A Community Midwife Takes Her First Steps in Bringing Expert Care to Mothers and Children in Rural Punjab
By Fatima Raja
SHEIKHUPURA, Punjab Province, December 2008 – Yasmin Faqir Hussain (22) remembers the fear, confusion and tragedy that often accompanied childbirth in years past. It should have been a joyous time, but in the event of a complication during delivery, things sometimes went badly wrong. "My own neighbour was bleeding profusely," Ms Hussain recalls. "The dai [traditional midwife] insisted that there was nothing wrong and kept her at home as the woman bled to death. There was no one to guide us."
In Punjab, Pakistan's most heavily populated province, only 38 per cent of births take place in the presence of a skilled birth attendant. In rural areas, the proportion is even smaller and contributes to Punjab's high maternal mortality rate, of 227 deaths per 100,000 live births. Conservative rural regions often lack awareness of the importance of trained attendants at birth, and many deliveries are performed by dais or family members who do not know when or where to refer women in case of complications. To address this, Sheikhupura is one of three districts in the province where UNICEF is supporting a midwife training programme targeting remote rural communities. The programme has been piloted in three districts in Punjab and the North West Frontier Province, pending a nationwide roll-out.
Ms Hussain is one of the first cohort of trained Community Midwives in Sheikhupura. She has undergone 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. She has been trained in antenatal and post-natal care and is expected to perform four checkups before childbirth and three after, to monitor the health and habits of mother and child.
Now, as part of her mandate, she has established a Midwifery Home in her house, serving a population of 10,000 people without health facilities nearby. A large room constructed of unplastered bricks has been decorated with colourful posters and equipped with delivery kits. For the first time, women in the village of Burakuh have someone who can give them antenatal care and advice a few minutes walk from their homes. Ms Hussain is equipped to conduct deliveries in her Midwifery Home, and having studied and worked at the District Headquarter Hospital in Sheikhupura, she has the contacts and credibility to link women undergoing complications with secondary level healthcare quickly and effectively. After birth, she has the knowledge and access to advise mothers on good practices during the critical weeks following birth when most child deaths occur.
Ms Hussain has overcome many barriers to arrive here, caring for mothers in her own Midwifery Home. She belongs to one of the poorest families in the village. When she was a little girl, she contracted polio – Pakistan is one of only four countries in the world where polio remains endemic. Today she is healthy and strong, but still walks with a limp. The experience has left her with a commitment to work against preventable diseases and death. In the three months since she established her Midwifery Home, it has also exposed her to the ignorance and prejudice she must overcome. "There are people who refuse to let me touch them, saying that I have had polio and they don't want to die at my hands," she says. With her family's staunch support, however, she works to end this ignorance. "I have four women who come to me regularly for antenatal care," she says. "There are fifty more whom I visit at their homes. As I give them good advice and care, they trust me, and so my work is increasingly accepted."
"Most maternal deaths are preventable with skilled birth attendance," says Dr Naila Sarfraz, UNICEF's Maternal and Child Health Officer in Punjab. "It is critical to address the three delays that cause maternal deaths: delay in seeking care in an emergency, delay in reaching a health facility, and delay in receiving suitable care...."
Since October, Ms Hussain has conducted two deliveries already, and taken a third, with complications, to the District Headquarter Hospital. "The first time, the dai told me to step back as I was only fit to work in a hospital. She didn't use gloves, and when the baby was born, she tried to clean the child the traditional way, with a handful of ashes." The second time, however, Ms Hussain took control. She overrode the dai's orders and made the mother walk around to encourage dilation. "Dais are good and experienced women, but they lack knowledge of medicine and hygiene," says Zahida Khatun, Ms Hussain's tutor during her training. "I have heard of dais using veterinary medicines, such as oxytocin, on people. But dais are important decision-makers so our community midwives work closely with them, learning from their experience and educating them as they can."
After the second successful delivery, Ms Hussain feels that a barrier has been broken between her and the community. Women have started coming to her with intimate problems that they don't wish to take to a male doctor. "Women didn't trust me at first, as a young girl with polio who claimed to be better than the dai. But they test me with small problems, and then become my regular clients. One woman who had had a Caesarean at a private hospital, started coming to me to have her dressings changed. She was so impressed by my skill and knowledge that she left blessing me. For her next child I know she will come to me, and bring her sisters as well."
The women who have benefited from her care are full of praise. Mumtaz Abbas, who belongs to one of the most influential families in village, is one of her supporters. Although she delivered her one-month-old daughter Zoya in a hospital, she takes her to Ms Hussain for post-natal checkups. "In the past year, there have been three or four cases where the baby died during childbirth," she says emphatically. "Women and men like myself and my husband, we are educated enough to know that Yasmin Faqir Hussain can be trusted to be clean and skilful. Because she was trained at the Sheikhupura hospital, she knows whom to contact there to get prompt attention if we face complications."
"Most maternal deaths are preventable with skilled birth attendance," says Dr Naila Sarfraz, UNICEF's Maternal and Child Health Officer in Punjab. "It is critical to address the three delays that cause maternal deaths: delay in seeking care in an emergency, delay in reaching a health facility, and delay in receiving suitable care. Community midwives living and serving within communities and watching for complications, advising women to save and prepare for childbirth, and familiar with people and services in hospitals, can address all three."
In January 2009, the Community Midwife programme was officially launched, with the deployment of 87 young women in Kasur, Mardan and Sheikhupura districts by UNICEF and the government's Maternal, Newborn and Child Health Programme. About 2,500 more midwives are in training, and the programme hopes to deploy 15,000 trained community midwives in the next three years. Each will establish her Midwifery Home in a designated underserved area, with delivery equipment worth Rs 30,000 (US$ 375), and supplement a monthly stipend with fees for her services.
"You can't underestimate the importance of having trained people on the ground," says Zahida Khatun, the midwifery tutor. "Since this programme started, I've had midnight calls from students who have gone home for the holidays and found themselves dashing to take a woman facing complications to the hospital, because she was the only one who knew what to do and where to go. Because a trainee community midwife was there, in the midst of confusion and worry, a mother and a child's lives were saved. That is the true benefit of this programme."