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Reflections from training Traditional Birth Attendants in Myanmar, Megan Jenkins (Trainee midwife)

Posted on 31st August 2018 by Philippa Wilford

It is a truth universally acknowledged that a country in possession of a high maternal and neonatal death rate, must be in want of more midwives.

Indeed the World Health Organisation has declared that the best investment into healthcare services is in the midwifery workforce since midwives can provide 90% of the essential care needed for women and newborns and contribute towards ending preventable maternal and neonatal deaths.

And yet in many countries women are still dying in childbirth as they have no access to midwives. These women are being denied their basic human rights. The Millennium Development Goals identify midwives as being the cornerstone to improving the health of whole communities, but in the remotest mountain regions of Burma whole communities are born, live, give birth and die without the support of healthcare, hospitals, doctors or the much needed midwives.

Instead these women rely on the bravery and courage of their fellow village women, their Traditional Birth Attendants (TBAs) to safely monitor them through pregnancy, support them to birth their babies and guide them through the fragile early days of motherhood helping them to nourish and sustain their babies. These TBAs provide a lifeline for the most desperate women, and yet many of them are illiterate, uneducated and have received no training. Knowledge, combined with cultural tradition, is passed down through the generations of TBAs and they learn their skills from village elders or their own mothers. Whilst their experience is huge, their knowledge and practice is not evidence based and can be unsafe.

In April 2018 I travelled out to Burma with 2 midwives to deliver a TBA training programme. Four days of travel navigating the almost impassable dramatic mountain passes of Chin State brought us to Lailenpi, a sprawling mountain village clinging to the dusty slopes, deep in the jungle and overlooking the border with India. A village little known to the outside world, 8 hours motorbike journey from Matupi, its closest town, and completely isolated during the 6 months of monsoon season. And yet the village was entirely alive with a vibrant Christian community (rare in Buddhist Burma), all eagerly awaiting our arrival.

Our work was orchestrated through the charity ‘Health and Hope’, founded by Dr SaSa. Born and raised in Lailenpi, through famine and poverty, Dr SaSa managed to escape military rule to gain an education in India and then to Armenia to complete a medical training. He vowed to return to his beloved home village bringing health and hope to his people. His charity has trained hundreds of Community Health Workers from neighbouring villages, and with the help of 2 dedicated midwives from England, over 160 TBAs have now also been trained. It was a great privilege to accompany this trip and assist with the next phase of the programme.

Forty TBAs had gathered in Lailenpi. They had come from 12 different villages. Some of them arriving on the back of motorbikes, some of them walking for several days over the mountains, such was their eagerness to come and be trained by the ‘English midwives’. Dedicated to helping the women of their villages, these TBAs left their families and their farms to come and spend 10 days with us. As I heard their stories and learnt more about their experiences of losing mothers and babies in childbirth it was easy to understand their fear and their desperation to learn the skills we would teach them that will enable them to save lives. Despite the advanced equipment and drugs we are lucky to have at our disposal in maternity units in England, the expertise of a good midwife are founded in knowledge, the use of all our senses and competent manual skills. The most valuable tool we have is knowledge, and this we can share worldwide.

Over the 10 days we delivered a dynamic and interactive series of lessons from education on reproductive health, family planning, protection and prevention of sexually transmitted infections, antenatal health and care of the pregnant woman, postnatal care, recognising the unwell mother or baby and the importance of referral into the healthcare system. Teaching could be as simple as the importance of handwashing for the prevention of the spread of infection, or how to encourage and support upright, active birth to the complexities of managing obstetric emergencies of a shoulder dystocia, a postpartum haemorrhage and neonatal resuscitation. Each lesson was carefully chosen for its potential for impact. We were teaching the skills that transcend language barriers and are transferable across international borders.

As the week unfolded the team of disparate women formed a sisterhood, sharing their experiences of birth and death. Together we laughed and cried and as they saw our respect grow for their extraordinary wealth of experience so their trust in us grew and friendships formed. With mutual appreciation for one another the teaching and learning was powerful. These women are used to learning by rote, not to question, just to accept. By the end of the week they were all probing for answers in order to further understand the anatomy and physiology of birth mechanisms and how their actions could help to prevent morbidity and mortality. Watching the enlightenment on their faces as they grasped a new concept was the best reward we could ever ask for. One TBA said at the end of the training ‘Rote learning is what we have always done. These topics are so great because we can see, hear, touch and ask any questions we want to. The practical sessions are so helpful because you can really imagine and practice.’

