Labor Pains

In the midst of a civil war, becoming a mother was its own battle.

Melinda Gates has me thinking about the time I became a mother. When the Gates Foundation co-chair recently said that improving family planning for the global poor is her new personal mission -- and that she is making it a top priority for the world's biggest public health philanthropy -- it immediately brought me back to my own experience giving birth to my son 20 years ago. Back then, the thing I needed most was not family planning, but a well-trained midwife.

I was 18, an unwed and pregnant young woman about to have her first baby in the midst of Liberia's civil war. Just weeks before I went into labor, a rebel group took control of my town, a suburb of the capital, Monrovia. Anyone who could run away did, including all doctors and nurses. I had no choice but to find a traditional midwife and ask her to help me have my baby.

I walked for an hour or more to a remote village. The path was narrow, and thorns grabbed my legs from the bushes. I was already in labor -- and in pain -- by the time we reached the home of an elderly woman whom my baby's father knew. I lay on the floor of her hut waiting for the baby to come. That night, it was raining cats and dogs, and the rebels were shooting. Just after the gunshots began, my son came. He was small, but healthy.

But then, the afterbirth was stuck. I was confused. I thought that with the baby already out the ordeal would be over, yet I writhed in pain. The old woman helping me knew little more than I did -- only what she had learned from her own mother. That included a belief that the afterbirth was stuck because I had sinned. She accused me of adultery and demanded that I confess the name of my lover. As I bled, she beat my legs.

Finally, I pulled a name out of the air and offered it to her. In an adjacent room, a man knocked some old cups together. He said he was consulting the gods of our ancestors and that they would allow me to live because I had confessed the name. The midwife gave me a teaspoon of kerosene because she believed it would help finish the birth, and I passed out before I had the chance to hold my first child. But I survived.

Other young girls were not so lucky. Even today, nearly a decade after the end of the civil war, and in Africa's first country with a female president, Liberia has the world's 10th-highest maternal mortality rate. Health clinics and hospitals are few and far between. On average, the World Health Organization reported in 2010, Liberia has only three nurses or midwives and less than one doctor for every 10,000 people. Bad roads make it difficult for most of us to access what medical resources there are.

Like all numbers, these only tell part of the story. These numbers in particular were collected over a nine-year period -- a period that in my country represents the end of the civil war and the beginning of recovery. It's difficult to overstate how many things war destroyed here and how much we've had to recover from.

But Liberia is making progress. This year, for example, newly reelected President Ellen Johnson Sirleaf has made increasing the number of competent birth attendants a priority for her second term. That means that most rural villages and towns rely on traditional birth attendants who practice home deliveries -- with habits handed down from their mothers and grandmothers. Some still use folk cures, like herbal concoctions, and the delivery fee they earn from each pregnant woman's family makes them reluctant to refer their clients to modern medical clinics.

This is where women like Miatta Abraham come in. I met Abraham in March, when I was interviewing newly trained traditional midwives, or TTMs. I was writing a piece for Front Page Africa, an investigative paper, on what maternal health in Liberia looks like 20 years after my own traumatic experience.

TTMs are an integral part of the country's strategy for reducing maternal deaths. Supported by international donors, the Liberian government so far has trained 6,000 TTMs to improve their delivery skills, offer basic prenatal care, and recognize early danger signs in pregnant women that might necessitate a transfer to medical clinics before complicated labor begins. Abraham, 38 years old, lives in a village in Todee district on the rural outskirts of Monrovia. "[In] some of the villages, there is no car road," she told me, "so people tote [the pregnant woman] in a hammock" to reach a clinic in a time of crisis.

Even in the face of complications, rural Liberian women often don't want to make the arduous trek through the bush, says Abraham. Instead, they would prefer to pay a village midwife $20 to deliver the child at home. Abraham thinks that this financial incentive, still in place from the old system, makes it harder for newly trained TTMs to convince families to move at-risk pregnant women into clinics before difficult births. TTMs are unpaid, like many of the jobs that support Liberian health services, which means that trained volunteers like Abraham often have less clout in villages and are considered less professional than the untrained women who still receive money from families.

But training and pay aren't the obstacles preventing reform of the country's birthing system. John Flomo, the officer in charge at the Todee District Clinic, says that what happened to me the first time I gave birth is still happening today. "Many of these midwives, before their training, were still practicing the method of forcing pregnant women to confess to having outside affairs before the baby would come," he told me. The hope is that providing formal training for midwives will help make delivery a matter of science, not superstition.

