August 9: Drs. Susan Hughmanick and Art Dover don’t know how much the nurses and midwives of the Mother and Child Health Care Association (KAMM) know. So they have prepared a basic lesson for the morning, but reserved as much time as needed to answer questions during the afternoon. (Some of the women have walked for many miles to speak with Susan and Art, so Dr. Sadock Wilson goes with me to a nearby café to arrange lunch, purchased with twenty-five dollars of Karimu money, to feed twenty-two people!) Susan and Art also encourage the women to interrupt the lesson with questions at any time.
As was the case for yesterday’s conversation with Dr. Wilson at the Dareda Kati Town public health clinic, a short walk from where we hold today’s open-air meeting, my notes will jump around quite a bit. To Susan and Art who might read this, I apologize for any omissions or misrepresentations.
Susan stresses the importance of feeding colostrum and of going on to feed breastmilk only during the first six months of life. Art adds that breastfeeding has sanitary, hence life-saving, advantages in developing countries where hygienic conditions are poor. (Diarrhea resulting from consumption of fluids which, unlike breastmilk, may be unclean is the leading cause of death among Tanzanian infants.) The nurses and midwives confirm the claim made yesterday by Dr. Wilson that substitution of less nutritious or even harmful foods for breastmilk is common. Yielding to this tendency also sacrifices some of breastfeeding’s natural family-planning advantages.
In response to two questions from the midwives, Susan insists on the damaging effects of alcohol use during pregnancy and mentions the possibility that an HIV-positive mother could rely on another woman to breastfeed her baby. The women seem unfamiliar with wetnursing, but receptive.
One KAMM member observes that breast engorgement and infections often prevent mothers from breastfeeding. Susan asks Dr. Wilson whether he and his nurses can treat these conditions at their clinic, and Sadock assures the women that this is the case.
Another woman asks whether physical abuse of the mother by the father during pregnancy will result in a “crazy” baby. (I wonder to what extent this misconception contributes to the widespread practice of keeping “crazy” children out of the public eye?)
Susan and Art also field questions about the health effects of sex during pregnancy, which many women believe must always hurt the child.
Inevitably, the topic of genital cutting comes up. The practice, overwhelmingly prevalent in this area, often causes post partum haemorrhaging because of the inelastic scar tissue that it generates: the tissue cannot stretch and must therefore tear in order to let the baby out. And, sometimes, exit by way of the inflexible tissue takes so long that the baby dies.
Susan also lists the other health hazards associated with genital cutting, including the greater likelihood of tearing during intercourse and the consequent greater risk of contracting HIV. (I’m reminded of one of the points made yesterday, that whether or not thirty years in prison appropriately punish the practice of genital cutting, the Tanzanian government needs to do a better job of educating about its health hazards.)
Dr. Dover then explains and demonstrates neonatal resuscitation, advising means other than mouth-to-mouth because of the risk of transmitting infections. He mentions, without quantifying, the possibility of HIV transmission. But the fear of such transmission, whatever the precise risk, may inhibit efforts at resuscitation, so teaching alternate means is crucial.
Susan goes on to teach about the importance of a clean birth environment for preventing fatal infections. It is vital as well that the mother should keep herself clean. Susan illustrates her lesson about hygiene by using one of the Clean Birth Kits donated by Gloria Upchurch, a San Francisco-based photographer who often works with nonprofit organizations like Karimu to publicize and promote our work. The Kit includes soap, plus a scalpel, for severing the umbilical cord, whose immediate disposal in a pit latrine Susan insists on. (Birth attendants typically use razor blades.) It also includes alcohol for cleaning the severed cord—though Susan notes the alternative (and ancillary benefits) of using the father’s drinking alcohol!
Returning to prenatal care, Susan talks about the need to visit Dr. Wilson’s clinic if the fetus goes a day or most of a day without moving.
After the doctors finish teaching, they and Marianne and I accept an invitation to visit the home of one of the KAMM members, to which we take along several other Karimu volunteers, for food and sodas. Although Yasenta is a seamstress rather than a midwife, she belongs to KAMM by virtue of her status as a community leader; she has already served on the Ufani School Committee.
Yasenta and her husband Léoncé, a farmer and furniture-maker, expect their sixth child next February. When she goes into labor she will walk for forty-five minutes to Dr. Wilson’s clinic in the town center and then either take a bus or hire a private car to drive her several miles to the Catholic hospital. Whereas the bus costs less than a dollar, a private car would charge twenty. She could also choose to walk well beyond the town center to the Catholic Church which, Dr. Wilson told us yesterday, might charge ten dollars—still too much.
I’m afraid that I am guilty of wearing out our volunteers who have done construction work at Ufani School today by firing questions at Yasenta and Léoncé, who withstand my interrogation in good humor (and more patiently than I would, no doubt, if the circumstances were reversed).
But at least I learn some things: Yasenta and Léoncé do not boil their family’s drinking water and they do all sleep under the mosquito nets Karimu gave them last year, which have helped keep the family malaria-free.—Don Stoll