"Miss, we cannot read or write"

36 World Health • September-{)ctober 1992 "Miss, we cannot read or write" Maureen Minden After training, traditional birth attendants in a remote part of Nepal are passionate in their desire for better treatment of girl children. N epalese women say that "in childbirth, death comes for women" . After a successful birth they say "I survived". Maternal mortality in Nepal is under-reported at a figure of 8.5 per 1000 births; a study two years ago in Kavre assessed it at 12.1 per 1000. Infant mortality is more than 123 per 1000 live births. For the past three years in Kavre, a middle-range mountainous district in Nepal, auxiliary nurse-midwives and I have been teaching maternal and child health care to village women. Divisive factors seem to overshadow the commonality of human needs; the mountain terrain, ethnic and language differences, the caste system, gender discrimination and illiteracy - all these seem to fragment our efforts to spread health education. As a member of the British ~ ~~~~~==~~~~~~==~~~~====~~~~~ Monitoring pregnancies is o key element for mother and child survival. Voluntary Service Overseas, I work within the government health care system as a district public health nurse. There are nine health posts, the most remote requiring two or three days' walk. Under the Division of Nursing 's traditional birth atten- dant (TBA) training programme, we have taught at all of the health posts: 15 women at each post, one trained TBA for every two to three villages. A drop in the ocean, but a begin- ning! The programme involves a ten- day basic course, a four-day re- fresher course within a year, and six two-day supervision meetings every month. The women are illiterate. The training is minimal, designed in the face of such constraints as : limited funding; no staff at some health posts; no roads or transport in most of the district; some TBAs living two to three hours' walk from the health post; and women tied to the home and the land- with plant- ing, monsoons , and harvesting from June to October. Cultural beliefs and practices vary, but in Kavre certain views seem to prevail , the most influential being that menstrual blood, and conse- quently the blood of childbirth, is a source of pollution . Very often women give birth alone, thereby not polluting anyone and avoiding the obligation to give gifts and do purifi- cation rites. The mother-in-law is tradition- ally the birth attendant for her daughters-in-law. Sometimes she attends only the first birth, the women giving birth alone after that. Some, having gained a reputation as wise, may be called by other fami- lies in the community if a birth is difficult or complicated. Prior to taking the course, with no know]- World Health • September-october 1992 edge of the germ theory or sources of infection, TBAs used to advise women to give birth in the animal shed to avoid polluting the home. Since there is no knowledge of the uterus and its functioning in labour, a cloth is tied tightly around the abdomen to prevent the child from "going upwards into the mother's heart and killing her." If the placenta is not delivered within a few minutes, the woman's hair is pushed down her throat to make her vomit in the belief that this will help her to expel the placenta. After birth there is no effort to control bleeding; this "bad blood" (menstrual blood of the months of pregnancy) must come out! "' ~ Nutrition is a serious problem. ~ Many foods are restricted in preg- ~ nancy as harmful, including oranges, ~ ~~~~~==~~~~~~~~~~~~~~~ tomatoes, pumpkin, honey, and A doll used in training TBAs. sometimes green leafy vegetables. The connection made between the pregnant woman's nutritional status and that of the baby growing within her is obscure. The postnatal diet is white rice, herb broth, and ghee (clarified butter); everything else legumes, peas, green vegetables, fruit, milk, and yoghurt- is with- held. The mother 's intake of water is severely restricted since it is thought to give the baby stomach pains. At the beginning of the course, the TBAs and I discuss our different backgrounds. They tell me, "From when we were little we never had the chance to go to school; Miss, we cannot read or write". We discuss their experience and skills, based on their care of families, homes, fields and animals. After a few days of Learning how to read and write: a right long denied to Nepalese women. 37 classes, they say "Look at us . Who would have thought we would be getting education!" As they develop some understanding of our bodies in health and illness, and aspects re- lated to childbearing, they begin to believe that perhaps, even in Nepal, so many women and babies need not die and they themselves could be instrumental in improving health. The Division of Nursing's pro- gramme has developed flipcharts and a teaching manual for village level, but demonstrations, directed discussion and role-playing bring the information alive. The TBAs are passionate in their desire for better treatment of girl children. Today they advise pregnant women about nutritional needs during pregnancy and after the birth, as well as the need for tetanus immunization, giving birth in a clean place, man- agement of labour, early recognition of problems, safe cord-cutting tech- niques, early care of the baby, family planning and much, much more. These TBAs are eager to share their experiences, and sometimes thank the district nurse-midwives, who are now their role models, for clarifying some problems they have long struggled with. They tell them, "You teach us. We can improve life in our villages." • Mrs Maureen Minden is a state registered midwife and has worked in Nepal as a member of the British Voluntary SeNice Overseas (VSO}. Her address is 7 Hill House, Southside, Steeple Aston, Oxfordshire OX6 3RY, England