Midwives under pressure

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.

By ANN WANG | FRONTIER

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.

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Midwife Phyu Phyu Htwe holds the one-month-old baby of Garu Nang Baisan, 16. (Ann Wang / Frontier)

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“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.

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Pongya Nin Ngamdan, 32, is 36 weeks’ pregnant. Here she is examined by the midwife Daw Phyu Phyu Htwe at her house in Putao’s Zino village. (Ann Wang / Frontier)

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.

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The Rawang people have been encouraged by village elders to have at least five children, putting a strain on midwife services in their communities. (Ann Wang / Frontier)

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.

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Ma Bu Atam, 40, from Nan Kham village is nine months pregnant with her fourth baby. All of her children were born without the help of a midwife, because there was no-one available during delivery. (Ann Wang / Frontier)

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.

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Daw Phyu Phyu Htwe, 33, travels around the local area by motorbike. She was sent to Zino village one year ago and is transferred to a new city every two years. (Ann Wang / Frontier)

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.

By Ann Wang

By Ann Wang

Ann Wang is a award-winning visual journalist based in Yangon and a former photo editor of Frontier. She holds a photojournalism master degree from Boston University and grew up between Taiwan, New Zealand and China. She produces still images, long-term photo essays and videos with an interest in Asia and South East Asia. She is a regular contributor for The Stand, the Huffington Post and Jetstar Magazine.
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