Nurse-midwifery in a developing country: maternal and child health in Mozambique

This report describes the current status of maternal and child health care (MCH) in Mozambique and was prepared by an American nurse-midwife, hired by the Mozambique government as an instructor for the country's nurse-midwife training program. The socialistic government, under its international cooperates program, hires advisors and instructors to help implement the nation's many health, education, and economic development programs. In 1975, when the country was granted independence, the health care system was grossly inadequate. During the colonial period, the health system was oriented toward providing care for the white, urban population rather than for the country's largely rural population. Prefessional jobs were reserved for Portuguese nationals, and Africans were not allowed to attend the nationhs medical schools. When independence was obtained, all but 50 of the nation's 600 physicians left the country. The development of MCH services is given a high priority by the current government. It is estimated that currently 35% of the all children born in the country die before they reach the age of 5 years. The maternal mortality rate is estimated to be 300/100,000. Efforts to improve health conditions are hindered by a lack of trained personnel, money, and medical equipment and supplies and by an inadequate transportation network. Despite these obstacles, progress in the provision of MCH services is being made. MCH units are being established throughout the country. These units are generally operated by trained nurse-midwives. A national nurse-midwife training program is conducted at the National Health Science Institutes in Quelimane. Trainees must be at least 18 years of age and have 6 or more years or primary schooling. The 2 1/2-year training program is intensive and students receive practical experience by working at an adjacent provincial hospital. Upon graduation, most assume the responsibility for operating a rural MCH unit. They are expected to provide services for a large population and to do so with little or no medical backup and minimal equipment and supplies. As part of their training, they learn how to prioritize health care and how to recruit community volunteers to help run the unit. The rural MCH units provide prenatal services, including high risk pregnancy referrals, nutritional counseling, and treatment for parasites and anemia. Many of the nurse-midwives operate well child clinics. These clinics provide immunization and chloroquinization services and treatments for parasites and anemia for children under the age of 5 years. Nutritional counseling is provided for the mothers of the children. Growth charts are used to identify malnourished children in need of hospital care. The midwives encourage breastfeeding. Recently a family planning component was added to the MCH program. Oral contraceptive, IUDs, foam, and condoms are provided. The program stresses the use of contraception for spacing rather than for limiting child births. Infertility is common among the rural women, and some midwives provide limited infertility counseling and evaluation. 30% of the country's deliveries are now performed in maternity units. These units range from hospital facilities to small, minimally equipped rural units. In most rural units, the deliveries are performed by nurse-midwives without medical assistance. Given the poor health status of rural women, pregnancy complications are common, and the units are too inadequately equipped and staffed to cope effectively with these complications. As a result, maternal morbidity and mortality is high. The majority of the country's deliveries are still performed at home by untrained traditional birth attendants. No effort is being made to train the traditional birth attendants or to bring them into the national health care system.     

Pregnancy outcome in late maternal age in a high-income developing country

Aim  

This study aimed to compare the pregnancy outcome at maternal age 35 years and above with those aged between 20 and 34 years in a high-income developing country.     

The burden of caesarean section refusal in a developing country setting

Objective  To investigate the prevalence, aetiology and outcomes of caesarean section refusal in pregnant women.
Design  A prospective controlled study.
Setting  University of Nigeria Teaching Hospital and Aghaeze Hospital, Enugu, Nigeria.
Population  A total of 62 Nigerian women who declined elective caesarean section.
Method  Interviewer-administered questionnaires at the time of caesarean section refusal and postdelivery. The delivery outcomes of the subjects were compared with that of a matched control group of women who accepted caesarean section.
Main outcome measures  Prevalence, maternal reasons for caesarean section refusal and the resultant maternal and perinatal mortality.
Results  The prevalence of caesarean section refusal was 11.6% of all caesarean deliveries. Maternal reasons for refusing caesarean section include fear of death, economic reasons, desire to experience vaginal delivery and inadequate counselling. Outcomes were significantly worse among women who refused elective caesarean section than in the controls with a maternal mortality of 15% (versus 2%, P = 0.008) and a perinatal mortality of 34% (versus 5%, P < 0.001).
Conclusion  There is a high prevalence of caesarean section refusal in south-eastern Nigeria. Women declining caesareans have very poor maternal and perinatal outcomes and need extra support.     

Characteristics of maternal deaths following cesarean section in a developing country

A retrospective analysis was made of 27 maternal deaths after cesarean section occurring over a 5-year period. Sepsis was the single most important cause of maternal death (81.5%). The commonest indications for the cesarean sections were obstructed labor (59.3%) and cord prolapse (18.5%). The causes of maternal deaths were classified as avoidable and recommendations were made for their prevention.     

