Changes in delivery practices of Tajikistan women
Reported, January 6, 2012
Whos got the scissors?
Help me hang these plastic flowers up, someone! Requests are flying across the room, and the activity is
hectic. A midwife is cutting a piece of light, flowery material to make a new pair of curtains, while a young
neonatologist is painstakingly drawing a large, red apple on one of the walls. Flowerpots are produced from no one knows where and placed by the side of the bed, while a group of eager nurses cover chairs and tables with
cheerfully-printed textiles.
The scene is a delivery room in a small maternity hospital in the town of Kurgan-Tyube, Tajikistani. Originally the room contained nothing more than a bed and a washbasin, but now it is undergoing a radical change. A group of local midwives,nurses, neonatologists and obstetricians/gynaecologists are redecorating it with all the ingenuity they can muster and whatever material they can find.
Their efforts are part of a two-week training course in essential obstetric and newborn care, initiated by the WHOs European Making Pregnancy Safer initiative. After one week of theoretical tuition, members of the group are now about to begin practicing their newfound skills at the citys maternity hospital. Their first task is to make the delivery room more welcoming for the women who come to give birth here.
Our primary task is not to provide knowledge, explains one of the course trainers, obstetrician/gynaecologist Gelmius Siupsinskas. It is to make the participants understand and appreciate that they themselves can make a difference.
What we teach is basically that all care should be family-centred and evidence-based, that the role of idwives should be upgraded and only essential, low cost effective interventions should be made. We encourage participants to question their own routines and critically examine every prescribed drug and examination carried out on a patient.
The town of Kurgan-Tyube, where the course is held, lies in the Khathlon region, which is one of the poorest areas in the country. Tajikistan is in itself the most impoverished of the former Soviet Republics, and has been plagued by economic upheaval and civil unrest since the country gained its independence in 1991. A WHO study shows that real government spending on health care is now less than a tenth of pre-independence levels.
The proportion of home deliveries is high, and many maternity homes are insufficiently staffed and equipped. Among Tajik women, health care is to a large extent related to child bearing, which makes women particularly susceptible to economic changes. Official statistics are imprecise, but surveys indicate that both infant and maternal mortality rates are alarmingly high.
Many of the problems we see here are the same ones we had in our own countries ten years ago says Gelmius Siupsinskas, who, like one of his co-trainers, is a Lithuanian, while the remaining three trainers are from Russia.
Its important that the participants dont think we come from another world, but realize that we understand their thoughts and reactions, since we have experienced the same changes ourselves. 2 Like them, we were part of the rigid healthcare system of Soviet times, with its over-emphasis on medication and technology.
Suddenly there is a buzz of excitement in the group: the first woman in labour has arrived. She is short and frail, dressed in a lilac nightgown and printed headscarf, and seems embarrassed by all the commotion her appearance causes.
Her name is Gulnora, she is twenty-five years old and this is her third delivery. The first two were carried out at home, with the aid of a traditional birth attendant, now deceased, which is why Gulnora has decided to deliver in a hospital this time.
Irina Stepanova, midwife and trainer, explains about the course and asks whether she wants to deliver in one of the newly decorated rooms with the doctors and midwives in training, or in a traditional delivery room with the ordinary staff. After a moments hesitation, Gulnora decides to try her luck with the course participants. She inspects the two decorated rooms and chooses the one she likes best, but insists that the door be firmly closed during her delivery; she is too shy to have anyone but Irina Stepanova plus a participating midwife and an obestetrician/gynaecologist present while she gives birth.
A few hours later she is found lying happily, but tired, on the bed, her rosy daughter resting serenely on her chest. It was much quicker and easier to give birth here than at home, she says.
There was so much to look at in the room, and the nurses talked and laughed with me the whole time, helping me to forget the pain.
Next time she delivers (most Tajik women have several children), she is sure to come back here,and might even bring her husband, Gulnora says. She has heard the midwives talking about this possibility, and even though she, as a Moslem, found it a strange concept at first, she now thinks it may be a good idea to let her husband see how strenuous it is to give birth.
For Djamilya Sultanova, the participating midwife, the delivery was also a gratifying experience. The attractive rooms and the way we let the woman decide for herself what position she wants to give birth in allows for a much more rewarding and interesting way of working, she says. I didnt even notice how the time was passing.
While waiting for the next woman in labour to arrive, the participants talk about the problem of excessive medication, a common problem in many Central Asian maternity hospitals. One of the doctors cites a recent case in which a 38-year old woman with pre-eclampsia was prescribed 23 different medicines. After some discussion in the group, the participants agree that only three of these were relevant, and some certainly harmful.
Im very pleased that this case was referred to by one of the participating doctors, says Gelmius Siupsinskas. After the discussions we had, I believe that at least some of these medicines will be removed from practice in the future.
As the hours pass more women in labour arrive, and the participants continue practicing what they have learnt during the theoretical week. One young woman turns up with her husband, and when asked, he agrees to stay and support his wife during the delivery. For many Tajik men this would be unthinkable, but Izatullo, 25, who is a salesman, is quick to adopt the concept.
Its not something weve practiced in my family and when we left home I really had no idea I would be asked to do it, he says, but my wife and I have decided to support each other in difficult situations, so its really quite natural for me. Izatullo turns out to be the perfect support; patiently holding, stroking, bearing up and encouraging his wife Zulligja during her ordeal. After four hours their efforts are crowned with the birth of a healthy son, whose name will be Shodmehr, the couple announce. I really liked the way the nurses and doctors treated me and the little one, says Zulligja afterwards, as she is resting in the two-bed room she shares with another mother, their newborn infants placed in high iron cots beside them. I felt I was in charge the whole time, and allowed to choose the position that was most comfortable for me.
At courses closing event, participants are dressed up for the occasion, the women in long, brightly patterned dresses, the men in suits. Participants and trainers gather in the lecture room with invited guests of honour, including representatives from the Tajik Ministry of Health and the WHO Liaison Office in Dushanbe. Three of the mothers who have given birth during the week are also among the guests. One of them is Zulligja, with Izatullo by her side.
The trainers reflect on their experiences from the week. Eight healthy babies have been born, three delivery rooms redecorated and many new practices learnt. When asked to share her thoughts about the birth of Shodmehr, Zulligja smiles shyly and says: If I have a daughter one day, Ill tell her that its very hard to give birth. But Ill also tell her that whatever position she wants to deliver in, that is the one she should use.
Credits: Malin Brin, Fondazione Cariverona and the Swedish Expertise Fund
More Information at:
http://www.euro.who.int/__data/assets/pdf_file/0003/128721/
make_a_difference-Tajikistan_new.pdf