To reinforce the expansion and sustainability of our training we piloted a ‘Train the Trainer’ initiative, where 7 returning TBAs, highly experienced, skilled and competent were selected to receive additional training in order to equip them to become the Trainer. This scheme was devised to enable the training to spread to villages that we can’t reach, thereby preventing reliance on outside expertise. Together we discussed the barriers to rolling out their teaching and covered topics from adult learning theories and assessing success of teaching, practicalities of accessing villages during monsoon season, gaining respect from village elders, language and dialect differences and availability of equipment. These 7 Trainers practiced delivering some sessions to small groups of TBAs followed by feedback from the groups. By the end of an intensive programme the Trainers were ready to head out on motorbikes with an action plan and 3 identified rural villages each in which to train even more TBAs. Like the concept ‘light one candle and then let the flame spread’, our work can now have a far greater and more wide reaching impact, hopefully benefiting more women, babies and families. The Trainers were keen to take up their new role, to share their skills and knowledge and raise the safety standards in neighbouring villages. One Trainer said, ‘I want to share the knowledge, I have the heart to travel to other villages. I can combine my knowledge with sharing experiences so that mothers can still be safe in villages where there is no midwife.’ Statistics show childbirth and pregnancy-related complications are the leading causes of death among women in Burma, mainly due to delays in reaching emergency care. Until the government trains enough midwives to reach all the remote villages, trained TBAs offer an effective solution.

The assessments we held at the end of the programme demonstrated to us their acceptance of new theories that break their traditional norms. For example, the TBAs are now confident in facilitating upright birth for a vaginal breech and immediate skin to skin contact at birth between the mother and neonate to aid with thermoregulation, breastfeeding and the complex transition of the neonate to extrauterine life. During the emergency drills the TBAs worked in pairs and together managed a series of complex birth events, encouraging team work and collaboration. We distributed equipment and Clean Delivery Kits (CDKs) which will help provide for basic neonatal resuscitation and a more sanitary birth environment, ensuring at every birth there is soap, gloves, a clean sheet for the mother, a wrap for the baby and a cord clamp, to prevent the use of threads from their skirts as is traditional.

What did we achieve? If the effects of this training reach no further than these 40 women, we know that there now exist 40 women empowered with knowledge and understanding, with skills of communication, team work and the realisation that their contribution to maternal and neonatal health is so greatly valued. One Trainer thanked us for the training saying, ‘Now I have been trained, I have peace, confidence and courage when I face different and difficult things. I have patience to wait rather than rush so the women have a better experience of childbirth. I want to save more mothers and babies and I want other, less experienced TBAs to have the same, so I want to train them.’

Yet we know that this training programme has much greater effect than individual empowerment. Since the TBA training programme launched in 2013 no mother in the town where the project was started has lost her life in childbirth, thanks to the skills that the TBAs have been equipped with. As such they have now closed the under 5’s section of the orphanage in Lailenpi. What greater testament could there be to the power of education, knowledge, midwifery skills and the contribution of TBAs, than the closing of an orphanage?

Close to completing my midwifery training this trip offered an exciting opportunity for me to combine my passion for midwifery and teaching with my love for travel. It has also opened a window onto the ways I can continue with voluntary midwifery work amongst some of the most disadvantaged communities. However, far greater than what we were able to give, was what we gained from living amongst these open and kind women. Received into their homes and lives we became engrained in their culture and traditions. Every night we were visited in our wooden house on stilts by a small group of TBAs bringing us gifts and offerings of eggs from their hens, bananas and papaya fruits, wild honey they had harvested from the jungle, small fish from the river and fabrics they had woven. These people of Chin State, who have very little themselves, were unendingly generous in sharing everything with us, from food to friendship, in order to show their gratitude for what we had come to teach them. The experience was humbling and inspiring and I can’t wait to return to them.

