Liberian obstetrics The birth and development of midwifery

-L

ewebpment by Ruth A. Etzel, B.S. Part II l

I.ibaria’slocationin West Africa.

Ms. Etzel earned her B.A. in Biology Summa Cum Laude from the University of Minnesota, and is currently a first year medical student at the Unive~ of Wisconsin. tier research in Liberia waa sponsored by the Minnesota SPAN bin (the Student Project For --.-.-Amity Among Nations).

In prehistork: times only the husband or a female relative was permltted to assist a woman in labor. Before long. however, it became strictly the domain of women and remained so in Liberia until quite recently. fn the 1930% most women in labor would not stay in the same building where a man was present, much less permit a man to deliver them. Dr. Norman Sloan, who was at Curran Hospital during this period, did only eleven deliveries during his last two years, and the women he attended were mostly the wives of the hospital workers. Despite the fact that ma. ternal and infant mortality ratec in the area were extremely high, the v&ge l Editor’s Note: Part I of this popcl appeared in the Wfntcr. 1976, issue of JNM.

JOUflNAL OF N~~=~W~RV

midwives would not entrust their difficult cases to the hosphaafuntil the coming of Esther Bacon in the early 1940’5. Though she had the advantage of being 3 woman herself, at first the native midwives scoffed at the suggestion that this young American nurse might know anything about delivering babies. She soon proved her obstetrical competence, and demon. strated her willingness to go wherev. er her help was needed, rather than insisting that the village midwives bring their dlffkult cases to the hospital. Before long, she was being summoned to help the mtdwives with troublesome deliveries tn many vUlages.With her lantern in hand, she never refused a call for help day or night. but set off on foot or on horseback for the town where she was needed. In the eyes of the country midwives, her successes were nearly beyond comprehension. For instance, Esther was once called for a retained placenta and upon arrival she found th& the lady had been moved outside under a tree since she was in shock from blood loss and the people did not want her to die in tile house. The remarkable Miss Bacon hung a bottle of in~avenous fluid on a tree branch, restored the woman’s pressure and succeeded in removing the placenta. After having surmounted the fore Vd. XXII, No. 1, Sprtn~ 1977

and trust of thz !:.d@noii

midwives, Esther started to reao the results of her efforts when the midwives began sending some of their problem patients to her at the hospital. However, they still did not want a man present, as evidenced by the fact that when a visiting doctor-walked in to Curran Hosoital in the mid 1940’s. Esther’s V.&I admitted obstetrics patients pkked up their belongings and left as he entered the building.’ In the late 1940’s the tribal women’s reservdions about coming to the hospital broke down, and hospital

health and well-being and child rests with midwives, eries than

of the mother the traditional

who perform more any other group

deliv-

fie paucity of statistics makes it difficult to accurately assess the actual status of maternal and chid care in Liberia, or the influence of the traditional midwives upon this aspect of the nation’s health. However, one can make estimates based on ap proximate figures from recent years.’ Uberia is divided into nine coun-

ties, each vided there

of

which

is furthex

suhdt-

into &t&s. In Lofa County are four dJ&!Us Kotphun D&t-

rict, Voinbma Dkkict Zorw Disekt azd Bopolu Dtskkt. (See Figtres 1.2 and 3) In mid-1974. It was estimated that there WeiO appoxhlittely 250 trad%onat mkhtives pracWng in Zorzor Dktrkt’s 52 towns and numerousfarmviUag~“Ifor~euses the diskkt’s estimated population of

:wrsn Lutheran Hos&lllaf, zxzor. ubsia, Mmdes the TraditIonal Mfddfr Education Commltko. !o,lng of 2 April 1974.

