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The Love Offer

By Ann Davenport, A&S '05 (MA)
Illustration by Stephanie Dalton Cowen

On a hot summer day in 1991, in the village of Licoma, high in the isolated Andean mountains of western Bolivia, our Save the Children staff members sit through another tedious meeting. The small, crowded room stinks like a dirty sauna. Wooden tables, wooden chairs, and the wooden floor barely absorb the sweat of 24 bodies. No electricity means no fans, and open windows only invite in more flies. Eyelids drift downward. Hands cover yawns.

Suddenly, the screen door bangs open. A pre-adolescent boy stands there panting, his black hair wet with sweat from running down the mountain. "Come quick," he says, looking at me. "The baby won't come out, and Papá told me to bring you." I am the midwife-in-residence working for Save the Children in this province. I recognize the boy as the eldest son of Carmen and Juan, a couple who recently made a prenatal visit.

A staff driver, Alberto, volunteers to take us to the footpath leading up the hill to Juan and Carmen's village. We drive down the dusty road as fast as we dare and soon find the footpath to begin our climb. Forty-five minutes later we arrive, breathless, knees wobbly, hearts pounding. I survey the cluster of adobe huts. We hear sobbing from one small home — the one the boy walks toward. A few men and women sit on the dirt patio under the shade of a large fig tree, quietly staring at us.

I enter the dark interior. "What happened?" I ask, panting. Juan kneels on a dirt floor next to a very still Carmen, who is prostrate on a red wool rug. Wiping away tears, he explains, "My wife was in labor all night and this morning. The baby finally came out. Then she looked at me with terror in her eyes, and she died! Just like that!" He holds her hand in one of his and covers his face with the other, crying.

I search my birth bag for a stethoscope. What could have happened? Her body is still warm, though I hear no heartbeat. A small circle of blood coagulates between her legs. "No hemorrhage," I decide, due to the small amount of bleeding. Maybe the uterus tore. I feel the womb to determine rupture, but it feels intact. No twin inside. No placenta nearby.

Then I remember the baby.

"Where's the baby?" I ask, grabbing Juan's shoulders. He points to the other side of the room, where, on top of some dried sheep skins, a naked, fat baby boy lies still. He is wet, barely breathing, and cold to the touch.

Grabbing a nearby piece of cloth, I pick the baby up and race outside. Rubbing him warm and dry, I try to stimulate his heartbeat. Approaching a silent woman sitting nearby breast-feeding a toddler, I tell this mother what I need to do, shove the toddler out of the way, and place the newborn onto her bare skin.

"We have to warm up the baby," I say, "so his heart will beat and to make him cry. If you stimulate a baby like this, and he cries, he'll be all right."

Oh, please cry, I silently beg, rubbing him while the woman stares up at me. Within a minute, the baby cries and begins suckling. Ah! That miraculous sound!

Relieved, I look for a spot in the shade where I can catch my breath and collect my thoughts. But no one moves over to let me under the tree. No one offers a tin cup of water — the usual custom when an outsider visits a village. No one congratulates me or smiles with shared relief.

The women stare at their bare feet. Some men look me in the eyes without any gesture of gratitude or contentment. Am I the only one who feels a sense of accomplishment? One dark-brown, weathered farmer finally voices what the others are apparently thinking.

"Why did you do that, doctora? Who will feed this baby now? Who will take this baby now that the mother has died? Will you? You should have left alone what nature had intended."

When I began to work for Save the Children in 1991, I had had no previous experience with cultures or governmental health policies outside of the United States. I didn't know, for example, that when contraceptives began to appear in Bolivian towns in the late 1960s, rumors circulated that the U.S. Peace Corps was attempting "genocide" of Aymara or Quechua indigenous peoples. In the 1970s and '80s, under Bolivian dictator General Hugo Banzer, health policy prohibited the distribution of family planning information, made abortion illegal, and encouraged couples to have as many children "as God gave them." Those policies changed in 1990, when Bolivians elected a new government. The new leaders appointed health ministers more open to family planning, and World Bank loans to the country offered incentives to promote family planning.

Radio campaigns were easy enough, but access to pills, condoms, or IUDs was difficult due to the isolation of the residents, or to their resistance to imposition from "outsiders." For many years, family planning methods were unheard of in rural provinces. Women lived their entire reproductive lives pregnant, lactating, or post-partum. During this time, Bolivia had the highest maternal mortality rate in the Western Hemisphere. (Today it is second only to Haiti.)

Many rural people counted on traditional methods — celibacy or waiting three months after childbirth — for spacing children or reducing the number of pregnancies. Other traditions included plant medicine to abort a fetus, and sometimes a vaginal insertion of caustic substances to provoke abortion, which could be deadly to the mother. When those methods failed, infanticide was one time-honored backup method.

"Here is a crying, wiggling, full-term baby boy," I say. "This is a baby, not a puppy. I'm not going to put a knife in his heart or drown him now. Will you? Or you?" I was therefore surprised and delighted when Carmen, a 32-year-old Aymara Indian eight months pregnant with her 10th baby, walked two hours from her mountain home to the health post for a prenatal visit. Juan accompanied her. He had attended Carmen's previous nine births at home without a hitch. But now they wanted to meet the new gringa midwife and get information about avoiding further pregnancies.

