Desert Midwives

Photographs by Veronique de Viguerie

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This feature was shot in October-November 2009. A full edit of 80 images available on request. The following text was written by independent journalist Manon Querouil, and is for reference only. Anyone wishing to publish the text must obtain rights from the author, whose contact details we can provide.

A cry can be heard in the night. Under a blue patchwork tent in the Sahel, Ada has just given birth to her sixth child, a little girl. “God’s choice is inevitably a good one,” she murmurs before dozing off to sleep, with the infant feeding from her breast. Kneeling next to her, Issa gathers up the items from her birthing kit, including a mat, bucket, and rubber gloves, which are spread out on the sand. It was over fifteen hours of work, but at least the mother and her daughter are both well. “Al Hamdoulilah,” says the midwife, looking up to the skies and giving thanks, with a tired smile on her face.

Like her mother and grandmother before her, Issa has been travelling the desert in Mali since adolescence, from camp to camp, helping nomadic women through childbirth. It is this ancestral know-how that the Medicins Du Monde (MDM) teams decided to make use of, in order to deal with one of the highest infant and maternal mortality rates in the world. “We didn’t reinvent anything!” says Hamzadah Ag Didi with a smile. In 2005, this large moustachioed man was put in charge of recruiting the first generation of retrained traditional midwives, including Issa herself. “We just worked from the principal that we could teach them a few little things which can save lives, and also provide them with hygienic kit, enabling them to hone their undeniable expertise.”

Five years later, these simple and realistic methods have produced results. Around fifty midwives, aged 17-60, have been retrained by the MDM teams in the Kidal region of northern Mali. As most of them are illiterate, “We make sure we don’t overwhelm them with information,” explains Mohamadin, the phlegmatic instructor working for the program. He meets with groups of women in tents in the middle of the desert, hammering home his explanations ten times, twenty times, with illustrations in hand, then quizzing and correcting them. After a week’s training, followed by a catch up session ever three months, these “girls”, as he refers to them, are ready to assist a hygienic birth, using the kit provided by this NGO. They are also able to detect at-risk pregnancies, which can be common when the mother is adolescent, or is having babies in quick succession.

The other mission for these midwives is to get any difficult cases referred to a local medical centre. Indeed, this part of their work has made a significant contribution to the level of prenatal consultations in the region, which have risen from 11% to 35% since the program began. However, it is something that is far from natural for Tuareg women, who, due to modesty and tradition, normally give birth far from gazing eyes, hidden under a tent or behind a tree. “It’s out of shame of showing their pain, and baring their naked body,” says Dadia, a rather stern midwife in her 50s, from Kidal. In the eyes of the Tuareg people, pregnancy itself is a shameful ‘illness’ which women go out of their way to hide for as long as possible, not a happy event. Even the very word ‘midwife’ doesn’t exist in their Tamashek language, which instead discreetly refers to a phrase translating as ‘those that bring an end to it’.

In addition to the cultural attitudes which have been hard to change, another factor has been the limited transport options, with the local medical centre often being a few days’ walk away. So in some communities in and around Kidal, the midwives have put in place communal benefit funds which families can contribute to. These funds are used to pay for travel and healthcare costs, which can then be paid back into the fund through sales of livestock. In 2008, eighteen women in difficulty were able to be quickly evacuated using these funds. However, the isolation of these nomadic people in an inhospitable land on the doorstep of the Sahara remains a significant challenge for the Medecins Du Monde teams.

Since 2006, this region, a crossroads from trafficking of all kinds (arms, drugs, cigarettes, etc), has also become the epicentre of the Tuareg rebellion against Mali’s government, and is the supposed sanctuary of the group ‘Al-Qaeda in the Islamic Maghreb’. This has had disastrous consequences on local security, making access to healthcare even more difficult for these nomadic communities, often cut off from any form of help. In some villages along the border with Algeria, like Abeibara or Tin Essako, no medical teams are willing to risk visiting them, due to the danger to their staff. In these abandoned areas, the midwives have become the “only health support”, stresses Ahmed Mohamad Ali, the MDM regional coordinator. And their follow-up training and monitoring “is a real headache”, sighs Mohameddin, who has to seek out his “girls” for days on end in the vast desert.

