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Primary health care and the perinatal period
Early Human Development, 29 (1992) 211-215 Elsevier Scientific Publishers Ireland Ltd.
211
EHD 01277
Primary health care and the perinatal period P.M. Dunn Department of Child Health, University of Bristol, Bristol (UK)
This short discussion of the importance of primary health care in the perinatal period begins by listing the underlying problems responsible for present deficiencies and then outlines ways in which the situation might be improved. Key wora%: primary provision
perinatal care; reasons for inadequacy and methodology
of
There are 125 million births each year in the world, the majority taking place in homes in the rural and per-i-urban communities of developing countries. The health care needs of these mothers and the 1500 million children throughout the world today constitute the greatest challenge of all if we are to achieve the target set out in the Declaration of Alma-Ata in 1978 that by the year 2000 all the citizens of the world should attain a level of health that permits them to lead a socially and economically productive life. Indeed, it has been calculated that in developing countries more than 80% of the workload of the primary health worker is related to mothers and children. The present situation is daunting. On average throughout the world one out of every 12 babies will die during the first year of life, the mortality for the developing world being 10 to 20 times that of developed countries. Birth asphyxia and trauma, malformations and infections are the main problems in the perinatal period, while malnutrition, gastroenteritis and respiratory infections are chiefly responsible thereafter. Yet modem medicine has the means to readily prevent or treat most of these major problems. Why then do they persist or even increase? It seems to me that there are five main reasons: (1) There is the population explosion which threatens to double the world’s population in a generation and throws a destructive burden on natural food and other reserves. Correspondence to: P.M. Dunn, Department of Child Health, University of Bristol, Bristol, UK. 0378-3782/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
212 (2) Following on the increase in population there are the profound socioeconomic and demographic changes that have accompanied industrialisation and intensive modem methods of farming, leading to urbanisation, disruption of the traditional family structure and to the dependence for survival on motley rather than on agricultural barter and self-support. (3) The low general level of education and literacy, often combined with deeply held prejudices and customs, has hindered efforts to encourage community and family self-help. (4) There has been the failure of government to appreciate the importance of primary health care both from socio-economic and humanitarian viewpoints and to afford it an appropriately high priority. (5) Last but not least, there has been the failure of the medical profession to grasp the fact that its most important role in the world today is the prevention rather than the treatment of disease and that to achieve this they must share their knowledge with paramedical health workers and indeed the whole community. This failure is likely to continue as long as medical students are selected from the upper intellectual and economic strata of society and given a long and expensive training in therapeutic medicine similar to that received by their predecessors. It is hardly surprising if such doctors prefer to practice their therapeutic skills in the social setting to which they are accustomed, namely the wealthy areas of towns. Not only does such medicine have the wrong priorities but, because of the escalating cost of modem medical therapy, there is often little money left over for primary health care. Moreover, the medical profession also tends to impede efforts towards self-help in communities by refusing to recognise or to educate paramedical staff to do the work they are not always inclined to do themselves. Modern hospital orientated obstetrics tend to have had a particularly inappropriate and damaging effect on maternity and perinatal care in general. By focusing on pathology and high technology in hospital, birth has not only become a much more expensive and surgical an event, but has been robbed of many of the spontaneous and exciting emotional aspects often associated with home delivery that are so important to family and community bonding. Furthermore, many hospital practices and customs tend after a time to be also practised in the community - such as delivery in the dorsal position and the wide use of analgesic drugs. To reverse the trends of the past and overcome looming problems will require a revolution in attitude and effort. Ideally, government aided by the medical profession should take the lead in the organisation and provision of primary health care. Indeed, it is important that obstetricians and paediatricians see their role in the future as that of the total development of the MCH and specialist services in their area, naturally in collaboration with public health doctors and administrators and in close cooperation with the community itself. However, in practice it seems probable that the initiative is in many cases likely to depend on the energy and vision of individuals and any lasting success on the interest communities have in helping themselves. Mobilisation of untapped resources and particularly the efforts of the people themselves should be central to any scheme for improvement. The remainder of this short introductory paper offers a few suggestions on the way in which primary MCH care might be established in an area in which little or no
