fire is lit though. From this gestation the woman and her husband will not have sex again until the baby is 3 years old - as her body has to continue growing the child and to then give the body time to heal.  When the woman is in labour her female relatives support her and assist the Maasai midwife and once the baby arrives the women sing for hours and the warriors slaughter a goat and the whole Boma celebrates. The woman is brewed a traditional Maasai medicine (like a herbal tea) to give her strength to recover and provide for her baby.

A bonfire in front of a hut to indicate the woman was pregnant. 

In all honesty the midwifery this Traditional Birth Attendant (TBA) spoke of was generally what I expected to be observing during my placement - more focus on normality and low risk, women uniting to support each other, keeping birth a natural physiological process surrounded in practice that's based on cultural traditions.
Now in the dispensary clinic I'd met several women who had lost babies in the past while delivering at home and the doctor had told me of situations where Maasai women had died in childbirth that could have been prevented if they had a trained professional present rather than a traditional birth attendant, so I don't completely believe that she has never had an emergency but can understand that she wouldn't want to openly advertise any fatalities she's had to an outsider like myself.
The doctor at the clinic told me about outreach programmes that are being launched in more remote areas of Tanzania, where nurses and midwives use motorbikes as the quickest form of transport over rough and changeable terrain. In Tanzania 57% of women give birth without a healthcare professional in attendance (in the UK it's <1%) (White Ribbon Alliance, 2012) and this is mostly due to the remoteness that some families live in. Logistics and costs of improving this and increasing the number of formally trained midwives undoubtedly lie in the government's hands...another issue we have in common.
There is discussion surrounding TBAs and providing them with training to help deal with emergency situations. But after meeting this TBA, I personally wonder whether they would be receptive and engage with this...or take offense, declaring they don't need to be trained in such matters because their traditional practice has served them well. And from what I was told, why would a TBA want/need training when she claims to have never had an emergency situation? Speculation on my part of corse!
This woman was an absolute inspiration. Her ethos pretty much covered the Promoting Normal Birth campaign by the RCM here in the UK and I would have loved to have had the opportunity to attend a birth with her - to see a home birth, Maasai style! I adored my time at Maasai for various reasons and would go back in a heart beat, but meeting the Maasai midwife was really the icing on the cake!