ZAWIYA AHANSAL, Morocco (WOMENSENEWS)--Aicha Sasbou, who has worked for 30 years as a traditional birth attendant in this remote region of the Atlas Mountains, clearly remembers her first delivery.
She was called along with her aunt to help her own sister. Her job: hold the candle and provide light for the delivery, since there was no electricity. But once the baby arrived, Sasbou forgot her duties in her excitement and shifted the light to see the baby instead of aiding her aunt in cutting the umbilical cord.
Since then, Sasbou has helped deliver around 25 babies in the homes of two of Zawiya Ahansal's villages, including those of two of her daughters. She's had no formal training, but with each delivery her skills have grown.
When a woman is in labor in one of these poor, Berber-speaking towns, Sasbou instructs her to squat and hold on to a handle hanging from the ceiling. She massages the pregnant woman's belly with olive oil and feeds her the oil to speed up the labor.
Morocco has made great strides in improving maternal health in recent years, decreasing its maternal mortality ratio by over 60 percent since 1990. But women such as Sasbou, in remote parts of the country, can only do so much when a woman runs into serious trouble and access to life-saving care is a two-hour walk away, on a rough mountainous path sometimes blocked by snow.
"Seventy percent of mothers who die do so on the way to the hospital," said Dr. Abdelghani Drhimeur, head of communications at the Ministry of Health in Rabat. "It takes one hour to hemorrhage and die or even less."
These types of barriers have created a wide maternal health gap between city and certain rural women that Mostafa Lamqaddam, Peace Corps' health program manager in Rabat, said could curb the country's swift progress on maternal health. "The [maternal mortality] rate may stabilize. Probably the system will hit a limit."
Rural, Urban Disparity
In Morocco, 112 women die per 100,000 live births, according to a 2011 report by the Ministry of Health and the United Nations Population Fund. But the maternal mortality rate in urban areas in 2010 was 73 deaths per 100,000 live births, compared 148 deaths in rural areas.
Fertility rates also diverge. In 2009, the average number of births per woman in Morocco was 2.2; but in rural areas it was 2.7 compared to 1.84 in urban areas, according to the 2011 report.
In a place such as Zawiya Ahansal those numbers are drastically different.
Mereim Elmadkouri, who thinks she's 41 and also lives in Tamdarot like Sasbou, had two children, one of whom died. But Elmadkouri, who runs a women's association here, said she's the exception in this region.
"Women here have five kids or more," said Elmadkouri, sitting in her home, which lies on a steep, rocky incline above the river. "Even if they are poor they still give birth, even if children are expensive. Most want boys rather than girls."
Her head covered in a purple scarf and her fingernails polished with henna, Elmadkouri said she had her children at home with the help of her sisters. But this was partially why she lost her daughter, she added, during a difficult labor.
Sasbou, who doesn't know her age, has had eight children. She also gave birth at home, which she said is the general preference of women in the villages here. "It's easier for them to give birth at home," she said, holding her mouth because her few remaining teeth hurt that day. Bundled in a gray sweater, her head covered in a black and white scarf, she added, "It has to do with money and because the road is far."
A Rough Path
The Peace Corps carries out maternal health work in many hard-to-reach areas of Morocco, but not here.
From Marrakesh, the tourist-filled city, with its bustling old town, souks and palaces, the drive to Zawiya Ahansal is 125 miles, taking five to six hours along a winding mountainous road that turns into rocks and dirt as you approach the region's first town, Amzeray. The closest hospital in the area, en route, is in Azilal, around a two hour drive away from Amzeray, if the road isn't blocked with snow.
The government opened a health clinic staffed with nurses and midwives in the next town over from Amzeray, Aguddim, in late 2009. Aguddim is also the last town an ambulance from Azilal can reach, as the road for vehicles ends here.
From Sasbou's town of Tamdarot--a car-free place without any road for vehicles--the clinic can only be reached by foot or donkey. A 3.7 mile rocky trail to Aguddim runs alongside a river, goes up and down a mountain and requires two stream crossings. On a good day, the walk can take two hours, bypassing herded goats and sheep, green fields of crops, men on donkeys and women carrying sticks on their backs. Travel time likely rises for a pregnant woman making the trek.
In part to help bridge the gap between locals and the government's health resources in the area, Cloe Medina Erickson's organization, Atlas Cultural Foundation, kicked off a health education program in Zawiya Ahansal earlier this year. As its first initiative, the group and its partners conducted four community health awareness days in late May, which over 50 women, including the villages' traditional birth attendants, attended daily, she said.
In developing a health education program for the region, Erickson realized that traditional birth attendants not only required midwifery training, they first needed training in such basic things as sanitation, hygiene and nutrition before moving on to more technical skills.
"Midwives can fill the role of a community health worker," she said. "They can also become a liaison between the general population and the government nurses and midwives who often do not speak the local language or understand their traditional customs."
In addition to building clinics, the government is trying to reach rural women through various initiatives, such as sending mobile teams to provide a range of preventive care, including family planning, said Drhimeur.
The initiatives seem to be helping, said Genevieve Chabot, executive director of Iqra Fund, an organization that's partnered with Atlas Cultural Foundation. From talking to women in the region, "rates of maternal mortality have gone down. It used to be quite a few a year in each village and now I hear it's much less. One to three every two years," she said. "The government clinic here definitely impacted rates."
Elmadkouri explained that most women in her village don't use the clinic because it's far and difficult to reach. In contrast, Aicha Ssadki, a sheik's wife who lives in the town where the clinic is based, Aguddim, said she and others here do regularly visit the clinic.
Ssadki, who guesses she's 37 and wore a leopard print housecoat and a beige head covering, said that after a few women died in her village, many of her village's women became afraid to give birth at home. She had two of her five children at home; the others she had in Azilal's hospital.
"I prefer to give birth at the hospital because the doctor knows more things than my mother in law," she said. "In this village most women prefer to go to the hospital in the last month of pregnancy . . . They now understand giving birth in the hospital is safe."
Juhie Bhatia reported from Morocco on a fellowship from the International Reporting Project (IRP), an independent journalism program based in Washington, D.C. She's the managing editor at Women's eNews.