In conflict-afflicted eastern Myanmar, until recently obstetric care was often crude, unsterile and dangerous for both mother and child, health experts say.
When labour pains began, traditional birth attendants routinely pushed the woman's stomach, sometimes injuring or killing the baby; others used sharp slivers of bamboo, which had been cleaned with charcoal, to cut the umbilical cord, leading to deadly infections.
"Services were very limited. Maternal deaths, pregnancy-related issues like anaemia and infant mortality, were very high," Nay Htoo, programme director for the Burma Medical Association, a Mae Sot-headquartered community-based organization (CBO), told IRIN.
In parts of eastern Myanmar, the infant mortality rate is 73 deaths per 1,000 live births, compared with 14 in neighbouring Thailand.
At the same time, the maternal mortality rate is 721 per 100,000 live births, three times the country's national rate of 240. In neighbouring Thailand, that figure stands at 48.
With high levels of conflict, forced labour and human rights abuses, such health indicators are particularly dire, but ignorance and dangerous traditional practices are also at fault.
To address these problems, in 2005 several CBOs, the Center for Public Health and Human Rights at Johns Hopkins University, and the Global Health Access Program launched the Mobile Obstetric Medics (MOM) project - dramatically boosting access to care.
The MOM project brought community-based maternal and child health workers from Myanmar's Shan, Mon, Karen and Karenni states - unstable regions where ethnic militia and Burmese troops for decades have waged war - to Thailand for training in ante-and postnatal care, sterile deliveries, treatment for complications, as well as family planning services.
These maternal and child health workers would then pass on their new knowledge and skills to village health workers and traditional birth attendants, making sure that if complications arose, this triumvirate would cooperate and coordinate to provide care.
In the year after the MOM project began, only 5.1 percent of deliveries were attended by a skilled provider, according to research published in 2010.
By 2008, births attended by health providers trained to deliver emergency obstetric care had increased to 48.7 percent.
"The MOM project was a huge success," Luke Mullany, an associate professor at Johns Hopkins Bloomberg School of Public Health and lead author of the 2010 paper, said.
"Our collaboration and the work of our implementing partners produced a three-tiered network of community-based providers who were able to provide elements of basic emergency obstetric care at high coverage," Mullany explained.
Integer, a former maternal and child health worker in Karen state's Kler Lwee Htoo District, who like many Burmese goes by just one name, said some traditional birth attendants kept long nails in case of difficult deliveries, to fatally puncture a baby's head, releasing tissue to shrink the head, allowing the baby to be delivered.
"Before, they didn't know sterile methods or even the stages of delivery and when to begin the delivery," said Integer, now reproductive health programme coordinator for the Karen Department of Health and Welfare, a CBO involved in the MOM project.
"After training, they got that knowledge, and they also learned about high-risk pregnancies. When they see a high-risk pregnancy, they can send the patient to the nearest clinic for further examination."
The maternal child health worker travels around her area to train, supervise and assist the traditional birth attendant twice a year.
Older birth attendants
Each year, about 25 health workers illegally cross the border into Thailand for a MOM project refresher course with the Burma Medical Association.
One challenge, say Nay Htoo, is passing on these lessons to older traditional birth attendants.
"Some still lack the skills to follow the protocol, step by step, especially the very old traditional birth attendants. Most are illiterate, so you have to use symbols to train them," Nay Htoo said.
"The traditional birth attendant is a stakeholder in the community. If they don't trust you, they will not join the programme, and you cannot implement the programme successfully. To change people's ideas, especially the older people, is not easy."
Health workers in the MOM project are given traditional birth attendant kits that include gloves, scissors, gauze, cotton as well as dietary supplements and medicines.
Because of ongoing tensions between ethnic groups and the Burmese government, ethnic Burmese CBOs try to improve care in their home country from Thailand.
"Even though we are based in Thailand, our services are in Burma, particularly in IDP [internally displaced persons] communities. We want to be based in Burma to provide our services to the communities effectively; however, the time does not permit us to be based there yet," Nay Htoo said.
"Every time we bring people back and forth for training and project re-supplying purposes it's very difficult, but we know how to deal with local authorities in Burma and Thailand."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions