Giving birth here is largely a silent affair.

Women might allow themselves a few closed-lipped “Mmm” sounds. But it’s a stark contrast to cries we’ve come to associate with giving birth in the U.S.

Epidural injections to dull the pain are rarely available here, too, making the feat even more impressive.

One woman told me that making noise is considered shameful for the woman, proof that she can’t bear the pain of birth. My host sister, Fanja, says it’s simply because the women here are strong.

In fact, the women I talked with were as surprised to learn that American women make a lot of noise as I was to learn that rural Betsileo women here don’t. It’s no surprise Betsileo means “the invincible ones.”

I learned this a few weeks ago after Fanja had her second child, a healthy baby girl. Lying on a concrete floor with only a grass mat for cushioning, she gave birth at home with the help of a midwife and several family members.

I’m not exactly sure how long it took Farantsa to come into the world. I’m still kicking myself for bowing to our American ways of giving people privacy and heading home after lunch to wait for word. When I returned a few hours later, I was just in time to see the midwife wrap the new baby in a blanket and remove the placenta.

And just like that, I became an aunt to a little Betsileo girl.

Over the past several months, I’ve learned quite a bit about pregnancy in my village, largely through Fanja. Some things have been pleasantly surprising, like the free services available for pregnant women at the local health clinic. Others have left me deeply concerned, especially the abundance of pregnant teenage girls in my area.

Like in the U.S., women here can purchase a pregnancy test if they suspect they’re pregnant. But many women still don’t know about it, and most learn after missing their period.

As soon as they suspect they may be pregnant, women are encouraged to visit the local health clinic to see the doctor. This visit is free, as are the monthly follow-up appointments. Women receive a mosquito net from the clinic for free, as well as iron supplements.

Most women don’t know the gender of their baby until after they’ve given birth. As Fanja put it, only the rich people here can afford an ultrasound. But after we were involved in a small tuktuk accident, I offered to pay for one so we could confirm the baby was OK. It cost me a little over $9.

Virtually up until the day a women gives birth here, she continues working. For Fanja, that meant cooking, cleaning, selling goods from her store and processing rice, a labor-intensive process that involves pounding grains repeatedly until the rice and husks are separated. In her last trimester, she hiked up into the mountains several times to visit her rice fields, even spending one morning planting rice seedlings.

People here believe that resting too much will make the birth especially difficult. Me, I simply marveled at the fact that two weeks from giving birth, Fanja was still trekking 40 minutes up the mountain side like it was nothing.

When the time comes, women have the choice of giving birth either in the health clinic with a doctor or at home with a midwife.

Women who choose to give birth in the health clinic may have the option of traveling by vehicle, if one is available, but most walk more than a mile or are carried in a cloth. However, it’s only an option for women who go into labor during the day. As I wrote previously, people here avoid traveling at night.

The cost of giving birth at the clinic depends on the length of time and difficulty of the birth. It’s pretty expensive for folks here, and most give birth at home. Midwives are cheaper and are available to respond at all times. Plus, there’s no limit to the number of family members who can witness the birth. Husbands are also allowed in the room, but other male relatives are not.

Once Fanja was covered up and put to bed following Farantsa’s birth, family and friends began filing into the room to congratulate her and her family on the new child. An hour after giving birth, there were more than a dozen people sitting in the room celebrating with small cups of beer and soda, just feet from where Fanja was resting.

To my shock, I learned that Fanja would be moving in with her older brother and sister-in-law a couple villages over. While women are expected to work up until giving birth, the Betsileo have strict customs about resting afterward. With no other woman in her home to take over the cooking and cleaning, and no female relative able to temporarily move in with them, it was her best option.

Customarily, women here are expected to remain bundled up in bed with their newborns anywhere from two weeks to three months. The length of time often depends on a family’s resources, Fanja said. Because of this, women from wealthier families are often able to rest longer than those from poorer families.

Even though the temperatures often reach the low 80s here, women wear several layers and close the windows when it’s breezy to protect their health, and the baby’s, too.

Fanja was so hot at times, I could see sweat dripping down her face. Once when she got up to use the bathroom, I laughed as she wrapped two blankets around her sweatshirt-clad body in the heat of the afternoon.

Still, the biggest differences I’ve seen between the U.S. and Madagascar is the culture around breastfeeding. Everyone from office workers in the capital to rural women breastfeed freely in full view of everyone: sons, brothers, fathers and strangers.

As one woman told me, breast milk is free and always available, unlike formula, which costs quite a bit here.

But perhaps the most surprising thing for me was the variety of birth control options available at the local health clinic here. In many parts of Madagascar, birth control measures are either unavailable or rejected for cultural reasons. But in my region, women can get an IUD, an implant or an injection for roughly a dollar.

Fanja received the arm implant after having her first son at 17. But over a year ago, after she and her husband decided to try for their first child together, she had it removed.

Families are extremely large here, however, leading me to believe many don’t know about birth control or choose not to use it. Teenagers would especially benefit from educational programs, I think. I’ve seen girls as young as 12 pregnant here.

And if the health risks of teenage pregnancy weren’t enough, abortion is illegal across Madagascar. Women often seek them out anyways.

Some doctors quietly offer the service for a hefty fee. But most often, desperate women turn to risky home remedies to end their unwanted pregnancies, sometimes leading to death for both the mother and child.

That’s how a close relative of my host dad died, Fanja tells me. Doctors couldn’t save the pregnant teenager after she ate a concoction meant to prompt a miscarriage and became fatally ill.

Women don’t often die due to pregnancy complications, Fanja tells me. But many babies are stillborn or die shortly after birth. For every 1,000 children born in Madagascar in 2021, 45 died during their first year of life, according to the United Nations Children’s Fund.

There’s still a lot I don’t know about child mortality in Madagascar, so I’ll stop there. But I do know that poor nutrition plays a significant role in these premature deaths. That’s a big reason my fellow volunteers and I continue to talk with women about eating more protein, calcium and nutrient rich foods.

With this in mind, I’m going to continue teaching women about nutrition and hope some of it sticks. Already, I know some of it has.

As for Farantsa, I’m personally going to make sure she grows into the smartest, healthiest little girl in Madagascar.

Note: This column was written with Fanja’s consent.

A reader asked about last month’s column:

I noticed the men removed the horns from the cattle. What will they do with them? — John Wood, Turner

This was an interesting question. As it turns out, people here don’t do anything with the horns, I’m told. They’re removed simply to get them out of the way, as the Betsileo eat the meat on the skull and the brain too. Little goes to waste here.

Have a question? Send it to van.paolella@gmail.com or by snail mail to the Sun Journal at 64 Lisbon St., Suite 201, Lewiston, ME 04240.

On a personal note:

A couple of weeks ago, I planted dozens of trees with the local high school environmental club. After a month of back and forth, I was able to connect with the man who runs the local government nursery and bring more than 80 trees back to my village (for free!). The high school students were thrilled, and we ran out of room planting them around the high school. I’ve learned that while folks here want to plant trees, there is a major gap in knowledge on how to do it well. I’m planning to work with the club and the community to teach them about the importance of biodiversity and planting native trees. And if all goes well, we’ll soon build a tree nursery near the high school and put theory into practice.

Vanessa Paolella is a Peace Corps volunteer in Madagascar, a former award-winning staff writer for the Sun Journal and a Bates College graduate. The views expressed in this column are hers alone and do not reflect the views of the U.S. government, the Peace Corps, or the Madagascar government.

Editor’s note: A statistic on infant mortality in this story was corrected.

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