- Email: [email protected]
Delivering women centered maternity care with limited resources: Grenada
Features Reproductive Health Matters, No 4, November 1994
D l veringYomen-CentredMaternity LimitedR sour s Virginia Hight Laukaran, Adity Bhattacharyya and Beverly Winikoff Maternity care in the Caribbean island nation o f Grenada is organised and provided largely by trained nurse-midwives and maternal mortality is relatively low. This paper discusses h o w the various elements o f this care - emphasis on third trimester coverage, health education for women, clear protocols for managing serious complications, round-the-clock coverage, effective referral, good communication and record-keeping, and limited use of physicians and t e c h n o l o g y - can be used as a model b y other countries to reduce maternal deaths.
~
I-IE maternity care system in Grenada can be described as a success in achieving and maintaining a low level of maternal mortality in spite of a limited use of technology. Most maternity care is provided by nurse-midwives, who are trained at government expense on the British model in a threeyear, hospital-based nursing p r o g r a m m e , with an additional nine-month p r o g r a m m e in midwifery. Antenatal care is provided t h r o u g h a network of multi-purpose health centres and smaller health stations t h r o u g h o u t the country. Although midwives are employed in all of these as district nurse-midwives, the majority of births take place in the general hospital. About ninety percent of births are attended by nurse-midwives, as there are 1.5 obstetricians per 100,000 population. Just over ten per cent of w o m e n deliver at home, usually attended by district nurse-midwives, with the r e m a i n d e r of births occurring in medical facilities. Attendance at h o m e deliveries on re ques t of the family is g u a r a n t e e d by the g o v e r n m e n t and this entitlement is u n d e r s t o o d by the population. Gre n a d a has no untrained midwives, presumably because there is g o o d access to qualified ones. Private maternity care seems to be rare. In 1988, less than one p er c e n t of nurse-midwives who attend births w e r e in private practice and less than one percent of normal hospital births w e r e p e r f o r m e d by general practitioners in private practice. Nine p e r c e n t of vaginal deliveries at the general hospital w e r e per-
f o r m e d by obstetricians in 1988, of which many, perhaps most, w o u l d have been done on a private basis. The backbone of the early detection and referral system that controls maternal mortality is in the hands of w o m e n w h o are trained to ser;ve their w o m e n clients with professionalism and compassion. The system of primary health care and midwifery in which they work is part of the British colonial legacy in Grenada. In Britain, as in most developed countries, maternity care has c h a n g e d considerably. In Grenada, maternity care still follows an older pattern, using only limited technology. This is mainly because of the cost of technology, the need for highly trained personnel to use it and the cost and difficulty of maintaining it. The Grenadian materniW system is very small in scale and part of a health care system w h o s e basic infrastructure is already in place. Because of its successes, its applicability as a model for other countries is w o r t h y of consideration, t h o u g h many of its features may not easily be replicable elsewhere. This p ap er attempts to identify the operational features and the most essential factors that contribute to safe pregnancy for w o m e n in this setting, and give some indication of what w o u l d be required for these to succeed in other settings.
BACKGROUND G r e n ad a is located in the southern Caribbean, 90 miles from the mainland of Latin America. It is a very small country, less than 650 square kilo-
Illl
Laukaran, Bhattacharyya and W i n i k o f f
m e t e r s . T h e p e r c a p i t a i n c o m e w a s U S $ 960 in 1987 a n d t h e i n f a n t m o r t a l i t y w a s 18.1 p e r 1,000 live b i r t h s . T h e b i r t h r a t e w a s o v e r 30 p e r 1,000 p o p u l a t i o n a n d 37 p e r c e n t of t h e p o p u l a t i o n w e r e u n d e r 15 y e a r s o f age. T h e r e a r e s e v e n p r i m a r y h e a l t h c a r e c e n t r e s , o n e in e a c h o f t h e p a r i s h e s o f t h e i s l a n d of G r e n a d a a n d o n e o n t h e i s l a n d of C a r r i a c o u , plus 29 satellite h e a l t h s t a t i o n s t h a t p r o v i d e m o r e limited h e a l t h s e r v i c e s . T h e r o a d s y s t e m a n d t e l e p h o n e s e r v i c e a r e well d e v e l o p e d . B o t h geography and infrastructure provide the f o u n d a t i o n f o r a n effective p r i m a r y h e a l t h c a r e system. In t h e first six m o n t h s o f 1990, w e c o n d u c t e d a s t u d y o f G r e n a d a ' s m a t e r n i t y c a r e s y s t e m . Details o f s t u d y m e t h o d s a n d f i n d i n g s a r e a v a i l a b l e f r o m t h e p r o j e c t r e p o r t . 1 S t u d y m e t h o d s included direct observation, interviews with midwives, d a t a c o l l e c t i o n f r o m r e c o r d s at all levels o f services, including information on transfer of p a t i e n t s , m a n a g e m e n t o f c o m p l i c a t i o n s in t h e parishes, and a hospital chart review of comp l i c a t e d c a s e s f r o m 1987 a n d 1988 to o b t a i n information on treatment of complications and specifics o f care. The great majority of antenatal and intraparturn c o m p l i c a t i o n s a r e r e f e r r e d to St G e o r g e ' s G e n e r a l H o s p i t a l f o r t r e a t m e n t . T h e s m a l l e r dist r i c t h o s p i t a l is n o t e q u i p p e d to h a n d l e o b s t e t rical e m e r g e n c i e s o r p e r f o r m c a e s a r e a n s e c t i o n s . Data on maternal deaths were obtained from h o s p i t a l r e g i s t r y b o o k s , w a r d a n d m e d i c a l staff, District N u r s e M i d w i v e s , a n d t h e R e g i s t r a r G e n e r a l ' s Office. A s e a r c h w a s m a d e o f t h e r e g i s t r y list of all d e a t h s in 1987-88 a m o n g w o m e n a n d girls 12q48 y e a r s o f a g e a n d d e a t h c e r t i f i c a t e s were examined for any that mentioned pregnancy or might plausibly relate to reproductive causes.
In 1987 a n d 1988 t h e r e w e r e six m a t e r n a l d e a t h s a m o n g 5,803 h o s p i t a l deliveries. T w o o f t h e s e w e r e d u e to e c t a m p s i a ; t h e o t h e r f o u r w e r e d u e to a r u p t u r e d e c t o p i c p r e g n a n c y , s e p t i c shock, antepartum haemorrhage, and postpart u m h a e m o r r h a g e c o m p l i c a t e d b y sickle cell disease. Based on hospital records, the frequency of b r e e c h p r e s e n t a t i o n w a s 2.2 p e r cenL t h o u g h uneventful breech deliveries were not always r e c o r d e d . No c a s e s o f o b s t r u c t e d l a b o u r occ u r r e d . P r o l o n g e d l a b o u r o c c u r r e d in a n esti-
m a t e d 2.5 p e r c e n t o f deliveries, p o s t p a r t u m h a e m o r r h a g e in 7.7 p e r cent, a n d d i a b e t e s in j u s t u n d e r 1 p e r cent. T h e r e w e r e c a e s a r e a n s e c t i o n s in 3.9 p e r c e n t of G e n e r a l H o s p i t a l deliveries. T h u s , t h e m a t e r n a l d e a t h r a t e is relatively low, i n d i c a t i n g a s u c c e s s f u l m a t e r n i t y care system. 2
O R G A N I S A T I O N A N D DELIVERY OF MATERNITY CARE C o m p r e h e n s i v e a n t e n a t a l c a r e is a c c e s s i b l e to all w o m e n in G r e n a d a f r e e o f c h a r g e t h r o u g h nurse-midwives, with referral to an obstetrician in a n e m e r g e n c y . T h e quality o f c a r e c a n b e a t t r i b u t e d t o t h e t r a i n i n g p r o g r a m m e at t h e G e n e r a l H o s p i t a l a n d t h e q u a l i f i c a t i o n s of t h e m i d w i v e s , w h i c h p e r m i t t h e m to a p p l y t h e i r k n o w l e d g e in i n d i v i d u a l c a s e s a n d to m a k e sophisticated judgements. T h e s u c c e s s o f t h e s y s t e m r e s t s in p a r t o n t h e e a r l y d i a g n o s i s of k e y c o n d i t i o n s at a p o i n t w h e n t h e y c a n still b e t r e a t e d successfully. E a s y a c c e s s to a n t e n a t a l c a r e is m a d e p o s s i b l e b y t h e n e t w o r k o f h e a l t h s t a t i o n s , w h i c h a r e usually w i t h i n w a l k i n g d i s t a n c e o f m o s t villages, a n d b y t h e p r e s e n c e o f a q u a l i f i e d n u r s e - m i d w i f e in e a c h o f these. The dispersal of the primary health care c e n t r e s a l l o w s w o m e n g r e a t e r a c c e s s to c a r e , k e e p s t h e c a r e p r o v i d e r in t h e c o m m u n i t y ; a n d encourages greater understanding o f local n e e d s . This in t u r n e n c o u r a g e s g r e a t e r t r u s t in t h e r e l a t i o n s h i p b e t w e e n p r o v i d e r a n d client a n d facilitates s u c c e s s f u l c o m p l i a n c e w i t h m e d i c a l recommendations, follow through on referrals, and comprehension on the part of the care provider of individual needs. P r o g r a m m e s s e e k i n g to r e p l i c a t e t h i s a c c e s s w o u l d h a v e to r e d i r e c t r e s o u r c e s to r u r a l h e a l t h facilities. P r o v i s i o n o f m i d w i f e r y s e r v i c e s in r u r a l a r e a s s h o u l d b e less costly t h a n p h y s i c i a n s e r v i c e s a n d e a s i e r to a c h i e v e .
Emphasis on third trimester coverage In G r e n a d a , as in o t h e r places, m a n y w o m e n d o n o t i n i t i a t e a n t e n a t a l c a r e until m i d - p r e g n a n c y . However, most life-threatening complications eclampsia and pre-eclampsia, haemorrhage, o b s t r u c t e d l a b o u r , s e p s i s - a r e m o r e likely to o c c u r in t h e t h i r d t r i m e s t e r a n d a r o u n d b i r t h . S i n c e c o v e r a g e o f a n t e n a t a l c a r e in t h e t h i r d
1121
Reproductive Health Matter& No 4, November 1994
trimester seems to be excellent in Grenada, complications that eventuate in fatal outcomes are rarely missed. P r o g r a m m e s with p o o r c o v e r a g e may wish to set a goal of 100 p er c e n t c o v e r a g e for third trimester care before increasing the p r o p o r t i o n of first trimester care. F u r t h e r m o r e , if early initiation of care is over-emphasised, the result in some places could be a falling off in the proportion of w o m e n wh o c o m e for third trimester care, particularly if there are fees for antenatal care.