After a few hours of searching in a 4x4 vehicle under the baking sun, he finally locates Tahone, trained last year in the region of Aghabo, around 50km to the south of Kidal. “Before the training, I had never heard of tetanus. I was seeing babies die a few days after birth, without understanding why,” explains this young woman, who herself lost three of her own children, victims of what she thought at the time was a “natural death”. Leaning on one of the poles of her tent, which she shares with a tired-looking goat, Tahone confides that she previously also didn’t know where to cut the umbilical cord. “Some midwives said that the longer you leave it, the quicker it would fall off. Since then I have learnt that you have to leave it the length of three fingers, and tie it up with a piece of string so that it doesn’t drag in the sand.”

“This program has revolutionized the work of the elders,” says Daya, the youngest midwife retrained by MDM. As decided by her community, this young girl was permitted to pursue nursing studies in Kidal, with an end goal of working in the medical centre in Aghabo, which, like many others in the region, has no female medical staff. She proudly says, “I belong to the new generation, who just dream of another life. There is nothing here. Learning is the only way for me to get out of this situation and help my people.” Dr. Abdullai Ag Zakaria, from the MDM team, confirms with a smile, “These girls are a lot more curious than their mothers were. I even get young patients coming to my office in Kidal, making up illnesses just to be able to see the town!”

The ‘town’ consists of a small number of fragile houses made of ochre clay, which seem trapped by the surrounding desert. Kidal, the regional capital, only has 5000 inhabitants. Although electricity and cell phones have arrived in recent years, the way of life seems to have scarcely changed since the dawn of time. The Tuareg people are eternal nomads, and lead a rudimentary and unchanging lifestyle, following the needs of their livestock, constantly on the search for waterholes. According to the slightly annoyed head of healthcare in Essouk, a very Islamicised area 70km from Kidal, where no women have come to give birth for three years, the Tuareg people demonstrate fierce suspicion and mistrust of modern medicine, and of these “men in white coats who don’t speak the same language.” Recently an MDM team was even chased away under a barrage of stones being thrown at them, during a vaccination campaign, as they stood accused by the locals of trying to inject them with a deadly virus.

“The nomads are like wild deer,” declares Mohamaddin eloquently, who also readily defines himself as a “desert feminist”. “I am proud of working with women, and for women. My relationship with by retrained midwives is based on respect and trust. I share their secrets, but also the challenges they face in daily life.” The main challenge being the resistance their husbands show in letting them abandon their homes and livestock, sometimes for days at a time, with no financial gain. “We earn nothing except the thanks we get for our acts of kindness. It makes me happy, but doesn’t help me earn a living!” complains Dadia. “We have vowed to sacrifice ourselves for others,” sums up Issa, the most diplomatic of them, who also admits being less and less able to deal with the long and testing walks through the desert.

“If we don’t help the midwives, it’s the whole nomadic community that will suffer,” says Mohameddin, who hopes to get enough funding to be able to buy each of his midwives a donkey, to make their travel easier. “The only limit on what I can do comes from my feet,” confirms Teriat, brushing aside the two grey plaits of hair that frame her worn face. For decades, this midwife, who has become a veritable local celebrity, has been incessantly pacing this immense region of rock and white-hot sand, and has personally assisted with “a few hundred births”. “Her presence is a true blessing,” smiles Fatimetou, aged just 20, and already pregnant with her third child. “My mother helped me with my first birth. She made me do everything: run, suspend myself from a tree, she even sat on my belly, all so that the baby would come more quickly. For my second birth, Teriat took care of everything, and believe me, I noticed the difference!”

This assessment is backed up by many Tuareg women, to the point that these retrained traditional midwives now take care of half of the births in this region. The confidence that the local population places in them also helps to form a precious link between health organizations and the nomadic communities. “It is the only means we have to raise health awareness,” says the head of the healthcare centre in Kidal, Abdul Kassou Maiga. Conscious of what is at stake, the MDM teams have prepared them as follows: from January to April 2009, the retrained traditional midwives carried out 193 informative sessions in local communities on topics as diverse as malaria prevention, vaccination, and even contraception. “Yes, condoms are haram (meaning forbidden by Islam) here,” reveals Dadia in her usual frank manner, “but as we are well respected here, we have some scope to inform women of the methods that exist to avoid yet another pregnancy.” “It’s an early victory, but we must go further, to develop a mobile healthcare system that is adapted to the Tuareg way of life,” says an ambitious Ahmad Mohamad Ali, the regional coordinator. He does however understand in the meantime that they have to get the authorities in Mali to recognise the desert midwives for what they are doing: spearheading a possible reconciliation between tradition and modernity.