Home in Texas

I'm home in Texas. The air-conditioner says it's 75 degrees inside. The plastic thermometer with the red hummingbird stuck on the window says it's 87 degrees outside. Clement is asleep in the other room. Mom is downstairs organizing papers, moving them from one pile to another to the trash, fighting and losing to their fiercely swift reproductive rate.

About two weeks after arriving in Ghana, Clement was told that he would have to wait until August to resume classes. For a couple days the dean of the medical school said he might be able to continue this term but in the end he was told, "Sorry, come back in August." Since I had not yet started working we decided to try to come to Texas. My cousin Jon's wedding was scheduled for April 5th in Austin and I desperately wanted to attend. We booked the first available visa interview which was over a month away (March 26th) and bought - as we were told by the travel agent and believed after trying four different agencies - the last two seats on any flight heading to the US after March 26th and before April 5th. Then we waited and sweat.

Every day Clement walked to campus and entered the human pin ball game of trying to obtain a letter addressed to the consular at the US Embassy saying that he was enrolled in the fall term. The dean referred him to the registrar, the registrar told him to return tomorrow and then tomorrow and then tomorrow and then finally told him to go to the international student section. At the international student section they did not have the correct letterhead he was told, “Come back tomorrow” for about a week. Then once the letterhead arrived they told him he needed a letter from the registrar addressed to the student section. The registrar said it wasn’t her responsibility to write the letter; finally a secretary from the dean’s office copied a letter from his file which had already been sent to the student section. The man in the student section was satisfied with the copy but then asked if Clement had paid the fee associated with the letter they would write. Once the fee was paid – involving of course visiting another office and waiting in another line – the man at the student’s section told him he needed a passport picture. When I very calmly (much more calmly than I wanted to) reminded the man that Clement had been visiting the same office daily for weeks and suggested that it might be a good idea to explain on the first visit what is needed, the man became indignant, told me not to tell him how to do his job and with a mix of passion and anger said that his job is to help students – at least we agreed on that point. Finally, five minutes after the University officially closed, the day before we had to leave for Accra, Clement was handed the letter.

In Accra we stayed with a cousin of Peter and Abigail Kyei – friends from Kumasi. Having never met us she welcomed us hugs, cooked for us, and refused all help. In Kumasi we had been frustrated by the weekly unannounced interruption of our water supply but in her neighborhood we learned that for at least the past 15 years, water has only flowed through the taps on Wednesdays. For the rest of the week people buy water and fill tanks behind or above their homes. Without intending to do so, I have become very good at bathing with surprisingly small volumes of water. It seems to me that in the US our wealth as a nation buffers us from so many “coming” hardships due to global warming and population growth that have already arrived in many countries. After a few more days of waiting, on March 27th Clement was given a ten year tourist visa and on March 28th we arrived tired but happy in Austin to the loving hugs of my parents, a cool night, a quiet drive home on a wide highway, a hot shower, and clean soft sheets - I don’t remember ever feeling so grateful.

I am eager to work. I miss birth. I miss feeling useful. I'm driving Clement slightly crazy by asking him 1,000 times a day "What do you want to do now?" Still, it is wonderful to be here. I adore my parents. They are generous, wise, kind, and aging. I love my family. My cousin’s wedding was beautiful, the love professed deeply rooted, and my heart skipped an entire measure of beats from the excitement of surprising my paternal aunts, and uncle, and cousins who flew down from Michigan.

Two weeks later we also spent a weekend with my mom’s family in Houston and Raywood. Raywood is a small farm town in East Texas where the vast majority of residents are direct relatives of my mother’s. Once Clement assessed the place he leaned in close and said with a smile, “You never told me that you have a home village.” We started our visit with an entertaining tour of the cemetery, learning which deceased married couples were first cousins, hearing the story of two who hid under an overturned wagon to wait out a storm and then emerged alive and pregnant, we learned who was an infamous womanizer, who died from tuberculosis, who died from syphilis, and who died in childbirth. We ate a big lunch then concluded our visit by dancing Zydeco with my mom’s cousins in someone’s den. I let the joy flood every cell - sitting with Clement, watching my mom laugh out loud with her cousins, then turn around after each song to pull someone else to the dance floor. She was radiant and our time together is rare and precious.