Short and slightly built, Carmen was a little pale but still had most of her teeth, which was a good sign. I talked with the couple about Carmen's risk of hemorrhage, her nutrition, and their knowledge about family planning.

Juan looked a little older than Carmen. He had Brazil-nut brown skin with thick, calloused farmer's hands. He and Carmen touched hands quite often, an unusual gesture of affection between a rural Indian husband and wife.

Despite my urgings, Carmen refused to give birth at the health post. She preferred her own home, where she had given birth nine times before.

"Please send someone for me when you start labor," I told her, then said to Juan, "I'd be happy to assist you and Carmen — free of charge!" He smiled at me to be polite. Deep lines surrounded his brown eyes, and I couldn't help but wonder if he was laughing at the very idea of me helping him with the birth.

Now, only a few weeks after that calm prenatal visit, I find myself having to justify to Carmen's angry neighbors why I am struggling to save her child's life. I'm confused and hurt. I consider my fear and my response to this accusation while wondering about the Spanish word for "lynch mob." Shaking inside, I take some deep breaths. My mouth is so dry, how can I speak? I finally stand up and walk over to the woman still breast-feeding the baby.

"Here is a crying, wiggling, full-term baby boy," I say. I retrieve the "bundle of joy" from the unhappy woman, and hold him out at arm's length for all to see.

"This is a baby, not a puppy. I'm not going to put a knife in his heart or drown him now. Will you? Or you?" I ask, pushing his squirming, healthy body into the faces of a few men around me.

"Oh, no, doctora, we're not talking about killing him! You don't know your Spanish!" someone shouts.

But I know exactly what they're talking about. In Spanish, as in English, "to kill" and "to allow to die" are different verbs and different concepts.

"Well," I retort, "he's not an animal, he is a human being. He has a father and brothers and sisters and a family and a community, and now you want to kill him — because to let him starve to death is the same as killing. It's slower and crueler than a knife, too."

"But how will his father feed him, doctora?" another woman says. "How will his brothers and sisters take care of him now that they have lost their mother?" These farmers, hardened by surviving a hand-to-mouth existence, all nod their heads in agreement. We argue intensely. More people gather for this impromptu community meeting.

I suggest we ask the opinion of the father, now standing at the open door of his home. Grief stricken, Juan waves us away. I ask the village elders for their opinion. I ask the siblings for theirs. (The older boy offers to keep the baby with him, which brings guffaws and grunts all around.) I talk about adoption. Everyone has an opinion, and they all want to punish me for bringing this dilemma into their lives.

"YOU take him! You're the one who saved his life!" someone shouts at me.

"I am very sorry, but I cannot," I reply. "The Bolivian government prohibits foreigners from adopting Bolivian babies."

I offer to buy baby formula and bottles for anyone who takes the child. I ask about other couples in other villages nearby who might be willing to raise him. Juan comes out of his hut and sits with us. He says he will regalar (literally "to gift") his son to anyone who wants him. There are no takers.

At long last, a tiny, wrinkled grandma hauls herself up from the dirt using her cane. She says nothing at first, until everyone becomes quiet and looks toward her. Her eyebrows come together in anger and her lips press tight into a straight line. She speaks to the crowd in a shaky voice, her finger pointing impolitely at each of them.

"I'll take the boy," she declares. "You all know me. I have nothing in my home. Nothing. But I have love. And that is something I see here no one has. That is what makes you poor."

I stand up to hug her, but she only allows a kiss on the cheek. While I talk with her about arranging a drop-off of baby bottles, formula, and cloth diapers, she continues to glare at the people sitting around the dirt patio. They examine their feet, do not return her gaze, and then begin to leave.

Did Carmen have to die? What could have prevented her death? Why do women continue to give birth at home, instead of with trained health care providers? What difference can service organizations, such as Save the Children, make in the world? I didn't think about those questions then; I only focused on saving one life, like all midwives do in each instant that confronts us. I can only guess that Carmen may have died of an embolism or perhaps a ruptured uterus. An autopsy is prohibited in Aymara culture, and the custom is to bury the dead within 24 hours.

While all the "negotiating" about the baby's fate was taking place in the yard, two elderly aunts had been washing and preparing Carmen's body. They called me in at one point to ask what they should do about the placenta still inside her. In Aymara tradition, it's important to bury the placenta in a secret place near the home so the spirit won't come back to claim the life of the baby.

"Well, since she is now a spirit herself," I said, "Maybe we should just bury her with the placenta inside — what do you think? Then they will both protect the baby."

They agreed, and that night, Carmen Maria, 32 years old, mother of 10 children, wife to Juan for 14 years, was laid to rest under a full moon rising over the steep tropical mountains of western Bolivia.

Ann Davenport, A&S '05 (MA), is a nurse, midwife, and a consultant for JHPIEGO, a Johns Hopkins affiliate that improves health care internationally for women and children. This spring, she received a master's degree from the Writing Seminars.

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