Emphasis on health education Health education is given strong emphasis in Grenada's antenatal care, particularly for primigravidae. Individual counselling or g r o u p sessions are used, d ep en d i n g on the size of the clinic, the pattern of attendance and the priorities of the nurse-midwife. Individual sessions are conducted by the midwife, while g r o u p sessions are led either by the midwife or a student u n d e r her supervision. This education emphasises the particular signs of p r e g n a n c y complications; when, w h e r e and h o w to seek care; and health and nutrition information. Other p r o g r a m m e s that wish to incorporate successful patient education in antenatal care would need to give appropriate attention to the inclusion of these elements in the protocols for antenatal care, particularly for primiparas, and strong emphasis in midwifery training to the acquisition of educational skills. The effects of such an emphasis in G r e n a d a w e r e often mentioned by the midwives and students we interviewed and w e r e also clear in the educational sessions w e observed.
Laboratory services Provision of laboratory services is a major challenge to the health care system and is given high priority by antenatal care providers. Because laboratory facilities are located only at the General Hospital in St George's, considerable time and effort is devoted to weekly transport of blood and other laboratory samples to the hospital and to obtaining the test results. The specific a r r a n g e m e n t s vary in different parishes but lost samples, broken tubes, and lost results are am o n g frequently m e n ti o n e d problems. Although in some areas it is difficult to complete the laboratory work before the w o m a n
delivers, nurse-midwives value the completion of laboratory results and devote considerable effort to transport a r r a n g e m e n t s and to follow up and repeat laboratory w o r k in o r d er to use the test results. A large part of the effectiveness of laboratory testing comes from nurse-midwives ensuring that they get the results.
Most deliveries attended by nurse-midwives Maternity care in G r e n a d a makes very sparing use of physician services, supplies or equipment. Thus, general physicians w h o have no obstetrical training rarely attend deliveries. Forceps deliveries w e r e rarely used (7 per 1,000 General Hospital deliveries), caesareans w e r e p e r f o r m e d in only 3.9 percent of General Hospital deliveries, and vacuum extraction was not used at all during the study period. All normal deliveries and most other vaginal deliveries are attended by nurse-midwives. These involve limited use of medications, interventions or diagnostic tests. Hospital protocols require that the p r o g r e s s of the first stage of labour is m o n i t o r e d every four hours by vaginal examination, and vital signs and any other symptoms are also monitored. In practice, there are an average of 19 w o m e n on the maternity w a r d at any one time and t w o midwives and an assistant are responsible for their care. On many occasions, adhering to the protocols may be difficult. Student midwives rotate on and off the ward. Nurse-midwives monitor fetal condition with a fetoscope, a traditional adapted short stethoscope for use on the enlarged abdomen, and by checking for m e c o n i u m staining of the amniotic fluid. During the second stage, the w o m a n is transferred to the delivery r o o m w h e r e she is attended by qualified midwives or student midwives on rotation. Most w o m e n receive no intravenous drip, no episiotomy, and no routine analgesics or anaesthesia. Episiotomies w e r e carried out for only 1.5 percent of births; yet the proportion of w o m e n with second d e g r e e lacerations was only 5.6 p er cen t and third degree lacerations only 0.06 percent. Although normal deliveries are allowed to progress without intervention, midwives are trained to recognise early signs of intrapartum complications and to notify specialist obstetricians, w h o serve as consultants, for guidance.
1131
Laukaran, Bhattacharyya and Winikoff
L i m i t e d u s e o f p h y s i c i a n s and technology The m a n a g e m e n t of labour and delivery makes minimal use of expensive t e c h n o l o g y in Grenada. This limits costs and foreign exchange expenditures, minimises the allocation of scarce skilled personnel, and reduces maintenance and monitoring of equipment at the expense of patient care. In contrast, many developing countries rely heavily upon physicians to attend uncomplicated deliveries, which is likely to increase costs. Even w h e r e the supply of physicians is high, there is often a lack of qualified personnel in low income and rural areas. Often, the driving force in limitin 9 the use of midwives is the oversupply of physicians in higher income, urban areas. Countries faced with such p r o b l e m s may wish to consider increasing the utilisation of midwives for uncomplicated deliveries in regions or areas w h e r e physicians are scarce and incomes are relatively low. This would imply changes in training, credentialin9, legal aspects of service delivery, and d e v e l o p m e n t of locally appropriate protocols for care. A n o t h e r benefit of such a strategy might be to decrease reliance on m o r e costly hospital deliveries, since normal deliveries could be performed by nurse-midwives in out-of-hospital centres or at home, d e p e n d i n g on the setting, provided that the necessary infrastructure for transfer and backup are established. This redirection of resources is likely to result in savings and o t h er benefits, since the same transport and referral systems can be used for all types of e m e r g e n c y medical care, not just for maternity cases. Qualitative research on w h a t w o m e n value in birthing care is necessary first, in o r d e r to ensure that out-of-hospital settings are accepted and desired. In Grenada, there was inadequate staffing of free-standing birthing centres, with the result that w o m e n w e r e sent or referred themselves directly to hospitals. Clear protocols for managing serious complications The effectiveness of the referral and t r e a tm e n t system for pre-eclampsia, antepartum h a e m o r rhage, gestational diabetes and malpresentation seems to be essential to the attainment and maintenance of low maternal mortality in Grenada. While Grenadian nurse-midwives take con-
siderable responsibility, there are clear protocols for the m a n a g e m e n t of major life-threatening complications, which are known, understood, and utilised by the great majority of them. Their c o m m i t m e n t to following this process was demonstrated in practice and in interviews. One of the unique features of the referral and t r eat m en t system in Grenada is that w o m e n w h o are referred for diagnosis of a suspected complication, for example, gestational diabetes, do not continue to receive care at the higher level to which they are referred unless the severity of the condition or unresponsiveness to t r e a t m e n t require continuation of seco n d ar y level care. W h e n e v e r possible, the patient is sent back to the referring midwife with instructions for follow-up at the lower level as needed. W h e n necessary, the District Nurse-Midwife visited the h o m e of the patient to provide follow-up care. The return of the patient to the iower level of care is necessary in o r d er t o r a t i o n the consulting obstetrician's services. This also permits access for those in need of urgent care rather than overloading the consultant's roster with routine follow-up. The chart review of p r e g n a n c y complications revealed that most cases w e r e detected early e n o u g h to be treated successfully and avert maternal deaths. F o r less severe conditions, that do not rep r esen t a clear risk of maternal death but may predispose to p o o r e r maternal or fetal outcome, however, t h er e was less a g r e e m e n t a m o n g different midwives on what the protocols for t r eat m en t were. Conditions that received attention but w e r e considered to have l o w er priority were: m o d e r a t e or mild anaemia, previous low birth w e i g h t in the infant, previous p r e m a t u r e labour, previous fetal loss, stillbirth or p o o r obstetrical history, fetal distress in labour, p r o l o n g e d gestation or p r o l o n g e d first stage of labour. Efforts to reduce the stillbirth rate w e r e u n d e r w a y during the study period. Round-the-clock coverage Midwives are mostly able to see all their patients from 8am to 12-1pm. This allows several hours in the afternoon to follow up on laboratory results, referrals and appointments. In addition, roundthe-clock availability of nurse-midwives in each health centre and station is almost certainly a key element in the successful t r eat m en t of complications of pregnancy, labour and delivery.
1141
Reproductive Health Matters, No 4, November 1994
In t h e s t u d y p e r i o d , all c a e s a r e a n s e c t i o n operations were performed by one of two obstetric c o n s u l t a n t s . G e n e r a l p h y s i c i a n s did n o t perform caesareans even on an emergency basis. Until r e c e n t l y , t h e t i m e d e l a y b e t w e e n t h e decision to p e r f o r m a c a e s a r e a n a n d t h e . i n i t i a t i o n o f s u r g e r y w a s o f t e n 2-3 h o u r s , e s p e c i a l l y at night. Operating theatre nurses, blood technicians, anaesthesiologists, and sometimes pharm a c i s t s h a v e to b e called in f r o m h o m e b e t w e e n 4pm and 8am and on weekends. The hospital d r i v e r f r e q u e n t l y s p e n d s h o u r s p i c k i n g t h e m up. Coverage for emergency surgery was improved by requiring a junior nurse to remain on the p r e m i s e s 24 h o u r s a day. S e n i o r s t a f f still c o m e from home, but they can scrub for surgery immediately because the operating theatre has been prepared by the junior nurse while they are in t r a n s i t . Essential linkages for effective referrals It is useful to c o n s i d e r t h e s t e p s t h a t a r e n e c e s s a r y f o r s m o o t h a n d s u c c e s s f u l l i n k a g e s in the referral system: • T h e p a t i e n t a t t e n d s t h e a n t e n a t a l clinic b e f o r e the condition becomes severe. • T h e n u r s e - m i d w i f e o b t a i n s clinical o r l a b o r a t o r y e v i d e n c e a n d p r o p e r l y a n d c o r r e c t l y determines the need for a referral. • The nurse-midwife successfully communic a t e s t h e i m p o r t a n c e o f a r e f e r r a l to t h e pregnant woman, and where appropriate her family, b y p r o v i d i n g h e a l t h e d u c a t i o n a n d m o t i v a t i o n as n e e d e d . • The nurse-midwife contacts the referral c e n t r e a n d o b t a i n s a specific a p p o i n t m e n t at a clinic a n d t h e p a t i e n t a t t e n d s t h e a p p o i n t m e n t as s c h e d u l e d . • I n e m e r g e n c y cases, t h e n u r s e - m i d w i f e n o t i fies t h e h o s p i t a l m a t e r n i t y u n i t o f a n i n c o m i n g e m e r g e n c y a n d t h e w o m a n is p r o v i d e d w i t h emergency transport. • The nurse-midwife schedules a follow-up visit f o r t h e w o m a n , t o e n s u r e t h a t s h e h a s a t t e n d e d t h e s e c o n d a r y level clinic as p r e s c r i b e d , h a s b e e n a t t e n d e d to a n d / o r g e t s t h e r e c o m m e n d e d t r e a t m e n t as n e c e s s a r y . • If t h e w o m a n fails to a t t e n d f o r t h e f o l l o w - u p visit, t h e m i d w i f e c o n t a c t s t h e w o m a n t o ensure that her condition has been taken c a r e of.