The future as usual is uncertain, Clement and I will live 4 months of our first year of marriage with my parents, hopefully I will find a per diem nursing job while we are here, then we will return to Ghana August 1st, leaving all the trappings of middle class America behind. When I consider the future I feel the responsibility weigh on me as the sole provider for a new family. I wonder if my career as a part-time volunteer will be enough. I still refuse to spend any more than a fraction of a second considering job possibilities that would be more lucrative than midwifery.

Suffering and Joy

If we grow up in a secure household in America we learn – and may come to believe – that everyone has the right to pursue happiness. Although we are not told this explicitly, in America, in our consumerist culture, this most certainly means a right to the external pursuit of happiness. It is highly debatable whether in actuality all Americans share this right but I won’t get into that. The thought that captivates me is the simple idea of being free to pursue happiness. It is beautiful. Happiness as a sustained state of being in the world – as opposed to on a remote tropical island in a four star facility but rather in life around people, with all the pain, despair, and suffering that involves – must be an internal state. This pursuit of internal happiness is truly open to everyone but the path towards its achievement is far more difficult. I am beginning to think that the only people who achieve internal happiness are highly evolved spiritual beings. For the rest of us here on this planet, so distant from God, we are left mostly to our own devices to increase our compassion, learn grace, and find joy. Our relationships with ourselves are often tragically flawed not to mention our relationships with each other. We create pain, witness pain, experience loss, and misplace priorities. Living in Malawi and working in the labor ward there over the past few years has had a profound impact on my spirit. I am still unsure of how to characterize this impact; at the moment perhaps I can say it has left me with a greater sense of surrender. I have seen much inequality and cruelty; I have gained no understanding its purpose. We might grandly hypothesize that spiritual evolution requires suffering but when so much suffering is merely a degradation of life, the conclusion that most readily arises is that we as a global community are responsible for its unnecessary existence. I am exhausted, I feel a desire to rest but an inability to turn away. Certainly, I have deepened my respect for those who walk through life with their eyes open and radiate joy. I wrote before that I want to find more joy in life and I am renewing that intention.

Home?

We are now in Kumasi. Initially we stayed at the home of one of the lecturers from KNUST who has been a friend to Clement. He took us around to see the housing options and we made a decision. Of course before we made the decision I had a few hours of panic. Flats are difficult to find around the University as most homes and buildings have been converted into hostels, which are essentially private dorms. We saw a very nice hostel within walking distance from the University and a lovely simple two bedroom apartment for the same price at a significant distance from campus. We chose the hostel. So, here I am 32, newly married and living in a dorm with my husband. We have a single room with an attached bathroom (which it seems we share with a family of small mice), we sleep in a single bed, share a “kitchen” - consisting of a sink and two burner hot plate - with four to six others, and wash our laundry in the shower. There is no common space inside, no garden outside; there is no place to sit with friends or breathing room when Clement and I need a few minutes apart. I keep asking myself, “How did I get here and what am I doing?” then I argue with myself for the underlying sense of entitlement. After each wave of panic Clement gives me the needed hug and reminds me that I am just going through culture shock and will adjust. I need to find a source for good chocolate and ice cream then I'm sure I will be able to live happily.

Arrival in Ghana

Clement and I have arrived in Ghana. Like so much of life, it was an adventure getting here - of course there was the necessary and sad bit of saying goodbye to good friends, moving out, selling our things, and packing. Then there was the unnecessary bit of DHL losing my passport when I shipped it with them to the Ghanaian High Commission in Harare, Zimbabwe to get a visa. They were very apologetic but the extra stress led to a few tears and a delay of a week. Finally we left Lilongwe on the 8th of February and, after a night in Addis Ababa, arrived in Accra in the afternoon of the 9th. During the trip as I considered what I was leaving behind and the unknown towards which I was headed, my excitement and anxiety seemed to counteract each other and left me feeling empty.

As soon as we passed through immigration in Accra we found Clement’s classmate Moses waiting for us at the baggage claim with a warm smile. He brought us home to his wife and two little boys. So here we are in their home with all our earthly possession in four bags. We have no home and little idea of what will come in the next days, weeks, months. I must consciously remind myself that beginnings are always difficult but they always pass. I remember my first days in Malawi at the Kapondas’ home filled with excitement but also loneliness and boredom. Now, here I am again in a similar predicament. This need to start life over again and again, to experience new countries and cultures, is at times a burdensome compulsion. However, I doubt this realization will prevent future reoccurrences. At least this time we are two and at least Clement survived culture shock and successfully made a few friends last semester.

