Primary Mother Care and Population

By Maurice King

This book has 400 pages 400,000 words and more than 700 illustrations. It tells you how to deliver a mother at home, or in a health centre. Although it is mainly written for assistant midwives, it will be useful all kinds of medical reader, including especially medical students, and indeed for the general public, since all the technical words are carefully explained.
As the preface says the authors are concerned with the ever widening gap between: (1) 'High-tech hospital obstetrics, with its increasing reliance on laboratory methods, foetal monitoring, and high rates of Caesarian section. And (2) the needs in the districts for the practical management of obstetric problems. Instead of transferring the difficult hospital methods into primary care, it tries to spread modern 'low-tech' skills as widely as it can, and to adapt them to the difficult conditions under which you work. The authors imagine that most of you are in an isolated unit, and are unable to refer your patients to hospital. If you are lucky, you will enjoy good facilities, but more often you will have to make do with almost none
Not only does it deal with delivery, and with care after delivery it also discusses antenatal care and family planning, both those methods which are used before conception, and those which need to be used afterwards.
Chapter 2 'How many children?' is especially important, since it is concerned with the problem of 'too many people for the land to support and nowhere to go'. This is called ‘demographic entrapment’ which is much too difficult for most people to discuss, so do read what it has to say!
Chapter 4, 'Making a good start' is about 'sex and relationships education', and is most useful for schools and for teacher training colleges.
Chapter 6 is for devout Catholics want to learn about ‘The Natural Methods’ of family planning which the Roman Church allows.
Chapter 9 on 'The Post-coital Methods' is for mothers who have become pregnant by mistake, and don't want to be pregnant. It stresses that the earlier you do something about this the better!
Some chapters have received a particularly high marks - particularly Chapter 19, 'The Third Stage of Labour’, discussing bleeding after delivery which is also called postpartum haemorrhage or PPH.

• Language: English
• Publisher: XinXii
• Release date: Sep 1, 2015
• ISBN: 9789966724953

Book preview

Preface

July 3rd 2011

A slightly better-off person drinks tea every day, a rich person is one who can drink a coke with his meal Wealth and poverty as seen by a Malawian villager.

Ninety-nine percent of all deaths in childbirth are in the least developed countries. These are our target. Primary Mother Care..." was begun in the late 1970s by Hugh Philpott and Sam Ross in Durban, as a sequel to WHO’s Primary Child Care. In 1982 it joined GTZ’s (GIZ’s) Kenya project - Primary Surgery (two vols), and Primary Anaesthesia, which have long been completed with great acclaim (both OUP, obtainable from [e-mail]). That project aimed to systematise all the tasks in surgery, obstetrics and anaesthesia, which a general duty doctor in a district hospital in the developing world could reasonably be expected to do. The obstetric part of this task proved particularly difficult, so it was divided into two. Those tasks which are common to all suitably trained health workers are here. The others, Caesarean section for example, are in Primary Surgery. This too is having a second edition by Michael Cotton. However, the first edition remains available.

During Primary Mother Care’s long gestation Africa changed. Hugh Philpott conceived it before AIDS, against the ordered adequacy of South African health services of the late 1970s, with well trained staff and sufficient supplies and equipment. This Edition was completed in 2010 against the declining health services of most of sub Saharan Africa, where hundreds of square kilometers have barely an aspirin, where the Structural Adjustment Programmes of the World Bank have left many of the poor with even less health care than they had before, and where 25% of antenatal mothers, or more, may be HIV positive. Where there are health services, their technical quality is often getting worse. (16.7)

•It became clear that Primary Mother Care would have to grapple with the problems of communities outgrowing the carrying capacities of their ecosystems, so ‘...and population’ was added to the title. When the most eminent demographer of Africa [Jack Caldwell] told me that he thought that most of the continent is demographically trapped, the true magnitude of the problem became apparent. It is therefore the concern of Chapter 2 How many children?, which is thus the beginnings of Primary disentrapment.

•Primary Child Care, was a great success - its many readers ranged from ‘dressers’ to postgraduates. We follow its example, and write for anyone who can understand what we say. There is something here for everyone.

•We are concerned by ever widening gap between: (1) ‘Hi-tech’ hospital obstetrics, with its increasing reliance on laboratory methods, fetal monitoring, and high rates of Caesarean section. And (2) the needs of the periphery for the practical management of obstetric problems. Instead of transferring difficult hospital methods into primary care, we have tried to spread modern ‘low-tech’ skills as widely as we can, and to adapt them to the difficult conditions under which you work. We imagine that most of you are in an isolated unit, and are unable to refer your patients to hospital. If you are lucky, you will enjoy good facilities, but more often you will have to make do with almost none.

•Family planning and the management of sexually transmitted infections (STIs) should now be an integral part of safe motherhood. For example, any trained worker should be able to insert an IUD (8.6) and treat GUD (12.9). Because ‘fertility awareness’ (6l3) is so readily achievable, we describe the natural methods in detail.

•We describe the postcoital methods, because they should now be part of any family planning service, and available in every health unit. Traditional postcoital practices are universal, and are still an important part of fertility regulation in many developing countries, just as they were in the industrial world a century ago. We have therefore taken the unusual step of describing how you can make those in your society safer, and thus prevent many tragic maternal deaths at the hands of unskilled traditional abortion practitioners (TAPs).

•We are passionate supporters of ‘the family’ - a necessary task in view of worldwide weakening of family values, and the epidemic of AIDS, of other STIs, and of teenage pregnancies. So we have done our best to provide other ideals of sexual behaviour, than those so insidiously promoted by an increasingly globalized media (‘fun morality’). We take a strong moral line. Our necessary explicitness will offend some readers. Our moralizing will offend others. We hold out our right hand to the Catholic Church, and our left hand to the ‘postmodernists’. It is surely better to leave you arguing about all this, than to say nothing.

•We describe the destructive operations, symphysiotomy, and some other procedures which are not done when Caesarean section is possible. Unfortunately, there will be times when some of you cannot refer a mother in obstructed labour, so that there may be no hope of her being able to get a Caesarean section. Should you do nothing and allow her to die, or get a fistula? Or should you attempt a destructive operation, most probably ‘from this book’, never having seen one done before? Putting ourselves into the unhappy position of your patients, most of us would rather have you do your best, than do nothing.

•Professor Zacharias of Ludhiana pointed out that in putting together Primary Surgery, I was not an editor but, that scarce and precious species, a knowledge engineer. Editors normally receive completed chapters from experts, and merely edit them, whereas I write the chapters and then ask experts if they are correct. Even so, the failings of Primary Mother Care are mine. I am responsible for all of them, technical, political and otherwise. The blessings of these pages - if such they have - are those of its editors and many contributors, especially the artists. We ask forgiveness where we cannot trace the long lost origins of some their drawings. All our artwork and our text is yours for the taking. Please forgive us for using sections, not page numbers, they make re-editing a book, so very much easier. We are especially grateful to Amanda Zhang of Shanghai KS Printing for her care in printing these pages.

Besides being a labour of HOPE!!, this is also a labour of LOVE!! - see Dr Naim Janmohamed’s story of the Masai mother and her ruptured uterus in Section 23.3.

Glen Mola, Jim Thornton, Michael Breen, the late Colin Bullough, Douwe Verkuyl, Priscilla Busingye and Maurice King.

Chapter 1 Introduction

June 3d 2011

Mothers have a difficult life. They have to plant, weed, harvest, cook, sweep and wash. Mothers in middle Africa have an average of about six children. Some have ten or more. In delivering these children they run a serious risk of death - half a million mothers die each year. It is as if a jumbo jet full of them crashed every 6 hours, night and day, and killed everyone. Almost all the mothers who die in childbirth are in the developing world, and most of them are in Africa. This book is to help you save their lives.

1.1 Mothers have a difficult life

Many mothers become pregnant too often, too quickly, with too short a time between births. They have babies when they are too young, and when they are too old. They often have babies they don’t want. Unwanted babies are a much greater risk for both a mother and her baby. But there is now no reason why any mother should have a baby she does not want. The high risks of unwanted babies explains why family planning can save the lives of millions of mothers, and tens of millions of children. So the first step in caring for mothers is to help them prevent the pregnancies they don’t want.

You can teach a mother how to keep healthy, and how to prepare for labour. If birth is likely to be easy, you can deliver her yourself in a health centre or at home. If it is likely to be difficult, you can refer her to hospital. If you cannot refer her, you may be able to deliver her by the methods that we describe here.

The babies of these mothers are also at serious risk. Some of them are so severely injured at birth that they are disabled all their lives. Most of this death and disability can be prevented. We tell you how to deliver a baby and care for him immediately after birth. If you want to know how to care for him after this, read Primary Child Care. This book and that one describe Mother and Child Health, or MCH. This book is about the ‘M’ in MCH, but don’t forget the ‘C’ because a mother and her child are part of one another.

There are other mothers like Mama Mbewe. Her story explains why family planning is so important. Some of them only menstruate once. A few of them never menstruate at all, because they become pregnant before their first period. Mothers like Mama Mbewe spend most of their lives pregnant, or breast feeding. Sometimes they have two children in the same year. They care for more children than they want, and who die from the diseases that Primary Child Care describes. In later chapters Mama Mbewe has many questions to ask the Knowledge Engineer!

Figure 1-1 MAMA MBEWE (born 1960) is a village mother in Malawi. Tell me, how many children you would have liked? Four, if they were alive and healthy. How many children have you had? "I have had 12 and three abortions, but only 8 are alive. The average Malawian mother has 5.6 children (Malawi’s total fertility is 5.6) but some do have 12. I started having babies when I was 16 and I have been pregnant or breast feeding ever since. I was 40 when I had TADALA, and I thought that my menopause had come. But then I had THOKAZANI and CHIFUNDO, the twins, and after that I had dear little M0FATI, with Down’s syndrome who died.

1.2 How many mothers die?

Half a million mothers die each year, half of them in Africa will. ‘Maternal’ means mother and mortality means death. The maternal mortality ratio (MMR) is the number of mothers who die for every hundred thousand babies who are born alive - mothers’ deaths per 100,000 live births. Two live twins count as two live births. In the old days, before there was modern medicine, the MMR was about a thousand (1000) and sometimes 2000. This is the ‘normal’ human MMR. A thousand deaths in a hundred thousand births is 1%. So a mother had about a 1% chance of dying each time she gave birth. If she had 10 children she had about a 10% chance of dying in childbirth. In Africa one of every 12 women dies because of pregnancy or childbirth - this is three in a class of 36 girls. Almost everyone knows of someone in their family who has died in childbirth. How many of your relatives have died in childbirth?

In communities where there is no modern health care the MR is still about 1000, to 2000, and sometimes even more. MMRs of less than 1000 are mostly lower because: modern health care has prevented mothers dying, and women’s social conditions have improved. Before AIDS became common the MMRs of many developing countries had fallen to about 300. Now AIDS has pushed them up again. In the industrial countries the MMR has fallen to between 2 and 10. Mothers in these countries almost never die in childbirth. When they do die in pregnancy, it is often from a disease, such as heart disease, which is made worse by pregnancy.

The low maternal mortality of the industrial countries is new. Before 1850 it was about 1000 per 100,000. After 1850 infection started to be controlled, so that by the 1930’s England’s MMR was only about 500. Since then antibiotics, blood transfusion, safer Caesarean section, better anaesthesia, and drugs for hypertension have all lowered it to about 10.

Mama Mbewe is our village mother

Maternal mortality

A maternal death is the death of a mother while she is pregnant, or within 42days (six weeks) of the ending of pregnancy from any disease caused by pregnancy, or made worse by it. If she dies from some other disease not due to pregnancy (such as a road accident), this is not counted in the MMR.

However, about half of maternal deaths around the time of delivery are commonly not caused by delivery. These other causes include: malaria, TB, respiratory infections, AIDS opportunistic infections, and meningitis, etc. So remember that a mother can die from any of these things.

Even if she is only a few weeks pregnant, and her pregnancy kills her (for example an ectopic pregnancy), she is a maternal death. Six weeks (42 days) allows time for any infection, or anaemia, etc., that might have been caused by her pregnancy, to kill her.

Unfortunately, many countries and many clinics do not know how many of their mothers die. This is because: Nobody keeps records of deaths, or reports them. Maternal mortality is difficult to measure. You can find a figure for the maternal mortality in your country in Section 3.14. Better, you can measure it in your district as in Section 3.12.

MATERNAL CARE AND MORTALITY IN USA

The Hutterites live in closed farming communities. They own no personal property, are very religious and share everything. They never mix with other communities, and have no radio, no television and no newspapers. Hutterites always marry Hutterites. They use no family planning and have the highest fertility ever recorded. But they use ordinary medical care and are delivered in hospital, or by trained midwives. Their MMR is about 9, the same as the rest of USA.

The Faith Assembly are also very religious, but they never use ordinary medical care and are delivered at home by untrained people. Their MMR is 872.

LESSONS: Both these groups are healthy well nourished North Americans. The Faith Assembly who use no modern medical care have a much greater maternal mortality (97 times greater). Being healthy and well nourished is not enough by itself to prevent death in childbirth and reduce maternal mortality. Good medical care is also needed.

HANS SCHALES writes from Zimbabwe" The health system in this country has completely collapsed and it is a wonder, that mother nature, the best obstetrician keeps the MMR below 1000!

Figure 1-2 THE MATERNAL MORTALITY RATIO, or MMR is the number of mothers who die for every 100,000 babies who are born alive. HIV/AIDS now causes many of these deaths in some countries [Malawi]. In the most fortunate countries the MMR is about 10. There is uncertainty about many of these figures [there are wide confidence limits] Data for 2008. 1990 data in brackets. {}

1.3 The five killer complications

The five main causes of maternal deaths are much the same in most of the developing world. These five killer complications are: Bleeding (APH and PPH, 25%). PPH is commonest single cause. Unsafe abortion (infection and bleeding 13%). Infection (puerperal sepsis, 15%). Eclampsia, which is fits caused by high blood pressure (12%). Obstructed labour (8%). Together, these cause about three quarters of all deaths. The causes of the other quarter include anaemia, malaria, ectopic pregnancies TB, and heart disease.

These are mostly the same diseases that used to kill mothers in the developed world 100 years ago. Note that both and are caused by infection - which should be easily preventable - see Section 18.6.

Unsafe abortions cause at least 20% of maternal deaths in the world (9.12). In some Latin American and African countries they cause half the maternal deaths. If a mother becomes pregnant with a child she does not want, she often asks someone to abort her (remove the baby). Or she tries to abort herself (9.12). Unless an abortion is expertly done, it is very dangerous. About 50 million mothers are aborted each year and at least 100,000 of them die.

If ‘diseases’ such as abortions, anaemia, and infection, kill mothers, what ‘causes’ these diseases? They are mostly caused by poor social conditions, malnutrition, and poor medical care, or none. Most of the mothers and babies who die are in the villages, or in the poor parts of big cities. They do not have enough money, or food, or clean water. Most of them deliver their babies without any trained help. Sometimes, they do not come to hospitals and clinics, because these provide poor medical care.

Mostly, mothers either die at home, or present late in hospital as unbooked emergencies who have had no antenatal care. Those mothers who most need care are least likely to get it. Unfortunately, we seldom know which mothers are going to have difficulty. So we need to be ready for any difficulty, whenever it happens, and wherever it happens. We must also able to refer a mother quickly.

Many mothers die from several causes together - like Mrs Fathalla below. Malaria, and anaemia, and obstruction, and malnutrition, and infection can all help to kill the same mother.