With the most serious pregnancy complications, t h e o m i s s i o n o f a s i n g l e s t e p in t h i s p r o c e s s w o u l d r e s u l t in t h e risk o f d e a t h . In G r e n a d a , t h e f r e q u e n c y o f m i s s e s in t h i s s e q u e n c e o f e v e n t s m u s t b e r a r e s i n c e t h e r e is a d o c u m e n t e d f r e q u e n c y o f c o m p l i c a t i o n s , yet a l o w m o r t a l i t y .
A n t e n a t a l r e c o r d c a r d r e t a i n e d by t h e woman T h e a n t e n a t a l r e c o r d c a r d is also e s s e n t i a l to c o m m u n i c a t i o n , s i n c e it s u m m a r i s e s all clinical and laboratory findings, any treatment or conc l u s i o n s , a n d r e c o m m e n d e d follow-up, w h i c h a woman then keeps and carries with her between p r i m a r y a n d s e c o n d a r y level clinics. Patient-retained record cards have been used n o t o n l y in G r e n a d a b u t also in o t h e r c o u n t r i e s . This s y s t e m o f r e c o r d k e e p i n g c a n b e v a l u a b l e in e m p o w e r i n g w o m e n t o t a k e c o n t r o l of t h e i r o w n care. W h e n h a n d i n g o v e r t h e c a r d , t h e y c a n t a k e the opportunity to communicate their own needs a n d c a n feel t h e y a r e p r o v i d i n g t h e b a c k g r o u n d i n f o r m a t i o n t h e p r o f e s s i o n a l s n e e d to d i a g n o s e and treat them.
Good communication C o m m u n i c a t i o n b e t w e e n n u r s e - m i d w i v e s at t h e p r i m a r y c a r e clinics a n d t h e r e f e r r a l c e n t r e s is e s s e n t i a l to t h e s m o o t h f u n c t i o n i n g o f t h e s y s t e m . S u c h c o m m u n i c a t i o n w a s f a c i l i t a t e d b y t h e existence of strong informal networks among the nurse-midwives, who have their training and social b a c k g r o u n d in c o m m o n . M a i n t e n a n c e o f t h i s i n f o r m a l social n e t w o r k in G r e n a d a w a s j u d g e d to b e a n i m p o r t a n t a s p e c t o f t h e s u c c e s s o f t h e m a t e r n i t y care. Face-to-face meetings among midwives are usually f o r m a l a n d t a k e p l a c e o n c e m o n t h l y at t h e p a r i s h level. T h e y a r e m a i n l y for t h e p u r p o s e o f administrative coordination and supervision, r a t h e r t h a n f o r c o m m u n i c a t i o n o f clinical information. Parish supervisors, who are public health nurses, attend a similar monthly meeting at t h e M i n i s t r y o f H e a l t h . T h e s e f a c e - t o - f a c e m e e t i n g s w e r e n o t t h o u g h t t o b e e s s e n t i a l to t h e m a i n t e n a n c e o f c o m m u n i c a t i o n o r o f social n e t w o r k s . It w a s j u d g e d t o b e m o r e i m p o r t a n t to have radio or telephone communication for e m e r g e n c y use. In a l a r g e r s y s t e m , w h e r e t h e r e a r e m a n y m o r e s t a f f a n d less o p p o r t u n i t y t o m e e t i n f o r m ally, s u c h m e e t i n g s m a y b e d e e m e d to b e m o r e
15 I
Laukaran, Bhattacharyya and Winikoft'
important. At the same time, providing midwives with field radios might be considered to permit both the communication of necessary information and the maintenance of a functional, professional network. Empowering nurse-midwives empowers pregnant women Several features of the Grenadian system are emp o w e r i n g for nurse-midwives and their clients. Well trained nurse-midwives in local settings provide a tangible role model for the benefits of h i g h e r education. Nurse-midwives r e p r e s e n t their w o m e n clients from positions of responsibility, are able to help to maintain life, and have the authority to get the health care system to r e spo n d to the w o m e n ' s needs and desires. The service e m p o w e r s p r e g n a n t w o m e n by letting them make their o w n choices as they take advantage of health care. In o r d e r to see a nursemidwife, w o m e n need not rely on expensive t ra ns p o r t n o r on the permission or acquiescence of others. Finally, communication a m o n g the midwives is e m p o w e r i n g because it provides a structured forum in which a cadre of professional w o m e n can share their problems and needs. Other countries wishing to e m p o w e r nursemidwives would need to consider the develo p m e n t of strong training and credentialing p r o g r a m m e s , clear n o r m s and job descriptions, adequate salary and benefits, and standards to permit the d ev el o p m e n t of a high level of professional practice.
C L I N I C A L M A N A G E M E N T OF O B S T E T R I C COMPLICATIONS T h r o u g h o u t the world there has been much interest in the use of social indicators such as age, parity, and socioeconomic status to identify high risk pregnancy, in o r d e r to focus antenatal care t o w a r d those wh o m e e t specific risk criteria. However, the sensitivity and specificity of such indicators is limited. 3 A l t h o u g h the strategy outlined by the Pan American Health Organisation for maternal and child health in the Caribbean suggests that the utilisation of a risk-based approach may be advisable, no effort is m a d e in Gren ad a to identify high risk pregnancies according to social criteria. 4 Instead, clinical conditions, specific to each
woman, are indications for referral. These include: severe oedema, hypertension, albumin or glucose in urine, severe anaemia, bleeding, small-for-dates abdomen, large-for-dates abdomen, malpresentation, or suspected multiple pregnancy. W h e n these or other signs of possible complications are detected by the nursemidwife in the antenatal clinic, the w o m a n is referred to the obstetrical clinic for evaluation. P r o g r a m m e s wishing to replicate this feature of the G r en ad i an system would need to shift resources away from the risk identification process and establish m i n i m u m standards of care, to permit early diagnosis of potentially fatal conditions. Although this would imply a shift of resources from seco n d ar y to p r i m ar y care, it leads to a r e d u c e d case load at the secondary level and to earlier initiation of care, w h e n conditions are m o r e easily treatable. There is one exception. W o m e n with m o r e than five previous births are e n c o u r a g e d to deliver in hospital because of the increased risk of complications. Potential cases of obstructed labour are referred to hospital on an urgent basis. The actual prevalence of obstructed labour is hard to d e t e r m i n e because cephalopelvic disp r o p o r t i o n is rarely diagnosed in Grenada. X-ray pelvimetry is not used to diagnose it and every w o m a n is given a trial of labour. Pre-eclampsia is detected in antenatal clinics and referrals are made for further treatment. P r o g r a m m e s benefit from the d e v e l o p m e n t and implementation of strict protocols for referral and t r eat m en t of pre-eclampsia, generally the cause of maternal mortality with the longest lead time from onset to outcome, thus permitting early intervention in most cases. W h e r e nursemidwives are not available, p r o g r a m m e s could consider training other health workers and equipping them to take blood pressures and refer w o m e n with elevated readings. Postpartum w o m e n are observed carefully for excessive blood loss and most bleeding complications are m a n a g e d without blood replacement. The only routine medication used for births attended by a midwife is 5 IUs of oxytocin given at the birth of the head of the baby - to assist in clamping down uterine vessels and minimise blood loss. Any hospital patient who loses 500 mls of blood is considered to have excess blood loss; the -
1161
Reproductive Health Matters, No 4, November 1994
o b s t e t r i c i a n is n o t i f i e d a n d t r e a t m e n t is i n i t i a t e d immediately. When the physician arrives, the p a t i e n t is e x a m i n e d t o d e t e r m i n e t h e c a u s e of bleeding and any retained placental fragments a r e r e m o v e d . If b l e e d i n g c o n t i n u e s , i n t r a v e n o u s fluids a n d s o m e t i m e s e r g o m e t r i n e a r e a d m i n i s t e r e d . T h e t h i r d level o f t r e a t m e n t , r a r e l y u s e d , is w h o l e b l o o d , p r e f e r a b l y f r o m r e l a t i v e s o r f r o m t h e b l o o d b a n k . In 1987-88 t h e r e w e r e 246 w o m e n at t h e G e n e r a l H o s p i t a l w i t h p o s t p a r t u m h a e m o r r h a g e , a r a t e o f 7.7 p e r cent. O n l y 17 u n i t s of b l o o d w e r e u s e d in t h e y e a r f o r w h i c h d a t a w e r e available. In o u t p a t i e n t m a t e r n i t y units, b l o o d loss is m o n i t o r e d in m u c h t h e s a m e m a n n e r as it is in t h e h o s p i t a l . In c a s e s o f i n c r e a s e d b l e e d i n g , t h e s a m e t y p e o f t r e a t m e n t is used. H o w e v e r , if first stage treatment does not stop the bleeding, intrav e n o u s fluids a r e g i v e n a n d a n i m m e d i a t e t r a n s fer to t h e G e n e r a l H o s p i t a l is initiated. A t h o m e b i r t h s , t h e m i d w i f e is e q u i p p e d w i t h o x y t o c i n a n d p r o c e e d s in g e n e r a l l y t h e s a m e m a n n e r . For other programmes, an alternative strate g y m i g h t b e t o t r a i n b i r t h a t t e n d a n t s in t h e m a n a g e m e n t o f all c a s e s o f e v e n m o d e r a t e b l e e d i n g w i t h u s e o f o x y t o c i n a n d r e f e r r a l to t h e n e a r est h e a l t h facility. Local h e a l t h c e n t r e s w o u l d n e e d to b e e q u i p p e d to h a n d l e s u c h cases. P o s t p a r t u m i n f e c t i o n s a r e t r e a t e d in p r i m a r y health centres and health stations. Grenadian women with a normal recovery and healthy newborns are discharged from hospital a p p r o x i m a t e l y 12 h o u r s p o s t p a r t u m . S i n c e t h e s i g n s o f p o s t p a r t u m i n f e c t i o n a r e likely to s h o w up o n l y a f t e r d i s c h a r g e , w o m e n a r e ref e r r e d to t h e i r local h e a l t h c e n t r e o r s t a t i o n f o r p o s t p a r t u m c a r e a n d a r e i n s t r u c t e d to r e p o r t t h e r e in c a s e o f fever, foul d i s c h a r g e , pain, o r problems with the neonate. T h e key f e a t u r e s in p r e v e n t i o n of fatal infections are patient education to recognise the signs of infection and the importance of treatm e n t , availability of a n t i b i o t i c s at m u l t i p l e service d e l i v e r y p o i n t s , a n d a n a w a r e n e s s a m o n g care providers of the importance of management of p o s t p a r t u m f e v e r s a n d o t h e r s i g n s o f infection.
