Call Mama Doctor

Chapter 12. Fanya Bidii: Childbirth in the Bush

By Louise Jilek-Aall, M.D.

Giving birth to her first child is a major milestone in a woman's life. It is the great trial which will decide whether she is to live or die. While working among the tribes of the Ulanga district, I was astonished at the indifference people displayed toward a woman who did not recover from childbirth. It seemed to me that there was not much regret shown for a young woman who perishes in childbirth or much sympathy for her if she could not deliver a healthy baby. In the opinion of the people, the mother herself is to blame for whatever goes wrong during the first pregnancy. I would find such a woman lying neglected in a dark corner of her hut, covered with filth and blood, with only dogs and flies cleaning her infected wounds. Often I came too late, either because nobody had bothered to get help or because the village was too remote and I would see the patient only because I happened to pass through. Sometimes the expecting woman would try to seek help at a mission dispensary or at the Ifakara hospital, traveling if necessary for days through the bush. Some never made it and had to give birth on the way. Puerperal fever, a retained and infected placenta, or severe blood loss and physical exhaustion were often the cause of death. No wonder women approached their first childbirth with apprehension and fear, and that there were numerous taboos and rules to protect and guide them to a safe delivery.

Although I had gathered experience in obstetrics both at hospitals and with midwives in outpost missions, I dreaded being called out to a village to help a woman in labor. The dark huts, uncomfortable and narrow, are ill-suited for childbirth. During the long hours in the dark I often wondered with a sigh why labor pains always have to come on at night and why most babies are born in the early morning hours. It is a myth that African mothers deliver babies easily, especially those living in rural tropical regions. Undernourished and infested with intestinal parasites as they are, they are often poorly developed, with a narrow pelvis and frail physical health. Their anemic condition makes even small post-partum bleeding life-threatening. Old women who have successfully given birth to many children take the lead during delivery and at first I found it very frustrating to cope with them. They talked a lot and tried to interfere with my obstetrical practice, and I used to demand that they leave the hut if I was to take over. But with time I learned that it was better not to provoke these powerful women's wrath by excluding them, since their goodwill was essential for both the young mother and her newborn child. I came to fear them myself too, for when excluded they had plenty of time to set in circulation the wildest speculations about what was happening inside the birth hut. This could be most unpleasant when delivery was not progressing smoothly. There was one event in a village far away from any hospital, which taught me much about the interaction between the expecting mother and her old women helpers. Their behavior towards the woman in labor appeared very strange to me at the time, but I soon found out that they were only acting according to custom.

I had just arrived at Ruaha after a day-long journey by landrover from the Mahenge mission of Kwiro. It was already late and I did not expect to start working before the next day and was looking forward to a good meal in the cool dining room of the mission. But I did not even have time to change or to refresh myself before there was a knock at the door. The priest brought me a trembling young man and asked if I would please help this man's young wife who was in labor. Things were not going well and she was bleeding from the nose, the young man said. That was an unusual place for a childbearing woman to bleed, so I felt alarmed myself. The man assured me that his village was close to the mission, so I took along what I needed for delivery and went with him. As we hurried up and down the hills, through the bush, over streams and far into the forest, I cursed myself for having believed him so readily; people wanting help fast always insisted that they lived “not far away.” I had not eaten anything since the morning and my tongue was glued to my gums from thirst. But I consoled myself thinking that someone from the mission would bring me refreshments if I stayed away for a long time, since everybody knew that I could not drink unprepared water or eat indigenous food because of the ubiquitous typhoid fever.

The sun had set before we finally reached the little village half-way between Ruaha and Sali. As we crossed the village square women flocked to me, thanking me for coming to help one of them in her hours of trial. They made some remarks indicating that they expected difficulties for the woman in labor. She had not been a good mwali. I understood that there had been some irregularities in her behavior during pregnancy, and I had the feeling that the general attitude towards the expecting mother was rather negative. I found the woman in labor frightened and extremely upset. She was only a girl, fifteen years of age at the most. I looked at her frail body, narrow hips and huge abdomen, and felt the same apprehension as the women outside. She had fresh bruises on her chest and arms; her dry lips were also badly bruised and blood trickled from her swollen nose. “You have beaten her,” I exclaimed. The husband avoided my indignant look. He bowed his head and muttered, “Yes, Mama Mganga, it was necessary; she is lazy, she will not do her work.”

