Health care for pregnant women and children under 5 has been free for almost a year now. I have just spent three days with about 30 local midwives at a local conference and have really enjoyed learning from them about the challenges and fustrations of working here. Some of the challenges they face must make working very difficult - it seemed that doctors will often not attend a woman when called, drugs might run out or be locked away somewhere, they are lacking good, knowledgeable role models who are prepared to challenge existing poor practices. It would appear that small changes have been made - the partogram (chart used for a visual summary of clinical information in labour) has recently been introduced and the midwives have some understanding of how to use it. Since the introduction of the free healthcare initiative pregnant women are attending an average of four antenatal appointments, I think this is a big improvement from what was usual previously, although the midwives find this a challenge as it has significantly increased their workload.
I think one of the biggest challenges to improving the midwifery care here is getting the midwives to believe that they can make a difference, that maternal and infant mortality can be reduced, not just by better equipment and fancy resources, but by being more diligent in the basic care of women. Much of the care described to me was based on the idea of 'this is what we have always done and what we all do', rather than what is actually the best care practice. They laughed at ideas of women kneeling to give birth and looked skeptical about the idea of reducing their episiotomy rate on primips. I am excited to be working as a midwife this year, but anticipate that this is the start of a steep learning curve, not only about the practice of midwifery here but how practice is influenced by the wider culture and beliefs.