Meeting a Traditional Midwife in Malawi

Marianne Littlejohn and I volunteer for Operation Smile by teaching the Helping Babies Breathe (HBB) programme.

In June of 2014 we were flown to Malawi to teach at the Kamuzu Central Hospital in Lilongwe . Over five days we taught approximately 40 people each.

Malawi is an amazing country. It is incredibly poor but we were really pleasantly surprised by the hospitality and kindness and receptiveness of everyone we met.

What I love about the HBB programme is its focus on normal birth, its simplicity and its adaptability to whatever environment it is presented in. We have so far taught in high tech hospitals, to home birth midwives, low resourced settings, to doulas and mothers. Each course is different because it works with the experiences and environments the people being taught bring to the workshops. Kamuzu Central Hospital is a reasonably well equipped hospital with sensitive and compassionate midwives. Some of the people we taught were very experienced midwives, doctors and paediatric nurses with many years of experience with very compromised babies. There was interesting discussion and sharing of stories and knowledge – we definitely learned a lot from the people who attended these workshops.

One of the women we taught, Violet, a highly experienced midwife, told us about the work she used to do providing training and education and equipment to Traditional Birth Attendants (TBAs) in her region.

TBA is the term used to describe traditional or lay midwives who have no ‘officially’ recognised training. Usually they have learned their skills from other traditional midwives. It is a controversial title as it takes away the centuries old title of ‘midwife’ from those women who have always attended pregnant and labouring women and who often carry skills and knowledge passed down through generations.

Violet told us about a TBA living in a village not far from Lilongwe and offered to take us to meet her if we could organise the transport.

The following day we organised a car and a driver and were driven about 45 minutes outside of Lilongwe over dusty and bumpy clay coloured roads, past simple handmade clay brick homes and thorn trees and goats and women wearing colourful cloth skirts.

Along the way, Violet told us that TBAs had been the backbone of maternal care for a very long time in Malawi. She told us that the Malawian government had trained many TBAs in basic midwifery skills to provide care for pregnant and labouring women. The government had also provided updates and further education every month to the TBAs to ensure their skills were kept up to date. The government had also provided the TBAs with equipment and medications. It had been Violet’s job to provide these updates and education to ensure that the TBAs were following best practice when caring for pregnant and labouring women. Violet’s duties had also been to ensure that the TBAs were stocked with the medicines and equipment they needed. She had enjoyed this work. She had enjoyed the travelling and admired the TBAs she was responsible for.

Two years previously, in a drive to encourage women to seek care from hospitals, the Malawian government had banned TBAs. This had not really changed the birth statistics in the hospitals, Violet said, all it had done was driven the TBAs underground and yet most rural women still sought care from the TBAs they knew and had grown up with, and who had probably attended their mothers when they themselves were born. Lack of transport to the hospitals made it difficult for mothers to get to the hospitals even if they wanted to. The government was no longer providing education or supplies to the TBAs.  Also, the banning of the TBAs had made it harder for the TBAs to refer and transfer mothers for medical care when they really needed it.

We were driven to a solid looking brick building surrounded by much simpler ones. An elderly woman sat on the porch with two pregnant women. She rose to greet us as we approached the building with Violet. The two older women, who had not seen each other in twelve years, were happy to meet again and we were introduced to Mai Nayele who shook our hands with her gnarled ones. She was small and dressed in the same colourful cloth you see on most women in Malawi. Her face was wizened and her eyes milky with cataracts but her speech and gestures were animated.

 

Mai Nayele was happy to meet us and show us around.

She spoke only Chichewe so Violet translated for us.

Mai Nayele showed us into her clinic which was simple and filled with donated hospital beds. A British woman, who had met and admired Mai Nayele, had  raised the funds to build the clinic. We met a young mother who had birthed the day before. She sat on  the floor with her baby in her arms. We spoke to her briefly and admired her baby and she told us that she had felt very cared for by Mai Nayele.

Mai Nayele showed us into the room where most births happen.

She told us that approximately three hundred women birthed at her clinic per month. We thought this was a translation error.

Three hundred?

But no, it was true. Mai Nayele, with one assistant, attended around three hundred births per month! She had the paperwork to back it up and showed us her birth log book. Rows and rows of names, many on the same day, had birthed at her clinic and with her. She herself is illiterate but her brother records every birth for her.

Wow! This was impressive! How did she do it? How did she care for so many women on her own?

We found out that most women are instructed and encouraged to labour for as long as possible at home with support of other female family members. Most women arrived at the clinic ready to birth and Mai Nayele was there to facilitate that process.

“How does Mai Nayele prevent tearing?” Marianne asked.

“Oh. No one tears,” translated Violet for Mai Nayele, “I make an ointment using herbs and oils and I rub it on the perineum while the baby births and the perineum stretches.” As Mai Nayele described this she showed us with her hands how the perineum stretches.

Mai Nayele is a very well known herbalist and medicine woman and she also told us about a local herb which she used to make contractions stronger if a mother’s labour was not progressing. She also showed us the combination of pills (which included malaria medication) that she used for post-partum haemorrhage.

She showed us the certificate she had received from the government in 1978 after she had completed her TBA training.

She also humbly showed us the Humanitarian Award that had been presented to her for her work by the government in 2008.

“Did she mind being called a TBA?” We asked, “Did she find the term derogatory?”

“No,” Violet translated for Mai Nayele, “ I am a TBA.”

And that was that.

She also showed us the boxes from UNICEF that the government had given her when she had first qualified and which used to be regularly restocked with equipment and medicines. Now they were nearly empty.

We then moved onto the building opposite. This is where Mai Nayele saw women during their pregnancies. It was a simple room with a bed covered in black plastic. The bed was situated underneath a window with no glass in it. A stool with a clay cup on it was next to the bed and a plastic bucket stood in the corner of the room.

A pregnant woman visiting would be asked to lie on the bed but Mai Nayele did not use her hands to palpate and check the lie, position and growth of the baby. She did not check blood pressure nor test urine. She had one very simple diagnostic tool and she had been using it for over thirty years.

A mirror.

A tiny, smudged with speckles of dirt, plastic framed mirror that lived on the window sill above the bed. And a cup of water on the stool.

Mai Nayele told us that she would sprinkle some of the water from the cup onto the mother’s belly and, using the mirror, would reflect the sunlight pouring through the window onto the droplets of water. Somehow, using this tool, she would know at around 28 weeks gestation (about 7 months pregnant) whether the pregnant mother could birth safely at her clinic or whether she would refer her on to a hospital.

That simple.

As I mentioned, Mai Nayele is a well known herbalist and healer and she showed us the concoction infusing in the plastic bucket in the corner – it was for epileptics she said. Then she led us to the adjoining room with a rickety wooden table in it. A pile of sticks and leaves lay on it and a bowl of white powder that she had pounded from the dried plant.

This powder, she said, was what she used to stimulate contractions if a labour was going too slowly.

The sun was beginning to sink in the sky and it was time for us to leave. Mai Nayele had given us a lot of her precious time and she had answered all our questions with great patience.

On the way back to Lilongwe we stopped to buy some carrots and tomatoes and peas in their pods from the side of the road and munched on those as we discussed and mulled over this visit.

We both wished that we could spend more time with her and learn from her.

It is difficult to describe Mai Nayele.

She is humble and old and small and unfussed.

Yet she has an incredible strength to her.

What an incredible person to have met on this visit.