213
prior organisation exists. Of course, much will depend on local socio-economic and demographic factors, on the resources available and on the existing customs and prejudices; always there will be need for flexibility in approach. The first step must be to ascertain the size of primary health care needs, the resources in funds, services and facilities potentially available and the nature of any special local factors or problems. As any local health service must be based on community and family self-reliance and self-help, it is essential from an early stage to collaborate closely with local administration, with leading citizens, particularly school-teachers and also with untrained health workers such as traditional birth attendants. The next step should be the provision of primary health clinics (including maternity care), with the aim of eventually providing one within walking distance of everyone in the community (this may be 5-10 miles in rural areas). It is essential that such clinics should be sited close to places likely to be visited by mothers and children such as the local school. Whatever the funds and support available from further afield, it is important that the local community itself actively helps to provide and take a pride in the provision of this, their own new health clinic. Each primary health clinic needs to be closely associated with a referral centre providing secondary health care, usually the closest hospital in the region. Such a hospital would hopefully be the source from which doctors and nurses would regularly visit in order to advise and educate and from which medical supplies would come. It would also be the referral centre for problem cases; hence a transport system also needs to be developed. Means of communication by telephone or wireless are also most important. In a perfect world, primary health care clinics would be staffed by trained doctors, nurses and midwives. In reality this will often not be possible. Anyway the greatest use should always be made of local paramedical staff and, in particular, traditional birth attendants. The latter already live amongst and know the community and its problems and hopefully also have its confidence. Experience has demonstrated how much improvement may be achieved by just a few weeks of initial medical training either in hospital or in the clinic. Of course, such training needs to be supplemented at regular intervals, preferably ‘on site’. Above all the emphasis must be on nonintervention when all is normal and on referral either to the visiting doctor or to hospital when complications arise. Paramedical staff such as these should be formally enrolled into the primary health care team and given a badge or certificate and a uniform and the confidence and responsibility that their work deserves. Primary health care should extend beyond screening for disease and simple remedy or referral (Table I). It must also embrace preventive medicine and, in particular, birth control, immunisation and health education, The latter should be especially aimed at young mothers and children and should include advice on nutrition, on hygiene, on family planning, on reproductive health, on breast feeding and on the avoidance of disease. The school teachers should also be enrolled whenever possible in the team and given the appropriate information to pass on to children during their formative years. Education is indeed fundamental to the improvement of health by indirect as well as direct means. Thus, better agricultural methods may lead to improved nutrition,
TABLE I A list of the skills and functions, some or all of which might be taught to traditional birth attendants prior to enrolment into the primary health care team and practiced in the setting of the rural maternity health centre A.
Antenatal
Care
Ascertainment of mother’s past medical and maternity history. Estimation of expected date of delivery. Physical examination of mother, including fetal palpation and auscultation. Measurement of maternal weight, height, temperature, blood pressure, haemoglobin. Examination of urine for albumin and sugar. Taking blood for grouping and examination for syphilis. Advice on diet, vitamins and iron. Advice on personal hygiene, on not smoking, etc. Advice on and preparation for breast feeding. Detection of disease and pregnancy complications requiring referral to doctor. Treatment of simple conditions. Active immunisation against tetanus. Recording of observations and management. B.
Normal
D.
Soon after (i) Mother
(ii)
E.
Infant
Follow-up (i) Infant
Labour
Recognition of importance of confidence and relaxation. Freedom of mother to remain mobile and adopt preferred posture. Non-use of analgesia, oxytocic drugs, or artificial rupture of membranes except under direct medical instruction. Recognition of complications requiring immediate referral. C.
Delivery
Use of gravity. Freedom of mother to choose preferred posture, Non-use of episiotomy or instrumental delivery. Maintenance. of hygiene especially in division of umbilical cord (after delivery of placenta). Possible use of oxytocic agent in emergency for serious postpartum haemorrhage. Use of i.v. infusion for emergency hypotension. Repair of minor perineal tears (selected TBAs). Recognition of complications requiring medical advice. Simple resuscitation for birth asphyxia. Recording of perinatal events.
