Incorporating the traditional birth attendant into the health team: the Malaysian example

Domiciliary deliveries have always been the responsibility of traditional birth attendants. Since Independence, acquired in 1957, educated young women have been trained as auxiliary midwives and sent to serve in rural communities where they usually are met with resistance by the established traditional birth attendants. To counter this and to incorporate the traditional birth attendants into the health team, new roles were developed for each so that the two would be able to cooperate and support each other rather than rival and antagonise each other. A specific experience in one area of Malaysia is examined as an example.     

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.     

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)     

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.     

The benefits of school screening for scoliosis in the central part of The Netherlands

The Netherlands has well-organized school health services, and children are assessed on a regular basis for scoliosis among other disturbances and pathologies. The purpose of this study was to assess the benefits of an annual screening programme for scoliosis in the Netherlands. Three cohorts of 10,000 children sampled at 10, 12 and 14 years of age, respectively, were followed for 3 years. Children with a positive bending sign were referred to a second screening stage, in which external asymmetry was quantified. Children diagnosed via the programme (group 1) were compared with those children who had been referred for treatment independently of the screening (group 2). The total number of children in these groups combined was then compared with the number that would have been expected on the basis of accepted prevalence figures for idiopathic scoliosis given in current literature. Over 30,000 children were screened. Although the programme established a total of 57 cases of definite scoliosis (0.18%), the 34 cases (0.11%) already known, mainly detected by previous school health checks, were more severe regarding the risk of progression and treatment. The annual screening programme did not detect a single case that needed surgery. These figures provide the basis on which to decide for or against adopting an annual screening programme for scoliosis; the decision is a socio-political one. Based on this study, we expect all scoliotic patients needing treatment should be detected in time if periodic health checks will be maintained biennially. On medical grounds, it is our view, that screening for scoliosis should not be performed in the Netherlands annually.     

Strategic planning of the master programme in health informatics at Aalborg University: targeting and updating the programme, to meet explicit customer needs

Education is essentially giving people new skills and qualifications to fulfil certain tasks. In planning and managing educational programmes it is crucial to know what skills and what qualifications are needed to carry out the tasks in question, not to mention the importance of knowing what tasks are relevant to carry out. The programme in health informatics at Aalborg University produces health informatics professionals. The students are developing skills in solving informatics problems in health care organisations. The programme has been running for 3 years now and to maintain the perception of the aim for the programme a number of activities have been launched. In the following, the programme will be presented, the activities to obtain information on how to keep the programme targeted and updated will be described and the changes that are going to be introduced will be outlined.     

Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment

Obesity affects ovulation, response to fertility treatment, pregnancy rates and outcome. In this prospective study, a weight loss programme was assessed to determine whether it could help obese infertile women, irrespective of their infertility diagnosis, to achieve a viable pregnancy, ideally without further medical intervention. The subjects underwent a weekly programme aimed at lifestyle changes in relation to exercise and diet for 6 months; those that did not complete the 6 months were treated as a comparison group. Women in the study lost an average of 10.2 kg/m2, with 60 of the 67 anovulatory subjects resuming spontaneous ovulation, 52 achieving a pregnancy (18 spontaneously) and 45 a live birth. The miscarriage rate was 18%, compared to 75% for the same women prior to the programme. Psychometric measurements also improved. None of these changes occurred in the comparison group. The cost savings of the programme were considerable. Prior to the programme, the 67 women had had treatment costing a total of A$550,000 for two live births, a cost of A$275,000 per baby. After the programme, the same women had treatment costing a total of A$210,000 for 45 babies, a cost of A$4600 per baby. Thus weight loss should be considered as a first option for women who are infertile and overweight.     

A history of the training of asylum nurses

The national training scheme for asylum attendants, devised in the late 19th century, did not arise ex nihilo. Several philanthropic and imaginative madhouse keepers of the previous century had understood the link between successful treatment of lunatics and the quality of staff who cared for them. They had therefore aimed to recruit a 'good class' of person to work in their institutions, and to create an environment which would tend towards the civilization of the patients. A few even entertained the notion that training attendants would enhance their ability to understand and care for those in their charge. Training received increasing attention in both medical and political circles throughout the 19th century until a national scheme was inaugurated in 1891. The scheme achieved only a modest success in that, while it drew upon the undoubted enthusiasm of those who trained under it, it did not enhance the attendants' career opportunities or their pay once they had qualified. Training as a means of solving management problems was doomed to failure, and widespread dissatisfaction amongst asylum nurses erupted during the 1920s, only 30 years after the scheme had started.     