POSTPARTUM CARE H e a l t h c e n t r e s t a f f a r e m e a n t to visit in t h e first f e w d a y s p o s t p a r t u m to e x a m i n e b o t h m o t h e r a n d b a b y a n d t o e n c o u r a g e t h e m to s e e k c a r e
e a r l y if n e e d e d . A t t h e s e visits, c a r e o f t h e i n f a n t and breastfeeding advice are given and an a s s e s s m e n t is m a d e o f t h e risk of p r o b l e m s o c c u r r i n g . If t h e r e a r e e x i s t i n g o r p o t e n t i a l p r o b lems, o n e o r m o r e a d d i t i o n a l h o m e visits a r e m a d e . H o w e v e r , n o t all h e a l t h c e n t r e s a n d s t a t i o n s in G r e n a d a h a v e sufficient s t a f f to m a k e t h e s e h o m e visits o n a r e g u l a r b a s i s a n d s t a f f d o n o t a l w a y s find o u t w h e n p a t i e n t s h a v e d e l i v e r e d . T h e p r o t o c o l f o r p o s t p a r t u m c a r e also calls f o r a p h y s i c a l e x a m i n a t i o n o f t h e m o t h e r at six w e e k s p o s t p a r t u m , at w h i c h t i m e f a m i l y p l a n n i n g is o f f e r e d . As in o t h e r d e v e l o p i n g c o u n t r i e s , t h e a c t u a l c o v e r a g e is v e r y low. T h e r e a s o n f o r this p o o r c o v e r a g e , in t h i s p a r t i c u l a r c o n t e x t , w a s r e p o r t e d as r e l u c t a n c e o n t h e p a r t o f G r e n a d i a n w o m e n to o b t a i n s u c h c h e c k - u p s s i n c e t h e y w i s h to a v o i d pelvic e x a m i n a t i o n s , a n d p a r t i c u l a r l y p a p s m e a r s , w h i c h a r e c o n s i d e r e d to b e painful. I n f a n t s u r v i v a l in G r e n a d a c o m p a r e s f a v o u r ably w i t h o t h e r C a r i b b e a n n a t i o n s . All h e a l t h y babies room-in with their mothers and are b r e a s t f e d . I n f a n t f o r m u l a is a v a i l a b l e o n l y w i t h special orders and premature babies are given e x p r e s s e d b r e a s t m i l k . H i g h risk n e o n a t a l c a r e w a s l i m i t e d b y lack o f i n c u b a t o r s a n d o t h e r e q u i p m e n t , b u t r e c e n t l y a special c a r e n u r s e r y h a s b e e n e s t a b l i s h e d f o r low b i r t h w e i g h t a n d sick b a b i e s .
CONCLUSIONS Grenada provides an illustration of a maternity c a r e s y s t e m w i t h v i r t u a l l y all b i r t h s a t t e n d e d b y qualified m i d w i v e s , w h o m a i n t a i n a c o m p l e x , reliable, a n d well r e g a r d e d p r i m a r y c a r e s y s t e m and who keep the load on the secondary system a n d t h e f e w o b s t e t r i c i a n s at a low a n d w o r k a b l e level. A g o o d f u n c t i o n i n g r e f e r r a l s y s t e m m a k e s this possible. The essential features of the referral system are the use of a maternity record card t h a t is k e p t b y t h e w o m a n , effective c o m m u n i c a t i o n a m o n g p r i m a r y c a r e p r o v i d e r s a n d be~ t w e e n t h e p r i m a r y a n d s e c o n d a r y c a r e levels, a n efficient e m e r g e n c y t r a n s p o r t s y s t e m , a n d r e f e r ral b a c k to p r i m a r y level as s o o n as p o s s i b l e . T h e G r e n a d i a n s y s t e m m a k e s n o e f f o r t to use social c r i t e r i a to p r e d i c t risk s t a t u s t o m o d i f y t h e antenatal care package. Midwives refer women f o r s e c o n d a r y c a r e o n l y w h e n t h e i n d i c a t i o n s of
1171
Laukaran, Bhattacharyya and Winikoff
complications arise. Efforts are concentrated on providing every w o m a n with a basic standard of primary care, with emphasis on the third trimester of p r e g n a n c y and delivery. Until recently, there w e r e notable gaps in secondary level care, due to limited availability of medications, x-ray, laboratory facilities, and operating theatre space. Nevertheless, relatively good maternal survival had been achieved in G r e n ad a even before these recent improvements, making it a p p a r e n t that the system of maternity care is not only h u m a n e but also effective. Further effort is n e e d e d to increase the c o v e r a g e and acceptability of routine postpartum care. The g o v e r n m e n t continues to seek to reduce maternal mortality, stillbirths and perinatal death rates to a minimum. Obstacles to applying this system in other countries can be substantial. In a n u m b e r of countries, such as Uganda, Ghana, Malawi, and Zimbabwe, the midwifery system established under the British continues, and midwives enjoy professional recognition, respect and social status in their communities. However, there are not e n o u g h of them and the infrastructure, referral networks and resources for providing the same level of care as in Grenada are less developed. In other countries, midwifery has n e v e r attained a high status and the professionalism e n c o u r a g e d by the British system is lacking. In India, for example, this may be due to cultural and religious prohibitions that limit contact with body fluids considered to be unclean, such as those during childbirth, to people with low status. In still other countries, maternity care in the formal sector is firmly u n d e r the parvenu of physicians, as in much of Latin America. In many
p o o r e r countries, traditional birth attendants have been kept largely outside the formal sector and relatively or totally untrained. With or w i t h o u t an extensive primary health care system, there may be interest in developing c o m m u n i t y - b a s e d midwifery care. Such a system is currently u n d er d ev el o p m en t in Indonesia on a massive scale, w h e r e 18,000 of an intended 34,000 c o m m u n i t y midwives are being trained over a five-year period, as part of a major gove r n m e n t c o m m i t m e n t to improving maternity care. 5 Access to trained midwives at the primary care level is one w a y to achieve the early diagnosis of maternal complications, t o g e t h e r with an effectively functioning system for secondary care. Provision of e m e r g e n c y obstetrical services, the intervention that has been most attractive to many countries, without attention to primary care services and essential linkages for referrals, has not always been effective in preventing maternal deaths, since patients often arrive too late to be treated successfully. Integrated planning strategies, based around well-trained nurse-midwives, can simultaneously strengthen e m e r g e n c y care and the p r i m ar y care systems that enable e m e r g e n c y services to be effective.
Acknowledgements The field research in Grenada was supported by the Population Council through USAID contract DPE-5966-Z-O0-8083-O0, project number 9365966. The cooperation of the Ministry o f Health of Grenada, and particularly the midwives, is gratefully acknowledged, as is the editorial assistance of C Jared Coffin.
1181
Reproductive Health Matters, No 4, November 1994
References
and Notes
1. Laukaran, Virginia and Bhattacharyya, Adity, 1990. A case study of maternity care in Grenada. Final report to the Population Council. November. 2. Laukaran, Virginia Hight, 1991. Achieving safe motherhood with limited resources: a case study of maternity care in Grenada.
MotherCare Working Paper No 6. June. In Grenada there were 1.03 deaths per thousand pregnancies during the study period. This compares to 3.4 in Haiti, 6 in Bolivia, an average of 1.6 for Central America and the
Caribbean, 20 for Mali, 3 for Uganda, and 5.9 for SubSaharan Africa on average. These data (other than Grenada) from: The progress of nations: the nations of the world ranked according to their achievements in health, nutrition, education, family planning, and progress for women, 1993. UNICEF. New
York, Burgess of Abingdon, 1993. Rooks, Judith and Winikoff, Beverly, 1990. A reassessment o f
planning settings. Proceedings o f a seminar. Population Council,
New York. 4. Maternal and child health strategy for the Caribbean community. PAHO Office of
Caribbean Programme Coordination. Barbados, 1983. 5. Leimena, F L. Future directions in management of maternal mortality in Indonesia. Presentation at the 8th World Congress on Human Reproduction, April 1993.
the concept of reproductive risk in maternity care and family
RESUMEN E n la isla c a r i b e f i a d e G r a n a d a , la a t e n c i 6 n m a t e r n a es o r g a n i z a d a y p r o v i s t a g e n e r a l m e n t e p o r e n f e r m e r a s - c o m a d r o n a s p r o f e s i o n a l e s y la m o r t a l i d a d m a t e r n a es r e l a t i v a m e n t e baja. E s t e t r a b a j o c o m e n t a c o m o los v a r i o s e l e m e n t o s d e e s t e s e r v i c i o - 6nfasis e n la c o b e r t u r a e n el t e r c e r t r i m e s t r e , educaciOn s o b r e s a l u d p a r a la mujer, p r o t o c o l o s c l a r o s p a r a el m a n e j o d e c o m p l i c a c i o n e s s e r i a s , a t e n c i 6 n las v e i n t i c u a t r o horas, un efectivo sistema de referencia, b u e n a comunicaci6n y m a n t e n i m i e n t o de registros y un limitado u s o d e los m 6 d i c o s y la t e c n o l o g i a pueden ser usados por otros parses como modelo p a r a r e d u c i r las m u e r t e s m a t e r n a s .
RI~SUMI~ D a n s l'~le d e la G r e n a d e , aux Petites Antilles, les s e r v i c e s d e m a t e r n i t 6 s o n t o r g a n i s 6 s et a s s u r 6 s principalement par des infirmi~res/sagesf e m m e s qualifi6es. La m o r t a l i t 6 m a t e r n e l l e est r e l a t i v e m e n t faible. Les a u t e u r s e x a m i n e n t comment d'autres pays pourraient, pour r6duire leurs taux de mortalit6 maternelle, p r e n d r e p o u r m o d 8 l e d i f f 6 r e n t s 616ments d e s s o i n s a p p l i q u 6 s h la G r e n a d e : i n t e n s i f i c a t i o n d e la c o u v e r t u r e au troisi~me trimestre, 6ducation sanitaire des f e m m e s , p r o t o c o l e b i e n d6fini p o u r la p r i s e e n c h a r g e d e s c o m p l i c a t i o n s g r a v e s , c o u v e r t u r e 24 h e u r e s s u r 24, s y s t ~ m e s efficaces d ' o r i e n t a t i o n , d e c o m m u n i c a t i o n et d e s t e n u e d e s d o s s i e r s , m i n i m u m d e r e c o u r s aux m 6 d e c i n s et ~ la technologie.
