Unique birth posture for Karamoja

A midwife demonstrates the use of a birth cushion at Rupa Health Centre in Moroto District. Many women in the Karamoja suub-region would rather give birth in the squatting position, with the aid of a birth cushion. Courtesy photo.

What you need to know:

For generations, women in Karamoja sub-region have given birth in the squatting or kneeling position. Aware of this cultural preference, UNICEF introduced the birth cushion, a method of delivery that meets the needs of the Karimojong women and encourages them to come to the health centre.

“I gave birth to my first and second child at home, while squatting. My grandmother used to cover my mouth and nose and would task me to push harder. It always felt painful. I got tears in my anus and bled a lot when I was giving birth to my second born,” narrates Teddy Kolibi, a mother of three.

This is the culture in Karamoja. Most mothers who go into labour deliver while squatting or kneeling. According to them, the pressure exerted by the knees and hands that hold the ground, makes it easy for them to push and give birth in a very short period of time.

Clementina Ilukol, the only midwife in Rupa Health Centre II, Moroto, says that the majority of mothers previously did not deliver in health centres.
“We would receive mothers after giving birth. They did not come in for antenatal services at all. Most of them would come running while bleeding after getting tears in the anal canal because they had tried pushing before it was time,” she says.

Dealing with the unfamiliar
“The two times I gave birth on the delivery bed, I got difficulty in breathing. It felt like I was suffocating. I also took long trying to push the baby.

The birth cushion eases everything for me,” the pale Kolibi divulges in Akarimojong, translated by Ilukol.
As for Jane Lariong, a mother of five, giving birth on the delivery bed means she has to expose her private parts which is very uncomfortable for her.

“I know when I lie on the delivery bed, I will not be covered as much as I would be when using the birth cushion,” she reasons, explaining why she is not interested in giving birth on the delivery bed anymore.

The introduction of birth cushions
In October last year, UNICEF introduced birth cushions, so that mothers could give birth in health centres using their preferred method of delivery but with the help of skilled midwives.

A birth cushion is a padded pillow or support that allows a partially squatting position for delivery.

The birth cushion is designed to offer a more comfortable and modified position for mothers giving birth.
Rebecca Kwagala, the programme specialist UNICEF, explains that these birth cushions which are made in Kampala, have increased the number of mothers giving birth at health centres.

“We started with a pilot project in 2012 after realising that pregnant mothers prefer giving birth while squatting or kneeling.
Upon realising that indeed most mothers preferred the birth cushions to the delivery beds, we rolled out the project in the whole Karamoja sub-region. We distributed one birth cushion per health unit,” she explains.

There are 11 health units in Moroto District, each staffed with one enrolled midwife.
Approximately 90 per cent of the mothers coming into the sub-region’s health centres prefer using the birth cushion to the lithotomy position. In the lithotomy position, the mother is lying on her back with her legs up.

Changing times
Before the birth cushions were introduced, Ilukol used to receive only five mothers out of the projected 37, delivering every month.

“The first month these birth cushions were introduced, I received 26 mothers with 21 of them delivering using the birth cushions and five using the delivery beds,” she states.

According to Ilukol, it takes a maximum of ten minutes for mothers to give birth on this soft and confortable birth cushions.

Also, mothers rarely experience post birth difficulties like heavy bleeding after delivery when they use the modified squatting or kneeling position aided by the soft cushion.

On average, out of 35 mothers who give birth at Rupa II Health Centre, 28 use the birth cushion.

How it works
The birth cushion consists of three pieces, the box cushion, a small chair that allows the midwife to view the perineum (the area between the anus and the vulva) of the mother and a soft cushion placed on the ground between the legs of the mother, to receive the baby when it is born.

“The box cushion has two metallic handles on both sides. The mother sits at the edge of the cushion and holds the metallic handles tightly.

A white piece of cloth is placed on her laps to cover her private parts (since most mothers do not like to expose them) and she starts to push,” Ilukol explains, adding, “as the mother pushes, the pressure that is exerted by the cushion helps to compress the sphincter muscles hence preventing any tears during birth.”


Driving mothers to health centres
In a bid to increase the number of mothers that attend antenatal services and give birth at health centres, UNICEF has introduced rewards for community members who accompany pregnant mothers to the health facilities.

Martin Ngolobe, the field supervisor UNICEF, says that since there are no ambulances in Moroto, they decided to start rewarding members of the community that offer means of transport to mothers who are in labour.

“Those that escort the pregnant mothers to the health centres, either for antenatal services or giving birth are given a transport refund.

Those from nearby villages are given a refund of Shs5,000 everytime they take the pregnant mother to the health unit and those accompanying mothers over long distances (over 10km) are given Shs10,000,” Ngolobe explains, before adding that Shs25,000 is given when the mother is referred to the regional hospital.

Also, after the mother has given birth, they are given a “mama kit, a bag that contains a towel, bed sheet and clothes for the baby.
This, according to Ilukol, serves to motivate the mothers to give birth in health centres.

Village Health Teams (VHTs)
Some local volunteers, termed Village Health Teams (VHTs) have also been trained by UNICEF on the benefits of delivering at the health centres.
“These VHTs,” Ngolobe says, “have helped hold dialogues in different villages, sensitising the mothers about giving birth in a modified squat position which has also led to an increase in the number of mothers giving birth in health centres.”

With the help of VHTs, the presence of the birth cushion at health centres has also drawn more mothers to access other health services such as testing for HIV.

Birth cushion vs maternity bed

In 1989, a study led by Dr. Jason Gardosi of the Milton Keynes General Hospital in Buckinghamshire, England, which followed the deliveries of about 400 women, roughly half of whom used the cushion, found that labour was shorter on average for women delivering by birth cushion, than those in the semi recumbent (lying) position.

‘’The main advantages of squatting,’’ Dr. Gardosi said, ‘’are that there is a greater opening up of the pelvic bones than when lying down and that the voluntary expulsive forces that women can generate are stronger, more efficient and better coordinated with the contractions.’’

The median length of the second stage of delivery for women using the cushion was 35 minutes, compared with 45 minutes for those in the semirecumbent position.

The study also found that nine percent of the women using the cushion required a forceps delivery, compared with 16 percent of those using the more traditional position. In a forceps delivery, there are increased risks of damaging the baby’s nerves or collarbone.

Other measured factors, such as blood loss, remained similar for both groups.

“This provides more evidence that no woman should be put into bed while in labour,’’ said Doris B. Haire, a medical sociologist with the National Women’s Health Network in Washington. ‘’Women function better when they are in an upright position,’’ she said.

But Ms. Haire, who had studied various delivery methods, including the birth cushion, in more than 60 nations, cautioned that the cushion may not be ideal for some women who find the position uncomfortable
In addition, she said, some doctors prefer the semirecumbent (lying) position because it allows them greater control in the delivery.

The birth cushion, which can be used on a bed or floor, is made of two large foam plastic cushions joined by a narrow bridge. The woman sits on the bridge, which is easily compressed, allowing her to sink into a modified squatting position. Because most of her weight is supported by her thighs, the position can be maintained with little effort.

In addition, supported squatting allows for more effective pushing, which, the study reported, is a major reason for the lower rate of forceps deliveries and a shorter second stage.

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