Contributor: Mary Helen Carruth and Takhima Jabarova

Khujand, Tajikistan — Conventional wisdom says a woman's second pregnancy usually goes smoother than the first. Not so for Matluba, a 24-year-old living at the mouth of the Ferghana Valley, the most fertile and densely populated region of Central Asia. While giving birth to her second child in the maternity ward of a hospital in this sleepy regional capital, she encountered a serious complication that threatened her life.

Tajikistan's rudimentary health system is characterized by outmoded equipment, threadbare facilities and under-trained clinicians. But Matluba's chances of survival were enhanced by what her attending midwives and obstetrician had learned only weeks before. They were among the first medical practitioners to complete Mercy Corps' "lifesaving skills" training, which included a simulated rescue of a mother whose post-birth bleeding was as bad as Matluba's.

The two-week trainings are part of the agency's Child Survival Project, an ambitious attempt to improve adverse maternal and child health indicators in one of the poorest former Soviet republics.

The project seeks to improve the health of more than 50,000 women of reproductive age and nearly 30,000 children under five in Tajikistan's northernmost province, Sughd, a crowded agricultural region where ethnic Tajiks, Uzbeks and Kyrgyz live amidst a patchwork of national borders. Under the old Soviet system, people in this region enjoyed universal access to a wide array of health services, including prenatal care, childbirth services and immunizations. With Moscow paying 40 percent of the country's health bill, Tajikistan boasted of maternal and infant mortality rates comparable to Western Europe.

But the republic's vaunted healthcare system fell apart following the Soviet collapse and the ensuing civil war, which lasted until 1997. Many trained medical providers fled, vaccines and antibiotics became scarce and clinics began to crumble. Today, even urban hospitals lack adequate supplies, modern equipment and reliable heat and electricity.

A 2000 UNICEF study estimated that one mother dies for every 1,000 births in Tajikistan — a rate lower than the world average, but five times higher than the average for developed countries. Substandard care for pregnant women has broader implications: various researchers have correlated poor maternal and child health with high rates of poverty.

Training birth attendants

Mercy Corps' Child Survival Project tries to shore up the country's lagging health system, in part by bolstering its capacity. Since October, the agency has trained five instructor pairs — teaming one midwife with one obstetrician-gynecologist — to deliver the Basic Life Saving Skills class to more than 100 peers. The trainers demonstrate techniques such as how best to prevent infection, safely deliver a placenta and staunch post-natal bleeding.

Earlier this month, a team of monitors found that the sessions had made a big difference in the hospital maternity wards here in Khujand, the cultural and industrial capital of northern Tajikistan. Straddling the Syr Darya river and flanked by craggy mountain ranges, Khujand has a long and storied history as the farthest outpost established by Alexander the Great's armies and a stop on Asia's famed Silk Road. Today it is a low-key city featuring tree-lined boulevards, the colorful Panjshanbe Bazaar and nearby Sheikh Massal ad-Din mosque, and narrow, windy residential streets that about 150,000 Tajiks, Uzbeks, Russians and other ethnic minorities call home.

The five monitors — four health department trainers and the Mercy Corps program coordinator — found that trained practitioners in Khujand had improved their communication and diagnostic skills, adopted international sterilization protocols and learned how to reduce trauma and maternal bleeding during birth. Most notably, midwives were now able to assume greater responsibilities and develop more balanced partnerships with attending obstetricians.

Witnessing a difference

In one case, the maternity ward staff used what they learned about new birthing positions to avoid a risky Cesarean section. The woman, Manzura, was tiring during prolonged labor, and her baby's heartbeat was weakening. A shift in position prompted a healthy delivery and, organizers say, demonstrated that the teachings emphasizing noninvasive alternatives to surgical procedures had stuck.

How the staff dealt with Matluba's perilous situation perhaps best illustrated the magnitude of what they had learned.

The early stages of Matluba’s labor progressed without incident, and in time she delivered a healthy nine-pound, 11-ounce girl. But during the delivery of the placenta, the fluid-filled organ also called the afterbirth, Matluba started to bleed profusely. Her attending doctors and midwives used a technique called bimanual compression and started an intravenous flow of the hormone oxytocin.

It was the response they had been taught at the training, and it successfully stopped the hemorrhaging.

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