CARE under the Integrated Family Health Initiative (IFHI) is working in Bihar, India to improve Maternal and Newborn healthcare practices, including the quality of care. As part of the project, health system strengthening is being undertaken through participatory approaches by creating Quality Improvement Teams at the health facility level comprised of Doctors, Managers, Nurses and front line health workers. The following experience was shared with a CARE staff by Gayatri who gave birth at the Primary Health Centre in Naubatpur block, Patna, Bihar, that is supported by the initiative.

It was in the wee hours of the morning, when I first felt the pain. It was more like a cramp in my stomach. I ignored it till the time I could not bear it any longer. From that moment onwards till I reached the room for delivery in the Primary Health Centre (PHC) was something I can never forget; it was like sitting on the roof of a crowded bus. I was cold yet seemed like I was suffocating to death!

But I kept reminding myself that worst was yet to come. I had heard that our PHC, Naubatpur was not one of the best places to deliver. Yet thinking of nothing else at that early hour, we had rushed to the same PHC.

Thankfully, things at the PHC had changed. This time, it was not very difficult to find the nurse that day, as she was in the typical white saree worn by nurses. I don’t think I had seen her in a white saree on previous visits. What had brought about that change?

As I entered the Labour room, I couldn’t help but wonder who had done the magic there? It was clean, very clean for that matter. I had come to the PHC about 6 months before, and it was smelling worse than a cow shed. The labour table had even had a rubber sheet on it! I still can’t make up my mind, whether it was due to looking at the Labour room or due to the Nurse’s dress that I felt as if I was in safe hands! Whatever gruesome stories I may have heard about the hospital, I suddenly felt there was no other place better than this to welcome my baby into the world. Something was surely happening here, but I could not figure out what. Well, truly at that moment, I had no energy to think about it!

It was well past 10 am that my little angel finally came. When I came to my senses (literally), I was assisted to breastfeed my baby by an attendant. There was a quiet demure lady standing at a corner, smiling at me. Her smile was saying; ‘You and your baby are perfectly alright’. I smiled back.

Then some further memories of that smile came back. She was Seema, from an organization called CARE[1]. I had also seen her earlier when I came for my antenatal care visit (ANC). That time I had seen her talking sense into a few men[2] who were lingering around Labour room. At that time, the Out-Patient-Department (OPD) and Labour room were practically next to each other, so one could hear the women screaming in the Labour room even from the OPD. And to tell you the truth, those screams from the Labour room during my ANC visit actually scared me to come there! As part of the changes at the facility, the Labour room was shifted to a more private place and curtains were hung. These changes made a huge difference!

Photo Credit: Jaspreet Mahal

Six months earlier, when I had accompanied my sister-in-law for her delivery in the same hospital, it was very scary. There was a huge commotion in the Labour room, for a baby just born had not been breathing. I remember Seema taking charge of the situation. She had put the baby in some machine in the ‘Child corner’ and used oxygen to make him breathe again. I learned that day there was something special in our PHC for new born babies to help them survive.

As I was being taken to the ward after my delivery, I heard Seema say to the Nurse, “You really did a great job for this woman, Gayatri, you should be so proud of yourself!” I don’t know about the Nurse, but I was filled with so much love for this wonderful lady. I am sure the Nurse also felt so much pride and responsibility at that moment. Seema then helped the Nurse refill her delivery tray for the next woman.

The posting below from Blossum Gilmour, Mamayo Health Project Manager at CARE, describes CARE Papua New Guinea's training program for Village Birth Attendants (VBAs) in remote areas and their efforts to increase the number of women seeking maternity care at health centers.

Credit: © Josh Estey/CARE

Where did you give birth?

In my family's coffee garden.

Who assisted you?

No one.

This is how a conversation started between CARE PNG staff and a new mother in rural Papua New Guinea. CARE had agreed to help the provincial government assess the support available to pregnant women and new mothers, and while the conversation above was common, the reasons why women were alone in the bush while giving birth are as individual as the women themselves.

The staff tried to delve to the root of women’s reasons for not going to a health centre to give birth and most of it came down to fear: fear of the health worker who is not from their village and doesn’t speak their language, fear of seeking help from a male health worker, fear that their family will be asked to pay for the service, fear that the medications they’re given will hurt them, fear that the health worker will yell at them and make them do things that feel painful or wrong.

It is a generally accepted fact that health workers in rural areas are ill equipped to deal with obstetric emergencies—they have not received the training or tools needed—and the nearest hospital is an expensive flight away.

Their inability, and in some cases unwillingness, to provide basic antenatal and obstetric care speaks to a more deeply-rooted issue.

‘Do you know what the women of PNG call midwives? Barking dogs… because they never stop making a terrifying racket’ said a teacher in a university midwifery program. She went on to explain that the unit on bedside manner has just been taken out of the new midwifery curriculum. She wants to teach new midwives that they are service providers and need to have empathy for their clients but there are other priorities for the time being.

So what is the solution? Where to begin?

CARE PNG, in collaboration with the Provincial Division of Health, is training Village Birth Attendants (VBAs) in some of the most remote areas of PNG. The primary role of the VBAs is to decrease the number of barriers to women giving birth at a health facility. VBAs are chosen by the women of their community and they are women themselves. This alone seems to engender trust. VBAs are then trained. They learn how to recognise the signs of high risk pregnancy and how to counsel women to go to the health centre for an antenatal check-up, but also to address the individual fears that women have. VBAs then accompany each mother to the health centre and act as her advocate - both translating and explaining what the health workers is doing and ensuring the woman agrees to the interventions. VBAs assist the health worker throughout the antenatal checks and delivery, a constant companion and champion for the mother. Finally, when they are not able to get a woman to a health centre, VBAs are able to safely attend an uncomplicated delivery.

It’s far from perfect—VBAs are a stop-gap measure in the floundering health care system. That said, they are having an impact by championing Respectful Maternity Care and providing companionship to women in facility-based labor and birth—more women are having antenatal check-ups and it’s hoped more will agree to professionally assisted births. VBAs are changing how women view the health care centre—one mother at a timeCredit:

© Josh Estey/CARE