Doula in Training experience in West Africa.

Esther Wilsi attended the CAPPA Labour Doula training program in November, 2018 with our Full Circle Doula and Instructor, Sonya Duffee. She shares her personal experience of travelling to West Africa to volunteer at the local hospital maternity ward. 

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 Google image: The maternity hospital in Sassandra, West Africa

​​My husband is working in Sassandra on the Ivory Coast of West Africa.          
I decided to go visit him. I, fortunately took the CAPPA Labour Doula course with Sonya prior to leaving. Once I arrived in Sassandra, I went to the Hospital General De Sassandra (HGS) and asked for one month work experience as a doula in training. 

Doulas roles are not known in Ivory Coast, at least not in Sassandra.
I was granted permission to help in the delivery room and to follow the midwives directions.

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Esther ( far right) at Doula Training

It was hard for the midwives to grasp the idea of the role of a doula. “So you just want to spend time with the mother to be, give her relaxing massage, talk to her and hold her hands? “

​“Yes,” I would reply. They will laugh and say, “wait and see, these women are not grateful at all, they will abuse you”.

Let, first of all introduce you to the delivery room.

It’s a big room divided in 3 5 feet section. There is 2 bathrooms (toilet). One is to be used by the mother to be or pregnant women and the other one has a sink where there is a basin with a bleach solution, a big garbage bin with a bleach solution where the basins used for birthing are disinfected; there is a smaller garbage bin where all placentas are put before being buried by the hospital staff.

There is only one person allowed in the birthing room, the mother to be. No other family members is allowed in, and men are strictly forbidden. 
There is only one position allowed during labour, on the left side of the body facing a white tiled wall. This position is to be kept regardless of the length of the labour.

After giving birth, the mother is kept in the room for 15 to 20 minutes in order to verify that there is not unusual bleeding; if not, she is cleaned with wet rags, a traditional pads is installed, she dresses up and is moved to the pre / after birth room.

​The pre / after room is a bigger room with 10 beds, 2 big doors and 2 windows. It gets quiet hot in that room by lack of fan.
Upon arrival to the delivery room, all pregnant women are given IV, regardless of how dilated they are or not. 

The hospital area outside. Image Google 

On busy days, if they are not enough dilated, they are sent back in the pre /after birth room until the midwife decide that they are dilated enough to be moved to the delivery room.
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There are 2 birthing options given: a vaginal delivery or C-Section. Most women choose the vaginal option. 

​Only one woman asked for a C section when she could no longer stand the pain. She made us swear to not tell to her family that it was her choice, but instead that it was the doctor recommendation. In this culture, a woman is considered strong only when she can give birth naturally through her vagina. 

My first impression was the lack of materials.
Many days, there were no gloves available in the delivery room or needle with thread to suture a woman who had an episiotomy. 

Upon arrival, the midwife gives a prescription for a birth kit. The mother to be family go to the hospital pharmacy and get a free birth kit. The birth kit has 10 pairs of gloves, needle and thread, umbilical cord clamp, cotton gauge… 10 pairs of gloves are quickly used; between doing the HVI test, installing IV, taking blood sample, checking for dilation…The family need to purchase more gloves and cotton gauge. In general, there were 2 midwives, 2 LPN, 1 hygienist and 2 trainees (cleaning the room and materials used) on duty at time. The whole hospital had one gynaecologist and another doctor who was training to become one. 

The gynaecologist performs the C-Section, cleaning of the uterus (after and abortion made outside of the hospital or miscarriage) and sees pregnant women or women who want to become pregnant.
After a week observing and not interfering with their practice, I was treated less like a foreigner. They still kept calling me “The Canadian girl” and no one knew my name.

When they started looking at me differently, I dared asking for some favours. Some got given to me with a “the Canadian girl you do what you want” and some other time with “we don’t do this here”. Regardless of the answer, I will thank the midwife.
Not only did they no longer interfered when I was by a mother side by making unpleasant comments, but they would even sometimes call me when a pregnant woman was hard to deal with, mostly because she was in great amount of pain and didn’t know how to cope with it.
I was able to attend to 14 pregnant women and observe the change in the way they were coping with pain when they had me by their side.
Some women came in almost fully dilated, at that moment, it became almost impossible for them to grasp anything I was telling them.

There is a huge lack of information.
Most women had no understanding of what a contraction was and the contraction phases. Most women didn’t know how to push in order to expel the fetus. Women would come in and complain of stomach ache and low back pain and be sure that the pain would never end and that the baby would kill them. I noticed it even in mothers who gave birth before.

​Typical procedures, I noticed:

Episiotomies, if the pushing phase went longer than ten minutes, an episiotomy was performed. Once the baby out, the umbilical cord is cut right away and the baby is taken away and cleaned.

Fundal Massage, the midwife massages the uterus and the placenta is either expelled or pulled out.

Baby removed from mother, After birth the baby is wrapped up and placed in a heated incubator. No one informs the mother the sex of their baby or if baby is healthy or not. No one lets the family members know if all went well, while they are waiting outside.

