A Doula in Somaliland
Edna Adan–founder of the Edna Adan Hospital.
The Airbus says Sky Bosnia on its hulking frame, the life jackets read Lufthansa, the surly crew is Russian. I’m on my way to Hargeisa, capital of Somaliland, to spend two weeks as a volunteer doula.
At Djibouti International Airport, a classic misnomer, I board a Rent-A-Wreck plane for the 45-minute trip to Hargeisa. The plane has four propellers, bald tires, and an interior in shocking disrepair. There is no cabin crew. Suddenly, an unkempt middle-aged man wearing a golf shirt, tired trousers, and flip-flops crawls through a hole in the forward fuselage, pulls in a ladder, seals the door, and heads to the cockpit. He is our pilot.
Arriving in Hargeisa, I can’t find the driver sent to meet me. Edna, founder of the hospital where I will work, has forgotten to get my visa so the immigration guy won’t let me in. In a classic developing-country airport scene, people are barking orders that are ignored. I spot the driver who calls Edna Adan, founder of the Edna Adan Hospital. She talks to an official, then tells me to leave my passport, she will sort it out and I will get it back tomorrow. (I am officially in Somalia with no American embassy, and I’m not under the auspices of an organization!)
Edna, stunning in long dress and elegant headdress, greets me warmly. I am shown to my room—a basic but perfectly adequate single with private bath in a dorm for visitors. I join the others for lunch. Edna sits at the head of the table. Along with her are Brigitte, a French physician; Karena, a nurse from New York; BreAnn, a nurse from Massachusetts; Dirk, a German OB-GYN; and Freida, an Austrian nurse-midwife.
The hospital is smaller than I expected. It is clean and equipped with two ultrasound machines and a decent delivery room. There is a lab, a pharmacy, and a small grocery store in the well-guarded compound. People mill about the compound, mostly family members, guards and workers. The women, in hijab or black chadors, stare at me as I explore. They don’t allow me to take their picture. Behind the hospital in the laundry, women compete to have their images snapped.
The history and politics of Somaliland are complex. One of several colonized regions of Somalia that sought independence in the 1960s, Somaliland declared itself free from British rule several decades ago and has been fighting for recognition as an independent nation since. To date, no country recognizes it as distinct from Somalia.
Somaliland is dry and dusty in the long absence of rain, and mostly flat with a pleasant climate at over 4,000 ft. above sea level. It is one of the poorest countries in the world. Canvas or wooden business stalls, goats in the deeply pocked roads, and inadequate houses, often shacks made of corrugated metal and rags, provide a visual for deep poverty. Life expectancy is under 50, women are usually married between ages 15 to 25 and have between 5 and 12 pregnancies, and FGM is universally practiced.
My first night at the hospital I have my initial doula experience. Mom is about 18; it is her first child. She labors so well I think she must be in the early stages of labor but she is on the delivery table and the midwife is doing things that suggest the baby is coming. Mom moans, clinging to my hand; I stroke her arm and whisper that she is strong and can do this; soon her baby will be born. A student nurse translates. The mother nods in acknowledgment. I support her head while she pushes; she grasps my arm. Then suddenly her son is born, his wet little head emerging, his body sliding quickly out. “Good job! Look at your little baby!” I tell Mom. “Thank you!” she says in English, squeezing my hand.
Next morning, I have my second birth. This is Mom’s third child and she chooses to stand through most of her labor. Hibo is the midwife and a more calming, competent soul I’ve never met. I encourage Mom, massage her hips and back, stroke her arm, talk to her in whispers. I sense that she is comforted by my voice and my touch. She leans on my shoulders, laying her head against me as if she were a child. I reassure her. She climbs onto the delivery table. Hibo gently examines her, tells her when to push and when to stop. She is holding on to me for dear life. Grandmother appears. Am I usurping her position? She tells Hibo, “It is beautiful the way she is helping my daughter.” A bigger reward I cannot imagine. Finally, a big, healthy boy is born. Mom thanks me profusely. I say, “I honor what you have done.” She kisses my hand. I kiss hers in return.
The C-section is just beginning when I enter the OR in my scrubs and mask. Mom is getting an epidural. When she is numb, Karena swabs her belly with antiseptic. She is draped. Dirk takes a scalpel and makes the first cut. Working quickly, he opens the uterus and pulls out a baby girl whose head appears normal despite hydrocephalus. There is a terrible hair lip and cleft palate. She is whisked off to be resuscitated. It has all happened in half an hour. By morning, the baby is dead.
