By Dr. Mary Dunbar
What does every mother hope for when she thinks about the delivery of her baby?
It’s almost certain she wants to deliver her baby with a person she trusts, who is kind and has the skills to ensure her safety.
She wants to be treated with dignity and respect, and with consideration of her culture and beliefs.
She hopes to be kept informed of her progress in labour and have a choice about what happens to her during her stay at the health facility.
IN LABOUR? CONSIDER THE JOURNEY TO A HEALTH CENTRE
Now let’s travel together on a long journey on a red, dusty potholed road that runs through ever-present parched rice fields.
Along the way small groups of local people are huddled together, seeking solace and shade under the dust laden, thirsty trees. In the background are forlorn, skinny cattle foraging in the transient ‘desert.’ Everything is burnt and dried by the relentless, overbearing sun.
This is the typical road that women travel on during the dry season to deliver their babies at the local health centre. In the wet season the road is impassable and the cost of travel is considerably increased because of the need to hire a boat to reach their destination.
Finally we arrive at the health centre, one typical of rural health centres in communities where World Vision works in East Asia.
A MIDWIFE TO AID DELIVERY
The two or three health centre midwives, have usually received one year training. Often the midwives are young and inexperienced, and come from outside the local area.
If the community is lucky the health centre will have at least one midwife who has completed a three year secondary midwifery course. The midwives work in shifts over a 24 hour period and deliver up to 30 babies per month.
There has been an exponential increase in the midwives workload during the last few years.
REDUCING MATERNAL MORTALITY
Governments are committed to achieving the Millennium Development Goals.
One of their priority targets is to reduce the maternal mortality ratio. A key indicator of progress is an increase in the number of women who deliver with a skilled birth attendant.
Through policy changes and incentives for midwives and mothers, good progress has been made in increasing the number of women who deliver their baby in a government health facility.
When the MDG achievements are evaluated this will likely be one of the achievements that will be celebrated.
Despite this success a current dilemma is that the great effort and resources required to renovate rural health centres and strengthen the quality of maternal and newborn services has been unable to keep up with the pace of the demand.
FACILITIES FOR DELIVERY
There is a huge gap between the basic minimum requirements for a safe and clean delivery and the reality.
Inside the health centre the delivery room is gloomy and dank.
There is one window with vertical metal bars, but no curtains. The floor tiles are cracked and covered in a layer of dust. The peeling stone walls are decorated with old stains and faded health promotion pictures in pale pastel colours with indiscernible shapes.
A stark lone light bulb swings precariously on a string from a hook in the centre of the ceiling. Electricity comes from a local private generator, but is cut off daily at 11pm.
After that time the light supply is provided from a bulb powdered by a car battery that is provided by the families of pregnant women who go into labour during the night.
A thin wire line is strung above the sink and covered with used washed plastic gloves hung up to dry. There is also a large pair of plastic boots in the corner.
The centre piece of the room is an intimidating and dusty antique wooden delivery bed, with huge stiff wooden stirrups on either side. The bed is folded down the middle in readiness for the next delivery.
The great height of the bed from the floor makes it impossible for a pregnant woman to climb on or off the bed without the assistance of at least two people.
The rest of the cluttered room space is occupied by a locked glass door cupboard and an assortment of broken equipment such as scales, a disused oxygen tank and piles of used registers on top of dusty desk.
The sink does not have running water. Water is very scarce during the dry season as is pumped from a muddy pond and stored in a water jar in the room.
The only furniture in the post natal ward is three metal, mattress-less beds that are also covered in layers of dust. The health centre has one dilapidated latrine that does not function in the wet season due to flooding.
In addition there is no cooking or bathing facilities. The only source of water is from the dried up muddy pond adjacent to the health centre.
The government policy requires post partum mothers and newborn babies to stay at the health centre for a minimum of two days after delivery.
In this health centre the midwives report that women stay for 24 hours and then return home with their newborn baby on the back of a motorbike, or motorbike trailer.
Some health centres report that women only stay for a few hours after delivery due to the lack of facilities. Women explain they return home due the fear of ghosts in health centres that lack electricity.
LINGERING QUESTIONS FOR ORGANISATIONS
The question for World Vision and other community based organisations that work with community health workers to promote safe and clean delivery is: should we be doing more to improve health facility infrastructure and increase the quality of maternal and newborn services at health facilities in remote areas?
It’s clear that we cannot ethically promote facility deliveries in health centres that fail to meet the basic minimum requirements for a safe and clean delivery.
Governments’ scant resources will likely take several more years to reach the most remote areas.
In the meantime women’s experience of labour and delivery will remain more of a scary horror story than a momentous fulfilling experience of celebration and joy.