Midwifery in Morocco
The social complexities of rural healthcare
Unlike most rural towns in Morocco, Ifli (Ifli is the fictional name of the site of study in Capelli’s “Risk and Safety in Context.”) has its very own hospital. Ifli is a small oasis town, lying on the border with Algeria. Through its hospital, residents have access to a doctor and nurses, as well as medically trained midwives. However, many people prefer to receive their obstetric care from kabilas, local traditional birth attendants.
Kabilas rely on three systems: Galenic, Prophetic, and herbalistic medicine. Galenic medicine has been inherited from the Ancient Greeks, Morocco’s ancestors, and emphasizes a balance between several dichotomies including hot/cold, wet/dry, and open/closed. Prophetic medicine requires religious or spiritual healers in order to address illness caused by invasion by spirits. Herbalism relies on the use of plants and herbs as healing tools. Neither kabilas nor most residents of Ifli place high value on science or biology as a particularly valuable form of medicine.
This shouldn’t be surprising, considering the hospital is widely considered to be the least safe place to give birth. Its ten staff positions — including only one doctor, a general practitioner — are constantly cycling through new faces for short spans of time. There is no ultrasound machine, no operating room, no laboratory, no specialists. The next closest hospital, which is better equipped, is nearly 70 miles away.
However, trips to the hospital can be dangerous if they are even possible. Ambulances are not always available and rarely have medical equipment. Even an hour long drive could be deadly for someone who experiences complications partway through the journey. People who give birth must navigate this complicated matrix of risks in order to claim the best care possible, which generally includes a combination of kabila-provided care and local public health services.
Prior to the 1950s, there were no state-sponsored midwifery programs. For nearly all rural and semi-urban residents of Morocco, kabilas were the only available birth attendants. Throughout the 1950s and 1960s, there was an increased emphasis on public health and the legitimization of trained medical professionals, evidenced in part by the 1960 law that “conferred ultimate recognition and authority to the medical officer” over any other healers, including kabilas as well as trained midwives. This androcentric law was likely a misguided attempt to address the deep inequalities of healthcare between urban and rural areas.
The data doesn’t go back much farther than the 1990s, but it’s not difficult to imagine how the numbers above may have looked in the mid-20th century. The major attempt to address quality of obstetric care came in the form of midwifery programs centered in Rabat, the capital of Morocco. These programs shifted between one-, two-, and three-year programs. Some were targeted at nurses wanting to acquire a specialization in birthing and midwifery, others designed for moualidates, similar to American CPMs.
The hope was that these programs would produce a greater number of skilled birth attendants, as moualidates and nurse-midwives could complete their training much more quickly than physicians could — not to mention that gender norms and financial consideration generally steered male doctors away from the field of obstetrics. The programs had an explicit emphasis on benefits to rural communities and newly trained midwives were expected to relocate to areas without a strong medical presence. Unfortunately, it didn’t quite pan out like this. Cultural biases against educated and independent women limited enrollment; a nurse-midwife program out of the Ecole de Cadres in Rabat graduated less than 250 midwives in thirty years. Those who did graduate often stayed to look for work in Rabat or other cities, limiting the programs’ success even further.
Though they were not as robust as had been hoped, these programs did succeed in introducing medically trained midwives to many rural areas. The number of Moroccan midwives has grown significantly, though there is still unmet need for skilled birth attendants at over 30%.
The life of a rural midwife in Morocco is not easy. From the moment she arrives, her presence is marked by confusion and distrust. Young midwives often serve in their positions short-term and these communities have seen many come and go. As she begins to get established in her new home, a midwife will have to contend with the faith placed in the local kabilas. The midwife is newer and younger with little knowledge of the particular culture that now surrounds her. She likely has irregular hours, sometimes working twelve hour shifts for several days in a row and other times she’s without work for days on end. Once she graduates, the state provides no support for her in her new role. Some areas don’t have easy access to a hospital or any ambulance service available.
Expectations for midwives vary between settings, but the range of areas midwives can cover is wide. In addition to delivery, midwives may be expected to provide care for the family and child any time from conception to age five. They may be required to provide family planning services for young couples or counseling for young women on marriage and reproductive health. Confusion often develops about what care this new midwife is providing and those who are giving birth may not know who in their community is providing which services.
Reproductive health care is plagued by cultural issues as well. The illiteracy of many rural women presents challenges, as do taboos around discussing sex and sexuality.The midwives can experience what they feel to be a hostile community, unsafe or burdensome work conditions, and a desperate lack of support; they are understandably eager to move on. Women and others who receive midwifery care, however, often feel as if they get an inexperienced, out-of-touch, overworked, over-medicalized young women who may or may not be gone in a year.
From a statistical standpoint however, Morocco seems to be on the right track for maternal and newborn health care. In 2004, the country had approximately one midwife for every 289 births, not far off from the World Health Organization’s standard of 1:200 — and as noted earlier, midwifery has only grown as a profession since. In late 2013, the Ministry of Health launched a plan to expand coverage for and newborn healthcare. The mortality rates for mothers, infants, and children under-five have all dropped dramatically in the past three decades.
And Morocco’s mortality rates have continued to stay below the world average, right on track with other countries in North Africa and the Middle East.
These improving health indicators come as a double-edged sword: Morocco has become increasingly ineligible for international aid. The United States Agency for International Development, which historically has provided about half of international assistance for reproductive health, has redistributed its funding to focus on economic development. And while midwifery is widely viewed as a necessary and sustainable avenue for increased reproductive safety, some worry that relying on midwifery alone may re-entrench sexist expectations around the feminine/domestic sphere and further distance rural women from well-rounded healthcare and general cultural visibility.
The future for Moroccan midwifery and Moroccan reproductive care on the whole looks bright for many reasons. The real issues become clear once we grapple with the complex social and cultural landscape that midwives and rural women navigate. State-sponsored programs and international aid can close the gap to a certain extent, but without paying careful attention to the stories of those who lives are deeply affected by the realities of maternal care, a truly equitable healthcare system will never be achieved.
