THE TRADITIONAL MIDWIFE AND ANTENATAL SERVICES IN ZAMBIA
Item
- Title
- THE TRADITIONAL MIDWIFE AND ANTENATAL SERVICES IN ZAMBIA
- extracted text
-
THE
TRADITIONAL
MIDWIFE
AND
IN
ZAMBIA
ANTENATAL
SERVICES
by
B.Nurse (Manchester)
Gill
Tremlett
S.R.N.
S.C.M.
H.V. Cert
A Dissertation submitted to
The Institute of Child Health
University of London
In part fulfilment for the Degree
of M.Sc. in Mother and Child Health
December 1983
N.D.N. Cert
ABSTRACT
A study was carried out to evaluate the effect of the training of
traditional midwives in Zambia.
Itiis dissertation presents »ne part
of that study.
It focusses on the process of providing antenatal care in both the
official and traditional maternity care services in a rural district
of Zambia.
It relates the care given to the local customs, beliefs and practices
relating to pregnancy and childbirth, and to the resources of the
health services.
In particular it examines the changes in the practice
of antenatal care brought about by the training of traditional midwives.
It does not relate the provision of antenatal care to the outcome.
Barriers to the effectiveness of the offical and traditional services
in providing adequate care for the high risk mother are examined.
I argue that barriers to the effectiveness of the official services
and the service of the trained traditional midwives often arise from
the exportation of Western procedures and knowledge (many of which are
being questioned in our own culture).
Instead I maintain that for any
health intervention to be effective one must treat both indigenous
and Western practices as cultural systems which require mutual
understanding and accommodation.
Finally suggestions are made as to how some of these barriers may be
overcome.
VOICES
On care in pregnancy
"We do not do it as you in the hospital
We notice the texture of the hair changes, months before the swelling
Her ears become pale, her face becomes pale
She gets lazy
- So we sit with her - we are not direct as you people
but we start far, far away - (she draws a big circle in the air)
We do not touch her
We just talk about how she feels, and married life
Eventually she will volunteer that she has not attended for one
or two months
(had a period)
Then we advise her in the traditional way"
Traditional midwife
Chikowa
On care in labour
"I heard a traditional midwife address a woman thus
"Come in my daughter, you were born in that corner many years ago
- of course you cried and urinated on me
- but I smacked your bottom hard"
The woman laughed and for a while forgot the pangs of childbirth
Kargbo (135)
On training
"We are proud of our women, our children and those who help our
women in childbirth.
We are proud of our tradition
Even our president does not discourage our tradition.
With our traditional ways we help and protect each other.
But do not let this training make them business women.
They too must keep the tradition.
They must not refuse any gift
- What I have must be enough"
Bwana Banda
Chikowa
ii
'l'
photo 1
Singing praises of the traditional midwives and local women
Mrs Kamanga sings a song of praise to the traditional midwives
either side of her. She encourages them to continue in their good
work and encourages women to follow their advices.
i
Acknowledgements
I must express my gratitude for all the help, advice and hospitality
I received while on attachment to the Ministry of Health in Zambia.
Without this I could not have done the study.
I would like to thank:-
-Dr. G. K. Bolla, Assistant Director of Medical Services
- Mrs. K. Sikota, Officer in Charge, Traditional Medicine
- Mr. Lwando, Dr. R. Patel and Carrie Osborne in the
Primary Health Care Secretariat
- The Overseas Development Administration for sponsoring my project
- My tutor, Hermione Lovel and
- My friends Ruth Hope and David Hughs
I owe thanks also to the many people who devoted time to discuss with
me and look after me; the rural people; traditional midwives; staff
of health centres; and the staff of Petauke Hospital.
Especial thanks are due to Mrs. F. Kamanga (Senior ZEN/ZEM Petauke
Hospital) for the enormous amount of time she spent helpingme.
My final thanks are for Mrs. Charity Zulu (Provincial Senior Nursing
Officer) from whom I learnt so much, particularly the importance
of praising people.
iv
CONTENTS
Page
ABSTRACT
ACKNOWLEDGEMENTS
iii
LIST OF FIGURES
xii
LIST OF PHOTOGRAPHIC ILLUSTRATIONS
xiii
LIST OF APPENDICES
xlv
SECTION ONE:
i
INTRODUCTION
Introduction:
The aims of training traditional midwives in
antenatal care and
Aims of the study
SECTION TWO: METHODS
15
Methods used in the study to investigate:
:Customs beliefs and practices in pregnancy and
childbirth
■.Barriers to the effectiveness of traditional
midwives in antenatal care
SECTION THREE; RESULTS
52
Results: Customs beliefs and practices in pregnancy
and childbirth
:Barriers to the effectiveness of traditional
midwives in antenatal care
SECTION FOUR: DISCUSSION
98
Discussion: Opportunities for improving antenatal care
and screening procedures for the high risk
mother.
IMPLICATIONS
REFERENCES
APPENDICES
124
V
<
*
Page
1.0.
INTRODUCTION
1
1.1.
Definitions
1
1.2.
The international interest in traditional midwives
and programmes for training them
2
1.2.1.
Health for all by the year 2000
2
1.2.2.
Inadequacy of some previous evaluations
of training programmes
3
1.2.3.
Unrecognised barriers to the effectiveness
of training programmes for traditional
midwives
4
1.3.
Zambia's interest in training traditional midwives
6
1.3.1.
Benefits expected from traditional midwife
training
6
1.3.2.
Training programmes for traditional midwives
in Zambia
7
The National Programme
7
The "village based" training of
traditional midwives in Eastern Province
8
1.3.3.
The problem of evaluation of training
programmes for traditional midwives in Zambia
11
1.3.4.
Evaluation of the effectiveness of traditional
midwives at high risk screening of pregnant
women
12
1.4.1.
Aim of the study
13
1.4.2.
Objectives of the study
14
t
>
VI
Page
2.0.
METHODS
15
2.1.
Limitations of previous approaches to studying
traditional midwives
15
2.2.
Sources of information used in the study
16
2.3.
The choice of country, the study area and a short
description of the people
16
q '?
2.3.1
Characteristics of Petauke District
18
2.3.2.
The physical characteristics
18
2.3.3.
The peoples
18
2.4.
Definitions
19
2.4.2.
Definitions of risk
20
2.4.3.
Components of an effective traditional
midwife screening programme for high risk
21
*1
2,5,
The study population
22
2.5.1.
The interpreters/co-workers
22
2.5.2.
Sampling of the traditional midwives
23
2.5.3.
Discussions with other women on their
experience of traditional midwives and
official maternity services
24
2.5.4.
Health staff interviewed
25
2.6.
Methods used to find out about traditional
midwives
Who they are and what they do
27
2.6.1.1.
Semi structured open ended questionnaire
with traditional midwives
27
2.6.1.2.
General discussions
27
2.6.1.3.
Observation of group discussions
28
2.6.1.4.
Role play
28
2.6.1.5.
Refinement of the questionnaire
28
2.6.1.6.
Application of the questionnaire
29
2.6.2.
2.6.2.1.
The pilot study:
Traditional midwives' dissatisfaction with
previous research
31
32
vii
Page
2.6.2.2.
Ten key features of the data collection
process
33
2.6.3.
Response to group interviews
36
2.7.
Methods of studying the effectiveness of traditional
midwives in providing antenatal screening for high
risk
i
38
2.7.1.
Previous approaches to the problem
38
2.7.2.
Limitations of previous approaches
38
2.7.3.
Methods used
40
<
!
2.7.3.1.
Methods for studying the major local causes
of maternal and perinatal mortality
40
2.7.3.2.
Methods to find out knowledge and use of
risk factors
42
2.7.3.3.
The questionnaires
43
2.7.3.4
Methods of studying womens preferences for
use and choice of antenatal and delivery
care services
44
2.7.3.5.
Records study of all perinatal and maternal
deaths in Chipata District Hospital in the
last year
44
2.8,
Limitations of the methods used
46
2.9.
Benefits of the methods
50
a
W
viii
Page
3.0.
52
RESULTS
Who becomes a traditional midwife? What do they do?
3.1.
Interviewed traditional midwives personal
characteristics
52
3.1.1.
Who becomes a traditional midwife?
52
3.1.2.
What does a traditional midwife do?
54
3.1.3.
Concepts of health and disease in pregnancy
and child birth
64
3.2.1.0.
The teaching and practice of care of the
high risk mother by the traditional midwife
73
3.2.1.1.
The teaching on high risk care as part of
the training of traditional midwives
73
3.2.1.2.
What risk factors have traditional
midwives been taught?
73
3.2.1.3.
Are the risk factors traditional midwives
learn relevant to the local causes of
maternal and perinatal mortality?
75
3.2.1.4.
What risk factors do traditional
midwives know and use?
79
3.2.1.5.
What change in care of the high risk mother
has taken place after training?
79
3.2.1.6.
Conclusion on the teaching and practice
of care of the high risk mother by the
traditional midwife
81
3.2.2.0.
Barriers to the effectiveness of the traditional
midwives in screening for high risk mothers
82
3.2.2.1.
Barriers to traditional midwives effectiveness arising from the community
82
A)
Beliefs concerning the causation of
disease and obstetric complications
83
B)
Concepts of health and disease
83
C)
Conclusion
86
Further barriers to traditional
midwives effectiveness in antenatal
screening for high risk
- arising from the community
86
ix
Page
3.2,2.2.
3.2.2.3.
3.2.2.4.
D)
Traditions relating to the place of birth
86
E)
The perceived benefits of staying at home
87
Barriers to traditional midwives effectiveness
arising from the traditional midwives themselves.
87
a)
Traditional midwives concept of their
role in antenatal care
87
b)
Traditional midwives and the communities
concept of disease or'problem'causation
88
c)
Inappropriateness of the antenatal
teaching of traditional midwives
88
d)
Inappropriateness of the criteria for
high risk
89
Barriers to the effectivness of the traditional
midwives screening for high risk arising from
the official maternity services
90
A)
provision of maternity services in petauke
90
B)
Utilisation of maternity services in
Petauke
91
C)
Barriers to effective screening
91
a)
Unavailability of trained maternity
staff
92
b)
Lack of finance
92
c)
poor organisation of antenatal
clinics in the hospital
92
d)
Midwives do not see the importance of
the concept of high risk screening
93
e)
Womens perception of midwives
attitudes to them
96
f)
Womens beliefs regarding the function
of the antenatal clinic
96
Barriers to the effectiveness of the traditional
midwives screening for high risk arising from
the trainers
97
a)
Lack of support
97
b)
Lack of supplies
97
c)
Future trainers' attitudes
97
X
Page
4.0.
98
DISCUSSION
What can be done about the problems identified?
1'
4.1.
4.1.1.
Opportunities for improving the care of the high
risk mother
- in the hospital
99
■
99
4.1.1.1.
Integrated MCH Clinics
100
4.1.1.2.
Afternoon antental clinics
100
Identifying the high risk woman
101
4.1.2.
4.1.2.1.
Redefining the criteria for high risk
103
4.1.2.2.
Are all primigravidae at risk?
103
4.1.2.3.
Are all grand multips high risk?
106
4.1.2.4.
A summary of the criteria for high risk
107
4.1.2.5.
Using the criteria for high risk
108
i) An action orientated antenatal
record card
109
ii) The information collection stamp
110
Benefits of a new screening system for
high risk
110
Opportunities for improving the care of the
high risk mother in the district
113
4.1.2.6.
4.1.2.
List of risk factors
113
4.1.2.2.
Training "Female indoor servants"
113
4.1.2.3.
Saving Petrol
114
4.1.2.4.
Improving the mothers shelter
114
Implications for staff training
'
1
4.1.2.1.
4.2.
’)
i
114
4.2.1.
In-service training - Bwino Magazine
115
4.2.2.
Training in Primary Health Care
115
4.2.3.
Training in statistics
115
1
Page
4.3.
Opportunities for improving the care of the high
risk mother by working with traditional midwives
117
4.3.1.
Using appropriate criteria for high risk
117
4.3.2.
Involve all practising traditional midwives
in the community
117
4.3.3.
Introduce new ideas slowly
120
4.3.4.
Involve the pregnant women in the community
120
4.3.5.
Involve traditional midwives and women in the
community in the planning
121
4.3.6.
Involve traditional midwives and women in the
selection of traditional midwives
122
5.0.
IMPLICATIONS OF THE STUDY
124
List
of
Figures
Page
To show the people involved in the study.
17
Summary chart of Sources of Information for studying Risk.
To show the discrepancies in reporting of statistics
To show the relationship of the woman in labour to the
traditional midwife.
41
47
54
To show the criteria taught to traditional midwives for high
risk and referral.
74
Priority Health problems in maternal and perinatal health in
Eastern Province
76
(a)
-
Causes of maternal mortality )
(b)
-
Causes of perinatal mortality)
notes
77
Traditional midwives' priority tasks and learning objectives
required to decrease maternal and perinatal mortality
developed from Figs. 5a and 5b.
78
To show the number of high risk women attending one antenatal
booking clinic
95
To show present high risk selection
102
xiii
List
of
Photographs
Page
Photo 1
Singing p/aises of the traditional midwives and local
women.
ii
Photo 2
Olongolongo - an example of the need to find. out about
local diseases
30
Photo 3
Photo 4
Demonstration of one woman pretending to be in labour
Other labour positions demonstrated
Delivery of the placenta
56
57
58
Photo 5
Assisting a placenta out
60
photo 6
A protected child
62
Photo 7
An inappropriate record card
94
Photo 8
A well prepared mother with an antenatal card in a plastic
bag and a new razor in readiness
118
xi v
Appendices
Appendix 1
Traditional midwives questionnaire
Traditional midwives training in risk concept
Trained traditional midwives Supervisor Interview
Appendix 2
Health Personnels knowledge of the risk concept
Appendix 3
Causes of Maternal Death at Chipata General Hospital
Appendix 4
Checklist for antenatal card analysis
Appendix 5
Records study for reasons for fresh still birth
Appendix 6
Antenatal Mothers Questionnaire
Questionnaire for mothers in rural health centre/
hospital/mothers shelter
Appendix 7
Observation of physical facilities and basic equipment
for antenatal screening and delivery
Appendix 8
Checklist for antenatal care by Midwives
Appendix 9
Checklist for antenatal care by trained traditional
midwives
Appendix 10
Checklist of traditional midwives equipment
Appendix 11
The temporary "antenatal record" used in Petauke Hospital
Appendix 12
Action orientated record cards for antenatal screening
1
INTRODUCTION
1.0.
Over two thirds of the babies in the world are delivered by traditional
midwives.
These midwives are not trained in Western medicine but
rather in the traditional system of birth (1).
they deliver over 90% of the births (2).
In some rural areas,
In Kenya despite three
generations of Western style medicine only 15% of women deliver under
'modern' medical supervision (3) and in the more urbanised country
of Zambia 60% of births still occur at home (4).
1.1.
Definitions
The World Health Organisation use the term "traditional birth attendant"
or TBA to define such a person who assists the mother at childbirth
and who initially acquired her skills delivering babies by herself
or
by working with other traditional birth attendants (5).
However recent studies show (6,7,8) this definition to be narrow,
understating her actual functions in both mother and child health.
The function of these attendants is not just to assist at the birth.
Many are healers.
Many care for and advise women right through
their reproductive years, not just helping them physically during
pregnancy, birth andihepuerperium.
They also advise on child care,
infertility and traditional forms of child spacing (9,10,11,12,13).
In some societies women in labour are assisted by women who specialise
in childbirth and have many years of experience.
In other societies
women are assisted by older female relatives who have relatively less
experience in assisting at deliveries but have a vital role in such
2
other areas as psychological support and passing on the traditional
customs, beliefs and practices of the culture to the younger women
(14).
Their importance in the passing on of traditional beliefs and
customs is shown for example by the name given to the traditional
midwife among the Bemba people "nacimbusa" or "mistress of the
matters of tradition" (15).
Thus in this study the term traditional midwife will be used in order
to emphasise that she is not just a birth attendant.
Also in its
original sense the term midwife comes from the middle english mid-wif.
This means "with women".
It is a more appropriate term for a society
where pregnancy and childbirth are "women's business".
The term traditional midwife should be distinguished from midwife and
trained traditional midwife which are defined in section 2.4.1.
1.2.
The international interest in traditional midwives and programmes
for training them and the inadequacy of previous evaluations
1.2.1.
Health for all by the year 2000
The present international interest in traditional healers and
particularly traditional midwives derives from the goal of attaining
"Health for all by the year 2000".
This goal can only be achieved
through the implementation of primary health care, where;
"Primary health care is essential health care made
universally accessible to individuals and families
in the community by means acceptable to them,
through their full participation and at a cost
3
that the community and country can afford"
(Alma Ata Clause 6) (16).
and where health is defined as:
"a state of physical, mental and social well being"
(Alma Ata Clause 1).
Within the Alma Ata Declaration itself the importance of working
with traditional healers and traditional midwives as allies in
improving the health of the community is recognised (17).
This is
especially so for the traditional midwife who is seen as a link with
women of reproductive age who might not otherwise be reached by the
usual health services.
Some member states of the World Health Organisation (WHO) have
therefore developed programmes for training traditional midwives in
order to bring more appropriate maternity care to as wide a
population as possible, especially the rural majority.
Tills dissertation will examine one outcome of training programmes for
traditional midwives in one part of Zambia.
courses is adapted from the guidelines of the
The content of these
World Health
Organisation (18).
1-2.2.
Inadequacy of previous evaluations of training programmes
Very few countries have attempted to evaluate the efficiency of their
training programmes and even fewer to determine the effects of training
on traditional midwives' practice (19).
A high proportion of the
evaluations carried out concentrate only on the aspect of "family
planning" (20).
A few countries such as Sierra Leone (21), Burma (22), and Bangladesh
(23) are studying the effectiveness of traditional midwives in providing
health care and specific tasks in screening 'high risk' mothers.
Studies .in India (24) have tried to determine the impact of training
traditional midwives on the utilisation of antenatal clinic services.
However a number of these studies have produced highly variable results.
A controlled study in Bangladesh (25) showed that training traditional
midwives in the 'at risk' concept and hygiene resulted in a reduction
in the peri-natal mortality rate from 85.2/1000 to 23.8/1000.
(However
there are worrying omissions in the published baseline data).
In
contrast figures from a study in Andhra Pradesh (26) India indicate
that the peri-natal mortality rate for births attended by trained
traditional midwives is twice that of untrained traditional midwives.
Unfortunately the causes for this are not even discussed.
1.2.3.
Unrecognised barriers to the effectiveness of training
programmes for traditional midwives
It is beginning to be recognised that many training programmes for
traditional midwives have difficulty in achieving their goals (27).
Two major barriers to the success of such programmes are now
becoming evident.
a) "Health personnel pay little attention to the cultural aspects of
childbirth and dismiss the traditional beliefs and practices as
5
being primitive, ignorant and superstitious" (28)
and thus
b) Training is usually uni-directional with an emphasis on "upgrading"
the indigenous practices rather than exploring the possibilities of
reciprocal teaching and building on the traditional practices (29).
This disregard of such indigenous beliefs, values and practices
creates midunderstanding and tension between the traditional midwives,
their clients and the Ministry of Health (30).
It may for example
create a situation described in India where some traditional midwives
found that after training they were no longer acceptable to the local
people.
In order to overcome this rejection by the community the
traditional midwives rejected all their training.
They even used
the worse practices that perhaps they did not use before training
(31) thereby increasing the mortality rates.
Thus it is necessary to go beyond the attitudes of many medical
personnel who see only the need to "minimise hazards by a process of
educating
traditional midwives on the areas of defects in their
practice" (32).
Such approaches will destroy their confidence gained
through experience, and the public's faith in them that has led to
their justified self pride (33).
In seeking to train traditional
midwives attempts should be made to understand, build on and incorporate
traditional practices (such as local social support mechanisms) and
"upgrade" the Western-based obstetrical system rather than simply
attempting to eradicate or change the traditional one (34).
6
Zambia's interest in
1.3.
1.3.1.
training traditional midwives
Benefits expected from traditional midwife training
In Zambia training programmes for traditional midwives have been
organised by the Ministry of Health with some funding from UNICEF
since 1973 (35).
Four main benefits were anticipated from their training
A.
Providing more obstetrically appropriate services
There is recognition that more than 90% of hospital and rural health
centre deliveries are normal and could be cared for at home by
traditional midwives (36).
B.
Providing more culturally appropriate services
There is increasing recognition of the importance of the many diverse
traditional practitioners, which include spiritualists, herbalists,
faith healers and traditional midwives in providing services which
are "more firmly embedded in the social environment of the patient
and
C.
more personalised". (37)
Overcoming staff shortages in rural areas
There is a national shortage of midwives.
Rural areas especially
have few qualified female staff available for mother and child health.
In a society where pregnancy and childbirth are strictly 'women's
business' there is often little or no appropriate maternity care
provided to 'scattered rural population^. (38)
7
D.
Overcoming staff shortages in urban areas
There is also an interest in training traditional midwives in urban
areas.
The present financial constraints with concomitant decreasing
staffing levels and increasing workloads appear to be associated with
perinatal and maternal mortality rates that have been increasing for
the last ten years.
A large proportion of this mortality may possibly
have been avoided by: 1) identification and referral of "high risk"
women and 2) by decreasing the hospital workloads through increasing
the numbers of appropriately selected home deliveries (39,40,41,42).
1.3.2.
Training programmes for traditional midwives in Zambia
Two different approaches have developed in the training of traditional
midwives in Zambia.
Both programmes have an overall aim to reduce
maternal and perinatal mortality, but each seeks to achieve this
through quite different means.
(A)
The "National Programme"
The National programme aims to produce a few very highly trained
traditional midwives in each district.
These are trained to function
as "community midwives" providing antenatal, delivery and postnatal
care to many women.
For the first two years, 1973-75, short experimental
programmes were organised.
Now traditional midwives are required to
attend a six week course which is usually residential and based at a
hospital.
During this time they receive lectures on antenatal;
delivery and postnatal care, care of the newborn, family spacing and
health education (43).
They also participate in field visits,
antenatal clinics and deliveries in the labour ward.
After six weeks
successful attendance they receive a certificate and may receive a
delivery kit.
8
The stated objectives of the programme are:
(a)
To select and train traditional midwives with a view to improve
their knowledge and proficiency of the maternity care services
offered to the communities where they practise.
(b)
To encourage and re-inforce the positive and beneficial cultural
beliefs and practices whilst discouraging and eliminating the
influence of harmful practices about pregnancy and maternity.
(c)
To improve the collaboration between traditional midwives and
centrally organised system of maternity and child care.
(d)
To develop traditional midwives as a multi-disciplinary group
within the integrated health team.
(e)
To inculcate basic health practices related to personal
cleanliness.
Their major functions are to recognise abnormalities and make
appropriate referrals and undertake
safe delivery of normal cases
in homes (43).
(. B) The 'Village based" training of traditional midwives in Eastern Province
In contrast to the national programme, the village based training
programme aims to work with all practising traditional midwives in
one area in their home environment.
This programme aims to reach all
the traditional midwives and make small changes to the practices of
all those involved.
By doing this it is hoped that the programme
9
will have an appreciable effect on maternal and child health.
The person behind this change is Mrs C A Zulu, Provincial Nursing
Officer for Eastern Province who has had experience of working with
traditional midwives since 1970.
Her methods of working with women in the community developed from a
recognition that:
1.
