Maternity care amid Covid19 outbreak: Story of midwives in a remote Union Health Centre
By Mushtaque Chowdhury, Selina Amin, Bilkis Ara and ATM Nayeem[i]
Like most other countries, Bangladesh is facing the onslaught of Covid19. In a near lockdown situation, the normal life has been interrupted, education institutions closed down, devotees reduced in mosques and temples, and gathering of any type in the community is discouraged. However, the frontline healthcare workers (FLW) are on their toes providing services to the ailing people, both corona-related and otherwise. Unlike most of us, they cannot stay at home. One of these FLWs are the midwives. They are attending to duties in unprotected or partially-protected environments. The Midwife Led Care Centre (MLC) at the Charikata Union Health and Family Welfare Centre (UH&FWC) in Jaintiapur, Sylhet, is such a centre where midwives are continuing their care and services despite unfavourable circumstances.
Bangladesh embraced Midwifery as a new profession since 2012. Over the years the government took a number of steps to bring them into the mainstream of health service delivery in the country. Thousands of midwives have been trained through a rigorous 3-year diploma programme and most have been absorbed into a newly created cadre of public service and in NGOs and other organizations. BRAC University is a pioneer in training diploma midwives and, over the years, it has graduated 602 midwives through its seven outreach centres. The primary job of a midwife is to prevent maternal and newborn mortality and morbidity. In the current discourse on maternal health, provision of respectful maternity care in centres which are led and managed exclusively by midwives is being promoted in many countries. BRAC University decided to try this in the Bangladesh context and has been running two such centres, one in Urban Dhaka and another in rural Sylhet for over a year. In doing this, the University works with two NGOs — BRAC in Dhaka and FIVDB in Sylhet. In the latter, the University works with the Ministry of Health and Family Welfare in a Union Health and Family Welfare Centre in Charikata under Jaintiapur Upazila, about 50 Kilometres from Sylhet City. Here, four midwives, educated at BRAC University, are providing round the clock services to the local population. They all stay in the UH&FWC and take turn in giving antenatal care (ANC), post-natal care (PNC), family planning, and safe delivery services to mothers. They also visit the mothers in their homes to build rapport and follow up. They are young and, as a result, the community initially was not ready to receive their services. Within a few weeks, however, the scenario changed and women started to visit the centre, impressed by the behaviour of the midwives and quality of services provided. Even now when the whole country is in some kind of corona-hysteria, these midwives are offering respectful maternity care 24/7. (Charikata itself did not report any Covid19 patients but in neighbouring Dorbost, 23 homes were locked down).
At the start of the current situation, the midwives were a little scared as the mothers were not maintaining the social distance and were crowding up as before. They had minimum awareness about Covid19 and its horror, and had little ideas on the importance of cleanliness and cough etiquette. To bring discipline and enforce containment measures, BRAC University used posters and leaflets to make visitors aware about the gravity of the situation. A quick training session was organized for the midwives and other staff of the UH&FWC. A pail of water and soap was placed at the entrance and mothers were obligated to wash their hands. Attendants and visitors stayed outside. Midwives measured the body temperature before offering services to the mothers and if the temperature was above normal the mother were referred immediately to Sylhet Osmani Medical College Hospital after doing necessary counselling. These steps contributed to the midwives’ confidence building, reducing their worries and anxieties. They were also given personal protective equipment (PPE) by BRAC University which helped relinquishing any fear or stigma.
Lakshmi Rani, one of the four midwives, narrated how she managed a post-partum haemorrhage (PPH) in this critical time. An 18-year old woman with first pregnancy came to Charikata UH&FWC with prolonged labour. She was tried for delivery at home unsuccessfully and finally came to the midwife-led UH&FWC. Here she gave birth to a baby boy with normal weight. After 15 minutes of delivery the mother started bleeding. Lakshmi got worried and wanted to refer the case to a higher facility, but in the lockdown situation there was no way but to manage the PPH herself. With all her knowledge and skills she successfully managed the case till a transport was available to take the mother to Sylhet where she was transfused with a bag of blood. Both the mother and the newborn were released after two days. Lakshmi described how tensed she was but, on the other, was proud that she could save the mother with initial stabilisation in this difficult circumstance. Sabia Akter Ria, another midwife, managed a case of birth asphyxia (extreme respiratory problem) of a new born when the baby was brought to the Centre in a critical condition during the early corona days. Sabia applied the Helping Babies Breathe (HBB) technique and the baby cried within one minute, with normal heart rate. Every day such cases are being brought to the MLC and the midwives are managing the situations with their acquired knowledge, experiences, confidence, dedication, and, most importantly, commitment.
While the UH&FWCs in general struggle to attract maternity cases, this Midwife-led UH&FWC in Sylhet has set new examples of dedicated care and trust of the local people. In April 2020, 58 normal vaginal deliveries took place, in comparison to 68 in March and 63 in February. The Covid19 crisis did not alter the functioning or reputation of the Charikata UH&FWC cum MLC. Despite discouragement in view of the Covid19 situation, 170 antenatal visits took place in April alone. These show how the midwives have earned the trust of the local people. In addition, they also continued their family planning work.
The Midwives are always ready to offer care. Their respect for women’s individual circumstances and privacy encouraged mothers to have increased trust in this unprecedented situation. The Charikata MLC sets an example of how the frontline health workers are standing beside the worried mothers in the corona crisis.
[i] The authors are associated with the Developing Midwives Project of the BRAC James P. Grant School of Public Health, supported generously by UKAid.