And now there is also HIV/AIDS. The ‘five killer complications are ‘old diseases’. In the early 1980s AIDS came. Commonly, 20% or 30% of antenatal mothers in Southern Africa are HIV positive. In some areas more than 40% are HIV positive. They die about 10 years after being infected. Sometimes they die during pregnancy or soon afterwards. AIDS has about doubled the maternal mortality of Malawi and Zimbabwe. In countries of high HIV prevalence (11.1), it is much the most important cause of maternal deaths. The Global MMR in 2008 was 251, without AIDS it would have been 206. AIDS is not one of the ‘five killer complications’ - it is extra! But because it kills so many mothers and children, it is the most important disease to prevent, and - if possible - treat.

MRS FATHALLA (39 years, 7 pregnancies and 5 living children) died in hospital during labour. She had never used family planning, and her last child was unwanted. She was poor, she could not read, and she lived in a rural area. The doctor who treated her said she died from bleeding caused by placenta praevia. The consultant said that the bleeding would not have killed her if hookworms and malnutrition had not made her anaemic. She only had one bottle of blood while she was having her Caesarian section and she needed several. The doctor who did it was not completely trained. She arrived at the hospital after she had already been bleeding for several hours. She had bled several times during the previous month, and did not seek help.

The five killer complications

LESSONS: Most deaths have more than one cause. There are many places where we could have helped this mother to get off ‘the road to death’. See ZAREEN, Section 3.3 - the community diagnosis of pregnancy and labour.

1.4 Preventing maternal deaths

The deaths of mothers are more difficult to prevent than those of their children. Oral rehydration and immunisation are easy and save many children’s lives. Unfortunately, there are no easy ways of preventing their mother’s dying - except family planning to prevent them becoming pregnant! However, another easy way may be possible. For mothers living at home, without a skilled health worker, it may be possible to prevent PPH by giving them all 600 micrograms of misoprostol to take by mouth as soon as the baby is born. This is safe and cheap, but is still under trial. It could be the most important way of reaching Millennium Development Goal Five

Supervised deliveries also prevent mothers dying, but these need clinics and hospitals for Caesarean section which are expensive. Some are community methods (for example, improving the status of women) and some are medical methods (for example, Caesarean section).

MILLENNIUM GOAL FIVE

Reduce maternal mortality by three quarters by 2015.

This is three quarters of the 1990s figure. For example if the MMR of a country was 1000 in 1990, it has to fall to 250 by 2015. If it was 100 it has to fall to 25. In 2000 the United Nations set eight of these development goals. the fifth goal also has targets for increasing the percentage of births cared for by skilled workers, for family planning, and for antenatal care.

You can help your country to reach Millenniun Goal Five

Caesarean section and other surgical methods. If a mother has difficulty in labour, she may need vacuum extraction (24.3), symphysiotomy (24.7), Caesarean section (24.9) or a destructive operation (24.8). Safe Caesarean section needs safe surgical care - it does not necessarily need a doctor. Carefully trained mid-wives, medical assistants and surgical technicians can all do Caesarean sections safely. There must always be someone who can do it. Unfortunately, Caesarean sections need hospitals, and these are expensive. Mothers also need emergency transport to reach them. This is where mothers’ hostels (‘hotels’, 18.2) are so useful. Mothers can wait in these hostels during the last weeks of pregnancy, until they are delivered. If they need help, it is near.

Preventing infection. When the MMR in Europe fell from 1000 to 500 it mostly did so by preventing infection. The fall below 500 was mostly due to blood transfusion, antibiotics, and better anaesthesia, etc. So we should be able to reduce the MMR from 1000 to about 500 - if only we can prevent infection. The causes are infected abortion - see Section 14.6, and puerperal sepsis - see Section 25.6.

HIV/AIDS is often a mother’s greatest risk

The 5 killer complications: bleeding (PPH), abortion, infection, clampsia and obstructed labour.

Antenatal care. In developing countries a third of antenatal mothers receive no antenatal care. It helps to prevent many of the complications of pregnancy and labour, especially eclampsia, abnormal lies, and anaemia. Because most maternal deaths happen at delivery. Antenatal care by itself does little. It has to be integrated with (be part of) a supervised delivery, and a referral system which works!

