Pregnant women and new mothers, at my clinic for the ante- and post-natal vaccine program, listen attentively to a public health officer explaining waterborne disease prevention.

Motherhood: is there a state of being so near-universally revered, so infused with a sense of power? True, it involves a lot of blood, screaming, indignity, and poo, but it’s kind of a neat magic trick to be able to transform two indistinct blobs of protein into a new person. (I mean, it doesn’t require any particular talent, it’s sort of automatic, but still.) By choice, it’s not something I anticipate being a part of my career-and-travel-centric life plan, but I recognize that for most people it is. My more fecund friends are already reaching – or have reached – the stage of life wherein it’s a practicality to be considered, and to them I say this: I will dote on your spawn. I am happy to be Cool Aunt Megan, who will take them to the zoo and teach them to count in Swahili and let them eat ice cream before bed, under the express condition that I can dump them back on you at the end of the day. (Best of all worlds, right?)

In this respect, my friends and coworkers view me as an entertaining oddity. Women who are educated and have jobs tend to delay marriage and child rearing, at least for a little while. A handful of them are around my age, and two of them are also unmarried. Both want children, and one while one says she’ll be happy to stop at three, the other confessed she wants at least five. At my clinic, everyone is either actively pregnant, or old enough that their children are grown and no longer need them. To hear me talk about my personal ambivalence towards marriage (if the right guy comes along, certainly, but not for its own sake) and disinclination towards being a mom (I’m going to be in school for another DECADE, who needs that expense?) must be as curious as watching me turn up my nose at someone offering me an ndoo full of cash. As the Coast shifts away from its bucolic, village-driven social structure towards one of commutes and semi-urbanization, motherhood is no longer a woman’s sole calling; however, it certainly remains her highest one.

For virtually all Kenyan woman for whom it’s biologically possible, motherhood is something of an inevitability. Region, tribe, education, and distribution of wealth account for variations in the when and how many, but overall, it’s rare to find a woman who doesn’t expect to have a large family. You cannot discuss the female experience in Kenya without paying due to these expectations. The raison d’être of this entry is to discuss what it means, how it works, and how I fit into the picture in my little corner of Kenya. (Per always, sweeping generalizations will do us little good.) Of course, motherhood doesn’t end with birth, but to limit the scope of this entry, I’m focusing on the sticky bits.

Several studies put the overall average age of sexual debut in Kenya as between 12 and 13. From my experiences in the educational system, I find this unsurprising; an emphasis on fear-based abstinence-only education and general sense of shame around discussing the topic of realistic sexual expression results (with disheartening frequency) in girls as young as fourth grade having to drop out due to pregnancy. According to the headmaster at one of the schools where I work, only about 1 in 5 students in the district will score well enough on the national exams to continue school after eighth grade, and most of those are boys. “For all the girls who remain,” he inquired matter-of-factly, “what are they to do? There are not enough jobs as house girls [domestic servants] and selling vegetables to go around. They may as well be married and do their duties.” It keeps them safe from becoming prostitutes, he argues. (I’ve blogged before about early marriage, so click here.) Nonetheless, motherhood often comes early.

In cities like Nairobi and Mombasa, hospital births are increasingly common. But in more rural areas, even those like my village that are within walking distance of a “town” (in the sense that you can find it on some maps), the overwhelming majority of women give birth at home, under the care of traditional birth attendants, or TBAs, who have served as midwives among the Swahili and Mijikenda communities for countless generations.

Which is … problematic.

Let’s start here: there’s no right or wrong way to become a mother. Too often, the culture wars surrounding childbirth (especially in America) are content to shame women instead of empower them – do you want a waterbirth? Natural birth? Birdsongs playing on your iPod in the delivery room? YOU’RE A DIRTY HIPPIE. Want an epidural? Feel comforted by the bleep-bloop of hospital machines? Considering a c-section? YOU’RE BASICALLY MURDERING YOUR BABY WITH YOUR OVER-MEDICALIZATION OF A NATURAL PROCESS. Neither of you deserve a baby! How dare you make different choices than someone else made!

