Suffering from the highest maternal mortality rate in Central Asia, Tajikistan has embarked on an ambitious plan to improve access to obstetric care. But statistics on home births show the country has a long way to go.
A recent survey found that at least 44 percent of the women who gave birth in Khatlon Province's Yovon district over the past year delivered their babies at home. In nearly half of those cases, the women gave birth without the assistance of a qualified midwife.
Strategia Center, whose survey covered September 2012 to September 2013, earlier identified Khatlon Province as having the highest rates of home births in the country, with about one out of every three women giving birth at home. In the northern province of Sughd, the number stands at about 20 percent, and in the eastern Badakhshan Province, 10 percent.
The Tajik Health Ministry says that, nationwide, the vast majority of women choose to give birth in hospitals or other facilities, with only 10 percent of women opting for home births. But it, too, notes that of the recorded home births, most take place without the presence of a qualified attendant.
The seriousness of the problem with home births is highlighted by the fact that for every 100,000 live births in Tajikistan, about 47 pregnant women die due to labor and delivery complications. The majority of the fatalities involve women who opted for home births.
The high maternal mortality rate has prompted Tajik health authorities to launch an initiative that intends to ensure every pregnant woman has access to obstetric care during pregnancy and childbirth by 2015.
There are a variety of reasons why women don't seek proper medical care during their pregnancies, says Firuz Saidov, a member of the team who conducted the Strategia Center survey. "Some of them live in remote villages and simply don't have anyone at home to take them to hospitals," he says. "Some are not aware of the risks involved."
Gulmoh Sobirova, a mother of five, delivered three of her children at home in Khatlon Province's remote village of Tanobchi. Her reason for delivering without medical supervision is simple: it's cheaper. While health care is officially free in Tajikistan, the practice of paying cash to doctors, nurses, and midwives is widespread.
"Many villagers are poor. It's cheaper to deliver babies at home," Sobirova says. "Some women in villages pay about $10-$60 to nurses who can assist during their childbirth. Of course, they charge additional money for any medication or injection you need. "
Sobirova estimates that she would have to pay up to $150 if she delivered her children at a hospital. The 37-year-old teacher says that although she didn't suffer any major complications, "the whole experience of giving birth at home was dreadful."
Signs Of Improvement
Although Tajikistan's maternal mortality rate remains the highest in Central Asia, there are signs of progress. Just five years ago (2008), the maternal mortality rate stood at 64 for every 100,000 live births.
There are no official statistics on how many infants in Tajikistan die or sustain injuries during home births.
Tajikistan has enlisted the help of international organizations such as the World Health Organization, the German Development Agency, and the UN Population Fund to make childbirth and pregnancy safer. Emergency obstetric-care centers have been constructed, the training of qualified midwives and nurses ramped up, and a greater emphasis has been placed on health education.
Strategia Center's Saidov says there are signs of improvements in prenatal care in Yovon district, where he says local health authorities have revived the Soviet-era practice of registration and regular medical check-ups for pregnant women. "Nearly 95 percent of women who gave birth in the past year had been registered by local health centers during the duration of pregnancy. Medical staff would visit them once or twice a month for checkups," he says. "Such practices didn't exist in previous years, and there was also a shortage of medical workers in the past."
The survey in Yovon district indicates that the majority of women who gave birth in the past year had access to a medical unit within a kilometer from their residence.
The quality of medical services and public health facilities in rural areas remains questionable. Hospitals and other clinics in villages often do not have modern sanitation facilities, and during the winter months they often have only a few hours of electricity per day.
But those same issues apply at home as well, and the word is out that they are better dealt with by professionals.
Sobirova says health officials have been encouraging women to seek help during their pregnancies. "There were many cases in villages when newborn babies or mothers died during childbirth at home," she says. "Nowadays, health authorities have become very strict and doctors are telling women not to give birth at home."
Written and reported by Farangis Najibullah, with additional reporting by RFE/RL Tajik Service correspondent Zarangez Navruzshoh in Dushanbe