Global Forum, Day 6

Spring roses in our garden

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question: Over the weekend we would like you to continue to discuss the question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Wait a moment!

This is a global forum, scheduled for eight days, attracting hundreds of participants from just about everywhere, and in the first seven days we have failed to discuss anything to do with the *regulated* health professionals. Questions that I was expecting to see would have been something like:
What evidence do you have relevant to global efforts to improve MDGs 4 and 5
that apply to the practices of midwives, neonatal nurses, obstericians, paediatricians, and other doctors who provide primary maternity services for women in pregnancy and childbearing, and for newborn babies?

I understand that maternal and perinatal morbidity and mortality is enormous in some African and Indian and other nations, amongst the poorest of the poor, where unregulated birth attendants are IT; where the terrain is difficult and emergency obstetric facilities are a long way away.

Yes, discussion of the roles of lay and traditional birth attendants is a significant issue, and deserves discussion.

But, these categories of 'health worker' are extremely variable, from country to country. Lack of systematic education, registration and regulation means that they are a poorly defined group. Any evidence is possibly of local significance only.

Discussion that focuses on lay and traditional health workers is like chasing shadows, while not noticing the elephant in the room, to mix metaphors.

The elephant that I am referring to is the regulated health professionals who provide primary care for women in pregnancy and birth, and for their newborn babies.

There are many practices undertaken by these regulated health professionals in primary maternity care settings that will either improve maternal and neonatal outcomes, or the reverse.

In the mid 1990s, WHO published a useful booklet 'Care in Normal Birth: a practical guide' in the Safe Motherhood series, that contains the sort of information I expected to be reviewed and debated in this forum.  Classification of practices in normal birth, into

• Category A: Practices which are demonstrably useful and should be encouraged,
• Category B: Practices which are clearly harmful or ineffective and should be eliminated,
• Category C: Practices for which insufficient evidence exists to support a clear recommendation and which should be used with caution while further research clarifies the issue, and
• Category D: Practices which are frequently used inappropriately.

In recent years, the Victorian Health Department has published Victorian Maternity Service Peformance Indicators.  The most recent set is for 2008-09.  Performance indicators that are relevant to all primary care settings include:
Mat 1: Outcomes for Standard Primiparae
Mat 2: Term infants without birth defects who require additional care
Mat 4: Vaginal births after primary caesarean section

The continuing increase in rates of caesarean births in developed countries is a matter of great concern in reducing maternal and perinatal morbidity and mortality.  Developed countries, such as Australia, set the standards of care that are transferred to hospitals in less developed areas.  Induction of labour for reasons of convenience and other non-valid indications leads to the cascade of interventions and increased rates of caesarean, whether it is done in Melbourne or in Port Moresby.  The impact of the primary caesarean on a woman's lifetime birth capacity and health must be considered. 

I see no point in isolating a category of maternity care provider and trying to focus on using that category to improve maternal and perinatal outcomes.  The practices that are carried out within the context of care, whether the woman is receiving primary care from a specialist obstetrician or a midwife, or some sort of traditional attendant.  The care should focus on the woman, not on the service provider.