In a country with a population of 221 million people, Pakistan has a troubling infant mortality rate of 55.7 deaths per 1,000 live births. For comparison, Bangladesh has an infant mortality rate of only 25.6 deaths per 1,000 live births. In the region of Balochistan, the rate is even higher—at 129 deaths per 1,000 live births. This region alone contributes to 37% of the infant mortality rate in the whole of Pakistan. This is due to lacking systems of medical resources, family planning, education about pregnancy and labor, and general isolation from the more developed parts of the country. This has led to not only emotional trauma for the people of Balochistan but also physical trauma to the mothers who go through serious medical and physical stress due to the lack of support during pregnancy and labor.
The Institute for Development Studies and Practices (IDSP) recognized this problem and created the Midwifery Leadership in Community Development (MLCD) project. This initiative trains Community Midwives (CMW’s) in Karachi to become trained professional midwives. Upon receiving their certification, these newly trained midwives go back to their communities and positively impact the lives of families through their expertise. These CMW’s are rural women from villages in Balochistan who want to be professionally and medically trained in order to become the medical and emotional support system for these women and children. I had the opportunity to speak with Dr. Quratulain Bakhteari, the founder of IDSP and mastermind behind the MLCD project, on why this project is crucial to the people of Balochistan and how it is positively impacting their lives. Dr. Bakhteari launched IDSP in 1998 and has worked to improve the lives of millions of people across Pakistan for the past 30 years. Dr. Bakhteari shed important information and insight into the importance of this project.
Laila Mirza (LM): What inspired the midwifery program?
Dr. Quratulain Bakhteari (DB): The inspiration and determination came from the prevailing apathy by the government’s health system which resulted in mothers dying during labor. Out of every 100,000 live births, 650 mothers die in Balochistan, resulting in the highest ratio in Asia. While Balochistan has the most natural resources out of any region in Pakistan, it is also the region that struggles the most when it comes to socioeconomic issues. Twelve years ago, our concern for dying mothers in Balochistan took us on a very insightful journey. This helped our non-medical team from the Institute for Development Studies and Practices (IDSP) to find out the root causes behind the high rates of women and infant mortality.
We came to the conclusion that children who are raised without their mothers are more likely to lack positive attributes such as leadership skills and creativity. One can understand the consequences of a generation raised without their primary caregivers.
These two factors became the driving force to initiate the program of Continued Medical Education for Community Midwives.
After some detailed research we have found the following facts:
- The government of Balochistan has trained more than 2000 community midwives (CMW) across the province.
- The 18-month CMW courses focused on the books and practice dummies.
- Unfortunately, no CMW was allowed to touch the mothers and practice hands-on birthing assistance to the mothers in the maternity wards.
- The only persons allowed to practice deliveries of babies in hospitals’ labor rooms were female medical students, nurses, lady health visitors, and lastly, CMWs are called to clean up the mess.
- Another major barrier is that more than 90% of babies are born at home. Therefore only 10 % of patients are in hospitals to practice safe deliveries of babies.
These above factors led to CMWs having next to no access to midwifery training, leading them to stay away from the occupation itself.
- Karachi, the largest metropolitan of Pakistan sees 90% of mothers coming to hospitals to deliver their babies
- Thus, there are lots of opportunities for CMWs to practice midwifery.
We designed a three months hands-on course for CMWs, where they experience delivering babies in the labor room of a large and very busy government charity hospital in Karachi.
The CMWs come to Karachi and live in the midwives’ training hostel in the hospital’s maternity wards. Under the supervision of hospital instructors and IDSP’s senior midwives, each CMW completes more than 50 deliveries and returns to her community with a midwifery kit.
Over the past 12 years, more than 360 community midwives have gone through these Continued Medical Education courses.
After three months on the medical site, the CMW gets engaged in the community-based practice of midwifery which they do for nine months.
