Midwifery in North Korea

by Jill Moloney

Project 1: Concern Worldwide, July 2004 to April 2005

Is part of the first health project (July 2004 to April 2005), I spent 3 months last year observing various outpatient and home-visit consultations in a county of South Pyongan province ­ a 2 hour mountainous drive north of Pyongyang. The Project has been supporting 3 Industrial Hospitals (located in mining towns), 5 ‘Ri Hospitals’ (located in ri’s ­ farming communes) and 12 ‘Ri Clinics’ (also located in farming communes, but don’t have inpatient services). I was able to attend 102 consultations, 49 of which were perinatal, and a further 10 ‘women’s health’ appointments. Of course these observations were very interesting, but the discussions I had with the health staff were even more enlightening.

Like most countries, the main causes of maternal death are related to high blood pressure, prolonged/obstructed labour, sepsis and post-partum haemorrhage. The staff were asking for new ‘delivery beds’ and telling me that North Korean women give birth lying down as it’s safer than the upright positions (traditionally squatting) adopted by women in days gone by. They were convinced that women would be able to rest better when lying down during labour and that the incidence of perineal trauma would be reduced in this position, not to mention the convenience of being able to see the birth and apply forceps, ventous and other interventions. Pelvimetry with a calliper tool is routine and anyone with a ‘narrow pelvis’ is referred for a caesarean section. As in many Asian countries, babies aren’t generally breastfed for the first couple days, though staff at one hospital believed that babies should be breastfed within the first hour of birth. Some of them are given rice water by bottle and others are given no sustenance at all until the milk comes in on day 3. One of the midwives even advised the women to express the colostrum and discard it! The doctors, midwives and doctor assistants I spoke to were aware of oxytocin, but had a very limited understanding of the wide range of roles of oxytocin, the factors that inhibit the release, and the factors that stimulate the release of the hormone. Most of the knowledge was about injecting oxytocin to stimulate or augment labour.

In addition to this, the health services are suffering from chronic under-funding, with facilities in a bad state of repair and not at all ‘women friendly.’ The women didn’t believe there was any value in seeking care, particularly for birthing services, as the hospitals are made of concrete and some had broken windows and no heating and were very cold, especially so in the winter when temperatures can fall as low as -30°C. Aren’t women clever and intuitive to know that these places were not suited to birthing! However, some of the hospitals have under-floor heating and one other had a stove- heater in the birth-room and they were much cosier. The floors were generally cracked and in a poor state of repair, so were an infection control risk. Some of the women’s homes aren’t particularly conducive to birthing either ­ some are cold and draughty and others were crowded and offered no privacy.

Of course this meant that I had many topics to cover on our 2 day ‘Perinatal Meeting’- we were not permitted to call it a ‘workshop’ as we aren’t permitted to provide ‘education.’ The meeting was facilitated March 1st to 3rd (started with lunch on the first day and finished with lunch on the third). We had 16 midwives, 2 ‘doctor assistants’ (which are similar to Australian nurses) and 6 doctors participate in the meeting. This was more than I would have liked, but there was such a demand and we were allowed to facilitate one meeting only. We were not permitted by the authorities to show any video footage and so it was all discussions and activities. We chose participatory methods, drawing on the collective knowledge of the group, so that the participants would realise that this was their knowledge, not the ideas of an expat that they are taught to be suspicious of! We did the session in ‘Empowering Women’ about the flexibility and movement of the pelvis and they were amazed by it. They also loved ‘practicing’ births using the fetal doll.

By the end of the ‘meeting’ the participants seemed to have gained an understanding of:

• Hormonal interactions and effects on the progress of labour
• The pelvis, pelvimetry (in that it should not be part of antenatal screening), and maximizing the pelvic diameters in childbirth by adopting upright positions
• Adaptations to the health services to make them more ‘women friendly’
• Breastfeeding ­ the benefits of early initiation of breastfeeding for the baby and the mother

During our discussions I found that the most troubling aspect of perinatal care for the participants was when they are faced with fetal malpresentation, especially breech presentation. I added a session about this and introduced ‘moxibustion’ as I knew that acupuncture and direct moxibustion are routine methods of treating chronic illnesses here, and so felt they would appreciate the value of indirect moxibustion. They were very interested and so we translated relevant sections of your article about breech presentation to distribute to them, along with a sample of moxa from China (they use mugwort here, but only in the direct moxibustion method, and they were interested to see how the Chinese manufacture this into ‘sticks’ for use in an indirect method for breech presentation).

Although they were ‘talking the talk,’ I wasn’t certain that this information would actually make a difference to the birthing practices. The participants said that although they could now appreciate the advantages of upright birthing and the disadvantages of lying down, they had never seen this kind of birth with their own eyes and so were uncomfortable about attending such births. This is where the video footage would have been useful and it was a pity that permission to show it was not granted. They were also still suspicious about the potential for perineal trauma when assuming an upright position.