Ghana is lot hotter than Malawi. The heat feels like Texas but Accra lacks the ubiquitous air conditioners present in nearly every home and shop in Austin. I don’t mind the heat. I much prefer this climate to the cold but Clement struggles with it. The streets are busier than Malawi; people move faster, are more assertive, more willing to express their opinions, and more likely to start a conversation. There is a wide variety of street food, of which I can only identify a handful, but I’m eager to taste it. In general the food is delicious and spicy but our encounters with vegetables have been minimal. I have only seen three green vegetables in the market – okra, a local green leafy vegetable, and lettuce and usually when they end up on your plate you must search for tiny flakes of green. Vendors flow up and down every street hurrying to make transactions through car and bus windows during pauses at intersections then swiftly jumping aside when the traffic movement resumes. Unlike Malawi the vendors here on the street and in the shops are mostly women and girls. I wonder about their education and their safety. The predominant local language is Twi (pronounced tree) but many people do speak English. Although there are very few faces which are obviously not African people don’t seem to take much notice of me and Clement. There are definitely fewer beautiful development aid vehicles cruising the streets than in Malawi - perhaps a sign of a more independent economy.

The most difficult part of moving is always the lack of friendship and this of course takes time. Wherever I walk small children shout oblonie (white person) and wave. One day as I was walking home with groceries in my arms I heard a small voice yell, "Can I help you?" followed by the patter of small feet. A group of young students in the school uniforms took my bags and escorted me home. Another day when Clement and I stopped to discuss directions on a street corner and a group of five little girls maybe 7 and 8 years old all came up to me and gave me hugs one by one, the last one planted a kiss on my belly. Not a bad welcome.

Cromwell

Cromwell has been living up north with his parents since shortly after his stroke. Over the past two years he managed to recover some of his strength but he was still walking with a notable limp. He came to our wedding in Mangochi and I saw him a couple weeks afterwards for a goodbye before our departure to Ghana. He was laughing as he recounted his experiences at our wedding, Cromwell does not laugh often and I was glad to leave with happy images of him fresh in my mind. Last night Cromwell's brother Jobson called to tell me Cromwell died on Friday and was buried on Monday. He had been watching football (the African Cup of Nations is going on in Ghana) when his heart started racing. An ambulance was called to transport him to the hospital. He died in route. He was 32.

The Unabridged Wedding Story

Clement’s sister Gladys arrived from Sudan in October she had left three years previously - three months before I arrived in Malawi – and this was her first visit home. I immediately liked her warm and talkative ways. Effie, Aisha, (two of Clement’s sisters) and I stayed up the first night listening to her stories. In 2004 Gladys was sponsored by a Malawian Islamic organization to study business management. Higher education opportunities are limited in Malawi and her sponsors promised her a rare straight path to a degree. They assured her that the school possessed good facilities and they promised that she would be taught in English. Thirty Malawians accepted the scholarship including Gladys and her best friend. Although anxious about taking such a blind step, Gladys and her friend allowed their anxiety to be replaced by excitement once in Khartoum as they drove to campus past modern high rises and wealthy neighborhoods with manicured gardens. Finally they reached campus and were deposited in front of several large plastic shipping containers, which had been converted into dorms but in the heat functioned more like ovens. Tears spilled over and continued flowing for days. They could not return to Malawi; everything had been paid for by the organization and their families would never be able to cover the expense of a return ticket.

The second disappointment came with the discovery that classes would be taught in Arabic. Without an alternative, Gladys and her cohort spent the first year studying Arabic. At the end of that year, still not fluent in Arabic, Gladys managed to negotiate with her sponsors to allow her and her friend to transfer to another school where classes were taught in English. (The remainder of her cohort stayed at the original school.) During her first true academic year Gladys performed well, obtaining A’s in all her courses, but at the end of that year her sponsors transferred her to yet another school which would not accept any credit for the courses she had taken. Gladys arrived in Malawi after three years away with only one year of academic credit. That first night she told me, “Joanne, my dream is to obtain a masters degree.” Gladys is a bright woman, someone who in the States would probably obtain her PhD by her mid to late 20s, but given the tortuous trajectory of her education, a masters will be a significant achievement.