Creation of a neonatology facility in a developing country: experience from a 5-year project in China.

In 1983, Project HOPE was invited by Zhejiang Medical University to collaborate in developing a neonatal intensive care unit (NICU) at the Children's Hospital in Hangzhou, China. The initial approach involved renovating facilities, purchasing equipment and supplies, placing short-term consultants in the unit as teachers, and bringing selected leaders to the United States for brief fellowships. An evaluation at 18 months disclosed poor organization and leadership, inconsistent clinical care, and unsatisfactory utilization and maintenance of facilities and equipment. Therefore the strategy was revised to include long-term physician and nursing consultants, establishment of ties with HOPE Biomedical Engineering projects, and development of formal education programs. The unit was transferred to the Chinese after 4 years and an evaluation 1 year after transfer revealed an actively functioning independent NICU with evolving effective leadership, established purchasing and preventive maintenance programs, and continuing formal education activities. Unsatisfactory progress was found with the development of a transport system, some laboratory capabilities, adherence to admission and discharge policies, and various other administrative issues. Although the goal of establishing an independent NICU was realized, perhaps the most lasting accomplishment was the establishment of a facility and a format for development of a transportable education program aimed at improving neonatal care practices throughout a larger region of China.     

Decision-caesarean delivery interval in a Nigerian university hospital: implications for maternal morbidity and mortality.

This is a 5-month prospective study to determine the decision emergency caesarean delivery interval in a Nigerian tertiary hospital, the factors responsible for the delays and the consequent maternal and perinatal complications. One hundred and thirty-four emergency caesarean deliveries were analysed and the main indications were failure to progress/ prolonged labour (35.4%), previous caesarean-section/failed trial of scar (27.9%), cephalopelvic disproportion (26.8%), fetal distress (19.5%), pre-eclampsia/eclampsia (15.3%) and obstructed labour/ruptured uterus (14.7%). The mean decision-caesarean delivery interval was 4.4 +/- 4.2 (SD) hours (range 0.5-26 hours), median 3.2 hours and mode 2 hours. Bottlenecks within the maternity unit were responsible for delays in 31.7% of cases. Unavailability of paediatrician (19.6%), non-availability of anaesthetic coverage (13.6%), unreadiness of the operation theatre (11.9%) and seeking second opinion (6.4%) were other major causes of delay. There were 15 perinatal deaths, five of whom were directly linked to the delays i.e. a perinatal mortality rate of 3.7%. Four maternal deaths were directly attributable to delay, a maternal mortality rate of 3%. Other direct consequences of the delays were severe haemorrhage (10.3%), uterine rupture (2.3%) and disseminated intravascular coagulopathy (1.5%). Suggestions on how to minimise delays in emergency services and overall improvement in quality assurance control are discussed.     

Strategies to prevent eclampsia in a developing country: II. Use of a maternal pictorial card.

OBJECTIVE: To assess the efficacy and acceptability of a patient-held pictorial card aimed at raising awareness and appropriate health seeking behavior in response to prodromal symptoms of imminent eclampsia. METHOD: Pictorial cards (and posters) were issued to antenatal clinics and used to focus instruction and advice to pregnant women. Mothers were surveyed before and after the cards were introduced to assess maternal likelihood of seeking care if edema was seen, and of attending hospital if so advised. We monitored the eclampsia rate. Health workers were interviewed 6 months after cards and posters were issued to determine the acceptability of using the cards as part of routine antenatal care. RESULTS: The card was seen as widely acceptable by health professionals, and increased their own awareness of the prodromal symptoms of eclampsia and their discussion of these symptoms with antenatal mothers. Mothers' awareness and response to symptoms improved significantly and there was a marked drop in eclampsia incidence. Suggested improvements to the card were made by mothers and health workers. CONCLUSION: The cost of providing a card for every pregnant mother is likely to be offset by health service delivery savings.     