Traditional midwives have as much if not more to offer rural
communities than trained midwives.
2.
They are experienced and competent within their own social
framework and fulfil the expectations of the community.
3.
Women want to be delivered by someone they know and trust, usually
from their own family, not an outsider.
4.
Women have many family and agricultural commitments which must
be recognised.
5.
Women are comfortable learning in their home environment, a
classroom approach is alien.
6.
programmes must centre on what the traditional midwives already
do, give them confidence in their practical abilities and aim
to change only those practices which are harmful.
10
The main features of the programmes in Eastern Province since
Mrs Zulu transferred there in 1979 are that:
1.
A focus is made on areas with specific problems e.g. a very
remote area or a place with a high maternal or perinatal death
rate.
2.
A relationship is slowly built up with all practising traditional
midwives in the village or group of villages.
3.
A programme is then developed to suit the women and the resources
of the Health Service.
This may consist of weekly or monthly
visits in conjunction with immunisation or MCH teams, or it may
involve one midwife living in a village for 1-2 weeks up to a
period of 6 weeks.
4.
Hie emphasis is on:
(a)
Working with all practising traditional midwives in their
home environment.
(b)
Finding out what they already do.
(c)
Encouraging and praising them for this.
(d)
Midwives' and traditional midwives' sharing ideas and
learning from each other.
(e)
Improving a few of their techniques but changing little in
the way they practise.
(f)
Hygiene.
Thus the aim is to make traditional midwives safer in what they
already do with recognition of their value as traditional midwives
Officially both trained and untrained traditional midwives should
be registered with the District Public Health Nurse and/or staff of
the rural health centre.
Licenses have been granted by the Ministry
of Health since 1978.
After training the community is expected to continue giving the
traditional midwife the customary gifts of thanks for their help.
No government remuneration is given.
1.3.3.
The problem of evaluation of training programmes jfor
traditional midwives in Zambia
Despite the positive policies to support and improve the work of
traditional midwives in Zambia, personnel from both the Ministry of
Health and UNICEF have recently noted "a great dearth of information"
(44) existing "on work of traditional birth attendants".
In
particular their strengths and weaknesses, the duration of after
care which they provide to their clients and the inducements or
rewards which sustain their service to the community etc." (45).
Recently it has also been recognised that "the Ministry needs to
formalise its policy with respect to the nature of the support which
the Government Health Service can and should give to traditional birth
attendants within the overall framework of primary Health Care " (46).
An evaluation exercise has been carried out by Mrs K Sikota
in-Charge, Traditional Medicine in 1982.
Officer
Her study was very broad,
covering four provinces in a short period of time(47)
Her main findings were that:
1.
Members of the community do not understand the role of the trained
traditional birth attendant. In addition they assume that after
training the TBA is on the government pay role and no loneer
requires the traditional gifts.
6
2.
TBAs get inadequate support, supervision and further training.
3.
There are inadequate supplies of TBA kits and some of the
instruments could be excluded.
12
A study was devised within the framework of (the above) expressed
needs and a request to concentrate on remote rural areas (48).
However rather than repeat the broad evaluation exercise by
Mrs. Sikota.
The study aimed to supplement the
previous study by producing in-depth information about what is
happening within the maternity care system in one district.
1.3.4.
Evaluation of the effectiveness of traditional midwives at
"high risk" screening of pregnant women
This dissertation presents only one part of the research carried out
and focusses on an assessment of the effectiveness of the trained
traditional midwives in antenatal screening for "high risk".
The aim of training traditional midwives in "high risk" screening
The aim of any maternity care programme should be to provide adequate
pregnancy care in order to ensure the safe delivery of the mother,
and a healthy child.
Similarly one of the aims in training traditional
midwives should be to minimise the hazards which could be faced by
any woman for whom the traditional midwife provides care.
Although
the majority of women can be expected to deliver safely at home
some of them are more likely to develop problems which put the health
of their babies or themselves at risk.
Thus the training programmes
for traditional midwives in Zambia aim to teach them certain criteria
or "risk factors" which enable them to identify which women are most
likely to develop problems which require referral to a hospital or
rural health centre.
13
1.4 ,L Aim of the Study
The broad aim of this study is to assess how effective this
high
risk" screening procedure is; to discover any barriers to its
effectiveness, and to suggest ways in which these may be overcome.
The antenatal care is assessed not only in terms of
provision of a service, but also in terms of its cultural
appropriateness.
The objectives of the study included a detailed analysis of
customs, beliefs and practices associated with pregnancy, childbirth
and the puerperium.
Thus this study would seek qualitative data rather than quantative
data; to find out what happened in the past as well as what is
happening now; to identify trends in thinking and behaviour and to
analyse the conceptual framework of the local people in order to give
reasons for the observed behaviour patterns.
The aim of seeking this data was to analyse the dynamics of what is
happening in the traditional and official maternity care services.
Only when an understanding has been gained on what is going on both
in traditional and official maternity care can a useful analysis be
made of the effectiveness of the antenatal care and screening for
the high risk mothers.
14
1-4.2.
Objectives of the Study
1.
To identify who becomes a traditional midwife and what they do.
2.
To identify the teaching and the practice of care for the high
risk mother.
Specifically:
2.1.
What risk factors have traditional midwives been taught?
2.2.
Are the risk factors traditional midwives learn relevant?
2.3.
What risk factors do traditional midwives know?
2.4.
What change in care of high risk mothers has taken place after
the training?
3.
To identify some of the barriers to the effectiveness of the
antenatal care provided to the high risk mother
4.
(a)
from the traditional raidwife
(b)
from the community
(c)
from the health services.
(d)
from the trainers of traditional midwives
To identify some opportunities for improving the care of the
high risk mother.
15
2.0.
2.1.
METHODS
Limitations of previous approaches to studying traditional
midwives
Two main approaches have been used by others to study traditional
midwives and the effect of training.
The anthropological approach
of some workers towards the work and role of traditional midwives
has been positive and constructive (49,50,51), but this is countered
by the results of enquiries (often done by medical personnel) which
seek to assess the level of technical knowledge of traditional
midwives who may or may not have had some training.
These studies
often denigrate, trivialise or sensationalise traditional practices,
judging them only in terms of western 'scientific' obstetric or medical
practice (52,53,54,55,56,57) without looking objectively at the
benefits of their practice or the reasons behind their actions.
Some evaluators have even accused traditional midwives of being
"professionally conceited" when they express no interest in seeking
aid from official health services (58).
Neither of these type of approaches has allowed interation with the
traditional midwives in such a way that the traditional midwives are
asked to make any direct contribution to the methods used or the
propositions that purport to be about them or for them.
I felt it was vital to involve them both in decisions on the methods
used and in formulating proposals out of our discussions.
16
2.2.
Sources of information used in the study
Most of the information for this study was obtained from interviews
and general discussions with trained and untrained traditional
midwives.
Further information was obtained from the sources indicated in
Fig-1 overleaf and Fig.2 . p.
2,3.
The choice of country for the study area, and a short description
of the people
The study was undertaken in Zambia for two reasons: Firstly the
importance of traditional health practitioners in Zambia in providing
health care is officially recognised and supported in the primary
health care policies (37).
Secondly there had been an interest
for
expressed by the Ministry of Health/furtherevaluation of the training
of traditional midwives.
The study was carried out in Eastern Province as this was the only
area which had been involved in hospital and village based traditional
However it was decided to focus most of the study
of petauke
on the particular district/for the following reasons:
midwife training.
1)
Limiting most of the study to one district facilitated an analysis
of how official maternity care services interrelated with the
traditional services.
2)
Six training programmes had been organised in the district since
1978.
Three of these followed the national guidelines for the
17
NATIONAL
Officer in charge
Traditional Medicine
Assistant Director
Medical Services
P.H.C.
Secretariat
PROVINCIAL
Provincial S.N.O.
(Trainer of
traditional
midwives)
Provincial
Health Education
Officer
Medical Superintendent
Provincial Hospital
Provincial
Medical
Assistant
DISTRICT
1 trained trainer
of traditional
midwives
District Health
Education Officer
and Public Health
Nurse
District Medical
Officer
1 untrained trainer
of traditional
midwives
6 Public Health
Nurses
(1 trained and 5
student family
health nurses)
1 BSc. Student
2 Registered Nurse Midwives
8 Enrolled Nurse Midwives
4 male traditional
healers in district
organisation
3 Medical Assistants
3 "Female Indoor Servants"
or "Cleaners" who also
do deliveries in RHC
83 women attending antenatal
follow up clinic
28 women attending antenatal
booking clinic
16 women staying in the hospitals
mothers shelter aaaiing labcur
LOCAL
32 untrained
traditional
midwives
Fig-1 •
58 trained
traditional
midwives
70 women in villages between
4 hours and3 days walk
from district HQ
To show the people involved in discussions on the study
18
training of traditional midwives and three were village based.
3)
One midwife, Mrs. F. Kamanga , had been involved to some extent
in each of these programmes.
This would tend to minimise
variations in outcome due to differences in the personnel teaching.
4)
I would have an opportunity to attend a two week training
programme in the remote village of Luwembe.
2.3.1.
Characteristics of petauke District: Eastern Province
2.3.2.
The physical characteristics
The Eastern Province of Zambia is relatively isolated from the rest
of Zambia by the deep rift valley of the Luangwa.
To the east of the
valley, the land forms a plateau at 4000 ft which is mainly suitable
for shifting agriculture although there are some belts of fertile
soil.
Outside the few towns the population is scattered and lives by
farming.
Villages are often very small and more frequently depending
upon soil fertility.
People in the valley live by hunting, fishing
and farming.
Hie rainy season from November to April cuts off many people from
services.
2.3.3.
Few roads are made of tarmac.
The Peoples
The peoples of petatke District and Eastern Province are the Nsenga,
Chikunda, Nyanga, Chewa and Ngoni.
These matrilineal
peoples have a
19
common history originating in what is now Zaire.
As migration has
only occurred over the last 5~6 centuries, ethnic differentiation is
rather recent.
Thus anthropologists have written
The Ngoni, originally cattle herders have been so absorbed by the
Chewa that "the Ngoni-Chewa might be considered only variants of one
continuous culture" (59) and further that "the Chewa differ little
from the Nsenga, Chikunda, Nyanga" (60).
Consequently differences in
their customs and practices would be expected to be small.
2.4.
Definitions
It is necessary to define a number of the terms used in this study.
2.4.1.
Definition of traditional midwife
This is defined in the introduction section 1.1.
2.4.2.
p.
Definition of midwife
The term midwife is used to denote a person with formal medical
education who is officially registered and licensed.
2.4.3.
Definition of trained traditional midwife
The term trained traditional midwife is used to denote a traditional
midwife who has received some form of training from the official
health services.
2.4.4.
Definition of untrained traditional midwife
The term untrained traditional midwife is used to denote a traditional
midwife who has learnt her skills from other traditional midwives
through an apprenticeship.
However she has not had an additional
training through the official health services.
21
frequent pregnancies (62).
In certain situations culture and customs may act as risk factors
by limiting the education or status of women or withholding food in
pregnancy or perpetuating unhygienic practices, or as is more common
in developed countries - unnecessary intervention in pregnancy or
labour (63).
2.4.3.
Components of an effective traditional midwife "screening"
programme for "high risk"
The effectiveness of traditional midwives in screening for women of
"high risk” was evaluated by matching traditional midwives' knowledge
and practice with the components necessary to make the procedure
effective.
These components were developed from World Health
Organisation guidelines contained in "Risk Approach in Maternal and
Child Health Care (62) and are listed below:
(a)
Traditional midwives learn "risk factors" which are appropriate
to their locality and which correlate with the major causes of
maternal and perinatal mortality.
(b)
Traditional midwives use these "risk factors" to identify "high
risk" women in their community who require referral to the
hospital or rural health centre for assessment or delivery.
(c)
"High risk" women follow the traditional midwives' advice and
attend hospital or rural health centre.
(d)
For the traditional midwives' work to be effective it must be
supported by an efficient service in hospitals or rural health
22
centres for providing "high risk” screening and adequate care
for those who develop problems.
This support system should
comprise the following components
use of criteria for "high risk" which correlate with the
i)
major causes of maternal and perinatal mortality;
use of criteria which do not classify more women as "high
ii)
risk" than can be adequately cared for by the services;
iii)
accurate assessment of a womens' risk status;
iv)
clear explanations by midwives to women of "high risk" on
where they should deliver and why;
a clear indication on the antenatal card if a "high risk"
v)
woman should deliver in hospital;
vi)
early self referral by "high risk" women in accordance
with midwives instructions;
vii)
2.5.
a useable transport system.
The Study population
2.5.1.
The Interpreters/Co-workers
In order for this study to be of benefit to the trainers of traditional
midwives
it was important to work together with them.
I was
extremely fortunate that Mrs. C A Zulu, Provincial Nursing Officer
and Mrs. F Kamanga, Senior ZEN/ZEM at Petauke Hospital could spare
the time to work with me and they became not just colleagues and co
research workers, but good friends from whom I learnt a great deal.
23
2.5.2.
Sampling of the traditional midwives
After discussions with the traditional midwife trainers it was
decided that any form of sampling was inappropriate for the following
reasons:
1)
One of the main research tools was group discussion and it would
be unrealistic to try and define who should be in those groups
2)
The traditional midwife trainer who helped as my interpreter had
not been able to visit the traditional midwives living in remoter
areas for three years.
Many traditional midwives would feel
offended if they were excluded.
It was important to maintain
morale by visiting all of them and praising them for their work.
Thus the study aimed to contact as many as possible of the traditional
midwives who had been trained in Petauke district since the training
programmes started in 1978.
In addition discussions were held with 32 untrained traditional
midwives, 10 of whom were outside Petauke District.
A particular effort was made to visit traditional midwives situated
far from the district boma
(headquarters), especially those in the
Luwangwa valley about 100 kms away along difficult and infrequently
used roads.
In total, discussions were held with 90 traditional midwives between
22 July and 30 August 1983.
24
Fifty eight of these traditional midwives had received some training,
they included:
1)
33 traditional midwives trained for only the first two weeks of
a proposed 6 week village based training programme in 1976.
22 were from Mwape and 11 at Chikowa.
2)
4 traditional midwives trained for 6 weeks atSinda rural health
centre in 1981
3)
16 trained for 6 weeks in hospitals at Minga and Petauke in
1978 and 1979
4)
5 trained for 6 weeks at Sinde-misale in 1981.
In order to widen the perspective of the study six traditional
midwives in another district (some 300 kins away) were visited.
These had been trained in a village based programme which was closely
associated with the rural health centre.
Unfortunately due to lack
of time and transport I was unable to visit more programmes in other
districts.
The fifty eight trained traditional midwives visited represented
50% of all those trained in the areas visited who were still living.
2.5.3.
Discussions with other women on their experience of traditional
midwives and the official maternity services
Discussions were held with three other groups of women.
1.
Discussions with village women
Discussion was only possible at 4 villages; Luwembe , Chikowa, and 2
25
small villages 20 kms from the hospital.
It included 70 women.
No attempt at random sampling was made.
All willing women were
included.
2.
In one case all women of child bearing age came.
Discussions with antenatal clinic attenders
All 28 women attending one antenatal booking clinic were interviewed.
Brief discussions were held with 83 women in the antenatal follow-up
clinic.
More detailed discussions were held with another 25 women
who were selected by taking them in groups of five, leaving intervals
of 20 women between each group selected.
3.
Discussions with mothers in the mothers'shelter
All 16 pregnant women staying in the mothers' shelter at the hospital
awaiting the onset of labour were interviewed.
2.5.4.
Health Staff interviewed
Discussions were held with the health staff indicated in Fig.-l.
In addition it was planned to hold structured interviews on "Health
personnel's knowledge of the risk concept"with: the traditional
midwife trainers; all midwives in the district hospital and some in
the provincial hospital; midwives and medical assistants in the rural
health centres and other personnel assisting at deliveries e.g. the
"female indoor servants" or "cleaners" at the rural health centres.
However these interviews were limited by time and transport
availability.
Five health centre staff were not interviewed as they
were attending funerals.
Due to the huge distances between the
hospital and rural health centre it was not possible to randomly
select these people.
I went where there was transport.
26
In all structured interviews on the risk concept were held with 2
traditional midwife trainers, 5 of the 7 midwives working in the
district hospital, 5 midwives at provincial level, 3 medical
assistants and 3 "cleaners" from rural health centres. The one
in the district
rural health centre midwife/was unavailable on the day of our visit.
For questionnaires see Appendix 2.
2.6.
Methods used to find out about traditional midwives;
Who they are and what they do
The methods used to find out about both trained and untrained
traditional midwives developed from discussions held with the
traditional midwife trainers and the traditional midwives themselves.
The implementation of these methods is presented in the following
section.
2.6.1.1.
Semi structured open ended questionnairewith traditional
midwives: entitled "Traditional midwives questionnaire"
A semi structured open ended questionnaire was used to gather
information on the customs, beliefs and practices associated with
pregnancy, childbirth and the puerperium.
It was developed from a
questionnaire designed by Dr Ruth Hope and myself in a similar study
in Newcastle (64).
It was revised with the help of the traditional
midwife trainer and 5 community nurse-midwives and then pre-tested
on 10 untrained traditional midwives.
This was done as part of a
community diagnosis in order to gather much wider information on
food, water, sanitation, etc.
2.6.1.2.
General Discussions
Open unstructured discussions were held with other people in order to
get a wider understanding of customs, beliefs and practices and the
role of the traditional midwife.
These people included: the
traditional midwife trainers, 197 women in antenatal clinics and in
the community, 4 male traditional healers, some community leaders and
47 health personnel.
29
"(If yes) what happened?"
"What usually causes a woman to bleed in pregnancy?"
"Is it a problem?"
"Can anything be done about it?"
"Who do they usually go to for help?"
"What did you used to do about it?"
A second refinement was the introduction of questions on diseases not
recognised by "Western medicine".
For example, in Luangwa valley
(but not in all other places) olongolongo is described by traditional
midwives as a disease of the baby's cord, identified by red or black
nodules (see photo overleaf).
These nodules are only irregularities
in the blood vessels but are locally thought to be signs of a severe
and sometimes fatal illness.
If a child had olonglongo a number of
things may be applied to prevent death, e.g. herbs, ash, rat faeces
and sooty cobwebs
.
*
It was thus important to ask specifically about
this disease as generally traditional midwives did not apply anything
to the cord.
♦(These sooty cobwebs are reputed to have beneficial antibacterial
and haemostatic effects) (65).
2.6.1.6.
Application of the questionnaire
The revised questionnaires are shown in Appendix 1.
Interviews were conducted through the interpreter/co-research worker
who would translate each question and answer in turn, rather than
repeating questions in a fixed order with standardised wording.
Thus questions asked followed the trends in the conversation.
This
Gave a much more personal
approach which
=n
r
wiuun is
is especially
important where
30
Photo 2:
An example of the need to find out about local diseases
In some areas the dark nodules on this cord are thought
to be a sign of a severe and sometimes fatal illness called
olongolongo.
To prevent this, the cord is treated with
preparations which may include herbs, ash, rat faeces and
sooty cobwebs.
Normally the cord is kept dry and clean.
31
people need to assess the interviewer before deciding whether to
trust them.
This freedom of translation was particularly necessary
as the co-worker used two different languages and tried where possible
to use the local idiom.
In order to overcome the criticism that a trainer of traditional
midwives or a midwife would be biased in the way she gave or translated
sometimes
answers, two interpreters were/Used. Mrs Kamanga, the traditional
midwife trainer, would translate my questions as she was able to
phrase things in a way that made the women feel very free and relaxed.
The second interpreter would then translate the answers.
After the
interview I would then correlate the answers with Mrs Kamanga's
interpretation.
I found the answers given appeared to be honest translations.
In
addition my working knowledge of Swahili (a related language) permitted
me to follow much of the conversation.
2.6,2,.
The pilot study
A pilot study was carried out in Petauke District with the aims of:
a)
identifying key problem areas requiring study
b)
orientating myself in the community
c)
orientating myself to the current health situation
The pilot study involved group discussions with a total of 13 trained
traditional midwives at their homes and 14 local women who were
called upon by the traditional midwives to participate.
32
2,6.2.1.
Traditional midwives' dissatisfaction with previous research
From this study it was evident that the traditional midwives were
dissatisfied with the approach of a previous group of evaluaters.
The 9 main reasons for the traditional midwives' reaction to the
previous evaluation were:
i)
The traditional midwives were most unhappy that there had been
no feedback to them on either the opinions of the evaluation
team or what their own communities said about them;
ii)
They did not like members of the community being interviewed
privately on their assessment of the traditional midwives'
work after training;
iii)
They themselves did not feel comfortable with individual
interviews;
iv)
v)
Problems raised by the traditional midwives were not discussed;
The traditional midwives felt the questions asked by the
very
evaluaters were not/relevant to their problems, work and
experience;
vi)
They felt they were being tested ; "They tested what I could
remember, not what I do";
vii)
Some did not like to be interviewed by men - "Men should not
ask about women's business"
viii)
Some did not like to discuss their level of literacy or other
personal details with strangers ; "Why should I be shamed by
strangers?";
33
ix)
The traditional midwives were not warned in advance that
visitors were coming.
Thus not all managed to participate and
a few senior traditional healers/traditional midwives felt
particularly that they had not been respected - "We were not
warned and had no time to prepare food".
Thus many felt these interviews
had created mistrust and had
contributed to one traditional midwife refusing more deliveries and
moving to another village.
In order to prevent a recurrence of
such resentment the following set of research tools and techniques
were adopted.
2.6.2.2 .
i)
Ten key features of the data collection process
Overcaning mistrust by working with traditional midwife trainers
In order to overcome traditional midwives' mistrust of a
foreigner it was important to be introduced to them by people
who already had established a good relationship with them.
It was thus most fortunate that two traditional midwife trainers
could assist me in this way.
ii)
Notification of visit:
Where possible the appropriate village leaders or chief and
the traditional midwives were notified of our coming.
iii)
General discussion on community problems:
At the beginning of the discussion, considerable time was
allowed to discuss the problems of the community.
Such
problems ranged from lack of contraceptive services within
three days' walk to lack of food.
34
This open beginning also allowed an assessment of how
interested the traditional midwives and/or community were in
mother and child health and changing practices.
iv)
Individual interviews minimised
Most interviews were conducted as group discussions with
traditional midwives or local women.
If the discussion was
to include the communities' opinion of the traditional
midwives' work, it would be conducted in the presence of the
traditional midwives so that discussion could be open, mistrust
minimised and some problems ironed out.
v)
Explanation of the aims of the discussions:
Considerable time was normally spent with leaders and traditional
midwives explaining our aims and in particular my interest in
the study.
It was made clear that people did not have to
participate and that we would value their criticisms of any of
the questions or the way we expressed ®urselves or behaved.
vi)
Emphasis on sharing ideas:
It was also clearly stated that we believed that traditional
beliefs and practices have as much if not more to offer than
Western medicine and that our approach should be one of sharing
ideas and knowledge.
On this basis we were able to discover the disparities between
what the women had learnt and what they did in practice and
what from their training they liked and found useful and what
was difficult or unacceptable.
35
vii)
Interviews are not examinations:
It was made clear that we were not testing their knowledge
from the training programme.
viii)
Panel Discussion:
At the end, time would be allowed for a panel discussion
with the traditional midwives and other women in the community
followed by the trainer going over areas of their knowledge
on which she was concerned if necessary.
ix)
Praise and encouragement:
Finally, time would be spent publicly praising the traditional
midwives, to encourage them in their work and make the
community realise how much they and their services were valued
by us.
x)
Women Only:
Men were not involved in these discussions, despite the strong
desire of some male healers to be involved.
