The night that she died, a full moon rose over the village. As the daylight faded out and that irreverent globe of too-bright white light ascended, a crowd gathered around and women began to wail. They thrust their hands up at the sky and cried out the name of the woman who lay motionless and pale in the van that had tried in vain to get her to the hospital. I caught a glimpse of one of my students–the woman’s 12-year-old daughter–in the middle of the throng, grief contorting her young face into something beyond her years and tears streaking her cheeks as she wept. At some point, people who know what to do in these situations shuffled the wailers into a room to calm them and the rest of us sat in silence on benches outside their house, heads in our hands. The silence was occasionally broken by people sighing or making noises of disappointment and disapproval, words of welcome and condolence being exchanged quietly each time someone new arrived, or some woman being again overcome by grief and screaming out into the night. Near dawn, they buried her inside her house, as is the tradition, under the floor in the room where just the night before she had slept, while a 9-month old fetus prepared to enter the world. Her husband, my work partner, was stoic and accepting beyond belief, telling everyone that it was the will of God to take his only wife and what was left for him was to take care of his four children.
It turns out to be one of the heartbreaking things of the world: a newborn baby with no mother. What should be a joyous day of welcoming a new member into the family becomes filled with shock and sorrow and confusion. Maternal mortality, or the death of a mother in the process of or directly after giving birth, is something we see fairly rarely in the states nowadays, but in the developing world, giving birth is one of the more dangerous things a woman will do in her life. The newborn baby girl cried incessantly all night, as if to remind anybody who might have forgotten that something was seriously wrong. And the next morning, before anyone had recovered from the fatigue of the previous night’s mourning, it became clear that the problem of the baby had to be dealt with. What does one do with a newborn without a mother in the middle of rural Africa?
The woman in this story was a friend of mine–as my work partner’s wife, she had taken care of me through that first confusing visit to post and our relationship evolved from there–and while language barriers kept us from exchanging too many words of depth while she lived, the way in which she died hurt me because I keep wondering “Could I have done more to prevent this?”
She had done everything right during her pregnancy–gone to pre-natal consultations, taken her vitamins, even gotten an ultrasound to ensure that the baby was doing well and would be born in good health, and of course she had planned to give birth in a health center, not at home. But there is a lack of qualified health personnel in Benin, especially in the rural areas, as in much of the developing world. So though she gave birth in a medical facility (the private clinic in town, not the health center where I am based), she wasn’t fortunate enough to be assisted by a well-trained aide. In the majority of rural medical facilities in Benin, and I’d venture a guess that this is true in much of the developing world, much of the day to day work is done by informally trained nurse’s aides because people who are well-educated/well-trained prefer to work in more urban areas, leaving a serious personnel shortage in places like the one where I live. Thus, you have nurse’s aides, and then the informal aides to the nurse’s aides who have their hands in most of the daily work. There are qualified personnel supervising the aides, in theory, but in practice one or two people cannot be present twenty four hours out of the day, seven days a week. This is how it came to be that my friend’s wife was assisted in her birthing by a young apprentice who missed the signs that this birth should have been performed in a larger hospital. The interesting thing about practicing medicine in remote areas that lack trained personnel is that it turns out to be fairly possible to avoid and treat many problems based on observing only the signs; i.e., you see a lack of color in a child’s palm/inner eyelid or you note that a pregnant woman’s blood pressure is outside of a certain range and you know that both of those cases need to be referred to a higher level medical facility, though you don’t know what causes the signs or what the underlying problem is. The training of even low-level medical personnel (largely funded by international aid) on recognizing these types of signs seems to have been fairly successful in the Beninese healthcare system, and is probably the reason that we don’t see more maternal or child deaths in my health center.
So one might well say that it must have been the will of God to have this woman die in childbirth. It was quite simply bad luck for her to encounter complications while supervised by someone lacking training. We have young apprentices like this at our health center as well, and they also perform births by themselves at times and usually it goes fine. What presents itself here is the sharp reality of living in a resource-poor country: you do your best with the human and material resources available, and that has to be good enough. Perhaps at the time that my friend began hemorrhaging post-birth, the clinic’s trained nurse was taking care of a seizing child with a raging fever, or perhaps she was out of town, buying new drugs for the pharmacy, sleeping, or any variety of things; I don’t know because I wasn’t there. But by the time the apprentice realized that she was in over her head, the woman had already lost so much blood that they had barely gotten her into the vehicle to take her on the 30-minute ride over a dirt road to the larger hospital in Glazoué when she died.
The baby girl, Fidelia, is one of my biggest worries these days. I just see so many ways that her story could end badly and quickly, and not many realistic paths to avoid such chances. I’ll do what I can personally to help, but when it comes down to it, the reality of the situation is this: If she’s a fighter, then she’ll make it. If not, well, she could easily join the ranks of the 6% of babies under one year of age who die every year in Benin.
