I had been in Tedda, a village in the northwest highlands of Ethiopia, for months, caring for several thousand Ethiopian Jews passing through a transit camp en route to Israel. They walked through mountain highlands and malarial lowlands for up to 3 weeks, armed and traveling in groups for protection from bandits and wild animals. The camp was a grassy site of a few acres, with residents living in tents, shelters, and papyrus huts. There were few amenities except for a small clinic. It was a two-bedroom cottage with a cement floor, cold water, and a Western toilet, making it the most modern building in the village.

Friday was quiet. In the evening I lit Sabbath candles with the children and invited the residents into the clinic for Kiddush, blessing the Sabbath wine. There had been no electricity for several days, and most people retired early. Saturday was blazing hot, and we slept all afternoon.

The early evening calm was broken when someone came in to inform me of a sick woman. I asked him to bring her to the clinic. Most of the people had no experience seeking medical care and had never seen a physician. We constantly encouraged them to come in when they were ill. My job was to treat their malaria, tuberculosis, scabies, and malnutrition and to keep them well. Childbirth was a particular challenge. In their villages, births were assisted by local women, trained or otherwise. I was not confident in their skills and knew that sterile technique was nonexistent. At the same time, as an internist with a bit of obstetric training, I felt that my own skills were limited to normal deliveries.

When the patient hadn't arrived in a few minutes, I wandered around the camp until I located her. Zewdie was a 20-year-old woman, pregnant with her second child, lying on the dirt floor of her canvas tent, surrounded by four or five relatives. They lifted her and guided her along a path to the clinic.

A dozen people followed her in; most were relatives but others were curious and simply wanted to observe. I promptly ordered everyone out so I could examine the patient and deliver the baby. Zewdie and three women remained: Birtukan Fassika, the 60-year-old daughter of Kes Fassika, a well-known rabbi from the Semien Mountains, and two others. All were dressed in traditional clothes: loose hand-woven white cotton dresses with colorful, embroidered designs along the borders. Birtukan's worn brown skin was well-lined, bespeaking her years. She had short gray hair covered with a black cloth which smelled of the pungent eucalyptus smoke of her cooking fires. Birtukan's one upper tooth fit perfectly into a gap in her well-stocked lower jaw. Around her neck she wore two metal beads on black threads as well as two strings of thin white beads.

Alemu, my health assistant, had walked into the village to eat, leaving me alone. Zewdie alternately squatted on her bed or lay on the right side. In Amharic, I asked her to lie on her back. She ignored me. I gently eased her onto her back and examined her. She was about 6 centimeters dilated, not yet ready to deliver. I felt frustrated by the paucity of support, Zewdie's lack of cooperation, and my own limited obstetric skills.

The electricity returned and I put on some water to boil ("just like in the movies," I thought), planning to tie the cord with dental floss and cut it with a boiled razor blade. The women had far different plans that excluded me. The brief exam I had undertaken without explanation did nothing to improve our relationship. Attempting to regain control, I asked Zewdie to lie on her back and eventually shouted and pounded the mattress, all to no avail. A crowd had gathered outside listening to us.

Alemu returned and produced an infant suction, thread, and a sterile blade, then cut the corner of a clean blanket in which to wrap the baby. Birtukan realized what we were doing and calmly handed me a razor blade and a piece of twine. Neither was very clean, but nonetheless she was prepared. The patient was kneeling, leaning forward with her arms around the neck of another woman, Birtukan sat on the bed behind the patient with her hand supporting Zewdie's buttocks. Alemu explained to the women that we wanted the patient on her back so we could assist the birth.

Birtukan, clearly the designated birth assistant, looked up. "This is not for men," she said firmly.

I was not permitted to touch the patient. Zewdie moaned during her periodic contractions as I stood by. I felt helpless and impotent, controlled by an illiterate, homespun midwife. My anger was increasing and I considered forcing Birtukan and the others out so I could take charge. Zewdie's choice, however, was obvious. I reluctantly backed off.

