Childbirth in the Global Village

Implications for Midwifery Education and Practice

Dawn Hillier

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134476732
• Topic: Medicine
• Subtopic: Health Care Delivery

Is the experience of childbirth becoming 'globalised'?
Is the encroachment of the western medical model dehumanising a profoundly human experience?
If so, what can midwives and midwife educators do about it?

These are the questions at the heart of Childbirth in the Global Village which highlights the role that globalisation plays in changing childbirth practices and its implications for midwifery practice and education.
Built around the vivid personal stories of women and midwives experiencing childbirth in four very different cultures

Childbirth in the Global Village will resonate with the experience of midwives everywhere and makes a strong case for redesigning the midwifery curriculum to reflect the interconnectedness of childbirth, midwifery education and practice around the globe.

Chapter 1
Women’s stories, women’s lives

Four women’s stories

Ama’s story

Ama gently woke me. Whispering so as not to disturb the other occupants of the hut, she pantomimed gestures to ensure my understanding. Victoria, my guide and translator, had spent the night with another family in the village.

It was still dark outside. It was also surprisingly cold, but I knew it would become very hot once the sun was up. Ama lit an oil lamp – there was no electricity – and started a fire to prepare some food.

While the porridge was cooking, she bathed herself and the children, using water she had collected the evening before. The children were thin with large abdomens but they smiled and giggled as she told them a story, which Victoria had arrived in time to translate.

Ama handed me a brightly coloured plastic bowl with what looked like gruel in it. She looked apologetic and sad. It was not much and she gave herself even less. After breakfast, Ama’s nine-year-old son, who had a long walk to school, set off. It was just after 5a.m.

We left Victoria behind and set off for the fields. Ama was carrying her nine-month-old baby on her back. In one hand she had a hoe. Over the other arm she carried food and water wrapped in a bundle. Her young daughter followed behind with a large tin can on her head. She was about five years old. Girls learn domestic chores and help in the home from a very early age.

Ama was heavily pregnant and she bent almost double all day as she tilled the soil. She had provided me with a hoe so that I could help, but I did not have her stamina and had to frequently retreat to a nearby tree to rest. It was very hot and the work repetitive and hard. The soil was dry and dusty and clogged my eyes, nose and mouth. By the end of the day the red dust had penetrated my clothing down to my underwear.

At sunset, Ama, her children and I made our way home. We collected water in the large tin can and firewood, which she and her daughter carried on their heads. Balancing a bundle of firewood on my head was a skill acquired over the three-mile walk back to the village along the dusty track. Despite our tiredness, Ama attempted to teach me to carry the water can on my head which afforded them both a great deal of amusement.

When we reached the hut, Ama settled the baby on the ground, then began to prepare the main meal of the day. She announced that we would have a special meal – lye soup and fufu. I suspected this was a reward for my hard work.

Ama lit a fire outside her hut. The other women were doing the same. There was a general air of camaraderie among the women. Calling out to each other, sharing their day and telling stories. Victoria could not translate fast enough and there was a great deal of joking and laughter. I could not understand what was being said but I understood the feelings being expressed through their gestures and generosity.

Victoria informed me that it was a great honour to be given chicken since the villagers rarely eat meat but she said they would be offended if I refused to eat the meal. For some reason Ama seemed revived with the thought of preparing a special treat for her guests and family. The other women began to arrive with gifts of food too. Some rice, yams, plantains and oranges. It would be a feast. The village elders came to join in the gathering and began to ask questions about my life in England. The children gathered around to listen. Visitors were rare and a great source of entertainment.

The sound of hollow, regular drumming was carried on the evening breeze. The women were pounding fufu, the staple food of these Ghanaians that usually accompanies soup.

After the meal the women started to dance and sing. They had dressed in different clothes and put on their beads. They were clearly in a mood to celebrate. It was dark and the only light came from the campfires and oil lamps. Victoria informed me that as with the symbolic designs on the clothes worn by the women, each dance movement conveyed a recognisable message and meaning. For Ghanaians, dance is a dramatic expression of life itself as important as language and conveys a whole range of experiences. Drumming and singing are essential accompaniments to dance, setting the scene and creating the mood. The dancing sometimes follows the music but it can be in opposition to it for dramatic effect.

After the small celebration, Ama and the other women cleared up and then gathered what yam and plantain they could spare to take to the local town. We began the long walk along the dark road into the nearest town, which was about six miles away. On arrival Ama and the other women set up roadside kitchens. They fried yam and sold it to passers by. The income would supplement their diet and provide needed cash for school fees, clothes, and other things for the children.

Ama and her friends returned home to await the return of their husbands from the local bar where they had been drinking fermented palm wine. Ama had to attend to her husband’s needs before she could retire for the night. Soon it was time to rise again. Ama was tired. I sympathised with her. I was tired too but I was leaving that day. Ama’s life would continue, long after I had gone, along its traditional path.

(Ama, Ghana, 1991)

Emefa’s story

In another village, Emefa is about to give birth to her fourth child. Huddled in a corner of the hut she was lying on the floor, or rather on a piece of thin cloth that was once brightly coloured. No cushion or comfort as we would know it. No pillow for her head and no mattress for her back. She lay curled into a small ball on her left side, her pregnant and contracting uterus protruding from her thin frame. No sound came from her. No sound came from the midwife either. She was seated in the corner of the dark hot hut, waiting. Suddenly, Emefa gave a low whimper and hauled herself into a sitting and then squatting position. The midwife crept over to her and gently supported Emefa’s back as she bore down. No words, no commands, no yelling. The expulsive contraction was handled in a quiet and dignified fashion. Once it was over, Emefa lay down on the ground again to rest until she was required to continue the process of giving birth. Her body was practised in the art of birthing. She had already had three children before. Another contraction gripped Emefa and she lumbered up into her squatting position again. This time, the midwife crouched in front of her, waiting. The baby’s head appeared gradually, slowly making its progress into the world. How did the midwife know that it was time? No words had been spoken by either of them. It was almost mystical. A kind of unseen and unheard language passed between Emefa and the midwife. It was as if Emefa’s body had communicated its readiness to the midwife and she needed no verbal information to guide her in what was happening to Emefa at that precise moment in time. A soft whoosh and the baby’s body was born into the steady and confident hands of the midwife. And still there was no sound. The baby did not cry, not because there was any problem, but because it was a gentle birth. The baby was breathing and at once handed to his mother – a boy at last. She had had three girls before. Her husband would be pleased and the village would rejoice.

(Emefa, Ghana, 1991)

Six weeks later I was visiting a small village in Malawi where I met another woman during childbirth. Sitting in the shade of nearby trees, a group of women were making the traditional porridge given to labouring women to provide energy for the hard work ahead. These women were the friends and relatives of the labouring woman and they were there to assist the midwife and give support – a show of solidarity in their womanhood. As they stirred the gruel, they chatted about the family, the strife, the joys and events that shaped their lives. Any conflict was resolved during these meetings since con-flict could delay the birth and cause complications. The women’s chatter was interspersed with songs and stories of bygone days and important events in the community. The elders told of the line of descent and ancestry of the new baby, creating his or her identity and place within the life of the village. In a hut close by, the labouring woman was nearing her time. The midwife moved between the hut and the group of women, listening. She knew the family; knew their history and physical condition. She had delivered the young woman herself with the help of her husband. Indeed, she had delivered the young woman’s own mother as well. She did not anticipate any problems. The labouring woman was healthy and well nourished. She had no reason to be concerned. She went about the business of preparing for the birth. The women took turns in visiting the labouring woman in the hut to offer encouragement, to massage her or feed her some of the porridge or just sit silently in the corner offering a reassuring presence. This was the young woman’s first child. Everyone was looking forward to a new member of the family, especially if it was a girl.

