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PAKISTAN: Community Midwives Gain Recognition But Concerns Remain

Zofeen Ebrahim

KARACHI, Feb 7 2010 (IPS) - As Kanwal Gul, 25, lay on the delivery table a year ago, preparing to give birth to her first child, she made sure the traditional birth attendant (TBA) assisting her knew exactly what to do. Put on the gloves, she instructed her.

Gul also made sure a plastic sheet had been laid out on the delivery table just before she was to give birth and that the TBA had her safe delivery kit.

Gul belongs to village Mahmood Taheem, in Matiari district of the province, some 230 kilometres north of the port city of Karachi, where she has been working as a community midwife alongside three TBAs.

A certified midwife since 2004, Gul received a one-week training in community midwifery three years ago through a pilot project initiated by the United Nations Children’s Fund (UNICEF), in Sindh province, between November 2006 and December 2007.

“We all learned to be hospital midwives. But the (community midwifery) training prepared us to deliver in villages using only the most basic facilities, or even without medicines,” says Afshan Keerio, who practices in her village in Sanghar district in Sindh. Others say they learned the importance of sterilisation during delivery.

In contrast, a traditional midwife may be completely unschooled, having learned her trade from her mother or mother-in-law, as is often the case among TBAs in rural villages, but without fully understanding the female anatomy.

All throughout her pregnancy, Gul continued her task as a community midwife while seeing to it that she had her monthly antenatal checkups to ensure she and her baby were not at risk and she could go for home delivery. A year later, both mother and daughter are safe and leading a healthy life.

Gul runs a birthing centre, the next best thing to a basic health centre, in her poverty-stricken village, which helped her build the facility with the support of UNICEF.

The station is equipped with a delivery table and an intravenous drip stand. In the small courtyard is a latrine. Outside the compound is a hand pump provided by UNICEF.

Qadir Dino, the village councilor, credits Gul for the decline in maternal deaths in Gul’s village. “Fewer mothers are dying while giving birth,” he says, albeit without citing any data.

“Earlier, whenever there was a (pregnancy) complication, we would rush the expectant mother to any of hospitals in the adjoining towns of Hala and Bhit Shah,” says Dino.

Transport is a big problem, he says, since it is also very expensive. “And once we reach the hospital, there is no guarantee that they (the medical staff) will entertain us, since we’re poor and uneducated. We usually run from pillar to post, and even after paying are unable to get quality treatment,” Dino explains.

“With the birthing station, at least we know that if there is a complication, Gul will handle it or refer us to the hospital, and with her note, we can now expect them (hospital staff) to attend to our patients now,” says Shah Khatoon, mother of four.

A UNICEF birthing station project helped ensure the development of a strong referral system of community midwives (CMWs) with doctors from hospitals.

While the midwives have begun gaining the respect and trust of some villages, the TBAs have had to accept their slightly decreased stature, often grudgingly. Many villages, however, have yet to recognise the role of CMWs, since they still rely on the services of TBAs.

Gul says that while the TBAs do not say anything “to my face,” they make her feel as though she “has taken away their business.”

Each day, according to UNICEF’s ‘State of the World’s Children 2009’, 500 newborns across Pakistan die before they turn a month old. A newborn baby dies at least once in every four minutes in the South Asian country, which has the eighth highest newborn mortality rate in the world.

According to the Pakistan Demographic and Health Survey (PDHS), the maternal mortality rate (MMR) in both urban and rural areas during the period 2006-2007stood at 276 per 100,000 live births. The MMR is pegged at 175 in urban centres and 319 in rural settings, which form the majority of Pakistan’s population.

Under the Millennium Development MMR goal, Pakistan hopes to reduce the current ratio to 140 by 2015.

The PDHS survey reveals that only four in ten (39 percent) births in Pakistan are attended by skilled health personnel, with 60 percent of births handled by unprofessional and untrained persons, or TBAs, thus compounding the risks of maternal and newborn morbidity and mortality. Only a third (34 percent) of all deliveries take place in health facilities.

According to the United Nations Population Fund, “the single most critical intervention for safe motherhood is to ensure that a health worker with midwifery skills is present at every birth, and transportation is available to a more comprehensive level of obstetric care in case of an emergency.”

Dr Shershah Syed, a leading Karachi-based gynecologist and a women’s rights activist in the South Asian country, pins no hopes on doctors to reduce maternal deaths in Pakistan.

“Doctors, specially female ones, will never work in areas where maternal deaths are highest – the villages. Only a midwife from that area will be able to work and provide basic obstetric care,” he says.

Dr Farid Midhet, a Pakistani heading the Medical Research at Qassim University College of Medicine in Saudi Arabia, blames Pakistan’s ministries of health and population welfare for their lack of vision, or for failing to promote midwifery as a separate profession, saying it was always lumped together with nursing.

Efforts are underway, however, to amend the Nursing Act. Other ongoing measures are the conduct of short-term courses for midwifery teachers, pretesting of a new curriculum for community midwifery and strengthening of health facilities to make sure these can provide backup support to midwives.

In 2008 the Ministry of Health launched a five-year national community midwifery training programme under the maternal, neonatal and child health programme of the government to train some 12,000 midwives in community midwifery and deploy them in underserved areas across the country.

At present, some 6,263 CMWs are undergoing training under the programme. Some 1,230 CMWs have already completed their training.

“It gives us hope that with skilled birth attendants at the doorstep, we can achieve the Millennium Development Goals (MDGs) 4 and 5 [of reducing child mortality by two-thirds and maternal mortality by three-quarters] by 2015,” says Dr Nabila Zaka, a specialist with UNICEF on Maternal and Child Health Care.

MDGs are eight goals that respond to development challenges and form part of the Millennium Declaration adopted by 189 nations during the U.N. Millennium Summit in September 2000. They are intended to be achieved by 2015.

Despite the growing recognition that is being accorded to community midwifery in Pakistan, it seems this is not enough. “More needs to be done, particularly in the practical aspects of training of midwives, which should be strengthened,” says Imtiaz Kamal, president of the Midwifery Association of Pakistan, which comprises midwives and obstetricians.

“There is an urgent need for regulatory mechanisms for midwifery practices to protect the midwives and the women they serve,” she says.

Kamal is also concerned that “a majority of midwives are receiving diplomas on the strength of their theoretical training only.” Worse, she says, “Pakistan has no formal programme to prepare midwifery teachers. Nursing instructors are teaching midwifery at present.”

But Dr Zaka, UNICEF’s maternal and child health care expert, says these concerns are already being addressed. For instance, she says, midwives are already being identified from the community where they are most likely to stay and work, and trained in midwifery skills at local health facilities.

“These community midwives will be registered and regulated under the rules and regulations of the Pakistan Nursing Council and will practice midwifery in their respective areas under the supervision of district health authorities,” she explains.

Such measures seem to have begun to bear fruit.

Every day, from the government-run basic health unit where she works from 8 a.m. to 2 p.m., Keerio, the community midwife, proceeds to her birthing station so she can serve the needs of village women that otherwise have no access to basic health care.