A short time later, the contractions slowed. Birtukan announced that she needed a "kai doro" and "itan". I wondered if I heard her correctly asking for a doro (chicken). I was astounded when one of her assistants soon entered carrying a live, red, squawking chicken upside-down by its legs. As Zewdie leaned forward, Birtukan took the chicken in her right hand and made large circles with the bird's breast against Zewdie's back. Another messenger entered and showed me a yellow, crystalline substance wrapped in an old newspaper.

"Itan," Alemu commented quietly, "frankincense".

Smoking coals on a metal grate were brought in, and the frankincense was added. The room immediately filled with thick, pungent smoke. Birtukan continued making silent circuits with the bird in a businesslike manner. I quickly opened the window to prevent us from being asphyxiated. As the air cleared, Birtukan turned to me. "This will speed the labor," she said, as a teacher speaks to a new student.

Before she finished her explanation, the baby crowned. Zewdie was kneeling steadily on her hands and knees. I immediately gloved and caught the baby boy, moving him away from a pool of amniotic fluid on the plastic mattress. He breathed easily and his color was good. As Alemu and I clamped the cord, Birtukan and her assistants put a shawl over Zewdie's back to block the baby from the crowd of people watching at the doorway. Alemu appeared nervous as he tied and cut the cord, and his usually steady hands trembled. He had done this many times, however, and I did not comment.

We laid the baby on a piece of cut blanket and waited for the placenta. I was relieved that things had gone smoothly thus far. I always feared an abnormal presentation. This time it would have been more difficult because of Birtukan's presence and my marginal role in the birth. Birtukan called for "gunfo," a thick mixture of oil and boiled wheat for the mother to eat.

With the stress of the delivery behind me, I wanted to understand Birtukan's techniques.

"Birtukan, why the chicken?" I asked.

"Koleh, an evil spirit," she explained, "separates the patient from God and slows the birth. We use the red chicken and incense in every birth to block the Koleh".

"But," I asked, "what happens if the baby still doesn't come?"

She looked up. "Then you have to stand the pregnant woman up". She stood to imitate the position. "You keep her standing, but make her bend as far forward as possible from the waist, grabbing her ankles with her arms and keeping her head down by her knees. Then two men must pick her up by the legs and shake her. If that doesn't work," she continued, "you have to turn the woman upside-down and shake her some more. Then you point her head toward the floor and gently shake her again. Keep it gentle. After doing this several times, instruct her to squat. This will rotate the baby if it is in an abnormal position".

Birtukan admitted that although she had delivered countless babies, she had used the more extreme maneuvers infrequently. I asked her how she got all her knowledge, and she replied that as a young girl she observed the older women in the village.

She looked over at Zewdie and added, "If this fails, I call in a more senior person".

"Who would be more senior than Birtukan?" I wondered.

"A few women," she went on, "put butter on their hands and insert them in the uterus to rotate the baby until it is in a position to emerge on its own".

Alemu called that the placenta had just been delivered.

"It looks good," I commented. Birtukan was behind me.

"Hulu wutual," she assured us, "It's all out".

As I bathed the baby, I asked Birtukan why she had held up a shawl while we cut the cord.

"Buda—evil eye," she replied. "A lot of people were watching. If any had evil eye, the baby would become sick". Ethiopian mothers often stay inside for weeks to protect their newborns from such things.

Word spread throughout the camp that the baby was born, a healthy boy. The room filled with women who brought fresh coffee made over fires lit after the Sabbath ended at nightfall. They painted Zewdie's hair with butter twelve times, each accompanied by high-pitched ululations.

The chicken squawking in Zewdie's room next to mine woke me before sunrise. I rolled over and asked myself, "Was it really necessary for a chicken to sleep in the clinic last night?" I walked into Zewdie's room to check the baby.

"Dam nebur," Birtukan announced without emotion, "there was some bleeding".

I saw that the baby was very pale and his blanket was soaked with blood. Birtukan had retied the cord with her twine. The baby was less active than he should have been. His skin showed signs of dehydration and his heart rate was slower than expected. It made no sense to me since I expected an increased heart rate from blood loss. I was confused and becoming nervous.

I woke the staff and we made an oral rehydration solution with extra sugar. The baby was now asleep, so I inserted a nasogastric tube, confirmed its position, and slowly gave fluid through a syringe. Soon after, he stopped breathing. Alemu carried him into the examination room and I began gentle chest massage and mouth-to-mouth breathing while he suctioned frothy fluid from the nose several times a minute.

The baby seemed cool. Alemu suggested we move into my bedroom which gets the morning sun. He picked up the baby and rushed him in, lying him on a clipboard on my bed to support compressions. I placed the baby in warm water and continued the process for several minutes, soaking myself and the floor. I couldn't believe this was happening. Last night this was a healthy newborn and an uncomplicated delivery. As I looked at him in the bath, something inside me said, "In a minute he'll wake up and be normal". When we transferred him to the bed, the frothy sputum coming from the lungs became blood-tinged, strongly suggesting pulmonary edema. I surmised that he had a congenital heart lesion. We continued resuscitation, but there had been no signs of life for over a half hour.

"Any suggestions?" I asked the staff.

Nobody volunteered. We all felt crushed. I thanked everyone and halted our efforts, almost 12 hours after his birth. A nurse went in to tell the mother that her baby had died. Loud wailing arose from the room next door.

I called for our regular morning prayers to begin and asked a few men to prepare a grave in the Tedda Jewish Cemetery, a remnant of the time when hundreds of Jews lived permanently in the village. I asked Birtukan to explain the burial custom. As an old woman and the daughter of a rabbi, she would certainly know how to prepare a body. She instructed me to wash it, tie together the wrists, thumbs, and ankles with twine, and cover it with "abujedi," a yellowish cotton in which Ethiopians wrap corpses. I followed her instructions, placed the body in abujedi, and sewed it shut.

Alemu wrapped a sheet of wicker around the abujedi. I noted how well Alemu tied knots in the wicker, then realized that he had tied the umbilical cord. At that moment, he paused, looked up, and said, "I'm sorry". I said I understood. I did not blame him and I was not convinced that blood loss was responsible for the baby's death.

I asked a young Ethiopian rabbi nearby to officiate at the funeral. He explained that when a newborn dies, it is their custom to bury the body without ceremony and without a rabbi. We carried the body to the cemetery, across dried ploughed fields, and up a hill. When we arrived at the site, we found the earth was hard and dry. The prepared grave was too small, so Alemu and I took picks and enlarged it.

I counted the mourners. There were nine men and an equal number of women. We could not say Kaddish, the prayer for the dead, without ten men. Our worlds were far apart. Kaddish was my tradition, not theirs. So was sterile technique and barring animals from the delivery room. Despite this distance, I looked at these people with admiration and wonder. Their faith, strength, and tenacity had kept them together for centuries. Only with openness and respect for their traditions could I be successful with them. This meant considering Birtukan a colleague rather than an adversary and tolerating the chickens, ululation, and my limited role.

I felt calm but drained. I took the body and placed it in the grave. Several of us put handfuls of dirt on the corpse, then took turns filling the grave with a shovel. Afterwards, we placed a large pile of stones over the site to mark the grave.

It seemed too soon to leave. We all sat down. Alemu gave a talk. Then I said, "Dear God, we thank you for the birth of this baby, and we pray that you protect its soul, now and forever". Alemu translated. We sat for a few minutes more in silence. We were on a hill overlooking brown, rolling farmland. The sides of the hills were dotted with mounds of grain. Cows grazed in the distance. The wind blew gently on us. It was peaceful, idyllic. A baby on a woman's back cried as the mother shook her shoulders to amuse her.

"Ishi," I said, "OK".

We stood up and slowly filed out. The men carried their dulas, walking sticks or shovels or picks.

"Qoy, qoy," I called. "Wait a moment. I want to thank you for coming. Many of you are not related to the family at all. I appreciate your being here".

"Chiger yellem," they replied, "no problem," as they walked away.

Later I stopped into Birtukan's tent. She was sitting on the ground, chatting with a relative. "I know you feel very bad," she said to me. "We all feel that way".

"Birtukan, you're right," I replied. "How long will it last?" She looked into my eyes.

"A week. A week, and that's it," she said confidently.

"How can you be so certain?" I asked.

"The Bible says so," she answered.