Better transport. As soon as a mother has difficulty she needs to be referred quickly for hospital treatment. So survival (the prevention of death) in pregnancy and labour depends mostly on: diagnosing difficulties early, and transferring her to hospital quickly - by any kind of transport.

More trained workers, and more hospitals. Half the world’s mothers are delivered by untrained workers called traditional birth attendants (TBAs). In Africa 60% of them are. These TBAs need training. But even trained TBAs are not as good at preventing maternal deaths as modern health workers. So preventing maternal deaths needs more trained health workers, especially many more midwives, and medical assistants. It also needs more hospitals. There are very many mothers to care for, so all trained workers must be good at training other workers (3.8). About 15% of mothers need skilled care at delivery. Without this care they either die or suffer long-term disease or disability. So much more Primary Mother Care is needed!

Screening for risk factors. You can look for mothers with ‘risk factors’ (15.1). These show that a mother is more likely to have difficulty in labour. You can then give her special care. This saves some lives, but most difficulties and deaths happen in mothers with no risk factors. So you have to monitor (watch) all labours carefully.

Reaching the most vulnerable (easily harmed) mothers. All societies are unequal - there are richer families and poorer ones. The poorest, least educated, most hungry, and most isolated (distant) mothers get least care. They are most likely to die. Somehow you are going to have to try to reach them all!

Better nutrition. Good nutrition reduces maternal mortality, especially when mothers have been well nourished for several generations. Improved nutrition also prevents anaemia.

Improving the education of women is important because educated mothers are less likely to die than uneducated ones. In Zaria in Northern Nigeria mothers with no schooling and no antenatal care had an MMR of 2,900. If they had been to school and had antenatal care it was ‘only’ 250. The more years of school a mother has had, the safer she is. Educated mothers: • Are much better users of family planning, so they have fewer children and can take better care of them. • Have longer birth intervals. • Marry later. • Accept health education better. • Get better care during pregnancy. • Avoid harmful traditional customs. All countries with low maternal mortalities have good education for women. Education for women is measured as ‘female literacy’ - the percentage of women who can read and write. For example, female literacy is 99% in Jamaica and 9% in Burkina Faso.

Most maternal deaths have several causes!

Preventing maternal deaths

MMR mothers deaths per 100,000 live births

Improving the status of women is important for reducing maternal mortality. In some communities men make all the decisions. When a wife wants health care, or family planning, her husband has to agree first. When he wants sex, she cannot say: No! She is not equal to him (her status is low). In other countries women decide things equally with men (the status of women is high). They are also better at saying No! to their husbands. Many illegal (unlawful) abortions in a society are a sign that they are not good at saying No! to sex. It is a sign that the status of women is very low indeed. If a mother is to say No!, her husband must learn that she can say No!. This can be difficult!

The low status of women has to be changed. This change is political, it concerns power in society (who has power over whom). So you may need to work hard politically, to change it in your country. You may need to start your own group, or even your own political party. This will not be easy. It may also be dangerous and need courage. In those countries where women now have an equal status, women once had to fight for it. Some of them died for it.

Women can only play their full part in society when they don’t have too many pregnancies, too many labours and too many children. So the status of women influences (changes) family planning, and family planning influences the status of women. Family planning is one of the best ways to stop women being ‘poor, powerless, and pregnant’. All this needs political will (determination). Persuading the politicians may be easier if you know the MMR in your district. Health workers have never yet been effectively mobilized (organized, empowered, 3.7) to prevent the wider causes of maternal deaths - will you be the first? The Knowledge engineer is doing his political best - see the end of Chapter Two.

WOMEN IN INDIA This is how an Indian lady doctor described the status of women in India: 45% of Indians are children. Half the rest of us are women. Unfortunately, our culture is dominated by men and boys so that we women and girls are oppressed. We have less food and education and have fewer legal rights than men. We run the risks of bearing children and have the burden of bringing them up, and caring for their mental and physical development. Yet it is we who spend the greatest amount of energy caring for our homes, working in the fields and carrying head loads for the public works schemes. For this we are treated like chattels (possessions), battered (hit) by our husbands, raped by the contractors and the police, and burnt as brides. This is why every one of us mothers must know what we alone can do. When we bring up our own children we must make no difference between our sons and our daughters. We must make our daughters feel that they can do anything their brothers can do. If we are treated like chattels or sex objects, it is because we ourselves accept this. In our own homes we must show what we can do in society as a whole. No health programme can succeed unless it actively involves us women, and does not treat us only as ‘targets’ for MCH and family planning programmes.

