Sunday, October 26, 2008

Midwife Training

Midwife Training

This past week three other volunteers and I hosted a traditional birth attendant (TBA) training in Tounfite. It was the culmination of several months work. There were some problems, but I think it was an unqualified success.

Mara Hansen, a fellow volunteer, started organizing this workshop several months ago, before I was even in Morocco. In her community, she had been moved by several stories of death during childbirth. Since her community is isolated and the government provided medical facilities are lacking, most women give birth in their homes, with the help of other women. We have little power to change the services provided by the Ministry of Health, so the idea is to empower local women as midwives so that the community can be more self-sufficient. Ideally, the government would be providing these services, but some of these villages are so isolated that it is difficult for them to do so. When I got to my site, Mara worked hard to include me on the project. My community is equally isolated, so there is a similar problem here as in her village. I set up some meetings and she came to my site to recruit the women. I spoke with the men who had concerns about sending their women away and Mara talked to the women. The other two volunteers involved were David and Kristen LaFever, a married couple in Tounfite. They traveled to a village much more isolated than either Mara’s or mine and recruited two women from there.

Still before the training, there was a ton more work to do. We had to find ways to feed all these women and places for them to sleep. We had to set the program with the nurses who would be running the training. We had to go to the Ministry of Health and get their approval. Etc etc etc, a lot of boring stuff. But onto the training. I wasn’t able to observe the actual training (because I’m a man) so I’m just going to give my perspective on things, supplemented with what I was told about the training.

On Sunday morning, the transit that I had arranged for arrived in my village to pick up the women. It was raining and the transit was early so the women weren’t ready. One told me she couldn’t come that day; could she come tomorrow? It was an inauspicious start and it was clear that a lot of the women were worried about leaving their houses for so long.

When we got to Tounfite, there was time to kill so the women went there separate ways. All the women and us volunteers met later that day for dinner at David and Kristen’s host family. The LaFever’s host family is just their host mom (who is widowed) and their host sister (who is divorced). The two women make a living by cooking for weddings and other events, so they were the perfect family to help us host the training. The opening dinner went well. Some of the older women are pretty feisty and love to joke around. 70-year-old Rkiya Kouru saw me dancing in the kitchen and came up and danced alongside me. Rkiya is pretty hilarious; she’s constantly making jokes. Talking with the women from Mara’s site, they were amazed to learn that I helped with harvest in my site – men in their community do not do that sort of work. At the end of the night, we accompanied some of the women back to the places they would be sleeping. Rb-Ha, who is probably 72 years old, cried when we dropped her off at her house, thanking us for our generosity.

Monday morning we all met in the sbitar (health center) to start the training. Two professional midwives would be leading the training, with a younger local girl helping with translation (the midwives don’t speak Tamazight and most of the women don’t speak Arabic). Mara and Kristen would sit in on the training and help out when they could, while Dave and I were relegated to kitchen duty. We spent a lot of our time preparing tea and food, cleaning up, running errands, and the like. The role reversal was obvious: the women were the focus of the training, learning and being served, while the men were working behind the scenes.

Mara and Kristen were ecstatic with the success of the first morning’s session. The midwives leading the training were really good at what they were doing. Moroccan pedagogy is generally based upon rote memorization, but the trainers were leading an interactive workshop and engaging the women. Given that most of these women hadn’t been to school in maybe 30 or 40 years (if at all), having such competent trainers was crucial. It was a big relief that the quality of the training wasn’t something that we had to worry about.

However, we had our first and biggest problem to deal with. 10 women had spent the night at David and Kristen’s host family’s house. We had told the host family that they could expect 5 or 6. Furthermore, many women told us that morning that they couldn’t stay with the family whom they had stayed with the night before and had nowhere to stay. We panicked a little bit. Before the training, I had asked all of my women if they had a place to stay in Tounfite during the training. I explained to them that it was easier for us if they could stay with family, but if not, we would find a place for them. Every single one of them told me that it was not a problem, but here they were telling me that they could no longer stay with that family. Maryam, a 23 year old from my village told me that she was ashamed to stay with the people she had stayed with last night. Maryam has already been divorced twice, meaning that she’ll probably live with her family for the rest of her life. Her explanation was that it was unacceptable for a woman to be out all day long and then come back for dinner, expecting food without having worked. My host mom, Mina, didn’t know anyone in Tounfite. I had asked a family in Tounfite (whose mother was already attending the workshop) if she could stay with them. So I had the permission from the man of the house. But Mina was ashamed to stay there – the man of the house was out of town and she didn’t feel like it was appropriate to impose on them.

