As someone who is an advocator of women's rights in health care, I have spent most of this year looking forward to seeing my first birth in the developing world. Alongside other students from Swansea University I travelled to Ghana at the beginning of June to experience health care in a different context. For many of us, the highlight of our trip was set to be seeing some form of surgery, but for me it was seeing a natural birth. As a maternal mortality obsessive, I wascurious as to how women are approached during labour.

According to travel guides like 'Lonely Planet', Ghana is Africa for beginners. It was thanks to this phrase that I believed I would go into a birthing situation that is not too different to what we experience in the UK. Two weeks into my trip I was to be proved wrong. On the morning of June 27th, I walked into the labour and delivery ward in Ho Municipal Hospital to find that a woman was groaning in pain. The midwives did not seem particularly moved by her sounds, so I chose to go and sit with her and give her some comfort. Her name was Marchita, she was a mother to one other baby, and had suffered from an ectopic pregnancy late last year.

As I sat with Marchita, midwives slowly began to fill the room. She was catheterised and the bag was overflowing; when I pointed this out to the midwives, they did not seem to care. One proceded to perform a vaginal examination on her without her permission. This naturally made me gasp, as the midwives at home always ask. After deducing that Marchita was 8cm, the midwife asked her to move onto the floor while she changed her sheet. As she was ready to climb back on the bed, she began to contract. I moved to help her and the midwife barked 'NO she is lazy' at me. As she struggled to move from the floor, she was sharply slapped. Again, this was another gasp moment for me, but I did not feel there was much I could do.

A few minutes later, Marchita started to push. She began whispering for me to help her, and was fighting the urge to shout out. I went to grab the midwives, who pointedly ignored my request to attend to the labouring woman who was ready to push. After some badgering on my part, one decided to follow. Once again she proceded to perform a vaginal examination without permission, this time as Marchita was contracting and in pain. As she shouted out, the midwife slapped her again. I later heard a rumour that women in Ghana are encouraged not to shout during labour, as doing so means that the baby is not their husband's. 

After finding that Marchita was fully dilated, the midwives walked her across to the delivery suite. As she walked she carried an IV on her head, and her catheter bag in her hand. The catheter bag was leaking urine everywhere; when I pointed this out to the midwife, she ignored me. We helped Marchita to the bed, and I continued to hold her hand. The midwife once again went to perform a vaginal examination, but this time chose to stretch her cervix and showed me the baby's head. Marchita was made to adopt a position where she rested on her lower back, held her legs, and pushed. After 10 minutes, the midwife chose to break her waters, using a pair of scissors from the side. 

After half an hour, more midwives filled the room. Marchita had several good attempts at pushing, but each time the baby's head retreated and she collapsed in exhaustion. Her failure to deliver and attempts to rest were met with shouting, mocking, and more slapping. Watching the process was excruciating; I am not qualified to intervene with a birth, but I desperately wanted to help. By this point, I was no longer allowed to hold her hand, she was very much alone. The midwives eventually chose to take their forceful tactics up a notch. While one straddled her from above and pushed down on her abdomen, another stretched the cervix, while one slapped her legs into position, and another mocked her cries.

After a short while, the midwives disipated while muttering about Marchita pushing for 45 minutes. One returned with a razor, and without a word she began to shave her pubic hair. Marchita lay there exhausted, and while myself and my friends knew they were prepping her for a c-section, she clearly had no idea. Once again, the midwives refilled the room. Their aggressive tactics continued, and after five minutes Marchita produced a beauitful baby girl. While some of my friends cooed over her, I stayed to hold Marchita's hand as the placenta was delivered. She was injected (without her permission) and the placenta was delivered moments later.

Initially after watching Marchita give birth, I was angry. Undoubtedly, being in the throes of labour is one of the most vulnerable points of any woman's life. In the UK our midwives lovingly encourage a variety of birthing positions, they console us, gently help us to breathe, and ask our permission before anything invasive. Here, it felt like I had watched someone be abused. No matter how many times I tried to frame what I saw in the context of existing cultural differences, I still felt disturbed. Maybe if Marchita had been consoled and allowed to shout, she would have progressed easier. 

The maternal mortality rate in Ghana currently stands at 350/100,000, or a 1:66 lifetime chance. While this has fallen significantly since 2006 (by 100), it is still astonishingly high. While at Ho Municipal Hospital, I did feel that I could identify several key areas that needed to be addressed. First of all, the levels of hygiene were unacceptable. Dripping catheter bags and scissors pulled from the side are a recipe for infectious disaster. In addition to this, I noticed no routine monitoring other than the vaginal examinations. Although the unit lacked a doppler, there were other means available of listening to both baby and mum's blood pressure. Finally, I am a firm believer that a little compassion goes a long way on a maternity unit. 

In order to be balanced, I did manage to justify some of the midwives' actions. With a lack of monitoring equipment, they most likely did not have time for the niceities that surround informing a woman that a c-section may be her only option. It appeared that they were in a state of panic over her not delivering by 45 minutes, and the lack of equipment heightened their fears that something would happen. In addition to this, going straight in for a managed third stage reduces the risk of post partum haemorrhage, which is one of the highest causes of maternal mortality in the developing world.

Overall, the experience of watching a birth in the developing world opened my eyes to just how unequal maternal care is worldwide. If Ghana is 'Africa for beginners', and therefore relatively developed  compared with the rest of the continent, I dread to think what the rest of Africa must be like in terms of birthing experiences. I can only hope that as UNICEF and the World Health Organization continue to meet millenium development goal 5 that more women obtain the safe birthing experiences they so desperately need and deserve.