Separate
discussions were held with them as they rather dominated the
women.
2-6.3
Response to Group Interviews
Group interviews with traditional midwives
Discussion with traditional midwives and village women was normally
carried out in groups.
These groups ranged in size from 2 to 36.
I
Where very large groups were encountered, they would be split up
into groups of 5-6.
Discussions with traditional midwives were normally
conducted sitting on the ground outside in the shade of a tree.
On
several occasions women were posted to keep away young men and children
who showed too much interest in "women's business".
The anticipated
benefits of group discussions were that the participants would feel
less threatened and that personal idiosyncracies in the working
methods of traditional midwives would be put into perspective.
However far more than this was gained.
Only when the traditional
midwives talked in a group did the relationships between traditional
midwives become apparent; we saw;-
■
- who the leaders were;
who the traditional midwives turned to for the answer to a specialist
in r
.
|( u n n H
36
question;
who the senior traditional midwives were and who they were training;
who worked alone;
traditional midwives themselves would point out differences in their
i:
practices and give explanations as to the reasons.
In addition the praise given to some traditional midwives indicated
their high standing within the community.
37
Also certain disagreement became apparent: for example, in one village
one traditional midwife was attempting to discredit another.
Only
by meeting in a group did the misinformation given us become apparent.
Group interviews with local women
The value of group discussions with local women was shown by the
differing answers obtained to questions given in a group or
individual situation.
Individually interviewed women said they chose
to deliver in hospital 'because its best to be in hospital'.
Interviewed as a group 75% of the women said they came because they
were afraid of "ufwiti". (p.
)
In contrast some somen would not talk in a group as certain rules
of kinship forbid speaking in the presence of ones mother-in-law etc.
38
Methods of studying the effectiveness of traditional midwives
2.7.
in providing antenatal screening for high risk factors
2.7.1.
Previous approaches to the problem
Previous studies attempting to assess the effectiveness of traditional
midwives in referring women in need of special care have either
1)
used structured interviews with traditional midwives on who
they would refer(66); or
2)
assessed the increasing coverage of antenatal care provided by
the traditional midwives themselves, or by referral to an
antenatal clinic.
2.7.2.
(21,24)
Limitations of previous approaches
Usually it is assumed, e.g. Ghana IDS Study (64) that the major
causes of maternal mortality rate and perinatal mortality rate in
developing countries are now well enough known to be able to plan
an effective health programme.
However from my experience of working
with traditional midwives previously it was suspected that local
factors might
be important also, e.g. drinking of oxytocic herbal
infusions in labour, beliefs concerning causation of obstructed
labour, etc.
Ihe study clearly showed they were and it is suggested that traditional
midwives' antenatal and delivery care may well be greatly improved
if organisers of programmes first identify the local risk factors
for maternal and perinatal mortality.
41
FIG 2
SUMMARY CHART OF SOURCES OF INFORMATION FOR STUDYING RISK
(TMW = Traditional Midwife)
Traditional customs
and practices in pregnancy and chjIdbirth
Mothers' knowledge of risk factors
Untrained TMWs understanding of
risk factors
--Trained TMWs understanding
of .isk factors____ --____— ■ ,
TMWs practice of antenatal
care
Mothers' choice of place for
previous delivery in relation
to risk status
Village
Mothers' choice of birth attendant
TMWs referrals to antenatal
clinic and the proportion who
refuse to comply
(antenatally or in labour)
TMW trainers
teaching of
'criteria' for high
risk
staffing
facilities
staff knowledge of
risk factors
The percentage of high
risk women delivering in
the village
-^Population coverage
Rural Health
Centres
Percentage of stillbirths
or neonatal deaths
Organisation of
clinic services
referrals to hospital
(antenatally or in labour)
staffing
midwives knowledge
high risk factors
antenatal clinic
facilities
Mothers' knowledge of their
risk status as related to
that indicated in the card
Hospital
Antenatal
Clinic
>opulation coverage
provision of antenatal
record cards
perinatal mortality rate
midwives marking of the antenatal
card to denote a high risk mother
mothers' reasons for
refusing to deliver in hospital
organisation of clinic services
effectiveness of the screening
procedure in antenatal clinic
mothers' reasons for
choosing to deliver in hospital
^mothers' reasons for
choosing to come to the
Low birth weight' mothers' shelter to await
Delivery Ward
Population coverage
for deliveries
Delivery
records
Causes of <Maternal
Mortality
Perinatal mortality
rate
rate
International
and
Provincial
Level
International
and
National Level
Percentage of 'high risk'
women delivered in hospital
-^Causes of Perinatal
Mortality
42
2.7.3.2.
Methods to find out knowledge and use of risk factors.
Sources of information on the knowledge and, use of risk factors by
traditional Midwives and health personnel are summarised opposite in Fig.2.
Information on the knowledge and use of risk factors was to have been
obtained from ten sources but was in fact only obtained from six.
(a)
Discussions with ten midwives, 90 trained and untrained traditional
midwives and 3 medical assistants.
(b)
Discussions with 83 pregnant or breastfeeding mothers from: the
antenatal clinic; mothers' shelter and villages between four hours
and three day's walk from the nearest maternity unit.
(c)
Analysis of 300 antenatal records of mothers attending the
antenatal clinic in order to identify whether the card is marked
appropriately to indicate a mother at risk (a red cross or star
on the top of the card or written explanation in the same place).
(d)
Interviews with 51 mothers in their villages and 28 mothers
attending antenatal clinic on whether they had been informed where
they should deliver.
This was then compared with the information
on the antenatal record, or the obstetric history would be
verified by the traditional midwife. (Appendix 6)
(e)
Analysis of 130 of the most recent delivery records to identify
whether the records of those choosing to deliver in hospital show
a preponderance of women at risk.
(f)
Observation of the facilities and functioning of 4 antenatal clinics
at the district hospital.
(g)
(Appendix ?)
Analysis of delivery records in the district hospital over the
last three years to identify the proportion of low birthweight
babies.
(h)
An observational study of the antenatal care provided by midwives
in hospital was planned but due to lack of space could not be
done.
(i)
(Check list in Appendix 8)
Ar observation'’.! study of the antenatal care provided by traditional
midwives was planned but became unappropriate as it would have
created mistrust.
(Appendix 9)
43
(j)
An observational study of the traditional midwives' delivery kit
was planned but only two had been provided with them 5 years
previously and the kits were no longer used.
2.7.3.3.
(Appendix 10)
The Questionnaires.
a)
Traditional Midwives Questionnaire.
All 90 trained and untrained midwives interviewed were interviewed
to ascertain their knowledge and use of the risk concept.
The
questions relating to this were included in the semi structured open
ended questionnaire entitled "Traditional Midwives Questionnaire"
described in section 2.6.1.1.
b)
Health Personnel: Questionnaire.
Health personnel involved in antenatal care and/or delivery were
interviewed to ascertain their knowledge and use of the risk concept,
using a questionnaire entitled "Health personnels' knowledge and use
of risk concept" (see Appendix 2).
The questionnaire was pre tested on
midwives working in the provincial hospital with the help of the mid
wifery tutor.
Very little change was made to the original questionnaire.
This questionnaire was to have been used with all district hospital
and RHC midwives.
However of the 17 RHCs only one had a resident
midwife who was unavailable on the day we visited.
Thus this interview
was carried out with 5 of the 7 midwives based in the hospital and 5
working at provincial level.
In addition 3 medical assistants and 3
female indoor servants were interviewed.
The questionnaires were developed from those of Amegavie (1982) (136)
c)
Methods of studying community knowledge of risk factors.
Community knowledge of risk factors in pregnancy was studied
through semi structured open ended interviews with women in the ante
natal clinics and in the villages.
These questionnaires are presented in
Appendices 2 and 6.
The women interviewed included:one
i
All 28 women attending/antenatal booking clinic.
ii
All 16 women staying in the mothers' shelter on
iii
25 of the 166 women attending antenatal follow up clinic.
iv
51 recently delivered women in two villages 4 hours walk from the
v
8 women 3 days walk from the nearest hospital.
hospital.
August 1983.
Each village had a trained traditional midwife.
44
2.7.3.4.
Methods for studying women's preferences for use and choice of
antenatal and delivery care services.
a)
District records of the number of antenatals registered in the
hospitals and RHGs.
t>)
District records of the number of deliveries in hospitals and
RHGs.
c)
A study of midwives preference for the place of delivery of
mothers (included in the questionnaire on high risk)
d)
A study of 83 antenatal follow-up clinic attenders on their
choice of place of delivery for their last pregnancy.
choice was then correlated with their risk
the antenatal card.
Their
status obtained from
They were also asked who assisted in their
delivery and whether they were a relative.
Finally they were
asked for their reasons for choosing that place for delivery.
e)
A study of all 51 women in two villages who had delivered in
the previous 18 months.
Their choice was then correlated with
their stated risk status and verified by the traditional midwife.
They were also asked who assisted in their delivery and whether
they were a relative.
Finally they were asked for their
reasons for choosing that place for delivery.
The questionnaires for d) and e) are presented in Appendix 6.
2.7.3.5.
Records study of all perinatal and maternal deaths in Chipata District
Hospital in the last year.
The records of all perinatal and maternal deaths in the last year
were to be studied and a questionnaire on cause of death and
indicators of high risk
was
*
to be filled in for each of these records,
(estimated 'To. 130)
The data was then to be transferred to a summary
sheet and analysed.
(Appendix 4b)
*The criteria for high risk were those used in the midwifery school.
45
The indicators of high risk to be used ares-
2.1.
Place of residence.
2.2.
Marital Status.
2.3.
Age: mothers under 18 years and above 35 years are to be
regarded as 'at risk' while those between 18 and 34 years
to be considered as normal.
A.
2.
2.5.
Height: Any woman less than 150
cms to be considered at risk.
Parity: first pregnancy and fifth or later pregnancy are to
be regarded as 'at risk'.
2.6.
Income or employment: or occupation.
2.7.
Chronic diseases;
known to affect outcome of pregnancy and
therefore regarded as putting women at risk were -
2.8.
-
diabetes mellitus
-
hypertension
-
renal disease
-
sickle cell
-
malnutrition
Previous Obstetric history:
any woman who has had any of the
following are to be regarded as 'at risk':-
previous antenatal problems; pre-eclampsia or antepartum
haemorrhage or anaemia.
-
previous problems in labour or puerperium; e.g. caesarian
section or other abdominal or perineal operation, ruptured
uterus, nost-nartum haemorrhage, retained placenta.
-
previous still birth, early neonatal death or baby weighing
less than 2.5 kgs.
2.9.
Present antenatal history:
any woman having previous obstetric
history, anaemia or abnormal presentation is to be regarded
as being at risk for the next pregnancy
deformities - physical
mental illness
46
2.8.
Limitations of the methods used to study:
2-8.1.
"Causes of maternal and perinatal mortality?
2.8.2.
"The screening of high risk women"
I had been requested to present reommendations on the content of
future training for traditional midwives.
From previous experience
I considered it important to identify whatever local causes of
maternal and perinatal mortality (and associated high risk factors)
it was possible to discover.
The limitations can be divided into 3 groups:-
a)
Limitations of the statistics available:-
i)
Urban hospital bias in data on mortality
The studies of maternal and perinatal mortality are derived
from hospital data from urban areas where for example there
is a much higher incidence of pre eclampsia and sexually
transmitted disease (39)(40)(68)
ii)
Errors in recording data and confusion of definitions
Some of the problems of statistical data analysis have
already been presented in a review of the implementation of
primary health care in Zambia;-
"Although there is diligent data recording and
consolidation at all levels of the health system,
this effort lacks purpose beyond a fulfilment of
instructions from 'above
.
*
There is a general
lack of epidemiological approach to the health
activities.
There is also a lack of well trained
47
statistical officers to work in the information
system down to the district .
(69)
This problem is apparent at all levels from RHC to national
level and can be illustrated by studying Petauke District
Hospital's delivery statistics for 1982.
These statistics
were traced (by GT) from the ward delivery book totals to
provincial level and then cross checked by a personal study
of each entry in the ward delivery book.
Table 3
To show the discrepancies in reporting of statistics
Total
Deliveries
Total
Still births
Neonatal
Deaths
Personal cross check
845
35
13
District hospital
record (71)
829
40
7
Provincial record (70)
834
39
10
petauke District Hospital Delivery Records 1982
to show the discrepancies in reporting statistics
The discrepancies between the ward totals and the cross checking are
accounted for by:
1)
A confusion of definitions.
Neonatal deaths are frequently
counted as still births and not as live births which die.
This
is epitomised by one entry which reads "Still birth at home baby
came in gasping”.
2)
Multiple pregnancies are often entered as only one single birth.
Data at provincial and National level are based on such statistics and
are thus limited in accuracy.
However as. can be seen from Tabl? 3 above, errors also occur in addition
and also in the transfer of figures from one record to another.
48
However, where statistics were needed in this study it was decided
to concentrate on the corrected and updated statistics given me by
the previous Provincial Medical Officer (72) rather than the published
Provincial Annual Report (70).
For national data,figures were taken from the as yet unpublished
1980 Country Health profile (4).
b)
Limitations of interview methods for risk
i)
Verbal reports of the care provided should be validated
by observation
Validation of verbal reports by observation was
inappropriate for studying traditional midwives' attitude
to and use of "risk factors" in petauke.
A situation where
traditional midwives felt they were being tested would not
allow them the freedom to be honest about what actions they
really took.
Similarly midwives' assessment of a woman's
"risk status" should be validated.
This was attempted.
However only the obstetric history could be validated and
accuracy of
not the/palpation,due to lack of space, time and staff in
the antenatal clinic.
ii)
Study of health personnel includes few rural health
centre staff
The study is restricted as observations were limited to
district and provincial hospitals, as the only rural health
centre based midwife was unavailable when visited.
small numbers of health personnel were interviewed
Only
49
iii)
Verbal reports of referral should be validated
Validation of verbal reports of referrals could not be
done as hospital, rural health centre and traditional
midwives' records were incomplete.
These limitations were to some extent overcome by using many different
sources of information.
2.8.3.
Limitations of the methods used to study traditional midwives'
customs, beliefs and practices
i)
Limitations of interviews on customs and practices
Asking questions is simple but is open to errors.
The quality
of material is greatly dependent upon the interviewing technique,
structure of questions and translation.
There may be reluctance to share such information with someone
from an alien culture especially where it concerns subjects
that are considered taboo or alien.
Reluctance may also be found among those who normally make
earnings from such information.
Conversely the desire to give answers to please the interviewer
can distort the outcome especially where the interviewer is
obviously working with the Ministry of Health.
The optimum as shown by Claquin Et.al (66) would be to validate
verbal reports by observations of customs, especially of delivery.
50
It was hoped to achieve this during a 2 week stay in one
village while attending a training course for traditional
midwives.
Unfortunately this was disrupted for 8 days by
funerals.
ii)
Lack of background information
The lack of relevant anthropological literature made it difficult
to quickly orientate myself to the culture and peoples conceptual
framework of health and disease.
A review of such literature in the School of Oriental and African
Studies and at the University of Lusaka revealed only passing
references to this district, although material was available on
neighbouring ethnic groups (8,59,73,74,75,76,77).
Material from studies sponsored by the Ministry of Health in
Zambia such as the national workshop on traditional medicine
(49), Sikota (47) and Edlrisooriya (78) do not detail
customs, beliefs and practices in pregnancy and childbirth
according to locality.
Thus they only provide a very general
basis for attempting to understand the local conceptual framework
for health, disease and problems in pregnancy.
2.9.
Benefits of the methods used
The aim of the study was to provide practical information and
suggestions for improving the training of traditional midwives.
I went to Zambia with no set programme of where to go, what to do or
what problems to investigate.
Initial discussions with senior health
personnel suggested certain areas for investigation, namely antenatal
care and an evaluation of different types of traditional midwife
51
training programme.
It was thus necessary to attempt a broad overview of a wide range of
issues.
An in depth approach in one small area would have been
inappropriate.
A composite approach was used, utilising analysis of
statistics, interviews, observation, group discussion, role play and
most important, learning the indigenous technical knowledge.
Individually each of these methods has weaknesses but used together
they provide a composite picture.
uniformity.
This picture does not however seek
Information from one source may validate or contradict
information from another.
In this way a dynamic picture is developed
of what is happening.
Methods were devised and used which appeared to be the best to
investigate the problems seen and needs recognised within the resources
available.
Ihe very broad and open framework allowed an understanding
to be developed of the conceptual framework behind people's beliefs
and practices and the importance of these in people's actions.
52
3.0.
3•1•
RESULTS
Who becomes a traditional midwife and what do they do?
This brief summary is a composite picture compiled from discussions
with 90 traditional midwives, their trainers and over 200 women in
Petairke District.
Interviewed traditional midwives' personal characteristics
Range: 40-85.
Age:
Average 54 *
.
years
(Women's average life expectancy 54 years) (80)
Number of children:
Range: 2-15
Average 8.9
Number of years practised as traditional midwife: 2-50
*
Literacy: However village traditional midwives are almost
illiterate.
Traditional midwives selected for government training
were often secretaries or chair persons to womens clubs or
UNIP*
** and many were selected for their literacy.
3.1.1.
Who becomes a traditional midwife?
Almost every grandmother becomes a traditional midwife and so
the relationship between the majority of traditional midwives
and pregnant women is one of kinship, rather than "professional to
client".
Other studies in central Africa report similar
kinship ties.
(15) (7 )
♦This question was not asked of all traditional midwives
** United National Independence Party
53
These findings contrast to much literature which depicts
traditional midwives as a relatively small number of women with
specialist skills.
Women among the matrilineal Nsenga, Chikunda and Chewa look to
own
their/mothers and grandmothers for help in pregnancy and labour.
If the girl moves to live with the husband's family she may turn
to the mother-in-law.
Ihus in each family there is a traditional
midwife who will pass on her skills to responsible daughters.
"I learnt from my mother who was getting old and
going to die.
I had 4 children by then"
"My grandmother taught me when I had my first saying -
"Look you tie the cord like this ... remember because
my eyes are not good for long ... watch because you
will need to help others.
That was in 1949"
Over her years of apprenticeship some traditional midwives may
also learn specialist herbal skills.
Other women in the
community, recognising these skills, may call on her abilities
and knowledge.
respected.
By her success she will become "known" and
Some traditional midwives develop skills as herbal
and spiritual, healers.
The ’known"traditional midwife is called to assist women outside her
own family and may as she becomes more senior, begin to teach and
supervise 4-5 juniors who operate together. This group.may deliver
women outside their own families.
Traditional midwives rarely work alone as solitary people are feared-
as is shown by such phrases as:
54
"You eat alone like a sorcerer"
"You move and live alone like a sorcerer"
Pregnancy, childbirth and infancy are considered very vulnerable and
dangerous states and so women and infants must be protected by the
close supervision of a trusted relative.
Thus a delivery attended by
a non-relative traditional midwife must be supervised and witnessed
by the pregnant woman's mother or grandmother.
The mother or grandmother
can ensure that necessary customs and rituals are adhered to and
Only in this way can traditional midwives
"witchcraft" prevented.
avoid blame if problems occur.
Only a very small number of women outside hospital are delivered by a
non-relative as shown in Fig.4 below.
Birth attended by
Sample population
Hospital
Grand Mother Other
Non
Alone
Mother
Relative relative
TBA
83 births to ante
natal clinic
attenders
28%
30%
12%
*
1%
6%
24%
51 births to village
women 20 kms from
hospital
27%
47%
14%
0
12% ,
0%
1%
6%
38%
Study among the
Shona in Zimbabwe (7
k
56%
___________
Fig.4. To show the relationship of the woman in labour to the
traditional midwife.
* One mother-in-law
3.1.2.
What does a traditional midwife do?
Responsibilities of the grandmother/traditional midwife
As a grandmother, traditional midwives are responsible for guiding
55
the younger women through puberty, initiation, pregnancy and child
birth.
Theyimplicitly transmit the values and beliefs of the
society and give psychological support.
During the initiation period at puberty the girl is given
moral
lessons related to her future life as a wife and mother.
Now however
this period of initiation has been shortened from 1 year to 2 weeks
„ state, .
to comply with the demands of/education.
First pregnancy
During a girl's first pregnancy the traditional midwife recognising
the changes in her complexion will delicately discuss the pregnancy
with her.
Little information is given for fear of frightening her.
Indeed a girl with her first pregnancy is dressed with a special white
cloth or white beads to signify to others that she must be well
protected and not disturbed or worried by 'foolish talk'.
She will be
given the traditional advice on diet and cleanliness (both moral and
physical). The traditional midwifes do not palpate her but may
inspect the abdomen and will ask if the baby is kicking well.
Women
are encouraged to work hard in pregnancy so neither they nor the baby
are lazy in childbirth.
Herbs
Herbal preparations in the form of an infusion or pounded with
porridge may be used to "stabilise" the pregnancy at about 5 months;
term herbs
or to treat some of the problems in pregnancy; At/may be given to
stimulate or speed labour.
They do not appear to use the intra vaginal
preparations used by the Luvale in Western Province who have a
(8)
concomittant extremely low fertility rate.
Herbal preparations are
said to be given more often as treatments than as a preventive.
56
"In labour" - a demonstration by 5 traditional midwives, to show:
i)
Sitting position
ii)
One senior traditional midwife kneeling to receive
the baby and at the same time encouraging the mother
saying: "come out, come out, come and see your
mother"
iii)
One traditional midwife supporting each leg
iv)
A fourth traditional midwife wiping the woman's face
v)
White chitenge round the woman's back to support her
(normally held firmly)
vi)
Ring of cloth to sit on
(the women have moved slightly to allow me to take the photo)
58
Photo 4
Waiting for the placenta to deliver
Now the baby doll has been delivered.
The mother moves to a squatting and then a
kneeling position for the delivery of the
placenta.
The senior traditional midwife hold the
baby doll, waiting for the placenta to be
delivered before cutting the cord.
59
Traditionally women in early labour walk round and continue with
household chores, closely observed by a traditional midwife.
As
contractions get stronger she adopts a sitting position leaning
against a wall or in to the arms of another traditional midwife (p.57).
Birth
Traditional midwives' demonstrations of positions in labour show women
to use sitting, squatting and kneeling positions (see photos 2,3 and
p.57).
They believe these are natural positions to help the baby come
downwards.
A ring of cloth underneath the woman contains the faeces
and the baby is born on to the bare earth or a cloth.
Several
older women or traditional midwives may be involved in supporting the
woman in labour; one to support her from behind, either by holding her
or by holding a cloth round her back (photo 2 p.57).
Two others may
support her knees and another woman usually covers her face to
prevent her seeing blood.
It is believed that the sight of blood
may cause her death if she or her husband have been unfaithful.
Labour is not necessarily private.
In additional to the traditional
midwife's assistants, others may come to observe.
Some of these come
to give support, but others may be looking for signs of fear or lack
of control so as to make gossip.
Labour is said by 18 traditional midwives to be more painful when the
membranes rupture early producing a "dry labour".
Women in labour are careful to suppress cries of pain and may be taken
away from the house into the bush if they are not controlled so that
the noise cannot be heard by men.
