Trainee Midwives Bring Expert Care to Rural Women in Pakistan
By Fatima Raja
NANKANA SAHIB, Punjab Province, February 2008 – Tabassum Naseem walks through the dimly lit women's ward at the Nankana District Hospital. She pauses to gently examine a pair of twins only three days old. The mother is exhausted after a C-section, but smiles proudly. Tabassum smiles back and continues to the next bed.
Tabassum is training to be Community Midwife at the Nankana District Headquarter Hospital. She is one of 35 young women undergoing an exhaustive 18-month residential course supported by UNICEF to learn how to safely and expertly attend childbirth, monitor women for signs of complications and refer them to hospitals if necessary. Once fully trained, each woman will return to her home village to establish a Midwifery Home with UNICEF support. Each trainee has been selected from communities of at least 10,000 people which do not have health facilities nearby.
In Punjab, Pakistan's most heavily populated province, only 33 per cent of births take place in the presence of a skilled birth attendant. In rural Punjab this falls to 26 per cent and contributes to Punjab's high maternal mortality rate, of 300 deaths per 100,000 live births. Nankana is one of three districts in the province where UNICEF is supporting a midwife training programme targeting remote rural communities.
Tabassum comes from Meli Burji, a village 90 minutes away from Nankana Sahib, the district capital. She has had a harder journey than many of her colleagues. Married four years ago at the age of 21, she is separated from her abusive husband and returned to her parents' home with her three-year-old daughter, Irfa. "I used to feel a mental tension all the time," she says. "It's very difficult for single women. Often families don't let women do anything outside the house." Luckily she had a supportive family and when her father heard about the midwifery training programme, he suggested she apply. Now, she lives at the hospital and visits Irfa every Sunday.
Growing up in a remote village, Tabassum was familiar with the difficulties women faced when giving birth. Traditional birth attendants often did not practice basic hygiene and were reluctant to send women who were facing difficult deliveries to hospital. "They tell you all children can be born at home," she says. "They say, we'll give you an injection and you'll be just fine!"
During her training, Tabassum learns to conduct normal deliveries and when a woman ought to be referred to a hospital. She and her fellow trainees also learn to deal with the barriers to safe delivery in their communities. "People here are poor and can't afford transportation," she says. "We'll counsel the women to save for their time of need."
Azra Parveen, the head nurse at the hospital who is in charge of the training programme in Nankana, stresses the importance of counselling. "We teach them to work independently," she says. "These young women must know how to talk to their patient, to her husband, to her mother-in-law. We play-act how to deal with each of them for the good of the mother and the child."
Practical experience and skill acquisition are stressed during the training. Tabassum and her colleagues recently returned from a three-month stay at a major tertiary hospital in Lahore, where they received hands-on training under the supervision of experienced obstetricians. "We saw everything there," Tabassum recalls. "There were times when we'd be delivering one baby and another woman would go into labour – I'd strip off my gloves, clean up, put on a new pair and start again."
There is still a year to go before Tabassum and her colleagues return to their villages, but they are determined to serve their communities. "I came here with the motivation to do something for myself and my village," she says. "It's difficult, but I've vowed to stand on my feet and I'll carry my burdens myself."
Since 2004, with UNICEF support sixty-nine health facilities were upgraded to provide Emergency Obstetric and Newborn Care services in 11 districts and in the capital, Islamabad. Sixty-seven of these facilities provide 24-hour services. More than 60 per cent of all deliveries are conducted by skilled birth attendants in nine out of eleven focus districts. Seventy-four community midwives in three districts completed their 18 month training and are now providing their services to pregnant mothers in their communities.