Ariela weighs in again

May 29th, 2009 :: Voyage au Mali

Last night the mango rains came. It started in the evening with lightening striking every once in a while as I walked back home from the internet café. At night, no one can see that I am a tubabo (white) and I can get really close before they realize this and the little kids begin yelling it after me. During the night it began to pour, louder that I have ever heard before, rain unlike any I have experienced before. If I had to guess what a monsoon feels like, this would be it. The sound was soothing, and yet astonishing. I got up and looked out the window at the yellow sky and the huge drops hitting the ground. It was very intense.

This morning, everything is muddy and it’s a bit cooler. Day one of the second stage has begun. Madame Berte has returned to Sikasso, a fact that I think will greatly influence the environment of this second group’s experience. Yesterday, when talking about breast feeding, she made some of the mothers sit on a chair at the front of the room and ‘demonstrate’. The little girl I had played with the previous day (and spent the afternoon with her strapped to my back—I will be doing this with my own children in the FAR future---it felt so natural and freed my hands to do whatever, while she was cool as a cucumber and happy to play my hair and smile) was turned this way and that as her mother and Madame berte tried to make her stay still in the correct position…it was a jovial room, everyone was laughing and asking questions—the best kind of active learning.

Dr. Coulibali is incredibly dynamic and a great facilitator- he gives great positive reinforcement and makes the women feel comfortable and keeps them engaged. It’s hilarious to me that all the photos in the slideshow presentations show white babies feeding on white breasts. I don’t think the matrones will be encountering many white bodies en brousse in the near future.

The women were asked to come up with topics they are hoping to learn in this stage. One woman said she wants to know what happens because the baby will be washed and fine and then she’ll return and it will be dead. This is astounding. This is their reality. I try to imagine such a scenario in the U.S…. the women WANT to know why this is happening, what they can do about it…mind you, this is not their matrone training. They have been practicing and doing their best with little resources, combating these occurrences with little understanding of the sources of these deaths. I say to myself, well I am happy that they get to have a forum to ask questions and learn here, and this must mean so much to them, but on the other hand, I think of the women who returned to their villages today. It seems so unfair to place so much responsibility on someone without fully preparing them. They are the best care most women in Mali can hope to get.

We had the women fill out a short questionnaire, and one question was, which part of being a matrone do you like most? A majority put down: I love everything about birth. For these women, it’s a calling to be a matrone; this is how they center their identity. In this sense, while overworked, underpaid and under prepared, these women truly love what they do, believe in its importance and continue to do it lovingly despite the conditions. For me, who finds pregnancy and birth fascinating, miraculous and so powerful, these narratives fill me with pleasure.

My next idea, get a VW van and put up a matrone-education traveling show. Hey, as one of the only white people around I am already a circus show, why not go all out?

Ariela weighs in

May 28th, 2009 :: Voyage au Mali

Here are some comments from Ariela. She is the undergrad student from Mich. that came along . She's been unbelievably helpful and a fantastic travel companion. So I'll cut and paste her comments below.

I’m sitting in a long room swollen with Matrones to twice is capacity; two ceiling fans are feebly trying to dissipate the intense heat and humidity of the hot season in southern Mali. Around me are 38 matrones, each dressed in beautiful pagnes of intense colors and patterns, beautiful embroidery and matching head scarves- it is obvious that they put quite a bit of effort into their appearance at this, the second day of the first matrones stage. As I write this, the matrones are discussing the needs of the newborn; both the basics as well as which practices are most beneficial. Each woman is called on in turn to read out loud the French slides, which are then discussed heatedly in Bambara. Some stumble with the French, after all, their first language is usually Minianka, then Bambara and then French. They discuss and debate, growing more confident and willing to ask questions and acknowledge that they are unsure about the specifics of a process: they want to know, it’s pretty incredible to see how intent they are, how they yearn for this knowledge. It’s also shocking how much they do not know. After these three days, they will return to their small village en brousse, and continue their work, independently (or with the help of a traditional birth attendant) delivering and caring for the pregnant women of the village. It’s obvious that these matrones get how important and rare an opportunity this is for them- and things are coming up that remind me of how much work is yet to be done. These women are all here, engaged, and the matrone leader from the department is taking charge of this entire training and seems fully in-step with the importance of these days. However, the slides are speaking of the steps of care these women are supposed to follow, even though the women lack the tools and equipment to perform them.