1.5 A problem for the whole family

If a mother dies, her husband loses his wife, and the children lose their mother. Her baby often dies too, especially if he is very young and should be breastfeeding. If a Bangladeshi mother dies in childbirth, her baby has a 95% chance of dying in the next 12 months. When she dies, half the young children in her family may also die, especially the girls, and her husband may leave the others. So when maternal mortality’ kills a mother, the whole family has problems.

Figure 1-5 MORTALITY RATES for babies and children at different ages measure different diseases, because each disease has its commonest age. In this book we are concerned with babies’ deaths around the time of birth for which we use the peri- (around) natal mortality. The neonatal mortality is deaths from birth to one month. The postneonatal mortality is deaths from a month to a year. Infant mortality is deaths under a year, and childhood mortality is deaths per thousand children under 5.

1.6 The Perinatal Mortality Rate

Two people take part in birth - a mother and her baby. We have thought about her death - what about his death?

Perinatal means around the time of birth. So the perinatal mortality rate (PMR) measures deaths around the time of birth - from just before birth to just after it. The PMR is the number of babies weighing more than four hundred grams (400g) who are born dead (stillbirths), or who die in the first week of life, for every thousand (1000) births. Note that: • The PMR uses 1000 births alive or dead, not 100,000 live births like the MMR. • When we count the PMR we count a hundred times more mothers than the MMR. This is because, when care is good, mothers are about a hundred times less likely to die than their babies. • The time before birth is not measured as a ‘time’ but as a weight. A baby has to weigh 400g or more, and he usually weighs this at about 22 weeks. So abortions when he weighs less than 400 g don’t count in the PMR. • If birth is going to kill him, it usually kills him in the first week. This is why deaths after the first week don’t count in the PMR. • 400g is the official WHO figure, but it is too low for the developing world. It used to be 500g. It was lowered from 500g to 400g, because if perinatal care is very good, some 500g babies can occasionally live. Even teaching hospitals, seldom save 500g babies. 1000g would be a more practical figure for the developing world.

Where there are no modern health services the PMR is between 100 and 150 - between 100 and 150 babies die for every thousand babies who are born. That is about 10-15%, say one in 10. In the less fortunate developing countries, the PMR is between 80 and 100. In the more fortunate developing countries it is between 25 and 80. In Europe the MMR and the PMR are both ‘about 10’.

A problem for the whole family

In the developing countries many perinatal deaths are in normally formed, normal birth-weight babies weighing more than 2,500g. They mostly die before their mothers reach hospital. Most dead babies are forgotten about and never registered (recorded by the government), so most communities don’t know their PMR. In South Africa, for example, the common causes of perinatal deaths are: Unexplained intrauterine death, mostly IUGR (20.6), syphilis (12.5) and postmaturity (2.17). These are mostly preventable by good antenatal care. Asphyxia (difficult breathing, lack of oxygen through the placenta) - preventable by good fetal heart monitoring in labour (20.1). Spontaneous preterm labour - dealt with by Kangaroo Mother Care (20.16). Other causes are Birth injuries. Eclampsia (13.3). Abruption (14.13). Cord prolapse (20.14). Malpresentation (21.1). Of these (asphyxia) is usually caused by obstructed labour. The commonest cause of this is CPD (head having difficulty going through the pelvis).

In a malnourished district about a third of the deaths are in IUGR babies (IntraUterine Growth Restriction or the baby not growing normally in the uterus, 20.6, 13.7). These babies are born too small (low-birth-weight). These causes should be easy to prevent and treat.

