Midwifery in Zanzibar, Tanzania
Zanzibar is an island archipelago of two main islands, Unguja and Pemba, semiautonomous of Tanzania in East Africa (below). Zanzibar’s culture is influenced by its position in the Indian Ocean and its historical position as a trade port. Zanzibar’s population of 1.3 million is diverse, including ethnic groups such as Bantu, Arab, Persian, and Indian. Stone Town is the cosmopolitan and tourist-heavy section of the capital of Zanzibar City, and is a World Heritage Site. The population of Zanzibar is 99% Muslim, in contrast to more mixed religious identities in mainland Tanzania.
Over the past five centuries, a series of empires have colonized Zanzibar, including the Portuguese (1504), Omanis (1698), and British (1890). Zanzibar gained independence in 1963 and a month later overthrew the government creating a democracy that would be dominated by one political party for the next fifty years. Four months after the revolution, Zanzibar joined mainland Tanganyika, forming Tanzania in order to suppress socialist movements in Zanzibar. Zanzibar and Tanzania differ in terms of colonial, political, religious, ethnic, and cultural history. All these factors play into the healthcare system in Zanzibar, particularly for maternal care and midwifery.
I stayed in Zanzibar for four months last spring, and my homestay sister Zuleikha* from Stone Town recently gave birth to her second child, a daughter named Maryam* on November 9, 2018. She told me over Whatsapp:
“The labour pain was terrible. It hurt so much. I had a normal delivery but I got two stitches … because when baby was coming out she tore a membrane. But at least it took just a week and it got better. Now I am doing quite well now. I was like, ‘I want six kids…’ but now I’m kinda rethinking😂😂😂😂.”
Zuleikha is from a wealthy family in urban Stone Town, and has access to the best hospital in the islands, Mnazi Mmoja (above). She described the birth of her first son Ali* and the state of the maternal care system in general:
“At the hospitals, they usually opt for normal delivery, but if things get complicated that’s only when they go for C-section. Like as for my case I was supposed to deliver normally, but at the end I had a placental abruption so it was an emergency and I had to undergo C-section. I didn’t receive any pain medication, just antibiotics, and that was a government hospital. On one bed two patients are kept because of insufficient space regardless [if] you have been operated on or normal.”
International organizations often stress maternal and infant mortality as important “development indicators,” but in Zanzibar, these factors are especially important due to cultural and religious values that center on family and children. Mothers** are highly valued in the Qur’an and are preferred three times more than fathers by the prophet Muhammad. There is no sin or punishment attached to childbirth as there is in the Judeo-Christian tradition, and “although in Islam there are many ways to open the gates of Paradise, the vehicle especially chosen for the woman is that of pregnancy, childbirth, nursing, and conscientious rearing of her children.”
The implications of these religious beliefs can be seen in 3.11% population growth rate. According to the 2010 Tanzania Demographic and Health Survey, 90% of married women who don’t yet have children want to have a baby, and two-thirds of married women want more. Even 43% of women with five children report wanting another child. This reflects the mean ideal number of five children, and the actual total fertility rate of 5.1 children in Zanzibar.
Some progress has been made to reduce the maternal and infant mortality rates in Tanzania, according to UNICEF. Maternal mortality rate (MMR) was 556 per 100,000 live births in 2015, and infant mortality was 43 per 1,000. Both these rates have dropped in the past two decades, however MMR reached its lowest point of 232 per 100,000 in 2012, and is rising again. The number of women who give birth at facilities with skilled assistants has increased as well, improving by about 20% now reaching over 60%. However, the mortality rate for children under five is 88 per 1,000 live births.
About half (47%) of mothers give birth in an Emergency Obstetric Neonatal Care (EmONC) health facility, although the average varies greatly among areas of differing population density and socioeconomic class. About half of health facilities in Zanzibar however do not qualify as EmONC (see map above), and rates for birth in lower-tech facilities in general could be as high as 77%. Overall there is better maternal care in the Urban District of Unguja. Mothers in the urban district are also more likely to be able to afford and access healthcare as it is the wealthiest region in Zanzibar, with the highest density of hospital facilities. The C-Section rate is only 4.4%, which is below the WHO recommendation of 10–15%, and this also varies by location. This is likely due to lack of OB/GYN staffing trained to perform this kind of surgery.