CThe majority of the births in Liberia still take place

LoFACOUNTVlfWLTHFAUUIB

in the home

or at a dage clinic.

deliveries have been steadily ing in number e*fer since.’

incres-

Though the number of hospital deliveries is increasixg yearly, (at Curran Hospital there was a 5.3% increase from 1972 to 1973 and an. other 6.7% incresse from 1973 to WI%), the ma)Aty of the births in Liberia still take place in the home or at a village clink, and in most cases the mother is attended by an empirical midwife. It is apparent that a tremendous amount of responsibility for the

JOURNAL OF NURSE-MIDWIFERY .Vol. XXII, No. 1, Spring 1977

19

and child in Liberia must begin with the traditional mfdwives. In 1949. because the hospitals and clinics were becoming concerned about the number of mismanaged pregnancies that were being brought to them, the Liberian Government started a program to train the indigenous midwives. The ~infstry of

Because of their attempt to improve

importance. the status

an\ of ma

i

Figure 2 ---_

Health’s records show that one mid. wife was graduated in 1949. then the program was inactive until 1956, when eleven midwfves completed their training. An average of eleven have finished the course every year since then. ’ *

Originally, the training was done over a year-long period, with classes for two hours one day each week in Monrovia. This was later revised to nine months of lectures, with four lectures each month, and three months of practical experience in a hospital or clinic. Since 1971, a more concentrated course has been taught, allowing the Ministry to offer two training programs each year. The new four ntonth course includes classroom lectures for four hours a day, two Gays a week, for six weeks, followed by ten weeks of practice in a hospital or clinic. The traditional midwives who attend are taught about the importance of good personal health habits, and they learn how to name the pelvic organs, or identify the signs and symptoms of pregnancy, and to identify the danger signs during labor. They

receive instrtnlction in c!pan delivery techniques, and -xe taught how to care for the newborn baby. Although there is no written testing during the course, since the majority of the women know how to read and write nelthcr English For their native tongue, periodic eva1uatior.s are done by a supervisor. Tiiose midwives who are thought to have adequately learned the proper methods and to have demonstrated their abiL:y to perform in the hospital sening. are awarded government certification arid may re turn to their villages to continue their practice with the b!essing of the Mini stry of Health. Although such certification con notes government approval. it by nc mid means assures the traditional wife of a place on the governmen payroll. The smhl! number of mid wives who are salaried by the government

(in 1975

there

JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Spring 1977

were

65

21

number delivered by each midwife each year about 4.3.infants. Assuming that each midwife b responsibfe foraviliageof 1OOpersonrandthat Liberia’s -&th rate -is 50 per 1000 (see Table 2J, thl3 leaves about 14% to be delivered in hospitals and dinks by individuals other than tradiiional midwives. After the tradttional mtdwife training progam in Monrovia had gotten started, a comparable, though less comprehensive program was in!& ated in Bxw County, and by 1971 two additional prmamr were underway In Nimba and Grand Gedeh Counties. Roughly 650 midwives, or less than 8% of the country’s total, had undergone tmining as of becemher, 1975. Recause they are normally not placed on the government payroll when they complete the trainiag program, the midwives sometimes find themselves in an unfavorable finandal posItion. Thy are caught between MO worlds they have not completely fomaken the traditional life, but they have taken steps toward emkacing modem ideas. Thus netther are they repaid for their assistad in the tradittona! way, with gifts of rke, meat, kola nuts and fruit, nor are they paid the fee that would be owed the maternity clink or the hospital for comparable sarvkes. Because of their status In limbo, ,they may receive no more than $1.00 and “‘pk@ of Msres from the tenlly” for a successful delivery.

stand whg only a tiny proportion of the country’s estimated 8,000 tc 10,000 Praditional birth attendants have been receptive to Western methods. Those who have won government certification are clearly an unusual group. The ma@ity of midwives throughout the oxmtry continue to practice midwifery as they have been tau&t by their iredece&ors This is duein large part to the fact that many of t&em reside in remote areas of the ~xwnby which have not yet been

T&k 1. Years of Practice 8+Number of @eliveriss pbtformed by Midwives in 1975Tralnin9 Program wdwH0

---pmYeen of Prwlcr -.----

: 3 4 : 7 JcmldAL

DoHveriee 2lkl

77 24 z 34 4 --

;t: 25 ii 12

QF MJRSE-MfDWlFERY 0 Vol. XXII, No. 1, spfing 1077

In a seat numtw of cases, the mtdwife b hardly interested in a monetary retmbursement for the care she provides. Often it b enough to he invited to share a mea) with the grateful family, or to be given a small token of their sincere appreciation. Nevertheless, there me times when the midwife objects to not receivtng her fsir share of the payment. For exnmde, it is not uncommon for the vtlloge midwife to deliver the baby of a woman who has rsgbtered at the local clinic and paid the maternity fee there. But because she b not on the government payroll the midwife rewives no part of the $15.00 fse even though she was the attendant at birth. The mother, havmg already ex. pended such a large sum, is uniikelj to he willing or able to pay the midwife an additional fee. ‘This gross inequality needs to he promptly remedied, but that cannot he IT. compfbhed until there exbb a much more widespread, uniform proyrom for training and certifying trailitional midwives.

