Re-posted by request:
In October 2011, I had the opportunity to spend two weeks volunteering as a doula in a hospital in Hargeisa, capital of Somaliland. What follows are excerpts from my journal about that experience.
The airplane which carries me from Dubai to Hargeisa, capital of Somaliland, is so old it looks like pieces of metal will fall off any minute. The tires are virtually bald and the interior is shocking with broken seats, filthy carpet, no working lights or air vents. There is no cabin crew and the aisles quickly fill up with luggage. There is the smell of urine and sweat. Upon arrival, people at immigration are shouting, shoving, snarling themselves up, barking orders that are ignored. I spot a man who must be my greeter. We drive to the hospital.
Edna, the founder and major domo of the hospital is stunning at 74 in her long dress and elegant head dress. She greets me warmly. I am shown to my room – a basic but perfectly adequate single with private bath in a dorm for visitors. I shower, unpack, and join the others for lunch. Along with Edna are a French physician who has come to do ‘hands on’ work after years in research medicine; a Finnish nurse-midwife and former missionary who has worked in Ethiopia and Somalia for most of her long career; a German-American nurse from New York City and another newly graduated nurse from Mass.; an OB-GYN from Germany; an energetic Austrian-born nurse-midwife now living in England; and an English nurse-midwife.
Lunch, like every other meal, is goat meat on the bone cooked with cabbage, a diced vegetable mix, rice, gravy with potato and carrot, salad, watermelon and bananas. There is fruit juice or bottled water to drink. (Breakfast is cereal, bread, a watery porridge and Somali pancakes.)
The hospital is smaller and less developed than I had thought but still the best hospital in Hargeisa. It is clean and equipped with one (rarely used) incubator, two (probably overused) ultrasound machines, and a decent delivery room and surgery. There is a lab, a library, Edna’s Computer Room, Edna’s Pharmacy, Edna’s Supermarket, and an ambulance on the well-guarded compound situated on a busy road unofficially called Edna Street. The hospital has a maternity wing and a medical-surgical wing which includes a room for pediatrics. It accommodates about 60 patients.
Many people mill about in the compound, most family members and visitors, some guards or other workers. The women, all in hijab and many fully covered with only eyes showing, stare curiously when I walk around the grounds. They do not allow me to take their picture. Several mosques surround the compound in this deeply Muslim country and there are frequent mullahs’ calls to prayer beginning at 4:30 a.m.
The history and politics of Somaliland are complex. Suffice to say that it is one of several colonized regions of Somalia that tried to unite for independence from France, Italy, and Britain in the 1960s but failed to coalesce effectively. Somaliland declared itself free and independent several decades ago and has been fighting for recognition as an independent nation since.
Somaliland is dry and dusty in the long absence of rain, and mostly flat with a pleasant climate at just over 4,000 ft. above sea level. It is one of the poorest countries I’ve ever seen. The canvas or wood business stalls, the goats in the road, the deeply pocked dirt roads, and the simple, inadequate houses (often no more than shacks made of corregated metal and rags) all provide a visual for the deep poverty here. Life expectancy for men is about 47; in the absence of data the high maternal and infant mortality rates are not known. Women are usually married between ages 15 to 25 and can expect to have between 5 and 12 pregnancies. FGM is universally practiced. It is a deeply religious culture and a mysterious place. I have no idea what is actually going on around me: I can’t understand a word that’s being said, and people outside the compound resist communicating (unless it’s to beg). They generally find us so aberrant as to be laughable. Many men are addicted to the local narcotic weed, khat, which they would sell their souls to chew.
The first night there I have my initial doula experience. The mom is about18; it is her first child. She labors so well I think she must be in early labor but she is on the delivery table (women always deliver in lithotomy position in a delivery room) and Asha, the midwife, is doing things that tell me the baby is coming. Mom moans and clings to my hand; I stroke her arm and whisper that she is strong and can do this; soon her baby will be born. A student nurse translates what I am saying. The mother nods to me. I support her head while she pushes; she grasps my arm. And then her son is born, his wet little head emerging first, then his body sliding quickly out. “Good job! Look at your little baby!” I tell Mom. “Thank you!” she says in English. “Thank you,” squeezing my hand. I go to bed happy that I’ve been able to help in this remote place.
On the morning of my second day I have my second birth. This is Mom’s third child and she too labors well, choosing to stand through most of her labor. Hibo is the midwife and a more gentle, calming, competent soul I’ve never met. I encourage Mom, massage her hips and back, stroke her arm, talk to her in whispers. Even when she doesn’t know what I’m saying I sense that she is comforted by my voice and my touch. As she leans on my shoulders she lays her against me as if she were a child. I stroke her head, reassuring her. At 9 cm. she climbs onto the delivery table. Hibo gently examines her, tells her when to push and when to stop. She is holding onto me for dear life. Three student nurses observe; I hope they are seeing the importance of emotional support during birth. Mom’s mom appears — I cannot tell from her expression if she thinks I am usurping her position, but then she says to Hibo, “This woman is beautiful the way she is helping my daughter.” A bigger reward I cannot imagine. Finally, a big, healthy boy is born. Mom thanks me profusely. I tell her I honor what she has done. She kisses my hand and thanks me again. I kiss her hand back and thank her. Hibo is not surprised by this exchange but the young nurses seem stunned at what they have just witnessed.
The next day a C-section is just beginning when I enter the OR in my scrubs and mask. Mom is getting an epidural. After she is draped the German doctor takes a scalpel and makes the first cut. Working quickly he opens the uterus and pulls out a baby who is hydrocephalic. “Very little brain,” he says. The baby also has a terrible hair lip and cleft palate. She does not breathe readily and is whisked off to be resuscitated. Hibo tells the family what has occurred. By the next morning the baby is dead.
I spend the next morning first on rounds in Maternity where four babies have been born during the night and a woman with eclampsia is in trouble, then in the Outpatient Department where the doctor is doing pre-natal checkups. I’m invited to palpate mothers’ tummies and to listen to the fetal heartbeat through a primitive wooden instrument.
With the other women I visit the local market. Crowded with stalls and not always easy for western women, we are in search of cloth from which traditional long dresses can be sewn. We quickly choose colorful cloth for $4 each and then find two women sitting at sewing machines who in no time stitch the material into full-length “moo-moo” like dresses. (Cost: $1). The women are friendly and try speaking to us as they sew on their antique machines. “Inshallah, I see you again!” one of them says when she is finished. “Inshallah,” I reply.
The next morning I wonder into the maternity ward. Four babies have been born during the night but no one is in labor. I visit baby Hodu, everyone’s favorite – a pretty six-month old little girl who keeps getting a dreadful infection on her head and face that has caused loss of pigmentation and scabbing. No one knows why she has this condition or why it recurs after treatment. Hodu is gorgeous but developmentally delayed. She faces an uncertain future. She lies in a bed all day with her young aunt watching over her
I help the mom with eclampsia who has had a C-section in the night because of her severe hypertension. Her baby boy is a fighter at 28 weeks and less than 3 lb. He seems to have a sucking reflex and has a good chance of survival if he can start nursing. For now, Mom pumps and feeds him through a syringe. I position the baby between his mother’s breasts, a technique known as Kangaroo Care which has shown good results for survival with premature babies. I wrap him in blankets and encourage the exhausted mom. Her mother is there along with a young aunt who speaks good English so we visit as I sit with them. Mom is expert at breastfeeding having had seven other children; she is able to squeeze out a few drops of colostrum and get them into the baby’s tiny mouth.
On Monday morning I hurry to the labor room where an induction is due to begin. Hibo tells me the husband has not yet given permission; he will come at 9 a.m. There are two other women in labor, and another woman awaits her husband’s signature for an induction. The chances are the men will not consent; they have likely consulted numerous family members. More likely, they will take their wives on a round of doctor visits until they find one who tells them what they want to hear.
I am beginning to see the dark side of this country and culture, where voiceless, disempowered women must have their husbands’ permission to have a C-section or an induction for medical reasons. (If they need a hysterectomy their father must agree – her body belongs to him.) I watch as husbands come to sign (or not), ignoring their laboring wives who walk the halls. Imperious and authoritarian, they swagger in and out self-importantly. The doctor says he has seen them deny their wife her life, even when she is crying to be rescued, because “Inshallah” it is God’s will (and maybe he doesn’t like this wife so much anymore.) He has seen babies die unnecessarily – “Inshallah”. A woman here often holds less value than a camel; she has absolutely no personhood. Her function in life is to marry, bear many children and obey her husband. Her body is not her own. She has no genitals remaining; by the age of nine or 10 they have been cut off. A husband expects to have sexual intercourse with his wife every morning and every evening, unless she is bleeding. No wonder women have upwards of nine to 12 pregnancies; they are not even given time to rest from the last pregnancy before their husband demands his right to enter her again. God only knows what kind of domestic abuse occurs in shacks and shanties throughout this country of ritual, tradition and male supremacy.
