Unsafe practices associated with labour augmentation

In Katcho villages there is a traditional belief that if pregnant women with prolonged labour travel to a health facility in a bull cart it will accelerate the woman’s labour. In the study villages, it is a common practice for women in labour to be taken to the health-care facility on a bull cart if she is not progressing well. She takes with her the baby bag, a bed sheet, water bottle, and razor blade or scissors in case she delivers along the way to the health facility.

At the health facility, the LHV, midwife or the doctor (public or private) induces labour using a Syntocinon intravenous therapy. In most cases, women remain in the facility until childbirth. However, there were situations when women could not afford a private practitioner’s fee or they did not wish to give birth in a public hospital setting. On these

166 occasions, women asked for a Syntocinon intravenous therapy to induce labour, and upon completion of the intravenous therapy, they returned home. The births were then attended at home by the same dais who accompanied the women to the health facility. This practice is against the WHO protocol of labour induction which states that induction should only be performed when there is a clear medical indication and the expected benefits are higher than the potential harms (301). It should only be done by medically trained personnel (such as doctors or midwives), and it is best if it can be conducted in a facility so that the patients can be looked after in cases of failed induction, which leads to an emergency caesarean section (301).

Nishat said that if a doctor or a nurse performs a labour augmentation drip (Syntocinon IV therapy) and does not conduct the delivery then they will charge much less than the delivery package which includes hospitalisation charges, doctors’ fees, and the cost of medicines. In private clinics, an induction costs women PKR800 (AU$10) compared to the normal delivery package which is between PKR1,500-3,000 (AU$19-38) with a private doctor and PKR1,000-2,500 (AU$13-32) with the midwife (see Appendix 8).

Induction and normal delivery is free in a public hospital. But most of the women preferred not to wait in the hospital facility after induction; they wanted to return home. As mentioned above, women prefer to give birth at home with a dai. Also, after giving birth in a health facility they want to reach home in daylight hours as there is limited transport to their village at night. Finally, they avoid staying in the public health facility due to the behaviour of the staff. While some women were fortunate enough to reach their home before giving birth, other women gave birth on their way home. Nishat from Syed Peerani had six children. She mentioned that her third baby was born on the roadside. She was induced by a private midwife in a health facility and was returning home to give birth with a dai. But then she went into active labour along the road they stopped and the dai attended her delivery.

I was coming back home after being induced. We thought that I had enough time that I could reach home, but then the baby was coming out. So we stopped the bull cart and my dai took me to the roadside where I delivered my baby. (Nishat, age 31 years, Syed Peerani)

167 According to Nishat, women who have an induced labour in the health facility with the intention of delivering at home, know that the delivery can occur on the way home so they go well prepared. I asked Nishat whether she knew about the risks associated with leaving the health facility after an induction and she said she didn’t know of any risks. Nor could she recall receiving any instructions from the LHV after induction or in preparation for her return trip home.

Nishat felt that having an induction in a health facility and then returning home to give birth was a cost-effective and time-saving option. She considered that there were no associated risks or harm to the mother and baby if the delivery occurs at the roadside. However, she did mention feeling embarrassed to deliver this way. Women consider birthing to be a private matter, so having a roadside birth would place all birthing woman in an awkward position.

I do not find it risky or unsafe. The dai will look after me anyway, be it home or the roadside. But of course, no one wishes to deliver this way, it’s very embarrassing. (Nishat, age 31 years, Syed Peerani)

Another woman, Zubia from Bashir Machi, mentioned that her labour was not progressing well and the dai referred her to the health facility. Bashir Machi is, as mentioned earlier, the remotest of all villages in the study site and had limited transport. The only option available to her at that time was her husband’s motorbike, but she said that she was so tired because she had been in prolonged labour that she could not travel on the motorbike. Her husband went to the CMW clinic in Tando Jhark which is 15 to 18km from her house. The CMWs who work in Tando Jhark were responsible for looking after all the women who birth in the Katcho area. The CMW can conduct the delivery either in the CMW house/clinic or at the woman’s house, whichever place is most convenient for the woman. In this case, the CMW was a Syed woman, who was not allowed to go into another caste’s para. She could only look after people of that caste in her own clinic. So instead of the CMW, her husband Mr Hussain, who was not a trained male nurse, went with Zubia’s husband and he administered the Syntocinon intravenous therapy. Mr Hussain, a primary school teacher, had learned to administer intravenous therapy and injections from his CMW wife. He went with Zubia’s husband on his motorbike to their house and administered Syntocinon to Zubia who was in established labour.

168 I had a prolonged labour and after 12-14 hours my dai said that I

needed to be induced. My husband called CMW Sadaf but since Syed women are not allowed to go in others’ paras, her husband [Mr Hussain] came to administer the drip [Syntocinon] instead. He took PKR1,000 [AU$12.25], which include PKR800 for medicine and PKR200 for his return travel. After that my dai helped me with the delivery. (Zubia, age 31 years, Bashir Machi)

There are four important issues in this case. Firstly, the dai’s delayed identification of the severity of the situation put Zubia in a position that she couldn’t travel on the available vehicle. Secondly, the remoteness of her village and lack of transportation: the only option available to her was the motorbike and she didn’t want to travel on the motorbike because of her condition. Thirdly is the caste system which restricted the CMW’s access to her patients in their house. The Syed caste is the most religiously conservative caste and the Syed women mostly remain in their house unless there is an emergency. Despite the fact that a CMW should assist woman in childbirth in their home, she could not do so because of cultural barriers. The fourth issue to note is the administration of the drug Syntocinon by a school teacher who was not trained to attend a childbirth, induce labour, or provide emergency obstetric care if women have childbirth complications. As Zubia did not have access to transportation she was placed in a situation where she and her baby were at significant risk of death.