As the baby comes the traditional
midwife talks to the child to encourage it out, saying "Come out,
come out, come and see your mother".
Delivery of the placenta
The placenta is usually delivered with woman in a kneeling or squatting
position (see photo 3,4).
The whole process is physiological, The cord
is not cut until the placenta is delivered.
No traction is applied
to the cord although herbal infusions may be given if the process is slow.
60
Photo
5
The traditional midwife is assisting a slow placenta
out by applying abdominal pressure
The baby doll is wrapped up but the cord is still attached
to the placenta.
61
Cutting the cord
The cord is not usually cut until after the delivery of the placenta.
Traditionally the cord was tied with a piece of cloth torn from the
woman’s skirt-like wrapper of chitenge) and cut with a piece of sugar
cane, sharp grass or metal blade.
Now razors are often used, usually
bought by the women in pregnancy.
Post partum
The traditional midwife will draw and heat water to wash the woman and
cook munhoyo (a sweet root beer) or porridge to increase her milk. The
baby is also given a ritual bath containing herbs and eg baobab bark
to make the baby fat like the tree.
This care may continue until the
cord falls off when it is considered safe to allow the baby outside.
The Placenta
Correct care and burial of the placenta is so important in preventing
infertility and misuse in "witchcraft" that the matter was debated
nationally in the 60s and midwives in hospitals are supposed to give
women the option to take the placenta home with them.
At home the
placenta and cloths are buried in the floor of the house and smeared
over so no-one can tell where they are.
The placenta and cord are
specially positioned to indicate a symbolic unity with the mother and
ensure her continued fertility.
The newborn child
Certain herbal baths, rituals and charms are used to protect the child
against disease and disease induced by the immoral behaviour of other
people.
Traditional midwives also treat diseases of young children
with herbs.
Bracelets are also put on the child's wrists so increase
in size can be easily seen (photo 6).
A special charm cord is sometimes
put round a girl-child's hips to ensure that her hips are big enough
for her future childbearing.
62
Photo
6
This child is well protected.
She was delivered by
Aida (above), a very experienced trained traditional
midwife.
The tightening bracelet on her left hand
indicates that she is putting on weight and the amulet
around her neck will help protect her from diarrhoea.
But Aida also knows to give her more to drink when she
has diarrhoea.
63
The responsibility of the traditional midwife
Traditional midwives said that helping a woman in labour was a moral
duty and they would not refuse.
They emphasised the need for moral
purity of traditional midwives to protect the health of the mother
and child.
In some places this extended to traditional midwives'
abstension from sleeping with her husband until the parents of the
new baby came with a gift of thanks to announce that the child was
healthy and strong, and was no longer at risk if the traditional midwife
had sex with her husband.
The rewards of being a traditional midwife
Once the mother and child are strong, about 2 weeks to 3 months after
delivery, the mother will bring a gift for the traditional midwife.
In some areas this gift was quite valuable, including the mother's
pregnancy clothes, the cloths used at the delivery, the bowl the
baby was washed in, full with pounded maize meal etc, and the husband
may contribute some money, usually about IK (5Cp), and some vaseline.
In other areas the gifts were more modest, but maintain a very strong
symbolic importance.
A successful traditional midwife gains respect and has high status, but
does not make a living through this.
Variations in the care given
The traditional midwives varied considerably in the amount of care
they gave.
Some only attended for the delivery, while others
considered their responsibility continued from a girl child's birth
to her initiation and beyond.
Traditional midwives who delivered
non-family members appeared to provide less care pre and post natal.
64
3.1.3.
Concepts of Health and Disease in pregnancy and Childbirth
Initially in trying to understand women's concepts of health and
disease in relation to pregnancy and childbirth I had no framework
within which to work.
It was only after I had completed my interviews
with traditional midwives that I met Mrs. Jane Mutambirwa, a lecturer
in health education at the University of Zimbabwe, who is carrying
out similar studies among the Shona peoples.
I will thus present my findings and then show how these relate to
those of Mrs. Mutambirwa.
Keeping Healthy
In answering the question "how should women keep healthy in pregnancy?"
the women gave 6 distinct types of answer.
A. "She must keep herself clean"
The first answer usually given was that a woman must keep herself
clean to remain healthy in pregnancy.
The word clean and the concept
of cleanliness have many meanings, those identified include;
i)
physical cleanliness of the whole body by washing
ii)
Cleanliness of the pubic area both through washing and keeping
the pubic hair cut, plucked or shaved
iii)
Moral cleanliness in terms of only sleeping with the spouse.
This applies to both the husband and wife.
One story given was of a woman, daughter in law to one
of the traditional midwives, who had an APH and
continued bleeding.
Traditional medicine was given
(to purify the woman from misdemenours) but it did
not work.
Eventually she gave birth to a stillborn baby "with skin
that came off stinking".
The traditional midwives
listening shook their heads
saymg "she must have been
very, very unfaithful".
65
Most other stories however described the unfaithfulness of
the man.
iv)
Cleanliness in terms of social relations.
Ihis was a difficult subject to talk about.
However the women
in the mothers shelter were the most open.
Some found it easier to speak in the mothers shelter as there
were no neighbours nearby.
10 of the 16 pregnant women had
come to the mothers shelter to deliver in hospital specifically
because they believed that they were likely to have problems
in labour due to other people's "interference".
Cleanliness in terms of social relations was described as
"not making anyone wish anything bad onto you", and "not
making them feel "bitter" or "jealous"'.
Thus pregnant women feel obliged to maintain harmonious social
relations in order to protect themselves from other peoples
conscious or unconscious ill wishes (called "ufwiti" in the
Nsenga language).
v)
"Cleanliness" was also used by 2 traditional midwives to imply
a clean relationship with ones ancestors, but unfortunately I
did not discuss this in depth.
Thus the idea of cleanliness expressed here is much wider than that
used in medical practice and involves elements of physical, moral,
social and spiritual cleanliness.
Other ways to keep healthy in pregnancy and prevent childbirth problems
In addition to keeping "clean", pregnant women tried to prevent
problems or harm occurring to themselves or the baby through certain
other actions:
3.
Avoiding certain actions
Certain activities and actions are curtailed in pregnancy to prevent
difficulties in labour.
Thus pregnant women should not:
66
: sit or stand in doorways
: start a journey and turn back part way
: stand at cross roads
: sit on a chair
: step over somebody's legs
These things are thought to be associated with prolonged labour,
transverse lie or breech.
Obviously some are simple idea
associations e.g. turning back before completing a journey has
a simpler parallel in prolonged labour.
However others have
deeper meanings e.g. It is believed that certain witchcraft is
carried out at crossroads.
As pregnant women are more
"vulnerable" they are told not to stand at crossroads.
C.
Avoiding certain foods
Certain foods are avoided as they are thought either to affect the
progress of labour or the development of the child e.g.
Two types of rats are avoided.
One is very fat and "may
make the baby big so it can't come out".
The other is
avoided as it is known for its habit of just peeping out
of tunnels and then disappearing.
Mothers fear that this
may happen also to the baby in second stage.
Similarly eggs are said to be avoided as "eggs have no
doors, so how could the baby come out?"
Some also
believe that it can cause the baby to be bald.
In each area other quite different food taboos were mentioned,
the above were the most common.
D.
participating in certain activities
Pregnant women are advised to keep working and not become lazy to
prevent the baby becoming lazy during labour.
E.
Eating more
Pregnant women are advised to eat more to avoid becoming weak herself
and the baby being born with arms "as thin as my fingers".
67
F•
Avoiding "things which will disturb her"
Pregnant women were described as "ill" and "weak" and as such were
described as "able to catch things easily" or "she can easily get
disturbance".
This "disturbance" could affect the pregnant woman herself or be
passed on to the baby.
The "disturbances" described included anger, unhappiness, seeing a
deformed or ugly person or a bad accident or other unpleasant incident.
Where possible precautions are taken.
Disturbance is avoided by e.g.:
instructing husbands to be "more gentle” with the wife so
as not to make her angry, etc.
perhaps the special white cloth and beads worn by women with
a first pregnancy serve the same purpose, that of avoiding
frightening the girl with stories of other peoples bad
labours.
Other precautions against "disturbances" were described e.g.:
on passing an ugly or deformed person the pregnant woman
should hold her breath, look away and empty her mouth of
saliva by spitting to prevent the baby being affected by
a similar deformity.
This action was observed on visiting a couple who had recently given
birth to a child with a hare lip and cleft palate.
On being asked
why the visitor who accompanied me spat she said she "did not want
to catch that" and not once looked directly at the child.
(This
visitor had had primary and secondary school education).
Traditional midwives recognition of normal pregnancy
Traditional midwives seem to recognise a new pregnancy early, but do
not discuss it publicly, especially if they are not a member of the
family.
68
Ulis lack of discussion can be interpreted as a form of protection.
The pregnancy is "hidden" until it is quite obvious when
susceptible to outside influences.
Outsiders do not discuss a
pregnancy for fear of being accused of harming a pregnancy.
Older women recognise pregnancy in several ways:
"We notice the texture of the hair changes months before
the swelling.
Her ears become pale and translucent, her face becomes
pale, she gets lazy
"
"Her breasts change"
"Her belly grows larger”
Other signs of normal pregnancy described were early nausea and
vomiting, swelling of the legs, backache, fatigue, palpitations,
mild headache, dizziness, craving for certain things to eat and
kicking of the baby.
Excessive swelling of the legs was associated with twins and
occasionally severe paleness.
Excessive backache was associated with possible abortion or miscarriage
Thus there are also certain changes in pregnancy which the traditional
midwives consider normal, but in Western obstetric practice are
considered pathological e.g. paleness and swelling of the legs.
Unfortunately due to lack of time I was unable to explore these
concepts of health and disease further, in particular in relation to
non-pregnancy states, in order to develop a clear framework of the
main concepts.
Ulis requires much further study
69
I was thus most excited to meet Mrs. Jane Mutambirwa who has done
similar work among the Shona in Zimbabwe and who describes very
similar beliefs, values and concepts of health, but sets it in a
much broader conceptual framework (51) (7).
She starts from the way in which health is defined differently in
Western and Traditional Shona society and then relates this to the
different means used to treat disease and problems in childbirth.
"in Western psychology it is believed that a person's growth
and development is influenced by interaction with his or
her physical and social environments.
Thus scientific
medicine which is built on western psychology emphasises
the promotion of bodily or physical health".
"By comparison in traditional psychology it is believed
that a person's growth and development is influenced by his
or her interaction with the physical, the social and
spiritual environments.
Thus traditional psychology
investigates the spiritual, social and physical
environments for the causes of a disease", (p.2)
"Thus health problems associated with pregnancy are
diagnosed and treated according to their source of origin.
However, because it is essential for a person to be moral
before they can have eternal spiritual life, moral
behaviour is considered to be of paramount importance".
Jane Mutambirwa describes four main causes of pathology in pregnancy
and childbirth.
70
"Momhepo" or bad environmental air
It is believed that environmental air contains good and bad elements
and that if these are in balance good health and prosperity will
result.
However, if "bad air" dominates, susceptibility to illness is increased.
This "bad air" can originate from two sources:
i)
Physical bad air.
This originates from the physical environment,
e.g. decaying matter or seasonal change.
Ttiese sources are
considered natural, causing coughs, colds and fevers.
They have
no spiritual significance.
ii)
"Bad air" originating from an immoral or unhygienic social
environment or spiritual environment.
This results in a lowered
immunity or resistance to health problems.
According to Shona beliefs deficiencies in the social environment
or maternal ancestor protection increases susceptibility to such
health problems as jinxing, sour relationships, accidents,
problems of fertility, epilepsy, etc.
In contrast, deficiencies in the spiritual environment or paternal
ancestors protection are associated with life threatening health
problems e.g. Tb, cancer, all health problems to do with bleeding.
In addition in pregnancy two further causes of pathology are described
iii)
"Unhealthy" body vapours or odours "mulcumbari". e.g. A deformed
person's "mulcumbari" can be picked up by a passing pregnant
woman causing distortion or deformity of the unborn baby.
This is countered by the pregnant woman spitting out the
"mulcumbari" (as I found one of my interpreters doing in Zambia).
iv)
Unhealthy or unhygienic emotional or moral situations.
It is
considered that a woman who is angry or in any moral conflict
including unfaithfulness will not deliver normally until her
mind is free of unclean or immoral thoughts.
71
Comparison of the findings
In comparing the findings of Mrs. Mutambirwa and myself, several
parallels become very clear.
The most important of these is the
emphasis on social and moral causes of pathology.
My interpreters
used the word cleanliness, while Mrs. Mutambirwa uses hygiene to
describe social and moral environments conducive to good health
and prosperity.
Another parallel is between Mrs. Mutambirwa's terms "unhygienic
emotional or moral situations" and "mulcumbari" and my interpreter's
phrase "things which will disturb her".
Both studies emphasise the importance of moral and social health
and hygiene not only for the present mortal body, but also the
future life.
This has major implications for the treatments given for problems
in pregnancy and child birth.
Moral solutions e.g. confession to
infidelity or holding a grudge may be sought before recourse to the
official health services.
Ihese implications are expanded in sections 4 and 5 of the study.
72
Discussion
Thus relationships described between the traditional midwife and her
client are usually personal, informal, supportive and holistic.
The
care provided centres not just on the physical birth process, but
social, spiritual and
also on the woman's emotions, family,/and sexual relationships.
It may
extend to helping with such household chores as cooking and drawing
water and also ritually protective actions such as bathing the baby
in herbal preparations.
Within the care given are many very positive and beneficial elements,
some of which are physical, others are social or psychological.
If traditional midwives are to be trained these positive elements must
be acknowledged and built upon in the training programme.
Previous
investigations have suggested classifying birth practices into
beneficial, neutral, uncertain and harmful (49) in order to define
what should be built on and what should be modified.
Such a
classification poses certain problems as practices may be denounced
by the medical establishment without an evaluation of their actual
effects.
Such judgements are made despite the fact that many western
obstetrical practices are not supported by conclusive evidence of
their positive effects (82,63).
There is a need to develop a wider set of evaluation criteria which
include scientific as well as traditional criteria.
73
3.2.1.
o. .The..teaching ana practice of care of the high risk mother by
the traditional midwife.
3.2.1.1.
The_ ^teaching on high risk care as part of the training of traditional
midwives.
The metnods of training vary considerably between those traditional
midwives trained in a hospital and those trained in a village.
On
both types of course three to four days out of the six weeks is spent
on antenatal care.
In the hospital based training there was one days
theory and two days practice in the antenatal clinic.
In the village
based training, three days were spent in discu.ssion, role play and
practice on local women and only one day was spent at the RHC.
Teachin,- methods in the hospital were fairly formal using posters,
blackboard, doll and pelvis, while methods used in the village were
much more informal and practical using demonstration, role play and
participation by local pregnant women.
3.2.1.2. What risk factors hove traditional mi dwiye s _ been _t aught ?
There is no set national curriculum or detailed guidelines for
traditional midwife teaching.
Thus risk factors taught to the
traditional midwives were identified from several points of view:
by interviewing the trainers using a structured, questionnaire; by
discussion with the traditional midwives and by examination of two
training curricula.
One of these was from a hospital programme and
the other from village based programme.
The criteria used varied according not only to the individual teaching,
but also according to the place of teaching.
Thus two groups of
hospital and village trained traditional midwives taught by the same
verson learnt slightly different criteria for high risk..
the village were taught fewer criteria as shown in Fig. 4.
Those in
--- 0 —14
Village training
petauke District
Hospital
Training
Only encourage
o
+
+
+
+
+
+
+
+
+
+
+
+
»
Village training
by Mrs Zulu
-'F •**
r i vj . v
TO SHOW THE CRITERIA TAUGHT TO TRADITIONAL MIDWIVES FOR
HIGH RISK AND REFERRAL
First baby (i.e. primip)
High parity (5th or 6th
*)
previous abdominal operation
*
Previous difficult labour
Previous PPH
Previous retained placenta
Deformity
Short stature
**
°
+
+
°
+
+
+(only severe)
+
+
+
+
+(only severe)
+
+
+
0
+
+
+
+
+
0
0
+
+
+
+
+
+
0
0
0
+
+
+
+
+
+
+
0
+
•
-
NOTES
* Any previous abdominal operation is used as a criterion.
♦ ♦ Shortness of stature is measured by observation only, not by reference to a standard
mark. In village based training shortness is usually taught by reference to a
specific part on the traditional midwife's own body at 145 cms. However hospital
trained traditional midwives used a point between 150 and 155 cms.
li__
pale conjunctiva
pale tongue and hands
Swelling of legs
Illness or weakness or vomiting
(as defined by client)
Abnormal lie
Multiple pregnancy
Headaches
Abdominal pain
Vaginal bleeding
"Sugar disease"
Fits
Sexually transmitted diseases
O
Examination
From this is is clear that traditional midwives taught in hospital learn the same as
student midwives.
Only in the village based training is a compromise reached and a more realistic set of high
risk criteria given i.e. not including all primips and para 5 or 6 as high risk.
75
In addition, the traditional midwives were taught to do:~
a simple obstetric history;
a simple history of past and present illness;
examination for anaemia and oedema;
abdominal palpation for number, lie and presentation of the
babies but not an accurate gestation.
Illis was either taught in the antenatal clinic or in the village.
Clearly both programmes were teaching recognition of certain risk
factors.
Were they the right ones?
3.2.1.3.
Are the risk factors traditional midwives learn relevant to
the local causes of maternal and perinatal mortality?
The relevance of the risk factors taught to traditional midwives were
assessed by comparing them with the major local causes of maternal
and perinatal mortality reported by trained and untrained traditional
midwives, and their trainers, medical assistants, midwives and the
provincial and national data described in section 2.7.3.1.
Unfortunately this district's data could not be used due to the lack
of data in the antenatal and delivery records.
The major causes of maternal and perinatal mortality found are
presented overleaf in Figs. 6a and 6b.
From these major causes using
the procedure developed in Ghana (1978) (67) (83) the priority tasks
and learning objectives which would be required to decrease the
maternal and perinatal mortality have been developed.
These are
presented in Fig.7.
Are the criteria the traditional midwife learns relevant?
By comparing Figs. 6a and 6b (Priority maternal and perinatal health
problems in Eastern Province) with Fig.5 (High risk criteria taught
to traditional midwives) it can be seen that the antenatal high risk
factors that traditional midwives learn are relevant for petauke
District.
There is a close correlation between the learning objectives required
and what is taught.
The main discrepancies are:-
1)
Young girls (under 16) having their first pregnancy are not
identified as a high risk group for traditional midwives.
76
FIG. 6
PRIORITY HEALTH PROBLEMS IN MATERNAL AND PERINATAL HEALTH IN EASTERN PROVINCE (10)
CAUSES OF MATERNAL MORTALITY
Contributing Conditions or
Risk Factors internationally
Contributing Conditions
locally in petauke
Ruptured Uterus (1)
Disporoportion
Malpresentation
Malposition
Previous Caesarian section
pushing on the uterus in
slow labour (3)
Transport difficulties due
to distance, fuel and
vehicles (4)
?possibly traditional
medicine (5)
Haemorrhage (1)
APH
PPH
Abortions
Placenta praevia
?Pushing from early 1st
stage (6)
Some women consider small
APH is normal (7)
Heavy bleeding after
delivery is sometimes
thought to be ’cleansing’(8)
Anaemia (white eye/paleness)
in pregnancy is thought to
be normal (7)
Multiparity
Anaemia
Complicated delivery
History of previous PPH
Previous APH
Puerperal Sepsis (1)
Unhygienic procedures
during delivery
Prolonged and obstructed
labour
Retained placenta
Complications of VVF RVF(l)
Pre-eclampsia and
Eclampsia (1) (2)
Aetiology unknown
Indications: oedema, weight
gain, increased Bp,
proteinuria
Traditional midwives using
the foot to support the
perineum as the mother
delivers (9)
Malaria (1)
CAUSES OF PERINATAL MORTALITY
Intra partum asphyxia
Low birth weight (1)
Sepsis
Tetanus (7)
?cold injury (hypothermia)
Antepartum causes
+VDRL positive
*
+Maternal illness and fever
esp. malaria
♦Abruptic placentae
♦Hypertension
*
Pre-eclampsia
+Premature rupture of
the membranes
+Placenta praevia
Twins
Primigravidae under 16
Grande multip
Previous SB or NND
Malnutrition in the past
and present
Intrapartum Causes
+Prolonged labour
♦Prolapsed cord
♦Malpresentation
♦Disproportion
♦Ruptured Uterus
postnatal Causes
Lack of asepsis in tying
and cutting the cord
Those marked ♦ are probably
not very relevant to
Petauke, especially in the
rural areas
Cord around the neck (2)
?Tonic contractions possibly
due to traditional
medicine (3)
Pushing from early first
stage (4)
Local applications to the
cord may include ash, maize
meal, rat faeces and sooty
cobwebs (5)
Babies are washed soon after
birth and then wrapped
without drying (5)
77
NOTES ON FIG.6
PRIORITY HEALTH PROBLEMS IN MATERNAL AND PERINATAL HEALTH IN
EASTERN PROVINCE (10)
CAUSES OF MATERNAL MORTALITY
1 Causes ol death at Chipata General Hospital 1979-1983 (Appendix 3)
Ruptured Uterus
Complications of VVF + RVF
Anaemia
Puerperal Sepsis
Haemorrhage (APH, PPH)
Eclampsia + Pre-Eclampsia
Malaria
Others
2
3
4
5
6
7
8
9
10
19%
17%
15%
15%
13%
8%
7%
6%
Pre-eclampsia and eclampsia are relatively uncommon in these rural
areas but are the most common cause of death in urban hospitals in
Zambia (Hickey and Kasonde 1977, Davis 1976) (133)
Information obtained from traditional midwives in Luwembe.
”If there are problems
how can we move
we can only look
for death". One traditional midwife.
Stated to be a contributory factor by five midwives.
Encouraged by one traditional midwife.
Obtained from all untrained traditional birth attendants.
Obtained from some untrained traditional birth attendants.
Observed in role play at Luwembe and Chikowa.
Adapted from IDS Research Reports 1978 p.19. (83)
CAUSES OF PERINATAL MORTALITY
+ Presented in order of frequency found at University Teaching Hospital
Lusaka (Watts and Harris 1982) (40)
1 In 1982 20% of the babies born at the District Hospital were less
than 2.5 kgs in weight. 20% of these were twins.
2 Reported as major cause of death by traditional birth attendants
and 'cleaners' and medical assistants.
3 lYie week of the study the MOH's servant had had a stillbirth after
4 hours of tonic contractions possibly precipitated by her taking
traditional medicine.
4 Reported by one traditional midwife.
5 Reported by untrained traditional midwives.
7 Only 10 cases of tetanus were reported in the province in 1982.
78
FIG.7
TRADITIONAL MIDWIVES PRIORITY TASKS AND LEARNING OBJECTIVES REQUIRED TO
DECREASE MATERNAL AND PERINATAL MORTALITY DEVELOPED FROM FIGS. 6A and 6B
Priority
Level
Top
Secondary
Priority
Antenatal Care
Delivery Care
Post-Natal Care
Recognise at risk and refer
for assessment
Clean delivery
technique
Cleanliness in
care of the
cord
Young primips (under 16)
Height under 145
Limp
Anaemia/pale mother
Previous abdominal operation
Previous stillbirth or
neo-natal death
Previous PPH
Grande multip (? 10+)
"Weak" mother
Abnormal lie
Hand and nail
washing
Sterilisation
of blade and
cord ties
Encourage
traditional
methods of
birth spacing
for healthy
children
Non interference Care of small
for dates or
in labour and
premature babies
delivery
Release or
cutting of the
cord if it is
round the baby’s
neck
Refer immediately
Bleeding during pregnancy
Severe headaches, fits,
giddiness
Swelling of feet
Abnormal severe vomiting
Malaria
Control of PPH
Immunisation needs
Resuscitation
Encourage
traditional
post-natal care
and fluids and
encourage
lactation
Referral of
bleeding
postnatally
Fever
Abdominal
tenderness
Offensive lochia
Breast and
nipple problems
Records
Pregnancies
Births
Stillbirths
79
2)
The cuu off point for shortness of stature varied from
3)
The village based training organised by Mrs. Zulu does not
145 - 155 cms.
