Silent suffering

This article focuses on the plight of women who are suffering from incontinence due to obstetrical fistula and other causes, and discusses the efforts of Dr. Hamlin and other individuals in helping these women. Obstetrical fistula is common in sub-Saharan Africa and has also been reported on the Indian subcontinent in Bangladesh, India, Nepal and Pakistan. The factors affecting this problem are complex. In some developing countries, childbearing is seen as a natural part of life wherein women usually give birth unaided, even when they have difficulties. Other factors include early pregnancy, continuous childbearing and breast-feeding, malnutrition, female genital mutilation, and inaccessibility of rural health services. Oftentimes, women with this condition have to suffer for many years before undergoing surgery. However, prevention is better than cure, prevention involves a better education and care for women during pregnancy and labor, with more trained midwives and traditional birth attendants who know when to call for medical help.     

Training birth attendants in the Sahel

A small-scale training programme for birth attendants in a remote area of Burkina Faso was evaluated two years after it had been started. The evaluation methods included interviews with trained birth attendants and the analysis of health service statistics and survey data. The findings showed that the programme had been moderately successful in imparting knowledge and overcoming cultural inhibitions about assisted deliveries. However, the effectiveness of the programme was severely curtailed by structural deficits in the health system, especially lack of skilled staff, supervision and transport. In deprived areas such as the Sahel, it is probably the health centre, the hospital and the referral system that should be the first priority for improvement, rather than grass-roots practices.     

Effect of training on the resuscitation practices of traditional birth attendants

Training programs in more modern methods of birth asphyxia resuscitation were started for traditional birth attendants (TBAs) in 54 villages (population 62,427) of Raipur Rani Block near Chandigarh, India during 1989-1991. A continuing training program by the primary health center staff at 4 focal villages, for one day each month, had been in progress for several years. About 80-100 TBAs attended these sessions. Resuscitation methods included gravity drainage of secretions, physical stimulation by flicking at the soles of the feet, cleaning the mouth by a finger wrapped in gauze, mouth-to-mouth breathing, cardiac massage, and prevention of heat loss by wrapping the baby in multiple layers of cloth. In 1988, 31 TBAs also received advanced training in the use of the mucus extractor and bag-and-mask ventilation. Two trained field workers visited the villages once a fortnight to contact child workers, TBAs and health workers, and checking the local register of vital events to record births. Family members and/or the TBA who assisted at the delivery were interviewed, and a detailed birth history was recorded for stillborn and asphyxiated babies. TBAs assisted with the delivery of 1884 babies (93.7%). Of these, 31 asphyxiated babies and 30 recently stillborn babies were eligible for the resuscitation survey, but information could not be collected for 2 of the stillborn infants. Both traditional and modern resuscitation methods were used in 30 cases (51%), modern methods only in 13 (22%), traditional methods in 2 (3%), and no resuscitation effort was made in 14 cases (24%). Among 21 cases delivered by the trained TBAs, mucus traps and bag-and-mask were used in 33.3% and 42.6%, respectively. Instillation of onion juice and warming of placenta were practiced in a significantly higher proportion of cases by traditionally trained TBAs than by those who had received advanced training. Adoption of modern resuscitation methods by the TBAs demonstrates that they are likely to change their practices.     

What in the world is being done about TBAs? An overview of international and national attitudes to traditional birth attendants

Many of the half million women per year who die in childbirth are attended by traditional birth attendants (TBAs). Whether they fare better when such an attendant is trained remains uncertain; even the World Health Organization seems to have tempered its enthusiasm for TBA training recently. With some nations outlawing the practice of TBAs and others actively promoting it, there seems to be no consensus on what to do about this major and continuing workforce in maternity care. By themselves TBAs cannot reduce maternal mortality, whether they are trained or not. They need skilled, equipped and available support. As the professional group who must co-operate with TBAs and provide that support, midwives must, collectively and individually, assess, state and act on their attitude towards TBAs.     

Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision-makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first-line midwifery and second-line hospital delivery care.     

Interaction of patient and attendant reinforcement programs: The "piggyback" effect.

