Thursday was a rare slow day in the labor ward at Bottom labor. There was time to sit and to chat. I have seen much and learned much at Bottom but from the beginning I have also wanted to see birth outside the hospital in Malawi. (Over 50% of women in Malawi still deliver with traditional birth attendants (TBAs).) Thursday I mentioned this to Msiska and she told me about Mrs Msumba. Mrs. Msumba is a famous midwife working in a village on the periphery of the city. As Msiska described her, I realized that she was the same midwife mentioned by several of the clinical staff over a year ago in a derisive conversation about nurses who preferred to have her attend their births rather than deliver at Bottom (it sounded reasonable to me then and now). Msiska said Mrs Msumba had a lot of patients and always referred in time, and unlike other TBAs always accompanied the transferred women to the hospital. I was eager to meet her and asked Msiska how I could find her, in response she said “ukachula mkango udzikwera mtengo [if you mention a lion you must climb up the tree], she is probably on her way now.” I was skeptical since we had never met during all my time at the hospital but within a couple hours Mrs Msumba appeared with a patient and of course Msiska was not surprised. Msiska explained my interest to Mrs Msumba and I gave her my telephone number. Mrs Msumba said she would call when she had a laboring patient.
Sunday night Beatrice and I compiled a list of things to get done for the week for our little non-profit. Monday morning, thinking of nothing else but the non-profit, I woke up and opened the computer but within minutes woman called speaking in rapid Chichewa. I heard “TBA” quickly tossed in and figured it out. I asked if I should come and she said yes. The plan had been that one of the maids from labor ward would escort me but when I phoned her, her phone was switched off. I called Beatrice. She was at Kamuzu Central Hospital and said she would find someone who knew the way and accompany me. When I arrived at Kamuzu Beatrice was waiting with two women from Mrs Msungu’s village who had been delivered by her a couple months previously. The two women directed us through the village and then instructed us to stop at a hedge (a few green leaves budding on top a mound of dirt). From there they led us down a narrow muddy path at once widening and ending at a pen filled with fat guinea pigs eating palm leaves. Mr Msumba was cleaning the pen and after greeting him, the women who led us there called out to Mrs. Msumba who was next door at the her clinic. Mrs Msumba greeted us warmly and led us inside.
Her small clinic was divided into four rooms, the main room which contained a small cabinet with delivery supplies and gloves as well as two “bush” ambulances (tricycles with extended carts used to transport laboring women); a small empty room for prenatal examinations, a recovery room with a single bed, and a tiny delivery room containing only a basic cot for the baby. The building was made of unbaked brick painted with a cement floor and metal roof, it smelled faintly of floral body soap. Two women, having come for prenatal care, sat on the floor in the main room, the first was pregnant with her second child and had no living child and the second woman was pregnant with her fifth. Mrs Msumba counseled them, she talked to them about danger signs, she told the woman with her fifth pregnancy that she must deliver in the hospital (TBAs in Malawi are only supposed to attend second to fourth pregnancies). Every now and then I could hear the woman in the labor room moan and Mrs Msumba occasionally stood and peered in the delivery room. She examined the bellies of the two prenatal patients and let them leave.
During the month of November Mrs Msumba said she had had 62 deliveries and 19 transfers to Bottom. Only after looking through her record book and counting the names could I completely grasp that she alone had cared for 81 laboring women within a single month. Mrs Msumba began working as a midwife in 1975, apprenticed by her mother and grandmother. She laughed and shook her head when I asked if she knows how many deliveries she has conducted. She strays further than walking distance from her home and clinic only when transferring patients. There is no electricity at her clinic so some nights she conducts as many as three deliveries by candle light. She charges 500MK for her services (about US$3) but still many of the women cannot pay, so she often works for free, pays the transportation costs with her own money when women must be transferred, and sustains her family with small businesses such as raising and selling guinea pigs.
In the hospital the women must bring their own caretaker to cook and wash for them, if they have no one they do not eat, and they wash their own clothes after delivery. If the women come alone to Mrs Msumba she cooks for them, she heats bath water for them, she gives them water while they labor, and leaves a covered bucket by their side in case they need to vomit. The women bring a plastic sheet and a few cloths to place on the bare ground in her small delivery room. They labor there, Mrs Msumba encourages them to lie down. She does not yell. When I asked Mrs Msumba about vaginal exams she says she does not check regularly. She takes her time. She watches the women, their bodies and their body language. She palpates their abdomen to feel whether the baby’s head is descending into its mother’s pelvis. She can tell from a woman’s labia if her birth will be difficult. She says she takes her time. She says this way the woman only pushes once or twice and the baby is born.
Stella was laboring with her third baby. I sat next to her on the cement floor as she moaned and turned from side to side. Mrs Msumba walked between the rooms, attentive to Stella but calm. She listened to the baby. As the birth neared she changed clothes, put on gloves, and prepared her delivery kit – a cord clamp, a razor blade, and a piece of string set in her single kidney dish. Stella’s moaning intensified and Mrs Msumba instructed her to move from her side to her back. After two physiological pushes Mrs Msumba held Stella’s baby boy in her hands. She immediately put him on Stella’s breast and in another five minutes the placenta followed with barely a drop of blood. Mrs Msumba cleaned Stella and the room. It was an amazing birth to witness, we thanked Stella and Mrs Msumba but before we were allowed to leave Mrs Msumba ushered us to the steps outside where a lunch of eggs and nsima was waiting.
I asked a few more questions and then Mrs Msumba gave me her list of requests: electricity, a mattress, more metal kidney dishes, and a few blankets. As we were finishing lunch another laboring woman arrived. Mrs Msumba asked us to wait while she examined her just in case the woman needed to be transferred but within minutes she also delivered. We left feeling joyful. It is no mystery why women choose to deliver with Mrs Msumba rather than at the hospital. The care that women receive with Mrs Msumba is impossible to replicate in a hospital where the ratio of laboring women to nurses can be as high as 10:1.