(ii)
Mother
Delivery
Observation during puerperium. Detection of puerperal fever and other complications. Supervision of breast feeding. Examination and detection of anomalies or disease. Importance of warmth. Measurement of temperature. Establishment of breast feeding. Measurement of weight, height and head circumference. Administration of Vit. K,. Care of the umbilicus. Importance of mother-child bonding. Measurement of height and weight. Observation of developmental progress. Advice on nutrition and weaning. Provision of vitamins. Immunisation - TB - tetanus - diphtheria - poliomyelitis - whooping cough - measles - rubella General advice on hygiene and prevention of disease especially gastroenteritis. Oral rehydration of gastroenteritis. Advice on dental hygiene. Referral of problems. Record keeping. Supervision and advice on general health and nutrition Detection and treatment of anaemia. Supervision of breast feeding and weaning. Importance of spacing pregnancies. Methods of birth control, including importance of lactational amenorrhea. Education of community on health services available.
215
while an understanding of the cause of gastroenteritis may hopefully be followed by efforts to improve sewage disposal and secure a safe supply of drinking water, both essential ingredients to any primary health care programme. In all such projects it is necessary to harness the interest, the co-operation and finally the pride of the community in what should be to a large extent achievements by self-help. Although much may be achieved at relatively small cost, ultimately improvements in health tend to be limited by financial factors. Therefore, a health care programme should also focus on ways of improving local prosperity. Once more education is a vital weapon. Finally, if the public and governments are to be convinced of the importance and success of primary health care programmes, then evidence must be collected. This should include data on the situation existing prior to commencing the project followed by the prospective collection of information as the programme unfolds. To this end a record system, however simple, is essential. This introductory statement on primary health care may be summarised by re-emphasising the following key factors: Community and individual self-help; Use of local resources; Education and the use of teachers; Use of traditional paramedical staff; Improved hygiene and nutrition; Emphasis on prevention of disease; Immunisation; Family planning; Simple diagnostic technologies and treatment; Referral of serious disease; Record keeping; Close collaboration between the medical team and the community.
211
EHD 01277
Primary health care and the perinatal period P.M. Dunn Department of Child Health, University of Bristol, Bristol (UK)
This short discussion of the importance of primary health care in the perinatal period begins by listing the underlying problems responsible for present deficiencies and then outlines ways in which the situation might be improved. Key wora%: primary provision
perinatal care; reasons for inadequacy and methodology
of
There are 125 million births each year in the world, the majority taking place in homes in the rural and per-i-urban communities of developing countries. The health care needs of these mothers and the 1500 million children throughout the world today constitute the greatest challenge of all if we are to achieve the target set out in the Declaration of Alma-Ata in 1978 that by the year 2000 all the citizens of the world should attain a level of health that permits them to lead a socially and economically productive life. Indeed, it has been calculated that in developing countries more than 80% of the workload of the primary health worker is related to mothers and children. The present situation is daunting. On average throughout the world one out of every 12 babies will die during the first year of life, the mortality for the developing world being 10 to 20 times that of developed countries. Birth asphyxia and trauma, malformations and infections are the main problems in the perinatal period, while malnutrition, gastroenteritis and respiratory infections are chiefly responsible thereafter. Yet modem medicine has the means to readily prevent or treat most of these major problems. Why then do they persist or even increase? It seems to me that there are five main reasons: (1) There is the population explosion which threatens to double the world’s population in a generation and throws a destructive burden on natural food and other reserves. Correspondence to: P.M. Dunn, Department of Child Health, University of Bristol, Bristol, UK. 0378-3782/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
212 (2) Following on the increase in population there are the profound socioeconomic and demographic changes that have accompanied industrialisation and intensive modem methods of farming, leading to urbanisation, disruption of the traditional family structure and to the dependence for survival on motley rather than on agricultural barter and self-support. (3) The low general level of education and literacy, often combined with deeply held prejudices and customs, has hindered efforts to encourage community and family self-help. (4) There has been the failure of government to appreciate the importance of primary health care both from socio-economic and humanitarian viewpoints and to afford it an appropriately high priority. (5) Last but not least, there has been the failure of the medical profession to grasp the fact that its most important role in the world today is the prevention rather than the treatment of disease and that to achieve this they must share their knowledge with paramedical health workers and indeed the whole community. This failure is likely to continue as long as medical students are selected from the upper intellectual and economic strata of society and given a long and expensive training in therapeutic medicine similar to that received by their predecessors. It is hardly