Gladys also told us stories about the treatment of the Southern Sudanese by the government, the little she knew about the war that filtered through to eyes and ears despite censorship, her distressing encounters with members of the poorly trained and poorly educated police force, and the heat. Apparently the heat is so intense in Khartoum that people are warned not to directly enter a cold shower when coming from outside. During each year she spent in Sudan one or two foreigner students died this way from shock.

In celebration of Gladys’ return and in anticipation of Clement’s arrival more and more family and friends poured into the little house. The cooking and cleaning always got done, there were always plenty of stories and laughter, and somehow I still managed to find a quiet corner whenever I needed retreat. My friend Meera, a fellow midwife, arrived on December 17th. We spent long hours trading stories of the past months and then Clement arrived on December 19th. I had been counting down the days to his return for months but when he stepped out from the baggage claim in his tee-shirt and jeans he was so much more handsome and my love for him so much more overwhelming than I had expected.

My parents arrived on the 24th. They are both in their 70s and, though healthy for their age, were visibly exhausted by the two days of travel. My sweet little mother appeared to be on the verge of collapse as she stepped out from the baggage claim wearing a sweater, jacket, hat – in the summer of the southern hemisphere – and carrying two small bags. Clement and I hugged them both and my mother asked him to hold her on our way out to the car. The following days, leading up to the wedding, passed quickly. We celebrated Christmas with wonderful friends and food, wrote and designed the wedding program, arranged transportation to Mangochi for friends, met with the priest, and cherished our ordinary evenings with my parents, Meera, and Clement’s sisters.

Finally, the Thursday before the wedding, we packed my little sedan with five people and their luggage; Clement’s, his best man’s, and my father’s suits; my wedding dress; food; and the flowers. (Amazingly we bought all the flowers for the wedding from at Zikomo flower farm for $20.) Around 7pm, a couple hours after sunset, we arrived at Clement’s father’s house in Mangochi, peeled ourselves out of the overcrowded car and stepped into the overcrowded candle-lit house. Space was made on the couches and we were fed nsima and eggs. Clement’s father wanted to take my car to the village to deliver fuel to a truck which was waiting to drive the recently slaughtered bull to the cottage where my parents would stay, so it could be packed in the refrigerator. I handed over the keys but my car wouldn’t start. My parents and Meera were transported by another vehicle to the cottage. After about a half an hour several boys managed to push-start the car. Clement and friends departed to celebrate his penultimate night as a bachelor. I feel asleep on the couch. When Mr Chiwaula arrived with the cow in pieces in the back of the pickup, I followed them in my car to the cottage 20 kilometers out of town. While on our way Clement called, extremely disappointed, to say that the lodge/bar where the guys had planned to party with him (the only bar in town) had unexpectedly closed early. I headed to bed while five men packed an entire cow into two medium sized refrigerators. Meera laughed and said when she went to get water she tried to ignore the puddles of blood collecting under the fridge.

Friday was a blur, I met Clement, we picked up guests dropped them off, we forgot to eat and drink, everyone told us what was going wrong. The rehearsal, scheduled to begin at three began at five, Father Sax arrived at 6:30. The rehearsal consisted of dancing down the isle again and again. I was told that usually the bridal party rehearses for several days before the wedding, but we were apparently quick learners as we polished it off in just three repetitions. When Father Sax arrived we spent a few minutes discussing some of the components Clement and I had added and then, at last, we left the church to eat. At 4pm I had called the hotel, where we had booked our dinner a month previously, to tell them to expect us around six, the receptionist said they would be ready. Twenty of us arrived at the hotel at seven and the shocked waitress quietly asked, “That was for today?” I tried to be optimistic when she said they only had one cook and nothing was prepared but a friend called at that exact moment to ask how I was and the tears broke free. Thankfully Father Sax produced the desired miracle, he sat us all down, took drink and meal orders and within 30 minutes everyone was eating.

Saturday morning was lovely. The sun shined through a light rain. My dad drank coffee on the table outside facing the lake where Meera and I worked on the flowers. Little girls ran through the grass and then to the water’s edge. Fishermen mended their nets on the sand. The older girls and women sat inside slowly transforming the cow into samosas and snacks. I made the bouquets for me and Effie, as well as the corsages and boutonnières for the men and the parents. My heart calmed. Around 11am we drove to the hotel, which was a block away from the church, to get ready.