It’s incredible to me that this world of matrones opened up to me only four days ago, I could swear it’s been at least three weeks. Time moves slowly here in Koutiala. Before the trip I was so nervous and excited, realizing that I really had very little idea of what I was getting into. I am so glad that this was possible, and that now I am here, sweating and listening for the few French words code-switched with Bambara. It does not cease to amaze me how well children are integrated into these women’s’ lives. Some breastfeed while taking notes and listening to the lecture, babes passed out happily bundled on their mothers backs in a pagne or towel, a small lump of baby. The children of Mali rarely part from their mothers, and this stage is no exception. Some of the matrones are pregnant, most have left older children at home, this stage, these trainings are so vital, for the wellbeing of women and their babies at the highest risk, isolated and working with a lack of equipment. These matrones know how much rests in their hands.

Coming full circle

May 28th, 2009 :: Voyage au Mali

Okay, so here we are already on our way back to Bamako to start heading home. We left Kotuiala yesterday after a whirlwind second session. We took one night to go out to the village of one of the matrones who attended the first session. I'm going to paste some comments I wrote a few days ago. It starts at the beginning more or less and moves through to the end of the 2nd session's first day.

I will admit I was worried. This event had been largely based on a fantasy of seeing this group of women together in an environment where they could learn from and exchange ideas with colleagues and supervisors. A few months before we were supposed to have the event, I discovered that a good friend of ours, Sadio Sogoba, was in Koutiala. I thought Sadio was in the capital, Bamako. It was like a gift to find out here was in the city where I was trying desperately to get this event arranged. As soon as he heard what I had been working on he went to see the Medecin Chef, the physician in charge of the Koutiala region’s health activities/services. Until then, I was just a strange voice on the phone and I’m not sure the Med Chef had taken me seriously. Who could blame him? Regardless, if he wasn’t taking me seriously then he was unlikely to have started any real preparation for the event. After Sadio came to see the Med Chef and began clarifying dates and other details, the med chef became a lot more responsive. I got an agenda and a revised budget via email. I was encouraged. After that, his communication stopped again and I had only Sadio to assure me that the event still seemed on track. Fast forward to just before departure. I became nervous that I had been asking too much of the health center staff – did they have the materials, the time, the interest to put this event together? I had no intention of being the ‘trainer” – I tried that in Peace Corps and knew it didn’t work. Still, would they – could they – come through? Just before I left for Mali Ariela, an undergrad from U. of Michigan with an interest in Africa and women’s health, decided to come with me. I knew her through another colleague and felt confident she’d enjoy the trip. I was impressed she decided to go with so little notice. The trip was a bit stressful b/c of bad weather and I just barely made the flight out of New York. Still, we made it. My bags, of course, did not. Oh well. It was a good reminder that a good bit of this trip was out of my control and I had better get used to it.

We arrived in Mali in the wee hours of May 18th. We spent the day changing money and running a few errand. The next day we headed out to Koutiala. We took public transport which means tour-style buses from who knows what era from who knows what country. Our trip was made especially uncomfortable because despite the 100+ temperature, the driver did not apparently understand he had the heater on full blast. I kept burning my feet on the scalding radiator that ran along the windows. Sadio would later tell me that people burn their feet on this bus line all the time. Mental note to self: take a different bus line next time. Despite the heat, we arrived just in time to suffer the worst of the days’ heat wandering around Koutiala figuring out where we were going to stay. Ssdio, as usual, saved us. He had originally thought we could stay in the extra rooms of a quiet NGO. We arrived there and it was a bit far.

