Improving Midwifery Services in Tajikistan

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DUSHANBE, Tajikistan— Tajikistan’s maternal mortality ratio is among the highest of the Eastern Europe and Central Asia region. Fifteen per cent of women giving birth in Tajikistan do so without a midwife or skilled birth attendant to assist. For every 100,000 live births, about 47.5 pregnant women die due to labour and delivery complications. Most of these deaths would be avoidable – if women had access to obstetric care.

When midwives are educated, empowered, and informed of essential basic life-saving skills, they can avert the vast majority of maternal deaths. But in Tajikistan where two-thirds of the population reside in rural areas, there are only 4,000 midwives in the country to provide care to a population of 7 million.

Tajikistan was the poorest of the Central Asian republics when it became independent in 1991. A long civil war led to the deterioration of economic and social development, which affected health outcomes. Yet, maternal health is making progress, with the halving of the maternal mortality ratio between 1990 and 2008, according to information compiled for the State of World Midwifery 2011 report.

Working with national partners

The Government of Tajikistan has taken several steps to reduce maternal and infant deaths by adopting national and international legislative acts on maternal and reproductive health in compliance with the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and the Convention on the Rights of the Child (CRC). The Government, with UNFPA support, has also recently developed national strategies on reproductive health, safe motherhood, and family planning. Even though these strategies and many related measures have been approved, challenges to maternal health in the country remain significant.

“Although the health status has improved for many people, there are still too many women in the region who cannot afford and access quality reproductive health care. There are women who die giving birth and young people who cannot access basic reproductive health services,” said Thea Fierens, UNFPA Regional Director for Eastern Europe and Central Asia. “Urgent action is needed to prevent the further growth of health disparities, “ she said.

Early bleeding is the most common cause of maternal deaths in Tajikistan. Due to interventions taken by the Ministry of Health, including the development of national standards for effective prenatal care, maternal deaths caused by early bleeding have significantly decreased.

Quality midwifery services challenged

In Tajikistan, the quality of midwifery services remains a challenge. Medical training facilities report problems including lack training materials, limited teaching equipment and scarce accommodation for out-of-town students. Public health facilities outside of urban areas have poor physical infrastructure; the overwhelming majority of rural health facilities in Tajikistan do not have access to sanitation facilities or clean water sources.

A Tajik mother relaxes contentedly after the successful completion of the ultimate labour of love. Photo: William Daniels/Panos Pictures

Although the recruitment of young specialists, including midwives into educational training programmes related to maternal health is not difficult, after the completion of compulsory service, retention is a problem due to low-paying salaries. Upon completion of training, there is no standard certification or licensing of midwives in the country which compromises the quality of midwifery services and overall maternal health care.

UNFPA in action

UNFPA in Tajikistan closely cooperates with the Ministry of Health and supports capacity strengthening of reproductive health workers, including midwives, through continuing education, capacity building and supply of medical equipment.

In Tajikistan, UNFPA implements the “Beyond the Numbers Initiative” of the World Health Organization which not only monitors maternal deaths but seeks to improve understanding of why they happened and how they can be averted. UNFPA supports the training of doctors and midwives on effective perinatal care at the at all levels of the health system. An advanced WHO training of trainers on “Managing problems in Perinatal Care” is also supported by UNFPA.

UNFPA has also provided technical assistance to updating the training curriculums of maternal health education institutions in the country. “This initiative is considered a breakthrough as it raises educational programmes to the level of internationally agreed standards that will significantly contribute to improved quality maternal health education of doctors and midwives,” says Nargis Rakhimova, UNFPA National Programme Analyst on Reproductive Health in Tajikistan.

Midwives are actively involved in all aspects of the above-mentioned processes and the development of local midwifery protocols, she said.

“Though the midwifery situation in Tajikistan is improving, midwifery needs to be developed as a separate profession complementary to medicine with clearly defined roles and responsibilities for midwives,” said Ms. Rakhimova. “Midwives must work in partnership with other health care professionals and organizations, and they should not only be competent in their practice today but remain committed to maintaining that competence. UNFPA and its partners’ role in providing quality midwifery standards and services is critical,” added Ms. Rakhimova.

- Parviz Boboev