I had sat throughout the whole experience neither speaking nor moving. I had a strong feeling that I must not distract the woman or intrude upon her birth in any way. She was in control. The midwife was there to support and tend to her needs, not to interfere with the process. She neither examined nor issued instructions to the woman. Nature was allowed to take its course and the woman’s body was trusted to perform as it was meant to. Later I asked the midwife how she knew that the birth was imminent. She said she just knew. The way in which the woman moved and breathed let her know.

A few years later in Kuala Lumpur, Malaysia, I encountered a woman who was lying in a crowded corridor, clinging to the rails of her trolley and crying out in pain. People were walking by on all sides but none came to her aid. My translator told me that she was saying that the baby was coming. But no one was taking any notice. I placed my hand on her arm to offer some comfort and asked my guide why the woman was in the busy thoroughfare.

‘There are no delivery beds available and she is a third class patient in any case. Privacy is not an option for her.’ The woman was alone. There was no room for family attendants. Eventually someone came to assist the woman and called the doctors and nurses who were swarming about in their theatre gowns, wearing masks and gloves among the general chaos of the corridor with other people wandering all around. Not even screens were available as the woman began to deliver her baby in the middle of the corridor. This was the best the hospital could offer in the circumstances. One hundred per cent hospital confinement is insisted upon and doctors delivered the babies. In a city that was populated by more than 1,145,342 (1996), state provision for health services was stretched to the limits.

As the baby slid out of his mother, he was limp, blue and covered with a green slime. He was not breathing. The nurse grabbed him and rushed off to find help to resuscitate him. In the panic, no one told the mother what was happening and she screamed in terror. The doctor was called away to another patient and the woman was left alone. The placenta had not yet been delivered.

On the next floor in the private patients’ wing, a woman was labouring in a comfortable room with all the technical equipment available in case of an emergency. She had her husband with her. Clearly middle-class, the woman had requested the presence of two of her female relatives, which was granted. A nurse was also present throughout. As the baby began to make her appearance into the world, the doctor was called to conduct the delivery. He had been called away from the woman in the corridor.

Lisa’s story

On the other side of the world in Williamsport, Pennsylvania, USA, Lisa prepared to give birth. Lisa graduated in 1985 from a college in New York with a degree in biology and planned to pursue a career in medical research. But Lisa had always loved to act and she joined a small theatre company playing to schools. Later she joined an improvisational team and started to land small parts in television shows. Lisa married at the age of twenty-five and recently celebrated her thirty-ninth birthday. In this account she is looking forward to the birth of her first child.

My estimated due date came and went with no signs that I was anywhere near ready to give birth. My cervix had not ripened and I wasn’t dilated at all. The midwife suggested prostaglandin gel applications the following Monday if I hadn’t made any progress by then. To cut a long story short, I had three prostaglandin gel applications on the following Monday and Tuesday. The gel was successful in ripening my cervix, but it did not bring on labour and I was only one ‘fingertip’ dilated. The midwife, after consulting with a doctor, wanted to induce labour the following week. Since it was a holiday weekend and their office would be closed for three days, I was going to have to go to the hospital over the weekend so the baby could be monitored.

Luckily, the following Friday my waters broke at around 12.45 a.m. after going to the bathroom. I had been having some mild contractions while I was watching television that night but didn’t think anything of it. My waters were meconium stained, so I called the midwife. She instructed me to get to the hospital right away.

By the time we were on the way to the hospital, the contractions were coming about every 5 minutes but weren’t too strong then. When I got to the hospital, they hooked me up to the monitor for close to an hour to monitor the baby. The baby was fine. So, I started to walk about and rock in the chair during the early stages of labour. It didn’t take long for the contractions to become stronger. They were 3 to 5 minutes apart and were pretty intense, or so I thought. The nurse told me that they were nothing compared to what I was in for. I tried to use the breathing techniques I learned in our childbirth class, but they weren’t working very well. The contractions were close together and steadily building in intensity.

