Safe delivery: A matter of opportunity and trust

“For a rural woman like me, leaving the home premises to deliver a baby is something which needs courage, hope and trust,” says Salma, who has just given birth to a little baby boy at a Basic Health Unit (BHU), an occurance which is very uncommon in the culture she belongs. 

Why do many Pakistani rural women prefer to give birth at home with the support of an unskilled Traditional Birth Attendant (TBA) instead of going to a proper health facility? First and foremost, she feels “safe” (even if it is a false security) because she is surrounded by her family. Second, oftentimes health facilities are not available near to where she lives. And, thirdly, if a centre does exist, the family’s financial situation might not make this a feasible option.  

Another intangible but very important contributing factor for staying home is the trust that the community has in the local health staff who often face an uphill battle to increase the community’s trust in their abilities, while at the same time minimizing their fears.

“Giving birth to a child is purely a private matter in my culture,” says Salma, explaining why many women choose to stay home. “The health staff are considered to be ‘outsiders’ or in other words are not taken as trustworthy, irrespective of their genders,” she adds. 

              

Midwife Tahira Naseem (right) attending Salma (left), 18, who has just  delivered a baby boy at BHU Mondka, Muzaffargarh Pakistan

The community’s trust can only be won through years of experience and acceptance by the community—a sense of security that while false, is often offered untrained birth attendants, simply because of the amount of time they have belonged to a particular community. Right or wrong, the community does trust them.

Dr. Muhammad Aslam, the director of the basic health unit in Salma’s community. He shares the struggles they have faced what they have done during the past 12 years, since the health unit’s establishment to try to increase their perceived trustworthiness in the community. 

           

Dr. Muhammad Aslam, Incharge BHU Mondka talks about the local community’s rising interest in mother and child health issues

“The antenatal care services and labour room were established only two years back,” he recalls, noting the limited use they have been given. “Initially, the communities were reluctant or even in few cases were strongly against it,” he remembers. 

“Slowly and gradually the mobilization efforts and awareness campaigns run through the support of [the] World Vision Pakistan team [began] to reap fruit,” he says. “Before setting up this labour room, we hardly dealt with any pregnancy cases. But, [today we see] 40 to 50 cases per month,” he says, noting some obvious obstacles the facility had to overcome to better serve the women in the community.

            

Entrance gate of BHU Mondka carries a banner which reads “Antenatal care services are available 24/7” 

“Initially, the facility was available only during day hours,” he says. “Now [it] has become a round-the-clock [facility] and is likely to improve [even] further,” he says, mentioning additional services they have been able to incorporate, such as ambulances. “We pick them up from their villages and treat here at the basic health unit. In case of complicated deliveries, they are not only referred, but also [transported] to the District Head Quarters Hospital,” he adds.

“As the awareness about mother and child health issues is gaining momentum, the people of the community have started relying more on this facility. This on-going trend is really very encouraging for all of us,” adds Dr. Aslam. “To further amplify the trend, all we need is some more role models to make people believe this unveiled reality.” 

Salma is one of those role models. Her story is inspiring and impacting several other women in her vicinity to be able alter their thinking and attitude towards childbirth.

Salma, 18, belongs to a tenant family living in UC Kharrak, District Muzaffargarh, Pakistan. Her husband, Saleem, is a labourer who earns at most $2 to $3 a day. It was only a few months ago when she found out about her pregnancy through a Lady Health Worker (LHW), who works closely with World Vision’s social mobilization staff. The lady health worker gave her the news. 

First, she learned that she was carrying a baby. Then she also learned that she could have her check-ups at the nearby basic health unit.

After learning the news, Salma got excited and nervous at the same time. “I told [the health worker], ‘I am really excited to know about my pregnancy, but how would I go out for check-ups in this condition? No one would allow me, neither would I feel comfortable. Also, my husband cannot afford hospital expenses.’”

Salma felt that although she had options, the choice had already been made for her. “I had to choose between a dayee (traditional birthing attendant) or [going] to the basic health unit. The traditional birthing attendant was the most convenient and affordable option because everyone was familiar with the process,” she remembers.   “The [case] for the basic health unit, [on the other hand] was tough because we had no money and I was unsure about the process they would follow,” she says, noting how hard it would be to convince others of the benefits of the basic health unit when she wasn’t clear herself.  