surprising if such doctors prefer to practice their therapeutic skills in the social setting to which they are accustomed, namely the wealthy areas of towns. Not only does such medicine have the wrong priorities but, because of the escalating cost of modem medical therapy, there is often little money left over for primary health care. Moreover, the medical profession also tends to impede efforts towards self-help in communities by refusing to recognise or to educate paramedical staff to do the work they are not always inclined to do themselves. Modern hospital orientated obstetrics tend to have had a particularly inappropriate and damaging effect on maternity and perinatal care in general. By focusing on pathology and high technology in hospital, birth has not only become a much more expensive and surgical an event, but has been robbed of many of the spontaneous and exciting emotional aspects often associated with home delivery that are so important to family and community bonding. Furthermore, many hospital practices and customs tend after a time to be also practised in the community - such as delivery in the dorsal position and the wide use of analgesic drugs. To reverse the trends of the past and overcome looming problems will require a revolution in attitude and effort. Ideally, government aided by the medical profession should take the lead in the organisation and provision of primary health care. Indeed, it is important that obstetricians and paediatricians see their role in the future as that of the total development of the MCH and specialist services in their area, naturally in collaboration with public health doctors and administrators and in close cooperation with the community itself. However, in practice it seems probable that the initiative is in many cases likely to depend on the energy and vision of individuals and any lasting success on the interest communities have in helping themselves. Mobilisation of untapped resources and particularly the efforts of the people themselves should be central to any scheme for improvement. The remainder of this short introductory paper offers a few suggestions on the way in which primary MCH care might be established in an area in which little or no
213
prior organisation exists. Of course, much will depend on local socio-economic and demographic factors, on the resources available and on the existing customs and prejudices; always there will be need for flexibility in approach. The first step must be to ascertain the size of primary health care needs, the resources in funds, services and facilities potentially available and the nature of any special local factors or problems. As any local health service must be based on community and family self-reliance and self-help, it is essential from an early stage to collaborate closely with local administration, with leading citizens, particularly school-teachers and also with untrained health workers such as traditional birth attendants. The next step should be the provision of primary health clinics (including maternity care), with the aim of eventually providing one within walking distance of everyone in the community (this may be 5-10 miles in rural areas). It is essential that such clinics should be sited close to places likely to be visited by mothers and children such as the local school. Whatever the funds and support available from further afield, it is important that the local community itself actively helps to provide and take a pride in the provision of this, their own new health clinic. Each primary health clinic needs to be closely associated with a referral centre providing secondary health care, usually the closest hospital in the region. Such a hospital would hopefully be the source from which doctors and nurses would regularly visit in order to advise and educate and from which medical supplies would come. It would also be the referral centre for problem cases; hence a transport system also needs to be developed. Means of communication by telephone or wireless are also most important. In a perfect world, primary health care clinics would be staffed by trained doctors, nurses and midwives. In reality this will often not be possible. Anyway the greatest use should always be made of local paramedical staff and, in particular, traditional birth attendants. The latter already live amongst and know the community and its problems and hopefully also have its confidence. Experience has demonstrated how much improvement may be achieved by just a few weeks of initial medical training either in hospital or in the clinic. Of course, such training needs to be supplemented at regular intervals, preferably ‘on site’. Above all the emphasis must be on nonintervention when all is normal and on referral either to the visiting doctor or to hospital when complications arise. Paramedical staff such as these should be formally enrolled into the primary health care team and given a badge or certificate and a uniform and the confidence and responsibility that their work deserves. Primary health care should extend beyond screening for disease and simple remedy or referral (Table I). It must also embrace preventive medicine and, in particular, birth control, immunisation and health education, The latter should be especially aimed at young mothers and children and should include advice on nutrition, on hygiene, on family planning, on reproductive health, on breast feeding and on the avoidance of disease. The school teachers should also be enrolled whenever possible in the team and given the appropriate information to pass on to children during their formative years. Education is indeed fundamental to the improvement of health by indirect as well as direct means. Thus, better agricultural methods may lead to improved nutrition,
TABLE I A list of the skills and functions, some or all of which might be taught to traditional birth attendants prior to enrolment into the primary health care team and practiced in the setting of the rural maternity health centre A.