All of the figures given vary based on race and class as well, and the urban/rural divide in Zanzibar can be seen as a proxy for race and class, as wealthier Arab and Indian populations tend to live in urban centers and African populations make up the majority in the rural area. Infections such as HIV and malaria are also common in Tanzania, and instances are higher for mothers living in poverty. Poverty has been shown to be a key determinant in birth outcomes worldwide, and with 30.4% of Zanzibar’s population in poverty, 10.8% in extreme poverty, and intermittent power shortages in the islands, birthing mothers and their children can be affected adversely (below).
Birth in the over-crowded, open-air health facilities in Zanzibar can be a trying experience, as Zuleikha alluded to earlier. Due to pervasive understaffing in hospitals, care can be brusque, and mistreatment by hospital staff is common in some areas. Mistreatment tends to affect women more than men as “most women described their facility-based birth as satisfactory despite evidence of discrimination, verbal and physical abuse, abandonment when in need of care, extortion or unofficial fees, and detention in facilities for inability to pay.” According to this study, “pregnant women might act submissive for fear of social sanctions.” This behavior is also in keeping with the Muslim virtue of al-haya, or modesty and shyness, which might keep pregnant women from speaking up against abuse.
Hospitals also have a dearth of nurse-midwife staff, which could help relieve tension in maternity wards. Tanzania has the ninth lowest midwifery rate in a UNFPA list of 47 developing countries, at only about 2 midwives per 1,000 births, and an estimated 2,720 midwives total in 2015. It is estimated that Tanzania would need triple to quadruple its midwifery workforce to serve the number of birthing mothers in the country. Midwifery education is lacking in Tanzania, and most programs, if not all, are primarily tailored to nurse-midwifery. Nurse midwives must be formally trained, and most midwives practice in a hospital setting.
Public hospital births are covered by government insurance, although any additional medications must be paid for out of pocket. A very low number of births are attended by a doctor or OB/GYN (below), so most hospital births are attended by nurse-midwives, which are almost exclusively women. This is due both to lack of staffing in hospitals as well as the fact that many Muslim mothers would be uncomfortable being delivered by a man.
About half of Zanzibari mothers give birth at home and likely have help from traditional birth attendants (TBA). These rates are even higher for rural mothers who might be unlikely or unable to transfer to the hospital for their birth, leaving the home birth rate fairly high (above). Information about TBAs, or wakunga wa jadi, in Zanzibar is more difficult to find, but data from Tanzania as a whole can offer us some insight. In the 1980s and 90s the Tanzanian government began outreach programs to train TBAs medically.
This aided the medicalization of birth, and
“development efforts to ‘transfer knowledge’ to those who assist women birthing at home have a distinct agenda. National and international support for lay midwifery seeks to stabilize a biomedical vision of the body of the pregnant woman, the fetus, and those things that threaten them during home births.”
Today, most TBAs have a small medical kit of gloves, a razor blade, and thread for stitching. Training and medical knowledge are also quite variable among TBAs, some of whom received little formal education. Women who attend births but have not been trained by the government are unlikely to consider themselves TBAs, pointing to a shift in what is understood as “medical” care.
Zanzibar’s history of midwifery is complicated by its colonial history. In her memoir, Salme Said, an Arabian princess who lived in Zanzibar from 1840 to the 1860s, offers us a rare first person account of midwifery during the Omani colonial period.
“No [Muslim] will suffer the assistance of a medical man in such cases; midwives alone are allowed and admitted, and they are ignorance itself … The majority of them come from [India], and are much preferred to native women; I do not know for what reason, for a midwife from [India] knows as little or less of her business than those from Arabia or from the [Swahili] country. In fact, mother as well as child may thank God alone, and their constitution, if they survive at all or keep well afterwards, for they owe no thanks to their stupid and foolish nurses.”
This perspective offers us a sharp account of the racist and classist ideas held by the colonial royalty at the time. Said also wrote this account in Germany in the 1880s, so it reflects European stereotypes that have long-lasting effects on race relations in Zanzibar today.