Of course, as Gates notes, one of the most effective strategies for reducing maternal deaths would be to reduce the number of unplanned pregnancies, which the United Nations expects to approach 300 million worldwide in the next decade. Improving access to contraceptives can help those women. A 2011 World Health Organization study stated that only 11 percent of women in Liberia are using modern contraceptive methods -- for all of sub-Saharan Africa, the rate is nearly three times as high. Today in Liberia, 35 percent of women have family planning needs they aren't met.

But there's also a lesson in what happened to me two decades ago. Pregnancies, accidental or planned, should be supported by effective health systems. Women have many reproductive rights, and one of those should be giving birth safely. As the international donor community shifts its focus to helping women who don't want to be mothers, I hope we won't forget the ones who do.


Democracy Lab

Getting Ready for Life after Castro

Managing the transition to a democratic Cuba: A user’s guide.

Early this month, a senior Cuban official raised the possibility of loosening travel restrictions, potentially making it far easier for Cuban citizens to travel abroad as tourists. So far, little is known about the details of the policy Havana has in mind. But the flurry of interest stirred by this news reminds us that change in Cuba can potentially have far-reaching strategic and political implications, for its own people as well as for the regions that surround it.

There is a great deal that can be done in advance to prepare for the day when the post-Castro transition begins. The Cuba Transition Project (CTP) at the University of Miami, created in 2001 with the support of the U.S. Agency for International Development, has become a major authority on Cuban affairs. The project has released major studies on transition by both academics and experts, as well as a variety of other reports on topics such as political parties, labor unions, a free press, and economic reform. (The works cited in this article have all been produced under CTP auspices.)

In the early 1990s, many people expected the communist regime in Cuba to collapse. Those of us who followed the situation closely knew better, and subsequent events have borne out our caution. The post-Castro transition will indeed come one day, but when it does, it promises to be a long and complicated process.

The challenges are many. First, there will be the tremendous task of economic reconstruction. For nearly four decades, Cuba's extreme dependence on the Soviet bloc for trade, and the distorting effects of huge subsidies from Moscow, created an artificial economy. Most of Cuba's exports are in decline, and poverty is correspondingly growing. The internal market is weak, as domestic consumption is controlled by a strict and severe rationing system. Many transactions take place in the illegal black market, which operates in American dollars and with merchandise stolen from state enterprises or received from abroad. The Cuban peso has depreciated and its purchasing power has waned considerably. Huge and persistent government deficits, and the absence of virtually any stabilizing fiscal and monetary policies, have accelerated the downward spiraling of the economy. (Socio-Economic Reconstruction: Suggestions and Recommendations for Post-Castro Cuba, Antonio Jorge, and Institutions to Accompany the Market in Cuba, Ernesto Hernandez-Cata).

Moreover, sugar production, Cuba's mainstay export, has dropped to Great Depression levels. With low prices, a decline in sugar consumption worldwide, an increase in the number of competitive sugar producers, and widespread use of artificial sweeteners, sugar is a losing commodity with dire prospects for the future. Thus tourism, nickel exports, and even exile remittances have replaced sugar as the mainstay of the economy. Oil exploration in Cuba's northwestern waters seems promising, but profits must be shared with foreign partners, and costs are extremely high.

In addition to these vexing economic realities, there will be also a maze of legal problems, particularly concerning foreign investment and the status of assets acquired during the Castro era. Obviously, Cuban nationals, Cuban-Americans, and foreigners whose properties were confiscated during the early years of the revolution will want to reclaim them or will ask for fair compensation. (Property Rights in the Post-Castro Cuban Constitution, Oscar M. Garibaldi and John D. Kirby; Alternative Recommendations for Dealing with Confiscated Properties in Post-Castro Cuba, Mátias F. Traviesco-Diáz.) The U.S. and other countries whose citizens' assets were seized without compensation are likely to support such demands. Cubans living abroad await the opportunity to exercise their legal claims before Cuban courts. The Eastern European and Nicaraguan examples vividly illustrate the complexities, delays, and uncertainties accompanying the reclamation process. (What Can Countries Embarking on Post-Socialist Transformation Learn from the Experiences So Far?, János Kornai).

Cuba's severely damaged infrastructure is in major need of rebuilding. The outdated electric grid cannot supply the needs of consumers and industry. Transportation is inadequate. Communication facilities are obsolete, and sanitary and medical facilitates have deteriorated so badly that contagious diseases constitute a real menace to the population. In addition, environmental concerns such as the pollution of bays and rivers require immediate intervention. (Environmental Concerns for a Cuba in Transition, Eudel Eduardo Cepero.)

Economic and legal problems are not, however, the only challenges facing Cuba in the future. A major problem that will confront post-Castro Cuba is the power of the military. (The Cuban Military and Transition Dynamics, Brian Latell.) Cuba has a strong tradition of militarism, but in recent years, the military as an institution has acquired unprecedented power. Under any conceivable future scenario, the military will continue to be a decisive player. Like Nicaragua, Cuba may develop a limited democratic system in which Cubans are allowed to elect civilian leaders, but with the military exercising real power and remaining the final arbiter of the political process.

