Midwifery led Maternal Health Care and Ending Obstetric Fistula

Dr. Salahuddin Ahmed, Professor, IUB
I am not a doctor, but as a layman I understand fistula is preventable and treatable but many of the women do not know where to go to avail the services. Trained health workers and midwives can contribute to the improvement of the maternal health in the country.

Dr. Md. Azad Rahman, Field Officer, UNFPA, Sylhet
A skilled and trained midwife not only assures safe motherhood but also provides advocacy and counselling for pre-and post-delivery conditions. Therefore, every woman deserves to get services from a midwife. In the 65th session of the UN General Assembly, our Prime Minister stated that work is being done to double the trained health workers through training an additional 3000 midwives and staff all 427 sub-district health centers to provide round-the-clock midwifery service. At present, we have six-month long post-nursing course for existing diploma nurses and three-year long midwifery training starting from 2013.
Obstetric fistula is one of the most serious injuries that can occur during childbirth due to prolonged delivery pain and unskilled delivery. This situation also leads to severe socio-cultural stigmatisation. It is estimated that more than 73,000 women in Bangladesh are living with this injury, and some 2,000 new cases develop each year.
A number of strategies to eradicate obstetric fistula and programs like Community Fistula Advocate Initiative could help in this regard. Under this program, women after going through a fistula repair surgery go back to their community and can spread awareness. 

Dr. Murshed Ahmed Chowdhury, Prof. of Sociology, SUST Sylhet
Today I will talk on three subjects-- maternal health, midwife crisis and Obstetric Fistula. The maternal mortality and infant mortality situation has improved considerably which is good news for us, as both maternal mortality and infant mortality contribute to the overall development parameter. If we could diagnose high-risk pregnancy at the right time, the situation would improve.  
In terms of midwife, in our student life we saw that specified one year midwifery training was a part of the four year-long nursing courses, which was removed from the course afterwards. Unfortunately, here in Bangladesh we don't have the facility to carry out 100 percent deliveries in hospitals. Thus, a huge number of deliveries take place at home. We need a number of skilled and trained birth attendants who will ensure safe motherhood through screening of complicated & high risk cases, delivery and postnatal care. 
Obstetric fistula is a traumatic and debilitating childbirth injury. There are a number of UNFPA supported government medical institutes around the country that provide treatment and knowledge for Obstetric Fistula. However, many people are unaware of this service. Different stakeholders like the media, public representatives, MPs and religious leaders need to inform the community regarding safe maternal health and emergency obstetric services to prevent this injury from occurring in the first place. 

Dr. Abdus Sabur, Head of the department of Obstetrics & Gynecology, Jalalabad Ragib-Rabeya Medical College & Hospital
Midwife is an important component for maternal healthcare. They can play a much better role to understand the problems of a pregnant woman. In the country, around 50 percent of medical college students are women but unfortunately, they do not wish to work in the rural and remote areas. On the contrary, in rural areas, housewives prefer female gynecologist. So female doctors need to be motivated to work in the rural and peripheral areas. It is not possible to give comprehensive maternal services in all hospitals unless we have donors aid or corporate investments. It will probably take another twenty years to arrange all the maternal facilities in all the hospitals. 

Sabera Akther, ADC, DC office, Sylhet
Population growth of Sylhet is higher than the other divisions. But unfortunately we also have a shortage of trained midwives. Due to lack of training, midwives are not able to guide pregnant women for routine diagnosis. In most cases, a pregnant woman doesn't know what to do during pregnancy. To improve this situation, we have to focus on training midwives. The Department of Family Planning with the support of local government office could do the registration of midwives. We could engage Imams because they are important components in the society, they can play a vital role in awareness-building programmes. I personally emphasise on training modules for midwives and organising training programmes. 

Dr. Subhamay Majumdar, Chief Health Officer, Sylhet City Corporation
One of the major causes of maternal death is bleeding. We could reduce 80 percent of maternal mortality if we can stop the problem of bleeding. If we want to address the complexity of maternal health, we have to concentrate on Antenatal Care (ANC) and Postnatal Care (PNC) services. We need to train our midwives and paramedics. We have to elevate the nutrition programmes, apart from organising a compact and comprehensive training module at the root level and ensure more institutional delivery just like in Sri Lanka. I personally believe institutional delivery can minimise the chance of complications and infections. UNFPA and the media need to organise appropriate social awareness campaign in this regard. 

GM Abul Kalam Azad, Senior Superintendent of Police, Bangladesh Police
We could work on building awareness to reduce gender discrimination. We have centres in every police station dedicated to minimizing gender discrimination. In most police stations, we have women police personnel on duty. We know that the rate of maternal mortality is very high in Sylhet. 

Monita Sinha, Ayesha Siddika, Trainee Midwife/Nurse
When we joined the midwife training programme, we find out that our working area will be villages and our target group is mothers who are living in remote areas. What we found, mainly, is that many women living in rural areas also suffer from Fistula. They have a lesser understanding of hygiene. If we could reach them with the service, then we can minimise Fistula. We have to organize counselling of mothers in every village and provide incentive care for those who have pregnancy complexities. We believe prevention is better than cure. We could do counseling for prevention. It will help us reduce the maternal mortality rate. We are proud of supporting those mothers who are deprived from services. Neighbours and fellow villagers are more comfortable in sharing their problems with us in our villages than other people. We could serve better in our native village or area rather than elsewhere. It would be a struggle to serve people in other areas. We request the government to recruit three midwives in every union and urge for homogenous posting. It will create a better chance to improve maternal healthcare.

Brigadier General (Dr.) Md. Abdus Sabur Miah, Director Sylhet MAG Osmani Medical College Hospital, Sylhet
Bangladesh has experienced a dramatic decrease in maternity mortality rate and credit must be given to the  government for giving this issue importance. There has been a tremendous decrease in the number of child marriages and the overall improvement of our education system especially for women. What we need to do is work together as a single force and concentrate our effort on improving maternal, neonatal and child mortality in both the urban and rural areas.
We need to ensure standardization of district and upazilla health complex and should well equip these centers with trained health workers and skilled community-based birth attendants to improve deliveries in birth clinics. These health workers should be able to increase maternal care awareness in remote areas as well. Women need to be educated and empowered about maternal health issues. Most importantly the pregnant woman's husband and family should be supportive and concerned about her condition. They should support in improving nutrition, ante and post natal checkups and should not encourage early marriage. 

Kamal Ahmed Chowdhury, Professor of Sociology, Shahjalal University of Science and Technology
It is multilateral, multi-dimensional and multi-depth issue. It could not be solved by medical services alone. Bangladesh is a success story in child and mother healthcare. Thousands of people are going abroad as migrant workers and most of them are married. We have to concentrate on our maternal healthcare services especially for those women whose husbands are living abroad. The Government is trying to reduce the age of marriage from 18 to 16 years. This is unacceptable. There are many people who are unwilling to go to schools, colleges, universities in Sylhet. People of Sylhet have to change their perception towards maternal health issues and I believe education can help to reduce the problem. We have community clinics and community healthcare providers. We need to engage them with midwifery training programmes and services. Thousands of people now depend on the healthcare services of clinics. Community healthcare volunteers should have the training of midwifery. We have to focus on institutional deliveries. 

Mahfuz-ul Hasib Chowdhury, Senior Lecturer, Metropolitan University, Sylhet
Corruption has to be addressed in this roundtable. In the last few days, I came across the news that most parents, who want their daughters married off before they turn 18, manage to get false birth certificates after bribing concerned authorities. Both child marriage and maternal health are interlinked. Child marriage is a common phenomenon in the countryside. Due to financial crisis, many parents mentioned that they are forced to marry off their daughters when they are very young. This is not the right way to overcome your financial vulnerability. If the government wants to achieve no child marriage within 2041, dispersing of illegal birth certificates must be stopped.