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.     

Prevention of cardiovascular disease within the primary health care system--feasibility of a prevention programme within the Sollentuna primary health care catchment area

OBJECTIVE: To integrate prevention of cardiovascular disease within the primary health care. DESIGN: A prevention programme which combines population and individual high-risk strategy. SETTING: The Primary Health Care in Sollentuna, Stockholm, Sweden. MAIN OUTCOME MEASURE: Characteristics of, and risk factor prevalence among, persons registered in the prevention programme. RESULTS: During the first year more than 2000 persons, representing every tenth visitor and 6% of the population aged 15-60 years, were registered in the prevention programme. 90% were < or = 60 years and 62% were women. A large proportion (70%) had risk factors that required advice, treatment, and follow up. 24% of the men and 27% of the women were smokers, 68% and 62% respectively, had serum cholesterol > or = 5.2 mmol/l, and 33% and 22% had a diastolic blood pressure > or = 90 mmHg. CONCLUSION: The present study implies that it is possible to integrate a large scale prevention programme in the existing primary health care organization. The prevalence of risk factors in those who enter the prevention programme is high, which places great demands for treatment and follow up.     

Omental plug closure of large duodenal defects--an experimental study

An explosive epidemic of Q-fever that occurred at Jedl'ové Kostol'any (Nitra District) in April 1993, had an unusual mode of transmission, unprecedented in Slovakia. The submitted case-reports can be very instructive for both health workers and the lay public. The bulk of infection was spread in the local pub through contaminated garments of animal attendants assisting abortions and births of goats in a large capacity breeding centre of Gemersan Co. By their repeated visits to the local pub the infection most probably spread to other guests by aerosol. A total of 113 persons (103 males, 10 females) contracted Q-fever. Out of them 95 were infected by contact with the goat attendants (84%), and 18 were occupational diseases after direct contact with the infected goats. The human epidemic of Q-fever facilitated to trace an ongoing epizootic of coxiellosis in the herd of goats of Gemersan breed. In order to stop further spread of infection among humans and to contain the outbreak of coxiellosis among animals extensive epidemic and epizootic measures were taken.     

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.     

Denaturation and reactivation of dimeric human glutathione reductase--an assay for folding inhibitors

In response to a Department of Health, England, circular encouraging policies of named voluntary antenatal HIV antibody testing, one West Midlands health authority in England introduced a policy of raising the issue proactively at the first antenatal attendance. In order to facilitate this policy a short staff education programme was provided for midwives. This paper reports on part of a study which aimed to evaluate the impact of the HIV awareness training programme. A sample of midwives (n = 65) was randomly selected for inclusion in the study. Thirty-three had attended training and 32 had not. Data were collected using a self-administered questionnaire exploring knowledge of aetiology of HIV/AIDS, knowledge of transmission, knowledge of obstetric and paediatric HIV, attitudes to HIV, issues related to antenatal HIV antibody testing and opinions about the HIV awareness training programme. Results indicated no significant difference in levels of knowledge or in attitude between those who had attended the training programme and those who had not. Similarly, no significant difference was found in terms of how midwives would react to women requesting HIV antibody testing. Many of the results contradict the current literature and as a conclusion it is suggested that there is a need to review HIV-related training for midwives.     