I shadow Dirk on rounds in Maternity, then in the Outpatient Department where he is doing pre-natal checkups. He likes to instruct me as I watch the ultrasound screen. I’m invited to palpate mothers’ tummies, listening for the fetal heartbeat through a primitive wooden instrument.
I visit Hodu, a pretty six-month-old girl who has a recurrent infection on her head and face that causes loss of pigmentation and scabbing. No one knows why she has this recurring condition.
I help a mom who has delivered by Caesarian during the night because of severe hypertension. Her baby boy, dubbed Tiger, weighs slightly over two pounds at 28 weeks. He may survive if he can start nursing. For now, Mom pumps and feeds him through a syringe. I help her put flesh to flesh, positioning the baby between her breasts, a technique known as Kangaroo Care, which has saved premature babies in developing countries. Mom squeezes a few drops of milk and gets them into Tiger’s tiny mouth.
I have begun to see the dark side of this country and culture, where voiceless, disempowered women must have their husbands’ permission for a C-section or a necessary induction, or for that matter, for anything. I watch as husbands come, ignoring their laboring wives. Imperious and authoritarian, they swagger in and out self-importantly. Dirk has seen them deny their wife her life, even as she cries to be rescued: “Inshallah”—it is God’s will. He has seen babies die unnecessarily: “Inshallah.” A woman here often holds less value than a camel. Her function is to marry, bear many children, and obey her husband. Her body is not her own. She has no genitals; they have been amputated by the time she is ten.
Watching women give birth here is a testament to their strength and courage in the face of such a life. “She’s doing all the work and I’m doing all the sweating!” I tell Hibo as she delivers a woman’s ninth child. She makes no sound and then her baby pops out. It is whisked away to be cleaned up and Mom seems little interested; she lies patiently waiting for the placenta to be delivered. Then she gets off the delivery table as if nothing out of the ordinary has happened.
I teach first-year nursing students about emotional support during labor and delivery. First I check to see what is happening in Maternity and promise a young new mom that I will return after my class to help her. She squeezes my hand. When I come back, the nurse says, “The woman, she is asking for you. She says she want that lady!” The mom I promised to help has delivered her baby. I go to her, apologize, and exclaim over her new daughter. “Next time, Inshallah!” I say.
“Mashalla!” her mother says, smiling.
At the start of class I make small talk with the students before we get down to business. I write “Doula” on the board, telling them it is Greek for “woman helper.” I explain what we do and why and talk about the importance of emotional support for all patients. I tell them that in America we don’t always live close to our families so we need others to help us when we are in pain or afraid. I demonstrate what doulas say and do to make moms less afraid and more comfortable during labor. They seem rapt when I am speaking but when I ask questions or solicit their queries, they are silent. “Allah gave you a voice! Women’s voices are beautiful! You must not be afraid to use your voice!” I say, but it falls on deaf ears; they have been socialized into silence.
I ask again, “What have you learned today?” Silence. Twitters. I break the class into groups so they can practice supporting laboring mothers. They find role play hilarious so I try a single demonstration but this, too, seems literally too funny for words. I ask again, “What did you learn today?” One student suddenly says, “I learned that ‘doula’ means woman helper!” I’m so excited, I pretend to ululate; the others laugh and do the real thing. A few more students say something audible and I wave my hands in a hallelujah gesture. I conclude with a pep talk about the difference good nurses make and the need to honor as well as support the hard and amazing work women do having babies.
On my last day, I visit Hodu and Tiger and kiss Hibo good-bye. We have dinner at the hospital with Edna, who likes to be ceremonial when volunteers and staff leave. Dinner is a special treat: pizza ordered out and a cake. Edna makes a speech about what we have each contributed and thanks us for being part of her Hargeisa family. Brigitte and I are presented with T-shirts sporting a picture of the hospital.
Edna accompanies us to the airport. We promise to keep in touch. As we are taxiing in the Rent-A-Wreck plane, Brigitte and I smile bravely. We touch down safely in Djibouti and await our Sky Bosnia flight to Dubai. And so ends this African adventure of wild animals and willful men, voiceless women and vibrant girls, outrageous poverty, desert sands, market stalls, break-away nations, and tradition-bound babies. So much to understand; so many new friends; such amazing experiences. May there be other such gifts. Inshallah!
Elayne Clift, a writer, lecturer, women’s health educator and doula, traveled to Somaliland where she volunteered at the Edna Adan Hospital in 2011. She has worked and traveled in Asia, Africa and the Middle East. For more of her experience-based writing, visit www.elayneclift.com