El proceso de internacionalización

At the time of data collection, 56 CMWs were delivering SBA services in the TMK district. Two CMWs were allocated to Katcho villages, and only one was providing maternity care services to community, through her CMW clinic. In this study, not one home birth was attended by a CMW in Katcho villages.

107 Challenges faced by the CMW Program

Poor recruitment strategy for CMWs

According to one key informant, the CMW program had problems recruiting women to be trained and deployed as CMWs from the outset. The minimum education criterion for a woman to be selected to be trained as a CMW was to have completed at least grade 12 and to have studied science subjects in grade 12; they should also preferably be married and be motivated to work as an SBA in their village. The majority of females who met the selection criteria were young, unmarried, and lived in urban areas of the TMK district. As a result, after their CMW training, these young women returned to their city or town and provided CMW services there and not in the rural villages. Moreover, coming from conservative family backgrounds many young CMWs did not get permission from their families to travel to the remote villages for work, therefore, they only provided maternity-care services in their own village. Consequently, women living in remote locations such as Katcho villages did not see the benefits of the CMW training program, which was the impetus for the program in the first place.

There was a big push from the Provincial Ministry on the MNCH program to chase the target number of CMWs by the end of 2010. Also, the selection criterion was very strict, I mean, there is no way you will find a Matric pass (Grade 10) female in rural TMK district, rather than finding an Inter-pass (Grade 12) girl, who is also willing to work in remote locations. We managed to get quite a few girls fulfilling the education criterion, but then they never worked in rural villages due to family restrictions or not being able to visit remote villages (Key Informant, MNCH program)

Conversely, CMWs who were recruited and trained stated that the district CMW program management team did not explain their roles and responsibilities to them at the time of recruitment. Most of the CMWs interviewed were under the impression that after training they would be able to work as midwives in the district hospital, or at any other health facility. It was only during the training course that the women realised that they may have to work in a rural community. The lack of clarity around their work in the community was disappointing for them and for their family

108 members. CMWs stated that if they had known that they had to work in the community they might not have joined the training program because of conservative family values.

All CMWs expressed a desire to work in a facility-based environment, which they considered to be more ‘respectful’ and ‘dignified’ compared to working in the community. The CMWs mentioned that working at home was an option for them, and if a CMW could set up her own clinic then she wouldn’t need to go to the woman’s house. According to CMWs, providing home-based maternity care is more akin to the care provided by the dai, who has limited or no formal education and is not trained as a SBA.

I and my family thought that I would work similar to midwives at rural health facilities, not like a dai who delivers a baby at home. But I learned after the first six months that this is more like a dai job. (Shabana, CMW)

Other factors that influence CMWs’ decisions not to attend home births include cultural perceptions that women cannot go to a stranger’s house to provide a service or travel at night time. Culturally, in rural villages, accompanied travel is a norm for female, and is applied if a female (especially young and unmarried) is going outside her house to school, hospital, meet family, or even for work. Most of the CMWs recruited for the training program were unmarried, and given the aforementioned reasons, they could not visit the pregnant women to attend home births.

CMWs’ salary

The CMWs are trained as fee-for-service birth attendants. The expectation is that the fee charged to the client includes their service charges and travel costs to and from the woman’s home. During a health workers’ workshop, CMWs stated that women who need the assistance of a SBA in their home (or who use a dai) are likely to be the women who do not have money to travel to the health facility or to pay the fee for a private midwife. The CMWs felt that it was unreasonable to think that women would pay the CMW fee (service fee plus travel costs) because if the women had money, they would elect to give birth in a health facility. What remains a challenge for CMWs is they are not provided with a salary by the Ministry of Health, as occurs with

109 the LHWs, LHVs, and FWWs, and their patients (poor women) are unable to pay for their services.

We are here to replace the dais. Had these women had money to go to health facility, they would not use a dai, or us [CMW] for birthing, they would simply go to their preferred private practitioner. Why cannot we [CMW] be on salaries as are the LHWs, LHVs, or midwives? (Health workers’ workshop)

CMW Sadaf said that many women who come to her clinic to give birth do not have money for the costs of return travel and they have to walk miles to return to their home after giving birth. On many occasions CMW Sadaf gave women money so that women could use public transport to return home; she said she could not do this for every patient.

I know that these women are unable to pay my fee. Many times, when women visit my clinic, I give them transportation money for return travel from my pocket, as I know they do not have money to do so. (CMW Sadaf)

The CMWs argued that the CMW program focuses on developing a workforce to support poor rural women receiving maternity care, without considering the financial implications it has on CMWs. The CMWs said that the reason why so many CMWs do not offer home-based maternity care is because they are not paid for their services. They also noted that it is unreasonable and unfair for the Ministry of Health to assume that CMWs will provide maternity services to women and not have the full costs of the services covered by the program.

We [CMWs] all know that we won’t be paid for home-based birthing care because of women’s financial status. Now you tell me, without being paid for the service, is it fair that we deliver home-based care? (CMW health workers’ workshop)]

Lack of transportation support

While CMWs preferred to provide maternity-care services in a health facility, they are willing to provide home-based services if they are provided with transport to visit women’s homes. Katcho villages are sparsely located, and to get from one village

110 to another on foot takes 30 to 35 minutes, and many villages are in deserted locations. Travelling alone in these areas is not considered to be safe for a woman. In a health workers’ workshop, all CMWs raised their concerns over the unavailability of transportation services and the Ministry of Health’s expectation that they deliver home-based care nonetheless. Not only are the villages sparsely located, when there is an emergency situation at night transport is not available.

Poor infrastructure support from the MNCH program

The MNCH department facilitates trained CMWs to establish CMW clinics by providing essential medicine and basic infrastructure to the CMWs who have a separate space in their house to be used as a CMW clinic. However, the four CMWs who were interviewed said that the CMW program management team informed them that due to the Ministry of Health’s budgetary constraints, the MNCH department could not facilitate CMWs to establish CMW clinics.

There was an example of a public-private partnership in Tando Jhark village, where a private organisation called DKT International (292), in collaboration with the CMW program, refurbished a few CMW clinics across rural communities in Pakistan. The DKT Foundation1 _{provides affordable and safe options for family planning and}

HIV/AIDS prevention in developing countries by social marketing and entrepreneurship. In Pakistan, the DKT Foundation is engaging CMWs to provide couples family planning counselling and access to modern contraceptives. For this purpose, in TMK the DKT Foundation chose CMW Sadaf’s clinic being the only functional CMW clinic near Katcho villages. The DKT International provided her with some furniture and a toilet, and they painted the clinic inside and outside. Moreover, DKT International offered Sadaf a place in their family planning training course, which she could attend free of cost. In return, Sadaf would provide family planning services in her clinic, and keep the DKT International logo on her clinic (see Figure 3.3). However, due to Sadaf’s busy schedule, she could not participate in the family planning training program.

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Figure 3.3 CMW clinic refurbished by DKT International