Training helps Pakistan midwives curb maternal deaths
Midwifery training by a local NGO in Pakistan's Sindh province is helping traditional birth attendants better understand birthing complications and value safety in deliveries. In a country where young girls are married as soon as they reach puberty, the training has also encouraged women to question such cultural norms.
Until recently, 55-year-old Sabhai Bibi, a traditional birth attendant (TBA), known as a 'dai', used an age-old method of cleaning the vagina after birth.
"I'd shape gur [clarified sugar cane] and some herbs into a ball and put it inside the vagina. After two days I'd replace it with a ball of misri [sugar crystals] and remove it after five days," she said.
- A trained midwife shows off her new delivery kit/ Photo credit: Zofeen T Ebrahim/IRIN
Bibi, from the village of Sonu Khan Almani, some 300km from Karachi in Sindh province, is not the only one using such potentially unsafe methods. There are thousands of TBAs across Pakistan who handle most births in rural areas with minimal training and basic equipment.
Fatima Bibi, another TBA based in the nearby village of Qasimabad, after cutting the umbilical cord with a kitchen knife, would use ordinary thread to tie it. She also advised women to push with "full force" during uterine contractions, often not realising the cervix had not dilated. "I didn’t know this could lead to the tearing of the cervix and cause post-partum haemorrhage," Fatima said.
Most TBAs put kohl, oil and even cow-dung on the child's umbilical cord to make it heal faster. The colostrum, the first milk after birth, is wasted, and instead the child is given honey mixed with some herbal concoction, even butter or kheer (milk cooked with rice and sugar).
"Not any more," said Bibi, who has delivered over 100 babies since she started eight years ago. She picked up the trade from her mother-in-law.
"We were not educated and followed whatever was passed on to us," she said. Now, after 15 days of midwifery training, she is horrified by the risk she had put women and infants through.
TBA training programme
Bibi is among 104 TBAs trained under a programme by the Sindh Rural Support Programme (SRSP), a local non-governmental organisation (NGO).
"Since we started four years ago, I have found a sea change in these birth attendants," said Fizza Qureshi, coordinator of the training project, adding that TBAs play a crucial role in rural areas, where they carry out over 80 percent of deliveries.
The training includes understanding the anatomy of the reproductive organs, giving post-natal follow up counselling and educating women on breast-feeding, safe delivery methods, sexually transmitted diseases (STDs), family planning and child spacing. The TBAs are also provided with disposable safe delivery kits with sterilised birthing supplies that include gloves, a plastic apron, a plastic sheet, soap, clamps, a new razor, string and cotton balls.
"These cost only Rs 40 [about US$0.50]," said Qureshi. "If these kits are made cheaper still and made easily available in the market, this would further help ensure adherence to hygienic practices."
The training has also helped the TBAs to identify birthing complications in time and refer cases to the nearest hospital.
Since Saran Bibi received training a year ago, she has referred seven cases to hospitals. "In the past I would never allow my client's family to take her to doctors. I would consider difficult cases a challenge to my expertise. I never realised that some infant deaths could have been prevented," she said.
Questioning cultural norms
The training has also encouraged women to question certain cultural norms. "We had been brought up to believe that as soon as a girl got her first period she should be married off," said Khadija Bibi, 35, who has four children and has had two miscarriages. She recently had an intrauterine device (IUD) - birth control device - placed in her uterus after her fourth child.
"My husband refuses to use a condom," she said shyly.
"It's their husbands who do not want to adopt any family planning methods," said Pathani Bibi, another 'dai'. "They get married young, have too many children and thus many die of bleeding." The major cause of maternal mortality in these villages is by haemorrhage.
"We need to understand the important role of the TBAs," said Dr Ghulam Hyder Akhund, programme director of the government's Provincial Health Development Centre. He said these "life savers" are "virtually ignored”.
Pakistan's maternal mortality rate is 350 to 500 deaths per 100,000 live births and infant mortality rate is 83 deaths per 1,000 live births, the highest in South Asia. At present, the country is at risk of not reaching Millennium Development Goals (MDGs) 4 and 5 of reducing under-five mortality by two thirds and maternal mortality by three quarters.
