A film by Brenda Davis. 2014. 86 minutes. Multiple languages with English sub-titles.

A review by Sarah Rudrum

Following the challenging work of health care providers in Ethiopia, Cambodia, and Haiti, Sister introduces personal stories that illustrate factors contributing to ongoing high rates of maternal mortality. In Tigray, Ethiopia, Goitom Berhane is a health officer at a hospital; his patients are women who arrive with complicated births. It’s work characterized by frustration, pain, and small triumphs. Goitom is a compelling lead character with a knack for incisive commentary. He asserts that intervening in this crisis is not a duty only for physicians, who can save one life at a time, but for all of us. Goitom speaks of birth as a normal process that needs to take place “in the right time, in the right place, with the right skill”. The women he sees have generally attempted to labour at home, reaching the hospital only after difficulties arise. At times, his accounts of their labouring at home come off as though he is blaming women for their failure to seek care earlier. However, the film also depicts a young health extension worker as she walks long hours to bring health information and antenatal care to rural women in Tigray. These scenes shed light on the social and geographic realities shaping the prevalence of home delivery.

Transportation challenges are clearly brought forward as we follow Pum Mach, a Cambodian midwife working at a rural clinic. For complicated deliveries, she needs to refer, but her patients can’t afford to travel to the referral hospital. She laments the loss of an ambulance service; poor bridges and the presence of landmines also affect transportation to care. For Pum Mach herself, distance from home means she must stay at work Monday through Friday, returning home only on weekends. Travel is portrayed as a complex and multidimensional challenge, which resonated with my research on the social organization of maternity care and birth in Amuru, northern Uganda. Alongside gendered power dynamics entrenched in HIV-testing protocols and NGO partnerships, transportation challenges significantly contributed to women’s difficulties in accessing care in this low-resource, post-conflict setting. Absent from the film, however, was reference to innovative solutions to these challenges.

Poverty is a theme throughout although, perhaps due partly to the decision to focus on three countries in three continents, the particular roots of poverty are not examined. In Haiti, the film follows Madam Bwa, a traditional birth attendant, as she makes her way through a crowded urban slum, providing patients with antenatal care and commanding advice. It’s clear that the challenge for mothers in her community doesn’t end with safe delivery. It’s painful to see malnourished babies, but such scenes are important to understanding that social and economic interventions are necessary alongside medical intervention.

Advocates for maternal health have repeatedly called for greater attention to sexual and reproductive rights. In Haiti, Madam Bwa promotes family planning, but none of her group members use contraception. In Ethiopia, Goitam’s patient has had a tubal ligation at her own request based on advice that an injury to her uterus would make future pregnancy risky. Her smiling husband says, “we have enough children”; their fifth baby has unexpectedly survived an emergency C-section. Pressure to have large families and lack of access to birth control are largely implicit in the film where they might have been explicit. Lack of access to abortion and the harm caused by unsafe self-induced or back street abortion are never mentioned.

In Vancouver, Sister was screened as a fundraiser for Shanti Uganda, an organization providing maternity care in central Uganda. A panel discussion introduced analysis building on the problems depicted in Sister. With reference to the decades-long conflict in her native northern Uganda, retired nurse Caroline Okot Bitek spoke of the devastating role conflict can play. She characterized war as a time when progress towards adequate health care and reproductive rights “moves backwards, instead of forwards”. The particular challenges for reproductive rights during conflict was the theme of a Reproductive Health Matters issue. Okot Bitek also discussed gender relations. Lack of support from husbands when it comes to seeking care or child spacing has a real impact, and polygamy often plays an impoverishing role, diminishing support for each woman. However, there is also social change in this area; in a Ugandan example she described, women are no longer discouraged from eating chicken, a high-protein food that for some time was coded as ‘male’. Nutrition during pregnancy is difficult to manage for many rural women in rural northern Uganda, so this shift in taboo is significant to maternal health. Dr. Farah Shroff and Dr. Dorothy Shaw shared stories from their rich experiences providing care in the global south, consistently returning to the point that maternal deaths are preventable.  Collectively, the panellists emphasized two points: the roots of the maternal health crisis in social inequalities and the importance of mobilizing political will. Though the film was less than clear on existing solutions and how to take action, it was deeply moving in its intimate examination of health workers and their patients. Sister inspires empathy and illustrates challenges shared across diverse settings and is a valuable film.

Read Sarah Rudrum’s paper Traditional Birth Attendants in Rural Northern Uganda: Policy, Practice, and Ethics

On 18th May 2015, RHM published a blog by Sarah on the outcome of a landmark case in Uganda in which the government has been held ‘accountable for its failure to protect, respect and fulfil human rights’ of women in childbirth.