Developed an experimental approach for assessing the possible interaction of separate reinforcement programs for attendants and patients on an open psychiatric ward. 16 chronic mental patients were reinforced with lunch for engaging in work behavior. 16 attendants were reinforced with trading stamps for successfully completing assigned behavior modification tasks. Interactions were defined as the effects of the patient's work behavior of introducing and removing the reinforcements for attendants. Results suggest that the introduction of reinforcement for attendants significantly increased patient work behavior, while the removal of reinforcement significantly decreased it. This "piggyback" design has been shown to have utility for exploring the interactions that govern the behavior of members of 2 groups who are independently reinforced within a social system. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On reflection and prejudice

The condition referred to as "birth asphyxia" occurs as the result of a hypoxic-ischaemic insult during the process of labour and delivery. There is no standard clinical definition for birth asphyxia, but its incidence in term infants has been differently reported to be between 2.9 and 9.0 cases per 1000 deliveries. In term infants the risk of death appeared to be closely related to the duration that the Apgar score is severely depressed. The best predictor of disability in surviving infants is abnormal neurological behavior in the neonatal period referred to as hypoxic-ischaemic encephalopathy. Unfortunately, there are no generally accepted treatment regimens for birth asphyxia and traditional methods for treating hypoxic-ischaemic encephalopathy have not been shown to improve outcome.     

Impact of health centre availability on utilisation of maternity care and pregnancy outcome in a rural area of Haryana

Six hundred married women of 15-45 years age group were interviewed in 4 villages of the district Ambala in Haryana. Impact of health centre (HC) availability on the knowledge, opinion and practices related to maternity care and pregnancy outcome was assessed after adjusting the effect of socio-economic status. Except 17 women (2.8%), everyone knew at least one correct purpose of antenatal care (ANC) and 98.2% women had contacted health staff for ANC. However, knowledge of the respondents about the components of ANC was found to be poor in study villages. Traditional birth attendants (TBAs) conducted delivery in 76.1% cases in sub-centre (SC), 75.6% in villages without a HC compared to 49.8% in primary health centre (PHC) village. However, preference for TBAs in PHC village was 14.9%, in SC village 33.5%, and in villages without HC 36.3% (p < 0.001). Among respondents having better awareness about ANC components, preference and utilisation of modern delivery attendants was found to be higher. For maternity illnesses, consultation rate of government functionaries was 67.9% in PHC village, 52.2% in SC village and 55.8% in villages without a HC. Perinatal mortality rate of 76.0/1000 births in villages without HC was not significantly different from the rate of 87.4/1000 in SC village but rate of 38.9/1000 in the PHC village was significantly lower (p < 0.01). Awareness and availability of modern maternity services were found to have significant influence on the health seeking behaviour and pregnancy outcome.     

Number and timing failures among legitimate births in the United States: 1968, 1969 and 1972

More than one in 10 legitimate births that occurred in the United States during 1968, 1969, and 1972 were not wanted at all, and more than one-quarter of the births were timing failures. A substantial reduction in unwanted childbearing took place between 1968 and 1972. The proportion of legitimate births reported by their mothers to be unwanted ever declined from 13 percent in 1968 to eight percent in 1972. If, as reported in a number of cross-sectional surveys taken during this approximate period, there was a sharp reduction in wanted family size reported by married women, then these women would have remained at risk of having an unwanted birth for a longer period than when their wanted family size had been higher. Thus, these estimates of a decline in unwanted childbearing may be understated (although there was the countervailing trend of later age at marriage during these years). The decline in unwanted childbearing between 1968 and 1972 is only partially attributable to the shift toward lower birth orders that occurred. Declines in unwanted births occurred for almost all birth orders. There was no significant reduction in mistimed births. Because the decline in unwanted fertility during the study period was much greater for nonwhites than whites, the traditional racial differential in unwanted childbearing narrowed considerably between 1968 and 1972. In 1968, 12 percent of the white legitimate births were classified as not wanted, compared to 21 percent of the legitimate births to nonwhites. However, between 1968 and 1972, nonwhites experienced extremely sharp declines in unwanted childbearing. Thus, in 1972 only 9.5 percent of the legitimate births to nonwhites were reported as unwanted, compared to 8.1 percent of the white births. Mothers of higher parity were much more likely to report a birth as unwanted than those of lower parity. Mothers who had completed more schooling were less likely than poorly educated mothers to report births as unwanted. Income level seems unrelated to whether the birth is unwanted, but is inversely related to whether it is a timing failure. Births that resulted from premarital conceptions tended to be reported as timing failures. Viewed from the cross-sectional perspective of period rates of population change, the elimination of unwanted legitimate childbearing would have had a substantial effect on population growth in each of the study years even without decreasing marital mistimed births or illegitimate fertility. The data also suggest that eliminating unwanted marital childbearing could significantly reduce completed family size. However, this conclusion must be viewed with great caution, since we do not know the future variations in timing and spacing of births, and the extent to which the childbearing experience of the sampled mothers is representative of their birth cohorts.     

Lay mental health counseling: The effects of lay group counseling.

8 therapeutic groups of 10 hospitalized mental patients each were seen twice a wk. for a total of 24 sessions by 5 trained lay hospital personnel. 70 patients served as controls. The lay personnel, primarily attendants, had been trained by an approach integrating the didactic approach which emphasizes the shaping of therapist behavior with the experiential approach which focuses upon therapist development and "growth." Heavy training emphasis was placed upon research scales assessing process variables, which had been predictive of positive patient outcome, rather than any particular theoretical orientation. At the end of the 3-mo period, significant improvement was noted in the ward behavior of the treatment group when compared to the control group. (19 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Blood pressure lowering effect of low intensity aerobic training in elderly hypertensive patients

OBJECTIVE: The prevalence and etiology of pre- and postpartum depressive symptoms in women in a variety of family forms have been well documented, but relatively little research has been conducted on the adjustment of their male partners. The authors' goals in this study were 1) to estimate rates of depression during the pregnancy and 8 weeks following the birth of a child in a large representative community sample of fathers in different family structures and 2) to explore the role of stressful life events, social and emotional support, the quality of the partner relationship, and socioeconomic circumstances. METHOD: This study describes the relations of family setting and other correlates to men's depressive symptoms during the pregnancies (18 weeks gestation, on average) and 8 weeks after the births of children for 7,018 partners of female participants in the Avon Longitudinal Study of Pregnancy and Childhood. RESULTS: Men living in stepfamilies had-significantly higher levels of depressive symptoms before and after the birth than did men in more traditional families. The effect of stepfamily status on depression was mediated by education, life events, social support, social network, and level of aggression in the partnership. CONCLUSIONS: There are similarities in the patterns and correlates of depression after the birth of a child for men and women. These findings point to the importance of family and partnership ecology in the adjustment of men before and after the birth of a child.     

Birth weight, gestational age and perinatal mortality: biological heterogeneity and measurement error

At low birth weight the variance of last menstrual period based gestational age is wide and the distribution is positively skewed toward higher values. In this study the variance of gestational age decreases rapidly as birth weight increases, skewness decreases and kurtosis increases in approaching the mean of the birth weight distribution. Some of the wider variance and positive skewness of gestational age at low birth weight appears to reflect heterogeneity of intrauterine growth, in which infants with high values of gestational age are growth retarded. We show by partitioning each birth weight group into two groups of infants with different gestational age distributions, that at low birth weight, infants with low gestational ages have higher neonatal mortality rates but lower fetal mortality rates than infants with a higher gestational age for birth weight. The differences in mortality described between small infants at different gestational ages suggest that infants with a high LMP-based gestational age have experienced a slower rate of intrauterine growth. Some authors interpret the distributional characteristics as indications of systematic error in last menstrual period based assessment of gestational age. It appears from this study that the extent of systematic error in the estimation of LMP based gestational age may have been overstated in the past.     

Complexity of response as a factor in the vocabulary performance of schizophrenics.