1191
D l veringYomen-CentredMaternity LimitedR sour s Virginia Hight Laukaran, Adity Bhattacharyya and Beverly Winikoff Maternity care in the Caribbean island nation o f Grenada is organised and provided largely by trained nurse-midwives and maternal mortality is relatively low. This paper discusses h o w the various elements o f this care - emphasis on third trimester coverage, health education for women, clear protocols for managing serious complications, round-the-clock coverage, effective referral, good communication and record-keeping, and limited use of physicians and t e c h n o l o g y - can be used as a model b y other countries to reduce maternal deaths.
~
I-IE maternity care system in Grenada can be described as a success in achieving and maintaining a low level of maternal mortality in spite of a limited use of technology. Most maternity care is provided by nurse-midwives, who are trained at government expense on the British model in a threeyear, hospital-based nursing p r o g r a m m e , with an additional nine-month p r o g r a m m e in midwifery. Antenatal care is provided t h r o u g h a network of multi-purpose health centres and smaller health stations t h r o u g h o u t the country. Although midwives are employed in all of these as district nurse-midwives, the majority of births take place in the general hospital. About ninety percent of births are attended by nurse-midwives, as there are 1.5 obstetricians per 100,000 population. Just over ten per cent of w o m e n deliver at home, usually attended by district nurse-midwives, with the r e m a i n d e r of births occurring in medical facilities. Attendance at h o m e deliveries on re ques t of the family is g u a r a n t e e d by the g o v e r n m e n t and this entitlement is u n d e r s t o o d by the population. Gre n a d a has no untrained midwives, presumably because there is g o o d access to qualified ones. Private maternity care seems to be rare. In 1988, less than one p er c e n t of nurse-midwives who attend births w e r e in private practice and less than one percent of normal hospital births w e r e p e r f o r m e d by general practitioners in private practice. Nine p e r c e n t of vaginal deliveries at the general hospital w e r e per-
f o r m e d by obstetricians in 1988, of which many, perhaps most, w o u l d have been done on a private basis. The backbone of the early detection and referral system that controls maternal mortality is in the hands of w o m e n w h o are trained to ser;ve their w o m e n clients with professionalism and compassion. The system of primary health care and midwifery in which they work is part of the British colonial legacy in Grenada. In Britain, as in most developed countries, maternity care has c h a n g e d considerably. In Grenada, maternity care still follows an older pattern, using only limited technology. This is mainly because of the cost of technology, the need for highly trained personnel to use it and the cost and difficulty of maintaining it. The Grenadian materniW system is very small in scale and part of a health care system w h o s e basic infrastructure is already in place. Because of its successes, its applicability as a model for other countries is w o r t h y of consideration, t h o u g h many of its features may not easily be replicable elsewhere. This p ap er attempts to identify the operational features and the most essential factors that contribute to safe pregnancy for w o m e n in this setting, and give some indication of what w o u l d be required for these to succeed in other settings.
BACKGROUND G r e n ad a is located in the southern Caribbean, 90 miles from the mainland of Latin America. It is a very small country, less than 650 square kilo-
Illl
Laukaran, Bhattacharyya and W i n i k o f f
m e t e r s . T h e p e r c a p i t a i n c o m e w a s U S $ 960 in 1987 a n d t h e i n f a n t m o r t a l i t y w a s 18.1 p e r 1,000 live b i r t h s . T h e b i r t h r a t e w a s o v e r 30 p e r 1,000 p o p u l a t i o n a n d 37 p e r c e n t of t h e p o p u l a t i o n w e r e u n d e r 15 y e a r s o f age. T h e r e a r e s e v e n p r i m a r y h e a l t h c a r e c e n t r e s , o n e in e a c h o f t h e p a r i s h e s o f t h e i s l a n d of G r e n a d a a n d o n e o n t h e i s l a n d of C a r r i a c o u , plus 29 satellite h e a l t h s t a t i o n s t h a t p r o v i d e m o r e limited h e a l t h s e r v i c e s . T h e r o a d s y s t e m a n d t e l e p h o n e s e r v i c e a r e well d e v e l o p e d . B o t h geography and infrastructure provide the f o u n d a t i o n f o r a n effective p r i m a r y h e a l t h c a r e system. In t h e first six m o n t h s o f 1990, w e c o n d u c t e d a s t u d y o f G r e n a d a ' s m a t e r n i t y c a r e s y s t e m . Details o f s t u d y m e t h o d s a n d f i n d i n g s a r e a v a i l a b l e f r o m t h e p r o j e c t r e p o r t . 1 S t u d y m e t h o d s included direct observation, interviews with midwives, d a t a c o l l e c t i o n f r o m r e c o r d s at all levels o f services, including information on transfer of p a t i e n t s , m a n a g e m e n t o f c o m p l i c a t i o n s in t h e parishes, and a hospital chart review of comp l i c a t e d c a s e s f r o m 1987 a n d 1988 to o b t a i n information on treatment of complications and specifics o f care. The great majority of antenatal and intraparturn c o m p l i c a t i o n s a r e r e f e r r e d to St G e o r g e ' s G e n e r a l H o s p i t a l f o r t r e a t m e n t . T h e s m a l l e r dist r i c t h o s p i t a l is n o t e q u i p p e d to h a n d l e o b s t e t rical e m e r g e n c i e s o r p e r f o r m c a e s a r e a n s e c t i o n s . Data on maternal deaths were obtained from h o s p i t a l r e g i s t r y b o o k s , w a r d a n d m e d i c a l staff, District N u r s e M i d w i v e s , a n d t h e R e g i s t r a r G e n e r a l ' s Office. A s e a r c h w a s m a d e o f t h e r e g i s t r y list of all d e a t h s in 1987-88 a m o n g w o m e n a n d girls 12q48 y e a r s o f a g e a n d d e a t h c e r t i f i c a t e s were examined for any that mentioned pregnancy or might plausibly relate to reproductive causes.
In 1987 a n d 1988 t h e r e w e r e six m a t e r n a l d e a t h s a m o n g 5,803 h o s p i t a l deliveries. T w o o f t h e s e w e r e d u e to e c t a m p s i a ; t h e o t h e r f o u r w e r e d u e to a r u p t u r e d e c t o p i c p r e g n a n c y , s e p t i c shock, antepartum haemorrhage, and postpart u m h a e m o r r h a g e c o m p l i c a t e d b y sickle cell disease. Based on hospital records, the frequency of b r e e c h p r e s e n t a t i o n w a s 2.2 p e r cenL t h o u g h uneventful breech deliveries were not always r e c o r d e d . No c a s e s o f o b s t r u c t e d l a b o u r occ u r r e d . P r o l o n g e d l a b o u r o c c u r r e d in a n esti-
m a t e d 2.5 p e r c e n t o f deliveries, p o s t p a r t u m h a e m o r r h a g e in 7.7 p e r cent, a n d d i a b e t e s in j u s t u n d e r 1 p e r cent. T h e r e w e r e c a e s a r e a n s e c t i o n s in 3.9 p e r c e n t of G e n e r a l H o s p i t a l deliveries. T h u s , t h e m a t e r n a l d e a t h r a t e is relatively low, i n d i c a t i n g a s u c c e s s f u l m a t e r n i t y care system. 2
O R G A N I S A T I O N A N D DELIVERY OF MATERNITY CARE C o m p r e h e n s i v e a n t e n a t a l c a r e is a c c e s s i b l e to all w o m e n in G r e n a d a f r e e o f c h a r g e t h r o u g h nurse-midwives, with referral to an obstetrician in a n e m e r g e n c y . T h e quality o f c a r e c a n b e a t t r i b u t e d t o t h e t r a i n i n g p r o g r a m m e at t h e G e n e r a l H o s p i t a l a n d t h e q u a l i f i c a t i o n s of t h e m i d w i v e s , w h i c h p e r m i t t h e m to a p p l y t h e i r k n o w l e d g e in i n d i v i d u a l c a s e s a n d to m a k e sophisticated judgements. T h e s u c c e s s o f t h e s y s t e m r e s t s in p a r t o n t h e e a r l y d i a g n o s i s of k e y c o n d i t i o n s at a p o i n t w h e n t h e y c a n still b e t r e a t e d successfully. E a s y a c c e s s to a n t e n a t a l c a r e is m a d e p o s s i b l e b y t h e n e t w o r k o f h e a l t h s t a t i o n s , w h i c h a r e usually w i t h i n w a l k i n g d i s t a n c e o f m o s t villages, a n d b y t h e p r e s e n c e o f a q u a l i f i e d n u r s e - m i d w i f e in e a c h o f these. The dispersal of the primary health care c e n t r e s a l l o w s w o m e n g r e a t e r a c c e s s to c a r e , k e e p s t h e c a r e p r o v i d e r in t h e c o m m u n i t y ; a n d encourages greater understanding o f local n e e d s . This in t u r n e n c o u r a g e s g r e a t e r t r u s t in t h e r e l a t i o n s h i p b e t w e e n p r o v i d e r a n d client a n d facilitates s u c c e s s f u l c o m p l i a n c e w i t h m e d i c a l recommendations, follow through on referrals, and comprehension on the part of the care provider of individual needs. P r o g r a m m e s s e e k i n g to r e p l i c a t e t h i s a c c e s s w o u l d h a v e to r e d i r e c t r e s o u r c e s to r u r a l h e a l t h facilities. P r o v i s i o n o f m i d w i f e r y s e r v i c e s in r u r a l a r e a s s h o u l d b e less costly t h a n p h y s i c i a n s e r v i c e s a n d e a s i e r to a c h i e v e .
Emphasis on third trimester coverage In G r e n a d a , as in o t h e r places, m a n y w o m e n d o n o t i n i t i a t e a n t e n a t a l c a r e until m i d - p r e g n a n c y . However, most life-threatening complications eclampsia and pre-eclampsia, haemorrhage, o b s t r u c t e d l a b o u r , s e p s i s - a r e m o r e likely to o c c u r in t h e t h i r d t r i m e s t e r a n d a r o u n d b i r t h . S i n c e c o v e r a g e o f a n t e n a t a l c a r e in t h e t h i r d
1121
Reproductive Health Matter& No 4, November 1994
trimester seems to be excellent in Grenada, complications that eventuate in fatal outcomes are rarely missed. P r o g r a m m e s with p o o r c o v e r a g e may wish to set a goal of 100 p er c e n t c o v e r a g e for third trimester care before increasing the p r o p o r t i o n of first trimester care. F u r t h e r m o r e , if early initiation of care is over-emphasised, the result in some places could be a falling off in the proportion of w o m e n wh o c o m e for third trimester care, particularly if there are fees for antenatal care.