A review of perinatal mortality in an urban situation in a developing country

Perinatal deaths occurring within the City of Harare, Zimbabwe, during 1983 were studied. Data were collected from all known deliveries within the city. This included exact numbers from three central maternity hospitals, and from referring midwife-run maternity clinics. An estimate was made of the number of births and perinatal deaths occurring within the city, but outside these official maternity facilities. All perinatal deaths were reviewed. The birthweight, the cause of death, and the antenatal care registration status of the mother were established. There were 2103 perinatal deaths from an estimated 53,665 total births. Deliveries include 50,138 (93.4%) in hospitals or clinics, 972 (1.8%) before arrival to the maternity service, and an estimated 2555 (4.8%) outside the city maternity services. One thousand seven hundred and fourteen (81.5%) perinatal deaths occurred in hospital or clinic delivered babies, and 134 (6.4%) from babies delivered before arrival at medical services. An estimated 255 (12.1%) of deaths occurred elsewhere. A total of 6380 (12%) patients did not register for antenatal care. There were 909 (43.2%) perinatal deaths in this unregistered group of patients. The overall perinatal mortality rate (PNMR) for infants weighing 500 g or more was 39.2/1000. For registered patients the PNMR was 25.3/1000 and for unregistered patients, 142.5/1000. For infants weighing 1000 grams or more the PNMR was 31.6/1000. The causes of death in the 2103 perinatal deaths were established and classified by clinical cause and by a simple pathological grouping with breakdown by birthweight.(ABSTRACT TRUNCATED AT 250 WORDS)     

Perimortem cesarean delivery: its role in maternal mortality

Since Roman times, physicians have been instructed to perform postmortem cesarean deliveries to aid in funeral rites, baptism, and in the very slim chance that a live fetus might still be within the deceased mother's womb. This procedure was disliked by physicians being called to a dying mother's bedside. As births moved to hospitals, and modern obstetrics evolved, the causes of maternal death changed from sepsis, hemorrhage, and dehydration to a greater incidence of sudden cardiac arrest from medication errors or embolism. Thus, the likelihood of delivering a viable neonate at the time of a mother's death increased. Additionally, as cardiopulmonary resuscitation (CPR) became widespread, physicians realized that during pregnancy, with the term gravid woman lying on her back, chest compressions cannot deliver sufficient cardiac output to accomplish resuscitation. Paradoxically, after a postmortem cesarean delivery is performed, effective CPR was seen to occur. Mothers were revived. Thus, the procedure was renamed the perimortem cesarean. Because brain damage begins at 5 minutes of anoxia, the procedure should be initiated at 4 minutes (the 4-minute rule) to deliver the healthiest fetus. If a mother has a resuscitatable cause of death, then her life may be saved as well by a prompt and timely cesarean delivery during CPR. Sadly, too often, we are paralyzed by the horror of the maternal cardiac arrest, and instinctively, we try CPR for too long before turning to the perimortem delivery. The quick procedure though may actually improve the situation for the mother, and certainly will save the child.     

Using scorecards to achieve facility improvements for maternal and newborn health

The Government of Sierra Leone launched the Free Health Care Initiative in 2010, which contributed to increased use of facility based maternity services. However, emergency obstetric and neonatal care (EmONC) facilities were few and were inadequately equipped to meet the increased demand. To ensure provision of EmONC in some priority facilities, the Ministry of Health and Sanitation undertook regular facility assessments. With the use of assessment tools and scorecards it is possible to make improvements to the services provided in the period after assessment. The exercise shows that evidence that is shared with providers in visually engaging formats can help decision-making for facility based improvements.     

Acceptability of caesarean delivery to antenatal patients in a tertiary health facility in south-west Nigeria.

Today, caesarean section is one of the most commonly performed surgical procedures the world over. Despite the well-documented record of safety, the strong aversion of women in sub-Saharan Africa to the procedure, especially in the presence of life-threatening indications, is of great concern to many obstetricians. This cross-sectional study, aimed at assessing the knowledge of the patients about caesarean section and its acceptability as mode of delivery, was conducted among antenatal patients at a University Teaching Hospital in south-west Nigeria. A pre-tested structured questionnaire was used. Among the 201 patients surveyed, a high level of acceptability of caesarean section (85%) was found. However, 96.5% of those who would accept would give consent only after seeking the opinion of other people, especially their husbands. Previous major surgery and caesarean section were found to favour its acceptability, while age, tribe, marital status and the woman or her husband's educational status did not have any influence. With proper health education, especially during antenatal care, many more women would find caesarean section acceptable.     

Bilateral agreements to reduce maternal mortality in developing countries. The FIGO experience

In 1997, the International Federation of Gynecology and Obstetrics (FIGO) launched its Save the Mother program. Its overall objective is to mobilise obstetricians and gynaecologists in developing and developed countries to work together in an effort to reduce maternal mortality, through operational research demonstrating the feasibility and effectiveness of integrated comprehensive essential obstetric services. The FIGO Save the Mothers Uganda - Canada Project, jointly led by the Society of Obstetricians and Gynaecologists of Canada and the Association of Obstetricians and Gynaecologists of Uganda (AOGU), is one of the projects supported by FIGO. Conducted in Kiboga (Uganda), the project aims the reduction of maternal mortality and morbidity by a series of measures which target the district hospitals, community dispensaries and the community.