This is a reflective piece, written after being asked by the mother of a stillborn baby whether midwives were also affected by stillbirth. The setting was a rural hospital in southern Ethiopia that sees around 100 stillbirths every year, or two every week. One mother, Woinshet, wanted to hear how stillbirth felt for midwives, and gave permission for her name and story to be used so that other women could know that they are not alone in their sadness and loss, despite midwives maintaining a professional distance. In order to capture the emotive nature of the subject, and accurately reflect its impact, a simple narrative model rather than a more formalised structure has been used, to justify the emotional side of midwifery more fully, away from the science and clinical distance.
Dear Woinshet,
I expect you think that at the end of that day, I would have wandered back to my room, across the beautiful, jungle grounds, sighed, and put it down as a bad shift. Indeed, you may think, ‘That's not fair, she can take off her scrubs and leave the memories in the bucket of water she uses to wash them, but what happened will stay with me forever.’ What you do not know is that it will stay with me forever, too. I remember every baby who did not make it, and I remember yours. I remember knowing that you were sick with malaria, which wracked your body with fever, giving your eyes and your cheeks that flushed look, and which might have touched the life you created, though we will never know for certain. I remember touching your bump, and feeling your baby move, too easily, without kicking back, as a live baby might. I asked you about your pregnancy, how many months had passed, and how sick you had been. You were not sure about the first, although you thought the baby was about ready to come now the rains were here, but you were sure about the second, and you told me that you had been very sick. With a deep breath, I remember leaning over you with the faithful, battered pinard against my ear, and the fear and the sorrow I felt when the reassuring, whooshing, thump of the heartbeat did not echo back.
‘I know that you did not choose to be in such circumstances, unlike me, who accepted that, as a midwife, birth and death would collide far too often.’
It was nothing compared to how you felt; how your sister and your mother, and, later, your husband, felt. But I remember the look on your faces, the grief and the pain, and I felt responsible. I was your midwife. It was my duty, my privilege, to care for women like you and babies like yours, to guide you both through a healthy pregnancy and safe delivery—and I failed.
You thought it was your job to keep your baby safe, but it was mine, too. You do not bear the burden of guilt alone. I would say that you should not bear it at all, but I know that it would not change how you feel. It does not change how I feel when I tell myself that, and yet neither you nor I are responsible. You do what you can, when you can, in all the ways you can, and if that is true, you could not have done more.
In the seemingly endless moments that passed before I knew that I had to tell you, I thought of the outreach programmes that the hospital ran, the mosquito nets it distributed and the posters that were hung in the health centres. Despite knowing that we, the staff of the hospital, had done everything we could, still I could not shake the guilt, even though the baby had died before we first saw you. To be a midwife is to take a solemn vow to practise by the very concept that is enshrined in our title: to be ‘with woman’. That is how I can assuage the guilt; by being with you.
When I said to you that I was so sorry, but your baby hadn't made it, words that felt all too inadequate for the gravity and magnitude of what I was saying, and another midwife translated this into your native Amharic, I know that you looked at me and thought that I was mistaken. She's there, you created her, you would know if something was amiss. But in that moment, you realised, and I watched you steel yourself. Even with the malaria coursing through your body, I watched you gather yourself, nod, and know that this would change you forever, like it changed your aunt and your friend, and every other women who had lost their baby. It would change me forever, too.
I know that you did not choose to be in such circumstances, unlike me, who accepted that, as a midwife, birth and death would collide far too often. But you were there, and none of the protocols we have in place could have truly alleviated your sadness or pain. I could only be another changed woman, who would hold your hand and be with you through the sadness.
This is the most captivating element of my profession, Woinshet: that we call upon both art and science. I can tell you about the physiology of childbirth, about the chemistry and biology, but I can also trust my instincts that tell me that what you needed was someone to be there. It is the latter, as much as the former, that is the reason that midwives are the guardians of a centuries-old body of knowledge, which has helped women birth their children for all those years, and it is the latter that I knew I had to rely upon to help you birth your child.
So, gently, and together, we prepared for the birth. Gently, and together, we bought her into the world. Gently, and together, we held our breath and waited desperately for her to cry, even when we knew she could not. I remember how beautiful your daughter was, I remember tying off her cord, I remember weighing her. I remember wrapping her in a brightly coloured birth cloth, and handing her to your family so she could be laid to rest alongside others who had not made it. Above all, I remember looking at her and knowing that this is not fair.
In our corner of the world, in many corners of the world, the mortality rates are too high. There are too many women changed forever, too many brightly coloured birth clothes becoming shrouds. I wish that we, the midwives and doctors charged with looking after you, could have helped you. We could not, but maybe one day we can help someone else, and prevent another tragic stillborn story from being written. We can pay homage to those daughters and sons who never had a chance to live, but who still existed. Research and advancing the knowledge base are all we can use to get there, and there is a long way to go. But because of you, because of your baby, it is worth every step taken and tear shed. I do remember her, Woinshet, I do remember your baby. She was real, she existed, and her all too brief life touched me too. She did not die unnoticed, and when we have halted preventable stillbirth, she will not have died in vain.