Emphasis on health education Health education is given strong emphasis in Grenada's antenatal care, particularly for primigravidae. Individual counselling or g r o u p sessions are used, d ep en d i n g on the size of the clinic, the pattern of attendance and the priorities of the nurse-midwife. Individual sessions are conducted by the midwife, while g r o u p sessions are led either by the midwife or a student u n d e r her supervision. This education emphasises the particular signs of p r e g n a n c y complications; when, w h e r e and h o w to seek care; and health and nutrition information. Other p r o g r a m m e s that wish to incorporate successful patient education in antenatal care would need to give appropriate attention to the inclusion of these elements in the protocols for antenatal care, particularly for primiparas, and strong emphasis in midwifery training to the acquisition of educational skills. The effects of such an emphasis in G r e n a d a w e r e often mentioned by the midwives and students we interviewed and w e r e also clear in the educational sessions w e observed.
Laboratory services Provision of laboratory services is a major challenge to the health care system and is given high priority by antenatal care providers. Because laboratory facilities are located only at the General Hospital in St George's, considerable time and effort is devoted to weekly transport of blood and other laboratory samples to the hospital and to obtaining the test results. The specific a r r a n g e m e n t s vary in different parishes but lost samples, broken tubes, and lost results are am o n g frequently m e n ti o n e d problems. Although in some areas it is difficult to complete the laboratory work before the w o m a n
delivers, nurse-midwives value the completion of laboratory results and devote considerable effort to transport a r r a n g e m e n t s and to follow up and repeat laboratory w o r k in o r d er to use the test results. A large part of the effectiveness of laboratory testing comes from nurse-midwives ensuring that they get the results.
Most deliveries attended by nurse-midwives Maternity care in G r e n a d a makes very sparing use of physician services, supplies or equipment. Thus, general physicians w h o have no obstetrical training rarely attend deliveries. Forceps deliveries w e r e rarely used (7 per 1,000 General Hospital deliveries), caesareans w e r e p e r f o r m e d in only 3.9 percent of General Hospital deliveries, and vacuum extraction was not used at all during the study period. All normal deliveries and most other vaginal deliveries are attended by nurse-midwives. These involve limited use of medications, interventions or diagnostic tests. Hospital protocols require that the p r o g r e s s of the first stage of labour is m o n i t o r e d every four hours by vaginal examination, and vital signs and any other symptoms are also monitored. In practice, there are an average of 19 w o m e n on the maternity w a r d at any one time and t w o midwives and an assistant are responsible for their care. On many occasions, adhering to the protocols may be difficult. Student midwives rotate on and off the ward. Nurse-midwives monitor fetal condition with a fetoscope, a traditional adapted short stethoscope for use on the enlarged abdomen, and by checking for m e c o n i u m staining of the amniotic fluid. During the second stage, the w o m a n is transferred to the delivery r o o m w h e r e she is attended by qualified midwives or student midwives on rotation. Most w o m e n receive no intravenous drip, no episiotomy, and no routine analgesics or anaesthesia. Episiotomies w e r e carried out for only 1.5 percent of births; yet the proportion of w o m e n with second d e g r e e lacerations was only 5.6 p er cen t and third degree lacerations only 0.06 percent. Although normal deliveries are allowed to progress without intervention, midwives are trained to recognise early signs of intrapartum complications and to notify specialist obstetricians, w h o serve as consultants, for guidance.
1131
Laukaran, Bhattacharyya and Winikoff
L i m i t e d u s e o f p h y s i c i a n s and technology The m a n a g e m e n t of labour and delivery makes minimal use of expensive t e c h n o l o g y in Grenada. This limits costs and foreign exchange expenditures, minimises the allocation of scarce skilled personnel, and reduces maintenance and monitoring of equipment at the expense of patient care. In contrast, many developing countries rely heavily upon physicians to attend uncomplicated deliveries, which is likely to increase costs. Even w h e r e the supply of physicians is high, there is often a lack of qualified personnel in low income and rural areas. Often, the driving force in limitin 9 the use of midwives is the oversupply of physicians in higher income, urban areas. Countries faced with such p r o b l e m s may wish to consider increasing the utilisation of midwives for uncomplicated deliveries in regions or areas w h e r e physicians are scarce and incomes are relatively low. This would imply changes in training, credentialin9, legal aspects of service delivery, and d e v e l o p m e n t of locally appropriate protocols for care. A n o t h e r benefit of such a strategy might be to decrease reliance on m o r e costly hospital deliveries, since normal deliveries could be performed by nurse-midwives in out-of-hospital centres or at home, d e p e n d i n g on the setting, provided that the necessary infrastructure for transfer and backup are established. This redirection of resources is likely to result in savings and o t h er benefits, since the same transport and referral systems can be used for all types of e m e r g e n c y medical care, not just for maternity cases. Qualitative research on w h a t w o m e n value in birthing care is necessary first, in o r d e r to ensure that out-of-hospital settings are accepted and desired. In Grenada, there was inadequate staffing of free-standing birthing centres, with the result that w o m e n w e r e sent or referred themselves directly to hospitals. Clear protocols for managing serious complications The effectiveness of the referral and t r e a tm e n t system for pre-eclampsia, antepartum h a e m o r rhage, gestational diabetes and malpresentation seems to be essential to the attainment and maintenance of low maternal mortality in Grenada. While Grenadian nurse-midwives take con-
siderable responsibility, there are clear protocols for the m a n a g e m e n t of major life-threatening complications, which are known, understood, and utilised by the great majority of them. Their c o m m i t m e n t to following this process was demonstrated in practice and in interviews. One of the unique features of the referral and t r eat m en t system in Grenada is that w o m e n w h o are referred for diagnosis of a suspected complication, for example, gestational diabetes, do not continue to receive care at the higher level to which they are referred unless the severity of the condition or unresponsiveness to t r e a t m e n t require continuation of seco n d ar y level care. W h e n e v e r possible, the patient is sent back to the referring midwife with instructions for follow-up at the lower level as needed. W h e n necessary, the District Nurse-Midwife visited the h o m e of the patient to provide follow-up care. The return of the patient to the iower level of care is necessary in o r d er t o r a t i o n the consulting obstetrician's services. This also permits access for those in need of urgent care rather than overloading the consultant's roster with routine follow-up. The chart review of p r e g n a n c y complications revealed that most cases w e r e detected early e n o u g h to be treated successfully and avert maternal deaths. F o r less severe conditions, that do not rep r esen t a clear risk of maternal death but may predispose to p o o r e r maternal or fetal outcome, however, t h er e was less a g r e e m e n t a m o n g different midwives on what the protocols for t r eat m en t were. Conditions that received attention but w e r e considered to have l o w er priority were: m o d e r a t e or mild anaemia, previous low birth w e i g h t in the infant, previous p r e m a t u r e labour, previous fetal loss, stillbirth or p o o r obstetrical history, fetal distress in labour, p r o l o n g e d gestation or p r o l o n g e d first stage of labour. Efforts to reduce the stillbirth rate w e r e u n d e r w a y during the study period. Round-the-clock coverage Midwives are mostly able to see all their patients from 8am to 12-1pm. This allows several hours in the afternoon to follow up on laboratory results, referrals and appointments. In addition, roundthe-clock availability of nurse-midwives in each health centre and station is almost certainly a key element in the successful t r eat m en t of complications of pregnancy, labour and delivery.
1141
Reproductive Health Matters, No 4, November 1994
In t h e s t u d y p e r i o d , all c a e s a r e a n s e c t i o n operations were performed by one of two obstetric c o n s u l t a n t s . G e n e r a l p h y s i c i a n s did n o t perform caesareans even on an emergency basis. Until r e c e n t l y , t h e t i m e d e l a y b e t w e e n t h e decision to p e r f o r m a c a e s a r e a n a n d t h e . i n i t i a t i o n o f s u r g e r y w a s o f t e n 2-3 h o u r s , e s p e c i a l l y at night. Operating theatre nurses, blood technicians, anaesthesiologists, and sometimes pharm a c i s t s h a v e to b e called in f r o m h o m e b e t w e e n 4pm and 8am and on weekends. The hospital d r i v e r f r e q u e n t l y s p e n d s h o u r s p i c k i n g t h e m up. Coverage for emergency surgery was improved by requiring a junior nurse to remain on the p r e m i s e s 24 h o u r s a day. S e n i o r s t a f f still c o m e from home, but they can scrub for surgery immediately because the operating theatre has been prepared by the junior nurse while they are in t r a n s i t . Essential linkages for effective referrals It is useful to c o n s i d e r t h e s t e p s t h a t a r e n e c e s s a r y f o r s m o o t h a n d s u c c e s s f u l l i n k a g e s in the referral system: • T h e p a t i e n t a t t e n d s t h e a n t e n a t a l clinic b e f o r e the condition becomes severe. • T h e n u r s e - m i d w i f e o b t a i n s clinical o r l a b o r a t o r y e v i d e n c e a n d p r o p e r l y a n d c o r r e c t l y determines the need for a referral. • The nurse-midwife successfully communic a t e s t h e i m p o r t a n c e o f a r e f e r r a l to t h e pregnant woman, and where appropriate her family, b y p r o v i d i n g h e a l t h e d u c a t i o n a n d m o t i v a t i o n as n e e d e d . • The nurse-midwife contacts the referral c e n t r e a n d o b t a i n s a specific a p p o i n t m e n t at a clinic a n d t h e p a t i e n t a t t e n d s t h e a p p o i n t m e n t as s c h e d u l e d . • I n e m e r g e n c y cases, t h e n u r s e - m i d w i f e n o t i fies t h e h o s p i t a l m a t e r n i t y u n i t o f a n i n c o m i n g e m e r g e n c y a n d t h e w o m a n is p r o v i d e d w i t h emergency transport. • The nurse-midwife schedules a follow-up visit f o r t h e w o m a n , t o e n s u r e t h a t s h e h a s a t t e n d e d t h e s e c o n d a r y level clinic as p r e s c r i b e d , h a s b e e n a t t e n d e d to a n d / o r g e t s t h e r e c o m m e n d e d t r e a t m e n t as n e c e s s a r y . • If t h e w o m a n fails to a t t e n d f o r t h e f o l l o w - u p visit, t h e m i d w i f e c o n t a c t s t h e w o m a n t o ensure that her condition has been taken c a r e of.
