18 World Health • 50th Year, No. 2, Morch-Aprill997
Midwives for refugees
Maureen Minden
Women refugees coming to register with the midwives for advice on family planning.
Photo WHO/M. Minden.
T
he Burmese Border Medical Project run by the American Refugee Committee (ARC) involves several scattered refugee camps in remote areas of bamboo jungle along the Thai-Myanmar border. Prior to ARC's involvement in 1992 there had been no inter- national health agency presence.Most refugees are from hill tribes and have fled their homes in Myanmar. In 1994, the camps were relatively small but steadily growing.
They were also unstable, since they sometimes came under military attack and the refugees were forced to flee. Camp members needed to develop their own resources beyond their reliance on outside assistance, a need compatible with ARC's policy of community development along with emergency relief. In October 1994, I accepted the post of maternal and child health coordinator.
A year earlier, several young camp members (with formal educa- . tion that varied from grade 4 to grade
1 0) had taken a three-month ARC community health worker (CHW) course. A very small number of others had received 6-18 months of medical training from the Karen Army or the refugee committee.
These trained refugees were able to diagnose and treat common illnesses using drugs, injections and intra- venous infusions according to Medecins sans Frontieres guidelines.
ARC provided WHO-recommended essential drugs but there was no elec- tricity for refrigeration, nor was there likely to be any transport if ARC trucks were not around. Even with transport, in the dry season the near- est hospital was many hours away; in the rainy season, it could take days or be impossible to reach if rivers were flooded or roads washed out.
The conditions from which child- bearing women suffered included:
• general malnutrition;
• micronutrient deficiencies such as beriberi (vitamin B 1 deficiency), anaemia, and goitre (iodine defi- ciency);
• frequent episodes of diarrhoea, malaria and typhoid;
• high rates of miscarriage, still- birth and neonatal death coupled with frequent, closely spaced pregnancies;
• extensive tears of the birth canal at delivery, and prolapsed uterus;
• very limited access to family planning methods.
Many babies died in their first month
Within a year, young trainee midwives selected from community health workers, themselves refugees, were preventing problems, treating illnesses before they
developed into emergencies, and making sure that severe complications were recognized early.
of life, mainly because of:
• low birth weight (i.e. premature birth, malnutrition, or both);
• damage during birth (trauma), especially among second twins;
• infection of the umbilical cord, neonatal tetanus;
• diarrhoea, respiratory infections, malaria, and beriberi.
An evolving curriculum
It was clear that midwifery knowl- edge and skills were needed. In order to have health services with which women could be most com- fortable, female students only were selected from the eager CHWs. In recognition of their special training in maternal health they came to be known as the "MCH Midwives".
The students gathered in a single camp for the initial training and our curriculum evolved daily. There were three main considerations: the imme- diate needs of childbearing women, the resources available, and the pace at which the student midwives could learn. Willing mothers provided the students with some clinical experi- ence in the classroom, and were eager both to know what was going
World Health • 50th Year, No. 2, Morch-Aprill997
A student midwife learns haw to use a microscope. Photo WHO/M. Minden.
on and to learn about their own condition. The class held community awareness sessions, and asked camp section leaders and traditional birth attendants (TBAs) to call us when- ever they became aware of maternal or newborn problems. Theory was followed by case reviews, and more theory. Clinical experience was primarily community-based but sick mothers and newborn babies admit- ted to the camp clinic also received our care.
During the six months that we were together, we designed services to serve as a model for all the camps.
We also developed a personal record card for each client to keep, as well as registers for monitoring services and for data collection. Antenatal services were started and were soon followed by delivery services and first-week post-delivery care.
Maternal health clinjcs and home visits were also used to detect sick or malnourished children. The latter were referred to the malnutrition programme which offered supple- mentary feeding.
One student called Toetoe, who had higher education and was fluent in English, became very committed to the programme. She was also a role model for the others as she had two children and was practising family planning. Eventually, Toetoe became our MCH supervisor.
Together we trained TBAs, after which the experienced TB As worked alongside our MCH midwives or else called on them if they had problems.
When the midwives returned to their own camps, Toetoe and I went from camp to camp to support their efforts and to train TBAs. Some months later the midwives had gained enough experience for us to be able to introduce a six-week post- delivery clinic. This offered a chance to provide family planning, enrol babies in the child growth monitoring programme, and inform parents about such matters as immu- nization and foods to complement breastfeeding. We shared being "on call" for both emergencies and rou- tine practice, we ran community awareness programmes, and we reviewed cases and gave lessons on complications. The curriculum was condensed into written guidelines that were practical and possible, and these were translated into Burmese for the midwives.
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Learning to test urine to confirm a pregnancy is also part of the midwives' education.
Photo WHO/M. Minden.
19
Could they cope?
Doubts haunted me throughout the year concerning what could be accomplished towards improving maternal and newborn health. I wondered whether the midwives really could provide safe services, given their short period of training and consequently their limited skills and experience. As it turned out, within the year they were preventing problems, recognizing illness early and providing treatment. They were able to manage problems before they escalated into emergencies, and they made sure that severe complications were identified early and the mother or baby stabilized while a way was found to transport them to hospital.
Our refugee camp trainees be- came invaluable maternal health workers and primary level mid- wives. A "level 2" training course was planned for the following dry season. The most skilled MCH midwives would be sent to the mission hospital or to the clinic of Doctor Cynthia, herself a refugee, to learn how to perform episiotomies and suturing, and to gain experience in managing complications. Both the hospital and Doctor Cynthia welcomed the plan.
It was crucial that my post should be filled by a midwife with experi- ence of working in remote areas who could support these dedicated young women in continuing to develop their competence. To my relief, ARC recruited just such a midwife, and a letter from Toetoe last year indicated that the MCH midwives were pleased to have her support and were proud of the services they could now provide in their commu- nities. •
Maureen Minden is an international consultant in maternal, child and reproductive health.
Her address is # 208 1371 W 13th Ave Vancouver, British Columbia V6H IN7 .,
Canada. '
