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  • Midwives in Ethiopia

    Lives and Deaths of an Ethiopian Midwife

    By Stephen Buckley
    Washington Post Foreign Service
    Tuesday, October 7, 1997; Page A01

    Midwife Checks Mother/TWP
    Tamunie Hegisso checks for an unborn baby's heartbeat. (By Carol Guzy—The Washington Post)

    TULA, Ethiopia — Hana Yohanes, eight months pregnant, thought her baby might be dead. She could not feel the fetus moving. She lay in bed, weak and achy. She had been bleeding all day.

    "How are you feeling? Are you ready to deliver? Are you feeling sick?" asked Tamunie Hegisso, a traditional midwife, bush nurse and arguably the most important person in this village 165 miles south of Addis Ababa, Ethiopia’s capital.

    "The baby has stopped moving," Hana replied.

    Tamunie pressed her head to the 20-year-old woman’s belly. Then she pushed on it with both hands. She rested her head on Hana’s belly again.

    There were five small children in the hut, four of them belonging to Shurro Bekele, Hana’s neighbor and close friend, who was also pregnant. The children stood quiet and wide-eyed.

    Someone lighted a small fire in the late-afternoon darkness, illuminating Hana’s worried brown eyes. Her husband, in the middle of the hut, rubbed a hand over his face, distressed.

    "Try to save her life," he said. "I’ll do what you say."

    Tamunie said they must take Hana to a nearby clinic. "It’s my duty to save lives," she said before everyone rushed out of the hut.

    Tamunie, 61, has delivered babies here for 32 years. She has delivered the grandchildren and great-grandchildren of some of her fellow villagers. She helps with the births of about 100 babies a year.

    But she does more
    Midwife Attends to Child/TWP
    Tamunie sucks the stomach of an ill child, 1-year-old Tsion Taye, to "move the liver." (By Carol Guzy—The Washington Post)
    than deliver babies. She provides the village women with regular prenatal checkups, offers workshops at the church, examines neighbors’ babies when they come down sick.

    Everyone in this village of cactus plants and coffee fields seems to know the woman with the joyful brown eyes. Her angular face framed by a head of tight black curls, she often breaks into sudden grins. Her large, strong hands are seemingly in perpetual motion. She slaps her fist into her palm when she makes a point. She hugs strangers.

    "She comes and helps me all the time," Hana said later through an interpreter. "Even her touch is like medicine for me. When she treats me, it’s like someone has given me money."

    Traditional birth attendants, the formal title for people such as Tamunie, "are considered more important than an educator or agriculturalist," said Dawit Mengistu, director of an institute in nearby Awassa that trains health professionals. "She is held in high status."

    She is held in even higher status these days after receiving formal, government-sponsored training from the institute. She got tips on how to safely deliver babies, how to advise mothers (expecting and otherwise) on various issues, and she even received equipment to help her do her work.

    Such efforts over the past decade have helped Ethiopia slash its infant mortality rate — the number of deaths of children in the first year of life — from about 250 per thousand live births to 160.

    The government also has doubled its spending on health care and has placed greater emphasis on educating girls. But this East African country, with one of the highest fertility rates in sub-Saharan Africa, is far from defeating this problem.

    Foremost among the country’s problems is a lack of health facilities; only 48 percent of Ethiopians have access to a clinic or hospital. This dearth of facilities means poor prenatal care and routine childhood illnesses kill many children.

    And the fertility rate itself — the average family has seven children — is a problem: Health experts say that the fewer children a woman has, the more likely it is that they will survive.

    Starting Young

    It also does not help that sometimes girls here are as young as 12 when they have their first child. Forced marriages for pre-adolescents, combined with female circumcision, often do crushing damage to both mother and child.

    "When they are children, their bodies are not mature enough. . . . " said Sister Iqbal Mangha, administrator of a health center run by the Roman Catholic Church in the nearby town of Bushulo. "We have girls 11, 12, 13 here who have babies under their belt. Then she’s producing babies every year."

    Shurro, Hana’s close friend, is 26. She had her first child at 12. She had given birth to five other children, and was now nine months pregnant.

    She was not eager to give birth a seventh time. One afternoon recently, she said, in front of her husband, Shetu, "I don’t want to have any more children. He’s the one who wants more children."

    Shetu, defensive, replied: "What can we do? It is God’s will."

    The day after that exchange, Tamunie went over to check on Hana and Shurro. Hana sat up in bed, sipping coffee. The doctor at the clinic Hana visited had sent her home but said he wanted to watch her condition closely. Meanwhile, she could feel the fetus moving again. The bleeding had stopped.

    Tamunie examined Hana before going to Shurro’s hut next door. There the midwife did a quick check; the baby was apparently moving well. Shurro was feeling good.

    Now Shetu and three other men — neighbors — watched Shurro toil on her knees, straining water from vegetables, pounding coffee beans, splitting firewood. She also was being observed by Tadelech, one of Hana’s sisters. Tadelech is 12.

    Like most everyone in Tula, these villagers are from the Sidama tribe, which holds that girls of Tadelech’s age are ready to bear children. If she does not agree to be married, a young man probably will kidnap her.

    One of the neighbors in the hut predicted that a young man will abduct her soon. "She’s going to be married next year," the man said, unsolicited.

    The girl, sitting against a pole in the center of the hut, did not respond. Her hair was a torrent of black ringlets. Her eyes were wide and serious.

    "It’s good when a girl gives birth at 13 or 14," said Walana Wariko, 40, one of the men in the hut. "If she doesn’t, she’ll be sent from the house. We want our women to be pregnant."

