Channeling Tradition

Women walk into the health centre in Dera Murad Jamali, Pakistan.

This blog was originally published in Dawn. Written by Dr. Naveed Jafri.

The recently published recommendations in Lancet Every Newborn series strongly advocate ensuring the quality of care at birth. This is the time when most deaths occur and when most lives can be saved as well as long-term disabilities averted, through higher coverage of effective interventions.

However, since many decades the situation in Pakistan remains dismal. The statistics from Pakistan Demographic and Health Survey indicate that Neonatal Mortality in Pakistan is still high as out of every 1,000 live births 55 newborns die within a month of birth. Among other factors, a point of deep concern is that more than 48pc deliveries are being conducted by traditional birth attendants (TBAs).

According to the Global and National Newborn Health Indicators database (May 2014), Pakistan ranks on top for Still Birth Rate/First day Mortality Rate among South Asian countries. Despite a huge population, many key health indicators are far better in India than in Pakistan.

The traditional birth attendant, or ‘dai’ is an indispensable reality for millions of pregnant Pakistani women. What we need to do is to tap and hone their skills

In our country, a number of programmes and projects are being implemented to improve the overall situation of maternal, neonatal and child care. Two major programmes — the Lady Health Worker Programme (LHWP) and the National Maternal Newborn & Child Health Program (NMNCH) — claim to cover the 65pc of the population.

Community midwives (CMW) working under NMNCH programme are trained to conduct deliveries at community level but unfortunately due to multiple reasons, the programme has not been expanded yet to the level that was expected at the time of its conception.

An important task of the CMWs was to establish linkages with all the health work force working at community level but functional integration cannot yet be witnessed in the field.

Although TBAs are still considered controversial by a number of internal organisations, they probably share a significant burden of more than 47pc of deliveries being conducted by unskilled birth attendants in the rural areas.

Formal and informal links between the traditional birth services in a community and professional health services can facilitate not only the effective use of available resources as well as access to quality.

Since TBAs are from the rural setting, their bonding and relationship building with the rural community runs across generations.

Talk to a mother-in-law at the community level, it is not surprising to find that the TBA conducting the delivery of her daughter-in-law was actually trained by her own mother (TBA). This kind of relationship building is a key factor in convincing and attracting the families of rural areas to consult TBAs in case of emergencies.

The probability of conducting unskilled deliveries by TBAs is higher in areas which are not covered by frontline health workers.

The main reasons due to which Pakistan is not on track for achieving the UN Millennium Development Goals (MDGs) 4 & 5 are practicing multiple strategies, redesigning them repeatedly, implementing both independently and in integration resulting in a failure to achieve results as desired.

This is because the policies implemented till now have mostly been projects created and driven without considering local factors that come into play.

There is a dire need to revisit our policies and strategies and accept ground realities.

We have several evidences in South Asia and in Pakistan that the TBAs have been trained on Safe Motherhood patterns resulting in the betterment of maternal and newborn health indicators but unfortunately those models were not taken up by the government or scaled up due to the absence of any policy guidance for TBAs in our health strategy.

The rate of maternal and neonatal mortality can be lowered specially in the rural settings by improving the capacity building of TBAs through several interventions like antenatal care and identifications of danger signs during pregnancy, management of normal delivery process; detection of obstetrical complications and timely referral to the nearest health care facility and the establishment of linkages with first level health care facilities like equipping them with safe delivery kits to ensure safe motherhood.

Similarly, TBAs can be trained on simple interventions in order to decrease the infant mortality rate as well as immediate care of the newborn, promotion of early and exclusive breastfeeding, cord care, the detection of danger signs (preterm pneumonia/infection, asphyxia) and early referral of newborns to the first level health care facilities, etc. Studies have proved that the level of accessibility and acceptability of TBAs are much higher in our rural settings since they belong to the same vicinities.

The State of World Midwifery Report 2014 report launched two months ago, has also endorsed the importance of TBAs and urged that “TBAs will continue to be part of service delivery models in the coming years, including in those countries where there are severe deficits in the number of professional health workers. In communities where community health workers and TBAs hold a respected position, they can influence women’s use of midwifery care and can provide basic health information about healthy pregnancy, safe birth options, newborn care, nutrition, breastfeeding support, family planning and HIV prevention. Formal and informal links between the traditional birth services in a community and professional health services can facilitate not only the effective use of available resources as well as access to quality. Such links can also open a career pathway for community workers to enter professional midwifery cadre through appropriate education programs.

The government needs to acknowledge the important role of TBAs as a ground reality in Pakistan. Without doing that, long-term planning may be impossible.

Published in Dawn, Sunday Magazine, September 14th, 2014

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