Midwives: key rural health workers in maternity care

The most acceptable and attainable rural health worker for maternity care is frequently the traditional birth attendant or other personnel lacking clinical skills to treat life-threatening emergencies. When first referral level facilities are also poorly staffed and ill-equipped to deal with these emergencies, this again points to the need for training of and delegation to the trained midwife in rural areas. Unfortunately, their number is declining in rural areas of some countries most in need, e.g., Tanzania. Elsewhere, midwifery skills and knowledge have been integrated into basic nursing education, but practical skills are only developed postbasically when midwife educators are expert clinicians. The graduates of such training could be delegated responsibility for many lifesaving procedures in obstetric care. Successful clinical experience in use of these responsibilities will earn the midwife's needed community reputation as a trusted health worker.

Process indicators for safe motherhood programmes: their application and implications as derived from hospital data in Nepal

Measuring maternal mortality ratios is fraught with problems and underestimates. Therefore process indicators have been proposed for monitoring the availability and use of obstetrics services. We report the results of process indicators for measuring the availability, use and quality of obstetric care in five districts in Nepal between 1997 and 1998. The number of comprehensive essential obstetric care (EOC) facilities was adequate for four of the five districts, but none had a minimum acceptable level of basic EOC facilities as set by UNICEF et al. The proportion of expected births in hospital was 21.5% in Rupandehi and < 5% in Baglung, Kailali, Okhaldunga and Surkhet. The minimum acceptable level is 15%. The 'met need' for obstetric care which pertains to the proportion of all women with direct obstetric complications that are treated in hospital was 14.9% in Rupandehi and < 5% in the other four districts, against the required minimum of 15%. The caesarean section rate calculated of all expected births in the population varied between 0.2% and 1.4%. The case fatality rate was 4.0% in Rupandehi Zonal Hospital. Analysis of these indicators clearly identified tremendous underuse of maternity services which has stimulated national policy discussions in Nepal with ensuing safe motherhood interventions and monitoring strategies.

Quality of care in reproductive health programmes: monitoring and evaluation of quality improvement

As 200 million women become pregnant every year, at least 30 million will develop life-threatening complications requiring emergency treatment at any level of society where they live. But it is a basic human right that pregnancy be made safe for all women as complications are mostly unpredictable. This requires reproductive health programmes which are responsive to women's and their families' needs and expectations on the one hand and enhancement of community participation, high quality obstetric services, and both provider collaboration and satisfaction on the other. Monitoring and evaluation of these facets need to be an integral part of any safe motherhood programme, not only to assess progress, but also to use this information for subsequent planning and implementation cycles of national programmes. Lessons learned from ten years' implementation of Safe Motherhood programmes indicate that process and outcome indicators are more feasible for short-term evaluation purposes than impact indicators, such as maternal mortality reduction. The former are described in this paper with relevant country examples. This is the third, and last, article in a series on quality of care in reproductive health programmes. The first (Kwast 1998a) contains an overview of concepts, assessments, barriers and improvements of quality of care. The second (Kwast 1998b) addresses education issues for quality improvement.

Quality of care in reproductive health programmes: education for quality improvement

The provision of high quality maternity care will make the difference between life and death or lifelong maiming for millions of pregnant women. Barriers preventing access to affordable, appropriate, acceptable and effective services, and lack of facilities providing high quality obstetric care result in about 1600 maternal deaths every day. Education in its broadest sense is required at all levels and sectors of society to enhance policy formulation that will strengthen programme commitment, improve services with a culturally sensitive approach and ensure appropriate delegation of responsibility to health staff at peripheral levels. This paper is the second in series of three which addresses quality of care. The first (Kwast 1998) contains an overview of concepts, assessments, barriers and improvements of quality of care. The third article will describe selected aspects of monitoring and evaluation of quality of care.

Breech labor on the WHO partograph

OBJECTIVES

To assess the impact of breech labor management using the WHO partograph on fetal and maternal outcomes of labor.