    Then this from Hamara Bocku, 55: "A lady is born for fertility. The man wants to extend his generation. If the wife does not give birth, his name cannot be extended."

    The next morning Dawit, behind a desk choked with documents and books, described Ethiopia’s desperate battle to transform such attitudes.

    Essential to changing such viewpoints is the training provided by his organization, the Awassa Health Professional Training Institute, which worked with Tamunie for four weeks last March.

    Dawit said that traditional birth attendants such as Tamunie can more effectively articulate the dangers of pre-adolescent marriage and pregnancy to Tula residents than any outsider can. And they will listen to her.

    "People in the rural areas are very interested in being assisted by their own people," he said. "If you give people a choice, they prefer the [traditional birth attendant] who knows the culture, and who knows them."

    During her month-long training, Tamunie learned, among other things, how to clip an umbilical cord safely, how to wash a baby properly, how to instruct mothers on breast-feeding, when to send mothers to a clinic.

    She received a black box brimming with essential equipment: scissors, soap, a stainless steel pan, two stainless steel bowls, cotton swabs, a tube of tetracycline, a clear plastic mat and a towel.

    "I saw the difference when I got training," Tamunie said. "When I received my training, it was like I received light."

    Knowing when to send a mother to the clinic is essential to Tamunie’s work. Often parents refuse to take their children to see a doctor for lack of knowledge or, just as frequently, lack of funds. Sometimes the delay is fatal.

    An End, a Beginning

    One evening, Tamunie became enmeshed in such a case when a neighboring couple brought in their 1-year-old daughter. The girl, named Tigist, had diarrhea and had been sick for several days. The parents were worried.

    So was Tamunie. As she quickly examined the child — poking her chest and ribs, ear pressed to the infant’s chest — the girl cried out. Tigist’s head listed to the right. Her eyes rolled back into her head.

    "Take her to the clinic," the midwife told the couple, Abu Naramo, 20, and her husband, Batiso Belachew, 25. "It sounds like tuberculosis."

    The couple hurried off to the Catholic health center in Bushulo, which admitted Tigist. But it was too late. Shortly after the admission, as Tigist’s father told it later, the girl’s eyes bulged and her breathing grew labored. Then she closed her eyes and stopped breathing. She died in her mother’s arms.

    The next morning, Abu and Batiso trudged two hours back to Tula, to the compound of Batiso’s brother, where Tigist would be buried. In the hut, the dead baby was wrapped in a soft white sheet with green-and-purple embroidery.

    Eight women who had come to comfort the family squeezed into the hut. Some implored Abu to be courageous; others sat with hands over their mouths. Abu and Batiso were silent.

    Then two older men came to the tent and deftly tied the white sheet at both ends. Batiso bowed his head, wiped away tears. Abu was stone-faced. Then, as other women cried, a low sobbing filled the hut. Tamunie wept.

    Minutes later, even as men tamped the rich, chocolate-brown earth on Tigist’s grave, about 30 women sat outside the hut, listening to Tamunie as she paced, arms flailing.

    "God gives and takes the children," she said. "Be courageous. He will give you another child. What has passed has passed."

    The sun beat bright and warm. A lone black bird swept across the sky.

    Twice Tamunie told the group, "Take your children to the clinic. . . . When they become sick, take them immediately."

    Later in the day, about 3:45 p.m., Tamunie visited Shurro. The midwife expected the woman to give birth any day, and indeed, when Tamunie arrived Shurro was having contractions, about five minutes apart. Shurro groaned, grunted, shuddered. She gripped the edge of her wooden bed.

    Tamunie began preparations for delivery. From her black box she pulled a pair of scissors, a stainless steel pan, thread and cotton swabs. A neighbor came and went. Shetu walked in and stood at the head of the bed.

    The pains continued for more than an hour, drawing closer together, becoming stronger. Then they stopped.

    Tamunie had predicted as much. "She doesn’t have continuous contractions," the midwife had said just after arriving at the hut. "Usually, she doesn’t deliver until late night, early morning, between 3 and 5 a.m."

    Hours later, the children, having sated themselves with roasted corn, were asleep. The hut was quiet. Tamunie sat next to Shurro, cradling her. A few minutes later, the woman’s water broke. It was 3:10 a.m.

    Shurro moaned softly. Tamunie moved to the bottom of the blanket, and suddenly, the baby, a girl, spilled into the world. She had a round face, petal-smooth skin and shining black eyes. It was 3:16 a.m.

    "Get the blanket," the midwife said.

    Tamunie slapped the baby several times, then wrapped her and swabbed her eyes, ears and nostrils with cotton. Then the midwife removed the placenta and prepared to snip the umbilical cord. She measured carefully before tying it off with thread. Then she pulled out her scissors.

    But the scissors were not working. Tamunie, frustrated, gave up after three tries. She cut the cord with a razor instead.

    The hut was alive now. The children were awake and crying. Shetu was outside, chopping wood to build a fire.

    Tamunie stood in the dark, palms up, head tilted heavenward. She did a little dance.

    "Thank you, thank you, thank you," she said.

    Shurro’s eyes, meanwhile, reflected relief and weariness. She covered herself with a blanket and huddled close to the fire being built. A few feet away lay her new baby.

    It was a long time before the mother looked at the child.

    This series of occasional articles will look beyond Africa's wars, disasters and tragedies and chronicle how people on the continent go about their daily lives.

    © Copyright 1997 The Washington Post Company

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