"Equated pairs of schizophrenics and attendants were tested on two tasks differing in the complexity of the responses required. The performance of the schizophrenic group was significantly poorer than that of the attendants where the more complex response was involved. Where the less complex response was involved, the groups did not differ." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Heeding warnings ... from the canary, the whale, and the Jnuit, Part Two

There is a tension between traditional and modern definitions of reproductive risk and normalcy. These experts describe that tension as it plays out among the Inuit of Northern Canada from the perspective of a community midwife who has worked with the Inuit. She presents an analytical framework which classifies and illuminates the types of logic that compete in most birth settings around the world--a framework useful for showing how some types of logic can be supervalued while others, such as cultural or intuitive logic, are devalued or simply ignored, often at great cost. Part One presented political, scientific, clinical and cultural logic, and the influence of time. We now go on to look at professionalization and training and describe legal, personal, intuitive and economic logic. The author describes how the Inuit settlement of Povungnituk (POV) attempts to re-integrate the authoritative knowledge of the community by allowing Inuit midwives at The Maternity to choose their own criteria for balancing the imperatives of each kind of logic in decision-making for birth.     

Flight Attendants' Daily Recovery From Work: Is There No Place Like Home?

This article builds on earlier work on recovery from work during off-job time and specifically addresses recovery in flight attendants, a group of employees whose work is characterized by a high degree of emotion work demands. Forty-seven flight attendants completed daily surveys on a total of 4 evenings when they stayed at home or when they stayed in a hotel. Multilevel analysis showed staying in a hotel did not impair well-being at bedtime. Spending time on work-related activities during off-job time decreased well-being, whereas spending time on physical activities (i.e., sports) and experiencing off-job time activities as recovery improved well-being, also when initial well-being immediately after work was controlled. Time spent on social activities increased depression during the evening. As a whole, this study largely confirms findings from previous research with other professional groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exploratory spatial analysis of birth defect rates in an urban population

Are birth defect rates unusually high in particular urban localities? The answer requires that the birth defect rate for which 'significance' is claimed be adjusted for the variable population sizes of each area for which the rate is computed and for the spatial dependence of rates based on shared observations between neighboring areas. By address-matching birth and birth defect records to a digital road map, we are able to compute local birth defect rates at regular grid locations by dividing the number of birth defects that occurred in the geographical vicinity of a grid location by the total number of births in the same vicinity. We test for significance, at regular spatial intervals, against the null hypothesis that the observed rate at any locality could reasonably have arisen by chance alone, given the underlying geographical variation in births. Significance is determined by using Monte Carlo simulations, where each birth location has an identical probability of being a defect. From 1000 simulations, a statistical distribution of the birth defect rate for each grid location is determined. The proportion of the simulated birth defect rates that are less than the observed rate at any grid location is the probability that the observed rate is significant. These probabilities, portrayed as isarithmic maps, show areas that have significantly high birth defect rates. Our results show birth defect rates for the period 1983 to 1990 in Des Moines, Iowa, U.S.A.     

Factors that influence route of delivery--active versus traditional labor management

OBJECTIVE: Our purpose was to compare maternal and fetal factors that influence the route of delivery with active management of labor and a traditional labor management protocol. STUDY DESIGN: Data were collected prospectively on 346 consecutive patients receiving active management of labor and 354 patients who were managed traditionally. Within each group demographic and labor characteristics of patients undergoing cesarean section were compared with those of patients having vaginal deliveries by means of the Student t test, chi 2 analysis, and stepwise logistic regression. RESULTS: With both active management of labor and traditional labor management success in achieving vaginal delivery was related to the station of the fetal vertex at admission, the need for oxytocin augmentation of labor, the uterine response to oxytocin, the use of epidural anesthesia, and the development of chorioamnionitis. By means of multiple logistic regression analysis maternal age, height, payor status, and birth weight were also identified as risk factors for cesarean section with traditional labor management but not with active management of labor. CONCLUSIONS: Differences were identified in risk factors for cesarean section between active management and traditional labor management. Active management of labor may diminish or eliminate some patient characteristics as risk factors for cesarean birth.     

Time and space orientation in schizophrenics.

The spatial and temporal orientation of a group of 50 schizophrenics is compared with a matched group of 50 normal subjects selected from attendants and applicants for attendants at the Austin State Hospital. The results show that: 1. Schizophrenic S's are significantly poorer than normals on all the space and time orientation tests except that for bodily orientation. 2. The items that differentiate the schizophrenic from the normal have in common the absence of a frame of reference in the immediate perceptual field or to require attention to and retention of complex relationships. (PsycINFO Database Record (c) 2010 APA, all rights reserved)