Decolonizing Maternity Care: A History of Labor Practices in the Global South
Editor’s note: This is the first installment of a three-part series. Stay tuned for Part II!
The personal is political. Often it is the personal that moves us to action — it becomes a driving force for our passions, our commitments, and our hopes for a better world.
My great-grandmother died while in labor with her last born, who was also lost that day, leaving my grandfather and his siblings orphaned. (Don’t worry reader, my grandfather, although he never knew his mother and lost his father soon after, was raised with a lot of love and sympathy by our very large, village-sized family, and he lived a long and beautiful life. May Allah have mercy on his soul.) The legacy of her loss is what shaped me into the fierce advocate for birthing justice that I am today.
My great-grandmother should not have died that day. In her case, her child was already making their way out while she struggled to find transport from her Palestinian village to the nearest hospital in Jerusalem. According to Averting Maternal Death and Disability, about 15% of women develop complications during or after pregnancy globally, accounting for 303,000 maternal deaths annually, most of which could be prevented with access to emergency obstetric care and culturally competent birthing practices.
Long before the founding of modern-day obstetrics, there were many safe birthing techniques conducted by indigenous peoples worldwide. Oftentimes, these practices are glossed over in the legacy of birthing, but is there more that we can learn from these practices? I hope that through highlighting the herstory of a few practices that were carried out to support women during childbirth, we can honor our foremothers for being practitioners and protectors of a very sacred process and learn from their wisdom. The earliest recorded births throughout the world were accompanied by older women, and there are records of this in Europe, the Americas, Africa, Asia, and the Middle East. There are also records of women birthing on their own. Although written documentation of childbirth practices can be challenging to find, there is considerable artwork depicting scenes of childbirth in contexts around the world.
The first successful c-sections were performed in Africa
Africa has been ahead of the curve in many aspects of progress, it is where humanity originated, and cesarean sections. The first c-sections known to humans were performed in the Bunyoro-Kitara Kingdom in Uganda. Recently the written record of a Scottish doctor, Dr. Robert William Felkin, was found describing the c-section process in detail in 1879. He commented that the Bunyoro had a much lower fatality rate compared to those performed in Europe and the United States, which, at the time, had a fatality rate of nearly 100%. (Yes, reader, I was shocked too. Thankfully the procedure is much safer now).
The Bunyoro were performing c-sections long before this doctor came to observe the procedure and they had it down to a science. The delivery team consisted of an anesthetist, a surgeon, a surgeon’s assistant, and a midwife. They would lie the mother down on an inclined bed and sedate her with banana wine (which I can tell you is incredibly strong from only smelling it once). Next, the surgeon sterilized the tummy and a special curved knife and then said an invocation, or prayer, before cutting through the abdominal wall and then the uterine wall in the lower region of the abdomen. This would become known in Western medicine as a low-transverse incision and became a best practice for c-sections in 1926, about 50 years after the Buynoro were recorded to have developed the practice. After the incision the baby would be delivered, then the placenta, the umbilical cord cut. The team used various methods to dress the wound, they put pressure on the wound to reduce blood loss, used a hot iron rod (sparingly), and then pins and a suture to close the incision. The whole process was very quick to minimize pain and blood loss.
They would monitor the mother and baby closely over the next few weeks. On the third day, they removed one pin, on the fifth they removed three pins, and on the sixth, they removed the remaining ones. Each time they would remove the pins they would clean the wound of any pus and dress it with a new clean dressing. By the eleventh day, the wound was healed and the mother and her baby were healthy.
Birthing stools and birthing rooms in SWANA (Southwest Asian and Northern Africa, also known as the Middle East)
The SWANA region has some of the earliest documented use of the birthing stool dating back even to ancient Egypt, which has since been adapted and improved for the modern era. There is an artistic account of a Queen in either Iraq or Iran in the late 11th or early 12th century, who is documented using a birthing stool supported by two women, at least one of whom is assumed to be a midwife. Another interesting innovation in childbirth at the time was to have the mother and baby stay secluded in a birth room with an annexed sandala, which would functionally be a sort of neonatal or postpartum care unit.
Dr. Bousy M. Zidan describes the sandala as an “enclose[d] square framed fenestration with a whorl screen, to let both light and fresh air to get inside.” The birth stool allowed for the mother to have a supported vertical birth. Notably, it was not a best practice even for the Queen to give birth laying down. The birth room allowed for a 40-day healing period when both the mother and baby are immunologically vulnerable. The sandala allowed for fresh air to enter and circulate throughout the space preventing the growth of mold and bacteria.
Indigenous practices of squatting and vertical birthing in Latin America
The Birthing Figure is estimated to be of Meso-American Aztec origin, dating back to the Pre-Columbian period (although the exact time period of this piece seems to be up for debate by scholars of art history). What is striking about this sculpture is that the assumed position of childbirth is squatting and the baby seems to be emerging arms and head first.
Additionally, indigenous Peruvian women have been practicing a type of vertical birth using a rope and a support person. Typically the rope is hanging from the ceiling, the laboring mother grips the rope as she bears down (she can be squatting, standing, or leaning) and a family member supports her from behind. Meanwhile a midwife or birth attendant is ready to catch the baby so they do not fall on the floor. Since the mother does not lay on her back in this traditional birthing pose, it frees the coccyx bone to move back slightly as the baby comes down the birth canal. In general, poses that do not involve horizontal birthing (laying down) allow for more room in the pelvis and easier delivery. Recently, these indigenous birthing traditions have been incorporated into the care provided at health facilities in rural Peru and have improved birthing outcomes as well as increased birthing attendance at clinics.
Bridging the modern and the traditional
We can find hope for the future of maternal healthcare by understanding the past. The history of maternal and women’s health in the global south contains so much knowledge and wisdom that we can learn from and apply. These regions, though they struggle with some of the highest maternal mortality rates, deserve attention for their contributions to what we know about effective birthing practices today and investment so these traditions are not lost, but incorporated into current practice. Although globally there have been many improvements in maternal health and women are generally dying from childbirth less, there is still so much we can learn from birthing practices that pre-date hospitalized births. This is especially true now since global improvements in reducing maternal mortality have stalled.
Traditional practices can help us improve hospitalized births as well as make birthing at home or at birth centers safer and more accessible. These more holistic methods of birthing are becoming more common (and are arguably more necessary) in hospital settings. With the incorporation of birthing balls, peanut balls, and the slow resurgence of the birthing stool, there is hope. More intentional efforts are needed by clinical providers to liaise with communities to ensure culturally competent and respectful care is available to all birthing people.
Hospitals and clinics can be made more aware of and attuned to how people will find comfort in different birthing positions. By bridging the modern and the traditional, our societies can build provisions for birthing people to have the type of birthing experience and early childhood support that they need. We have always known horizontal birthing does not work for everyone, thus our societies should have options for birthing people. We have always known there needs to be ample time for bodies to rest and recover from childbirth, thus our societies should provide adequate time for recovery and bonding with children. We have always known the answers to our questions of ‘how best to provide care’ are found within the individuals and communities we claim to serve, thus we must do better to serve them.
Hana Hamdi was a 2018–2019 fellow serving as the Monitoring, Evaluation, and Research Officer at IntraHealth International in Kampala, Uganda. She holds a Master’s in Public Health from Columbia University’s Mailman School of Public Health. This fall, she will be starting an MSN in Nurse-Midwifery at Yale University. She currently resides in Kampala.
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