A great success: Training Traditional Birth Attendants in Myanmar

Posted on 4th May 2018 by Chris Jones

A great success: Training Traditional Birth Attendants in Myanmar
We have only ever done rote learning in the past, but this training you have given us is so great because we can see, hear and touch. We can ask any questions we want to. The practical sessions are so helpful because you can really imagine it and practice it with your hands!

Thanks to the generous financial support of our partners, we were able to run our first "Train the Trainer" workshop for Traditional Birth Attendants (TBAs) in Lailenpi Town, Chin State at the beginning of April.

Our TBA training programme started in 2013 and has, to date, equipped over 166 local women with the skills to support mothers and babies through pregnancy, birth and early infancy. Our workshops focus on reducing the rate of neonatal and maternal deaths and the incidence of infant and maternal illness. The training has been so successful in one village, that the under-5 orphanage has now closed with no maternal deaths in the last five years!

To reinforce the expansion and sustainability of this training, we have recently piloted a ‘Train the Trainer’ initiative, equipping our most experienced indigenous health workers with the skills to proactively pass on their midwifery knowledge to new trainees themselves, rather than relying on outside expertise. 

Our first ‘Train the Trainer’ workshop was run by three UK midwives during Easter, two of whom have made six prior trips to the region, having also supported the development of a bespoke training course for local women.

Following the six-day workshop, the new TBA trainers headed out to practice their skills in rural villages by training small groups of women across the region following a three-day curriculum. It was anticipated that they would each train up to four new TBAs. However, in the first village, sixteen women joined the training and in the second nineteen took part, so eager were they to participate and improve their knowledge.

In Zo Ma village, sixteen women attended the training even though they only invited five! During the time in the village, there was one woman who could not do any work and was lying in a flat position throughout her pregnancy.  When the TBA Trainer arrived she was able to help reposition the baby and the woman has been able to stand and start work again.  At the end of the training she came to give us a chicken to say thank you!

Another woman was told by a villager that she had cancer in her bladder because they did not know she was pregnant. The TBA Trainers examined her and found out she was four months pregnant!  She was so delighted she praised God and was so thankful to the TBAs.

The women were so excited that other villages were calling to them saying, please come to our village, we will send a motorbike to pick you up.

In each village they went to, there was always more women than invited.  They asked for help with vitamins and better nutrition.  They also said the time was too short being just three days and the villagers were not satisfied and wanted more!

The trainers and trainees had another surprise too. While conducting the training they were able to use their skills during a real birth, with mother and baby well looked after by all. The perfect training opportunity!

Our UK midwives will return to Chin State at the end of 2018 to review progress and receive feedback. They will also assess the extent of the knowledge passed on to the new TBAs through practical and theoretical appraisal and deliver additional training during their time there.

We're delighted with the impact of this project and it's all down to the financial backing of our supporters.  If you've been part of this project, thank you so much for partnering with us to bring health and hope to mothers and babies in western Myanmar!

We have, however, spent all of the funds raised over the last year and are now looking to secure further funding to enable the project to continue after the monsoon.

Can you help?  If so, please do share the link to this news page to enable this vital work to continue.

Cyclone Mora Rebuilding Appeal - Video Update

Posted on 15th October 2017 by Chris Jones

On the 30th May 2017, cyclone Mora swept across Chin State, western Myanmar, triggering landslides and destroying buildings in rural villages. 

At our main base in Lailenpi town, there was considerable damage to roads and homes and sadly our training centre was torn down by the high winds and torrential rain

Yet despite the personal impact and sorrow felt by our staff and the local villagers, hope is rising.

Health and Hope staff and a committed team from the local community have come together to dismantle the old training facility and prepare the ground for a new, reinforced training hall and dormitory to be built. 

Take a look at our short film to see what has been going on in Lailenpi since the cyclone hit:

As the film above shows, the site is now ready and waiting for rebuilding work to start.  We are grateful for the support of eMI-World who are providing world-class architectural and structural engineering support to help design a reinforced building which will withstand future cyclones and earth tremors.

In the last newsletter we asked for your help to raise £60,000 towards the rebuilding budget. We are delighted to report that, thanks to your generosity, you have helped us to raise nearly £45,000 towards this target.  This is enabling construction work to move ahead while additional fundraising is taking place. Thank you so much!

If you can help us to raise further funds towards this project, please contact us on or you can donate to our Rebuilding Appeal by clicking here.

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