And God help us all if you have an opinion about breastfeeding.

Nonetheless, I can’t deny that I personally have been influenced by a number of sources – reviews of medical literature, talking to American friends about their childbearing experiences, reading blogs by doula-types – into feeling that American-style childbirth *is* too often over-medicalized. Consider for example that the rate of c-sections in the US (which is, we forget, major abdominal surgery) is over 30%, more than twice the World Health Organization findings that they’re only recommended in 15% of births. Ultimately, we’ve made a multi-million dollar business out of convincing women they’re weaker, dumber, and more easily frightened than they really are.

But that’s America. This is Kenya. For many women, the risks are very, very different. Birth is indeed a natural process, and Kenyan women are stronger than most other women I’ve met, but we must be as careful how we view it in light of available medical assistance. Health facilities aren’t perfect; many are under-funded and understaffed. Others charge unreasonable fees (officially or not) or have less-than-stellar practices regarding infection prevention. But overall, they represent a better option. It can be a fine line to walk, between unnecessary medicalization and necessary aid.

When I go to outreaches or talk with women’s groups, part of my job is to convince them to give birth in a hospital. Bring on the doctors and the drugs! The more, the better! I feel vaguely traitorous in saying this, but many women shouldn’t be giving birth at home, alone or attended by a traditional midwife. American midwives and doulas have to undergo at least SOME – and often a great deal of – intensive training before they can hang out their shingle. TBAs learn in the traditional apprenticing way, following an older woman on her rounds until they can run the show themselves. They learn a LOT about women, culture, bodies, and spirituality. But as often as not, there are dangerous gaps in their knowledge. Commonly, they have relatively little information on how to prevent or stop internal hemorrhage, are limited in their ability to assess maternal risk, rarely mention testing for HIV or STIs, and are fuzzy on up-to-date nutritional guidelines for infants and lactating women. (If I had a dollar for every time I heard someone say you can stop a crying newborn by giving it sugary black tea, or make a woman’s milk come in by drinking intoxicating palm wine … oi.)

Furthermore, in Kenya, the situation can turn dire very quickly. Many districts have only one ambulance (if they have one at all), available by special order and at great cost. The maternal mortality ratio in Kenya is 441 in 100,000. In the United States, it’s 13 out of 100,000; still not great, but certainly better. There are inevitably differences among regions and socio-economic groups, owing to the availability and affordability of healthcare, but it remains that overall, if you’re giving birth in America, it’s a lot less likely to kill you.

I know a woman, smart and savvy, who decided to rely on her TBA for all her antenatal care. She’s of relatively advanced age, which should have set off alarm bells, but this was her seventh child and she felt she could handle it. Ordinarily, she could: as Abed in Community tells us, when it comes to childbirth, “The bus pretty much drives itself.” But her TBA had no way of knowing a) that she was pregnant with twins and b) they were positioned incorrectly. She spent three days in labor before her husband put his foot down and called for help, from which point it took them about 40 minutes on the back of a motorcycle and three hours on a public bus to get to a hospital that could help her. An emergency c-section yielded two stillbirths, and a woman who spent months in recovery before she could leave her home.

This is the way of too many births: they go fine, until they don’t. I have a hundred stories like this, each a little more heart-wrenching than the last.

I’ve already written about family planning/birth control, and the accessibility issues thererin. Proper access to birth control and the ability to plan one’s family is a MAJOR step in protecting maternal and child health (unintended pregnancy accounts for one-fifth of maternal deaths every year.) But even outside of that, there is hope. I am lucky to work in a facility that is, generally, respectful of mothers’ experiences and doesn’t automatically view TBAs as The Enemy. I personally work to educate people about their life options, both from the grassroots level of empowering students to make smart decisions to planning and delivering lectures at our deep-rural outreach clinics. I spend more time out in the community than any of the other people in my clinic, which gives me unparalleled access to rural villages. During the course of other work, I talk to pregnant women about “protecting their blessings” (getting proper pre-natal care) and get the contact information for their preferred local TBAs.

