Monday, November 8, 2010

Reducing maternal and newborn mortality and morbidity at the primary health care level

Today's discussion topic in the Global Forum is:
What practices or tasks can be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?

My quick response is to ask the same question differently, placing the focus on the woman-baby unit, rather than the tasks:
What needs do mothers and babies have that can be addressed at the primary health care level by health care providers other than medical doctors, and how will the addressing of these needs accellerate the reduction of maternal and newborn mortality and morbidity?

The *needs* at the primary care end of the health care spectrum are summed up as the protection, promotion, and support of the natural physiological processes in pregnancy-birth continuum, for both the mother and her newborn. Maternity health professionals are used to using this powerful group of words, 'protection, promotion, and support' in relation to the Baby Friendly Hospital Inititative. Maternity care providers would do well to adopt the same principles in relation to basic maternity services, and apply the same level of scrutiny before birth as we do to practices relating to breastfeeding.

The practices and tasks through which the wellbeing of mother and baby are protected, through which health promotion is achieved, and through which women are supported in giving birth to and nurturing their children are not the practice domain of any profession.

Midwives and medical doctors, and nurses in maternity and neonatal units, have the professional authority to intervene when complications are detected, so it is imperative that the 'protection, promotion and support' of the physiological processes in childbearing and initiation of breastfeeding in the immediate postnatal period are high priority 'practices' and 'tasks' for every person with professional roles in maternity care.

Family members and unregulated birth attendants have roles in primary maternity care, and the practices and tasks allocated to these members of a woman's community also have a significant potential to either work in harmony with natural physiological processes in childbearing and nurture, or to interfere.

The WHO statement "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: a practical guide. Page 4) is the guiding principle for all maternity and newborn care.

Returning to the forum question: "What practices or tasks can be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?"

Primary maternity health care relies on the midwife, who is skilled and able to act as primary care provider on her/his own authority, detect complications, and refer to medical services in a timely way. The practices and tasks that are provided by midwives at the primary health care level, and which will improve maternal and newborn outcomes are summed up in the International Confederation of Midwives’ (ICM) Definition of the Midwife (2005). This Definition establishes the following principles:
  • .1 The principle of ‘partnership’: “The midwife … works in partnership with women …”
  • .2 The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
  • .3 The principle of continuity of carer (‘caseload’) – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
  • .4 The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
  • .5 The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
  • .6 The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
  • .7 The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
  • .8 The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”
Education and health promotion, including diet, smoking and substance issues, exercise, the importance of exclusive breastfeeding, and locally appropriate messages such as clean water are vitally important tasks that can be delegated to unregulated health care providers.

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