Global forum, Day 2

The forum leaders have written:

Today we continue to discuss Day 1's question on:

"What practices or tasks should 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?"

However, we want you to elaborate more on specific issues within the context of "Optimizing the roles of health workers". In view of the global health workforce crisis, what could different cadres of health workers undertake that is outside their routine scope of work in order to reduce maternal and newborn mortality and morbidity? For example, can we recommend midwives to perform external cephalic version, instrumental vaginal delivery and caesarean section? Lay Health Workers for labour companionship? Can we recommend non-clinician physicians (or clinical officers) to perform caesarean section, hysterectomy for ruptured uterus e.t.c? At the PHC level, can midwives/nurses administer anticonvulsants? Uterotonics? Some of these practices are already included in existing WHO guidelines but not necessarily with a specific health cadre in mind.

I cannot imagine the plight of women who experience life-threatening complications when giving birth in isolated places, with no access to emergency obstetric care. When their distress is compounded by poverty and ill health and hunger and all the dreadful conditions we hear about in the developing world - I am overwhelmed with sadness.

The questions that the forum leaders have asked are obviously pressing the issue, when doctors are not available, what can non-doctors do?

Practising in a primary care situation (homebirth) in suburban Melbourne, I am confident that I can transfer to a well equipped and staffed hospital if progress is poor, if pain is excessive, if the baby is showing signs of distress, if the mother is becoming dehydrated, if ... any of a host of indications presents. It may take an hour from the decision to transfer to the assessment at the hospital -- that is a factor that is taken into consideration.

Women in isolated areas in outback Australia may need to travel many hours by whatever transport is available before they get to a hospital. Inuit women in the Canadian Arctic regions who give birth in Birth Centres in their own communities, in the care of their own midwives, have achieved improved outcomes when compared with their neighbours in other towns, who are required to leave their families and communities to give birth in hospital. [See the Birth Rites documentary.] The principles that I apply to primary midwifery care in the leafy and wealthy Eastern suburbs of Melbourne are the same principles that midwives apply in any primary maternity situation.

However, the principle of working in harmony with the natural physiological process, and not interfering without a valid reason, is the pathway to optimal primary maternity care.

The forum leader asked, "can we recommend midwives to perform external cephalic version?"
My experience with external cephalic version (ECV) is that the act of turning the fetus is not difficult. I have no problem with midwives who perform ECV in situations where emergency surgical backup is available, but would question the risk/benefit status in isolated primary health care settings.

The forum leader asked, "can we recommend midwives to perform instrumental vaginal delivery?"
Midwives are able to use Venteuse to assist vaginal birth. Forceps??

The forum leader asked, "can we recommend midwives to perform caesarean section?"
My answer to this is no. If a midwife wanted to upskill to perform caesarean - major abdominal surgery, that midwife would need to become an obstetrician.

The forum leader asked, "can we recommend Lay Health Workers for labour companionship?"
Of course.

The forum leader asked, "At the PHC level, can midwives/nurses administer anticonvulsants? Uterotonics?"
Where primary health care is isolated and timely transfer to an emergency obstetric facility is difficult (if not impossible), anticonvulsants may be life-saving for some mothers. As for uterotonics, midwives in primary maternity care settings need uterotonics to be available when post partum haemorrhage is occurring. I don't know if there evidence supports induction of labour at the PHC level unless specialist obsteric and anaesthetic and neonatal services are also available.  I doubt that such interventions, at the PHC level, would reduce maternal and neonatal morbidity and mortality.

post script:
The forum questions refer to a 'specific health cadre'. The term 'cadre' is unfamiliar to me, so I checked it in the online dictionary, which did not enlighten me much at all. Perhaps there is a simpler and better way to describe it, such as 'specific category of health care worker' ??