Once at the hotel I kept meeting people who needed to eat, others who needed rooms, and I still needed to deliver the flowers to the parents and candles to the church. I lost track of time. The wedding was set for 3pm. At 2pm I had a head of wet hair which I was desperately trying to towel dry. Thankfully four friends miraculously appeared with a hairdryer (I had never previously seen a hairdryer in Malawi) and they set to curling and pinning the masses while I put on my makeup. At 3pm I slipped on my dress and called Beatrice asking about our ride to the church. The car arrived after 30 minutes. I took a few deep breaths and got in next to Effie.

As we pulled up to the church everyone was standing outside, women singing Chewa wedding songs ran to encircle the car. Slowly the crowd filtered into the church and I was given permission to step out. I glimpsed my handsome joyful parents and then took their arms as Effie started dancing down the isle between the overcrowded pews. The choir’s voices flowed over heads filling all remaining space, and my eyes fixed on Clement.

Clement and I are both Catholic but have been raised in environments which made it impossible to believe any single path has a monopoly on truth. We are a Malawian and an American. Half of Clement's family is Muslim, the other half Catholic. Clement’s mom is Chewa, his dad is Yao. My mom's family is black American, my dad's family of German descent. Clement and I are accustomed to sitting in the middle, we respect and honor differences while always finding pathways to unity. We wanted our ceremony to embrace diversity and warmly involve all those in attendance.

The final result was a Catholic ceremony with our additions, our vows, and a lot of spontaneous ululating, harmonic singing, and movement. It was beautiful and basically unscripted. Through it all – sitting, standing, walking next to Clement – I felt incredible joy, deep calm, and complete awe that I could be blessed with such a life partner.

As we faced each other holding hands, Father Sax read “Blessing of the Hands," by Rev. Daniel L. Harris,

These are the hands of your best friend, young and strong and full of love for you, that are holding yours on your wedding day, as you promise to love each other today, tomorrow, and forever. These are the hands that will work alongside yours, as together you build your future. These are the hands that will passionately love you and cherish you through the years, and with the slightest touch, will comfort you like no other. These are the hands that will
hold you when fear or grief fills your mind. These are the hands that will countless times wipe the tears from your eyes; tears of sorrow, and as in today, tears of joy. These are the hands that will tenderly hold your children, the hands that will help you to hold your family as one. These are the hands that will give you strength when you need it. And lastly, these are the hands that
even when wrinkled and aged, will still be reaching for yours, still giving you the same nspoken tenderness with just a touch.

and then we exchanged vows,

I, Clement, affirm my love to you, Joanne, on this day of our wedding in the presence of our dear friends and families. I promise to embrace, respect, and honor your love. I promise to be a faithful companion on this walk through life. Today I humbly offer you my heart and ask you to take me as your husband.

I, Joanne, affirm my love to you, Clement, on this day of our wedding in the presence of our dear friends and families. I promise to embrace, respect, and honor your love. I promise to be a faithful companion on this walk through life. Today I humbly offer you my heart and ask you to take me as your wife.

Sometime later Father Sax asked us to move down the isle and offer the sign of peace to people, but before we could take a step the church enveloped us; a tidal wave of arms and bodies pulling us from one embrace to the next. It seemed to be a dramatic finale featuring all the major characters of our story in their best clothes and most joyful expressions Cromwell, Doreen, Memory, Msiska, the Nanthowas, maids from the hospital, Innocent and Ven, Tarek and Lara, Masauko, the Namaleus . . . In-between the moments of activity I sat next to Clement, my hand in his, awash in love.

We signed our marriage certificate and Father Sax concluded the celebration with the Apache Marriage Blessing,

Now you will feel no rain, for each of you will be the shelter for each other. Now you will feel no cold, for each of you will be the warmth for the other. Now you are two persons, but there is only one life before. Go now to your dwelling place to enter into the days of your life together. And may your days be good and long upon the earth.

From the church Clement and I were escorted to the village in a Mercedes in which we were instructed to standup through the sun roof – a hilarious and slightly embarrassing experience. The village welcomed us with drumming and singing and, though eager to join the scene, we were instructed to remain in the car until my parents arrived. We later learned that Father Sax had given them a ride but before joining the reception made a series of stops. The consequence was that Clement and I were trapped in the Mercedes for about an hour. Waves of faces undulated from the darkness to the car and back into the dark. Every once in a while a friend would approach and we would plead for news about my parents’ whereabouts and beg for snacks. Finally my parents arrived and to the dismay of those trying to choreograph our entrance, we claimed our freedom and leaped from the car.