Watching women give birth here is something to behold; it is a testament to their strength and courage in the face of such a life. “She’s doing all the work and I’m doing all the sweating!” I tell Hibo as she delivers a woman’s ninth child. She makes no sound, not even a mild moan (Hibo says Somali women don’t do that) and suddenly her baby pops out. It is whisked away to be cleaned up and Mom seems little interested for the moment; she lies patiently waiting for the placenta to be delivered. Then, cleaned up, she gets off the delivery table as if nothing out of the ordinary has happened, and is taken to her room. I follow carrying the baby boy she has just delivered.
In Prenatal Clinic a variety of situations present: a woman is worried about her frequent miscarriages and infertility; another has back pain with her periods; several others are doing routine check-ups; a shy woman appears with her husband complaining of urinary retention post-C-Section. The doctor can hardly contain his rage at the father who took so long to give permission for the C-section that she has had complications.
There are two C-sections in rapid succession. I observe and take photos. I’m astounded at how fast they are; it is a relatively simple (but quite bloody) operative procedure requiring great skill nonetheless. The mothers are again stoic as they are catheterized, receive epidurals and lie exposed on the OR table. (There is an irony about the prevailing female modesty in this culture while at the same time women seem to disregard the lack of privacy surrounding their bodies in the hospital. Do they feel their bodies, which have been infantilized by the removal of sexual organs and pubic hair, are not their own?)
Wednesday I head for the wards at 9:00 a.m. Last night I missed a twin birth, a breech birth, a D&C and a prolapsed cord. Today in Prenatal Clinic there are lots of giggles among the patients and the friends they have brought with them, while the doctor, a pixy of a nurse and I joke back and forth between patients. The longer I’m here the more I like the Somali women I meet; they have a good sense of humor, are generally warm and appear to welcome our help. At lunch we are joined by an American missionary surgeon and his wife; the doctor can hardly control himself as he whispers to me, “Can you imagine going to Wyoming and telling people to change their ways?”
Thursday I teach 26 first-year nursing students about emotional support during labor and delivery. Before class I check to see what is happening in the maternity wing and find three women in labor. I visit briefly with each of them and promise a young new mom that I will return after my class to help her. She squeezes my hand. When I come back after class the midwife asks me where I have been. “The woman, she is asking for you. She says she want that lady!” The mom I promised to help has delivered her baby, asking for me the entire time! I go see her, apologize, and tell her how beautiful her new daughter is. “Next time, Inshallah!” I tell her. “Mashalla!” her mother says.
At the start of class I make small-talk with the students. Then we get down to business. I write “Doula” on the board and tell them it is Greek for “woman helper.” I explain what we do and why and then talk about the importance of emotional support for all patients. I tell them that in America we don’t always live close to our families like they do so we need others to help us when we are in pain or afraid. I talk about how caring is at the heart of good nursing. I tell them about birthing practices in the 1950s and 60s in America and how women got together to reclaim their childbirth experience (careful to use language they can understand). I demonstrate what doulas can say and do to make moms less afraid and more comfortable during labor. They seem rapt when I am speaking, mesmerized perhaps by this elderly white lady who talks of strange things, but when I ask them questions or want to know what their questions or thoughts are, they are silent. I say, “Allah gave you a voice! Women’s voices are beautiful! You must not be afraid to use your voice!” but this falls on deaf ears – they have been long socialized into silence.
I break the class into groups so that can practice techniques to support laboring mothers; they think the role play is hilarious and do not take it seriously so I reconvene the class and try a single demonstration; this too is seen as – quite literally – too funny for words. So I decide I’ve done what I can for one class and ask, in closing, that each of them tell me one thing they’ve learned today. A few whisper rote answers: “Massage.” “Breathing.” “Talk.” A few actually seem interested. To my amazement, one student says, “I learned that ‘doula’ means woman helper!” I am so excited I pretend to ululate; the others laugh and do the real thing. When a few other students say something audible and original I wave my hands in a Hallelujah gesture. I’ve gotten through to a few of them! I conclude with a pep talk about the difference good nurses make, the need to honor as well as support the hard and amazing work women do in having babies, the healing touch and so on. I invite questions but silence prevails.
And so it comes to an end, this African adventure of extremes, of wild animals and willful males, of voiceless women and vibrant girls, of outrageous poverty and obscene affluence, of deep blue seas and desert sands, of market stalls and mega-malls, of break-away nations and tradition-bound kingdoms, of visionary women and violent men. So much to absorb and try to understand; so much more to be done; so many new friends; such amazing experiences! May there be other such times in which to contribute and learn. Mashallah!