Women wait with their children for prenatal consultations at a mobile health clinic run by the Adventist Development Relief Agency (ADRA) in Nyaungdon, Labutta township, Ayeyarwady Division. Pic: Christopher Davy

SUI Sui’s figure is tiny, making the bump beneath the 32-year-old’s faded flowered dress look overly swollen. Sui Sui is in the ninth month of her ninth pregnancy. In the still hat of midday, beads of sweat mix with the thanaka on her forehead. Despite her past experience, pregnancy doesn’t get any easier, she says.

She is among a group of 20 other pregnant women who have been waiting for almost an hour for prenatal consultations with the free mobile health clinic run by the Adventist Development Relief Agency (ADRA).

They are bundled up along the pews of a church in Nyaungdon, a mainly Karen village in Labutta township, Ayeyarwady Division. There are three faded orange sheets held up with string to offer a little privacy during the consultation. The pregnant women are gossiping quietly, exchanging news while a basic first aid workshop is taught from the stage beside the altar to another group of women by another ADRA doctor.

The doctor is explaining why the traditional technique of cutting snake bites out with a knife or stubbing a cigarette out on the bite is not a good idea. Children are perched on the dusty floor of the aisle, or sucking their thumbs as they watch the activities around them, their eyelids drooping.

Sui Sui says hopes this will be her last pregnancy. She whispers to me: “No, I don’t want to be pregnant after this one.”

She has her reasons for the fervency of her response. “I only have two live children – the others were stillbirths, miscarriages or died when they were babies,” she explains. “I want this to be the last one. I’ve been pregnant so many times since I got married when I was 16. It’s enough now.”

According to the UN Children’s Fund State of the World’s Children 2007, infant mortality rates are 75 per 1000 live births in Myanmar. It is often an inability to access healthcare, because of either poor infrastructure or cost, that explains the large number of children who die during birth.

Lack of health assistance also seriously threatens the mother’s health, say health experts.

The United Nations Population Fund (UNFPA) estimates that 3800 women die in pregnancy and childbirth each year in Myanmar and that 87 percent of maternal deaths occur in rural areas like Labutta township. Eighty-eight percent of the women who die in childbirth are likely to do so at home, before they even have time to reach a health professional.

Sui Sui has walked 20 minutes to reach the clinic today. She lives five hours by boat from Labutta town, and she has never had a trained medical professional at any of her children’s births. Just like 57pc of other births in Myanmar, according to the United Nations Development Program (UNDP) Human Development Report 2007/2008, the baby that is due in a few days will also likely be born at home with the support of a traditional birth attendant, and out of reach of a professionally trained medic.

Should Sui Sui experience haemorrhaging, infection or a complicated labour, there is not likely to be time to reach health assistance. Often women are reluctant to pay for a service that many in this group of women believe is not always essential.

“It would be too expensive to go to a hospital to give birth or to pay for a midwife to be there – though of course I would rather,” Sui Sui says, adding that she is grateful to ADRA for the mobile clinic, which since last August has visited this nearby village every couple of weeks and provides pre- and postnatal care as part of its cyclone emergency response. This is some of the first prenatal care Sui Sui has ever received.

Even the only midwife in the area, Thida Tun, agrees that cost is the main reason women prefer to have traditional birth attendants rather than midwives when giving birth.

“A midwife is normally K30,000 a birth,” she says, “whereas a traditional birth attendant is between K7000 and K10,000.”

This is one of the reasons Thida Tun offers her services for free. “But I can only do so because my son is supporting me,” she adds, noting the financial impact that Nargis has had on many delta residents.

Daw Khein Thain, 73, has worked as a traditional birth attendant since she was 20 years old. She lives in a village outside Kone Gyi, also in Labutta township.

Before Nargis, she padded her income by selling coconuts. But with most of the delta’s coconut trees destroyed by the cyclone, she must now rely on the UN Development Program’s (UNDP) livelihood program for the most vulnerable households to supplement the money she earns attending births.
“I was eight years old when I saw my first birth,” she says, smiling. “I’ve never received any training. I suppose I learnt everything from my mother.”

“I don’t imagine there will ever be a time when there isn’t a need for traditional birth attendants,” Daw Khein Thain continues. “There aren’t enough government-trained midwives and it’s a tradition that has gone on for generations. People feel reassured having someone with experience around.”

But she admits that when there are complications she does not always feel adequately prepared.

“When there are difficulties with the birth I try to get assistance from a midwife or other traditional birth attendants, but it is not always easy,” she says. “In recent years we’ve seen more husbands attending the births – 15 years ago that wasn’t done.”

Although the doctors at the ADRA clinic say that traditional birth attendants play an important role within communities where there is often only one professionally trained midwife to cover 10 or more villages, they say that the techniques used are sometimes unhelpful or even dangerous to the mother’s or child’s health.

“Many of the birth attendants won’t recognise something like a breech delivery for example,” explains 23-year-old Cherry Bo, a recent medical graduate from Yangon who has been based in Labutta township since June helping to run ADRA’s mobile clinics.

A breech delivery is a birth made complicated and risky by the baby positioning itself feet-first instead of head-first in the womb.

“Often the baby will die with its head still inside the mother and the birth attendant will have to cut the baby off at the neck to save the mother’s life,” says Wai Yan Zaw, another 23-year-old doctor working for ADRA.

It is because of the lack of formalised health training among birth attendants that ADRA has implemented a training program for midwives in various parts of the delta.

“Advising traditional birth attendants is really vital,” says Cherry Bo. “They can be taught to recognise when a birth is likely to be complicated and then recommend for a mother to go to Labutta or have a midwife or doctor attend.”
Persuading traditional birth attendants to try modern methods can be difficult though.

“Sometimes we tell them and tell them but they don’t want to hear us,” says Wai Yan Zaw. “It takes time to change what they have been doing for years.”
The success of ADRA’s program will be seen in the next few months as the NGO, like many others, scales back its emergency response efforts. Whether funding for the mobile medical clinic is assured into monsoon season is still unclear.

But even if the mobile clinic closes, it will be the training the ADRA doctors have offered to the traditional birth attendants, children and communities of southern Labutta township in basic healthcare, nutrition and sanitation that Wai Yan Zaw and Cherry Bo hope will continue to make a difference in the lives of mothers like Sui Sui.