At the age of 23, Eva Paulo is in labour with her fourth child.
I meet her outside the Nyarugusu health clinic in the Geita district of North West Tanzania. She’s pacing barefoot under a canopy of Jacaranda trees, accompanied by her sister-in-law, and cursing her fate like almost every woman who has ever found herself in this particular situation.
Unlike Eva’s previous three labours, this one has been slow and extremely painful. Now in her 36th hour, her narrow face and long neck are slick with sweat in the late-morning heat. As a wave of pain overcomes her, she collapses at the waist like a marionette whose strings have been cut, small hands gripping her bent knees for support. As the contraction subsides she pulls herself back up and drinks deeply from a pink plastic cup of tea, shaking her head the entire time as if to indicate she’s almost given up.
But in fact, this is just the beginning for Eva.
I’ve come to Tanzania to watch women give birth without water. The NGO WaterAid has brought me here as part of their campaign to raise awareness about the relationship between water, sanitation and maternal and infant health. And while I’m awed by the stoicism of health care workers and women like Eva, I’m also terrified on their behalf.
My own two recent birth experiences were complicated and, for entirely separate reasons, required serious medical intervention. (My first baby was an undetected breech and my second emerged unconscious and barely breathing due to a traumatic forceps birth and spent a week in the NICU.) Had I been one of the six women who gives birth each day in the tiny, basic Nyarugusu clinic, I may not have lived—nor my sons.
While in recent times so-called “natural” birth has been fetishized in the West by privileged mothers who seek it out as a personal choice, in most of the developing world it remains the only option. What seems like a distant historical memory for most North Americans—giving birth without choices, modern comforts or medical safeguards—remains a reality for millions of women on the planet today.
In Tanzania, only 42% percent of women give birth with access to running water, let alone pain relief or the option of medical intervention. This particular dispensary is a case in point. While it provides basic healthcare like infant vaccinations, contraception and family planning, HIV and malaria testing and prenatal care, the most crucial service they provide is maternity care. A tiny team of three registered midwives deliver an average of three to six babies a day.
These infants are being welcomed to the world in the most basic conditions imaginable. There are no doctors here, no fetal monitoring, no option for surgical or assisted (forceps) birth, and no running water on site. I’m told repeatedly by staff that they’re lucky to have electricity. At many of the clinics in Tanzania, babies who arrive at night are delivered by the light of a mobile phone.
Unsurprisingly, sanitation is poor. The floors and walls of the delivery room are flecked with blood and dirt and smell strongly of cleaning fluid mixed with afterbirth. Labouring mothers must use filthy squat-hole outhouses and the instruments used for cord cutting or episiotomies are often simply wiped down with bleach in lieu of sterilization. Mothers and their families are expected to hand wash their own dirty sheets before they leave the hospital—with water they have to bring themselves in jerry cans—because staff are simply too overrun to do so. And when a midwife wants to listen to the baby’s heart-rate, she uses an antique-looking horn that looks like a prop swiped from the set of the period drama Call The Midwife.
Like most Tanzanian women, Eva labours silently, breathing through each contraction with the strength of master-yogi as the pain rips through her. The midwives have instructed her (as they do all the mothers here) to keep moving in an effort to hasten the baby’s appearance, but she’s clearly exhausted—and increasingly alarmed. Both she and her sister-in-law are full of anxious questions, which they pose to each other in absence of a midwife. Why is the baby taking so long? Why has no one come to check? What if something’s not right? Why isn’t anyone telling them anything?
These are the common laments of all women in the darkest hours of labour, but in Eva’s case the questions are more heavily weighted. A complicated birth, here in rural Tanzania, is a matter of life and death. While Tanzania has made great strides in maternal mortality rates in recent years (there was a 47 percent reduction of the maternal mortality ratio between 1990 and 2012) the infant death rate remains comparatively high. Only five Canadian babies out of a thousand will die before their first birthday—in Tanzania, the same number is 51.
Poor sanitation means a simple neonatal infection can easily turn into a fatal case of sepsis. In fact, while Eva is examined, I talk to not one but three recently bereaved mothers at the clinic whose babies died from infection in the last three months alone.
In spite of the obvious, looming risks, the general atmosphere is calm. The clinic itself is tiny—just two buildings joined by an outdoor breezeway, all public spaces crammed to bursting with mothers and children waiting patiently to be seen by the over-worked staff.
The midwives here are calm and efficient and the mothers are similarly placid. The babies rarely cry and the toddlers don’t seem to tantrum.
In the bushes behind the “maternity ward” (really just two rooms separated by a screen) two or three women pace in the dust getting “exercise” as they cope with contractions.
Finally, the midwife Jackline comes to me with some welcome good news: Eva is in transition and will soon be ready to give birth.
When I peek around the doorway of the delivery room, Eva waves me in. She lies on a bed, looking exhausted but also somewhat relieved to finally have her feet up. The “delivery ward” here consists of one small room divided by a screen—one half for birth, the other for recovery. Until a woman is ready to deliver she isn’t allowed to have a bed in the birth room because others might need it.
Jackline appears and says all is well, the baby is in position. Eva smiles weakly and her sister-in-law, who is relaxing on the other side of the room gives a satisfied nod.
As Jackline prepares the instruments (a scalpel and scissors to cut the cord) she informs me breezily that in cases where the baby is breech or in severe distress, the clinic can call a Red Cross ambulance to take the mother to the hospital in the nearest town where caesarean sections are performed. This involves a 90-minute drive down a bumpy rural road with no streetlights. There’s only one ambulance and it’s not always available. She tells me of a woman who recently came in and quickly gave birth to a son. It was only when her labour pains didn’t let up abate that she realized it was twins. “I saw a tiny arm emerge,” she recounts, “The baby was in the wrong position!” The ambulance was called and the mother was rushed to hospital and later had her second twin delivered by emergency C-section. But many others are not so lucky. In cases of fetal distress or placental abruption, there is not much of anything to be done.
The NGO WaterAid is working with local government in the area to bring running water to this clinic and others. This, Jackline tells me, will change everything. “Then we can sterilize our implements and wash the babies. Women will not have to bring water of their own.”
For Eva, the moment has reached it’s crisis. She lays prone on the hospital bed, knees up and open, her belly still draped in a traditional African kitenge. She mutters to herself something in Swahili and closes her eyes, gathering strength.
The midwife stands beside her, stroking her arm and then as the next contraction grips her, Eva’s body tenses, she holds the side of the bed, back arched, every muscle quivering with effort. “Kushinikiza, kushinikiza,” whispers Jackline, the Swahili word for “push.”
When Eva goes limp this time, she lays back and drinks deeply from the pink plastic chai cup.
Calmly, without the faintest rush or panic, Jackline snaps on a pair of latex gloves. She takes the plastic packaging they were wrapped in and instead of tossing it out, spreads it flat under Eva’s bum—a cleverly recycled entrance mat for the new baby’s entry.
One more monumental push from Eva and a baby’s sleepy flushed face emerges from her body. Jackline pauses. “Ah,” she says, slipping a pair of fingers under the baby’s chin and giving a sharp tug. “The cord was around the neck,” she shows me. “That’s why baby took so long.”
With one swift tug, she pulls the cord up and over the baby’s head. Another big push and the body shoots out.
A perfect little girl, seconds old and wailing, is lifted onto her mother’s heaving chest.
It’s all over, and everything has just begun.