Today I had the honor of facilitating a training of 8 Traditional Birth Attendants from Macomia and the surrounding area. TBA’s are known as ‘matronas’ in Mozambique. MSF is dedicated to supporting them with capacity building as they are the only ones left taking care of the entire pregnant population since the insurgents made it to Macomia and all hospital staff fled. We provide transportation to them and they come to Ancuabe, about 2 hours south and we do the training there. It is too dangerous for us to try to stay in Macomia at this time and Ancuabe is halfway between our base and Macomia so we meet in the middle.
Matronas are chosen by their communities to serve. Many of them had a mother or grandmother or both, who also were matrona’s and they were handed down the knowledge from them. They are well respected in their communities. They are usually illiterate and have no formal training at all, although there was one young matrona, 25, who had an education to grade 12 and could read and write and speak Portuguese. Unless one has been to school, only the local language is spoke. In this case, the local language is Mancua. Portuguese is taught in school. Matronas are not paid for their work, not even in barter but a few reported being helped out at their farms by women they had served.
When I do these types of training, I like to get to know the participants and hear about their lives and understand the challenges they are facing. These women were truly amazing. They spanned in age from 25 to 80 with all but 2 being over 50. Although, other than Fatima, the 25 year old, they didn’t know their specific ages, they only knew what year they were born and then told us and we did the math for them. They were kind of amused to learn their ages. They had over 150 years of experience between them. Most had been midwives for many years with the longest being 51 years. I enjoyed hearing about their lives and they asked questions about mine as well. I learned that every single one of them had lost at last one child and some of them had lost 4 or 5. Most had given birth close to a dozen times. The childhood deaths were due to malaria or diarrhea and one of the women lost an adult son 2 weeks ago when the insurgents raided the village where he and his family lived and he was killed with a machete. He left behind 3 children of his own who managed to flee to the bush with their mother.
These women have seen a lot. I listened intently as they each told stories. I asked about traditions, superstitions and rituals surrounding pregnancy and birth that were specific to Mozambique. I am not completely sure they understood what I was asking and only because I am fairly certain they don’t even realize some of the things they do are superstitious or ritualistic as they have no frame of reference. I gave some examples from other cultures. They said pregnant women cannot eat rabbit or octopus (Mozambique has the Indian Ocean as its eastern border). It would not bode well for a baby if the mother did this although they could not say exactly what would happen because no one dares do these things! I asked if men ever attend the births, although I knew the answer already, and there was a resounding NO! This was against their culture and also, if a man attended his wife’s birth he would run away after that and she would never see him again. Men are not supposed to be seeing “that”. I also learned the average age of marriage for a girl was 13/14.
They asked me about what is done in my country that was a ritual etc. I really couldn’t come up with anything specific but I told them that a lot of women like to listen to music while they were in labor because they felt it helped relax them. They thought this was hilarious and there was uproarious laughter when the interpreter finished translating what I said and then they asked if it was to drown out the screaming. I did tell them that men routinely attend their wives births. They marveled at the fact that anyone was still married in the U.S.!
The presentation was on Power Point with as many pictures as I could manage to find. What little text there was, Fatima, the matrona who could read, read in Portuguese and then told the others what it said in Mancua. I asked questions and made comments through my interpreter. The topic this month was danger signs in pregnancy. We discussed each danger sign and their experiences, if any, with them. They have a better understanding of the causes and when to refer, although, as they pointed out, the hospital has been abandoned so there is nowhere to refer at the moment.
When discussing anemia, a huge problem in most African counties, there was not a lot I could offer them. Generally I would have them refer to the health clinic for iron tablets and discuss dietary support, but again, they pointed out they have little access to food, including rice and flour and certainly there is no poultry, eggs or meat. Food insecurity has been a huge issue since the insurgency began. I had little to offer as they said most of the pregnant women were living off of cassava leaves, which happens to be rich in iron and a staple in their diet because it grows everywhere so it is plentiful. So they are currently doing all they can do.
The matronas do no prenatal care, they only attend women in birth and general will go the next day to check on the mother and baby. They are called to a birth when the woman is about to birth generally. They have been provided with non-reusable kits they bring with them which consist of soap, gloves, an apron, small plastic sheet, 2 small towels, 2 cord clamps or ties, and a sterile razor blade. They have no neonatal resuscitation skills. They said if a baby comes out not breathing, they wiggle the cord back and forth at the base where it attaches to the baby, fan they baby with something to move air and if those things do not work they assume the baby has died. So without any supplies at all, I gave an impromptu baby resuscitation basics. I told them next time I would try to find a doll to bring so I could better demonstrate. They do not have Ambu bags so mouth to mouth is the only thing possible in this environment and there are a lot of diseases to be concerned about, COVID-19 being the least of it!
Then came the singing! When I finished my presentation, they collectively burst into song, which is what all TBA’s throughout Africa are known to do. It was wonderful and energizing and when they finished, I clapped and laughed and they saw that it really brought me joy and this made them happy. We are off to a great start so far. I will see them again in a month for another training. They requested I cover complications during labor. Anything I can teach them that only requires their hands, I will teach, since they have no access to medications of any kind. The next class happening will depend on the insurgents and how far south they come, things are changing here moment to moment and we adjust security and movement accordingly.
Being in Ancuabe, away from the base in Pemba, has been interesting. It is quiet here. It is just a simple village with no ambient light at night so the stars shine bright without light pollution to dim their shine. I hear crickets from my bed at night where I sleep under a net, safe from mosquitoes. In the morning I lie in bed and listen to the birds welcoming another day in Mozambique. Tonight I am sure I will sleep well because it was a long day, although very fulfilling. I imagine I will think about the matronas and wonder how many of them are venturing out in the starlit sky to greet yet another baby.
P.S. If you missed the podcast interview on Journey to Midwifery with Amber, listen at the link above!