T8bb 2. 13 Highest Slrthrate Countries in the World

--

Swaziland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~.3 ..52.2 Niger. . . . . . . ................... .51.8 Rwanda . . . . ..................... Dahomy . . . . ................... ..txl .Q Togo . . . . . . . ................... ..50 0.9 Bangladesh ...................... 50.8 Afghanistan. .................... ..!so .5 Angola ..................................................... .l SE3 Tome & Prfncipe ...................................... ..50.1 Liberia ........................................ ..l..........~ .. SaudiArabia.. .............................................. .Q South Yemen .............................................. .5&O North Yemen .............................................. -50.0

................. ................. ................. ................. ................. .................

SOURCE: Irving Wallace and David Walleohinsky, 7he People’s Almanac (New York: Doubleday, 1976). NOTE: Birthrate = births per 1,W9 population.

T8bh 3. Midwlves Who Have Complet~sdTraditional Midwife Training

Yrr

Montserredo County

BOWI

County

Nillh C-W

-1949 1955 1956 1957 1958 . 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1971 1972 1973 1974 1975

1 ... 11 ... 11 14 6

......... 4 ...... 4i 68 20

i 9 12 0 12 12 10 10 8 21 24 ... 166

...... ...... ...... ...... ...... ...... ......

......... ......... EJ 32 30 28 31 15 34 376

...... ...... ...... ...... ... ... ... z

12 13 10 15 14

42

64

Total = 648 JouRNAL.

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woman an easier labor than her weaker counterpart.* fthirtbeenshownthatacertain amount of variance exists among the phy&o&cal thresholds of patn of dtfferent peoples Thts ts reasonabte when one considers the tnflwnce that an tndiddual’s general physics1 ckwtronmant has on hts sensitivity. People kving in plmittve surroundings are usually credited with the ability to withstand greater skin pressure than those from tndustrialtsed sodeties without complaining.’ Understandably so. because while the native wcnan may feel with her nerve endings precisely as the Wes tern woman, “being reared in a ltfe of chronic s&ht discomforts,” she is unlikely to signd unpleasant reactions until t hurts quite sharpiy.3 Modern tial conditions, it appears, have lessened the power of the Western woman to stand the hard&p, fatigue. and mental and physkaj strain of childbirth and rendered her less capable than the na. tive African woman of completing the expulsion of the child naturally. Disadvantages The midwife in Liberia is faced with a slightly more complicated task than her Western counterpart for -veraI important reasons: (a) The African woman’s p&is is more often anthropoid, resulting in a high pro. portion of occipitopostetif r deliveries. (b) Many of the gtrls ae married just after reaching puberty and they are not physically large enough to give birth to their babies, necessitatzngdelivery by Caesarean section. (c) Malnutrition of the mother may result In organs and functions which are poorly developed, including a placenta that may be improperly formed. If a gld was undernourished as a child, her pelvis may be smaller than normal. (d) The practice of female “circumcision” causes a small iIuds?r of problems during delivery.

Tsbl. 4 Birth Statistics - Curran Hospital

Caesarean Section Symphysiotomy Vacuum Extraction Twins

54 4.3%

42 3.2%

Triplets

52 3.7%

0

‘0

O.l%

. ..