With the most serious pregnancy complications, t h e o m i s s i o n o f a s i n g l e s t e p in t h i s p r o c e s s w o u l d r e s u l t in t h e risk o f d e a t h . In G r e n a d a , t h e f r e q u e n c y o f m i s s e s in t h i s s e q u e n c e o f e v e n t s m u s t b e r a r e s i n c e t h e r e is a d o c u m e n t e d f r e q u e n c y o f c o m p l i c a t i o n s , yet a l o w m o r t a l i t y .
A n t e n a t a l r e c o r d c a r d r e t a i n e d by t h e woman T h e a n t e n a t a l r e c o r d c a r d is also e s s e n t i a l to c o m m u n i c a t i o n , s i n c e it s u m m a r i s e s all clinical and laboratory findings, any treatment or conc l u s i o n s , a n d r e c o m m e n d e d follow-up, w h i c h a woman then keeps and carries with her between p r i m a r y a n d s e c o n d a r y level clinics. Patient-retained record cards have been used n o t o n l y in G r e n a d a b u t also in o t h e r c o u n t r i e s . This s y s t e m o f r e c o r d k e e p i n g c a n b e v a l u a b l e in e m p o w e r i n g w o m e n t o t a k e c o n t r o l of t h e i r o w n care. W h e n h a n d i n g o v e r t h e c a r d , t h e y c a n t a k e the opportunity to communicate their own needs a n d c a n feel t h e y a r e p r o v i d i n g t h e b a c k g r o u n d i n f o r m a t i o n t h e p r o f e s s i o n a l s n e e d to d i a g n o s e and treat them.
Good communication C o m m u n i c a t i o n b e t w e e n n u r s e - m i d w i v e s at t h e p r i m a r y c a r e clinics a n d t h e r e f e r r a l c e n t r e s is e s s e n t i a l to t h e s m o o t h f u n c t i o n i n g o f t h e s y s t e m . S u c h c o m m u n i c a t i o n w a s f a c i l i t a t e d b y t h e existence of strong informal networks among the nurse-midwives, who have their training and social b a c k g r o u n d in c o m m o n . M a i n t e n a n c e o f t h i s i n f o r m a l social n e t w o r k in G r e n a d a w a s j u d g e d to b e a n i m p o r t a n t a s p e c t o f t h e s u c c e s s o f t h e m a t e r n i t y care. Face-to-face meetings among midwives are usually f o r m a l a n d t a k e p l a c e o n c e m o n t h l y at t h e p a r i s h level. T h e y a r e m a i n l y for t h e p u r p o s e o f administrative coordination and supervision, r a t h e r t h a n f o r c o m m u n i c a t i o n o f clinical information. Parish supervisors, who are public health nurses, attend a similar monthly meeting at t h e M i n i s t r y o f H e a l t h . T h e s e f a c e - t o - f a c e m e e t i n g s w e r e n o t t h o u g h t t o b e e s s e n t i a l to t h e m a i n t e n a n c e o f c o m m u n i c a t i o n o r o f social n e t w o r k s . It w a s j u d g e d t o b e m o r e i m p o r t a n t to have radio or telephone communication for e m e r g e n c y use. In a l a r g e r s y s t e m , w h e r e t h e r e a r e m a n y m o r e s t a f f a n d less o p p o r t u n i t y t o m e e t i n f o r m ally, s u c h m e e t i n g s m a y b e d e e m e d to b e m o r e
15 I
Laukaran, Bhattacharyya and Winikoft'
important. At the same time, providing midwives with field radios might be considered to permit both the communication of necessary information and the maintenance of a functional, professional network. Empowering nurse-midwives empowers pregnant women Several features of the Grenadian system are emp o w e r i n g for nurse-midwives and their clients. Well trained nurse-midwives in local settings provide a tangible role model for the benefits of h i g h e r education. Nurse-midwives r e p r e s e n t their w o m e n clients from positions of responsibility, are able to help to maintain life, and have the authority to get the health care system to r e spo n d to the w o m e n ' s needs and desires. The service e m p o w e r s p r e g n a n t w o m e n by letting them make their o w n choices as they take advantage of health care. In o r d e r to see a nursemidwife, w o m e n need not rely on expensive t ra ns p o r t n o r on the permission or acquiescence of others. Finally, communication a m o n g the midwives is e m p o w e r i n g because it provides a structured forum in which a cadre of professional w o m e n can share their problems and needs. Other countries wishing to e m p o w e r nursemidwives would need to consider the develo p m e n t of strong training and credentialing p r o g r a m m e s , clear n o r m s and job descriptions, adequate salary and benefits, and standards to permit the d ev el o p m e n t of a high level of professional practice.
C L I N I C A L M A N A G E M E N T OF O B S T E T R I C COMPLICATIONS T h r o u g h o u t the world there has been much interest in the use of social indicators such as age, parity, and socioeconomic status to identify high risk pregnancy, in o r d e r to focus antenatal care t o w a r d those wh o m e e t specific risk criteria. However, the sensitivity and specificity of such indicators is limited. 3 A l t h o u g h the strategy outlined by the Pan American Health Organisation for maternal and child health in the Caribbean suggests that the utilisation of a risk-based approach may be advisable, no effort is m a d e in Gren ad a to identify high risk pregnancies according to social criteria. 4 Instead, clinical conditions, specific to each
woman, are indications for referral. These include: severe oedema, hypertension, albumin or glucose in urine, severe anaemia, bleeding, small-for-dates abdomen, large-for-dates abdomen, malpresentation, or suspected multiple pregnancy. W h e n these or other signs of possible complications are detected by the nursemidwife in the antenatal clinic, the w o m a n is referred to the obstetrical clinic for evaluation. P r o g r a m m e s wishing to replicate this feature of the G r en ad i an system would need to shift resources away from the risk identification process and establish m i n i m u m standards of care, to permit early diagnosis of potentially fatal conditions. Although this would imply a shift of resources from seco n d ar y to p r i m ar y care, it leads to a r e d u c e d case load at the secondary level and to earlier initiation of care, w h e n conditions are m o r e easily treatable. There is one exception. W o m e n with m o r e than five previous births are e n c o u r a g e d to deliver in hospital because of the increased risk of complications. Potential cases of obstructed labour are referred to hospital on an urgent basis. The actual prevalence of obstructed labour is hard to d e t e r m i n e because cephalopelvic disp r o p o r t i o n is rarely diagnosed in Grenada. X-ray pelvimetry is not used to diagnose it and every w o m a n is given a trial of labour. Pre-eclampsia is detected in antenatal clinics and referrals are made for further treatment. P r o g r a m m e s benefit from the d e v e l o p m e n t and implementation of strict protocols for referral and t r eat m en t of pre-eclampsia, generally the cause of maternal mortality with the longest lead time from onset to outcome, thus permitting early intervention in most cases. W h e r e nursemidwives are not available, p r o g r a m m e s could consider training other health workers and equipping them to take blood pressures and refer w o m e n with elevated readings. Postpartum w o m e n are observed carefully for excessive blood loss and most bleeding complications are m a n a g e d without blood replacement. The only routine medication used for births attended by a midwife is 5 IUs of oxytocin given at the birth of the head of the baby - to assist in clamping down uterine vessels and minimise blood loss. Any hospital patient who loses 500 mls of blood is considered to have excess blood loss; the -
1161
Reproductive Health Matters, No 4, November 1994
o b s t e t r i c i a n is n o t i f i e d a n d t r e a t m e n t is i n i t i a t e d immediately. When the physician arrives, the p a t i e n t is e x a m i n e d t o d e t e r m i n e t h e c a u s e of bleeding and any retained placental fragments a r e r e m o v e d . If b l e e d i n g c o n t i n u e s , i n t r a v e n o u s fluids a n d s o m e t i m e s e r g o m e t r i n e a r e a d m i n i s t e r e d . T h e t h i r d level o f t r e a t m e n t , r a r e l y u s e d , is w h o l e b l o o d , p r e f e r a b l y f r o m r e l a t i v e s o r f r o m t h e b l o o d b a n k . In 1987-88 t h e r e w e r e 246 w o m e n at t h e G e n e r a l H o s p i t a l w i t h p o s t p a r t u m h a e m o r r h a g e , a r a t e o f 7.7 p e r cent. O n l y 17 u n i t s of b l o o d w e r e u s e d in t h e y e a r f o r w h i c h d a t a w e r e available. In o u t p a t i e n t m a t e r n i t y units, b l o o d loss is m o n i t o r e d in m u c h t h e s a m e m a n n e r as it is in t h e h o s p i t a l . In c a s e s o f i n c r e a s e d b l e e d i n g , t h e s a m e t y p e o f t r e a t m e n t is used. H o w e v e r , if first stage treatment does not stop the bleeding, intrav e n o u s fluids a r e g i v e n a n d a n i m m e d i a t e t r a n s fer to t h e G e n e r a l H o s p i t a l is initiated. A t h o m e b i r t h s , t h e m i d w i f e is e q u i p p e d w i t h o x y t o c i n a n d p r o c e e d s in g e n e r a l l y t h e s a m e m a n n e r . For other programmes, an alternative strate g y m i g h t b e t o t r a i n b i r t h a t t e n d a n t s in t h e m a n a g e m e n t o f all c a s e s o f e v e n m o d e r a t e b l e e d i n g w i t h u s e o f o x y t o c i n a n d r e f e r r a l to t h e n e a r est h e a l t h facility. Local h e a l t h c e n t r e s w o u l d n e e d to b e e q u i p p e d to h a n d l e s u c h cases. P o s t p a r t u m i n f e c t i o n s a r e t r e a t e d in p r i m a r y health centres and health stations. Grenadian women with a normal recovery and healthy newborns are discharged from hospital a p p r o x i m a t e l y 12 h o u r s p o s t p a r t u m . S i n c e t h e s i g n s o f p o s t p a r t u m i n f e c t i o n a r e likely to s h o w up o n l y a f t e r d i s c h a r g e , w o m e n a r e ref e r r e d to t h e i r local h e a l t h c e n t r e o r s t a t i o n f o r p o s t p a r t u m c a r e a n d a r e i n s t r u c t e d to r e p o r t t h e r e in c a s e o f fever, foul d i s c h a r g e , pain, o r problems with the neonate. T h e key f e a t u r e s in p r e v e n t i o n of fatal infections are patient education to recognise the signs of infection and the importance of treatm e n t , availability of a n t i b i o t i c s at m u l t i p l e service d e l i v e r y p o i n t s , a n d a n a w a r e n e s s a m o n g care providers of the importance of management of p o s t p a r t u m f e v e r s a n d o t h e r s i g n s o f infection.