This requires clearer guidelines.
classify every first pregnancy or woman of high priority as
high risk.
This difference arises from community opposition
to the use of these criteria and is discussed later.
(Section 4.1.2.1.
)
4.1.2.4.
In conclusion, the teaching provides almost all the relevant criteria
for antenatal at risk selection.
The effectiveness of traditional
midwives in using these criteria is now analysed, first by asking
what factors do traditional midwives know?
3.2.1.4.
What risk factors do traditional midwives know and use?
Traditional midwives were asked which women should be referred to or
delivered in hosnital.
All trained traditional midwives said they
would refer previous abdominal operations, multiple pregnancies,
abnormal lie, anaemia and swelling of the legs.
In addition those trained in the village emphasised that they would
refer those who had "general body weakness" or illness.
Those
trained in hospital said they would refer women with their first
or sixth plus pregnancies.
However neither traditional midwives trained
in the villages nor local women think first or sixth plus pregnancies
needed to be referred to hospital unless there are specific problems.
In contrast, untrained traditional midwives said they would only refer
those who were "ill" or for whom referral was an emergency, i.e.
hand and cord prolapse, prolonged labour and retained placenta.
3.2.1.5.
-Jhat change in care of the high risk mother has taken place after the
training of traditional midwives?
Desoite the trained traditional midwife’s knowledge of the risk factors,
their individual impact on the community was generally small as they
usually provide antenatal advice for their own families only.
80
Prior to training, their responsibility had been mainly to provide
antenatal and delivery care and advice to members of their own
families.
As shown in section 3.1 only 1% of women delivered at
home were delivered by a non relative.
After training, about 50%
of the midwives said they had assisted at the delivery of a non-
relative, but only eleven said that they had provided any antenatal
care or screening for high risk outside their own fa,milies.
These
eleven traditional midwives comprised of ten who were trained
together in Chikowa village.
One further traditional midwife who
had a hospital training said that she did not provide any specific
antenatal care.
However, when she knew of a woman who was high risk
she tried to get her to deliver in hospital, usually unsuccessfully.
Thus the majority of traditional midwives in antenatal care only had.
an impact on their own families, e.g.
"I refused to help deliver my daughter she was too pale"
"I took my daughter to hospital with a fit"
Traditional midwives' referral of non family members to hospital for
delivery seemed to have very little effect, e.g.
"In a survey of all 28 recently delivered women
from one village more than half of the women
would hove been classified as high risk: There were:
6
first pregnancies, 6 women with 6+ pregnancies,
1 twins, 1 breech and one woman with two previous
caesarian sections.
Yet all delivered at home,
despite all having attended antenatal care and
at least eight having been warned they should
deliver in hospital by the hospital trained
traditional midwife."
Traditional midwives greatest recorded impact on antenatal care was at
Chikowa, where since the training in 1979 a minimum estimate of 657.
of pregnant women have attended for antenatal care.
This antenatal
care has either been provided by a traditional midwife or by the
"Female Indoor Servant" of the RHC who joined the traditional midwife
81
training programme.
This vias the only RHC where a team spirit had been built up between
the traditional midwives and health staff.
It was also the only
one in Petauke District to keep records of deliveries done by
traditional midwives at home and have a friendly referral system
if problems should develop.
However, referral to the hospital
would have been difficult : - A 90 km journey along a very rocky road
requiring four wheel drive.
3.2.1.6.
Conclusion on the teaching and practice of care of the high risk
mother by the traditional midwife.
Prom this study of the teaching and the practice of the care of the
high risk mother by the traditional midwives, it is apparent that
there are barriers to their effectiveness.
explored
in the following section.
These barriers are
82
3.2.2.0. Barriers to the effectiveness of the traditional midwives in
screening for high risk mothers.
A Model System.
For traditional midwives to provide effective advice and care to
high risk mothers it is necessary for the tra.ditional midwife to
hold a consultation with the mother; to examine her, to advise her
correctly on where she should go for further advice or delivery.
Further, the place of referral should provide a parallel screening
procedure and adequate facilities for care of high risk women.
The women defined as high risk should understand and he ahle to
comply with advice given.
Finally, the traditional midwife should
be encouraged in her work by continuous support and further training
by the health staff.
This study identified barriers to the effectiveness of traditional
midwives at each of the eight points noted above.
Some of these
barriers arose from the traditional customs, beliefs and practices
and a failure to accept the new role of the traditional midwife by
both the traditional midwife and the community.
Other barriers arose
through a lack of support through the health services.
These
barriers to the effectiveness of the traditional midwife in care of
the high risk woman are described below.
3.2.2.1.
Barriers to traditional midwives' effectiveness arising from the
community.
The major barriers to the traditional midwives' effectiveness in
providing antenatal care arise from two sources
a)
or delivering
the unacceptability of advising/a non relative, and
b)
the unacceptability of many of the high risk criteria to women
in the community.
83
Why are there Carriers in the community?
A’
beliefs concerning the causation of disease and obstetric
complications.
As described in section 3.1.
The majority of traditional midwives and women interviewed have totally
different concepts of the causation of disease and problems in
pregnancy compared with health personnel trained in western medicine.
Through group discussions with trained and untrained traditional
midwives a picture was slowly built up of the conceptual framework of
these beliefs.
This was then correlated with the beliefs of some of
the local women in the village who were willing to talk about such
sensitive issues.
The conceptual framework developed is not rigid.
A continuum of
different beliefs was found, ranging from the very traditional to a
moderately "western" understanding.
Thus women living in remote,
rural areas who had little or no formal education held strongly to
traditional beliefs.
The few who were literate tended to have a more
"western understanding."
No attempt was made to quantify how many of
the traditional midwives held more strongly to traditional beliefs.
This would have been counter productive.
If the traditional midwives felt they were being tested they would
have given the answers they thought I wanted to hear.
B.
Concepts of health and disease.
In western psychology a person's health is dependent upon having a
healthy physical and social environment.
Scientific medicine, which
is built on western psychology, thus emphasises the promotion of
physical health.
In the traditional societies I visited health was a much broader concept
than this.
It involved not just physical health, but also social and
spiritual health.
These social and spiritual aspects of health involve
social relationships with the community and spiritual relationships
with ancestors and one's future children.
There is a belief that the
individuals' life goes beyond the physical death.
is invested in the children.
This continued life
However, health of the spirit, and ones
continued life after death, can only be maintained by conforming to
84
the norms of moral behaviour.
Thus "moral behaviour" or "social hygiene"
are considered of prime importance in maintaining hea,lth.
This is
especially so in relation to pregnancy and childbirth.
In order to gain an understanding of peoples behaviour and womens
choices in antenatal care and delivery an attempt was made to classify
the causes of disease.
However, in doing this I had no previous
framework to build on due to a dearth of literature on the subject.
Mothers and traditional midwives stated reasons for the causes of
disease or problems in pregnancy could be classified into five groups
i
"A natural disease or phenomen" i.e. something which is normal
and expected.
This includes paleness in pregnancy, swelling of
legs, early nausea and vomiting, backache, fatigue, palpitations,
mild headache, cravings and "Braxton Hicks" contractions.
ii
" Disturbance of Equilibrium"
Pregnant women are described as being "weak" or "ill" and in a
vulnerable state where they and the baby can be easily disturbed.
Such disturbance e.g. anger, unhappiness, seeing an ugly or
deformed person, are thought to affect the child.
Precautions
must be taken, e.g. on passing a deformed person the woman should
hold her breath, avert her eyes and empty the mouth of saliva
afterwards to prevent the foetus being "infected."
iii
Lack of "Social or Moral Hygiene''
Many of the problems in pregnancy and labour e.g. APH, prolonged
labour, PPH, stillbirth, are attributed to the unfaithfulness of
the couple - but most usually to the husband.
Transverse lie is
usually attributed to the wife misbehaving.
Rituals of protection and purification by confession can be
carried on only by trusted traditiona.1 midwives.
Hence the need
to be delivered at home by the grandmother or other close and
trusted relative.
iv
Ufwiti.
"Ufwiti is implicated in such serious problems as transverse lie,
breech, hand and cord prolapse and particularly obstructed labour.
It is sometimes also implicated in epilepsy and congenital
abnormalities.
The term 'ufwiti' comes from the nsenga language.
It is used to
describe a range of causes for which there is no adequate english
85
terminology.
Two types of ufwiti' are described.
The more
common and minor type of ufwiti' can be defined as an
unconscious, unintentional, malicious wish.
For example, a
woman who herself wishes to become pregnant may see a
pregnant neighbour.
Her feelings of jealousy in being trans
mitted can affect the health of her neighbour or the outcome
of the pregnancy.
The second type of ufwiti is less common but more serious.
It can be defined as a conscious effort to cause harm.
described two ways in which this may be done.
Women
Four women
said that "something" may be sent to block the vagina in labour,
thus preventing delivery.
None of them had witnessed this.
However, ten of the sixteen women in the mothers’ shelter said
they had come to hospital because they knew that someone had
tied a knot in a chitenge (a cloth wrapper) while at the same
time wishing they themselves would not deliver.
These ten women had spent as much as K5 (£2.50) on bus fares or
walked as much as four days so that if the ’jinx’ did cause
obstruction they could have a caesarian section.
However, the traditional midwives and women said that a hospital
c
i
delivery was not necessary for the minor ufwiti, as confession
by the person having the ’bad wish’ would overcome the problem.
In addition a woman could be protected from these ’jinxes’ or
• pollution’ by talcing the preventitive measures prescribed
usually by a close relative.
v
Breaking of Taboos.
A number of taboos were described, most of which have some
inherent logic, e.g. don’t eat eggs as eggs have no doors and
the baby won’t come out.
Don’t eat the species of rat which is known for peening out and
retreating, or else the same will happen when the woman is in
labour, etc.
Taboos also exist in relation to certain physical activities which
will also obstruct labour, e.g. standing in a doorway, sitting on
a chair, etc.
Many food taboos exist but vary from area to area.
86
C.
Conclusion.
Obviously the concepts of health and disease presented here are
superficial.
An outsider such as myself is unlikely to gain a deep
understanding in so short a time.
It requires much deeper study.
However, from this summary it can be seen that many village women
and traditional midwives regard problems in pregnancy as being due
to failure to comply with certain concepts of moral health and
hygiene.
Thus they may seek moral solutions such as confession
of the husband or wife to infidelity.
These solutions to problems
may be in direct opposition to solutions proposed through an
'at risk' screening procedure which emphasises physical health and
hygiene and professional care during labour.
Further, outsiders, even traditional midwives, are at risk in
enquiring about a, woman's pregnancy.
They may be accused of putting
'ufwiti' on the pregnancy and will be blamed if anything goes wrong.
However this blame does not seem to extend to antenatal clinics.
This last point has very important implications for the working
of traditional midwives in antenatal care.
A knowledge of these beliefs is fundamental to understanding womens
choices in relation to participation in antenatal care by traditional
midwives and official health services, and their choice of place of
birth and choice of assistant.
Further barriers to traditions. 1 midwives ' effectiveness in antenatal
screening for high risk - arising from the community.
D.
Traditions relating to the place of birth:
First pregnancies should be delivered at home.
There are strong beliefs that all children, but especially a woman's
first child, should be born at the woman's parents' home.
*
an<
Mothers
uraciuional midwives explained that this was necessary for many
reasons
a)
the pregnant woman may need certain traditional medicines during
her pregnancy to safeguard herself and the child.
These should
only be given by well trusted people such as close relatives.
87
) During labour itself the woman’s mother or grandmother must be
there to instruct her:in the traditional ways of behaving if it is her first
i.
pregnancy,
to
ii.
perform the usual rituals to ensure a safe delivery,
iii.
to
witness that the person who actually delivers the baby
does no harm,
to
iv.
give medicine to hasten deliver, and
if
v.
problems arise (e.g. prolonged labour which is thought
to be due to infidelity) the traditional midwife can serve
as a trusted confessor who knows the rituals to relieve
obstruction arising from this cause.
Outsiders are not trusted to do this.
E•
The Perceived benefits of staying at home.
Reasons given for delivering at home despite advice to the contrary
i
its cheaper,
ii
the children need someone to look after them,
iii
its too far to the hospital,
iv
its too expensive to stay near the hospital until you go
into labour,
v
there are friends and relatives at home to support you,
vi
also, women who h've had six or more successful deliveries
at home see no need to go to hospital.
3.2.2.2.
Barriers to traditional midwives' effectiveness in antenatal care
arising from the traditional midwives themselves.
Traditional midwives reasons for not carrying out antenatal screening
for high risk as they were taught stemmed from four different factors.
a)
Traditional midwives' concept of their role in antenatal care.
i)
Traditional midwives antenatal care limited to close family.
Traditionally traditional midwives provide antenatal care and
advice to their family members.
Since their training this has
changed little although many of them say they now deliver
women who are not related to them.
The three traditional
88
midwives who said they had advised non-relatives to go »o . os.itc.l
for delivery found the women did not comply"
ii)
One of
women had two previous caesarian sections.
Antenatal screening should be done by the antenatal clinic
Traditional midwives who lived near (up to five hoUx s wal.v) from
a hospital or RHC said that antenatal care and screening should
be done by the clinic.
b)
They saw no need for them to do it
themselves.
Traditional midwives' and communities' concept of disease or
'problem' causation.
i)
Womens fear of examination.
17 traditional midwives said that they could not do antenatal
care at present, even though they would like to, because the
older women in the community did not understand what they
were doing.
They thought that e.g. examination of the
abdomen for palpation or the eyes for anaemia could cause harm
to the mother or baby.
Thus pregnant women would refuse
examination by the traditional midwife.
ii)
Traditional midwives' fear of blame.
These 17 traditional midwives said they were afraid they would
be accused of causing harm to the pregnancy
"How can we tell her about the foods
you tell us? The girl's mother would
come and say,
What magic are you
putting on my child ?"
c)
Inapnrooriateness of the antenatal teaching of traditional midwives.
Hospital trained traditional midwives said they were unable to provide
the type of antenatal care they were taught to do as they did
not have tne facilities required,
hor examples— a separate hut5 a
bed; a stethoscope, etc.
Village trained traditional midwives did not see the need to have
these things.
This difference in perceived recuirements is
probably due to the fact that hospital trained traditional midwives
only scent 4‘a of the 6 week course doing home visits, so it is
difficult for them to adapt, while those trained in villages are
already experienced in working at home.
89
IHa?prooriateness of the criteria for high risk.
anj traditional midwives implied that the criteria for high risk
were inappropriate:"Je would have nothing left to do if we
followed instructions" but "we do not
want women to die here."
Traditional midwives varied in what they felt was a criterium for
high risk:
Primigravidae
Only three traditional midwives said they would prefer to refer
primigravidae as:"they are very different, they have
do not know when to push.
makes them difficult.
problems, they
They are scared and that
Even we traditional midwives
are not happy to help them in the village."
However other traditional midwives said they were competent to
deliver most primigravidae.
High Parity .
The traditional midwives interviewed had themselves had an average
8.9 childr en and many had not yet completed their families.
Not
one of them admitted to having problems in their most recent
pregnancy that required hospitalization.
that high parity
Thus few of them felt
was a risk.
Further, they said that many women experienced in childbirth
preferred
to deliver alone.
Breech.
At least 23 traditional midwives felt that a breech delivery was
difficult
"the breech baby often pulls its mothers heart out
as it comes"
But three senior traditional midwives said that breech was not
a problem.
Twins.
All traditional midwives said that twins caused problems
"the mother is tired and weak"
"her legs swell and she cannot work"
Four said they had referred relatives to the hospital for delivery
but only two of them went.
too far from the hospital.
The others went into labour at home
90
3.2.2.3.
Barriers to the effectiveness of the traditional midwives screening
for hi ph risk arising from the offi ci aj^mat ernit^se^vic es^
High risk screening by traditional midwives cannot be effective unless
it is supported by an efficient screening system in the hospitals and
RHCs and adequate care for those high risk women who develop problems.
A brief study of the antenatal services provided by the district
hospital and RHCs indicate a number of areas where the screening
procedure in particular may be ineffective.
Constraints on the effectiveness of the screening procedure arise from
both the district organisation of services and the provision of these
services at hospital and RHC level.
Thus this section presents a brief outline of the maternity care
facilities in Petauke District and their utilisation.
This is followed
by an analysis of the barriers to their effectiveness focussing
particularly on the district hospital.
A)
Provision of maternity services in Petauke District:ig82.
Within the district of Petauke are four hospitals (two mission run,
two government) and 17 Rural Health Centres (RHCs)
Each hospital
provides antenatal and delivery services and is staffed by at least
one doctor.
However, Caesarian sections are normally only performed
at Minga Mission hospital or at the neighbouring district hospital
of St. Francis, 70 kms
away.
Hospital antenatal services are not normally integrated with child
health services and at Petauke are provided only on two days per week.
Only one of the 17 RHCs has a resident midwife and can provide care
to pregnant women every day.
Other RHCs are dependant upon visits by
the mobile Mother and Child Health team which concentrates particularly
on immunisation.
Mother and Child Health team visits to RHCs are
usually monthly but remote places may receive only three visits a
year or less.
13 (76‘/o) of the RHCs do some antenatal care and 12 (60)o) report
deliveries.
However, some of this care is carried out by the male
medical assistants who usually have only had three weeks obstetric
training.
By custom, however, males have little to do with "womens
business and so many deliveries are assisted by the "female indoor
servants" who are employed to clean the RHC.
91
Since 1980 an unofficial two to four week training programme at the
provincial hospital seeks to train these ’cleaners’ in basic
antenatal care,
’at risk', referral and. safe delivery.
However, only two have been trained in Petauke District, leaving
14 RHCs without any "trained" female to carry out antenatal care and
assist at deliveries.
B)
Utilisation of maternity services in Petauke District :1982.
Estimated antenatal coverage (total) 1982
75%
Estimated antenatal coverage 1977
8470
Percentage of antenatals seen at RHCs
31%
Percentage of total antenatals seen at district hospital
26%.
Average number of antenatal visits per woman per pregnancy
3
Estimated total coverage of deliveries by hospitals and RHCs
29%
Estimated number of home deliveries
71%
(Estimated by G.T. from sources described in section
2.8.
Barriers to the effectiveness of the screening procedure for high risk
arising from the organisation of maternity services.
A screening procedure for high risk cannot be effective unless every
antenatal woman is seen either by a trained traditional midwife or
by a midwife in the antenatal clinic.
In Petauke District antenatal
clinics are held at each of the four hospitals.
Some RHCs provide
antenatal coverage on a weekly or monthly basis and in addition the
mobile clinic provides antenatal facilities for remoter areas.
However, over the last five years the numbers of antenatal attenders
has not changed significantly and in real terms coverage may have dropped
9% from an estimated 84% to 75%-
92
Constraints on the effectiveness of the system arising from the
organisation may be due to:~
a)
Unavailability of trained maternity staff.
There is a national shortage of midwives.
Thus unavailability of
appropriately qualified staff in the RHCs is a big problem.
Despite policies laying down a minimum of three staff including
an enrolled nurse/midwife for each R’dG this has been achieved
in only one of the 17 RHCs.
Thus antenatal delivery care is left to Medical Assistants who
have only had three weeks training in obstetrics.
The three
interviewed had very limited knowledge of the risk factors and
their only involvement in maternity care was when women came to
them in an emergency.
Antenatal and delivery care was left to the "female indoor servants".
Three were interviewed.
Two of them were very young and had had
no maternitjr training.
The third was experienced and had
joined a training programme for traditional midwives.
b)
Lack of finance.
The current recession has affected Zambia severely and this was
clearly apparent in the supplies of drugs and resources for
transport, etc.
During the study period at least 20% of mobile team visits were
ca.ncelled due to lack of oetrol.
,
„
oi public confidence in the /
Unfortunately this leads to loss
function
of regular attendence at antenatal
clinics.
c)
Poor organisation of antenatal clinics in the hosnital.
The organisation of the services results in midwives being severely
overworked in a very overcrowded clinic, one day a week.
In this situation they are unlikely to identify
women at risk,
and even less likely to be able to have effective communication.
In 1982 the district hosnital registered 26% of all registered
antenatals in the district.
However,
there is
booking and one follow up clinic per week.
follow up clinic can be severely overloaded.
only one
As shown below, the
In ordei' to overcome
this the traditional midwives have developed a very task orientated
approach.
Average follow up clinic attendance in dry season
122
Average follow up clinic attendance (annual)
80
Antenatal clinic attendance
September 82 - Aumst dp
I
93
At the firs i, follow up clinic observed, three midwives processed
66 ante, ratals and three deliveries in four hours.
This gave an average total possible contact period between
midwife anu antenatal woman of 2.9 minutes.
However, this period
was split into at least five or six separate portions which
comprised weighing, blood pressure, "obstetric history", physical
examination; receiving iron, folic acid and chloroquin, receiving
teuanus.
Each of these procedures required a separate queue and
resulted in 166 women sitting on the floor of an already full
20 bedded maternity ward.
Such a situation, especially where three antenatals are examined
together, is not conducive to useful communication, health,
education or the giving of confidential information.
Despite this, some pregnant women are highly motivated to attend.
Some spent as much as K5 (£2.50) on transport.
About 3O)o had
walked for 4-6 hours and one woman had walked for four days.
A similar picture was obtained at the other three clinics observed.
d)
Kidwives do not see the importance of the concept of high risk
screening.
i)
Kidwives do not write complete obstetric histories.
Only six out of 300 completed antenatal record sheets examined
during antenatal clinic gave more information than the number
of children born.
Five records indicated history of previous
caesarian section but no reason was indicated.
Only one
woman’s record hac a detailed obstetric history.
This had
been completed by a visiting public health nurse.
Four of the
midwives said it took too long to ask a detailed history.
Two
others said the women were "ignorant and do not know' if they
have had problems anyway."
ii)
Kidwives do not identify the high risk woman’s record as instructed
during their training.
Kidwives are taught to mark the high risk woman’s record with a
red star or a cross.
Not one of the 300 antenatal records
observed during the antenatal clinics attended had this mark.
Six traditional midwives who reported examining womens antenatal
record cards had found no such high risk indication for the last
two years.
94
Photo
7
To show the problems of an inappropriate antenatal
record card
- no room to write an obstetric history
- time consuming to complete
- easily damaged
(Actual example in Appendix 11)
(Compare with those in the Appendix 12)
95
liicwives do not tell all high risk women where they should
deliver and why.
A small study was made of all 28 women attending an antenatal
booking clinic.
Only one of the antenatal women had been told
to deliver in hospital despite the fact that 20 of them (57/°)
should have been classified as high risk according to the
criteria given me during interviews with these midwives.