Stillbirths

I

33 2.5%

41 2.9%

Tabk 5. Birth Statistics - Firestone Hospital (Harbel) 1975 Deliveries

Jan

Fob

Breech

6

9

5

l

**

13

13

CaesareanSection

2

4

6

l

**

2

4

175

159

149

l

**

152

167

Vacuum Extractlon

3

5

7

W*

5

6

TMns

4

a

4

7

8

22

-

Symphysiotomy

Triplets Subtotal Total

Mar

0

0

0

106

176

166

Apf

May Juno

10 127

July l ** l

170

2% 90.9%

**

3% 3.3%

00 182

5.2%

**

‘0. l

% of TOW

0.09% 105

1114

NOTE: Three maternal deaths were reported from Jan-July 1975. 24

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Each of these comp8cating factors will be dealt with separately in the paragraphs to follow. It is well known that a geat deal of variation exists in the shapes and skes of the pelves of different individuak. Caldwell and MaUoy have chsslfied female pelves into four types according to the shapes of the inlet: gynecotd, anthropoid, android, and platypeUoid. (See Figure 4) The pelvk of the majority of Ubertan women is most closely approximated by the anthro&d pelvis, in whkh the pelvk inlet b elliptical, wtth the long diameter antero-posterior.’ This is ako the most common type among Amerkan Negro women, accounting for almost 50%. The majority of white Amerkan women have the female type gynecoid pelvis, in which the pelvic inlet is round or slightly oval. Besides being narrower laterally and larger dorst-ventrally, the Liwhat shallower. Thus her pregnwcy is much more obvl0u.v the fundus can be palpated at 2 months rather than at 3 or 4 months whh deeper pelves. In addition, lightening (the sensation of decreased abdominal dktension produced by the descent of the uterus into the pelvic cavity) takes place much later than it does in a deeper pelvis. It occurs just before birth instead of two to three weeks before labor begins. The major consequence of the anthropoid shape of the pelvis in most Liberian women is the unusually high percentage of occipitoposterlor presentattons.’ This malpresentation occurs as a rest& of the relatively narrow transverse diameter in the anthropoid pelvjs, so the head usually descends in an oblique position. Consequently, normal uterine polar. ity is disturbed, since the tU-fttttngpresenting part applies unequal pressure In the lower uterine pole. The occipitoposterkx position is therefore as sociated with (1) skw, erratic, shortlived contractions, (2) early rupture of membranes with risk of cord nro-

Tabk 6. Hospital Births - Liberia Jan. 1-Dec. 31,1974 Live Births Female

County

Male

Montserrado

4186

Grand Bassa

503

Sinoe

76

StlllbIrlbs Male Fen&e

Metemat Deethe Abort&~

3748

99

87

12

445

496

1

4

0

0

65

0

0

0

0

68

4

4

0

0

143

0

4

0

0

939

34

33

5

38

597

26

23

0

25

541

33

34

7

i2

69

0

0

0

0

7934 999

141

Maryland

83 151

Grand Cape Mount Lofa

142 285

1016 1955

Nlmba

566 1163

Song

555

1096 Grand Gedeh Subtotal Total

65

134 7192

6666

13,868

JOURNAL OF NlJDSE-MIDWIFERY l VOI. XXII, No. 1, Sprtng 1977

197

189 386

24

550

24

550 26

Ispsl3#(3)pauseinbborafterrupture of rlwallhr8nes often leadb$ to &lcoorb&e and excemb& paMul labor. The mechankdn ol labor whm the head presents occlpitopoatsriorly mayhaoneoftwotypeszeitherti~ heairlmayrotatec?nteilody~the sytnphysk thtoudh a lotrg IIK: of 13B degmes, or it may rotate poatetlorly, through a Aott arc of 4-5degrees, to the hollow of the sacrum. (SeeFgurc 5) Once the head has comp!ccd it rotstbn, the mechanism of labor kcomes the same as for the ocdpnoanterior 0:‘ the occiplto-posterior po sition. II dttion does not occur, then aa impasse it reached and there k oix;tructoa labor. In such caws a forcepsdelhryoraCzxr5areansecUon may be just&d. Generally the delivery cm be completed spontaneously and the net result of the malunion Is a longer and more difA se&d complication that is more frequently found in Liberia is &ectly attritnrtahle to the cultural rimes of the A&an people, who both expect and encourage young girls to mate as soon after reaching putcrty ar poseMe. However, this causes difficult obstetrical problems due to the fact that the bony pe!yis has not yet assumed rts adult shape or size. Ihrefore the girls are oftm not krge enough to gtve hbth to th& babies. It is not until the gtrl t.sj reached the age of twenty that t!re os&ation of the sacrum and the :+ nominate hone is completed. Befo:e this, de!kery hy Caesarean sectton 13 often indicated due to cephalopelvx dtEpcoPQ~on A third important complicating fat ttx is the Ai& of matnutrition whose debilitating effects on both the mother and the unborn child are onI1 now heing fully appreciated. Evi dence tndtcates that a woman whc has been poorly nounshed through out her prqmncy - perhap! *lwx&out her life - is likely to bc , poorly dwdoped in all her organ and fmctions, The complex series of actions and mactions that make up I 26

