Learning to Trust “Doctor Apas” and the Midwifery Approach at the Community Level
By Ishrat Jahan
In the context of Bangladesh, the midwifery profession is relatively new. According to WHO, roughly 60% of deliveries in Bangladesh do not occur in health facilities or maternal clinics, and around 90% of such deliveries are attended by unqualified and unskilled birth attendants. However, midwifery services can often be the best possible alternative to ensuring that all women, regardless of their socioeconomic background, can access basic maternal healthcare services. The recent professional development of midwives in Bangladesh comes as a result of years of collaborative approaches and partnerships between the Government, NGOs, academia, professional associations, and donors, striving for a common goal to save the lives of women and babies through educating midwives.
At a BRAC Midwifery Led Care (MLC) Centre established in Mirpur, Dhaka, I came across 22-year-old Amena who was managing the reception desk. Here it is common for her to face many questions and doubts from pregnant women waiting for their appointments. During one of my many sit-ins at the clinic, I watched Asha multitask through the crowd with ease as she reassured the women and tried to answer their questions the best she could. Her calm demeanour established an efficient flow in the clinic, and her friendliness seemed to comfort the women.
But Asha is not just a receptionist; she is also this clinic’s newest midwife. She recently became a registered midwife in February of 2018 after completing a diploma in Midwifery from BRAC University in 2017. Asha is one of the four midwives who collectively oversee the daily operations and deliveries at this clinic. While shifts are long and working as a midwife is a highly challenging job, I could not find the expected signs of stress on Asha’s face as she went around calmly sorting through the register and checking up on labouring women.
“Handling every delivery is akin to being in a state of emergency,” Asha told me. “Anything can happen at any moment and you have to be prepared to handle it. It is strictly a part of our job to provide counselling to a woman during labour and make sure she is at ease.” The midwives not only handle every delivery with a critical sense of care, but throughout the day they also have to provide consultations to pregnant women and guide their family members, advise new mothers on family planning methods, and more.
However, while observing the clinic, we had found a sense the general unfamiliarity around midwives among the community members. One of the other midwives told me: “It’s not only the women who need convincing to stay in the clinic and try delivery on the chair, we have to mainly convince the relatives who accompany her first. A lot of times they object our advice even if the mother has not said anything herself.” I even heard family members who were coming and going (especially men) sometimes make passing comments during conversations with the midwives that showed that they did not consider them to be qualified to perform “doctors’ tasks.” However, the midwives and other staff would always respond informatively and with authority, telling the cynical individuals that the Centre was based on midwifery services.
On the other hand, I also found that many women from the community, especially those who had already given birth once, refer to the midwives as a “doctor apa” (meaning “sister” in Bengali) — acknowledging their professional standing both in terms of expertise and experience. Women who went through normal deliveries at the centre and where assisted by the midwives and support staff said they viewed the midwife as a professional whom they trusted and capable of handling their deliveries. One woman shared the following experience:
“I had initially been scared of being there and of what would do happen to me, and kept telling them to let me go home. But the midwives and community health worker consoled me when I said that I could not bear the pain anymore. They told me to eat so that I can get my strength back and made me stand up and do exercises, encouraging me to do them because they said it would speed up my delivery. I did not think any of these things would help, the pain was so much and I gave them a lot of trouble! But they helped me a lot and because of them I didn’t have to end up doing a C-section, which I later realised would have led to so much more suffering.” (New mother, delivered in September 2018, 18 years old)
The midwifery approach is rooted in a different philosophy of birth and consequently leads to different practices. Here birth is understood as something which women do, not something which is done to them. Thus, it empowers the woman giving birth by allowing her to direct the process while midwives offer support and assistance. Subsequently, the model for birthing clinics like the MLC, is based on the home, not the hospital and the midwife’s role is to facilitate birth, providing the space for women to be active participants in during childbirth — a concept that has already begun to spread itself through this one community in Mirpur.
Even with a few doubtful community members, it was still clear to me that the introduction of midwives in the delivery centre has meant a significant change in childbirth options for women and families within this area. Implementing midwifery practices is done by BRAC JPGSPH’s Developing Midwives Programme with the intention of creating a holistic environment for childbirth, where women are not treated as a separate body. This is currently being done through techniques and methods such as exercising and alternative birthing positions like using birthing balls or birthing chairs during labour. Through the MLC, women are given the space where an active role in their own care during pregnancy and birth is put on the forefront and where women are learning that the doctor apa at the clinic is someone they can surely depend on.
Ishrat Jahan is a research assistant at the CGSRHR, BRAC JPGSPH. Special mention goes to the Developing Midwives Project team. The blog is derived from an ongoing JPGSPH short study on women’s experiences of childbirth on the birthing chair at the Midwife Led Care Centre by the Developing Midwives Project. All photos by Kawser Ahmed, Advocacy and Communications Specialist, Developing Midwives Project, BRAC JPGSPH.