During the three week monitoring phase after the ‘meeting’ I visited all of the Project-targeted health facilities to check on the ‘women-friendly’ rehabilitation of the hospital birth rooms and to support the staff in the field. We had installed double-glazed windows and doors to insulate the birth-rooms, and tiled the floors to improve infection control. I would have preferred a good quality vinyl floor, but found it was too expensive for our limited budget. We also supplied curtains, cushions and pillows, and a mattress for the floor. The staff have put ladder-back chairs (without arms so that the women can sit on them backwards) and stools in the rooms as well. Most of the ‘delivery beds’ have been moved out of the rooms altogether, but as the birth room sometimes doubles as a gynaecology outpatient room, 2 hospitals have compromised by placing them to one side with a sheet over them so that they are no longer the dominant feature of the room. The communities are pleased with the changes made and are keen to use the birth-rooms now, but some are still too cold and so we are installing additional heating (after much time spent convincing the authorities that this is a necessity). Too late for the winter season this year, but hopefully will bring about improvements next year. Some staff have even been suggesting installing a rope (hanging from the ceiling) as this is a birthing aide that was in use in the grandmother days.

Sixteen of the eighteen births reported during the monitoring visits were with the mother adopting upright positions. The remaining two births were caesarean sections ­ for previous caesarean. The most popular positions were squatting and all-4s. One of the women had a ‘narrow pelvis’ by pelvimetry, but the staff trusted the messages in the meeting and decided to ‘allow’ the woman to labour. There were no complications and the woman was so happy to have avoided a caesarean section. There has been no perineal trauma in any of the births (a statistic that I think any birthing service would be proud of). All of the babies, except one, breastfed immediately after birth and the staff were surprised at how quickly 3rd stage was completed, and with so little blood loss, by comparison to those births they had attended where the babies didn’t breastfeed. The one exception was a baby that breastfed at approximately 3 hours after the birth and apparently this was because the mother was also feeding a one-year-old, felt exhausted and needed a sleep!

The staff were also very pleased with these ‘new’ birthing techniques as they now realise that their job is actually easier when the women give birth in this way. The participants have provided ‘active birth training’ for the staff of their facilities, and some are now offering their own ‘childbirth education’ sessions for pregnant women and any other interested community members. The grandmothers have advised during these sessions that this is a shift back to the way things were in their day (of course!) and that it was wrong of birth attendants to have forced women to lie down to give birth. They are pleased that the pendulum is swinging back again now.

One of the doctors is currently undertaking postgraduate studies in obstetrics and has chosen to write a thesis on birthing in upright positions. This is great as it will mean that the professors at the university will also be exposed to the messages and will hopefully make them think about their own curricula ­ and perhaps make modifications?! Of course there’s no resources in Korean language here in-country for her literature review and so we are providing her with some of your papers and others on the Birth International site, along with some relevant sections of the books we purchased for the Project (‘The Midwife Companion,’ ‘Empowering Women,’ ‘Obstetric Myths versus Research Realities,’ ‘A guide to Effective Care in Pregnancy and Childbirth,’ ‘Pursuing the Birth Machine,’ and the WHO ‘Care in Normal Birth.’). She has a friend that is reasonably fluent in English that can help her, and she has a translating dictionary that she said she would use. We are also having much of it translated for her by the Project national staff before we pass it on.

The participants of the meeting would also like some posters and leaflets depicting the support of women and providing comfort during upright labour. We approached the Ministry of Public Health and the Health Education Institute here in Pyongyang to have some culturally acceptable adaptations made to the drawings in ‘The Midwife Companion’ (similar to the work we did in Cambodia). I would have liked to have done this prior to the meeting, but with the sensitivities here in-country and the permission to show the video declined, we felt it would be wise to have the meeting first, before we drew too much attention to what we were doing, so that it would not be cancelled by the authorities (and then organise further resources). As it turns out this was probably wise as the Institute declined to participate in this activity. However, not to be deterred, we went to the staff in the field and asked them to draw the pictures. When they are completed Concern will take them back to the Health Education Institute and argue that it is Korean Nationals who have drawn them and want to use them in their own health services, not something forced on them by the expatriate community.

Due to the successful implementation of ‘women friendly’ approaches to perinatal care in this county the project is to be replicated in other Concern-targeted counties of South Pyongan Province.

Project 2: Save the Children UK – April to June 2005

I have a short contract with Save the Children (SC) until we leave the country at the end of June. As part of their current health project SC had planned to supply ‘delivery beds’ for the birth rooms. In early February the Programme Manager had asked for my input into the model they were to purchase from China. I told her that I believed they shouldn’t purchase any, and after some discussion she decided that they might purchase ‘gynaecological tables’ as a kind of compromise. She went to China to check them out more closely. She has now given it more thought and has decided not to purchase any at all, but to up-skill the field staff in supporting the normal physiology of labour instead.

Through this Project we are working with the closest thing we have to a local NGO here in DPRK ­ The ‘Korea Family Planning and Maternal and Child Health Association’ (KFP&MCHA). They have 200 volunteers who provide outreach services and education sessions on family planning, but they would like to focus on developing the maternal-child health side of their programme. They are also interested in the prevention of perinatal complications through supporting the normal physiology of labour and we have successfully conducted one ‘perinatal safety meeting’ in a county of South Hamgyong Province (a two day drive to the east coast of the country). If we gain the necessary permission from the government, the Project will also be working with the Provincial Midwifery School in South Hamgyong. It’s a great opportunity to work with the KFP&MCHA and the midwifery school so that these messages don’t leave the country when we do.

Anyway, that’s where we’re up to here in DPRK. Hope this long-winded message hasn’t been too boring for you – it’s been busy times for me, but satisfying work!