Table 7. Cllnlc Births - Libarla Jan. 1-Dec. 3l,lg74 county -Montserrado

Live Births Male Female

Mate

Stlllblrthr Female

66

44

0

0

Grand Bassa

51

43

0

0

Slnoe

60

66

0

0

Maryland

13

7

0

0

0

0

0

0

96

101

0

0

Nlmha

105

100

1

0

Bong

110

133

9

6 0

Grand Cape Mount Lofa

Grand Gedeh

50

51

0

Subtotal

673

526

10

Total

1198

6 10

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formed inadequately. Furthermore, her child, whose nutrition has been dependent on her and whose organs and functions are also poorly developed, may be less able to do his part well. Stephen Zamenhof contends that malnourished g&l babies, when they themselves become adults, may be unable to have a normal Preg nancy and adequately nourish their OWII babiesIn the womb. The reason is that the placenta, which is responsible for providing nourishment to the unborn child, may not be properly formed because the mother was malnourished at some time in her own infancy.’ In the past few years, improved educational programs for pregnant Liberians have made them aware 01 the dietary needs of the fetus, and the result has been a steadily increas ing birth weight. Unfortunately, if ths mother herself had been malnour

likely to bs small, since the shape of the pelvis, espedally as it h determined by the length of the conjugate diameter, is very much influenced by nutrition. Thus, as they become more aware of the importance of eating the proper foods during pregnancy, mothers with small pelvic outlets are glvlng birth to children of ever-increasing birth w@ht. The result is cephalo-pelvic disproportion whkh will lead to diffkult deliveries for the next several generations. The fourth factor which occasionally causes complications during delivery is the practice of female “drcumdsion.” When a young Liberian girl enters the Sande bush school she undergoes an operation in which the clitoris (a small elongated erectik body situated at the anterior angle o the vulva, which is homologous witt the penis in the male) is completeI\ or partkally exdsed. Though this i! Tablr 8 Birth Rates & Ratios (1971)

Crud. Live Birth Rat.

Standard Errcr

Natural Incmeso

Fertlllty

General Fertlllty

Total Fertllllty

GmeeRep&u&on

NetReprcduction

Liberia

50

1.690

2.9

69

203

5.6

2.7

1.6

Rural

51

2.696

2.6

70

208

6.3

3.0

1.9

Urban

47

2.!90

3.2

63

191

4.9

2.4

1.7

SOURCE: Liberian Ministry of Health NOTE: Crude live birth rate = the number of live births per 1,000 population Standard error states that the changes are about 66 in 100 that the difference due to sampling between the estlmate shown and the figure that would have been obtained by a complete count ;s I-css than standard error. The chances are about 95 in 100 that the difference is less than two times thestandard error and 90 In 109 that It Is less than 2% times the standard error. Note that the standard error does not include non-sampllng errors which may be greater than the sampling erro’. Natural Increase = the birth rate minus the death rate Fertility = children under 5 years of age per 100 women aged 15-44 years General Fertility = the number of live births per 1,ooO women aged 16-44 years Total Fertility = sum of the age-speoifk birth rates per 1,000 women aged 15-44 years Gross Reproduction = sum of the female age-specific birth rates per 1.006 women aged 15-44 years Net Reproduction = sum of the PrOdUctSof the female agsspeclflc years multlplled by the proportion of female suvivors to that age JOURNAL

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birth rates p& l,QQQ women

view chlldbkth as their ratson &e&e. Conseqoently,ithregardedasa natoral, healthy pmcess, though t retatnsanauraofmysterybecauseso much about ihe course of pregnancy remahs unknown. Several andent taboosarestiUftm+adheredto,and Wr effed Is pre&mtnan,$y benefIctalhthattheybokterthepregnant woman’s conftdence during thnes of stress. Obviously, any tradition with a detrimental infhmms would not have ourvtved to be passed down from getNMontogeneration. Many tndtgenous mtiwivas cork duct deliveries today much as their predewssors did decadss ago. Since he wsl major& of the cases they hmdkr are perfedly normal, the tradMonal methods are usurJly quite wtkfectory. It is only when complica-

