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Midwives Assisting Homebirths Face

Challenges in Rural Bangladesh

In Bangladesh many women still die during child labour. Many of these deaths occur at home. A trained midwife could prevent many of these deaths. In response, countries in South Asia are now promoting the policy of homebirths supervised by a trained midwife.

The Centre for Health and Population Research, Dhaka, looked at the experiences of midwives attending homebirths in the rural region of Matlab. In Bangladesh, 91 percent of births still take place at home and only 13 percent are assisted by a doctor or midwife. In 1987, almost 20 years ago, a health initiative was introduced in Matlab to allow midwives to attend women in the home.

Researchers conducted interviews and group discussions with 13 midwives in Matlab in 2003 and 2004 to learn what difficulties they faced during their work. The study found midwives experienced many problems conducting home deliveries. The biggest challenges they faced were related to attitudes of the family members who often wanted to maintain traditional childbirth practices. If a complication arose during labour it could take hours or even days to persuade the family to allow the mother to go to a hospital that offered care. Moreover, childbirth was seen as dirty and whoever touched a woman giving birth was viewed as impure. As a result the midwives did not receive the help and respect they expected.

Other difficulties confronting the midwives were:

• Feeling unsafe because they were required to travel and work at night. In Bangladesh women who travel alone may be at risk of sexual assault.
• Poor transport. The women had to travel on foot, by rickshaw or by boat.
• Delivering babies in dark and often dirty conditions. One midwife had to stand in the rain and be sprayed by urine from the neighbouring cowshed while the mother lay inside a cramped temporary shelter.
• Lack of equipment and supplies. Midwives often had to return to the clinic for extra supplies if something unexpected occurred. Sometimes, to save time, they took the new-born baby with them.
• Lack of training in homebirths and inadequate supervision. There was a monthly meeting to discuss problems but the midwives wanted more direct supervision.

Midwives felt more comfortable working in a hospital environment. However in the hospital the midwives behaviour was often reported to be inappropriate. Some midwives shouted at and humiliated their patients for screaming during labour, for taking too long to deliver or for refusing to show their genitals. The midwives’ modern attitudes clashed with the traditional values of the families both in the clinic, where the midwives felt more in control, and in the home, where the families were dominant.

The researchers suggest:

• adapting modern birthing methods to accommodate traditional practices as long as they do not endanger mother or child
• training midwives to show respect towards the women in their care
• community education programmes on childbirth and the role of the midwife so that families feel less threatened and offer more support

Even with these improvements the midwives will face many obstacles during homebirths. Governments should consider carefully whether a clinic or home-based approach is the best option for ensuring skilled birthing care.

id21 Research Highlight: 3 April 2007