HEALTH-PAKISTAN: Dearth of Trained Midwives Plagues Planners

By Zofeen Ebrahim Reprint | | Print |

Zofeen Ebrahim

KARACHI, Pakistan, Nov 19 2003 (IPS) - In the village of Talhi, in Pakistan’s Sindh province, water still tends to be transported on camel-back. That is how a midwife too gets her supply of water to carry out a delivery, and such a midwife is Margaret Gill.

In Talhi, she looks after the only birthing station available to women who live in the surrounding 150-odd villages. There are any number of ‘dais’ (traditional birth attendants, or TBAs), but Talhi is fortunate to have Gill at hand.

She is humbled by what she is able to do. ”Every time I hold a soft, slippery baby I say a silent prayer of thanks for its survival,” said Gill.

Most villages get by for deliveries using the experience of ‘dais’ alone. Fizza comes from one such village in the province of Punjab. ”I’d always linked giving birth to death,” she said, ”For this is what I have seen all my life. I never quite understood why women bled or why they suffered fits. There is so much illiteracy in my village and even today there is no hospital, no doctor.”

The maternal mortality rate in Pakistan is officially reported to be 533 per 100,000 live births. ”Eighty per cent of the births take place at home and of these, about the same percentage of deliveries is performed by ‘dais’,” said Dr. Sadiqua Jaffery, president of the National Committee for Maternal Health and professor of Obstetrics and Gynaecology at the Ziauddin Medical University in Karachi.

Dr. Shershah Syed, secretary-general of the Pakistan Medical Association and an associate professor at the city’s Dow Medical College, said, ”Doctors, and particularly women doctors, don’t want to go to these remote areas where there are the maximum number of maternal deaths.”

Syed believes the emphasis in training should be on midwives and not ‘dais’. Yet it was in the early 1970s that the Pakistan government recognised the need to train traditional birth attendants.

”Their practices were passed on from mother to daughter or daughter-in-law and were based on local traditions, but were without scientific basis,” recalled Dr. Talat Rizvi, one of the authors of the Trainer’s Guide for TBA Training when he worked with the Ministry of Health.

Perhaps the biggest setback to the training of the ‘dais’ was, as Rizvi explained, ”that after training them, no one bothered to supervise – they were let loose in the field without further monitoring”.

Imtiaz Kamal is 86 and is fondly known as the grandmother of midwifery. She endorses Rizvi’s observation and added: ”The health centres gave no support to these ‘dais’, who were never accepted by doctors.”

The emphasis then was on training numbers, and not necessarily the quality of training provided. Nor was this approach helped by the fact that the need to train illiterate 50-year-old women had not been adequately dealt with by the health authorities.

At the same time, the government initiated a programme in which posts for ‘dais’ were included at basic health units, under the supervision of doctors. ”But these poor women ended up being sweepers instead of getting trained,” recalled Rizvi.

However, it is over the last three years that there has been a renewed interest in Pakistan about midwives and their training.

Whatever the reason for the change in attitude, Rizvi is grateful. ”We must cash in on this opportunity now that the vocation of the traditional birth attendant is dying its own death, with the profession not being passed on to the next generation,” he said. ”Now is the time to raise the status of midwives.”

It is an objective that needs considerable work. Leela Mall, the principal of the Midwifery School at the Lady Dufferin Maternity Hospital in Karachi, said, ”We have to start teaching the girls from scratch.”

There are no trained midwifery teachers in the public sector and only a few in the private sector. ”The tragedy is that we have schools of midwifery but no trained tutors, nor even posts for midwifery tutors,” complained Kamal. ”Midwifery is taught by nursing instructors whose own knowledge of the subject is extremely limited.”

Rizvi also blames the low standard of teaching for the problem. ”Although the course is now being translated into Urdu to make it easier for young girls to comprehend, the tutors too need to be trained to impart education,” he said.

Those who stick to the rigorous training regime of 15 months have learnt the theory, but can they deliver babies? ”At best, most teaching hospitals midwives seldom get the hands-on training to deliver, as the doctors too need their training and therefore the midwives back off,” said Jaffery.

Finally, Kamal pointed out that unless the quality of training improves, Pakistan will find it difficult to prepare competent midwives capable of making an impact on the maternal mortality rate.