The reception took place in Chiwaula village in front of the chief’s house, under tents, between enormous mango trees, in candle-light. Traditional dancing and drumming was followed by a couple short inaudible speeches and then a mob scene that masqueraded as the cutting of the cake. The cake was delicious; worthy fuel for a small battle. Clement and I enjoyed a few minutes of dancing and then, when the exhaustion that had been marinating our bodies over the past week reached the saturation point, we decided to return to the hotel for sleep.

A man placed the car keys in Clement’s hand, said, “Sakuyenda [It won’t start],” and disappeared. We gathered a few boys to assist but there was a moment when I was actually pushing the car in my wedding dress before a friend told me to stop. The car started and at last we drove back to the hotel, dropping Effie and a friend home on the way. As we pulled into the hotel parking lot we were greeted by a raging party on the lawn just feet outside our beautiful room. A few more people called asking about transportation and finally Meera kindly took my phone to her room. Clement and I, giddy and exhausted, shared the same sentiment, “thank God we NEVER have to do that again!!” Sometime between 2 and 3am the music stopped and I drifted into a shallow sleep, happy and comforted by the breaths of my beloved at my side.

Oh God
Let all lovers be content
Give them happy endings
Let their lives be celebrations
Let their hearts dance in the fire of your love.
—Rumi

We are grateful to all our beloved friends and family who honored us with their presence and to those who were with us in spirit. Our union has grown on the foundation of love and support you have given us over the years; our wedding day was not ours alone but also yours. May God perpetually bless you all.
With genuine gratitude,
Joanne and Clement

Birth Outside Bottom

Thursday was a rare slow day in the labor ward at Bottom labor. There was time to sit and to chat. I have seen much and learned much at Bottom but from the beginning I have also wanted to see birth outside the hospital in Malawi. (Over 50% of women in Malawi still deliver with traditional birth attendants (TBAs).) Thursday I mentioned this to Msiska and she told me about Mrs Msumba. Mrs. Msumba is a famous midwife working in a village on the periphery of the city. As Msiska described her, I realized that she was the same midwife mentioned by several of the clinical staff over a year ago in a derisive conversation about nurses who preferred to have her attend their births rather than deliver at Bottom (it sounded reasonable to me then and now). Msiska said Mrs Msumba had a lot of patients and always referred in time, and unlike other TBAs always accompanied the transferred women to the hospital. I was eager to meet her and asked Msiska how I could find her, in response she said “ukachula mkango udzikwera mtengo [if you mention a lion you must climb up the tree], she is probably on her way now.” I was skeptical since we had never met during all my time at the hospital but within a couple hours Mrs Msumba appeared with a patient and of course Msiska was not surprised. Msiska explained my interest to Mrs Msumba and I gave her my telephone number. Mrs Msumba said she would call when she had a laboring patient.

Sunday night Beatrice and I compiled a list of things to get done for the week for our little non-profit. Monday morning, thinking of nothing else but the non-profit, I woke up and opened the computer but within minutes woman called speaking in rapid Chichewa. I heard “TBA” quickly tossed in and figured it out. I asked if I should come and she said yes. The plan had been that one of the maids from labor ward would escort me but when I phoned her, her phone was switched off. I called Beatrice. She was at Kamuzu Central Hospital and said she would find someone who knew the way and accompany me. When I arrived at Kamuzu Beatrice was waiting with two women from Mrs Msungu’s village who had been delivered by her a couple months previously. The two women directed us through the village and then instructed us to stop at a hedge (a few green leaves budding on top a mound of dirt). From there they led us down a narrow muddy path at once widening and ending at a pen filled with fat guinea pigs eating palm leaves. Mr Msumba was cleaning the pen and after greeting him, the women who led us there called out to Mrs. Msumba who was next door at the her clinic. Mrs Msumba greeted us warmly and led us inside.

