DADU: Lying on a gurney, 27-yearold Naseem Wazir grimaces as she shifts cautiously. She is clearly in pain.

Having travelled 30 kilometres from her village, Kasb, to a nearby town of Kakar in Dadu district, she had come to deliver her second baby at a birthing centre.

Upon examining her, Darya Khatoon, the midwife, tells her there is time still. `She is not ready to deliver, she looks up to tell her mother.

Crestfallen, Wazir`s mother looks at her daughter in despair. `It cost a lot to bring her here; I don`t think we will be able to come again.` Her first one, a boy, was delivered by the village dai traditional birth attendant (TBA) at home. Home deliveries by TBAs constitute over 51 per cent of all births in Pakistan; in Sindh the figure is 61 per cent.

Khatoon opened her health facility three years ago after she completed the18-month training in community midwifery, as part of the government`s Maternal, Neonatal and Child Health (MNCH).

The programme started in 2007-08 and to date over 1,300 women from acrossSindhhavebeentrainedtocarry out clean and safe deliveries in their respective communities. In the next five years, `a total of 2,000 community midwives [CMWs] will be deployed in the field serving a population of 15,000, says Sindh MNCH programme manager Dr Sahib Jan Badar.

Of the 12,000 across Pakistan, 7,000 have completed their training.

And yet, five years later, the maternal health has not seen much improvement, women continue to die while giving birth and dais continue with the harmful practice of childbirth.

According to the Pakistan Demographic and Health Survey (PDHS) 2006-07, the country`s maternal mortality rate is 276 per 100,000 live births (it is a whopping 314/100,000 in Sindh) and has remained virtually the samesince 1991. The infant mortality rate (measured by the number of deaths of children before they turn one) is 74 per 1,000 live births (it was 78 in previous PDHS 2006-07); under-five mortality is 89 per 1,000 (of which 60 per cent deaths are of newborns).

Given these gloomy figures, how can we aim to achieve the targets of reducing the under-five mortality to 52 deaths per 1,000 live births and infant mortality to 40 deaths per 1,000 live births by 2015, when the Millennium Development Goals will expire? While Khatoon is doing good business, she had to leave her village of Arif Samoon (six kilometres from the town of Kakar) to set up the health facility in the town, thereby killing the purpose of serving her community. She said she was unable to compete with the TBA or motivate pregnant women towards safe delivery at her birthing centre. But Dr Badar added: `It`s a new cadre and will take time to find acceptance.

Najma Baradi, 32, who decided to stay on in her village of Shah Hasan(also in Dadu district), after she finished her midwifery course a year back is still struggling to make her presence known in the community where four dais continue to work. Despite having a small one-room birthing centre, all the equipment and well stocked with supplies, she has only been able to carry out between 20 and 25 deliveries over the past seven months.

`For the women in the village, the comfort level is more important than cleanliness and modern and safe ways of delivery,` she said.

`Produce competent midwives who can demonstrate their professional superiority over TBAs,` says Imtiaz Kamal, a midwife educator and founder of, and adviser to the Midwifery Association of Pakistan who has, for long been crying hoarse over the dismal quality of training.

Acknowledging `there were gaps` in the training, Dr Badar says these are being plugged. One big step has been that from 11 nursing and midwifery schools, today there are 25, one in eachdistrict and she hopes that will shore up the level of training.

`I have also suggested that we make it mandatory for these women to get attached to a rural health centre, a taluka or a district hospital for three months and get practical training to deliver.

They will not get their diploma if they do not complete their training,` says Dr Badar. It has been observed that many women get their certification without having carried out even one delivery independently.

Ms Baradi volunteered at Dadu`s Civil Hospital for six months to get experience as she never got an opportunity during her training. Trained or not, CMWs have not been able to elbow the TBAs out, not yet.

`They are struggling for their share of the pie from well established TBAs, agrees Dr Ayesha Khan, who heads Islamabad-based Research and Development Solutions, but adds: `Not only are the dais cheaper, but also help with household chores during the post-delivery period.Farida Shah, midwifery adviser with Jhpiego, an international consulting firm and an affiliate of the Johns Hopkins University, in Baltimore, the US (and which is carrying out a USAIDfunded Maternal and Child Health Integrated Programme in Pakistan), says while competent midwives can be potential lifesavers, it has been a gargantuan task finding and training women for community midwifery programme.

She says: `Forty per cent of Sindh remains medically underserved and even lady health workers have not reached those parts of the country`s population.

That is why, says Dr Ghulam Haider Akhund, the district health officer at Dadu, `We need to do some out-of-thebox thinking.

He believes there needs to be flexibility in the eligibility criterion. Balochistan faced a similar problem but they decided to invest in women who were not necessarily all matriculate and provided them with a fast-track course and then made them sit for their matriculation exam, he explains.

While Ms Shah is not in favour of reducing the education level for eligibility as compromising on education levels will affect the sl
Last year Jhpiego carried out a survey of the trained midwives in five districts of Sindh, namely Dadu, Khairpur, Tando Allahyar, Tharparkar and Thatta. Of the 142 midwives trained since the programme started, only 112 could be tracked down.

Of these, only 43 were practising midwifery.

The report points to `bias in selection of students for training; inadequate quality of the training, lack of opportunities for supervised hands-on clinical training by the trainees and the absence of appropriate follow-up and supportive supervision in the community`.

`We found that the skills of the already trained midwives did not meet our standard,` says a disappointed Shah.

Dr Khan says CMWs business model is `flawed`. She says demand creation about their skills versus that of the TBA needs to happen and has not. `The government trained them partially and launched them into communities without due demand creation for their skills.

The MCHIP assessment showed a similar weakness.

There are many like Baradi who need hand-holding just a little longer. For the 69 trained midwives who were unable but still willing to give it another shot, their clinical skills were enhanced. They were attached to hospitals for four to five weeks for an intensive handson training at district headquarter hospitals. Those who are already working are being provided birthing centres, equipment and supplies.

In addition, Dr Badar says, it is impossible for one CMW to cater to 15,000 and this criterion should be reduced to 5,000.

These CMWs will also be trained and armed with business skills to market themselves. Today, Khatoon is doing a roaring business, but not in her village. The irony is women from her own village travel the distance to her if they want the baby to be delivered at a facility. In a month, she carries out anywhere between 40 and 45 deliveries. `There are no fixed rates here. Sometimes I charge as much as Rs2,000 per delivery but then there are times I charge as little as Rs700; at times just `hugs and prayers`.