BETRAKA,- Madagascar's traditional midwives, or 'matronnes', are often thought to undermine safe childbirth practices, delivering babies in unsanitary environments and without provisions to manage complications. Yet they are now being recruited to a campaign to get women to deliver in clinics or hospitals, part of a move to lower maternal and newborn death rates.

"We have more work than ever," said matronnes Bertine, 52, and Marnette, 51. The women, who are cousins, learned the trade from their grandmother 20 years ago. Now they are cooperating with the Centre Sante de Base (CSB II) in Betraka, a tiny village 50km north of the coastal town of Manakara, to ensure that all pregnant women in the area deliver at the clinic.

"Sometimes women ask us to do their delivery at home, but we tell them it's forbidden. It's much better here, as there are materials. Before, we only had our own two hands," Marnette told IRIN.

State of maternal care

Madagascar is "facing the triple challenge of fast population growth, growing poverty and political instability", according to the UN Population Fund's (UNFPA) 2011 State of World's Midwifery report.

Though the country - which has the highest adolescent fertility rate in Africa - has reduced its maternal mortality since 1990, it still has a moderately high maternal mortality ratio (MMR), says a new report on MMR trends produced jointly by UNFP, the World Health Organization, the UN Children's Fund (UNICEF) and the World Bank. Madagascar's MMR dropped from 710 deaths per 100,000 live births in 1990 to 240 per 100,000 live births in 2010.
According to 2011 estimates by the UN Inter-agency Group for Child Mortality Estimation, of every 1,000 live births in a given year in Madagascar, 43 infants die before reaching age one. This number has dropped from 50 deaths per 1,000 live births in 2007, but it is still much too high.

"Weak infrastructure, referral systems and equipment, and lack of qualified staff make access to health care especially difficult in the provinces," the UNFPA report said about Madagascar. Madagascar has about 3,000 health centres, but many are in disrepair or are closed because of the country's ongoing political crisis.

The country only has four trained midwives per 1,000 live births. And although there are 21 midwifery schools, which train skilled midwives to hygienically deliver babies and deal with complications, the number of graduates is not meeting needs. In many areas, people have to rely on traditional midwives as their main maternal care providers.

Priority focus

The government had made maternal and newborn health a top priority in 2008; a national plan for maternal and newborn health was launched the same year. A policy of free healthcare at birth - including expensive caesarean sections - aims to promote institutional birth and increase the use of skilled birth attendants during delivery to a target of 75 percent. Yet many areas struggle to meet this target.

The CSB in Betraka offers a success story.

"The mayor of this town had lost a family member to childbirth, so when we went to see him, he immediately set a new rule: Anyone who doesn't come to deliver at the CSB can be fined 100,000 ariary [about US$44]," Hasiaina Rakotoarinaivo, head of the CSB, told IRIN. "We also went to see the local [heads] and matronnes. They signed a letter saying that they agreed with the new rule. The amount of deliveries in the CSB doubled to 30 a month after that."

With encouragement from the matronnes, women in labour walk or are carried into the CSB. The matronnes come with them and assist at the clinic; they still receive their fee of 1,000 ariary (about $0.50) and five cups of rice.

In the 1980s, aid agencies tried to train traditional midwives, supplying them with sterile delivery kits. "The project to train matronnes was a total failure. It did nothing to decrease maternal deaths. These women were not equipped to deal with complications, and once they see that a delivery is not going well, the patient is often too far away from a hospital to be saved, as the most dangerous time for the mother is the first two hours after delivery," Achu Lordfred, chief technical adviser at UNFPA, told IRIN. "When the woman tries to deliver at home, there are too many delays for her to receive the help she needs."

But by convincing matronnes to promote hospital deliveries, health workers have found a valuable ally.

"It's good these matronnes come here. They assist with tasks we don't have time for, like fetching water and walking the women around the courtyard," skilled midwife Elia Razanadrambahy told IRIN.

Her colleague agrees. "When I was in school, the teacher told us that there will be matronnes to deal with once we started practicing. He said, 'You can either work with them, or against them, but I advise you to cooperate'," Miora Tahinjanoihay, another skilled midwife, told IRIN.

Convincing worked

Matronnes often use traditional practices that can harm women. Local doctors complain that they make women drink traditional herbs to speed up labour - a practice they say can rupture a patient's uterus.

Tahinjanoihay said women around Betraka are made to drink water with gold in it, which supposedly proves that the husband is the father's child. "Then, when there are complications, the women think it's the magic working and they become afraid," she explained.

"We show the townspeople the consequences of these methods. Sometimes women are brought in with convulsions because they drank this kind of herbal tea. After treatment, we use their examples to inform the villagers," she continued. "Women believe the traditional herbs will speed up delivery and clean the baby, but it often has the opposite effect."

"We found that it's easy to convince the matronnes to take patients to the hospital," UNFPA's Lordfred told IRIN. "These women are merely looking for respect and a special position in society. The problem we're working on now is for the [skilled] midwives to accept them. Often, when a matronne takes a patient to the hospital, the midwife will start to insult her and tell her off for giving traditional herbs. We try to convince them that it's better to work with the traditional healers, that fighting them is not going to work."

The agency is trying to reinforce hundreds of CSBs to handle the influx of deliveries. UNFPA has spent $2.6 million since 2008 to get 200 health centres up to a basic level for deliveries; a further 44 centres are now equipped to perform C-sections and blood transfusions. "Some places are easy to transform - they just need light or water. It's the more advanced units that are expensive, as they need equipment for operations," Lordfred said. The agency also trains midwives and pays their salaries.

"I came here because all my friends deliver here," said 28-year-old Raharisoa in Bekatra. She is expecting her second child; the first was born 15 years ago, at home with a matronne. "I didn't know there was a hospital then. I didn't have problems during the first delivery at home, but I heard it's better for your health to come here."

Source:  Integrated Regional Information Networks (http://www.irinnews.org )