RANGOON — The mornings were full of walking, says Khin Mar Shwe, a nurse near Burma’s biggest city, recalling her days as a midwife under the former military regime.
She was a young woman then, and would begin a few days every week walking from village to village in Taikkyi Township, knocking on doors to find expectant mothers who required assistance.
“Early, at 8 am, I would start my journey, and I would return at 4 pm, depending on the distance between villages,” she tells The Irrawaddy. “In the evening if a mother was about to go into labor, I would stay overnight.” The midwife, who has since become a nurse, was responsible for covering six villages, some about four kilometers apart. Sometimes she would ride by bicycle, and she almost always traveled alone.
Now 66 years old and a leading member of the Myanmar Nurse and Midwife Association, an independent professional group with more than 18,000 members, she laughs when asked whether she ever considered self-defense training. “Maybe it would help. And swimming training, too,” she says, reaching for a photo album of midwives at work over the past year. In several photos from Arakan State, a western coastal area, women are seen wading through knee-deep water.
“They have to swim because they go by boat,” says Dr. Nang Htawn Hla, president of the nurse and midwife association. “Sometimes the boat cannot reach the shore, so they go into the river. They change into their uniforms, with the red skirts, onshore.”
“It’s not only for maternal and child health,” she adds. “Because the villages have quite few health personnel, they rely on midwives to treat minor ailments, too.”
Midwives have long played a crucial role in Burma, where more than 70 percent of the nation’s 60 million or so population lives in rural areas, often without access to hospitals. The country’s public health spending is among the lowest in the world, with only about 3 percent of the government’s annual budget allocated for health care. A shortage of doctors and nurses, who are posted at hospitals in cities and major towns, has meant that midwives, known as “red angels” in some villages, are often responsible for much more than maternal health.
“They’re expected to do everything: primary health care, ante- and postnatal care, pediatrics, delivering babies, collecting health data. Rural health care providers joke that the midwife does everything except have the baby,” said Dr. Vit Suwanvanichkij, a public health researcher who has worked with Burmese patients on the Thai-Burma border for more than a decade, and who has recently visited health care professionals in the country. “They are so incredibly busy, underappreciated and underpaid for the essential services they are tasked with providing.”
There are about 20,000 midwives in Burma, up from about 8,000 in 1988 under the military regime, according to statistics from the Ministry of Health. While availability varies across states and divisions, each midwife is responsible for about 3,000 people on average.
With such a large pool of patients, they are struggling to reach everyone who needs help. Complicated pregnancies are among the leading causes of morbidity in Burma, while the World Health Organization puts the country’s maternal mortality rate at 200 deaths per 100,000 live births. In eastern Burma, the rate is more than triple that, according to a 2010 survey by the Burma Medical Association and ethnic health organizations. In neighboring Thailand, the maternal mortality rate is 48 deaths per 100,000 live births, according to the WHO.
Calls for Manpower
In addition to political reforms, Burma’s government, transitioning from nearly half a century of military rule, is attempting to improve its long-neglected health care system. Opposition leader Aung San Suu Kyi has prioritized health care reform since joining Parliament last year, with plans under way to renovate one of the best-known public hospitals in Rangoon, while the government last week removed more than 1,000 doctors from an official blacklist that had prevented them from practicing in the country.
Over the past two years, more midwives have also been appointed to rural areas, and they have received a larger provision of medicine and equipment, says Dr. Nang Htawn Hla. But even so, they are overloaded. “They go far distances, to hard-to-reach areas, but sometimes they can’t get to where they need to go,” she says.
“Everybody knows the problem. The government knows, too. But even if you could provide a motorbike, it wouldn’t always be able to reach the villages. In some areas you can ride a bicycle, in some areas a car cannot get access. Sometimes you can only get to villages by walking, so it’s like that, walking all the time. The only solution is to increase manpower.”
This year in May, officials from the Ministry of Health commemorated for the first time the International Day of the Midwife with the UN Population Fund (UNFPA). “I would urge all stakeholders to cooperate in ensuring that every pregnancy is wanted, all births are safe and to meet the need for skilled midwives to provide quality services for the people,” Dr. Thein Thein Htay, deputy minister of health, reportedly said at a ceremony in Naypyidaw to mark the occasion.
Certificate training is available at 23 midwifery schools around the country, and the Myanmar Nurse and Midwife Association says about 1,000 new midwives are licensed each year. However, according to statistics from the Ministry of Health, the number of maternal and child health centers has remained the same for 25 years, at less than 350 centers.
In rural areas, most births take place at home, typically overseen by a midwife or a traditional birth attendant, with the latter lacking formal training. Traditional birth attendants learn skills from their elders, but government-trained midwives and nurses say that sometimes they perform the deliveries incorrectly, potentially harming the mother or the baby.
The government also trains “auxiliary midwives” who assist with maternal health care but do not work in an official capacity or receive pay. These volunteers receive six months of medical training, while government-service midwives earn a certificate after two years of training and are paid about 80,000 kyats (US$80) monthly, says Dr. Nang Htawn Hla.
“They [auxiliary midwives] are mostly recruited from the village, and after training they go back and work there,” she says. “But this system does not work well, in my opinion. Because they are not paid, they also need to work for their living, so sometimes they are not able to perform as many deliveries. If they only worked as midwives, they might need to charge the mothers a fee.”
Poor education about maternal health care is also a problem for pregnant women in Burma. In hard-to-reach areas, communities often do not understand the importance of antenatal care, says Dr. Khin Aye Myint of the UNFPA in Rangoon.
“And usually they deliver with help from a traditional birth attendant, or in some areas with assistance from a grandma or mother or relatives. Faced with any complications—for example, high blood pressure or bleeding during pregnancy—they are not aware that they should go to other service delivery points,” such as hospitals.
Community members themselves lack transportation options to reach doctors. “They don’t have enough money to go there,” she says.
While hospitals are limited to cities and major towns, rural health centers are available, typically staffed with two health assistants and between two and five midwives, depending on the local population. Sub-centers in more remote areas are usually overseen by one midwife.
The UNFPA has allocated $300,000 to upgrade maternity wards and delivery rooms in 10 locations across the country, including Shan State and the divisions of Rangoon, Magway and Irrawaddy. In addition to providing medical equipment and training in reproductive health services, the UN agency—with support from the Ministry of Health and the Myanmar Nurse and Midwife Association—helped train 40 pre-service midwives last year and deployed them to several states and divisions to assist official midwives.
They reportedly received a warm welcome. “The communities have built houses for them, arranged for water supply and supported our pre-service midwives,” says Dr. Khin Aye Myint. “And the existing midwives also support each other.”