Around 5 a.m. one of the doctors from my midwife’s group came in to examine me to see how far along I was since my midwife hadn’t arrived at the hospital yet. She said that I was 4 centimetres and 90 per cent effaced. By that time, I was in pain. The contractions were about every 3 minutes and were very strong. The midwife had told the nurses to tell me that I could either go in the tub or have a pain-relieving drug. I didn’t want to leave the room so I opted for the injection. After that I was able to rest between contractions.

The midwife arrived and so did my mother, father, sister and sister-in-law. They were all in the room with me while I was in labour. The midwife examined me and announced that I was around 8 centimetres dilated. Around 8.45 a.m. or so, I started to get the urge to push. The midwife examined me and said that I was 9 centimetres dilated. She did not, however, discourage me from pushing. In fact, she encouraged me to push when I felt the urge. I stayed at 9 centimetres for only a short period of time. When she examined me again, she said there was still a little lip on the cervix so she wanted me to push through the next couple of contractions, which I did. All through this pushing, I was not in the position of giving birth. She just encouraged me to push lying on my side.

Around 9.30 a.m. the midwife encouraged me to sit up so that I could start pushing in earnest. After only twenty minutes of pushing, my baby daughter was born. It was the most amazing feeling. Even though I had had an injection I was wide awake and aware of everything that was going on. I saw her head being born, followed by the rest of her body. The midwife put her on my stomach very briefly because she had to be examined immediately by a neonatologist because my waters had been meconium stained. She hadn’t swallowed any meconium and was very healthy. She weighed a healthy 7 pounds 8 ounces and she had a full head of black hair.

(Lisa, Pennsylvania, 1995)

Melody’s story

Meanwhile, in England, Melody, pregnant for the second time, had planned to have a domino delivery in which her community midwife would deliver her baby in hospital and she and the baby would return home six hours later. All through the pregnancy Melody had seen her community midwife, Sara, and she was confident that all would go smoothly. Sara had delivered Melody’s first child two years previously and knew the family well. Melody had given up work as a part-time teacher at the end of summer term and now was enjoying the warm weather and playing with her son, James, in the garden of their small house at the edge of town.

In the early hours of Wednesday morning, Melody woke as her ‘waters’ had broken. She was not having any contractions as yet but as her previous labour had been quite short she thought she had better contact Sara. After waking her partner, Melody rang her mother and sister who were going to look after James while Melody was giving birth. Sara arrived just as the contractions began to increase and she stayed with Melody for the next hour as the contractions grew stronger and more frequent. Soon afterward Sara suggested that Melody and her partner should make their way to the hospital.

At the hospital, Sara undertook the usual admission procedures; the half-hour fetal heart monitoring that was required by hospital policy, the vaginal examination and the commencement of the partogram. Skipping the ritual bath, Sara encouraged Melody to put on one of her own nightdresses and lie on the bed. By now the contractions were very frequent and Melody was experiencing some urges to push. Sara, an advocate of gentle birth, darkened the room and turned on the music Melody had chosen during her pregnancy. Sara encouraged Melody to lie on her side and suggested that her partner massage the lower part of her back during contractions. Soon the urge to push was overwhelming, Melody gave a grunt, and the baby’s head emerged gently and smoothly followed by the baby’s body. A lusty cry followed and the baby was immediately put into her mother’s arms and Melody put her to the breast. Melody’s partner cut the cord and mother and baby were covered with a soft blanket to keep them warm. Twenty minutes later, the placenta delivered, observations of vital signs made, records completed, the mother and baby settled down for a few hours’ sleep before returning home to be...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures
• Acknowledgements
• Preface
• 1 Women’s stories, women’s lives
• 2 The global village
• 3 The nature of modernity: Society, development and risk
• 4 Experiences of childbirth in Africa
• 5 Experiences of childbirth in Malaysia
• 6 Experiences of childbirth in America
• 7 Experiences of childbirth in England
• 8 Symbolic exchanges in childbirth: Reflections from the case studies
• 9 Cultural implications for midwifery education and practice
• 10 The midwifery curriculum: A selection from culture?
• 11 There and back again: The ripples on the pond
• Bibliography
• Index