METHOD

All 1,740 breech presentations in a larger multicenter hospital-based study in South East Asia of the use of the WHO partograph in labor management were studied. The partograph was introduced into each hospital during the study and a before and after analysis of various labor outcomes was conducted.

RESULTS

There were 923 breech presentations prior to implementation of the partograph and 817 after. The overall Cesarean section rate was 29.7% (21.6% emergency and 7.6% elective). Introducing the partograph reduced Cesarean sections for multigravida from 27.1% to 19.3% (non-significant) but had no impact on the rate for primigravida (38.5% to 38.7%). Prolonged labor (> 18 hours) was reduced significantly among multigravida and primigravida (p < 0.05), despite a reduced use of oxytocin. Intrapartum stillbirths fell (non-significantly) from 1.9% to 1.1% (all parities combined). Fetal outcome, as measured by intrapartum deaths and Apgar scores < 7 at 1 minute, was significantly better (P < 0.05) when delivery was by Cesarean section rather than vaginally, regardless of use of the partograph.

CONCLUSION

The use of the WHO partograph in the management of breech labor reduces prolonged labor and (among multigravida) Cesarean sections and improves fetal outcome. In this study, however, Cesarean section was a safer method of delivery for the baby, regardless of use of the partograph.

Quality of care in reproductive health programmes: concepts, assessments, barriers and improvements--an overview

At the end of the first decade of the Safe Motherhood Initiative there are still, at a minimum, 1600 women dying every day from complications of pregnancy and childbirth: this is an intolerable human tragedy. The fact that there are almost 100,000 more maternal deaths annually now compared to 10 years ago, 585,000, must present a challenge to every citizen in society. Policy makers, health professionals, social workers, religious leaders, human-rights advocates and the media all have a responsibility to ask themselves: 'What can I do?' All have a role in affecting quality reproductive-health services, which are essential for the reduction of maternal mortality and morbidity, and are an intrinsic human right. The midwife is the obvious catalyst and linch-pin for this effort in the fabric of society. Three papers will address the issues of quality of care in reproductive-health programmes with particular emphasis on safe motherhood. This, the first, article describes the concepts of quality of care in reproductive-health programmes, the determinants of quality improvement, assessment tools for service quality, barriers to quality of care and quality improvement together with examples from relevant countries. The second article will address education issues relative to quality of care, and the third will describe the monitoring and evaluation of quality of care with relevant indicators and project results.

Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?

The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains. Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality.

Building a community-based maternity program

The MotherCare Project has as its goal the reduction of maternal and neonatal mortality and related morbidities, and the promotion of the health of women and newborns. To achieve these goals, maternal and family planning programs were strengthened in both rural and urban settings through three intervention strategies--policy reform, affecting behaviors and improving services. The fundamental premise in each project was to strengthen the weakest part of the maternity care pyramid, ensuring linkages among all levels of service--from community through to the referral hospital level. In rural Andean populations of Bolivia, knowledge of danger signs and women's response to them improved, increasing in use of prenatal and family planning services through a participatory problem-solving and community-based strategy. In West Java, Indonesia, bringing professional midwifery services and facilities closer to women together has resulted in a positive response to their use. Augmenting this intervention with a transport and intercommunication system together with improved hospital practice through perinatal mortality meetings and in-service training for doctors and midwives has reduced the maternal and perinatal mortality over a four year period. Hospital practice has improved in Uganda and in two states of Nigeria, maternal mortality and morbidity have been reduced in the training facility where seminars for physicians, training of midwives in life saving midwifery and interpersonal communication skills have taken place, and equipment and supplies have been improved. Furthermore, in rural Guatemala, implementation of norms and protocols, expert supervision and sensitization of hospital staff to the needs of the community has increased referral by traditional birth attendants (TBAs) to the hospital and reduced perinatal mortality.