I was frustrated. I think we were all frustrated. If we had known before the training that this would be a problem, we could have planned for it and arranged for more housing. But here we were, stuck with about 15 women who needed somewhere to stay and only an afternoon to arrange it. And why had they said previously that they had a place to stay? At times like these it’s really easy to chalk up such miscommunication to “cultural differences” and leave it at that. I’m not sure if I have a more nuanced explanation. I’m sure that there was a problem in the way I asked or the way I listened or something.

Our immediate solution was a bad one. Before the break for lunch, Mara and I told the women that if they had any place to stay, they needed to stay there. We said that we couldn’t impose so many people on the LaFever’s host family so please find somewhere else to stay.

We left the sbitar on our way to lunch brainstorming all the people in Tounfite that we knew whom we could ask to host a woman. We had a long list of people to ask. But when we got back to the LaFever’s house we made an important decision. No matter whom we asked and how willing they were to host someone, the women would feel ashamed to stay there. If we wanted the women to feel comfortable we only had one choice: to put them all up at the LaFever’s host family. This meant a huge increase in our spending that was unbudgeted for – so it would have to come out of our stipends. But it was the only option if the training was going to succeed.

When we returned from lunch, I realized that our decision was the right one. Many of the women had skipped lunch because they felt too ashamed to impose on someone. They were angry with us and their focus was not on the training. Even after we told them that we had solved the problem and that they were all welcome at the LaFever’s host family, the insult hung in the air for a little while. The silver lining was that, despite the insult and lack of food, no one had gone home. They were committed to the training.

That afternoon came another problem of a different sort. The midwives leading the training had received a letter from the Ministry of Health (their boss) saying that they had failed to evacuate a room in response to a request from Peace Corps volunteers (us). This letter was inaccurate: the room in question was empty and we had not made any requests. Our assumption is that the head of the sbitar in Tounfite made the complaint to the Ministry (there is a lot of friction between the head of the sbitar and the midwives). It was disheartening to witness the women that we were working with (who were doing an excellent job), being undermined by their superior on our behalf. So we wrote a letter to the Ministry saying that there was no problem.

The rest of day one was pretty uneventful, mostly we were reassuring women that they were welcome and that anyone who didn’t have family to stay with could stay with the LaFever’s host family. I was worried that some women would go home rather than impose themselves on someone. Luckily nobody did.

Day two saw more success in the training room. Sitting in our tea preparing room, Dave and I could hear constant clapping and laughter. I really wish that I was able to witness the training, but that was out of the question. One woman, Itto, who is 56 and from my village, had to go home for a day. The wife of her son was sick, so she had to take care of the house. She apologized profusely and I told her to come back the next day if she was able (she did come back). Hanou, 54 and from the most remote village that we recruited from (one of the most remote villages in Morocco) was feeling ill, so she stayed at the host family’s house in the morning, but came to the afternoon sessions.

That day the women doctors who work at the sbitar prepared food for the tea break. They were very involved in the training and excited to help in any way that they could. It seemed that they would come over to the training whenever they had a spare moment. They also promised to make lunch for all of the women on the following day. It was great to see so much enthusiasm on the part of Moroccan health workers. At my local sbitar, I see mostly disdain for the community that I work with. So it was awesome to see the doctors and midwives interacting with the women as equals and treating them with respect.

David, Mara, and Kristen all had other things to take care of that evening, so I was the only volunteer who went to the dinner that night. I’m really glad I did as it gave me an opportunity to interact with the women in a way that I hadn’t before. They were totally comfortable around me and we started joking right away. A ‘representative’ from each community would try to convince me to marry someone from their tribe. Naima from Mara’s community said that I to marry a girl from her tribe because they have lots of apples (which was persuasive). They would extol the benefits of their tribe and I would agree to marriage. Immediately women from another tribe would get ‘angry’ and start arguing about which community was better. The women finally agreed that the most remote tribe was bad (it is really poor) and that I should choose between the other two communities. I said I couldn’t choose, so they came up with a way for me to choose randomly and I ended up choosing Mara’s community. Well, there just happened to be two unmarried women from Mara’s tribe at the dinner! Naturally the next question was: which one do I want to marry? I said I couldn’t choose and that my host mom should make the decision for me. It was pretty hilarious: she made this big show of inspecting the women and asking them all these questions. She ended up choosing Rkiya, who is about 25. Rkiya has one child and is widowed. Her husband was murdered in Rabat because he failed to pay the people he was bribing for his job there. She is pretty quiet. The whole time the women were apologizing for joking around, but it was really enjoyable. It was especially good to spend time with them because I had been worrying about how they were feeling after we told them they couldn’t stay at the LaFever’s host family. Now that they had a place to stay, they seemed to be over it and feeling comfortable.