The room was crowded. A bunch of old women huddled together on a bed, while the expecting mother lay on the ground and pushed herself against the wall as if in self-defence. The old ladies were agitated and quite intimidating. I felt it too. “She is lazy!” They hurled out the accusation. “She will not fanya bidii!” I had often heard this expression used for a woman in labor. It can best be translated as “be courageous; take pains; work hard; pull yourself together.” The old women were gesticulating and talking all at once when suddenly the bed broke down under their weight and they tumbled onto the floor. With their arms and feet thrashing around they looked much like old crows in their dark clothes. I had to suppress a sudden impulse to laugh and used the moment of embarrassment to demand that everybody leave the room except for the girl's mother and a few others. We then restored the bed as best we could and assisted the girl to lay down on it. The bed was still out of shape and slanted to one side; but it was better than having the woman in labor lying naked on the dirt floor. The girl's mother brought forth a coconut she had saved for this event, cut it open, and asked me to wash my fingers in the clear fluid so that I could examine the girl internally.

The East African tribes among whom I worked had the unfortunate custom of making the woman bear down as soon as the first labor pains start. From that moment on, until the baby is born, she is not given anything to eat or drink or else they think the child will fall asleep and not try to find its way out. The ill-effects of this are two-fold. Being pushed downward before the mouth of the womb is open, the child's head presses on the half-opened muscular ring, causing the tissue to swell and not retract properly. Birth is therefore prolonged unnecessarily, even for days, and all the strength of the woman is drained. Because the hard-laboring woman has had nothing to drink or eat, she will be utterly exhausted before the final stage of birth sets in when she needs all her physical powers to expel the baby.

As I carefully palpated the womb of this young girl, I could feel the swollen muscular ring of the cervix. It was far from being wide enough to allow the baby to descend and delivery could not possibly proceed, even if the old women had all beaten her and forced her to fanya bidii. I placed her on her back with her legs elevated to get the pressure off the swollen tissue, gave her a pain killing injection, and in spite of the mother's protest, made her drink some water in which I had mixed sugar and vitamins. I then cleaned her wounds and put a moist cloth on her bleeding nose whilst I talked friendly to the terrified girl until she relaxed and dozed off. We all waited in the dark little room where a small fire on the floor gave the only light. I was hungry and thirsty and worried. The girl had very pale conjunctivae, a sure sign of anemia. Her arms and legs were skinny and all nourishment appeared to have gone into the child which seemed grotesquely large in her abdomen. Delivery would certainly be hard and very painful. Outside we could hear the old ladies debating angrily. I could have walked back to the mission to get some food for myself and still be back in time, but I did not dare to leave the young mother, lest her folks should beat her up again.

We were aroused by the girl's loud cry. Labor was setting in with renewed force after the pause. Mother placed herself behind the girl, took her daughter between her own legs and put her arms around the swollen abdomen. The others held the girl's legs apart and I knelt beside her. Each time the pains came on I made the women stroke the girl's arms and legs, massage her back and press her hands. Between contractions I let her walk. We talked to her and assured the frightened girl that everything was all right. It helped, and when the right time came, she clenched her teeth and bore down with all her might. Sweat poured down her body and the child seemed to rise up inside the womb, but all to no avail. The child's head seemed to be stuck in the narrow bony passage. Hour after hour we sat with her whilst waves of pain passed through her body. One could see the child move under the tight skin. The girl's moans and groans rose to long tortured wails.

Outside it was dark. Why did nobody come from the mission? I desperately needed some refreshment. At times my feelings of thirst were stronger than my concern for the woman in labor. My stomach was hollow and ached from hunger, the smoke from the fire burned in my eyes, the night was hot and the air heavy; it seemed to go on forever. At times the girl was in my arms. I looked down at the sweet childlike face, now swollen and contorted from the struggle. She trusted me, but I felt faint and could hardly find the strength to hold her up. The contractions became increasingly powerful. It seemed incredible that this frail girl had so much strength, but she was fighting for her life and for the life of her child. Restraining my wish to quench my thirst with the rest of the coconut milk, I again wet my fingers and examined the girl. The mouth of the womb was swollen and still not fully opened. During the next few labor pains I forcibly widened the opening with my finger. Blood trickled from the wounded tissue and the girl screamed in pain. “Enough, Mama Mganga,” she whispered, pleadingly in between the pains. I was sweating too and felt nervous. What if she was hemorrhaging to death? But something had to be done to make birth progress; the girl did not seem to have much strength left. Between the pains, her eyes rolled upwards and I thought she was unconscious. Her mother and the others also became increasingly anxious. Death seemed to lurk somewhere in the dark.