An integrated village maternity service to improve referral patterns in a rural area in West-Java

The Regionalization of Perinatal Care, an intervention study carried out in Tanjungsari, a subdistrict in rural West Java, aimed to develop a comprehensive maternal health program to improve maternal and perinatal health outcomes. The main inputs included training at all levels of the health care system (informal and formal) and the establishment of birthing homes in villages to make services more accessible. Special attention was given to referral, transportation, communication and appropriate case management, A social marketing program was conducted to inform people of the accessible birthing homes for clean delivery, located near the women, and with better transportation and communications to referral facilities should complications arise. The study design was longitudinal, following all pregnant women from early pregnancy until 42 days postpartum in an intervention and a comparison area. The population was +/- 90,000 in the intervention area and 40,000 in the comparison area. Inclusion criteria were all mother and infant units delivered between June 1st, 1992 and May 31st, 1993. Analysis showed the following results: Most women sought antenatal care (> 95%). In Tanjungsari, nearly 90% sought such care from professional providers as versus 75% in the control area of Cisalak. Most women with bleeding or bleeding and edema during pregnancy sought professional assistance in both the study and control areas. However, fever for more than 3 days received more attention in the study area versus control area (93 vs. 69%). Greater than 85% of deliveries in both areas were conducted by TBAs. However, in the study area, nearly one-third of those with intrapartum complications (17%) delivered in a health facility compared to one-tenth in the control area. This meant a hospital delivery, primarily with assistance of a doctor or doctor/midwife combination. Overall referral rates by TBAs were low -13% of women with complications in Tanjungsari and 6% in Cisalak. More women with intrapartum complications were referred in the study area than in the control, and more complied when referred. Women who suffered intrapartum complications were more likely to have a perinatal death. Perinatal deaths declined in Tanjungsari, but not significantly. However, the trend over the period of the intervention shows an improvement in the deliveries managed by TBAs with more deaths resulting in the hands of professionals. Either women were arriving too late or the quality of care could not meet the needs. There was no change in the levels or place of perinatal deaths in Cisalak.

Safe Motherhood--the first decade

In 1987 an international project, the Safe Motherhood Initiative, was commenced with the aim of reducing, by half by the Year 2000, the 500,000 maternal deaths which occur each year throughout the world. In this paper the progress of the Initiative is described and reviewed. The crucial role of the midwife in reducing maternal mortality is recognised and the work to be done in the future is identified. This paper was given as a keynote address at the 23rd Congress of the International Confederation of Midwives in Vancouver in May, 1993.

Abortion: its contribution to maternal mortality

Every year between 100,000 and 200,000 women die from illicit abortion. In this paper the magnitude of the problem is described, those most at risk are identified and methods of preventing unwanted pregnancy are suggested. It is argued that midwives have a major role to play in family planning counselling and the provision of contraceptive services. Midwives can also reduce maternal mortality by resuscitating women when emergencies arise from incomplete abortion. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop is Kobe, Japan, October 1990.

Obstructed labour: its contribution to maternal mortality

Every year 85,000 women die from obstructed labour and many many more lose their baby and have debilitating physical damage as a result. In this paper the extent of the problem is described. Methods by which obstructed labour can be prevented are given. Early detection and prompt referral for appropriate treatment are vital if damage is to be minimised. This requires particular attention in midwifery education which must include community experience which fosters dialogue and strengthens prevention. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop in Kobe, Japan, October 1990.

The hypertensive disorders of pregnancy: their contribution to maternal mortality

The hypertensive disorders of pregnancy and their complications are the major cause of maternal mortality in the developed world and the third most common cause of maternal mortality in the world. In this paper the extent of the problem is described and factors affecting pre-eclampsia and eclampsia are described. Ways of reducing deaths from these causes are suggested.

Puerperal sepsis: its contribution to maternal mortality

Puerperal sepsis is the second most common cause of maternal mortality in the developing world. In this paper the extent of the problem is described and factors affecting puerperal sepsis are identified. Methods of reducing the incidence of puerperal sepsis are suggested. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop in Kobe, Japan, October, 1990.

Postpartum haemorrhage: its contribution to maternal mortality

Postpartum haemorrhage is the major cause of maternal mortality in the developing world. This paper presents the incidences and discusses the causes and strategies for its prevention. The paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop in Kobe, Japan, Oct, 1990.