Number at high risk; 28 women at booking clinic
Primigravida
6
Gravida 5+
10
Height less than 155cms
2
Previous stillbirths
2
Previous caesarian section Total attenders
Fig. 8
28
to show the number of"hirh risk, women attending one
antenatal booking clinic, (high risk as defined by the midwives)
(Criteria such as multiple pregnancy and malpresentation
were not used as they could not be checked)
Of particular concern were three high risk women who were
unaware of their need for hospital confinement.
One woman was
primigravida, height 141 cms. and she lived four days walk
from hospital, the other two had had two andfour stillbirths
respectively.
None of the stillbirths had been written in
the antenatal record.
Bven the woman who was told she should
deliver in hospital had not been given a reason.
Sight women said that midwives"just encourage all women to
deliver in hospital!'
A further study among 51 recently delivered women in
villages four hours walk from the hosnital show the same picture.
Midwives were said to encourage all women to deliver in hospital.
The high risk women interviewed did not receive specific
instructions on where they should deliver unless they had twins,
breech or previous caesarian section.
96
e)
Womens perceptions ofmidwives2__gj'Xiji2^^=j^=j^^j=~_
High risk women may fail to deliver in hospital because of a lac„
of understanding or agreement on their status as high risk.
described earlier, however, 60 of the 79 women inuerviewed gave
the following reasons for women refusing to deliver in hospital.
Some of these reasons implicate a failure among some midwives to
either appreciate that women may be afraid of hospital or to give
them respect_________________ ___________ _________________________ _
"You don't get the help and respect you do from your family"
"Nurses are too young — how can an older woman go co
someone who has not had a child?"
"Nurses do not respect pregnant women"
"Nurses feel they are educated and do not respect the
uneducated"
"Fear of instruments"
"Afraid of the light, I might be operated on"
"Fear and shame"
"Too expensive - some hospitals make you buy clothes
for the baby before you take it home"
"Fear of being hit"
This last point was made by a very senior woman whose first
daughter was slapped in labour.
Much to my astonishment three
midwives present proceeded to justify this action by saying,
"women don't behave in labour and you have to make them,"
and admitted they had done it themselves.
f)
Womens' beliefs regarding the function of the antenatal clinic.
90% of women stated that their main reason for attending antenatal
clinic was to obtain an antenatal card, so that if they developed
problems in labour they could get an ambulance,
"if you do not have the card the nurses will not know
you and will refuse you."
Only 30% of women said they went to clinic to find out which way round
the baby was lying.
No other reasons were given.
Thus many women seemed to perceive the antenatal clinic and card only
as an insurance against disaster rather than a positive influence on
their pregnancy.
97
3.2.2.4.
Barriers to the effectiveness of the traditional midwives
in screening for high risk - arising from the training structure
In addition to barriers arising from the community, the traditional
midwives and midwives themselves, there were also problems associated
with the training structures.
Three basic problems were perceived:-
a)
Lack of support of traditional midwives
Generally support, supervision and provision for continued
training is poor.
Due to lack of transport and female staff in
the rural health centres many traditional midwives had had no
contact with their trainer or other midwife for 2-3 years.
Ihey
are thus not encouraged to continue providing new services.
Illis problem was particularly observed among the hospital trained
traditional midwives where the community were not involved in
discussions on her new functions.
b)
Lack of supplies
Supplies of razors, cord ties and delivery kits and delivery
forms were to have been supplied to the traditional midwives
trained in hospital.
The supplies have been very poor.
Initially traditional midwives were willing to travel a long
distance to collect supplies and make reports on their deliveries.
Now enthusiasm is low.
c)
Future traditional midwife trainers attitudes
It was observed that certain midwives who in the future will have
responsibility for traditional midwife training described
traditional midwives as "primitive", "dirty","ignorant" and"boring".
These attitudes are not conducive to smooth working with other
people.
Suggestions for overcoming these barriers are presented
in section 4.4.0.
98
4.0.
DISCUSSION
What can be done about the problems identified?
This study has concentrated on the process of providing antenatal care
and identification of high risk in the official and tradi
maternity service.
No attempt was made to relate the process to the
outcome of the care.
An attempt was made to relate the process of care to the traditional
customs, beliefs and practices and the resources of the health
services.
The results show that there are opportunities for improving
the process of antenatal care in both the traditional and official
maternity services.
The problems identified are not unique to Zambia.
They occur to some extent all over the world.
Numerous studies, especially in U.K. and U.S.A, highlight some of the
problems within maternity care services.
(84,85,86,87).
These studies
show that much of the dissatisfaction relates particularly to how the
care is provided rather than the content of that care (88).
Studies
in developing countries such as those by Malone (89) and Dissevelt (90)
have identified similar problems in the process of giving antenatal
care.
The services provided are described as being dehumanised,
fragmented and routinized (86), with overcrowding and lack of privacy
(87).
The breakdown of antenatal care into a series of tasks destroys the
role of the midwife in providing clinical assessment, advice,
information, emotional support (86).
)
re<=m+c ■
it results in the midwife's
t+
dissatisfaction with her own job (91 ,92 )
99
Continuation of such a routinized antenatal and delivery care will
result in those women most at risk failing to see the purpose of the
antenatal services and refusing to use them (93,94).
Many medical
staff meanwhile continue to take the line that what is necessary is
the
education" of women to appreciate the "true" value of antenatal
care ( 95), rather than assisting women to take responsibility for
their own health.
4.1.
Opportunities for improving the care of the high risk mother
Opportunities for improving the care of the high risk mother were
identified within each of the four areas defined for study.
Possible
ways of overcoming these problems identified will focus first on the
official and then on the traditional maternity care services.
It is
however recognised that in a country such as Zambia the trained health
personnel and
/material resources are very limited and solutions must be sought
within this constraint.
4.1.1.
Improving care in the Official Maternity Services:
In the Hospital:
Ihe demand for maternity services has been increasing as the public
become aware of its potential and the population grows.
However the
concomitant decrease in resources is putting a heavy load on the
present services.
This pressure was identified through the limited
time available per client, low standards of care e.g. failure to
complete the obstetric history, a low level of information giving and
a task rather than client orientated approach.
been found from studies in Lusaka (96).
Similar findings have
100
Solutions to this must aim at decreasing the pressure of the work
load.
Then the screening procedure for high risk can be effective
and the staff can then provide adequate care to these high risk
women.
Spreading the workload
Mental and physical fatigue play a big role when staff have to cope
with large numbers of women at one session all requiring the same
routine procedures and examinations.
Such pressure could be reduced
by:-
4.1.1.1.
Integrated Mother and Child Health Clinics
The provision of a daily mother and child health clinic service as
(97)
described by Morley in 1963 would greatly reduce the pressure on the
staff who have to cope with a huge child health clinic on Wednesdays
and similar overload at the antenatal follow-up clinic on Thursdays.
A further benefit is that the antenatal coverage may be increased as
mothers with sick children can attend, without making a separate
journey.
This is important as both this and other studies show that
many women feel regular antenatal check ups are not necessary.
only go if trouble arises (94).
liiey
Dissevelt (1980) (98) found that
integration of maternal and child health clinics increased the
utilization of the preventive child health services, decreased the
actual number of consultations made by clients and spread the work
more evenly among the staff.
4-1-1.2.
Afternoon antenatal clinics for those living nearby
At present nearly all clients come in the morning and are processed
by lunchtime, often so hastily that adequate examination is impossible
101
Although the clinic officially continues until 16.00 hours clients
rarely come in the afternoon and as a consequence staff are under
utilised although still on duty.
4.1.2.
Identifying the high risk woman
Enrolled nurse midwives such as those at Petauke are quite capable
of providing adequate antenatal care.
more senior staff.
But they need some support from
In particular there is a need for clearly defining
the criteria for high risk groups.
There is a need for clear
instructions for categorising and managing "high risk” and "not high
risk" women.
The criteria for high risk used at present are impracticable as:-
a)
too many classified as high risk
An unmanageable number of women are classified as high risk.
A confirmatory study in 4 places (see Fig. 9 ) showed that
if all primips and those with a parity of 5 or more are counted
or more
as high risk, 50%/of all pregnancies are high risk.
b)
hospital resources limited
At present petauke hospital provides delivery services for an
estimated 26% of all those antenatals who register in the
district.
c)
The facilities and staff cannot cope with much more.
criteria not acceptable to community
The criteria for high risk used are not acceptable to the local
women who therefore pay little heed to advice given.
This is
shown in the failure to increase the overall proportion of non
Tm- \»o
092G0
102
emergency primips and grand
multips choosing to deliver xn
hospital (see Fig. 9 below).
percentage with first or
fifth plus pregnancy
Number of women interviewed
one
All 28 attending/antenatal booking
clinic
one
83 attending/antenatal follow-up
clinic
57%
52%
All 51 recently delivered women in
2 villages 4 hours walk from the
hospital
50%
40 in villages 2-3 days walk from a
hospital
50%
130 non-emergency admissions to the
hospital
52%
Fig. 9
To show that present high risk selection does not result
in an overall increase of primips and grand multips
delivering in hospital.
A study by Malone in Kenya (89) using similar criteria to those in
petauke found 75% of the antenatals to be high risk.
Clearly
redefining the criteria for high risk is essential in order to
produce a useful tool.
The criteria used at present by midwives in Petauke are learnt from
such British textbooks as Myles Midwifery (99).
Such criteria are
being questioned by both professionals and recipients of maternity
services in Britain.
Studies such as those by Marjorie Tew (1981)
cast very serious doubts on the safety of hospital deliveries for
low risk cases in Britain (82).
Meanwhile studies such as those by
Voorhoeve in Kenya (1979) (100) showed that the still birth rate for
103
home deliveries in one area was 2.4% while in hospital it was 4.4%.
A second study in a different area found perinatal death rates at
home and in hospital to be the same (LOL) .
In neither case did there
appear to be any indication that women who delivered in hospital were
a selected group of higher risk.
In Petauke the figures available from records kept by traditional
midwives between March 1978 and December 1981 indicate perinatal
mortality results comparable with those of Voorhoeve i.e.: perinatal
mortality rate at home was 2.3% and in the district hospital was
4.5%.
Thus low risk women may well be better to deliver at home.
Criteria for high risk must be redefined.
4.1.2.1.
Redefining the criteria for high risk
Unfortunately due to lack of information on antenatal and delivery
records in Petauke I was not able to produce a list of locally
relevant criteria.
It is thus
necessary to rely on the published
literature to evaluate the relevance of the criteria being taught and
used at present.
4.1.2.2.
No.
Are all primigravidae high risk?
Other criteria can be used to define those primigravidae most
at risk.
a)
Height
Essex and Everett in Tanzania (1975) (102) showed that one in ten
of all primigravidae of height 146 cms or less required a
caesarian section for cephalo pelvic disproportion.
A further
104
study (1977) (103) showed that
neonatal deaths were found in
risk was negligible.
Thus in
about half the still birth and
short women.
Above this height the
Tanzania the high risk criteria of
146 cms or less is used.
This is a much more practical screening test for women likely to
have difficulty in labour than a clinical assessment of the pelvis
which cannot be done in a room where 3 women are examined together
(as at petauke).
Are results from Tanzania applicable in Zambia?
Differences in height can arise from different ethnic or nutritional
backgrounds.
The criterion of 146 cms or less as an indicator of
high risk is however more appropriate to people in Zambia than
that at present being used and taught at University Teaching
Hospital Lusaka.
The senior lecturer in community health recommends a
cut off point of 155 cms (40) which is greater than the 5 foot (or
152.5 cms)used in many antenatal clinics in Britain.
Recommendation
A height of 146 cms or less should be used to define those at risk
until further epidemiological studies have been carried out.
b)
Age
Very young primigravidae are likely to have more problems than
those at the more optimum age of 18-25.
studies in Tanzania (IM),
\ 10b )
Nigeria, Zambia (1C6), and the U.S.A. (107) have shown that very
young primigravidae (defined as under 15, under 16 and under 19
respectively) are more likely to have low birth weight babies.
The study in Tanzania found an increase -in
■
increase in anaemia in teenage
pregnancy, while those in Nigeria and Zambia found an ■>
louna an increase m
105
the rate of pre eclampsia.
Unfortunately none of these studies
analysed maternal height.
Two studies, one in Zambia and the
other in the U.S.A, showed an increase in perinatal mortality.
The others found no increase in blood loss or other complications
of labour.
Recommendation
There should be especial care of the very young primigravidae in
the antenatal period to identify and manage the possible
complications of pregnancy indicated i.e. anaemia and pre eclampsia.
Whether it is appropriate for young girls with normal height and
haemoglobin and no anaemia to deliver in hospital is open to question
for several reasons
i) They require a lot of psychological support which they are more
likely to get at home
ii) At home a sitting position is adopted in labour.
Several studies
including one involving seven countries in Latin America have
shown that primigravidae in labour in a sitting position have
(108)
shorter labours. The length of labour was shortened by an
average 36% compared to the 'horizontal' group.
In addition the
sitting position was less painful.
iii)
If a woman in labour adopts a sitting or squatting position the
cross-sectional surface area of the birth canal may increase by
as much as 30%.
Thus this position may help overcome quite
marked cephalo pelvic disproportion.(109)
Adequate care of the very young primigravidae will only improve
through a concerted effort by the community and the health services.
106
Young girls hide their pregnancies out of shame and may dispose of
the baby in order to continue schooling.
Such incidences ar
increasingly reported in Zimbabwe and Kenya (110) •
g
^is problem is
discussed in depth later.
4.1.2.3.
Are all grand multips high risk?
In statistical terms a grand multip is more likely to have problems.
A study in Canada showed that grand multips delivering in hospital
had a tenfold increase in maternal mortality and a doubling of the
perinatal mortality rate (111).
Studies in Nigeria show similar
results (H2).
Grand multiparity by itself however is not a useful criterion to use.
It is not acceptable to the women in the community and the service
could not cope with them if they all came for delivery.
How can the high risk grand multip be identified?
Studies on grand multips in Britain (113), Kuwait (114), Bangladesh
(115), Ghana (a6) and Zambia (117) show that the majority of these
maternal deaths occur among those women with toxaemia, hypertension,
kidney disease, antepartum haemorrhage, abortion, diabetes and such
complications of labour as ruptured uterus arising from
malpresentations.
Anaemia is also implicated in maternal mortaiit,, =
mor-canty among grand multips.
Anaemic women are more subject to
„„„„ .
co nuernprai
puerperal sepsis
and antepartum and
post partum haemorrhages and perinatal loss (118) (119)
The causes of perinatal deaths were associated w-i+b k- .v •
iolhu with birth injury,
anoxia and low birth weight.
107
Thus these studies show that many of the problems of grand
“ultiparity can be identified during pregnancy.
Recommendation
In antenatal screening for high risk where women experienced in
childbirth are reluctant to deliver in hospital it is more constructive
to identify additional risk factors such as anaemia and oedema.
Management of the grand multip should then be geared to identification
and treatment of these specific problems.
Women with persistent
problems e.g. chronic anaemia are more likely to be persuaded of the
need for a hospital delivery if the specific problem is explained
to them.
Women in the villages and traditional midwives see no need for all
grand multips to deliver in hospital, especially when they have the
other children to look after.
However some traditional midwives
recognised that women with "very many" children were usually "tired".
perhaps a more useful criteria would be that used by Essex &. Everett
(1977) (103) of 10 or more previous babies or maternal age over 35.
4.1.2.4.
A Summary of the Criteria for high risk
A standardised set of criteria for high risk should be developed
such as those by Essex & Everett (1977).
a)
Age
Below 16
Over 35
primigravidae over 30
b)
past Obstetric History
More than 10 pregnancies
More than 10 years since the last pregnancy
108
Caesarian section (or any abdominal scar)
Vacuum extraction or forceps
Third stage complications e.g. PPH or manual removal of
the placenta
Neonatal death in last pregnancy or more than one neonatal death
Three or more repeated abortions
c)
Maternal physical development
Height of 146 cms or less
Limp or polio leg
d)
Maternal disease
Bleeding since last period
Clinically anaemic
Bp 140/90 or more
Oedema and proteinuria ++
Sputum positive for AFP
e)
Abnormal Presentation
Breech
Transverse lie
Large for dates or suspected twins
4.1.2.5.
Using the criteria for high risk
Producing a practical and relevant set of criteria for high risk is
only part of the solution.
a)
They must be used.
Problems in using the present criteria
i)
The antenatal record cards are not structured, so it is not
easy to complete
109
ii)
Midwives find that taking an adequate history takes too
long (only one antenatal in 300 had a properly filled
in card)
iii)
Midwives forget to ask all the right questions
iv)
Antenatal record cards have not been available for 9 months
and stationery is in short supply
The space on the obstetric records which are being used as
antenatal cards is inadequate.
Thus midwives waste time
writing out the columns to be filled in.
(See Appendix 10 and photo 7 )
Thus the identification of pregnant women at high risk is
haphazard and time consuming.
b)
Possible Solutions
i)
An action-orientated antenatal record card
Workers such as Disseveld (120) and Essex & Everett (103)
have designed antenatal records which
a) are independent of memory
b) detect women at risk of complications during labour
c)
indicate appropriate action for each abnormality detected
d)
emphasise the treatment needed to prevent anaemia,
malaria, neonatal tetanus and malnutrition
e)
provide a record of the outcome of labour
f)
provide the mother with a permanent record of risks and
outcome of pregnancy (see Appendix 11)
Malone (1980) (89) found that the use of these record cards was
the "most influential factor" in improving antenatal care,
especially in the accuracy of the medical and obstetric history
and selection of high risk cases for appropriate management.
110
However with Zambia's present financial problems a
cheaper
interim solution is possible.
ii)
itie information collection stamp
Michael parent in his work in Tunisia (121) used a rubber
stamp to provide similar information.
any paper and would be cheaper.
This could be used on
A similar solution was
tried out using a Hecto duplicator (122) which I brought for
the hospital.
One benefit of either of the above suggestions is that the
information on them could be used in a future study to find
the locally most relevant high risk groups.
4.1.2.6.
Benefits of a new screening system for high risk
Studies in Tanzania (103), Kenya (8 9) and Kwazulu (123) show that the
use of these action-orientated record cards have a wide range of
benefits.
i)
It detects a manageable number of high risk women
Essex & Everett (108) found that about 18% of women had one or
more risk factors present.
This number is well within the
management capabilities of the present maternity services.
ii)
Most risk factors can be detected at the first visit
The same study showed that 81% of the total risk factors could
be detected at the first visit.
Larsen & Muller in Kwazulu
found that 85% of risk factors could be detected antenatally.
Ill
11:L)
Fewer anatenatal visits for low risk women
Thus if as shown above the majority of risk factors can be detected
in the first visit, appointment schedules for revisits can be
modified.
Women classified as low risk do not need the regular
frequent visits which sometimes result in women attending fortnightly
from 30 weeks (observed by G.T.)
Two visits would be adequate.
One visit early in pregnancy would
be necessary for an assessment and management of any problems e.g.
anaemia and first tetanus toxoid.
A second visit could be made at
about 36 weeks unless any problems arise and the second tetanus
immunisation could be given.
Antenatal visits should only be made if an objective can be
specified with a reasonable expectation of being met e.g. studies
such as that by Hall & Ching (138) indicate that it is not
worthwhile to look for pre-eclampsia until 34 weeks as the detection
rate is less than 1%.
One argument used against two visits in petauke was that it was
thought that tetanus toxoid could not be given to the mother until
after 28 weeks gestation.
However present WHO guidelines indicate
that there is no apparent danger to the foetus from this killed
vaccine.
J ml given in 2 doses with a minimum of one months interval
can be given at any time in pregnancy (124).
Obviously decreasing antenatal visits is controversial, but studies
quoted from Kenya and Britain have shown how much time is wasted
and how many opportunities are missed due to work overload and lack
of clear objectives and criteria.
iv)
More time available for high risk women
If the pressure of routine work can be reduced more time will
112
be available for building up a more personal relationship with
women who are likely to have problems.
In this way personal
and individual advice on health matters is more likely to have
an impact.
The necessity for improving the present system was identified by
finding 4 women who had had previous caesarian sections who
then had their subsequent deliveries at home.
One woman had
had 3 caesarian sections and then a home delivery.
She refused
to go to hospital as she feared being sterilised.
"If I stop having children, I lose my husband".
Solutions to such problems can only be found on a personal basis
with trust, not in an overcrowded, rushed and impersonal
atmosphere.
v)
Increased job satisfaction for midwives
This system should increase the job satisfaction of the midwives
by allowing them to detect problems and give appropriate advice.
The antenatal care is also time saving and reduces routine
boring procedures e.g. writing out a full obstetric history to
a simple quick series of ticks in boxes(see appendix 12)
The role of a more senior midwife or doctor
,
uoctor m antenatal care
needs however to be more clearly defined.
A regular time
schedule when all high risk women are seen could k
en could be organised.
113
vi)
Increasing consumer satisfaction
Clinics with clear objectives and short queues may encourage
more women to come.
it is disappointing to see that despite
midwives' hard work the numbers of women attending antenatal
by 9%
clinic in the district have decreased/since 1977.
4.1.2.
Opportunities for improving the care of the high risk mother:
in the district
Problems identified
Improving the situation in the district is difficult.
For many
reasons midwives do not want to work in remote rural health centres
and mobile clinics only have a limited impact.
Only one of the 17
rural health centres has a resident midwife.
This poses big problems.
The male medical assistants may have very little obstetric training
and those interviewed have scanty knowledge of risk factors.
areas women are unlikely to go to a male for help.
In many
The traditional
midwives in Mwape said "it is better to look for death" than go to a
man for help.
Some solutions
4.1.2.1.a)List of High Risk Factors
A simple list of high risk factors should be available in every rural
health centre.
Such criteria as height or age could be identified by
a man without alienating too many women.
b)
Training the "Female Indoor Servants"
If the women working in clinics are being requested by the public to
assist in deliveries they must receive some appropriate training as
was done in India
114
At present an experimental programme for training these women is being
run at Chipata Provincial Hospital.
Such training should however be
very simple and geared to facilities found in the rural health centres.
It could be greatly improved by giving these women simple guidelines
for high risk.
Consideration needs also to be given to their appropriate selection,
training and support.
4.1.2.3 .
There are also legal implications.
Saving petrol
Some workers (103) have suggested that if the "action-orientated"
antenatal cards are used appropriately mobile team visits can be
safely reduced.
In view of present transport problems (currently
20% of mobile clinics cancelled) this may be useful.
If petrol
became more available different places could be visited, perhaps at
two monthly intervals.
4.1.2.4.
Improving the mothers shelter at the district hospital
The district hospital provides a shelter for mothers awaiting delivery.
However a number of problems were apparent, i.e.: lack of water,
lack of sanitation (the latrines were blocked or had collapsed), lack
of cooking or washing facilities.
3 mothers in the villages said they would go to the mothers shelter
if there were better toilet and washing facilities.
At least 78 women and 2 men were found to be using the 2 rooms of the
mothers shelter at one time.
4.2.
This head count did not include children.
Implications for staff training
In the short term
A new system for screening high risk will require adequate training
or refresher courses for all staff, so that abnormal findings can be
interpreted and appropriate action taken.
115
4.2.1.
In-service training - Bwino Magazine
Training courses are however expensive.
Much information could very
effectively be given through Bwino the excellent journal for primary
health care workers. This is produced by the Ministry of Health. A list
of risk factors could be included to put up in the clinic.
