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Photo Essays

Wendy Marijnissen | The Dai

Conditions in the rural desert area of Pakistan are very rough. Most people live in huts and lack basic facilities like electricity and water. In these parts of Pakistan the maternal and neonatal mortality rates are the highest. Mithi, Tharparkar, Pakistan 2010
The Dai

Birth at home in Pakistan, no matter what social class or caste, involves calling the Dai. A Dai is an unskilled midwife or traditional birth attendant (TBA), who usually learn their trade passed on from generation to generations without any formal training.
Every 30 minutes a women dies during or shortly after childbirth in Pakistan.

Heartbreakingly, most of the deaths and complications surrounding childbirth are treatable. Young women die because they have no access to sufficiently equipped medical facilities, or because the traditional midwife (dai) doesn’t refer the women in time to the hospitals when complications arise and a caesarean section is needed. In a place where poverty is rife, most families can’t afford the medicine or care they require.

The women giving birth know their Dai personally from their neighborhoods and consider her the expert in childbirth. She is respected within her community and thus an important figure.
The Dai are valued somewhat differently by hospital staff though.
The terms Dai handled is synonyms for dangerous practices.
Paradoxically, many women say they are afraid of being ‘hospital handled’.
Most think the doctors deliberately complicate cases or perform c-sections to get more money.
Increasing costs of medicines and diagnostic tests have made treatment unaffordable for most people in Pakistan with low-incomes.
More and more people simply cannot afford the care they need and medicines are beyond their budget, leaving them with no choice but to call in the help of the Dai to assist their delivery.

6 pregnant women wait for the female doctor to examine them and do a check up during their pregnancy. Rural traditions like the bracelets on their arms make a prenatal consultation difficult for the doctors. In emergencies these customs cause many problems and take up precious time. Mithi, Tharparkar, Pakistan 2010

Slowly the Dai are educating themselves, many working part-time in government hospitals alongside skilled doctors.
The new generation of midwifes go to schools instead of learning the trade from their elders and work in more professional and hygienic environment.
At present it seems very unlikely Pakistan will achieve the Millennium Development Goals by 2015.
Affordable medical care and the availability to skilled female health workers during childbirth is crucial for reducing maternal deaths and birth complications like obstetric fistula and the Dai can help play a very important role.

A delivery room at home of a local dai. In the rural areas most women deliver their babies at home and lack of medical knowledge from the dai combined with poor hygiene are some of the major causes of the high maternal and neonatal mortality rate. Kandiaro, Pakistan 2010
21 year old Suni, 7 months pregnant, expects her second baby and dai Afroos checks the position of the baby. Besides working part-time in the local government hospital in the Orangi slum, Afroos has been a dai for over 20 years. She learned her skills in the traditional way passed on by her blind grandmother. Orangi town, Karachi, Pakistan, 2010
A woman with traditional bangles around her arms leaves the local doctors’ office. Traditional customs like the bangles often create problems in emergency situations, making it hard to take the blood pressure or give injections. Mithi, Tharparker, Pakistan, 2010
70 year old Samani has been a village dai in Mithi for the past 40 years. With her hands she demonstrates how she uses her hands instead of instruments in post-abortion care to clean the whomb. After having learnt the skills from her mother in law, she is now passing on her knowledge to her own daughter in law. Mithi, Tharparkar, Pakistan 2010
Dai Fatima checks the heartbeat of the baby in her clients’ belly. She loves bringing new life into the world and her most memorable delivery were twin male babies. Fatima became a dai after her husband died. Most women don’t trust the hospitals or can’t afford the proper care and therefor still rely heavily on the community midwifes and dai.Karachi, Pakistan, 2011
Sherbano has been a dai for over 40 years. She doesn’t know her age but recounts many of the deliveries she’s handled over the years. Trained by her mother and grandmother, she conducts both normal and breach deliveries. Most dai deny delivering any complicated cases and say they refer the patients to nearby hospitals. Yet most maternal deaths happen due to untimely referral or the lack of skill by the dai. Rehri Goth, Karachi, Pakistan, 2011
The dai locally known as Tara sits in her sleeping quarters where she delivers babies on the floor. Lack of proper hospitals and affordable medical care makes people use the services of the dai, who still are very important and respected within their community. No instruments of her own, Tara lets the patients buy blades and necessary medicine themselves, shifting part of the responsibility in case things go wrong. Orangi town, Karachi, Pakistan, 2011
21-year-old Sadef just gave birth to her second baby at dai Tara’s home. Her auntie and mother take care of the newborn baby boy and assemble their things, while Tara finishes up the care for Sadef. Both times, the births were assisted by the dai, and Sadef puts full confidence in her dai. Dai are usually seen as respected figures within their communities even though they are responsible for many of the problems. Karachi, Pakistan, 2011
A young baby receives oxygen on a bench in the outside courtyard of a rural medical centre. The syringe next to the baby is dirty and already used. Lack of hygiene and proper facilitated medical care cause many of the neonatal deaths in Pakistan. In the rural villages hepatitis B and C is very common because of unsafe blood transfusions and unhygienic conditions in treating patients. Kandiaro, Pakistan 2010
While Rabia recovers from her emergency c-section, mother Nazia waves a fan to make her daughter feel more comfortable during the night. In rural areas of Pakistan most women don’t have access to emergency medicine and many of the deaths during or shortly after childbirth occur due to lack of proper health care, facilities and skilled staff. Thari Mirwah, Pakistan, 2010
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