Introducing confident midwives: Midwifery Education--Action for Safe Motherhood

The present crisis in midwifery and the seriousness of maternal mortality and morbidity demands a rethink about the background and training requirements of each level of midwifery worker. This paper describes the background of the present shortage and mal-distribution of midwives. The reduction of maternal mortality by 50% at the turn of this century requires the development of a maternal health care team in which the midwife functions as the linchpin. In order to equip the midwife for the leadership functions in this team, the present educational system needs to be fundamentally improved. The rationale for the acquisition of epidemiological, managerial specialised technical and teaching skills by midwives is discussed. Implications for further education are high-lighted. Collaborative actions taken by the WHO, ICM, UNICEF and other governmental and non-governmental agencies to address the issue of midwifery are outlined. This paper was given at the 1990 ICM, WHO, UNICEF Pre-Congress Workshop on Midwifery Education--Action for Safe Motherhood in Kobe, Japan.

Maternal mortality: the magnitude and the causes

Half a million women die during childbirth in the world every year. This paper describes the magnitude and the causes and suggests ways in which this tragic loss might be reduced. This paper was the introductory presentation at the ICM Pre-Congress Workshop on Midwifery Education--Action for Safe Motherhood.

Maternal mortality: levels, causes and promising interventions

About two-thirds of the world's population live in areas where registration of vital statistics is unsatisfactory (Tietze, 1977), and in many countries such statistics from rural areas are unavailable or grossly underestimated (WHO, 1971). Most of the women who die in pregnancy and childbirth are poor and live in remote areas or city slums. Their deaths are accorded little importance and fail to enter registers.

Factors associated with maternal mortality in Addis Ababa, Ethiopia

A housing probability survey in which 9315 women were interviewed was conducted in 1983 to detect the incidence and aetiology of maternal mortality in Addis Ababa, Ethiopia. Maternal mortality for the two-year period from 11 September 1981 was 350/100,000 livebirths (excluding abortions). A logistic regression analysis selected antenatal care, occupation and income as risk factors for maternal mortality, after adjusting for age, parity, education and marital status. Odds ratios were 2.5 for unbooked women compared to those receiving antenatal care, about 3 for students, and maids/janitresses compared to housewives, and between 3 and 5 for those earning less than US$25 monthly, compared to those earning US$150 or more.

Viral hepatitis as a major cause of maternal mortality in Addis Ababa, Ethiopia

Causes of maternal mortality were investigated in Addis Ababa, Ethiopia, from September 1981 to September 1983. Viral hepatitis ranked third among the leading causes of maternal mortality behind septic abortion and puerperal sepsis. There were 26 deaths from viral hepatitis during the 2-year study period for a hospital maternal mortality rate of 91.0 per 100,000 live births. Although 30% of women who died of all maternal causes received antenatal care in Addis Ababa, only 13% of women who died from viral hepatitis in our hospital study received antenatal care. Low socio-economic status (SES) has been shown to be associated with low antenatal care utilization and with an increased risk of protein malnutrition. Malnutrition is considered a predisposing factor for liver damage. Suggestions for reducing hepatitis transmission and maternal mortality through education, better hygiene, and improved sanitation are discussed.

Maternal mortality in Addis Ababa, Ethiopia

Between July and September 1983, a two-stage probability survey was conducted in Addis Ababa, Ethiopia to obtain data on pregnancy outcomes for all women aged 13-49 in 32,215 houses. The survey covered a two-year period, from 11 September 1981 to 10 September 1983. Of the 9,315 women who were pregnant during those two years, 45 died from complications of pregnancy, delivery, and the puerperium. The maternal mortality rate for 1982-83 was estimated to be 566 per 100,000 live births. Mortality was highest for nullipara, the unmarried, women employed as maids/janitresses, and students. The most common cause of death was abortion. It appears that reliable data on maternal mortality can be obtained retrospectively through a probability survey.