I can pass this information along to the antenatal care specialist in our clinic, who runs training sessions for interested TBAs. These midwives are invited four times a year to learn about basic topics like assessing maternal health (checking for the pulse, figuring out how the baby is positioned) along with salient regional issues (prevention of mother-to-child HIV transmission, the need to sleep under a mosquito net while pregnant/nursing to prevent particularly deadly forms of malaria.) I’ve only been able to attend one of these sessions personally – I’m more a “fixer” for them than an actual facilitator – but they end with the midwives registering for our “on-call sheet.” This is a service my clinic offers to help bring them into the fold and give them a respectful role, while still being able to provide medical assistance to their clients.

I’ve never been pregnant in Africa. I’ve never given birth by lantern light. But I’ve been present at innumerable antenatal check-ups, spoken with young mothers, laughed with them, listened to their fears and aspirations. I’m generally familiar with their wants and needs. Most women feel more comfortable when connected with their culture during the process of birth – and understandably so. As we saw with beliefs surrounding witchcraft, incorporating meaningful tradition while trying to work around the less compatible-with-health aspects is a necessary challenge. Striking a balance between faith and fact is a delicate art. Each is a fulfilling component of the health portrait. Without acknowledging culture, you will accomplish essentially nothing, and possibly do more harm than good to the long-term mission of your organization.

The TBAs here aren’t in it for money or glory; they genuinely care about women, and genuinely want them to have safe, healthy births. They are strong, compassionate people worthy of admiration. Once they’re able to overcome certain myths and cultural obstacles, most of them are happy to become part of the “birth team.” That way, mothers get the best of all worlds. A laboring patient who arrives at our facility will receive a doctor’s care in (relatively) sanitary conditions from someone who can help her prevent infection and connect her to a district hospital if things go terribly awry. If she wants, she can bring her TBA with her, or ask us to call one from our on-call registry. The TBA can guide her through the traditions of birth and pain management with the spiritual support she craves, but not at the expense of accessibility to medical care, IF the need arises.

There’s nothing intrinsically wrong about the decision to start childbearing at 18, or to have five kids, or to not space them well. It’s certainly not ideal, and is often the result of a lack of information or options to the contrary (to say nothing of larger societal issues surrounding the role of women). Most women, once given the knowledge and options, make – or try to make – different choices with regard to things like birth spacing or limiting numbers. But regardless of WHAT they choose, if it’s a choice they make for themselves, and it’s not to the express detriment of the broader community (example: not vaccinating)? Fine. Risks can be managed. I have exactly zero interest in trying to seize local women’s maternal autonomy and tell them they ONLY MUST have 2.4 children at the proper intervals. Tell them they MUST breastfeed or not, MUST co-sleep or not, MUST have a hospital birth or not. I don’t want that kind of responsibility. Those aren’t my judgment calls to make.

At the end of the day, it’s all about education. TBAs must be better informed about what they can and can’t handle, as well as about basic preventative healthcare both before and after the child is born. Mothers need to be about the best health and parenting practices available, in the hope that they will take them to heart. Behavior change must be supported in the long-term. There are serious conversations to be had about sustainable populations, yes, but it’s just part of the total information package, right? No one can make those decisions *for* the woman herself. Knowledge and agency are the key ingredients. I grow sick hearing about women killed or rendered infertile by unhygienic births without a skilled attendant. I grieve with the Sunday school teacher who tells me she’s lost three nursery students in the past year to measles, an easily vaccine-preventable childhood illness. I celebrate with grandmothers who live in a state of perpetual bliss as they watch their half-dozen children raise strong, healthy herds of grandchildren to honor and assist them in their old age. For families to have wanted, loved, healthy children is a beautiful thing. (Even if I could do without them myself.)