tions ark that they are unable to provide the mothez and thud with the best care po e. -Rough such obsMkaldtfRcuhksdaveloptnonly a small number of btrths t ts nonetholess advkable to teach the county midwives to handle them successfully, as is presently being done. Alvmlnx The examlnatton of ho@taJ stattstks Is one means of asses&g the proportions of abnormal deltvedes occurrlng among Liberian women. In the past three years at Cunan Haspttal, there has been an un sally high percentage of Caesarez~ sections, Increasing from 4.7% in 1972 to 5.5% in 1973 and 5.9% in 1974.

This can be accounted for by the fact thatcasesinwhlchaCaesarsansectbn Is indtcated are referred to the hospital by the midwife in attendant whereas a m number of nod d&e&s are never recorded because they are conducted in the vikges. Comparison of Table 4 with Tabk 5 shows that a Ftrestone Plant&ion Hospttal, where all of the pregnant women are accommodated In a special maternlty vtllage durtng the last trImester of thetr pregnandes and dehvered tn the hospttal, the percentage of Caesarean sections ts only 2%. There b a subslanttal difference in the percentages of breech deliveries and symphystotomks performed at Curran Hospital and Firestone HW ptal as well. (A symphysiotomy in-

Age Specific Birth Rate (1971) Age of Mother

Total

_LiberiaAll Areag Male Female

Total

Rural Areap Male Female

Total

yrban Area% Male Female

lo-49

163

65

4

6

5

15-19

106

106

79

161

100

73

200

167

92

20-24

241

125

117

247

134

113

231

109

123

J-1

70

165

06

79

7

7

0

149

77

76

0

25-29

273

138

135

394

190

264

213

124

09

w-34

201

66

105

?64

66

106

192

97

96

35.61

167

93

74

162

‘Ia3

76

166

52

53

40-44

49

24

25

51

26

25

42

16

24

over 44

25

a

17

24

7

I?

26

12

16

SOURCE: The Liberian Ministry of Health NOTE: Birth rate is the number of births per 1,000 populatlon Women aged 25-29 years had the highest probability of haviny a child; 27 out of 160 women between these ages had a child in 1971. In urtlan areas It was the younger women, aged 20-24, who had the most children; 23 out of 100 women between these ages had a baby In 1971. 2s

JOURNAL OF NURSE-MIDWIFERY l Vol. XXII, No. 1, Spring 1977

valves the cutthg of the svmuhweal I were breech presentations. In addijoint to sllow forth0 vsgksl delivery ’ tbu, while nealy ‘91% of the of a child.1Whereas less than 2% of I mothers at Firestone had symphysithe dehe&s at Curran Hospital OVOT otomies, less than 4% of those al the last three years were breeches, Curmn did. Possibly this reflects the over 5% of those performed at Firepersonal biases of the attending phy stone during the first half of 1975 skians, nurses and midwives more

th~itdOeSMYsigniftcantdiiterermce inthewomen’sp&ico&2ts0rthe Sh?.OfthebhtS. ~epercentageof-9ww birthtotwins Iomains~cOnstantat34%,whkhlsahigherprokontbrucdmpoqr3Ol

Table IO. Vita! Statistics (1971)

Inl8nt Mortality

Stsndsni Error ?)C

Life Expectmky at Bkth

Median Ago of Do&

MedtmAQeol Infant Death 2.2 wks

Liberia All Areas

159

4.3

45.1

4.5

Rural

171

6.3

45.6

4.6

2.4 wks

Urban

126

5.9

44.0

4.0

1.7 WkS

SOURCE: The Liberian Ministry of Health NOTE: Infant mortality rate = infant deaths (under 1 year of age) per 1#JO live births. The major force affecting mortality In 1971 was the introduction and outbreak of cholera in the country during the latter part of 1970and early 1971. Of the 32,926 who died in 1971, 26,510 were in the rural areas and 6,418 were In the urban areas. There Is evidence that the enumerators of the survey missed some deaths in 1971, particularly among children who died Immediately after birth. Over 113 of the people who died wem children under age 1. As a result of the Increase In mortality, the life expectancy at birth dropped from more than 50 years in 1970 to about 45 years in 1971. Tablo 11. Hospitals 6 Health Workers (1975)

Population

Horpltalr, Hrlth Ctn.