These tensions only increased under British rule, starting in 1890. According to Maoulidi, “a distinctive feature of British administration that polarized the local population was the concept of a natural hierarchy of races,” meaning that the British imported racism that had “lasting and devastating effects on pro-independence policies as well as the revolution of 1964 and beyond.” This is particularly ironic because the British had outlawed slavery in the islands in 1897.
Racism extended into the medical field in Zanzibar under British rule, and hospitals were segregated well into the 1950s: “race and class determined the provision of health care. The best care was provided for European officers, followed by rich Indians and Arabs, with poor Indians, Africans and Arabs receiving the worst care.” The racism in the healthcare system extended into midwifery as well, as “in 1936, … only Africans were trained as midwives for rural services, while in Zanzibar Town, Arab women formed the majority of midwives who took care of Africans.”
In 1918, the British colonial government set up the Zanzibar Maternity Association (ZMA) through funding by Indian philanthropists. The European ZMA midwives trained midwives in Western medical practice and complicated birth. At the organization’s peak in 1938, 75% of births in Zanzibar Town were attended by a ZMA midwife.
This success was in large part due to the fact that the organization “did not insist on hospital care for expectant mothers and also aimed to provide culturally relevant services for the communities of Zanzibar Town via home visits.” Adding to this account, “most African women preferred the services of the [ZMA] at their own houses. Home visits brought medical services to purdah women who were unable to leave their houses.” In 1940, a Maternity Home was established in Zanzibar which trained a small number of midwives.
This period of colonial history marks a transition from traditional midwifery toward formally trained nurse-midwifery, though not necessarily in a clinic or hospital setting. The move toward skilled birth attendance lowered mortality rates, but it was not entirely humanitarian in nature. A study of British rule in Ghana in the same period states,
“the female body offered the British colonial government both private and public sites where power was enacted and enforced by their control of biomedicine. … despite the appearance of the government‘s goodwill in decreasing the maternal and infant death rates, and in saving mothers and children‘s lives, their effort cannot be seen merely as humanitarian, rather it was a well-calculated political scheme.”
The imposition of Western medicine not only replaced existing TBAs but also targeted birthing women as the subjects of this insurgence.
After the 1950s, and especially after Zanzibar joined Tanganyika in 1964, birth became more medicalized, and women were encouraged to go to clinics to give birth to reduce mortality rates and meet international health standards. Most contemporary discourse of midwifery in Zanzibar centers around nurse-midwives, who have completed a certificate in nursing and midwifery.
The Nurse and Midwife Acts passed in 1986 and 2014 narrowly define a midwife as someone who has “completed an approved midwifery programme … and has acquired the qualification requisite for registration and licensing to practice midwifery.” Clearly, “midwifery” in the eyes of the government is confined to nurse-midwives and does not extend to TBAs who attend half the births in the country at home. This disparity reflects a trend in the Zanzibar government, in which laws and regulations look good on paper, but are not always carried out in practice.
There are also a variety of NGOs involved with midwifery and improving maternal health today. NGOs such as Gap Medics allow foreign, or wazungu, students to shadow midwives for brief 1–12 week stays in countries around the world, including Tanzania. These programs are aimed toward students on their gap year between high school and college, but volunteers as young as 16 are eligible for the midwifery shadow program. The Gap Medics program no longer offers trips to Tanzania, but their program in the Dominican Republic runs at $1,400/week, with most students choosing to stay only two weeks.
In addition to voluntourism trips, several long-standing midwifery NGOs exist more permanently on the islands, with varying success and acceptance. These projects provide lifesaving medical services for mothers in Zanzibar and help train Zanzibari midwives, however their social impact can vary greatly. One missionary group provides midwifery kits to TBAs, and the husband and wife team from the UK state their mission as: “Caring for mothers and babies while sharing the Light of God.” This mission is likely pretty challenging to carry out in a Muslim majority country. Ironically, this group recently moved from Zanzibar to mainland Tanzania, perhaps to find a more complementary religious scene.
NGO groups have an important role in making birth safer in Zanzibar, however they would benefit from reading into the colonial history surveyed above, and working more directly with TBAs to form a cohesive and culturally appropriate birth model.
*Name changed for privacy
**Terms such as “mother,” “women,” and “female” (rather than more inclusive language) reflect the importance of these gender categories culturally and religiously in Zanzibar.