End of First Session

So far, this has been just amazing. The staff here has been amazing. The topic of the 3 day session is “Essential Newborn Care” ”. The first day we covered prenatal factors that affect the newborn. At the end of the session the matrone started asking questions of the facilitators. For example, “if I hear heart tones at the first prenatal visit but not at the second, what should I do” and “how many pills of iron should the woman take?”, and “when in pregnancy should she get the malaria medication?”. These discussions put everyone on the edge of their seats – like the were all dying to have these details clarified. It was fantastic to see them exchange ideas and information with each other and their supervisors.

Today we finished the first ½ of the event. 40 matrones participated in 3 days of “Essential Newborn CareThe next day, day 2, we focused on immediate newborn care. Participants got a chance to work with mannequins to practice going through the 11 essential steps of newborn care. We discussed newborn resuscitation, how to maintain the newborn’s temperature, and signs of danger that would necessitate a transfer. Today, the third and final day of the first session, was all about breastfeeding. Although it is rare for Malians to do any BUT breastfeed, they tend to supplement with water and other fluids too early. So, there was a lot of laughing when we used some of the participants’ babies as models so we could demonstrate appropriate latches and positioning. After the session, matrones just started asking questions about various breastfeeding-related problems and it became an informal Q&A. You could really feel that the matrones were taking advantage of having these women here. When the questions were over Madame Berthe gave the mannequin baby to a few matrones and asked them to practice giving women basic breastfeeding instructions. They started softly and hesitantly at first – not because they don’t do this all the time but just not typically in front of their bosses and colleagues – and then gained confidence as the facilitator gave her positive feedback, “that’s it!” or “exactly!”. This led in, somehow to a big discussion about whether or not there was such a thing as “dirty milk”. – it was established there was no such thing except for HIV+ women who need to discuss this with a doctor and also in some rare cases of maternal medications. Generally, women and breastfeed anywhere anytime!

The first day certain rules were agreed upon – one of which was to not sleep. The sanctions for this and other offenses include buying candy for everyone else. As we neared 2 pm in this heat I started to nod off. During the break no less then 5 or 6 matrones came up to me to remind me that I owed them candy! How embarrassing.

Madame Berthé is a sage-femme from the health administration in Sikasso. She’s one of the three facilitator’s here at the first session. She is a talented facilitator and gentle teacher. She has a sweet nature and is fairly quite. When she is leading a session, she comes alive and the participants seem to feel comfortable with her. Yesterday, she had ½ of the participants to practice immediate newborn care. She had them in hysterics because they began each participant’s “practice” with a birth including groaning and pushing encouragement from the matrone. They were just having a great time.

Madame Diarra is a sage-femme here in Koutiala. She is under the supervision of the med chef in Koutiala and also Madame Berthe. She is a very large woman which is unusal in Mali. She has kept people in line here – getting them going on time, chastising them if there is too much chit chat. But she still has the fantastic ability to answer questions without making the participants feel self-conscious.

Dr. Mustaphe Coulibaly. He is 30 years old I think. He is a physician who did specialized training with the Ob/gyn who was here for years. So be is the defacto ob/gyn man now. He’s from Koutiala – Minianka even – but he says a lot of people don’t know that because his skin is lighter than most people from here. I asked him if her was going to try and find a wife in Bamako. He laughed and said there were plenty of women he could marry here in Koutiala. I found this reassuring – it seems there are so few educated professionals who don’t want to go to Bamako. This guy is a fabulous facilitator – he just gets it. He’ll probably get snatched up by some ngo in the near future but for now Koutiala is benefiting tremendously from his service. He is bright as hell but still has this little boy character that peeks out now and then. As he sat frustrated with his computer he pushed the power button and spat out “this thing sucks” (nin miye deh!) like a little kid with broken toy.