Antenatal
Care
Ascertainment of mother’s past medical and maternity history. Estimation of expected date of delivery. Physical examination of mother, including fetal palpation and auscultation. Measurement of maternal weight, height, temperature, blood pressure, haemoglobin. Examination of urine for albumin and sugar. Taking blood for grouping and examination for syphilis. Advice on diet, vitamins and iron. Advice on personal hygiene, on not smoking, etc. Advice on and preparation for breast feeding. Detection of disease and pregnancy complications requiring referral to doctor. Treatment of simple conditions. Active immunisation against tetanus. Recording of observations and management. B.
Normal
D.
Soon after (i) Mother
(ii)
E.
Infant
Follow-up (i) Infant
Labour
Recognition of importance of confidence and relaxation. Freedom of mother to remain mobile and adopt preferred posture. Non-use of analgesia, oxytocic drugs, or artificial rupture of membranes except under direct medical instruction. Recognition of complications requiring immediate referral. C.
Delivery
Use of gravity. Freedom of mother to choose preferred posture, Non-use of episiotomy or instrumental delivery. Maintenance. of hygiene especially in division of umbilical cord (after delivery of placenta). Possible use of oxytocic agent in emergency for serious postpartum haemorrhage. Use of i.v. infusion for emergency hypotension. Repair of minor perineal tears (selected TBAs). Recognition of complications requiring medical advice. Simple resuscitation for birth asphyxia. Recording of perinatal events.
(ii)
Mother
Delivery
Observation during puerperium. Detection of puerperal fever and other complications. Supervision of breast feeding. Examination and detection of anomalies or disease. Importance of warmth. Measurement of temperature. Establishment of breast feeding. Measurement of weight, height and head circumference. Administration of Vit. K,. Care of the umbilicus. Importance of mother-child bonding. Measurement of height and weight. Observation of developmental progress. Advice on nutrition and weaning. Provision of vitamins. Immunisation - TB - tetanus - diphtheria - poliomyelitis - whooping cough - measles - rubella General advice on hygiene and prevention of disease especially gastroenteritis. Oral rehydration of gastroenteritis. Advice on dental hygiene. Referral of problems. Record keeping. Supervision and advice on general health and nutrition Detection and treatment of anaemia. Supervision of breast feeding and weaning. Importance of spacing pregnancies. Methods of birth control, including importance of lactational amenorrhea. Education of community on health services available.
215
while an understanding of the cause of gastroenteritis may hopefully be followed by efforts to improve sewage disposal and secure a safe supply of drinking water, both essential ingredients to any primary health care programme. In all such projects it is necessary to harness the interest, the co-operation and finally the pride of the community in what should be to a large extent achievements by self-help. Although much may be achieved at relatively small cost, ultimately improvements in health tend to be limited by financial factors. Therefore, a health care programme should also focus on ways of improving local prosperity. Once more education is a vital weapon. Finally, if the public and governments are to be convinced of the importance and success of primary health care programmes, then evidence must be collected. This should include data on the situation existing prior to commencing the project followed by the prospective collection of information as the programme unfolds. To this end a record system, however simple, is essential. This introductory statement on primary health care may be summarised by re-emphasising the following key factors: Community and individual self-help; Use of local resources; Education and the use of teachers; Use of traditional paramedical staff; Improved hygiene and nutrition; Emphasis on prevention of disease; Immunisation; Family planning; Simple diagnostic technologies and treatment; Referral of serious disease; Record keeping; Close collaboration between the medical team and the community.