Recently, a WHO event by the legislators of Balochistan stated that maternal mortality has gone down to 269 per 100,000 live births, which we believe is partly due to IDSP’s efforts in the field. We cannot forget acknowledging our committed donors and the great support of Joane Kygle, a philanthropist from San Francisco, California.
(LM): What do you hope to achieve with this program?
(DB): Our goal is to create women leaders in community-based reproductive medicine by creating a training program for these community midwives. Furthermore, since Balochistan has more than 30,000 isolated communities, we plan to have a minimum of one fully functional community midwife in each village. However, a big goal is raising funds as empowering one CMW costs $30,000.
We hope this vision will transform the lives and status of Balochistan’s often isolated, ignored, and weakened women. We are committed to establishing a great reference level for all women pushed down by dominating powers controlled by vested interest. Secondly, we hope for children to be raised by their mothers, a right that every child deserves.
(LM): Have you seen any tangible results from the program?
(DB): The results coming up are exceptionally encouraging. More than 350 Community midwives have delivered approximately 28,000 safe babies since 2010. Only one death was reported— which was due to delays in reaching the midwife. Furthermore, each CMW reaches 25 to 50 families per quarter, with each family having an average of 8 to 10 people. Encouragingly, antenatal care and family planning have both been increasing due to the midwives’ guidance. Also, in a break from tradition, young girls from traditional rural communities are traveling alone to Karachi to train as midwives. These midwives then become entrepreneurs, setting up their businesses by offering maternal and child health care at a community level. Thanks to these businesses, each midwife is earning an average of 20,000 RS, (160 Rs to a $) which allows them to become decision-makers in their families. Midwives also challenge community norms as mismatched arranged marriages are now being challenged by midwives. Furthermore, child marriages and girls’ nutrition are becoming relevant issues in the community. They are also a very important medical resource in the community. They encourage complete immunization against all communicable diseases mandatory in all families. Finally, each midwife has created a strong referral system with district hospitals in times of emergency which allows for safer deliveries of babies and better care for the mothers.
(LM): How did Covid-19 affect the program?
(DB): Covid-19 has caused the three months CME courses to be postponed, but nevertheless, the CMWS were a great support to their communities. They took awareness sessions, distributed masks, confirmed the quarantine of infected people, and are encouraging people to get vaccinated. We are planning to start re-continue courses by January 2022 with 25 CMWS waiting to register.
(LM): Why do you think this issue is so pressing in Pakistan and what can this program model for communities all over the world?
(DB): Pakistan is basically a rural country with huge mountainous regions in the North. These regions are mostly inhabited with isolated pockets of mountain communities. They have limited access to services in maternal care. Having a community midwife from within their own communities is very efficient and comforting for the mothers.
Secondly, giving birth to babies is a natural phenomenon. All women usually need is careful delivery and hygienic practices to keep the mother and the baby safe. The presence of a trained midwife with her professional midwifery kit is a very meaningful and effective system for isolated, traditional, and unexposed societies. Furthermore, there is a large population living in poverty where they cannot access any health care services. Midwives are very economical and affordable for most community members. A community-based maternal and child health care based on well-trained midwives is very relevant not only to Pakistan but all countries around the world that face similar challenges.
Dr. Bakhteari’s insights and experiences expose many problems within the Pakistani health care system, particularly when it comes to maternal and infant mortality rates. While this project is specifically based in the Balochistan region of Pakistan, the challenges and outcomes can be applied to most developing countries where women’s reproductive health issues are often left on the back burner, resulting in a fragmented community that grows up without their primary caregivers. These women who provide support and care for those in need are important and integral members of their rural communities. Empowering women to become healthcare providers allows for a more stable community that eventually feeds back into the next generation— allowing for the positive cycle to continue and encourage sustainable development for these communities.
I am a third-year student at McGill University pursuing a Bachelor of Arts in Political Science with a double minor in Islamic Studies and International Development. My passion lies in the intersection of religion, culture, and politics- specifically concerning women, South Asia, and Islam.