I felt lonely, weak and scared. What a difference it was, I thought, conducting delivery in the safety of a clean hospital with nurses and colleagues ready to help. Even death appears less frightening when one has all the devices of modern medicine around and knows that everything possible is being done. But here in the dirty, dark, windowless hut, smoky and hot, surrounded by scared and apprehensive women, hungry and thirsty, with the burden of responsibility on my shoulders alone, it was another story. “I am dying,” the girl gasped after an exhausting futile series of contractions. It was essential that she did not give up. Only her own strength, especially her mental strength, would help her ward off death now. Her moral strength, her tolerance for pain, her willingness to endure, her love for her family and her sense of duty would help her overcome the hardships facing her in this situation. Maybe that was what custom taught the girls during the confinement in puberty when they as mwali were shown that life for a woman is no fun there in the African bush, and that only by fanya bidii can they be prepared for the even harder ordeal of giving birth to their first child. I looked at this girl not yet fully developed for the task of giving birth. Being a mwali, closed up in a compound, protects a girl from getting pregnant too early, I thought, and remembered that the women in the village had indicated that this girl had not gone through her mwali period properly. Maybe there was more wisdom in their customs than I had thought.

Another violent contraction wrenched the girl from her semiconscious condition. She wailed and worked and struggled but could not get the baby to move down. I placed her on the edge of the bed with her legs hanging down, a position which sometimes helps when the baby's head is stuck in the bony passage but she could not endure that position for very long. I tried to remember other maneuvers. When the next pains came on, I had her hold on to the ceiling and hang down, but she dropped into our laps. Then the mother and her helpers turned against me: what good did I do? What use was there in my medicine? Why could I not make the child be born? The mother spat on the floor in disgust. Anger surged through me--as if I had not suffered with them through the night! “Alright, then, I will leave,” I said and stood up. I felt a sudden relief, seeing before me my bed in the cool quiet room at the mission where everything was right: no pains, no sweating, no screaming and wailing, no blood and dirt. I reached the opening of the hut, the cool fresh air struck my face, and without thinking of the impossible long way through the dark I was just going to slip out when I felt my leg seized from behind. “Please Mama Mganga, don't leave me, oh don't forsake me or I must die.” The girl held me back, sobs shook her body and her bloodshot eyes looked at me in despair. Of course I could not leave her. I turned and sat down again by the fire. My head was spinning and for a moment it was black before my eyes. I felt utterly powerless.

Just to do something and to give her and myself a break from the choking atmosphere in the hut, I made her come outside. The poor girl could hardly crawl, but she breathed in the fresh air with some relief. Then another pain threw her to the ground. She gave a wild shriek and all the old women who had been lingering around in the dark came to life. They rushed past me, seized the screaming girl and carried her into the hut. Now they took over; they seemed to know what to do. One took out of her cloth some white dye and painted a stripe across the girl's abdomen from the navel down to the pubic region for the baby to see its way. Others clapped their hands in front of the birth opening for the child to hear where to get out. When this did not help they sent for the men. The young husband who seemed out of his wits for fear was placed at the moaning woman's side and her father behind her back. He took her head on his lap, bent down over her sweating face and asked with a stern voice, “Who did you fool around with during the time of your pregnancy?” The girl gave him a scared look, then she glanced at her husband and at the other men around her. She whimpered, “I did not fool around with anybody.” She noticed the anger and disapproval on all their faces. A contraction interrupted the inquest. The old women slapped her full in the face when she gave in and screamed out in her pain. “Fanya bidii, haya! Fanya bidii,” they all shouted in a chorus and showed her how to bear down. They came in sweat themselves. It helped for a while.

In between the pains the father hovered over her urging her to name the adulterer who was causing her not to be able to give birth. It was obvious to everybody, he said, that she must have done something wrong. He told her to whisper the name into his ear if she did not want the others to hear, and he pinched her painfully to underline his words. But the girl only wept. Now she had lost all her courage and gave up completely. When the next contraction seized her she screamed and screamed and the continued over-breathing took away the effect of labor. The peoples' agitation was rising to a pitch. Suddenly they all jumped upon the girl. I was pushed aside and forceful hands closed around her nose and mouth, fists and feet stamped and pounded and kicked her body. I saw only arms and feet and flying clothes as the girl struggled to get her breath, giving out some awful sounds. Dust was whirled up, embers from the fire flew around and burned the clothes, a little boy who had slept in a corner started to scream, hens fluttered up in the air and rushed out of the hut. Just as I thought they had choked the girl to death the baby's head broke through. In the midst of the terrible confusion I tried to get hold of the head, but it was smeared with blood and slipped out of my hands. I shouted at the people who continued to pound the poor girl. Between hands and feet and sweating bodies I finally grasped the head and pulled at it. The girl writhed and gave a last terrifying scream, blood poured over my hands, but the baby was born.

