The isolated communities in the mountainous northern region of Pakistan have among the country’s highest mortality rates for young mothers and newborns. Typically only one in three births receive attention from a skilled birth attendant and not even 1% of child-bearing women receive complete prenatal care (at least four prenatal care visits, skilled birth attendant at delivery, and postpartum care). The extremely rugged terrain and harsh winters make it very difficult to keep trained health professionals working in such remote conditions. The Chitral Child Survival Program (CCSP) trains and deploys women selected by their own villages to become midwives and provide child health care in these logistically challenged communities.
A potential model for the Pakistani government’s program for training rural midwives, CCSP trains women identified by their communities. The project provides these women with the skills needed to provide maternal and newborn health care, recognize high-risk situations and provide referrals to the closest health facility. CCSP also aims to ensure the availability of affordable transportation to the nearest health facility (usually more than a two-hour walk away). Most important, CCSP establishes a model of a fee-based system that ensures the sustainability of community-based health care.
The first group of 28 community midwives all passed the Nursing Examination Board’s final written examination in December 2010, graduated from the Chitral Midwifery School (established by CCSP), were licensed in June 2011, and began work in July. With six months of “enhanced skills training”, in addition to the standard 18-month curriculum established by the Pakistan Nursing Council, CCSP community midwives reinforced their skills in key areas and gained new skills while waiting for their nursing registration.
Women face huge hurdles in becoming part of the community decision process in the very traditional society of Chitral. Despite that, through the extensive training provided by CCSP and through graduation ceremonies and installation events in their home villages, the community midwives have been recognized as skilled and legitimate providers of services able to play a strong role within their communities. The midwives work in tandem with other local health workers on integrated management of childhood illnesses.
Since training 28 community midwives and placing them in their villages, CCSP has established referral linkages between the midwives and facilities. Plans are in place for “presumptive shifting” for when a community midwife identifies birth risk factors. The project has monitored where communities are uncomfortable with women in the health care role and identified key variables to address. The project developed a behavior change communication strategy to raise awareness and foster healthier behaviors for prenatal care, delivery and the postnatal period.
Other focus areas
An innovative aspect of the CCSP is the introduction of community-based savings groups (CBSGs) to the Chitral region. CBSGs allow women to set aside resources for any purpose that might require funds, including health expenses. In addition to improving women’s access to finance, these groups are a powerful mechanism to empower women and increase their independence. By June 2011, over 170 CBSGs had been formed with over 3200 members.