The final day was by far the most chaotic. For the afternoon session, we had invited moqadems and sheikhs (community leaders) to come and talk with the women. The idea was that the women and the moqadems would make an emergency action plan in case there was a problem in birth that the women were unable to deal with. Inviting these people meant that we had to remind them that they were coming and provide and extra good tea break. Plus we had invited even more people to a closing dinner to be held that night. And there was lots of other running around to tie up odds and ends.

When the men finally showed up (some were late, others didn’t come), it led to what I think was a really productive meeting. It quickly became apparent that there had never been communication between these community leaders and the health staff at the hospital. The protocol for getting and ambulance to the village was unclear. There was a lot of important information passed between the two groups. It’s absurd that it took a foreign association (Peace Corps) to bring these people together in the same room. The sad part was that the meeting made clear that many of these isolated communities are pretty much on their own when it comes to dealing with such things.

We eventually split up into smaller groups, with each community meeting to talk about its specific problems. My sheikh and moqadem were both in attendance, which I was thankful for. They were very helpful in talking about an emergency action plan. Additionally, a doctor who was just assigned to my community last week came. She was instrumental in leading the conversation. My women really like her (she’s a breath of fresh air compared to what they’re used to dealing with). Even beyond working on this project, I’m hopeful that she can bring a lot to my community. The meeting ended with tea and some spectacular break food.

Our final piece of work was to make sure the concluding dinner went well. With the LaFever’s host family helping us, it wasn’t that hard to pull off. They were so helpful the entire week and we couldn’t have done the training without them.

At a cafĂ© before the dinner, I met the nephew of one of the women attending the training. Moha is 30 some years old and living in Tounfite, although he works at the government building in my community. He had been hosting his aunt, Hada, 50, who lives in Taararte. Taararte is about 28 km down the road from me and pretty much without any help from the government in terms of health care. They have a sbitar in their community, but it is unstaffed and locked shut. Hada was very relived by my doctor’s presence, because she will be making rounds in a van to outer communities.

The dinner was the most fun that I had all week. I had been working behind the scenes most of the time, so I didn’t get to interact with the women that much. Even during the dinner, I had to spend most of my time in the men’s room, entertaining the men we had invited. But I took a couple trips to the women’s room, where they had drums and everyone was dancing. The doctors and midwives from Tounfite had come and everyone was enjoying themselves. I danced a little bit, which everyone thought was hilarious. One of the songs they sang had lyrics that went, “Sma3eel (my Moroccan name) is like the moon.” It’s pretty much the best compliment you can give someone. Even though the celebration dinner wasn’t the real success of the training, it was the best opportunity I got to get a feeling for the mood of the women. They were overflowing with joy and very thankful.


Like I said, I think the training was an unqualified success. I can’t imagine it going better. I’m extremely lucky to have capable volunteers around me who helped to include me in the project. The next step is to facilitate meetings between the women we trained and the rest of the women in the community. I also hope to host another training with women from different communities, although that probably won’t happen for a year.

I believe this is the most valuable thing that I’ve done as a health education volunteer so far. The ironic part is that I did very little education myself. My role was primarily bringing people together and making sure the meeting ran smoothly.

The real effect of the training won’t be known for sometime, if at all. There aren’t statistics about maternal or infant mortality during birth, so there’s no way of quantifying the effect the training has had. Something that is completely unquantifiable is the way that we empowered these women. Helping with births and women’s health in general is not highly valued here. I think it was important to let these women know that we value the work that they are doing. I also think it was a good example for the men in my community to see an American man take such action and put women’s health as a priority.

A common refrain amongst volunteers is how unwilling people here are to change their ways. Yet these (mostly older) women, who were sick, tired, and in a completely foreign environment, were willing to sit down and learn for three days. Even though the midwife trainers were wonderful, it would have been really easy for the women to ignore them – they’re young and only speak Arabic. But the women engaged themselves and everyone benefited from the experience. There were women from other communities who heard about the training and showed up to ask if they could watch. At the end of the training, even though they were really tired, the women said they wanted more.


Franny said...

Dunc! sounds absolutely awesome. i think this has been my favorite post so far. keep up the good work! see you in a couple months!

love, fran

maryellen said...

kitchen folks @ OFS say 'way to go!'