Her small clinic was divided into four rooms, the main room which contained a small cabinet with delivery supplies and gloves as well as two “bush” ambulances (tricycles with extended carts used to transport laboring women); a small empty room for prenatal examinations, a recovery room with a single bed, and a tiny delivery room containing only a basic cot for the baby. The building was made of unbaked brick painted with a cement floor and metal roof, it smelled faintly of floral body soap. Two women, having come for prenatal care, sat on the floor in the main room, the first was pregnant with her second child and had no living child and the second woman was pregnant with her fifth. Mrs Msumba counseled them, she talked to them about danger signs, she told the woman with her fifth pregnancy that she must deliver in the hospital (TBAs in Malawi are only supposed to attend second to fourth pregnancies). Every now and then I could hear the woman in the labor room moan and Mrs Msumba occasionally stood and peered in the delivery room. She examined the bellies of the two prenatal patients and let them leave.

During the month of November Mrs Msumba said she had had 62 deliveries and 19 transfers to Bottom. Only after looking through her record book and counting the names could I completely grasp that she alone had cared for 81 laboring women within a single month. Mrs Msumba began working as a midwife in 1975, apprenticed by her mother and grandmother. She laughed and shook her head when I asked if she knows how many deliveries she has conducted. She strays further than walking distance from her home and clinic only when transferring patients. There is no electricity at her clinic so some nights she conducts as many as three deliveries by candle light. She charges 500MK for her services (about US$3) but still many of the women cannot pay, so she often works for free, pays the transportation costs with her own money when women must be transferred, and sustains her family with small businesses such as raising and selling guinea pigs.

In the hospital the women must bring their own caretaker to cook and wash for them, if they have no one they do not eat, and they wash their own clothes after delivery. If the women come alone to Mrs Msumba she cooks for them, she heats bath water for them, she gives them water while they labor, and leaves a covered bucket by their side in case they need to vomit. The women bring a plastic sheet and a few cloths to place on the bare ground in her small delivery room. They labor there, Mrs Msumba encourages them to lie down. She does not yell. When I asked Mrs Msumba about vaginal exams she says she does not check regularly. She takes her time. She watches the women, their bodies and their body language. She palpates their abdomen to feel whether the baby’s head is descending into its mother’s pelvis. She can tell from a woman’s labia if her birth will be difficult. She says she takes her time. She says this way the woman only pushes once or twice and the baby is born.

Stella was laboring with her third baby. I sat next to her on the cement floor as she moaned and turned from side to side. Mrs Msumba walked between the rooms, attentive to Stella but calm. She listened to the baby. As the birth neared she changed clothes, put on gloves, and prepared her delivery kit – a cord clamp, a razor blade, and a piece of string set in her single kidney dish. Stella’s moaning intensified and Mrs Msumba instructed her to move from her side to her back. After two physiological pushes Mrs Msumba held Stella’s baby boy in her hands. She immediately put him on Stella’s breast and in another five minutes the placenta followed with barely a drop of blood. Mrs Msumba cleaned Stella and the room. It was an amazing birth to witness, we thanked Stella and Mrs Msumba but before we were allowed to leave Mrs Msumba ushered us to the steps outside where a lunch of eggs and nsima was waiting.

I asked a few more questions and then Mrs Msumba gave me her list of requests: electricity, a mattress, more metal kidney dishes, and a few blankets. As we were finishing lunch another laboring woman arrived. Mrs Msumba asked us to wait while she examined her just in case the woman needed to be transferred but within minutes she also delivered. We left feeling joyful. It is no mystery why women choose to deliver with Mrs Msumba rather than at the hospital. The care that women receive with Mrs Msumba is impossible to replicate in a hospital where the ratio of laboring women to nurses can be as high as 10:1.

Last Day

Yesterday was my last day at Bottom. It was as I anticipated - just another day. I conducted one vacuum delivery and two normal deliveries. I sat and talked with and rubbed the back of a frightened 19-year-old as she labored. I helped resuscitate two babies. No one remembered that it was my last day except Msiska. She told me they’ll miss my skills. “Any time there is an asphyxiated baby we always wish you were here,” she said. She said she will miss my presence and my friendship. I bought a cake and it was eaten. After three years at Bottom I know, without self pity or drama that my presence had the minimal impact of a drop of water in a pool. That does not bother me. I know it was different with the women. And, I am ready for a change. I am looking forward to the future. I’m sure someday I will return and work again in the new maternity hospital. I hope to find the conditions better. I hope I will have more to give.