4.2.2.
In the long term - training of hospital staff in Primary Health Care
There is a need for hospital staff and especially midwives to learn
about and be involved in primary health care early in their training
instead of after qualification.
At least 60% of the midwives
interviewed commented that traditional midwives are "dirty",
"ignorant” or "primitive”.
Ihey saw the only way to reduce maternal
and perinatal mortality was to convince mothers to deliver in hospital.
These attitudes need to be overcome if traditional midwives are to
be well accepted.
Introducing primary health care into the hospital
training will assist.
4.2.3.
- training in statistics
If nurses and midwives are involved early in their training in primary
health care and community diagnosis they will begin to use the
statistics collected.
Increased interest in the statistics and use of
statistics should improve accuracy of recording data.
At present there
is still confusion over basic definitions of e.g. still birth,
gravida and parity.
gravida 0.
For example, antenatal cards were marked parity 2
This would indicate that the woman had had 2 children
without having become pregnant.
4 3.
Opportunities for improving the care of the high risk mother:
By working with traditional midwives
In a country such as Zambia which is proud of its cultural heritage and
traditions the opportunities for improving the care of mothers
116
through working with traditional midwives are many.
During my stay in Zambia I met with 58 traditional midwives who had
been involved in 7 very different training programmes.
Each of these
programmes represent different people’s interpretations of what is
necessary in the training of traditional midwives.
The programmes
presented a continuum of adaptation to different objectives and
different resources.
They ranged from the 6 week residential course
for selected traditional midwives at Minga, to the 2 week village
based programmes at Chikowa and Sinde-misale for all practising
traditional midwives which had developed very good links with the
rural health centre; and finally to the village based programme at
Mwape where 43 traditional midwives registered for training but where
none wanted anything to do with the rural health centre.
Within each of the programmes problems were identified.
Solutions
to these problems were sought through discussions with trained and
untrained traditional midwives and the trainers; observation of their
interactions with the community; and a study of the literature.
This dissertation only presents that part of the findings related to
antenatal care.
From the results presented in section 3 it would appear that these
programmes aiming to train traditional midwives in antenatal care
were having a limited impact.
However, by visiting traditional
midwives trained through such differing programmes it was possible tn
identify those programmes which were achieving some of the targets
117
in antenatal care e.g. identification of high risk and referral,
and those which were not.
4-3.0.
Improving the care of the high risk mother:
4.3.1.
Use appropriate criteria for high risk
Where traditional midwives are taught criteria for high risk that
they think are reasonable, they are more likely to use them.
33 traditional midwives specifically said that primips and gravida
5 or more are not high risk.
Further, if the traditional midwives
tried to refer them to hospital local women would not agree to go.
Thus using criteria outlined in section 4.1.1.5. which are geared
to finding specific abnormalities would be more acceptable to them
4.3.2.
Involve all the practising traditional midwives in the
community
In this area of Zambia women are delivered by their mothers or
grandmothers.
In some other countries e.g. India and Burma there are
just one or two traditional midwives in each village who are very
experienced and can benefit from a specialised training.
This
however is not appropriate in this part of Zambia.
The traditional midwives I met had done an average of 5.6 total
deliveries.
This compared closely with the 5-10 deliveries done by
traditional midwives in Zimbabwe (125,126).
Only two of the
traditional midwives interviewed approached the figures recorded in
Ghana (12) of 6.9 per year.
These two traditional midwives doing
relatively more deliveries (7-14 per year) had been trained in hospital.
However they had had negligible impact on the antenatal care.
118
photo
8
A well prepared mother with an antenatal card
in a plastic bag and a new razor in readiness
119
In the last year they had delivered in the village twins, breech and
a woman with 2 previous caesarian sections.
In contrast where all traditional midwives in one area are trained
together there can be a considerable impact on the antenatal care and
helping women to choose a more appropriate place f
r
*
where the population is 1080
Chikowa in 1980/34 antenatals were registered.
delivery.
In
21 deliveries were
done by trained traditional midwives at home and a further 8 were
referred to the rural health centre.
Since then all the twins born
in Chikowa have been born in the rural health centre.
In other countries such as Guinea Bissau (128), Sierra Leone (129)
(126), Zimbabwe (130) and Ghana (131,127) the training programmes
developed have taken into account the culture and geography of the
areas.
Thus where people live in remote scattered villages and work
mainly within their own families the training programmes aim to reach
all practising traditional midwives.
In Manicaland in Zimbabwe with its population of 1,098,000 aims to
train 4-6,000 traditional midwives.
Eastern province has a population of about 700,000.
A reasonable
estimate of the number of traditional midwives would be about 3-4,500.
Only by training those women who do the deliveries will there be an
impact on the health of mothers and children.
Giving a specialised
training to a few women would appear to have minimal impact
120
4.3.3.
Introduce new ideas slowly
Ideas need to be introduced slowly.
Trying to change deeply held
beliefs and traditional practices which have been followed for
hundreds of years can only be done after trust has been developed.
Older people need to have time to think over the new ideas and come
back with their questions and doubts.
Problems and difficulties will
need to be covered more than once.
This can be done in several ways:-
a)
meetings once a week in the afternoons at rural health centres
as at Sinde-misale(and Manicaland, Zimbabwe).
b)
meetings once a month in conjunction with the mobile team visits
c)
in remote areas which are rarely visited a one to two week
initial course can be followed up at more distant intervals.
An annual visit for 3-5 days was suggested by traditional midwives
at Chikowa.
4.3.4.
Involve the pregnant women in the community
Traditional midwives want to learn how to avoid problems arising in
labour.
However, many find that women do not want to be
examined
by a traditional midwife in pregnancy and will only agree to
examination when they are in labour.
Other programmes in Ghana (131) and Manicaland (130) in Zimbabwe
have found the same problem.
Traditional midwives are viewed with a
mixture of respect and suspicion.
They are not expected to elicit
information or examine pregnant women nor encourage them to attend the
clinic.
Such encouragement in Ghana "could be interpreted as taking
121
undue interest with evil intent" (131) causing haemorrhage, miscarriage
or a later failure to thrive of the baby.
Hospital trained traditional midwives did no antenatal care.
Those
trained in the villages mainly provided antenatal care to their
relatives but found that they needed encouragement to continue.
Expanding the traditional midwives’ role in providing antenatal care
will only be achieved if fear and mistrust in the villages is overcome
by involving antenatal women in the programme.
This is best done in
the village based programmes.
4.3.5.
Include traditional midwives and women in the community in
the planning
Traditional midwives must be involved in the planning of the training
programmes.
Many have heavy family and agricultural commitments
which must be met.
Dry season
In many areas courses can only be run during the dry season, when
women have more free time.
Residential courses such as those at
Minga incurred heavier financial commitment than expected as the
traditional midwives insisted on going home at weekends.
This can
be very expensive in petrol.
Afternoons
In village or rural health centre based programmes traditional midwives
often prefer to meet in the afternoons after having finished their
household work.
In village based programmes the mornings can then
be spent by the trainer in individual home visits to build up trust
with the younger women.
122
4.3.6.
Involve the traditional midwives and women in the selection
of traditional midwives
Traditional midwives and local women must be involved in the selection
of the traditional midwives for training.
Three main problems were mentioned by traditional midwives
1)
If only a few are selected they may not be those to whom
women turn and may actually be feared
2)
Not all traditional midwives are happy to be trained together.
This is important, as if they do not trust each other discussions
cannot be free.
At petauke traditional midwives were asked by the trainer if
they were all happy to be trained together.
In response they
asked for two women to be excluded because although they
respected them they were infertile.
3)
Some traditional midwives go for training in order to increase
their political influence.
This problem was discussed at the
provincial meeting of traditional healers in Chipata on 22nd
September 1983.
Obviously in some areas the political leaders
are of great benefit.
This has been found in the community
health worker programme (132) and for example Chief Mwape was
instrumental in ensuring a very high interest and attendance
rate in the 2 week training programme.
However in this instance
she was encouraging all trusted women to be involved, not a
selected few.
123
However in "womens business" issues of trust and confidence must be
taken into consideration.
If only one traditional midwife is
selected for training she may well not be used.
If all practising
traditional midwives are included in the programme the problems of
mistrust are minimised.
124
Implications of the study
Much has been wrxtten on the need for increased staff awareness of
the importance of the risk approach in antenatal care in Zambia
Hickey & Kasonde 1977, (133) Grech 1978 (39) and Watts & Harris 1982
(40).
The main emphasis has been upon directing "an educational
programme to women of reproductive age stressing the benefits of
proper antenatal care and supervised confinements" (39
).
The success of any such programme will be its acceptability to the
women who are its beneficiaries.
However the studies by Grech,
Hickey &. Kasande mentioned above indicate that about one third of
maternal deaths could have been prevented
on the mothers part.
by more appropriate action
Further, Watts & Harris suggest that those most
at risk are the least likely to attend antenatal care.
Such
disparities indicate a failure of communication.
From the findings of this study, it would appear that some of this
failure of communication arises from a lack of compatability between
the way in which health personnel communicate scientific health
concepts (e.g. of high risk in pregnancy) and the way such concepts
are received by those holding more traditional beliefs.
A programme based totally on a western 'scientific' understanding of
the risk concept will be doomed in rural areas where the majority of
people may believe for example that a difficult labour is due to a
"lack of social hygiene", infidelity, or "ufwiti".
Even in urban areas educated people such as nurses, medical assistants
and teachers have strong traditional beliefs (Edirisooriya 1976) (78).
125
In Zimbabwe it is estimated that 98% of indigenous people have a
traditional health orientation and only 0.5% have completely
scientific beliefs (Mutambirwa 1982)(139) and there is no evidence
that these beliefs will change quickly.
It is thus essential to form a bridge between these traditional
beliefs and western 'scientific
*
ones.
It is however difficult for educated urban people to understand
rural people with their non scholarly belief systems.
The effort of
understanding must first come from the health authorities and teachers.
This effort of understanding requires that existing and non existing
relationships between the traditional and scientific health concepts
and health care practices are identified.
If relationships can be
identified, they can be built on constructively and as such are more
likely to be acceptable to local people.
Implications for training traditional midwives
A traditional midwife is just one part of the traditional medical
system in her community.
Giving just one traditional midwife some
training in more 'scientific
*
impact.
health care may have a small initial
However by herself she cannot achieve lasting community or
individual participation.
Her new skills are seen to be apart from
the traditional medical system of the community and may be feared
or ignored.
Traditional midwives trained together in a village may be able to
126
support each other in introducing new ideas if they are convinced
that the women will benefit, for example referral of "high risk .
Traditional midwives at Chikowa identified the conflicts created in
the community by the introduction of new ideas: e.g. mothers were
afraid that cutting the cord differently or delaying the baby's first
bath could cause illness or death of the baby.
Therefore they had
only been able to introduce a few of the new practices taught. Unfortunately
the changes introduced were not those which would have had an impact
in improving maternal or perinatal health.
In discussion they said that by working together they could introduce
new ideas like antenatal care but they could only introduce a small
amount at a time.
They suggested that a 3-5 day course annually
would be appropriate after their initial 2 week course.
This
solution would seem appropriate in their rather remote village.
Different solutions will be needed in different places and this will
require flexibility on the part of those in the health services.
Implications for the training of traditional midwives
The implications of this study for the training of traditional midwives
can be divided into
5.
These will be expanded in a more detailed
forthcoming report.
i)
positive recognition of traditional midwives' expertise
There must be a positive recognition of the traditional midwives'
expertise in the use of herbs, and the psychological support
they give to pregnant women.
Most importantly among the traditional midwives I met
their
practice of allowing the mother to deliver her own baby without
127
interference from the attendant unless absolutely necessary
is in the best traditions of classical teachings in midwifery.
It is most worrying that some of those trained in hospital have
begun to do vaginal examinations, especially in view of the general
shortage of soap.
ii)
Build on what they know and do already
The trainers must identify those areas of the traditional midwives'
practice which are beneficial and build on them e.g.
a)
building on the traditional sex and family life education
given at initiation, e.g. especially in relation to schoolgirl
pregnancies
b)
building on the early recognition of pregnancy by the
traditional midwives and their consequent early giving of
advice on behaviour in pregnancy
c)
building on traditional nutritional advice -
"we tell her to eat more or else the baby's arms will be as
thin as my fingers"
"we give porridge with herbs to women who vomit (in pregnancy)
so they don't become weak"
d)
building on traditional midwives' remedies for problems in
pregnancy, e.g. women with palpitations in pregnancy often
wear a particular prickly seed on a necklace - this can be easily
recognised by midwives
Traditional midwives can be shown the association of the
palpitations with anaemia or perhaps high blood pressure and
the necessity for referral.
127
interference from the attendant unless absolutely necessary
is in the best traditions of classical teachings in midwifery.
It is most worrying that some of those trained in hospital have
begun to do vaginal examinations, especially in view of the general
shortage of soap.
ii)
Build on what they know and do already
The trainers must identify those areas of the traditional midwives'
practice which are beneficial and build on them e.g.
a)
building on the traditional sex and family life education
given at initiation, e.g. especially in relation to schoolgirl
pregnancies
b)
building on the early recognition of pregnancy by the
traditional midwives and their consequent early giving of
advice on behaviour in pregnancy
c)
building on traditional nutritional advice "we tell her to eat more or else the baby's arms will be as
thin as my fingers"
"we give porridge with herbs to women who vomit (in pregnancy)
so they don't become weak"
d)
building on traditional midwives' remedies for problems in
pregnancy, e.g. women with palpitations in pregnancy often
wear a particular prickly seed on a necklace - this can be easily
recognised by midwives
Traditional midwives can be shown the association of the
palpitations with anaemia or perhaps high blood pressure and
the necessity for referral.
128
iii)
use their traditional concepts of health
For example, most traditional midwives said they did not have time
to wash their hands in preparation for delivery.
The importance
of hand washing and physical hygiene could perhaps be taught by
building on concepts of moral hygiene or moral purity, cleansing
the individuals personality from evil influences by washing hands
before the delivery or attending to the newborn baby or the cord,
as has been suggested in Zimbabwe (139).
iv)
Decide on priorities in teaching
As introducing new ideas causes conflict both for the traditional
midwives and the women they help it is sensible to minimise the
conflict.
One way to do this is to concentrate on only teaching
those priority tasks which have been identified as important e.g.
in maternal or perinatal mortality, see Figs, 6a , 6b and Fig.7 .
These results indicate the importance of seeking local causes of
mortality, but in this instance have more import for natal and
postnatal causes.
v)
Don't destroy community support
The findings of this study
support those
of Sikota (1983)
(47) who found that 80% of traditional midwives no longer received
the traditional gifts of thanks from the community.
This caused
great resentment among some traditional midwives and one said she
had stopped working because of it.
This did not seem to be a
problem with village based training which seeks to change little
in the way they practice.
countries (134).
The problem has been noted in other
129
Implications for training health personnel
Tiie policy document on primary health care describes the disinterest
and contempt with which Zambian health practitioners have held
indigenous health practices (37).
If the concept of primary Health
Care is to become a reality this disinterest must be overcome.
One
step towards this would be to include the study of behavioural
sciences with practical field experience early in the training of
nurses and medical students.
Such courses should include the study
of customs, beliefs and practices of the people they work among.
Present
/courses structured such that the practical work follows after the final
exams does not allow constructive consolidation of theory e.g.
the Public Health Nurse Training.
This study shows that improvements in maternity care can only be
achieved through a team approach, with health educators and health
personnel in hospital and rural areas being willing to work with and
learn from those holding more traditional beliefs and values.
Finally in a country such as Zambia which is proud of its cultural
heritage, it is important for the beneficial customs beliefs and
practices to be recognised and utilised by the health services in
all aspects of its work, not just in antenatal care.
As an outsider I have no right to write about other
peoples customs, beliefs and practices, in isolation.
Nor have I a right to criticise those who are trying their
best to provide a service to others.
However I believe it is vital to get the foundation of the
training for traditional midwives right or we will do more
harm than good.
It is with this view that I have done
this study.
I would welcome any comments, advice or
criticism.
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Appendix 1
Questionnaire for Traditional Midwives
Keeping Healthy
1.
When a woman is pregnant what should she do to keep healthy?
2.
Are there certain foods she should eat?
3.
Are there certain foods she should not eat?
4.
How do you know when a woman is first pregnant?
5.
What happens when a woman becomes pregnant?
6.
- Who does she first tell?
7.
- When is it generally recognised that she is pregnant?
8.
- What happens when you can see the pregnancy?
9.
What might happen if people discuss her pregnancy before this?
10.
Who does a woman talk to about her problems in pregnancy?
- early?
11.
- late?
12.
When do you usually first talk to a woman about her pregnancy?
13.
Do you go to her, or does she come to you?
14.
Why?
15.
How does a woman normally feel in herself in pregnancy?
16.
Is pregnancy an illness?
17.
Do women here get early morning sickness/vomiting in pregnancy?
18.
Why?
19.
Is it a problem?
20.
Can anything be done about it?
21.
Do women here suffer with headaches in pregnancy?
22.
Why?
23.
Is it a problem?
24.
What can be done about it?
25.
What used to be done?
26.
Do women get abdominal pain in pregnancy?
27.
Why?
28.
Is it a problem?
29.
What can be done about it?
30.
What used to be done?
31.
Do women's feet swell in pregnancy?
32.
Why?
33.
Is it a problem?
34.
What can be done about it?
35.
What used to be done?
36.
Do many women get tired in pregnancy?
37.
Why?
38.
Is it a problem?
39.
What can be done about it?
40.
What used to be done?
41.
Do women get palpitations?
42.
Why?
43.
Do many women get white eye in pregnancy?
44.
Why?
45.
It is a problem?
46.
What can be done about it?
47.
What used to be done?
48.
Do women sometimes want to eat a lot of one thing?
49.
Why?
50.
What do they crave for/want to eat a lot of?
51.
Is it harmful to get cravings?
n n n n a
52,
Have any women you have looked after bled during pregnancy?
53.
If yes, what happened?
54.
What usually causes a woman to bleed in pregnancy - early?
- late?
n non
55.
Is it a problem?
56.
Can anything be done about it?
57.
Who do they usually go to for help?
58.
What did you used to do about it?
Antenatal Care
59.
How do you help or look after a woman when she is pregnant?
60.
Do you only look after pregnant women in your family or do you
see others as well?
61.
Do you examine women when they are pregnant?
regularly, or only when they have problems?
62.
When do you examine them?
63.
Why?
64.
What do you ask her?
65.
Why?
66.
What do you look at?
67.
Why?
68.
What do you feel for?
69.
Why?
70.
How often do you examine
71.
Do you have any problems in examining a pregnant woman?
72.
Which pregnant women would you advise to go to the antenatal clinic?
73.
Why?
74.
Have you referred women to the antenatal clinic?
75.
Why?
76.
Did they go?
Do you see them
a woman when she is pregnant?
77.
Did you go with them?
78.
Which women should deliver in the rural health centre or hospital?
79.
Have you referred women in labour to the rural health centre or
hospital?
80.
Why?
81.
How many?
82.
Did they go?
83.
Did you go with them?
84.
Why do some mothers have difficulty in labour?
85.
Why do some mothers die in pregnancy, labour or shortly after?
86.
Why are some babies born dead or deformed? (Why do some women
miscarry?)
87.
Where does a woman like to deliver her first baby?
88.
Where does she like to deliver her next babies?
89.
Why?
90.
How can a mother ensure that her baby is born healthy?
91.
What traditional medicine do women take in pregnancy?
92.
How do these help her?
93.
Do you take anything with you when you are called to a delivery?
94.
How many traditional midwives are usually present at a delivery?
95.
Do you make any preparations to the house?
96.
Can you show us how you look after a woman who is delivering?
97.
What did you used to do?
98.
When do you encourage the woman to push?
99.
When do the membranes break and the water comes out usually?
100.
If they burst early what happens?
101.
What is labour like if this happens?
102.
How do you deliver the placenta?
103.
What happens if it takes a long time?
104.
How do you cut and tie the cord?
105.
How did you used to cut it?
106.
How do you care for the cord until it drops off?
107.
Do you have olonglongo here?
108.
What is it?
109.
What do you do for it?
110.
What do you do if a woman bleeds after delivery?
111.
How long should labour last?
112.
How do you bury the placenta?
113.
Why?
114,
What do you do for a woman with a tear?
115.
What difference has your training made to your work as a
traditional midwife?
116.
How many deliveries have you done since your training?
117.
How many deliveries have you done this year?
118.
Do you do more or less since your training?
119.
Do you find the rural health centre/hospital helpful and friendly?
120
Do you get information back on the women you send to the
hospital/rural health centre?
121.
Who do some mothers like to go to antenatal clinic?
122.
Why do some not like antenatal clinics?
123.
Why do some mothers prefer to deliver in hospital?
124.
Why do others prefer to stay at home?
125.
How long have you been a traditional midwife?
126.
How did you become a traditional midwife?
127.
How are traditional midwives rewarded for their help?
128.
Is it the same from everyone?
129.
Do you have any problems in your work?
130.
Do you want to ask me anything?
131.
How far is it to the rural health centre?
132.
How far is it to the hospital?
133.
How do you get there?
134.
How long does it take?
135.
When did the last vehicle come here?
Personal Information (not always asked)
136.
How many children do you have now?
137.
Have any others died?
138.
How old are you?
139.
Did you learn to read and write?
Appendix 1 (cont)
Traditional midwives training - Risk Concept
Name:
Position:
Training:
Have you attended a course in training of traditional midwives?
What do you teach the traditional midwives to do for antenatal care
in their village?
Are they taught to diagnose pregnancy?
What are they trained to ask about in history taking?
What are they trained to examine in a pregnant woman?
Are they taught about Bp?
Are they taught about problems in the urine?
What do they provide for the pregnant woman?
What criteria are traditional midwives taught for referral in pregnancy?
When do you teach trained traditional midwives that a woman should
first come for an antenatal checkup?
How often do you expect the woman to attend antenatal clinic?
How often do you expect trained traditional midwives to see a pregnant
woman during her pregnancy?
Number of occasions?
How do you expect the trained traditional midwife to collaborate with
the local clinic and midwives for antenatal clinic?
Appendix 1 (cont)
Trained Traditional Midwives Supervisor Interview
Name;
Age:
Training:
Have you attended a course in the training of traditional midwives?
When? For how long?
How ®ften do you visit traditional midwives in the field?
Did you have problems with visiting the traditional midwives?
How did you spend most of the time during a supervisory visit?
What plans do you have for further supervision?
What plans do you have for further training of traditional midwives?
What ANC is done on a supervisory visit?
What feedback do trained traditional midwives get on women they refer
What problems do you think trained traditional midwives have with
trying to provide good antenatal care?
What do you think needs to be done to improve the ANC which trained
traditional midwives provide?
Do you say that all women should go once to the ANC?
What records do traditional midwives have?
Appendix 2
Health personnel's knowledge of the Risk Concept
1.
Name
2.
Place
3.
No.
4.
Nursing/Professional Qualifications:
( ) ZEN
( ) ZEM
( ) CDE
( ) MW Tutor
( ) ZRN
( ) ZRM
( ) PHN
( ) MR
( ) HA
( ) Midwife
5.
Have you done any midwifery training?
6.
For How long?
7.
How long ago?
8.
How long have you been working in a rural health centre?
9.
Do you help in the antenatal clinic?
10.
Now I want to ask you some questions about what women should do in
pregnancy
10.
