The sages femmes at the front lines of Muso’s clinical care
The French term for midwife is “sage femme”, or “wise woman”. The Malian midwives at Muso’s government-run partner health clinics embody this title, working to ensure high-quality health care delivery at the clinic level that integrates with a strong community health system as part of Muso’s Proactive Care model. Read on to hear a story from a midwife at the Yirimadjo community health center, a busy public health clinic in Bamako, Muso’s peri-urban Malian site:
Madame Samaké is a Malian midwife with over twenty years of experience. After finishing the Malian equivalent of high school, Mme Samaké spent three additional years in school to become a midwife. Her first job out of school was as a public health surveyor: she was a member of the team that went house to house collecting survey data for Mali’s 1998 national Demographic Health Survey. Shortly thereafter, she was posted to the Community Health Center of Yirimadjo. Today, Yirimadjo is a bustling community on the inner outskirts of the capital city of Bamako and its health center serves a population of over 177,000. But when Mme Samaké arrived in 2000, the peri-urban community felt more like a poor village and the health center served fewer than 10,000 residents.
Mme Samaké inaugurated skilled, facility-based childbirth in Yirimadjo. Seventeen years later, she is a wealth of community and institutional memory. When she first started, Mme Samaké was assisted by two auxiliary midwives; today she leads a team of twelve licensed midwives. Mme Samaké recalls that during the initial years, she conducted births using petrol lamps. Once, when she ran out of petrol, she convinced a laboring woman to go out into the yard, where Mme Samaké guided the baby into the world by moonlight.
Asked if she ever feels any nostalgia for those early days she laughed and shook her head. “There is nothing to feel nostalgia for. Do you know, we didn’t even have gloves then. We had thick plastic cleaning gloves and in between births we washed them and hung them out to dry. We sterilized our instruments over a charcoal fire. In the first few years, I was always taking care of electricity thieves—you know, the bandits who try to steal electricity by tapping onto the grid. They would come in with terrible burns and I would clean their wounds and do their sutures. Oh, and there were snakes everywhere. Snakes all over the yard! Can you imagine?”
But it wasn’t just the difficult conditions she worked in that caused her grief; it was also the seriousness of the complications she regularly encountered and her helplessness to manage them. At that time, many women preferred to birth at home. After long and complicated labors in the community, women would present to the health center in dire straits: often with a serious hemorrhage or a ruptured uterus. For those women whose uteri had ruptured in labor, Mme Samaké could not always find a fetal heart rate. Sometimes she was unable to save the woman or the baby. Recalling these tragedies she says, “I didn’t have the medications, the equipment, the support to manage these cases. And we didn’t have an ambulance at that time. It was very difficult. I used to go home and cry. I would say to my husband, ‘I can’t go back, I can’t do this anymore, I don’t have the courage’. But he encouraged me to stay. Who would do the work if I left? So I stayed. And things got better.”
Standing over an open box of generously donated maternity supplies from Muso’s partner Direct Relief International to the Yirimadjo health center, Mme Samaké comments, “There is really no comparison. Today and those early years. We had none of these things. It is difficult to even talk about it as the same center.” When did things start to change? In 2008 Muso began to partner with the Yirimadjo health center, and in 2010 the community came together to renew the mandate for the health center. Things started to improve. Muso partnered with the community health advisory commission to build new infrastructure, train the health center staff, and remove user fees for the poorer members of the community, activities which continue to this day. When the Yirimadjo health center saw a dramatic increase in utilization over the past five to ten years, Muso partnered with the center to increase staffing levels, implement new systems, and facilitate access to much needed equipment and supplies. “Today people come to see us and they say, ‘This isn’t a community health center! This is a hospital!’ We have more support, we have more resources, we have partners who bring us new partners who send us boxes full of needed supplies.”
Today Mme Samaké is the Lead Midwife at one of Bamako’s busiest community health centers. Her team of twelve midwives assists between 250 and 400 births each month. They are trained to use echography to date early pregnancies and to identify possible complications later in pregnancy. They work in teams of two to support laboring women, and they have access to the equipment and medications they need to manage complications that fall within their scope of practice. When a situation surpasses their expertise, they have access to an ambulance and tertiary referral care. She is grateful to her team members, and to the partners who have supported the health center’s transformation over the past eighteen years.
Yirimadjo Community Health Center midwives with their Focal Point for Maternal and Reproductive Health. Photographed from left to right: Madame Mariam Samaké, Lead Midwife; Djouma Diawara, Midwife; Dr. Sanou Clemence, Focal Point for Maternal and Reproductive Health.