It had a badly deformed head and there was no sign of life in it but I hurriedly cut the umbilical cord, took the slimy little thing and rushed out with it, remembering that there was a little stream behind the hut. There I dipped the limp body in the cold water, slapped its back and tried the usual manipulations to force out the first cry. But there was no sound; the baby did not breathe and I was just going to examine it closer when the old ladies came out of the hut. They looked around alarmed, and when they saw me with the baby, they ran towards me and one of them snatched the lifeless body out of my hands. I wanted it back. “Quickly, give it back to me, every minute counts, I must make the baby breathe.” I took a step towards them, but they looked so threatening and agitated that I stopped. What was the matter? Why this sudden hostility? I sensed danger for my own life. “The baby is dead, there is nothing you can do, it belongs to us.” It was the oldest woman speaking harshly to me. “This girl is no good and you have no right to the child's body.” She turned her back on me, wrapped the dead baby in a cloth with angry movements and marched off into the forest. Much later I learned that a stillborn baby is a very powerful item for use in witchcraft. Evidently the apprehensive old women I had barred from the hut during the delivery figured that I wanted the dead baby for black magic purposes.

Bewildered and dazed I returned to the hut to look after the girl. She was now crying softly. “My baby, I want my baby,” she whispered over and over again, ignoring the others who treated her with contempt. “What a useless woman you are,” they said. “The child is dead, it was all to no avail. ” The girl was bleeding badly and her abdomen seemed just as big as before. Still shaky from the confrontation with the hostile old women, I felt fear in this situation. If the girl died, what would happen to me so far away from the mission, alone with these suspicious people? I decided to remove the placenta manually in order to stop the deadly bleeding. Nobody seemed interested in what I did any more so I placed one hand on the girl's abdomen and with the other I felt my way through the torn tissues. Then my hand touched something like a little foot. I was electrified. Another baby! It had to come out quickly or the girl would certainly perish. She could not possibly give birth to another child. All my senses fully alert, I carefully slid my hand along the baby's body until I felt the groove of the neck, then feeling the chin I got my index finger into its mouth and with the guiding help of my outer hand I slowly turned the child around. Fortunately no contraction closed the womb around the child's body, which would have made the operation much more difficult. As it was, the womb was wide and with a little force I could guide the baby through the open birth-canal. It came out together with the after-birth and another gush of blood. The girl let out a yell; everybody turned to her and to their amazement saw me hold up a baby girl. It curled up its legs and sounded the well-known cry of a healthy newborn baby.

All the tension, hostility and unhappiness from before melted away. The women wept and laughed with joy, clapped their hands and caressed the new mother. They grasped my hands and thanked me as if I had conjured up the second child. Nobody had thought of the possibility that the pregnant girl might have twins. That was why she had had such a huge abdomen. The contractions of the over-extended muscle fibres of a womb holding twins are less effective than when there is only one child--one certain reason for difficult labor. The people in the bush, who believe that the placenta is another baby, deformed and therefore dead, see no difference between an after-birth and a stillborn baby; thus the same old lady now received the “real” placenta from my hands, wrapped it in another cloth and went out to bury it under a certain tree together with the stillborn baby from before. Eager hands now lit the scattered fire and prepared some food for the exhausted young mother. The uterus had meanwhile contracted to form a hard lump in her abdomen. There was no more bleeding, but I gave her a shot of a large dose of penicillin to prevent puerperal fever. The girl slept peacefully with a happy smile on her face. Now that she had produced a living child she had nothing more to fear.

I walked down to the river with aching limbs. It was already morning. People looked at me and laughed as I wearily washed off the worst dirt from the long struggle. As I stood there on the bank of the little river I felt I was going to faint. I quickly sat down. The people at the mission obviously had forgotten all about me and I knew I could not possibly walk back to the mission without some kind of refreshment. When I had recovered a little I asked for some cooked rice and chicken, thinking that when newly cooked it could not harm me. The women gladly complied and looked on amused while I ate what seemed to me the best meal I had ever eaten. The young husband appeared with a bicycle. Would Mama Mganga sit on the back while he cycled to the mission? He seemed embarrassed, maybe because of the way they had treated me. I was happy to leave and although it was an uncomfortable way of traveling, I was glad I did not have to walk the whole way back. The waters of the rivers we had to wade across woke me up, and when we reached the mission where everybody was still asleep, I felt refreshed and exhilarated. Stretching out on my bed, I felt that I had learned something.

To be born and to die in a natural way are processes which take time, I thought. Birth and death are painful and in many ways alike. Few are those who are well prepared for the agony of either. Once the process has started, there is no way back. Dying leads to death, and giving birth to the border of death “Ninakufa--I am dying.” Each woman I had helped in childbirth said these words at one point in her delivery. Some did die, but most found the strength to fanya bidii; they overcome death by giving life to a new human being.

Copyright © 1979 Louise Jilek-Aall
Reprinted with permission

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