What should a woman do to keep herself and baby healthy?
(
(
(
(
(
(
11.
)
)
)
)
)
)
Attend ANC
Eat well
Exercise
Hygiene
Rest
Other specify
When should she first attend antenatal clinic?
( ) Miss one period
( ) Miss two periods
( ) As soon as she knows
12.
In general do women attend antenatal clinic
( ) Regularly
( ) When problems
13.
How often should she come for antenatal care
( ) Monthly till
( ) 2 weekly till
( ) Weekly till
14.
Have you seen any women die in childbirth?
15.
Now I want you to tell me all the reasons you can think o£ that
women die in pregnancy, in childbirth or after the delivery
retained placenta
PPH
infection
slow referral
other ......
ruptured uterus
traditional medicine
prolonged labour
disproportion
abnormal lie
anaemia
eclampsia
PET
bleeding (APH)
abortion
malaria
16.
Have you seen any babies born dead?
17.
Can you tell me all the reasons you know for a baby to be born
dead or die soon after delivery
Prem
<2.5 kg
APH
Asphyxia
Injury
traditional drugs
prolonged labour
abnormal lie
prolapsed cord
infection
tetanus
18.
How can these mothers deaths be prevented?
19.
How can these baby's deaths be prevented?
20.
In the Antenatal Clinic/with a pregnant woman
What things do you look for that indicate that she will face
problems in pregnancy or labour?
- if you like, pretend you are examining someone
Anaemia
eyes, mouth
tongue, hands
Hb talquist
BP'P
Oedema
PET
Urine
Abdomen
- scars
- fundal height
- position
- head/high
- number
VV
Kaha
Pnm
< 18
Pnm 30+
35 +
6+ pregnancies
21.
Do you look for anything in the history?
Previous difficult deliveries SB
NND
Operations
eclampsia/PET
retained placenta
PPH
Bp t
)
APH
) „
Anaemia ) ComPlications of pregnancy
PET
)
Chronic disease disability
Who do you weigh ?
How often?
Do you measure the height?
How?
How short is too short?
How often do you hold Antenatal Clinics
here?
Which women should deliver in hospital?
Pnm
6+
Anaemia
APH
PPH
PET all/severe
Previous SB
NND
Operation
Multiple pregnancy
Malpresentation
22.
Which women should deliver in a rural health centre?
23.
Which women can deliver at home?
24.
Do you have a list of the problems that women can get in
pregnancy so you know who you should send to hospital?
( )
25.
Yes
( )
No
Where is it?
D/K
Wall
File
26.
Do you get information back on women you have referred?
27.
Do all mothers have an AN card?
28.
Do they keep it themselves?
29.
Do you have an Antenatal Register?
30.
Do you have a register of those with special problems?
31.
How do you mark the card to show that a woman should deliver
in hospital?
32.
Is there a place for pregnant mothers who have come far to wait
until they go into labour?
33.
How do you transport emergencies?
ambulance here
fetch ambulance
any vehicle
bicycle
34.
Are there problems with transport?
35.
How do emergencies come to you?
carried
bicycle
or car
36.
Do you give Tetanus Toxoid to pregnant women?
37.
How many times?
38.
Do you have problems with supplies?
39.
Do you have problems with the "cold chain"?
40.
Do you give any drugs or tablets routinely in pregnancy?
( ) Iron
How often?
( ) Folictoid
( ) Chloroquin
Any problems with supplies?
41.
Do you record?
(
(
(
(
(
)
)
)
)
)
Maternal deaths
SBs
NNDs
Number of deliveries
Referrals to hospital
42.
Are there any traditional midwives working near here?
43.
Have you met them?
44.
Do you work with them?
45.
What do you think of the way they work?
46.
Have any of them been trained?
47.
Do you think they should be trained?
Appendix 4a
Check list for Antenatal Record Card Analysis
Recommended place of delivery notes on card
Home
Health Centre
Hospital
Risk factors to be identified
Age less than 18
Age more than 35
Height less than 146 cms
Parity
0 or 5+
Any chronic disease listed
- diabetes
- hypertension
- sickle cell disease
- renal disease
- tuberculosis
- leprosy
- congenital heart defect
- others (specify)
Any major physical deformity of obstetric importance
- polio leg
- deformed pelvis
Weight - less than 35 kgs.
Complication of previous pregnancies
PET (oedema, proteinuria, Bp
Eclampsia
APH
Excessive vomiting
Others
Complications of previous labours
Labour longer than 24 hrs.
Eclampsia
Ruptured Uterus
Obstructed labour
140/90
Complications of previous labours (cont)
Retained placenta
PPH
Others
Abnormal delivery
Caesarian section
number
Forceps
number
Ventouse
number
Outcome
Stillbirths
number
Baby dead in less than
one week
number
Baby less than 2.5 kgs
number
Complications of this pregnancy
Anaemia
PET
Bp
140/90 on 2 occasions
APH
Excessive vomiting
STD
Others (specify)
Multiple pregnancy
Abnormal lie - breech at 36 weeks gestation
- transverse lie
people completing the card
Doctor
Midwife
Trained traditional midwife
Number of antenatal visits made this pregnancy
Weeks pregnant at first visit (by mothers estimation)
Completeness of card
Very incomplete
Maximum of 2 items not complete
Complete
Appendix <b (coni.)
•(
Data Sheet for Indicators of Hirh Risk.
SB
NND
ND
Number
Name
(J O 0 I
Place of Residence
0. Good
1.
distance from hospital.
Poor
Marital Status
0. Harried
1.
Single, divorced, widowed
Age
*
0. Between 16 and 35
Under 16 or over 35
..
1.
|[T U
■
•
Height
0. More than
cms
Less than
c:.is
1.
Parity
0. l-A
1. None or five or more.
Income
0. Medium or high
1. Low
Chronic Disease
0. None
1. Any disease listed
- major physical deformity (specify)
- diabetes
- hypertension
- sickle cell disease
- renal disease
- tuberculosis
- lenrosy
- congenital heart disease
- others (specify)
Nutritional Status
0. 35 kgs or more
1. Less than 35 kgs.
Complications of previous pregnancies
0. None
1. Any:-
anaemia (Hb
9g)
PET (oedema, proteinuria
Bp
Bp
140/90)
140/90 on 2+ occasions
APH
Excessive vomiting
Others (specify)
______
Complications of previous labours
0. None
1. Any:-
prolonged labour
24 hrs.
Eclampsia
Ruptured uterus
Obstructed labour
Retained placenta
PPI I
Others (sTecify)
Type of delivery
0. Normal
1. Not normal
Caesarian section
Ventouse
Forceps
Others (specify)
Outcome of baby
0. Livebirth
1. Stillbirth
Number of still births
Babies dying in the first week
0. None
1. One or more
Number dying in first week.
Birthweight
0. 2.5 kgs or more
1.
2.5 kgs
- small for dates
- preterm
36 weeks gestation
Present Obstetric History
Antenatal care
0. Some
1. None
Complications during this pregnancy
0. None
1. Some:anaemia (Hb
9
)
PUP (oedemia, proteinuria
Bn
Bn
140/90)
140/90 on 2 occasions
ARI
Excessive vomiting
STD
Others (specify)
Present labour
0.
24 hrs.
1.
24 hrs.
Position of babe.
0. Normal vertex
1. Abnormal
breech
transverse lie
Number of babies
0. One
1. 2 or more
Type of delivery
0. Normal
1. Not normal
caesarian section
ventouse
forceps
others (specify)
Maturity
0. 36 weeks +
1.
36 weeks gestation
less 28 weeks
28 - 30
"
31 - 34
"
34 - 36
"
Outcome of child
0. Livebirth
1. Stillbirth
Birthweight
0.
2.5 kgs
1.
2.5 kgs.
Outcome of mother
0. Live
1. Dead
Complications of labour or nuernerium
0. None
1. Any listed
PPII
retained placenta
eclampsia
sepsis
depression
others (specify)
Complications of puerperium - child
0. Alive at 8th day.
'
1. Died in first 7 days.
Was the woman referred
,
0. Mo
1. Yes
e»
Source of referral
0. Self
1. Traditional Midwife
2.
Mid', ife
3.
Doctor.
Reasons for referral
0. None
1. Anaemia
PET
Eclampsia
APH
Prolonged labour
III„
Retained placenta
PPH
Others
Time of referral
0. Mot anplicable/not referred
fl fl f l fl fl f l
1. Antenatally
2.
In Labour
3.
Post Natally
j (
Distance travelled to point of referral
\
1 mile
i
1.
2.1-2 miles
I
3. 3 - 4 miles
4.
4 miles +
;
i j
■ ♦
I
i
Appendix 5
Records study of reasons for fresh stillbirths
All records of stillbirth for the last 1 year were to be studied
to identify if the stillbirth was fresh or macerated.
The records for mothers with stillbirths were to be studied to find
problems associated with overcrowding, e.g. length of labour, length
of second stage, completeness of records, monitoring of foetal .heart.
Appendix 5
Records study of reasons for fresh stillbirths
All records of stillbirth for the last 1 year were to be studied
to identify if the stillbirth was fresh or macerated.
The records for mothers with stillbirths were to be studied to find
problems associated with overcrowding, e.g. length of labour, length
of second stage, completeness of records, monitoring of foetal heart.
Appendix 6a
Antenatal Mothers Questionnaire
1.
Number
2.
Where do you live?
3,
How do you come to antenatal clinic?
4.
How long did the journey take you?
5.
If by bus, how much did it cost?
6.
Why do you come to antenatal clinic?
7.
Did you have any problems with any of your previous pregnancies?
8.
Which mothers should attend antenatal clinic?
9.
Which mothers particularly need to deliver in hospital?
10.
Where was your last child born?
11.
If at home, who helped you deliver the child?
12.
Is she a relative?
13.
If in hospital - did you come to hospital in labour?
14.
Was it because you had problems?
15.
How did you reach hospital?
16.
Were you ever advised to deliver in hospital by a traditional
midwife?
17.
Why?
18.
Were you ever advised to deliver in hospital by a midwife?
19.
Why?
20.
Why do some mothers like to go to the antenatal clinic?
21.
Why do some mothers not like to go to the antenatal clinic?
22.
Why do some mothers like to deliver in hospital and rural health
centre?
23.
Why do others prefer to deliver at home?
24.
How many children do you have now?
25.
Have any of your children died?
(probe)
Appendix 6 b
Questionnaire for mothers in rural health centre/hospital/mothers
shelter
place
No.
1.
Why did you come to hospital to give birth?
2.
Who advised you to come here?
3.
Where do you live?
4.
Were you already in labour when you came?
5.
Did you go to the antenatal clinic?
6.
Why?
7.
Who advised you to go there?
8.
Why do some mothers like to go to antenatal clinic?
9.
Who do some not like antenatal clinic?
10.
Why do some mothers like to deliver in hospital or rural health
centre?
11.
Why do others prefer to deliver at home?
12.
Did you see a traditional midwife for help or advice?
13.
Why?
14.
Which mothers do you think should go to a rural health centre or
hospital to give birth?
15.
What problems may make a woman deliver in a rural health centre
or hospital?
16.
Where would you like to give birth to your next child?
17.
Why?
18.
How did you travel to the hospital or rural health centre?
19.
How long did it take'’
20.
How much did it cost?
21.
How many children do you have now?
22.
Have you had any children that died?
23.
Have you had any problems in previous pregnancies?
Appendix 7
Observation of physical facilities and basic equipment for
ft fl ft ft ft A
antenatal screening and delivery
An observational study of the health centres is to be made to find
out if the following basic facilities are present;-
- adequate waiting space
- adequate shade for protection from heat and rain
- toilet facilities for public
- drinking water facilities for public
- privacy for consultation
Observations are also to be made to find if the following basic
equipment needed for adequate care and screening is available
- examination couch
- delivery room
- table and chairs (minimum 2)
- delivery bed
- weighing scales (that work)
- privacy
- sphygomanometer (that works)
- table for delivery equipment
- tape measure
- suction equipment
- foetal stethoscope
- functioning sterilizer
- urine testing equipment
- oxygen
- blood sample equipment for VDRL
- drops - ergometrine
penicillin
- sterile syringes and needles
- cord ties
- sterilising facilities
- suturing needle and thread
- tetanus vaccine
- catheters
- drugs - iron, folic acid,
- disinfectant - routine for change
chloroquin
- antenatal records for mothers
- forms for statistics
II
Appendix 8
Check list for Antenatal care by Midwives
First visits - Full obstetric history
Mark
0
No
1
Yes
(
) Registration
(
) Age
(
) Problems in previous pregnancies
(
) Problems in previous labours
(
) Retained placenta
(
)
(
) Operative delivery (c/s or forceps etc.)
(
) Any bleeding before delivery
(
) Excessive bleeding after delivery
(
) Any stillborn babies
(
) Any babies dying in the first week
(
) Height
Normal delivery
All visits
(
) Mothers asked if she has any problems
(
) Advice given for these problems
(
) Advice given appropriate
(
) Weight
(
) Urine tested
(
) Blood for serology
(
) Examination of eyes or tongue for anaemia
(
) Blood for Hb.
(
) Examination of legs for swelling
After 7-8 months
(
) Examination of abdomen
(
) Fundal height
(
) Number of babies
(
) Presentation
(
) Checking of foetal heart
After 7-8 months (cont)
If appropriate
(
) Iron
(
) Folic acid
"
(
) Chloroquin
"
(
) Tetanus toxoid
"
given
If appropriate
(
) Mother referred to hospital
) Mother given next appointment
(
(
)Mother advised where to deliver
(
y Length of consultations
(
) Rapport between midwife and woman (tick)
(
) poor
(
) good
(
) Record card completed correctly
If mother is not specifically advised where to deliver, were any
comments made which would make the woman think it would be better
to deliver at home, health centre or hospital?
(
) Home
(
) Health centre
(
) Hospital
(
) What was her comment
(tick)
Appendix 9
Check list for antenatal care provided by trained traditional midwives
First vists - Full obstetric history
0
Mark
1
No
Yes
(
)
Age
(
)
problems in previous pregnancies
(
)
problems in previous labours
(
)
Length of previous labours
(
)
Retained placenta
(
)
Normal delivery
(
)
Operative delivery (c/s or forcepts etc.)
(
)
Any bleeding before delivery
(
)
Excessive bleeding after delivery
(
)
Any still born babies
(
)
Any babies died in first week
Height
All Visits
0
Mark
No
1
Yes
(
)
Mother asked if she has any problems
(
)
Advice given for these problems
(
)
Advice given appropriate
(
)
Examination of eyes or tongue for anaemia
(
)
Examination of legs for swelling
After 7-8 months
Mark 0
No
1
Yes
(
)
Examination of abdomen
(
)
Identification of size of uterus
(
)
Number of babies
(
)
Presentation
(
)
Checking of foetal heart
(
)
Checking of foetal movement
(
)
Mother told when she should be seen again
After 7-8 months (cont)
If appropriate
(
)
Iron
(
)
Folic acid
"
(
)
Chloroquin
"
(
)
Tetanus toxoid
"
given
If appropriate
(
)
Mother referred for routine check-up
(
)
Mother referred for follow up of a problem
(
)
Mother advised where to deliver
(
)
Length of consultation
Rapport between midwife and woman (tick)
(
)
Poor
(
)
Good
(
)
Record card completed correctly
Appendix 10
Checklist of traditional midwives' equipment
Score
0
(
)
Height measure
(
)
Foetal stethoscope
(
)
Drugs
(
)
Iron
(
)
Folic acid
(
)
Chloroquin
(
)
Antenatal records
(
)
Forms for statistics
(
)
Clean and tidy kit
No
1
Yes
(by observation - free of dust, insects and clean)
Cord ties either sterile or method of sterilisation known
Blade
The temporary "antenatal record” used in petauke Hospital
Appendix 11.
* MF
MINISTRY OF HEALTH
MF ■ IQ9 (wi)
OBSTETRIC RECORD HOSP CLINIC NO
Date of Discharge
A.N.C. NO.
HOSPITAL^CLINIC___________________________________ WARD No__________
109
Date of Admission
C.C. NO.
FINAL DIAGNOSIS
REASON FOR ADMISSION
PERSONAL DATA
Surname ------------------ ---------- Other Names
Residential Address
Nat. Reg. No.
Marital Status
Name of Husband
Religion
Postal Address
SUMLARY OF PREVIOUS OBSTETRICAL HISTORY (Especially Abnormalities, e.g. Caesarean S.)
PREVIOUS ILLNESSES/OPERATJONS
PRESENT PREGNANCY
L.M.P.Quickening
E.D.D.Menstrual History
Smmsary of A.N.C. Findir^s: 1st B.P.
at
Pelvic Assessment
W.R.Latest H.B.____
Weeks
Abnormalities
ON ADMISSION
Fundus
Weeks
Temp.
B.P.
Abdominal Palpation
F.H.Urine:
Anaemia
/
Heart
Oedema
P.V./P.R.
Alb.Sugar
Acetone
Abnormalities
Blood
Signature of Examiner
SUMMARY OF LABOUR
Membranes Ruptured Spontaneously/Artificially
Labour Commenced
Date/Time
/
19
Method of Deli very
Duration
1,n.
Stage 1
hrs.
Blood Loss
Infant Delivered,b,
Stage 2
hrs.
Delivered by
Placenta Delivered,m.
Stage 3
hrs.
Fully Dilated
SUMMARY
OF PUERPERIUM
,m.
ml.
Urine
BP
F H.
>
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
M
E
W
id
Temperature (Celsius)
o
A
—
w
m
w
w
oo
*
Day No.
Pulse
Reap.
Date
■■
Date
Treatment (Mot her)
Time
INFANT NOTES
Sign
Heart Rate
Resp.
Tone
Reflex
Sex
0
Absent
Absent
Limp
Nil
All Blue
or White
Colour
Apgar Score at 1 minute
Date
—
Time
Condition at Birth
1
Under 100
Slow Irreg.
Some Flexion
Some Motion
Pink Body
Blue Extre
mities
2
Over 100
Crying
Active
Crying
All Pink
Signed
Clinical Maturity.Birth Weight
Grass
Length at Eirik
Cord Separated on
Day
Abnormalities
Age on Discharge
Days
Discharge Weight
Grams
If Birth Certificate Issued, State Ko,
Treatment (Infant)
-
Signed
-------------------------------------------------------- ----------------------------
Appendix 12a
Action orientated antenatal record card by Dissevelt, Kornman
and Vogel (1975) (12(3>
B
Name
Individual Number
Clinic
Location
Year of birth
[
/
Sublocation
Criteria for Delivery at home
J___ I
Married
Criteria for Delivery at H.C. or Hosp.
Unmarried
Ar,c 1^-35 years______________________ / /_______ Age <15 >35
Previous obstetrical history.
Deliveries
/I /2/3 /I. /
Abortions
E.X27
Stillbirths
no
£_/
yes,
2^7
Abnormal deliveries
no
2__ /
yes,
2W
••
$3 E3
............................................
............................................
....................
••••
*
Caesarian section
Forceps
APH
no
2__ /
FPH
no
2__ /
yes,
yes.
£7
........... ................................
hr
LJ
>2h hr,.
/'<■,/
....................
no
2__ /
yes,
££/
Labour
First vesk mortality
*»
<2
9th mth preu: Head /
/ Other
" !
cun head enter: yes [ I Ko
/•■•'7
Antenatal conclusion for delivery:
At home / / At HC. /Z77 At Hosp,
Reason
Reason for referral during labour
_Physic»l d-»vrlor-rnt.
.1# yus.
Height (cm)
+
160 ’55
Pelvic-inlet (cm)
+
12.0 n-5
13.5 13.0
U.O ,3<5; ;y.e>
Pelvic-cutlet (knuckles)
Abnormalities
.r-7-
Delivery at .................
Alive
/ /
Birthweight
Date
/•?,-.-7
g
Sex
! *' J
Condition child at discharge
Alive
Specimen Antenatal record. Actual size 21 x 30 cm.
Sb
I
!
Died after
hours/dnyr.
Appendix 12b
Action orientated antenatal record card by Essex fa Everett
(1977) (103)
HEIGHT
BELOW H6cm»
FIRST VISIT ONLY
LIMP OR POLIO LEG
HISTORY OF COUGH FOR OVER
ADVICE ABOUT
4
ADVICE
ABOUT 1
DIET
WEANING
SEND SPUTUM
FOR TB TEST
WEEKS
'
‘---------- »
H IS T O R Y
DATE OF VISIT
bleeding since
r
L.M.P **
♦
OTHER
SYMPTOMS
=====
VERY
ANAEMIC **
♦
BP
IF OVER
140/90
♦
*
E X A M IN A T IO N
OEDEMA
PROVE'N
AND
***
FUNDAL HEIGHT
FOETAL HEART
FOETAL LIE
Br * Tf
*
Vx
VERY BIG OR
SUSPECT TWINS *
TREATM ENT
IRON
FOLIC ACID
CHLOROQUINE
TETANUS TOXOID
OTHER
DRUGS
about
Place
——
DELIVERY
OF
A D V 1C E
—
ABOUT
HOW TO
take
treatment
DATE OF
NEXT VISIT
TOLD TO
BRING CARD
Hb
S1S31
PROTEIN
IN
URINE
SPUTUM FOR
IF POSITIVE
TB
NAME
.OTHER COMMENTS
PATIENT SUMMARY
NORMAL
WRITE
DOWN
PAST
HISTORY
THIS
PREGNACY
* mos^yai cci'vcav
•[!(• »o OOCtOB
♦
A(ZCMAA|. »O "OJ*I’H
RISKS
(cont)
Appendix 12 b
RECORD FOR MOTHER
LABOUR
ANTENATAL CARD
RECORD
number
normal OVER 24 HRS
VD CS VAC EX FORCEPS BR OTHER
NORMAL
PPH
(normal I OVER 24 HRS |Iaph
APH
1__ 1
1
J
METHOD OF
DELIVERY
NAME OF
MOTHER
OTHER
VD CS VAC EX FORCEPS BR
NAME OF
HUSBAND
ADDRESS
MANUAL
REMOVAL.
NORMAL PPH
CONDITION
r>E GhTiSExI
Uanual 1
jtemoyal
1
PAST OBSTETRIC HISTORY
WEIGHT SEX[
AT BIRTH
DISCHARGE
AjB'clO fob Ai.v«jo«ia
D r. T
CONDITION
a! BIRTH
DiCHAHGE
A B|C'o|SB Ah««icMad
in
i~
IO
OR MORE PREGNANCIES
LAST PREGNANCY OVER IO YRS AGO
CAESARIAN SECTIONS
VACUUM EXTRACTION OR FORCEPS
|given||not given |
| G/VEN |INOT G
*VEN|
1
3 RO STAGE COMPLICATION
STILLBIRTH IN LAST PREGNANCY OR
MORE THAN I STILLBIRTH
NEONATAL DEATH in LAST PREGNANCY
OR MORE THAN I NEONATAL DEATH
ADVICE ON DISCHARGE
POST natal Clinic
3 OR MORE REPEATED ABORTIONS
PAST MEDICAL HISTORY
A NC ATTENDANCE
NEXT PREGNANCY
NEXT TIME
N0,ts
OVER 2 INFANT DEATHS - REFER
FOR ADVICE ON CHILD WELFARE
family SPACING
hospital DELIVERY
J
YES
~£L
OTHCR
TOLO Im AttP
CARO and BRING
WHEN PREGNANT
j
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