“I was so confused, reluctant and scared,” she remembers. Then the World Vision health mobilizer introduced her to Safia Irshad, a young mother from the next village over who had recently delivered her baby at the basic health unit. During the meeting, Safia told Salma how her cousin, Shamim, had died while attempting to give birth at her home. She also eased some of Salma’s fears, by walking her through how the basic health unit deals with pregnancies.  

Safia is also a member of one of  the community support groups formed by World Vision Pakistan. Each support group consists of a WV Social Mobilizer, a concerned lady health worker and community members, including both men and women, and Influential individuals, such as molvis (religious scholars) and teachers. 

These support groups act as a bridge between the basic health units and the communities for making referrals and spreading information and awareness on different health issues with a special focus on mother and new born child health, antenatal care and breastfeeding, to name a few.   

“I learnt was that I only have to get myself registered, and they will take care of the rest of the formalities,” Salma says, saving the best for last. “And, most surprisingly, there were no fees at all. It was totally free of cost.”

After registration, the staff at basic health unit gave Salma a schedule for the necessary check-ups and another document, called a “nutrition card”. The nutrition card helped Salma know what and how to eat and what to avoid during her pregnancy, also giving her some supplies to get started. “I was overwhelmed when they handed over a bucket of different food items for me,” she says. “World Vision staff also told me about danger signs of pregnancy and other such related issues which helped me a lot through the whole process at each and every stage,” She says.

“All this [information] strongly helped me to make this decision. Now, all I have to say is I made the right decision,” she says proudly, acknowledging that initially it was difficult to convince her husband and mother-in-law. Thanks to the solid information she had in hand, however, they eventually agreed.

           

Salma’s mother (left) and mother-in-law (right) are happy to see their newborn grandson

Samina, the lady health worker supervisor (LHS) at the basic health unit adds: “We have a referral mechanism which works through our lady health visitors, World Vision’s social mobilizers and mainly with the help of community support groups formed by World Vision…  These representatives collect local information about mother and children’s health and also refer pregnant women to the health unit,” she says. 

Midwife, Tahira Naseem, shares how the health unit’s care of pregnant women goes above-and-beyond expectations. Not only is the antenatal care is provided, but also patients are advised on mother and child nutrition programmes for which they receive approved food packs. They also receive, a baby kit: including bed sheet, clothing, mattress, bag, pillow, nappies etc.

           

Tahira Nasim, Midwife BHU Mondka, sharing her views on the antenatal care services provided by the health facility, Muzaffargarh Pakistan

World Vision’s health teams are ensuring full facilitation of the labour rooms which have been established at three health units in the area. The main objectives of this program are: mobilization of the community around maternal and child health, capacity building of the government’s health care providers, and developing the links between community and the concerned government department(s). 

According to Aqsa Rubab, a community project officer with World Vision: “We are working to change the behaviours and habits. [This is] the most important task for all of us. Our community mobilizers have been successful in forming Community Support Groups in each village. So far, 23 such groups have been formed. Each group includes a local health visitor, a skilled traditional birth attendant (if available), community activists and teachers. These support groups work closely with the communities and raise awareness on antenatal care, postnatal care, danger signs during pregnancy, birth spacing and safe delivery.”

“World Vision, for all its projects, believes in community ownership. This approach is likely to ensure sustainability of such significant initiatives which are helping the children and the communities. Still, there is a lot more to do because this is just a start and we have miles to go,” says Aqsa.

“I have decided to name my son Allah Wasaya, which means ‘saved by the almighty God’. I’m giving him this name because I trust God for his kindness for human beings” Salma explains with a hope in her eyes. “Now, when I look at my son’s face my heart is filled with overwhelming gratitude to those too who helped me in making this decision.” 

Salma also remembers a friend who had delivered her baby at home. Though the baby was delivered safely but she herself started having post-delivery issues especially a severe weakness due to the lack of guidance on proper care and nutrition. Salma can now easily understand the difference between her experience and that of her friend’s. “It did not cost me anything extra to seek the medical help, but it saved me a lot in terms of my and my baby’s good health after the delivery.” 

“While celebrating my success I feel sorry about those hundreds of unlucky women who lose their babies and their own lives because they do not have such opportunities or their families don’t support them,” she says. “My message for those like me is to feel blessed to have such an opportunity and for their families to change the way they think. All they need is to have trust to save themselves and their generations through making a right decision for their own good.”