Hospital BUlS

Montserrado

370,707

16

1282

Grand Bassa

122,345

3

115

6

37

50,612

2

48

5

20

County

Sinoe

Boofom -93

PlobSfoMf NL 501

Maryland

woQ6

2

256

5

33

Grand Cape Mount

58,287

2

74

6

24

Lofa

181,Wl

5

216

5

56

Nimba

248,682

3

201

11

64

Bong

181,802

4

155

12

51

71,070

2

80

2

22

1,354,682

39

2429

145

810

Grand Gedeh Total

SOURCE: Mlnlatry of Information, Cultural Affalrs and Tourism, A Netlon of Growth MU lkmbpamt rovla, Llberk: Prlntlng DiVMOn, Visual Aids Bureau, 1975.) xw#NAl.

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(Mom

29

portion than one finds In the U.S., dthough It is not unusual for We& Mrke. In 1469 the Ubeden governmeat begwrpop~groti-wln an atter @ to gat more

accurate

and

anrent estimates of births end deatha The survey hAded appwximatdy 70,000 people, or about 5% ofthaesttmatedpopulathm. The data suggested that 73,301 b8bkswerebominthemunttyi!l 1971. The fe&ty indtces shown in bble 8 show that the crude Bve bbth mteforUbertawas~per1000,wtth theruralareasat51perlOOOand theurba~areasat47perl~.ThIs was quite dose to the data obtained !n 1970 when the rate for Liberia was found to be 51 rur& and urban

par 1000, with the rates at 50 and 53

per looo, rospediwly. It should be noted that only a fractionofthesebhthstakepIacetnhospttakorheatthcenters.AsTable6 and Table 7 tndicate, the total num her of he births in hospitals during 1974 was 13,&Z& while the clhtcs had only 1,199 births making a totai of 15,057. This accounts for about 19% of the country’s total births, however, The other 81% are dehvered in homes an3 villages with the assistance of country rnidwtves tn mo* cases. Thus rbe lctluence of the ind+naus miduk~es on maternd and child health Is conr;lderable.

BIBl.lcHiRAp~

4. Bumon, id& C., ad Hanabook o Obdetrlu and Gynecobgy, 2nd ed Los Altos, C&oLanga Medicr P~!Abkcatlonr, 1966, p. 338. 50

Uberia

Interview,

13

Lawam, J.6. end Stew&, D.B.. eds. obate&s and Gynoeco~ In the Tko@x and Dcueloplng Coun~es London: Edwud Anlo@ 1%7.

ADDlTKWJ~REF’EREN~t%i We, Fetk. LPN, Curmn Lutheran Ho* ita ikor, Liberia Intewkw, 13 hlgurt 1975. hdarmn. 8yh. Peace Colps Volun~7~Konia. Ubsris. lnmrvisw, 18 July

Leboyer, Fredrick. skth wffhout Ience. New York Alfred A. Knopf,

kck, Alfmd C. Beck’s Gb&Mcal ke,&hed.EdttedbyE.StewartTaytor. 58khnow: WInlamB& Wtudnr co.,

Lovejoy, CO.; Helpk, KG.; end Bur. atah. AH. “Gait of Austmloptthecus,” Ametican JoumdofPhydcaf Anthmpfogy so (1973): 757.

jorton Women’s iva Our Sadie, Mm&Schuster,

Health Ouklvea 1973.

Rnc1966.

Book C&cNew %k

?ederkk?n, adyh ubdonwy, .uiheran Ho#tal, Zomx, ti. hew. 13 August 1975. H-d, How&d DcactoI..~~9~tY*

cwrwl Inter-

W. LJeuUs, Drugs and New Yodc Bkla

Hollmrhead, ‘W. Henry. Anatomy for Sutgemw, Vol. 2; Tha 7710~ Abdomen yi&‘M&. New Yark Hoeba-Harpa, Hutton, $gga

Donna Peaca Corps ubam. Intavkw,

Volunteer, 21 July

isimcson, Dmnna Mbdonary MIdwIfe, culT8n Lutheran Hosplta& zomr, ubada. lnterukw, 13 August 1975.