The first big problem is how to feed her, because in the developing world, exclusive breastfeeding for the first six months of life is an important foundation for good health and nutrition throughout the child’s life. Clearly, with no living mother, this becomes difficult. I had hoped that they would be able to find a surrogate mother to nurse her until she was old enough to start eating other things, but there is a strong cultural belief here that if another mother begins nursing someone else’s child like this, her own child will die. Thus, even though my work partner has a younger sister with a four month old baby, he felt he couldn’t ask her to nurse Fidelia because it would mean the death of her baby. I deployed all of my persuasive abilities for the case of the surrogate, but at some point you just have to accept culture because it’s deeply embedded and difficult to change. However, the newborn’s digestive system can’t handle food that one might feed to older children, meaning that if breastmilk isn’t an option, she has to be fed using baby formula, which is expensive, difficult, and often dangerous in rural Africa.
Formula feeding may be widespread in the U.S. but for Fidelia, I don’t see it as a viable solution. Anyone who has been a parent or an older sibling or even a babysitter for a young baby will remember the hassle of having to wake up multiple times during the night to mix up a bottle for that screaming bundle of joy. That was the fun part of having a kid, right? Now imagine doing that while you’re camping, and you’re coming close to seeing what it would be like to use baby formula in rural Benin.
You have no microwave, no safe water, and no dishwasher or even sink in which to clean the bottle. You wake up to crying in the middle of the night and know that you have to get up, find firewood, start a fire, boil water, wash the bottle with some of the boiled water, and wait for the rest of the water to cool before you can mix it with the formula and give Fidelia her bottle. And you’re going to do that several times each night? Not easy, my friends. It won’t be long before you start cutting corners–maybe washing the bottle with regular water at first, not bringing the water to a full boil, eventually using regular water or preparing the formula in advance and letting it sit all night–because after all, you are cumulatively exhausted and she’s screaming and everyone around you is waking up every night because the houses are so close together and they’re sympathetic that the child has no mother, but they still want to sleep. And each of those tiny corners puts the baby in a little more danger of diarrheal disease, one of the biggest killers of children under five in Africa. Then there’s the issue of the cost: formula is expensive, especially for a family that supports itself by farming. Each can of formula costs around 3500 francs, which is about $7, and will need to be bought every 2-3 weeks at first, and probably every week by the time she nears six months. For perspective, know that lunch money for most kids here is 50 francs, meaning that you could feed another child for over 3 months with the money that you’ll use for two weeks of formula. The prohibitive cost will lead to you trying to economize by reducing the amount of formula added per unit of water water, which will quickly lead to malnutrition, which in turn makes the child more susceptible to other illnesses. And to make the situation even easier for you, if the formula runs out, you don’t just zip out to the grocery store and buy more: you have to journey over that dirt road for at least 30 minutes and might not even find it in stock at the one pharmacy that sells it in town.
There was a glimmer of hope for Fidelia about a week after her birth: the social service center put my work partner in touch with a group of nuns that take care of orphan children. They said they could keep Fidelia with them in Glazoué for as long as the family wanted and it would cost them nothing, as long as they came and visited her whenever they could. So my work partner had accepted and sent her there–a tough decision but one that he made for the wellbeing of his child–and then less than a week later, the nuns called back to tell him that they could no longer keep her in Glazoué, but would have to send her to the larger orphanage about 3 hours away. He didn’t want her to be so far away, so he brought her back to village and now she lives with his older sister.
What would you do in this situation? It’s a pretty tough one. Like I said, I don’t see a lot of ways for it to have a happy ending. Which I suppose it’s so important to try to prevent things like this from happening. One way to do this is by boosting funding for healthcare and training for healthcare personnel; organizations like the World Health Organization and UNICEF and even our own USAID are doing good work in those areas, and as I mentioned above, it is having an impact. Another is to increase general education amongst the population about health issues, the danger signs in pregnancy and birthing, the benefits of having fewer children and spacing them well, etc, which is something that I’m working on with PC and many health-related NGOs also focus on. And a third preventive measure comes back to educating and empowering women and girls. Because a well-educated woman will take control over her own life, get married later, have fewer children (which reduces the risk of maternal mortality), have more resources available to her, and overall have a higher chance of a healthy, long life.
So I’m going to make another plug for our annual girls’ camp, Camp GLOW, which will take place in early August this year. We have the chance to make a real impact in these girls’ lives, an impact which can continue for years and impact the lives of the next generation as well, but we’re still missing our goal by over $1,700. I know that times are tough and money is tight, but please if you can spare a little bit to help us out, you will truly be making a difference. I also know that I’ve been letting down my end of this blogging deal and have been pretty bad about posting lately. I promise I’ll do better, and in exchange, I hope you’ll pass along my plea for help or the link to the blog to at least one person who might be interested or have missed the more recent posts. Here’s the link to donate: https://donate.peacecorps.gov/index.cfm?shell=donate.contribute.projDetail&projdesc=13-680-015
As always, thank you for all of your support through this journey. Stay well and enjoy the beginning of summer. Peace and love. CMK