An old-generation mobile phone rings shrilly next to a teapot.
Tengen picks it up and, without pausing, asks two questions: Blood pressure?
She writes down the answers in a notebook, puts on her pink apron, puts a stethoscope, a cloth measuring tape, an aluminum cone in her bag, and leaves her house walking through the sandy and dusty streets of downtown Kiffa, to the eastern Mauritania, heading to the central hospital.
In the same southern strip, but 5,000 kilometers to the east, in Chad, Lakone waits under a mango tree for the
that will take her along the highway of this part of the Sahel.
As soon as the first light of dawn enters, the day lends itself to visiting three health centers.
Tengen and Lakone are nurses and midwives, and the two broke with family tradition to train and pursue a profession.
Both of them, at some point in their youth, dreamed of a future that would transform the present.
In these two countries, the figures for maternal and child mortality show chilling data: in Chad, for every 100,000 births, 860 women die;
in Mauritania, there are 582 who lose their lives for every 100,000 births —the average in the European Union is six dead women.
A student walks into the practice room at the School of Public Health in Nouakchott—Mauritania's capital and most populous city—where she is trained in maternal, newborn and child health, and sexual and reproductive health.
More and more women are accessing this training.
Two nursing students take a manikin's blood pressure during postnatal control practices, in the practice room of the Nouakchott School of Public Health.
A group of pregnant women await their turn in the gynecological consultation of the Guerou health center, Mauritania, while an ambulance transports the young Mint during her labor. Pablo Tosco
Tengen, a midwife trained at the School of Health in Kiffa, Mauritania, reviews the medical record of Mebrouka Messoud, a six-month-pregnant woman, during her prenatal visit at the Kiffa health center. Pablo Tosco
Nurse Zeinabu Yaba performs an ultrasound on Lalla during her prenatal visit at the Guerou health center. Pablo Tosco
Tengen holds the basics of prenatal care: an earphone to listen to the baby's heartbeat and a tape measure to measure the size of the belly.Pablo Tosco
Tengen measures the size of the belly of his patient, Messoud, during her prenatal visit at the Kiffa health center. Pablo Tosco
Yaba assists Mint in the delivery of her first child at the Guerou health center.
In this place, around 10 deliveries take place every day, most of them to women who come from rural areas.
Mint places her newborn son on her chest, at the Guerou health center.
Kadja, a traditional midwife, with Kadja Nanga, six months pregnant, during an antenatal visit at her home.
The awareness and training work has generated an increase of almost 100% in the attendance of women for consultations, deliveries and care in health centers, reducing the risk for the mother and children.
Afaf Abdoul and Manara Abdoulaye, midwives at the health center in Malanga, Chad, during a family planning training.
One of the causes that increase the risk of maternal and child mortality is hypertension, a pathology that can trigger during pregnancy.Pablo Tosco
Kabon Kaba Nanga, a midwife at the Gondeye Health Center, Chad, with her patient, Kadja, during an antenatal visit in the new delivery room, antenatal and postnatal care. Pablo Tosco
Honorine is eight months pregnant and it is her third and last visit before giving birth to her fourth child at the health center in Gondeye, Chad.
Sabine Nanga, nurse, social worker and coordinator of the midwife training and family planning programme, stands with Raphael, Bernar and Brahima, nurses from the Koibo Health Centre, Chad, during a family planning training session for male health workers.
Fatima (in the background of the image) recovers after the loss of her first child during childbirth at the health center in Boyama, Chad.
Her mother and her neighbors accompany her.
Nathalie, a midwife at the Central Hospital of Sahr, Chad, assists Epiphany during her delivery. Pablo Tosco
Epiphany, a patient at the Central Hospital in Sahr, Chad, holds the feet of her newborn son.
Under the institution of marriage, girls are forced to have sexual relations with adults, and start pregnancy without any control or health monitoring.
The reasons lie in postpartum hemorrhage and the lack of resources to care for it, but there are multiple factors that trigger the silenced tragedy suffered by women in these countries.
The lack of sanitary infrastructure seems to be one of the main causes, but issues related to gender discrimination —based on cultural and religious beliefs that oppress, marginalize and exclude women— are the ones that root these statistics that do not finish explaining reality.
For example, forced and early marriage.
Lakone gets out of the
and enters a zinc-roofed building, surrounded by sand and mango trees, on the outskirts of a village of mud and thatch houses.