Montagu, Ashky. Lffc Sefore York New American Library, Morky, D&d. ~~~~~~~ Nelson, Liberia

Jtnlack, Frances T. Bureau of Health Mamb Point, Monrovia. Liberia. Inter v&w, 29 July 1975. Joint Studp Group of the InternMona Feds&on of Gpecology and Gb&etrk and the InMrnstiond ConfederatIon o hlklwive~ Mofunby Care In the World fntemdknd Suruey of MdWrfery Rat and Trofnfng. Oxfor& Pergamo~ Ross, 1966.

ke

Johnson, Helen. Mdwifery student, Cm ran Lutheran Hospital School of Mid wfuy and Pm&at Nursing, Zorzo Ubaria Intavbw, 6 Aogud 1975. King, Maurice, cd. Msdkai Core in DC uclgn(ng Counti Nair& Oxfor University Press, 1966. Konle,

lkomas.

Curran

JOURNAL

Lutheran

Her

OF NURSE-MIDWIFERY

VolunLiberia.

Skth. New 1964.

Paediatdc Pdorttler fn the World London: Buti~

Lob. Mklwtfe, ELWA Horptal, Interview, 19 June 1975.

Onabamko. Sanya Llnjo. Why Our CMIdren Be: 771~ Cause, and Suggeriionr for PreuenHon, of MortaMy In rM.k Afrlcn. London: Methuen & Co,,

Injent

Paul, P.E. “Mdwlmery In bmbkm Bush How&al,” Mklwiues Chronkk and NwsfngNotu (June 1971): 194-97. fhd, Gra~tly Dick. Chudbmh Fear. New York: Harper, 1944. Roberts, $;Harbel,

Without

Dr. Firertone Plantation iiou Uberb. Interview, 31 July

Isaacson, Jeannette. Missionary Mid&e, Curran Lutheran Hospttal, Zormr, Lt. berm. lntervkw, 6 August 1975. Missionary h;urse, Libda Intervbw, 2C

Vfo. 1975.

Man-Apes or ApaAh? 77~ Sdorp of Dacovcrl~r in Africa New York HottRImhart a wmat&, 1967.

McKinney, Mary. Pea Corps teer, J.F.K. Hocpuel, Monrovia, Interview, 6 September 1975.

km~r+n, Alice M; Fwcbman, Susan H; md Woodvtlk, Lucille, New Horbonr In mdw/fary. Bdumore: Wavedy Rem, 1933.

Jacobson, Ruth. ~b~~gmpk81,

1. Matons, Paul. “The D6Jelopment oi He&h Care in Zorzor.” Zo~zor. Ubera, 1974. &limeogaphed.) 2. Englemann. Georgia J., “Labor Among Rhnitrw Pcopl& in Palmm Fidky, The story of Chlfdbhi h. (New YOdCDOUbk&&DorwitCO. 193?& pp. 51-52 3. Freehan, Lawrence 2. and Fergu son Vera M. “The Quastkm of ‘Peln ksa chlldbnh’ lo Rknitlva cu;turfM: $Fw As” of ~ha&ktrl

pitit~i3~~r8gc

i. Adamr.on, Peter. “No Second CIIWICO,” 777a NC0 JntamdJon~ (Novarn~ba 1974): 18-19.

A.J. Chrfdblrth Yesterday and New York Emerson Books, Spencer, Rabat CBA Sympda 1186.

F. “Primlive Obstetrics,’ 11 (1949-60): 116D-

Tavrirr, Cero. “Mele Supremacy b on the Way Out. II wee jus! a phase in the Evolution of Culture,” &cho&gy Today 8 (January 1975): 61-69. Tboma Haber& The Bakhno~ Williamsand Wallace, Irving, The People% Doubleday&Co,

&dab& W&ins,

P&s. 1935.

and Wsdlechinsky, Aimmoc. New 1976.

David. Yorlc

Welma W&em E. “Secret Medklnes, Magic and Rues of the KpeUe Tribe in L&de,” Southu@ern Joumd of An. rhropokgy 5 (1949): 20843.

obrtrt-

WtlUams, J. WMtrkQm. WUliams r&s, 14th ed. Edtted by Louts M. Hellman and Jack A. Prltchrd. New Yorlc AppletonCenturyCroftr, 1971. l

Vol.

XXII,

No.

1, Sprln&i

1977