An immediate and significant reduction of the armed forces will be difficult, if not impossible. A powerful and proud institution, the military would see any attempt to undermine its authority as an unacceptable intrusion into its affairs and as a threat to its existence. Its control of key economic sectors under the Castro regime will make it difficult to dislodge it from these activities and to limit its role strictly to external security. Cutting the armed forces will also be problematic. The civilian economy may not be able to absorb large numbers of discharged soldiers quickly, especially if the government cannot come up with viable programs for retraining them.

The role of the military will also be shaped by social conflicts that may emerge in a post-Castro period. For the first half of the twentieth century, political violence was seen by many as a legitimate method to effect political change, and this could well have an effect on societal expectations in the future. Communist rule has engendered profound hatred and resentment. Political vendettas will be rampant; differences over how to restructure society will be profound; factionalism in society and in the political process will be common. It will be difficult to create mass political parties as numerous leaders and groups vie for power and develop competing ideas about the organization of society, economic policy, the nature of the political system, and unraveling the legacy of decades of communist dictatorship.

A newly free and restless labor movement will complicate matters for any future government. During the Castro era, the labor movement remained docile under continuous government control; only one unified labor movement was allowed. In a democratic Cuba, labor will not be a passive instrument of any government. Rival labor organizations will develop programs to protect the rights of workers, and to demand better salaries and welfare for their members. A militant and vociferous labor movement will surely characterize post-Castro Cuba.

Similarly, the apparent harmonious race relations of the Castro era may also experience severe strains. There has been a gradual Africanization of the Cuban population over the past several decades due to greater intermarriage and out-migration of a million mostly white Cubans. This has led to some fear and resentment among whites in the island. At the same time, blacks feel that they have been left out of the political process, as whites still dominate the higher echelons of the Castro power structure. The dollarization of the economy and the recent relaxation in the amount of remittances allowed to flow from the U.S. to Cuba has accentuated these differences. Since most Cuban-Americans are white, black Cubans receive fewer dollars from abroad. Significant racial tension could well result as these feelings and frustrations are aired in a politically open environment. (Race Relations in Cuba, Juan Antonio Alvarado - in Spanish).

Perhaps the most difficult problem that a post-Castro leadership will have to face is acceptance of the rule of law. (Establishing the Rule of Law in Cuba, Laura Patallo Sánchez.) Every day, Cubans violate communist laws: they steal from state enterprises, participate in the black market, and engage in all types of illegal activities, including widespread graft and corruption. They do this to survive. Getting rid of those necessary vices will not be easy, especially since many of them pre-date the Castro era.

Unwillingness to obey laws will be matched by the unwillingness to sacrifice and endure the difficult years that will follow the end of communism. A whole generation has grown up under the constant exhortations and pressures of the communist leadership to work hard and sacrifice for the sake of society. The youth are alienated from the political process, and are eager for a better life. Many want to immigrate to the United States. If the present rate of visa requests at the U.S. consular office in Havana is any indication, more than two million Cubans want to move permanently to the United States.

Under the normalization of U.S.-Cuban relations, Cubans will be free to visit the United States. Many will come as tourists and stay as illegal immigrants; others will be claimed as legal immigrants by relatives who are already naturalized citizens. A significant out-migration is certain, posing an added major problem for U.S. policymakers at a time of increasing anti-immigration sentiment.

While many Cubans want to leave Cuba, few Cuban-Americans will be inclined to abandon their lives in the United States and return to the island, especially if Cuba experiences a slow and painful transition period. Although those exiles who are allowed to return will be welcomed initially as business partners and investors, they are also likely to be resented, especially if they become involved in domestic politics. Readjusting the views and values of the exile population to those of the island will be a difficult and lengthy process. (The Role of the Cuban-American Community in the Cuban Transition, Sergio Diaz Briquets and Jorge Perez-Lopez).

The future of Cuba is therefore clouded with problems and uncertainties. More than five decades of communism have left profound scars on Cuban society. As in Eastern Europe and Nicaragua, reconstruction may be slow, painful, and tortuous. Unlike these countries, Cuba has at least three unique advantages: a long history of close relations with the United States; excellent preconditions for tourism; and a large and wealthy exile population. These factors could converge to transform the country's living standards, but only if the future Cuban leadership creates the necessary conditions for an open, legally fair economy and an open, tolerant, and responsible political system. Unfortunately, life in Cuba is likely to remain difficult for a while longer.

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