Midwives
in Myanmar do much more than deliver babies and provide maternal health care
but there are too few of them, especially in rural areas where they labour
under onerous workloads.
Ask Daw
Nayee Ziram how she feels about her 28 years as the only midwife serving six
isolated villages in Kachin State’s remote Putao valley and the response will
be a two-hour rant.
A Rawang,
Nayee Ziram, 54, has a long list of grievances, including low pay and a lack of
support from the Ministry of Health. One of her biggest complaints is a
demanding workload.
“There
are simply not enough midwives,” she told Frontier, adding that the six
villages for which she has sole responsibility have a total population of
5,000.
“Some
nights I am called out three times to deliver babies,” she said at her home in
Putao, where a corner of the living room has been transformed into a clinic.
As a
midwife in Myanmar, her duties are more than delivering babies and providing
maternal health care. She said midwives were also required by the Ministry of
Health to promote personal hygiene and environmental sanitation, the use of
safe water supplies and sanitary latrines, and to provide health education and
family planning counselling.
Midwives
are among the primary healthcare workers in rural Myanmar, where 70 percent of
the population lives. Their care is essential to preventing maternal mortality
and deaths among infants.
World
Health Organization figures show there’s been a significant decline in maternal
mortality rates in Myanmar, from 580 for every 100,000 live births in 1990, to
200:100,000 in 2013. However, the rate is sharply higher than in neighbouring
countries such as Thailand, where it was 26:100,000 in 2013.
The
importance of midwives was highlighted by figures released earlier this year by
United Nations Population Fund, UNFPA, that said 76 percent of deliveries took
place at home, where 90 percent of maternal deaths occurred.
Apart
from heavy workloads, midwives often face challenges in rural areas because
they often lacked electricity and mobile phone connections and have to travel
on bad roads.
Dr
Sarabibi Thuzarwin, a specialist in maternal, newborn and child health (MNCH)
with the United Nations children’s agency, UNICEF, in Myanmar, told Frontier
that midwives were often sent to remote areas without proper support, including
accommodation. She said midwives were being better paid because of an increase
in government funding, but inadequate incentives or hardship allowances made it
difficult to recruit them to work in remote areas.
One of
the biggest challenges facing Nayee Ziram before she begins her working day is
having enough money for the fuel she needs for home visits throughout the Putao
valley.
Despite a
challenging working environment and low pay, Nayee Ziram said midwives play a
vital role, especially in rural areas. “Most locals are afraid of going to
hospital because the cost of the journey and the healthcare can be a big burden
on families living under the poverty line,” she said.
Her big
concern is the paucity of midwives, of whom there are 21,435 throughout the
country, up from 19,566 in 2011.
Dr Hla
Hla Aye, the assistant representative in Myanmar of the UNFPA, said the
Ministry of Health was actively training and recruiting midwives and deploying
them in rural areas. However, she said the quality of the training needed to be
improved. The midwife training program had been extended from 18 months to two
years, but most trainees could not perform all of the seven “signal functions”
aimed at preventing deaths during pregnancy and childbirth.
Most
Myanmar midwives could perform four out of the seven, Hla Hla Aye said.
In a few
weeks, mother of four Daw Pongya Ni Ngamdam, 32, who farms rice at Zino
village, about 40 minutes by motorbike from Putao, will give birth with the
help of a midwife first time. Her four children were born with the help of older
women in her village, where the community’s first health centre opened in 2013.
Pongya Ni
Ngamdam is eight months pregnant, but it’s hard to tell from her thin figure.
“She is not receiving enough nutrition,” said the Zino village midwife, Daw
Phyu Phyu Htwe, who took up her position a year ago and is one of the few Bamar
living in the majority Rawang community of about 4,000 people. “Not leaving
enough time between pregnancies might be another reason” why Pongya Ni Ngamdam
is so thin, Phyu Phyu Htwe said.
The
Rawang, who number about 158,000 and are one of the smallest ethnic groups in
Myanmar, have been encouraged by village elders to have at least five children.
Pongya Ni
Ngamdam said she planned to have five children, “but it all depends on God”.
Because of her Christian faith, as well as a lack of knowledge, she has never
used contraception.
Family
planning has been a controversial topic in Myanmar. Contraception was banned by
the Ne Win regime because of unease about the country’s big neighbours and the
regime’s desire to encourage population growth.
“For a
long time we couldn’t use the term ‘family planning’, so we opted for ‘birth
spacing’,” said Hla Hla Aye. “Now we are in a new era, which is more open,” she
said, adding that it was a “breakthrough” in 2013 when the government committed
to Family Planning 2020, a global partnership that supports the right of women
and girls to decide whether, when and how many children they want to have.
Discussions
about family planning remain sensitive in Zino village. Midwives are required
to tell expecting mothers about contraceptives, but Phyu Phyu Htwe acknowledged
that education levels, social behaviour and religious beliefs made it difficult
to talk about family planning.
The only
two contraceptive methods available in the village were the rythym method, in which safe times for sexual
intercourse are based on a woman’s menstrual cycle, and birth control
injections that cost K800 each and need to be administered every three months.
Condoms
are nowhere to be found in Zino.
Phyu Phyu
Htwe has heard that the government was planning to provide free contraceptive
injections for women.
“I don’t
know when it is going to happen but I hope it is soon,” she said.
Ann Wang
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