There, in a small room with a desk and a stretcher, is where she receives and cares for women before and after giving birth.
Today she is waiting for Amina and Muhar, two pregnant women of five and six months.
She takes their blood pressure, auscultates and vaccinates, while they talk about everyday life.
She says goodbye to them and reviews some laminated pages with traditional-style illustrations, which announce the start of a task that fills her with satisfaction: the awareness-raising workshop on family planning to fight against early marriage and motherhood.
Bilal Isa and Fatima Arab Adam read family planning manuals at an early marriage awareness session at the Barata community health center in Chad.
“Child marriage expels girls from the education system, since they have to stay at home to gestate and carry out care tasks,” Lakone says to a group of men and women who are sitting on mats listening to her.
The midwife explains that under the institution of marriage, girls are forced to have sexual relations with adults, then they start pregnancy without any health control or follow-up, and give birth in their villages with the help of traditional midwives.
These, she reflects, cannot and do not know how to deal with the dangers and pathologies that occur before, during and after childbirth.
The health and life of the girls, specifically, is put at risk from the moment their marriage is agreed.
"This situation has caused many minors to end their own lives, there are numerous cases of suicide in the Hadjer Hadjid region, [in eastern] Chad," she warns.
The dangers and pathologies
Hypertension, hemorrhages, diabetes, abscesses, fistulas, infections, womb detachment, there are multiple causes for which a woman can lose her life during childbirth or after it.
Pathologies that, with access to information, prenatal and postnatal controls, could be mitigated and reduced.
However, in these lands, the ones who decide on the health of their wives and children are the parents.
In Chad and Mauritania, many men do not authorize pregnant women to be seen by a male doctor, because it would violate the family honor and dignity of his wife.
"This is where one can generate true social transformations, break patterns, taboos and question the privileges of men over women," says Lakone, who trained as a nurse in the city of Abéché, the fourth largest in Chad, and then he specialized in accompanying women from rural areas in their deliveries.
The health and lives of the girls are put at risk from the moment their marriage is arranged.
This situation has caused many girls to end their own lives
School dropout and the lack of educational projection have left the universities empty of women and very few of them get to have a degree that enables them to become health workers.
The fact that there are no women doctors and gynecologists shows that the chain of multiple oppressions against women does not end at the moment of forced marriage, but rather in the projection of a life restricted by that act.
Like a macabre parable, the lack of women's health professionals has led men, heads of families who decide for their wives, to prohibit them from having prenatal check-ups in health centers and to force them to give birth in their homes. their own homes assisted by traditional midwives, with the high risks that this entails.
Kadja, a traditional midwife, with Kadja Nanga, six months pregnant, during an antenatal visit at her home.
The awareness and training work has generated an increase of almost 100% in the attendance of women for consultations, deliveries and care in health centers, reducing the risk for mothers and children.
Added to this are the long distances between urban centers and rural populations and the lack of transportation, another major drawback to tackling this reality.
Given this, the Chadian Ministry of Health and Solidarity and the Mauritanian Ministry of Health, with the support of Expertise France in collaboration with other local partner organizations, have launched two programs aimed at reducing these numbers and improving infrastructure and services for a quality primary and sexual and reproductive health care.
Child marriage expels girls from the educational system, since they must be secluded at home to gestate and carry out care tasks ”
Sara Pizzocaro, coordinator of the project in Mauritania, explains that the program aims to "improve maternal, neonatal and child health, sexual and reproductive health, acting on the health system and infrastructure" by strengthening it with the communities.
An approach that contributes to reducing violence against women and promoting gender equality.
Tengen, the Mauritanian midwife, is one of hundreds of women who have questioned this system.
For this reason, she studied at the School of Public Health in Nouakchott, the country's capital, and traveled to Kiffa, in the
(administrative subdivision in some Muslim countries) of Assaba, to accompany and assist rural women.
In her daily work, she believes in the transformative capacity of education accompanied by resources and infrastructure.
In Kiffa, health centers have been rehabilitated, prenatal and postnatal care rooms have been built, and a delivery room, providing equipment and training.
Both Tengen in Mauritania and Lacone in Chad carry out work to raise awareness among families about the importance of prenatal control.
This has allowed almost 100% of new births to be performed in an assisted manner in medical centers.
The figures fill Tengen with pride, who says he will not rest on his watch until all the women receive the attention and care they deserve, since they make an enormous effort to get to the hospital.
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