What is the infant mortality rate in South Africa? The need for improved data

OBJECTIVE: To review recent infant mortality and birth registration data in South Africa and to investigate geographical differences. OUTCOME MEASURES: Estimates of infant mortality rates, proportion of births not registered, and proportion of births recorded in health services. METHODS: 1. Published infant mortality data for South Africa were collated. Demographic data from national household surveys (1993 and 1994 October Household Surveys and the 1993 Poverty Survey by the Southern African Labour and Development Research Unit (SALDRU) at UCT) were analysed using the indirect method developed by Brass. 2. Birth registration data were analysed and compared with the estimated number of births to identify regions with greater under-registration. The number of births recorded in the health services was analysed by province in order to assess and explore alternatives within health authorities that could complement the existing system. RESULTS: 1. Published estimates of infant mortality for the period from 1990 range from 40 to 71/1,000 births and estimates based on national household surveys conducted in this period from 11 to 81/1,000 births. 2. Completeness of birth registration in the nine provinces ranges from less than 10% in the Eastern Cape, North West and Northern Province to 60% in the Western Cape. An overall improvement from 19% to 60% could be achieved if births recorded through the health services were included in the vital registration system. CONCLUSIONS: The infant mortality rate in South Africa is not known with any certainty. The extent of completeness of the birth registration system was 19%, which indicates a need for urgent improvement in order to provide key health status indicators. This study indicates that there is some potential for improving the extent of birth registration if it could be facilitated through the health service. However, this alone would not achieve complete registration. RECOMMENDATIONS: Surveys will have to be relied upon until such time as routinely available statistics are accurate. The October Household Survey conducted annually by the Central Statistical Service as potentially an important source of health status information. It is imperative that either the design of the birth history questionnaire be improved or that it be replaced by a less frequent but more specialised demographic and health survey.     

Roaming through methodology. V. The prevention paradox: few with a high risk versus many with a moderate risk

With a good primary prevention programme a number of healthy individuals will never know that they had a narrow escape from disease and maybe even death. Large numbers of individuals participate in such a programme, while only a few of those would have fallen ill without it. Nevertheless such a population approach often will yield a larger health benefit (on a population level) than an intervention that only aims at the high risk group in the population. That has been called the prevention paradox. The choice between a population or a high risk approach has prompted lengthy debates in the Netherlands. Epidemiology offers a methodology to estimate the effects of different approaches. The health impact will be determined by the distribution of exposure in the population and the risk function of exposure. In the final decision on a prevention strategy other considerations such as cost-effectiveness of interventions, negative side effects, possibilities of identification of high risk groups and ethical issues can play a part.     

The impact of a mobile dental system on a school community. Part III--Teachers and parents response to a mobile dental system at school

According to the principles of the Primary Health Care Approach, planning and implementation of community health programmes should be carried out with the full participation of the community concerned (WHO, 1978). The introduction of the Mobile Dental System to the school environment is an example of a "Community health care/technology approach" where the programme was determined by the professionals for the community and not by the community for itself. Teachers play an important role in the implementation of oral health care programmes in the school, while parents provide the vital and appropriate context and continuity for the success of such programmes. This paper, therefore, deals with the responses of teachers and parents to an introduction of a mobile dental system at their school. A self-administered mostly open-ended questionnaire was distributed to all teachers in the four schools that participated in preventive programmes and were served by the Mobile Dental System. Based on the results it seems that both the teachers and the parents were apathetic in their commitment to the programme although they were quite willing to participate. Their participation was confined to compliance with instructions or suggestions given by the health professionals. It is clear that under these conditions the potential to sustain the momentum created by the introduction of the MDS is limited. It seems that only if the community is involved in the determination of their preferential needs, planning of the appropriate programme and playing an active role in its implementation, will the programme have a chance of long term success.     

Prosthodontic considerations when using implants for orthodontic anchorage

Between 8 December 1995 and 16 January 1996 seven laboratory confirmed cases of septicaemia owing to infection with Neisseria meningitidis serogroup C strains and one highly probable case of meningococcal septicaemia occurred in three electoral wards in south Rotherham and the Retford area of north Nottinghamshire. All cases occurred among children aged 1-17 years. One patient died. The public health response to this outbreak was the largest community prophylactic antibiotic and immunization programme against meningococcal infection, to date, in the United Kingdom. The target group for each Health Authority was 8900 for Rotherham Health Authorities and 8000 for North Nottinghamshire Health. Local logistical factors led to differences in the implementation of the programme by each Health Authority. At the completion of each programme, 8320 doses of vaccine had been administered (92.5 per cent coverage) during the Rotherham Health Authorities programme and 7660 (95.7 per cent coverage) during the North Nottinghamshire Health programme. The additional financial cost of the exercise amounted to approximately Pounds 125000 for each Health Authority. This paper describes the evolution of the outbreak, the decision-making process resulting in the immunization programme in each Health Authority, the implementation of each programme, problems identified and lessons learned.