​I made sure to congratulate the mother on her new born, tell her about the baby sex and the weight. I would go out of the room and let the family members know that all went well and announce the baby sex and weight to them. After the mother was moved to the pre / post natal room, I would assist with breastfeeding.

Here are few examples or changes that took place when I was there.

AHOE 
3rd pregnancy, 2nd one, delivered at 8 months passed away shortly after birth

She came in just for a check-up, she was in her 8th months along. After being checked the midwife, they decided to keep her, she was dilated. The amniotic pouch could be seen at the entrance of the vagina. The mother was really scared; scared that she would lose this one too.
She kept telling me how her last born died because she was not full term and that the same was happening with this pregnancy also. I stayed by her side and reassured her that at 8 months the fetus can live on its own. At one point, I wanted to leave for a minute to check on a pregnant lady who just came to the next cubicle; she held my arms and asked me not to leave her alone. I stayed. 
She gave birth to a beautiful baby girl. The pushing phase was quick, she didn’t even made a sound. I was by her side during the whole delivery and she did squeeze my hand pretty well. As soon as her daughter came out and the umbilical cord cut, I asked the midwife if I could put the baby on the mother breast. I was allowed to do so. The placenta came out pretty quick. When I removed her from her mum breast, she started crying, but by then I was not allowed to put her back on the mother breast.

KOUAME 
3rd pregnancy

It was great, I had more time to teach her breathing technique and do some hypnosis on her, mostly by telling her to focus on an object or just to look at me when the pain became unbearable. I taught her also how to push effectively. During the active labour,  I could see her panicking, I would then look only at her and ask her to look at me, in the eyes, even though the culture here teaches us that it is rude to do so. She would and I would tell her how strong she was and that she can do it. She would then go back to her breathing. When the time came to push, baby was born in two pushes and without an episiotomy.

KABOURE 
1st pregnancy

A young girl.. While coaching her, she kept looking at me, which meant turning on her back . All women were instructed to stay on their left side when in labour. The midwives were not happy about her not following this rule. I finally found out that she was deaf and good at lips reading. It was challenging, between having her stay on her left side and trying to pass the message through.
In order to make the delivery happen faster, the midwife placed a pill in her vagina. She was a strong young girl. In no time, quietly she pushed and the baby was out.


MARIAM

This one was the most challenging birth I have been part of.
A young married girl, 17 years old. It was her first pregnancy. She was circumcised, so the opening to her vagina was reduced. She couldn’t cope with any amount of pain. At each contraction, she would start crying, having big tears roll down her cheeks. I could not move an inch or leave her hand. She would just move into panic. It was really difficult. At times, I felt that she didn't understood French. I felt like she could not hear anything I was saying. I asked the midwife if the mother or auntie could be allowed in the room to translate to her what I was saying. Surprised, they allowed both.
After the visit, she was a bit more calm. She would move in the position she felt comfortable, and the midwife would not be happy. I would then ask her to be on her left side so I could massage her back; she would comply, but as soon as I would stop she would turn to another position. 
During the pushing phase, she pushed hard and the baby head was at the entrance of her vagina. She refused to push because it hurt anytime she would. Then the midwife decided to perform an episiotomy.
She started kicking and screaming, asking the midwife not to cut her and that she could push. She would try again and again, but nothing would happen. Her mother was allowed again in the room, but instead of encouraging her daughter, she started yelling at her, so she was asked to leave. It was challenging, because everyone else was telling her how her baby was suffocating and would die because of her fault. 
I would turn her head to me, look at her and asked her if she can push more. She started getting tired. By talking to her and explaining the reason of having an episiotomy, it was performed (according to the nurse), she calmed down a bit and was cut. She pushed hard and the baby head moved down to the vagina. The pain, “Burning sensation” made her jump and she almost sat on the baby head, the midwife reacted quickly.
Soon the baby was out and I saw her relieved from the pain. 
When asked her mother how they are planning to call the new born, she said, “Do not cut me”, making fun of her daughter. 
 
Most women would come to the hospital complaining of stomach ache, not understanding that they were having contractions.
Most women did not believe me when I told them that as soon as the baby is out, the contraction will stop. 
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Most women were afraid to even hold their baby once s-he was born. 
One mother asked me to remove the baby from her breast; she was feeling too much pain while being sawn after an episiotomy.


MY OBSERVATION
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When spending at least 2 hours coaching the mother to be:

• The only time episiotomies were performed were either the mother couldn’t push properly (lot of women were ashamed of having stool come out) or the midwife wasn’t patient.
• The delivery time was less: after couple of pushes the baby was delivered
• It seems easier for them to cope with the pain
• She still had enough energy to push
• She was less tired after the delivery

​A doula really does impact the delivery time and process.
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Doula, Esther Wilsi with a new baby.

Recently, my husband, who is still on Ivory Coast, told me that the neighbour who owes a store said I was liked by everyone. That not matter what was going on, I  made the women feel good and forget about all their worries. I am grateful I was able to make a small impact in the women of Sassandra who delivered in that hospital while I was there for a month. I would love to go back and spend a month or two volunteering in the hospital again.

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