Day 4 (1st day of Session B)

Today is Sunday and they would not normally be working. But because of the stage, the troops are supposed to be here. The feel was different today than the first day. Early this morning was the first real rain I’ve heard – and it was a good one. One of those mornings for sleeping. A real mango rain. So, by the time I got to the health center nearly all the matrones were here – about 36 in all – but the center was locked and they sat staring at the huge puddles that stood between them and our conference room. After several phone calls and some patience, the players arrived and the room was opened. All the table and chairs had been put away to soon Diarra had everyone working to get the room ready for the day.

Like last time everyone found a place at the table or in the chairs just behind. We handed out the coveted folders with notebooks and pens. Agenda followed. Diarra kicked things off by asking all the matrones to introduce themselves. They stood up hesitantly and mumbled their names and the village where they work. Then Coulibaly and Diarra introduced themselves and passed the parole to me. I did my schitk again – it was less emotional than the first session but it still felt great. They smiled back and gave me a little applause. It was, overall, a less festive start than the first session but I liked that is was calmer, more methodical. More orderly.

This time I took closer note of the process itself. After the intros Diaraa said, now we’re here as a village so we have to have laws. Like last time, we ended up with you can’t sleep, can’t have you cell phone go off loud enough to bother people, can’t leave without permission, no chit chat, and must actively participate. Next order of busniness – select a chief of the village, or dugutigi.. The immediately designated Madame Traore. She’s an older matrone that I remember from the Association de Matrones de Koutiala meetings I attended in 2003 and 2004. She has these coke bottle glasses that make her look older and smarter than she already does. After the dugutigi we passed out the pre-teste. Its at this point where the crowd seems anxious – too much French, too much medical language. The play with the test nervously in their hands and whisper to each other as thought they are trying to figure out what to do with it. This time Coulibably translates it for them question by question. The first session, only the post-test was translated which really made a comparison between their pre and post test impossible. We pointed this out and so they’ve corrected that and are translating them both this time. Madame Berthe went back to Sikasso which is a huge loss – but I think the remaining folks can pull it off. (end of session two day one).

Finished with first half!

May 23rd, 2009 :: Voyage au Mali

Well, I just wrote quite a bit and accidentally deleted - errr. But suffice it to say that the last three days - our 1/2 mark - have been phenomenal! The matrones are just soaking this up! The trainers are fantastic - one doctor and two highly trained midwives or "sage-femmes". All three truly apply adult learning principles to this event which has been amazing to watch. The pictures attached to this post are from the first day which was an overview of neonatal mortality and what the next two days would review in detail. It was so wonderful to approach the health center that first morning and find all of these women waiting and eager to go! Really, the session have been phenomenal. The best part is when they start asking questions and discussion gets going - there was a lot of debate about when/why to bathe a newborn, how many iron pills to give, how to treat and prevent malaria in pregnant went on and on. You could tell the matrones were going to take advantage of being around their peers and supervisors. I'll post more details about day 2 and 3 tomorrow. For now - enjoy these photos from Day 1. More to come on website. And, by the way, it's mango seasons so despite the heat its been fabulous!

Coulibaly does a gloving demo

Koutiala Training

May 21st, 2009 :: Voyage au Mali

This is a test of our Mali Midwives blog. If you are reading this because you contributed to Mali Midwives, you can give yourself a big pat on the back. I'm here in Koutiala enjoying one of the best days of my life. I feel like everything I have been struggling to put together just CAME together. I am so grateful to the staff at the health center for taking this opportunity wiht such efficiency, such professionalism. I am grateful to all the donors who made this possible. The staff here in Koutiala did exactly what I had hoped - they took complete ownership of the event. Today we began with the first group - 40 matrones in all. We were crammed in a sweltering room but the snacks and lunch were good, the trainers were fabulous, and there was an amazing energy. Even after this long day the matrone stayed to ask questions of their direct supervisor and her boss. It is a rare opportunity for them to be among colleagues and supervisors - they asked so many questions and you could tell that they were all listening, engaged, leaning forward, nodding, taking in. It was gorgeous to watch. I am so proud of this event I cannot find the words to express it. I am truly grateful for how this has worked out. I took a million pictures and will post as soon as I figure out how.

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