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From: Sanitation – Footsteps 9

Ideas for working with communities to improve hygiene, sanitation and health

by Dr Steve Brown.

I would like to open the discussion about the knotty problem of women like Anastausia who are given oxytocics, either by village healers, in the form of roots (‘Knotty Problems’ in Footsteps No.7) or, as I have seen in Bangladesh, by village ‘doctors’, in the form of oxytocin injections or tablets. The problem, of course, is that oxytocics are powerful stimulants of muscles in the womb and that, when given in a high or uncontrolled dose before the baby is delivered can cause the womb to burst.

I feel that we should avoid too quickly criticising and blaming either the healer or the woman, and we should avoid coming up with quick and easy answers. We need to make sure that whatever advice we give is actually relevant to the people and is possible to follow. We should observe the simple rule of seeking more information about the problem.

People are not generally stupid; they do things that are logical within their own understanding of the problem and in keeping with their own values and beliefs, and we should respect them for this. In this case we may need to find out the beliefs regarding:

  • the length of pregnancy
  • the best time for delivery 
  • where and how women should be delivered
  • who should be present
  • spirits associated with labour and child-birth.

People’s attitudes towards the health service are also influenced by their past experience of it. Is a visit to the local health centre a ‘positive’ experience or is it time-consuming, humiliating and seen as unfruitful? Is the service readily available and affordable?

With this information we should be better able to imagine ourselves in the position of the pregnant woman. The solution may be more to do with changing our service than with expecting other people to behave differently. It would be ideal if the plan of action could be discussed with village healers, groups of women and local midwives, and not just presented to people as ‘the solution’.

We should find out exactly what is being given to women and for what reasons. If oxytocics are being used to start labour, the answer probably lies in agreeing with village women, midwives and healers during training sessions or discussions that:

  • Babies will come when ready; if the baby appears to be late then probably dates are wrong.
  • Labour should not be induced at home because the dangers are very great.
  • If you think you baby is more than two weeks late go to the hospital for advice.

If oxytocics are being used to speed up labour, things are more complicated and some simple local research may be needed. In my experience in Bangladesh, most cases of delay in labour were due to exhaustion and dehydration of the mother. Both midwives and women may need training in encouraging food and drink during the first stage of labour, and not ‘pushing’ too early. If the village doctor has used oxytocics in such cases he may have helped many babies to deliver. However, if he used them when the baby was in the wrong position or the baby’s head was too big for the mother’s pelvis, he may have ruptured a uterus.

The woman in the village is in a very difficult position – doctors are often unwilling to attend delivery cases in the community and the woman already in labour doesn’t want to be moved. No wonder she uses local medicines first.

The answer, in the end, probably lies with:

  • antenatal screening of women to find our those at risk from difficult labours.
  • training of village midwives, not just in doing deliveries but in recognizing problems in delivery at an early stage so cases can be referred quickly.
  • working together with village doctors and healers to recognize the risks of oxytocics and to control the use and doses more carefully.
  • making health services readily available and improving transport facilities to hospital.

Would any other readers like to comment from their own experience?

Steve Brown is a doctor with many years experience in Bangladesh with Tear Fund.

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