Rebirth of a valley: A midwife's tale

When Sarah arrived in March, she looked out from the window of the MSF office at the mountain on the opposite side of the frighteningly steep valley and thought "That is a snowy wilderness. It's Yeti country. Nobody could climb that, let alone live in it." Now she knows that the valley sides are dotted with little villages and sub-valleys. And they are very much alive and reproducing. Eight child families are not at all unusual. And she is off plunging into the communities to find out how to get healthier mothers and babies - and how help them plan their families to the size they really want. That may still be eight!

The Reproductive Health project that Sarah is in charge of starting and developing is run by MSF because the Karetegin Valley has very special needs in a country that is struggling to recover from years of civil war. Tajikistan's independence from the former Soviet Union was followed in 1992 by brutal fighting between Islamist forces and the government. There is a peace agreement now but the five years of war left the Karetegin cut off as an opposition stronghold.

The health system suffered badly. As the midwife in one of the local hospitals put it, "So much was destroyed during the war here. We've had to try and replace equipment by using materials from homes. We need things that work, things that can be sterilised." Sarah is there to help put maternity care back together again; to train, organise and supply. "Nobody has ever given me a quarter of a million people and said "Sort that lot out". So I'm thrilled and I really hope that we'll leave things much better when we're finished in two years time."

Sarah comes from Bristol, where she has been a midwife since 1988. But that was itself a second career and she is particularly pleased that, in her fifties, she has been able to start her first mission for MSF. Building up to that, she had taken a tropical nursing course and had experience as a nurse/trainer for the V.S.O. in Albania and Namibia. She likes the fact that MSF are a front-line, medically focused organisation. But she also admits "I'm a slightly bloody-minded, difficult person and they seemed the natural match for that." Before she left for Tajikistan, Sarah had a two week orientation course, designed to give MSF volunteers the tools for the field.

What Sarah is facing up to now is a difficult mix of decaying Soviet medical structures, a population hit by war and economic decline, and very dispersed rural communities. Under the old system, 80% of children were born in hospitals. Now the proportion is reversed. Most are born at home with the help of rural midwives or traditional birthing attendants or neither. Some of the older midwives are well trained in the old Soviet fashion from pre-independence days ten years ago.

Many of the traditional practitioners picked up the art from their mothers or by trial and error. Sarah has been impressed with some of their skills. They may not be very mainstream, Western techniques but she can see they are safe. On the other hand, she has also seen some odd, folkloric additions. One habit is to place a large, cold stone on the abdomen immediately after birth. The clinical purpose is, well, mysterious.

One of the major issues she expects to be dealing with over the next few months is how to improve the management of the third stage. At the moment, it seems to present a number of hazards for the women of the valley. Sarah points to two fairly typical case histories in the same maternity ward of a provincial hospital. Both mothers had retained placentas and suffered severe post-partum haemorrage. One got to the hospital within two days and was in need of blood transfusion and treatment for anaemia. The other was only brought for treatment after she had partially recovered from an infection brought on by the birth - a month earlier.

The MSF plan so far is to update the skills of the obstetricians who are dealing with these emergency cases, improve the conditions in the wards and train the rural midwives to recognise and manage the problems much more quickly and effectively. On top of that work is the rehabilitation of the state family planning service at the same time. Under the old Soviet regime, abortion was a common form of birth control. That is now completely banned and so contraception is a major priority.

Sarah is impressed that the local understanding of Islam does not interfere with this work. And she is quite happy to follow the custom that women cover their hair with scarves. "If that's what it takes to get the job done, it's not a problem" she says.

But what about the nagging uncertainty of the security situation in the country? The peace agreement has meant more an armed truce between the two sides - with some freelance thuggery going on around the edges. Sarah has firm views about personal safety.

"I have to fight with my children about this... but my life is my own," she says. "MSF is very careful and if they think its all right for me to be here. That's good enough for me. I'm pretty sensible and I tend to think that being afraid is a bit boring. I don't like all those guns but none of them have been pointed at me. Anyway, midwifery is front line all the time. You never know that everything is OK until it's over."

What is very different about Sarah's midwifery in Tajikistan is that she is organising and planning work for six local MSF staff, who are themselves fully qualified doctors. It is not quite the normal hierarchy. And to avoid any embarrassment, Sarah's title very carefully avoids the terms "nurse" or "midwife". She is a "Reproductive Health Care Specialist".

"My only regret about all this is that I will spend all my time organising and never get to deliver a baby myself in the six months that I'm here," says Sarah. "So when I finish I can see myself rushing back to do agency work in London so I can get into a ward and remember what it's like to hold a new born baby."