Birth Protocols at Kafountine Clinic

The issue of birth and the phrase "Trust Birth" has been a part of fabric of my life for the last 7 years. I have helped women find their way through the birth of their children and their own birth as mothers.  I began my journey in this world of birth as a hospital-based doula and birth center-based doula. I went to The Farm and my Sista-midwives-mentors guided me into my new safety zone of birth out of the hospital, then to home birth, and to become a midwife birth assistant.  I have grown in confidence and conviction that birth is natural and almost always safe and became a midwife birth assistant who loves home birth. I have provided clients who thought they wanted a hospital birth, with information and emotional support and given them a safe haven in which to reflect upon that decision.  Many have re-evaluated their birth setting choices and chosen an out-of-hospital birth setting with a midwife; some have even helped catch their own babies.

I have shared my belief and faith that birth is a physical occurrence for a meta-physical change, and will be the best day of your life.

Yes, I have sometimes doubted the process of birth but never the outcome, not even in the face of babies who were not ready to be or stay with us.

I have studied everything I could get my hands on in my journey to midwifery but nothing has prepared me for what I have seen and felt here.

At Kafountine I have met women who trust birth and its outcomes without question. They trust birth because birth is.

I have met and worked with the sage femmes and matrones, collectively the Sista-midwives here, who routinely manage birth complications that many U.S. home birth midwives have little experience with, except to transfer. Here, even with the grossly limited resources available and the near impossibility of transfer, these Sista-midwives do not recognize our Western distrust and “what if” of the birthing process, of birth or birth complications—they just do what they can do, always prepared for whatever outcome God and nature dictate.

Kafountine clinic is a small clinic in a rural village in Senegal, West Africa. It treats every woman who enters, regardless of her medical condition. These clients are not risked out of this practice as with out-of-hospital birth practices. The client may have high blood pressure; diabetes; hypertension (all related to their diets of white rice, white bread, sugar and other starches); protein, calcium, and iron deficiencies; anemia; malnutrition;  dehydration; and other conditions that arise from often having children too close together.

I have witnessed and participated in the births with mothers who have partial placenta previa, pre-eclampsia, twins, breeches; babies with IUGR, oligohydramnios and polyhydramnios; numerous babies with thick meconium and several babies that needed resuscitation.  The Sista-midwives here managed these births on a routine basis, with no oxygen, no suturing skills, an ambu bag that is almost s old as I am and doesn’t work, and limited medications; IV fluids are only available when the pharmacy is open and must be paid for by the mother.  Just skills and experience and a trust in birth and acceptance of its outcome. Two clients have been transferred; one with a brow and nose presentation and one with a platypoid pelvis and an assynclytic presentation.

Their ways are clearly not the ways that are commonly used by midwives in the U.S., but we are not in the U.S. We are in what is called a “low resource setting” and that phrase is a great understatement for this setting.  The resources are severely limited – the skills and experiences of the Sista-midwives are its greatest resource, and a formidable one at that.  This is not a birth site where “nurturing and warm fuzzies” support is offered. “Tough Birth” is the protocol here.

These Sista-midwives are not proponents of “mother the mother” and “warm fuzzies” in labor. Tough love is practiced here by the midwives and the female family members – the message is birth is hard work! Verbal harassment and chastisement and threatened slapping are a part of the standard protocol; fundal pressure was used only once in our presence.  These practices were discontinued in our presence when we remarked about it.  Also, no female family members or friends are allowed to attend the birth.

I have to make it clear that some practices used by the Sista-midwives as part of their protocol here are hard for me to hear and watch. These Sista-midwives are zealous proponents of the Western hospital delivery practices that flourished in the 1950’s and 1960’s. For instance:

  1. Laboring mothers are required to birth lying flat on the delivery table with their hips resting on a large bed pan – if they attempt to birth in any other position they will be stopped, chastised, loudly hollered at with threats of potential adverse birth repercussions. Absolutely no squatting is allowed!
  2. Fundal pressure and fundal tickling is done with most births;
  3. Laboring mothers are required to keep their hands and arms folded on their chest – they are not allowed to touch their baby crowning or to have their baby placed on their chest. The Sista-midwives’ believe that the mother’s germy hands will infect her baby and their desire to perform the delivery and post partum care without the interference of the mother; and
  4. All cords are cut immediately because they believe delayed cord cutting can lead to infection.

    As one of the sage-femme’s commented when we lobbied for squatting, delayed cord cutting, skin-to-skin, “We used to do those things and then we got science.”  The Western Medical machine continues to spread its mis-information throughout the First World – the Home of Natural Birth.

    As a result of these practices and protocols, these women continue to have their babies in a field behind their homes alone, or with a traditional home birth midwife.

    The mothers, when they leave the clinic resume their working responsibilities immediately. They do not have any recuperation period post partum; when they return home they are immediately back in the full swing of their lives—cooking, cleaning, washing clothes, taking care of their husband children—hard women’s work (a perfect scenario for post partum hemorrhage).

    The medical protocols established by the Senegal Dept. of Health, in their compliance with the World Health Organization and USAID guidelines, have developed protocols for its clinics throughout Senegal that were difficult for us to understand  and appreciate at first.  They are so far from the protocols used by home birth midwives in the U.S.  But the homebirth reality of the U.S. is of little relevance in the reality of Africa.  We had to set our home birth reality aside, but bring our skills, experiences and knowledge, and step into the reality of birth in Senegal with its problems; and its solutions to those problems.

    The World Health Organization has stated that the biggest killer of women in birth and post partum hemorrhage; next, is infection.  It has recommended a more active management of both second and third stages of labor in order to reduce the risks of post partum hemorrhage.

    In response Senegal has developed protocols to address the WHO concerns and reduce maternal mortality and the reality of the Senegalese women's post partum life style:

    1. Pregnant women routinely receive iron pills throughout their pregnancy;  and
    2. Prenatal visits (4) focus on disease prevention by ensuring that pregnant women receive vaccinations;

    When in labor, women:

    1. Receive a vaginal exam every hour, even if their bags of water have released;
    2. May receive an injection of pitocin, intra-venous without perfusion,  if labor stalls;
    3. Receive an injection (IM) of pitocin when they are complete (cervix has completely dilated and effaced) in order to minimize time pushing;
    4. Receive another infection of pitocin (IM) as soon as the baby is born, even before the placenta is delivered.  The cord is cut immediately;
    5. May receive an injection of methergine and gauge curettage (for clot removal) after the delivery of the placenta. Methergine is not given if the woman’ blood pressure is high;
    6. May receive antibiotics  during post partum stay;
    7. Receive an injection of pitocin (IM) each day she is in the clinic's post partum unit; and
    8. Receive an injection of pitocin (IM) upon discharge along with iron pills.

    In addition, the baby receives an oral dose of polio vaccine and tetanus shot upon discharge.

    The liberal use of pitocin and several of the other practices here are ones that we would never do as out-of–hospital midwives.

    As much s the liberal use of pitocin and methergine and frequent vaginal exams (even after rupture) troubles me in Senegal these are their first line of defense against post partum hemorrhage.  We are outside of the protocols we know and understand, in a reality that Senegalese believe necessitate these drastic measures.

    We are not arrogant or neo-colonialist enough to carry ourselves as if we are here to bring our view of midwifery to Africa. We are here to bring our skills and information and assistance to our Sista-midwives and to help the women who are birthing. We teach and learn from each other.

    Given the above basic information, in the future I will write about the birthing women here.