POSTPARTUM CARE H e a l t h c e n t r e s t a f f a r e m e a n t to visit in t h e first f e w d a y s p o s t p a r t u m to e x a m i n e b o t h m o t h e r a n d b a b y a n d t o e n c o u r a g e t h e m to s e e k c a r e
e a r l y if n e e d e d . A t t h e s e visits, c a r e o f t h e i n f a n t and breastfeeding advice are given and an a s s e s s m e n t is m a d e o f t h e risk of p r o b l e m s o c c u r r i n g . If t h e r e a r e e x i s t i n g o r p o t e n t i a l p r o b lems, o n e o r m o r e a d d i t i o n a l h o m e visits a r e m a d e . H o w e v e r , n o t all h e a l t h c e n t r e s a n d s t a t i o n s in G r e n a d a h a v e sufficient s t a f f to m a k e t h e s e h o m e visits o n a r e g u l a r b a s i s a n d s t a f f d o n o t a l w a y s find o u t w h e n p a t i e n t s h a v e d e l i v e r e d . T h e p r o t o c o l f o r p o s t p a r t u m c a r e also calls f o r a p h y s i c a l e x a m i n a t i o n o f t h e m o t h e r at six w e e k s p o s t p a r t u m , at w h i c h t i m e f a m i l y p l a n n i n g is o f f e r e d . As in o t h e r d e v e l o p i n g c o u n t r i e s , t h e a c t u a l c o v e r a g e is v e r y low. T h e r e a s o n f o r this p o o r c o v e r a g e , in t h i s p a r t i c u l a r c o n t e x t , w a s r e p o r t e d as r e l u c t a n c e o n t h e p a r t o f G r e n a d i a n w o m e n to o b t a i n s u c h c h e c k - u p s s i n c e t h e y w i s h to a v o i d pelvic e x a m i n a t i o n s , a n d p a r t i c u l a r l y p a p s m e a r s , w h i c h a r e c o n s i d e r e d to b e painful. I n f a n t s u r v i v a l in G r e n a d a c o m p a r e s f a v o u r ably w i t h o t h e r C a r i b b e a n n a t i o n s . All h e a l t h y babies room-in with their mothers and are b r e a s t f e d . I n f a n t f o r m u l a is a v a i l a b l e o n l y w i t h special orders and premature babies are given e x p r e s s e d b r e a s t m i l k . H i g h risk n e o n a t a l c a r e w a s l i m i t e d b y lack o f i n c u b a t o r s a n d o t h e r e q u i p m e n t , b u t r e c e n t l y a special c a r e n u r s e r y h a s b e e n e s t a b l i s h e d f o r low b i r t h w e i g h t a n d sick b a b i e s .
CONCLUSIONS Grenada provides an illustration of a maternity c a r e s y s t e m w i t h v i r t u a l l y all b i r t h s a t t e n d e d b y qualified m i d w i v e s , w h o m a i n t a i n a c o m p l e x , reliable, a n d well r e g a r d e d p r i m a r y c a r e s y s t e m and who keep the load on the secondary system a n d t h e f e w o b s t e t r i c i a n s at a low a n d w o r k a b l e level. A g o o d f u n c t i o n i n g r e f e r r a l s y s t e m m a k e s this possible. The essential features of the referral system are the use of a maternity record card t h a t is k e p t b y t h e w o m a n , effective c o m m u n i c a t i o n a m o n g p r i m a r y c a r e p r o v i d e r s a n d be~ t w e e n t h e p r i m a r y a n d s e c o n d a r y c a r e levels, a n efficient e m e r g e n c y t r a n s p o r t s y s t e m , a n d r e f e r ral b a c k to p r i m a r y level as s o o n as p o s s i b l e . T h e G r e n a d i a n s y s t e m m a k e s n o e f f o r t to use social c r i t e r i a to p r e d i c t risk s t a t u s t o m o d i f y t h e antenatal care package. Midwives refer women f o r s e c o n d a r y c a r e o n l y w h e n t h e i n d i c a t i o n s of
1171
Laukaran, Bhattacharyya and Winikoff
complications arise. Efforts are concentrated on providing every w o m a n with a basic standard of primary care, with emphasis on the third trimester of p r e g n a n c y and delivery. Until recently, there w e r e notable gaps in secondary level care, due to limited availability of medications, x-ray, laboratory facilities, and operating theatre space. Nevertheless, relatively good maternal survival had been achieved in G r e n ad a even before these recent improvements, making it a p p a r e n t that the system of maternity care is not only h u m a n e but also effective. Further effort is n e e d e d to increase the c o v e r a g e and acceptability of routine postpartum care. The g o v e r n m e n t continues to seek to reduce maternal mortality, stillbirths and perinatal death rates to a minimum. Obstacles to applying this system in other countries can be substantial. In a n u m b e r of countries, such as Uganda, Ghana, Malawi, and Zimbabwe, the midwifery system established under the British continues, and midwives enjoy professional recognition, respect and social status in their communities. However, there are not e n o u g h of them and the infrastructure, referral networks and resources for providing the same level of care as in Grenada are less developed. In other countries, midwifery has n e v e r attained a high status and the professionalism e n c o u r a g e d by the British system is lacking. In India, for example, this may be due to cultural and religious prohibitions that limit contact with body fluids considered to be unclean, such as those during childbirth, to people with low status. In still other countries, maternity care in the formal sector is firmly u n d e r the parvenu of physicians, as in much of Latin America. In many
p o o r e r countries, traditional birth attendants have been kept largely outside the formal sector and relatively or totally untrained. With or w i t h o u t an extensive primary health care system, there may be interest in developing c o m m u n i t y - b a s e d midwifery care. Such a system is currently u n d er d ev el o p m en t in Indonesia on a massive scale, w h e r e 18,000 of an intended 34,000 c o m m u n i t y midwives are being trained over a five-year period, as part of a major gove r n m e n t c o m m i t m e n t to improving maternity care. 5 Access to trained midwives at the primary care level is one w a y to achieve the early diagnosis of maternal complications, t o g e t h e r with an effectively functioning system for secondary care. Provision of e m e r g e n c y obstetrical services, the intervention that has been most attractive to many countries, without attention to primary care services and essential linkages for referrals, has not always been effective in preventing maternal deaths, since patients often arrive too late to be treated successfully. Integrated planning strategies, based around well-trained nurse-midwives, can simultaneously strengthen e m e r g e n c y care and the p r i m ar y care systems that enable e m e r g e n c y services to be effective.
Acknowledgements The field research in Grenada was supported by the Population Council through USAID contract DPE-5966-Z-O0-8083-O0, project number 9365966. The cooperation of the Ministry o f Health of Grenada, and particularly the midwives, is gratefully acknowledged, as is the editorial assistance of C Jared Coffin.
1181
Reproductive Health Matters, No 4, November 1994
References
and Notes
1. Laukaran, Virginia and Bhattacharyya, Adity, 1990. A case study of maternity care in Grenada. Final report to the Population Council. November. 2. Laukaran, Virginia Hight, 1991. Achieving safe motherhood with limited resources: a case study of maternity care in Grenada.
MotherCare Working Paper No 6. June. In Grenada there were 1.03 deaths per thousand pregnancies during the study period. This compares to 3.4 in Haiti, 6 in Bolivia, an average of 1.6 for Central America and the
Caribbean, 20 for Mali, 3 for Uganda, and 5.9 for SubSaharan Africa on average. These data (other than Grenada) from: The progress of nations: the nations of the world ranked according to their achievements in health, nutrition, education, family planning, and progress for women, 1993. UNICEF. New
York, Burgess of Abingdon, 1993. Rooks, Judith and Winikoff, Beverly, 1990. A reassessment o f
planning settings. Proceedings o f a seminar. Population Council,
New York. 4. Maternal and child health strategy for the Caribbean community. PAHO Office of
Caribbean Programme Coordination. Barbados, 1983. 5. Leimena, F L. Future directions in management of maternal mortality in Indonesia. Presentation at the 8th World Congress on Human Reproduction, April 1993.
the concept of reproductive risk in maternity care and family
RESUMEN E n la isla c a r i b e f i a d e G r a n a d a , la a t e n c i 6 n m a t e r n a es o r g a n i z a d a y p r o v i s t a g e n e r a l m e n t e p o r e n f e r m e r a s - c o m a d r o n a s p r o f e s i o n a l e s y la m o r t a l i d a d m a t e r n a es r e l a t i v a m e n t e baja. E s t e t r a b a j o c o m e n t a c o m o los v a r i o s e l e m e n t o s d e e s t e s e r v i c i o - 6nfasis e n la c o b e r t u r a e n el t e r c e r t r i m e s t r e , educaciOn s o b r e s a l u d p a r a la mujer, p r o t o c o l o s c l a r o s p a r a el m a n e j o d e c o m p l i c a c i o n e s s e r i a s , a t e n c i 6 n las v e i n t i c u a t r o horas, un efectivo sistema de referencia, b u e n a comunicaci6n y m a n t e n i m i e n t o de registros y un limitado u s o d e los m 6 d i c o s y la t e c n o l o g i a pueden ser usados por otros parses como modelo p a r a r e d u c i r las m u e r t e s m a t e r n a s .
RI~SUMI~ D a n s l'~le d e la G r e n a d e , aux Petites Antilles, les s e r v i c e s d e m a t e r n i t 6 s o n t o r g a n i s 6 s et a s s u r 6 s principalement par des infirmi~res/sagesf e m m e s qualifi6es. La m o r t a l i t 6 m a t e r n e l l e est r e l a t i v e m e n t faible. Les a u t e u r s e x a m i n e n t comment d'autres pays pourraient, pour r6duire leurs taux de mortalit6 maternelle, p r e n d r e p o u r m o d 8 l e d i f f 6 r e n t s 616ments d e s s o i n s a p p l i q u 6 s h la G r e n a d e : i n t e n s i f i c a t i o n d e la c o u v e r t u r e au troisi~me trimestre, 6ducation sanitaire des f e m m e s , p r o t o c o l e b i e n d6fini p o u r la p r i s e e n c h a r g e d e s c o m p l i c a t i o n s g r a v e s , c o u v e r t u r e 24 h e u r e s s u r 24, s y s t ~ m e s efficaces d ' o r i e n t a t i o n , d e c o m m u n i c a t i o n et d e s t e n u e d e s d o s s i e r s , m i n i m u m d e r e c o u r s aux m 6 d e c i n s et ~ la technologie.
1191