In the industrial countries the few deaths are mostly in small low-birth-weight babies. Deaths are caused by: IUGR. Prematurity (baby born too soon). Foetal abnormalities. All these are more difficult to prevent and treat.

If we give good care, we can stop many babies dying in the perinatal period. We can make the PMR fall from whatever it is now, to perhaps 35 or even 25. In a developing country a PMR of 25 is a good target to aim for. If your PMR is less than 25--, you don’t need this book, you are already caring for mothers and their babies at least as well as this book describes.

One of the easiest ways to reduce the PMR in rural areas is for all district hospitals to have mothers’ hostels. Mothers who have difficulty in labour can then get help quickly. Some good hospitals have high PMR’s because they have many difficult deliveries referred to them. The important figure is the average PMR in the whole community, but this is difficult to measure. It will fall when mothers have good antenatal care and are better nourished. This is because well nourished mothers have fewer low-birth-weight babies. There is no easy way to measure the PMR in the community, but you can measure it in your hospital (3.13).

1.8 Communicating

When two people are communicating they understand one another. They are linked (joined) together as human beings by sound (talking), by touching (hand touching hand, etc.) or by sight (looking at the other person especially at her or his face). Two of the most serious problems everywhere are we health workers not communicating: with one another, and with our patients. There are serious social, professional and educational barriers (blocks) between us, and between us and our patients. For example, highly trained, upper class male doctors often have difficulty communicating with poor lower class/caste female auxiliary nurses and community workers. Most of us health workers are better educated and richer than most of our patients - we have a higher social and economic status (‘importance’) than they do. People with a different status often have difficulty communicating with one another. So we must be careful about this.

Figure 1-6 MATERNAL AND PERINATAL MORTALITY. This figure shows some of the same countries as in the previous figure, but using a different scale. One to ten, ten to a hundred, a hundred to a thousand, and a thousand to ten thousand have all been drawn equally (a log scale). Towards the top of the scale these figures are not exact. For example, Uganda’s MMR is probably not much different from Zambia’s - they are both about 1000. Towards the bottom of the scale they are more accurate. Norway’s for example is probably half that of the USA. The PMR is less often measured, so we only suggest what a good and a ‘not very good’ figure is..

Too many of us health workers treat mothers as ‘objects’ (things). We may be very busy with many mothers. There may be few of us, as in the clinic in Fig. 3-1. But there is always time to do some communication. So we should look kindly on a patient, touch a mother gently and speak to her by name. We should always give her some explanation of what is happening to her, and what we are going to do. Communicating, especially communicating kindly, is so important that it is the first word we explain.

If you communicate with a mother it will help to make the care you give acceptable to her (she likes it and will come for it). Care should also be accessible or easy to get. So there should be a clinic near her home, open at the times that she can easily come.

Counselling a mother is helping her to find the answer to her own problems herself. A counsellor is a helper who listens, and provides the necessary information, so that she can decide for herself. You can counsel one mother at a time, or you can counsel mothers in small groups. It is different from advising her, which is suggesting to her what to do. Reassuring her is trying to reduce her fears and worries. If it is your custom to pray, and a mother is much distressed, lay your hands on her and pray.

1.9 Ecology, demography

Ecology studies how all the living things (including ourselves) in a place (an ecosystem) live together. It also studies how they alter the place itself. We use the word ecosystem for the land on which people live. We are mostly interested in farm land as an ecosystem, and the numbers of plants, animals and people (who eat the plants and animals) that it can support. The carrying capacity of an ecosystem is the largest number of people (or animals) that it can carry (support) for ever without being destroyed. A hectare (2.1) is an area of land 100 metres square (about 2.5 acres). Slash and burn cultivation is burning the bush, and planting in the ashes (2.2). Agroforestry (2.2) is growing crops (for example maize) together with leguminous (plants of the bean family) trees and shrubs (small trees).

Communicating, ecology, demography

A person’s lifestyle is the way he lives. Resources are the things which are used to do something. Land, food, water, and fuelwood are all resources that people use for living. Pollution is the harm done to the ecosystem by smoke, or dangerous chemicals in water, or too much carbon dioxide in the air.

The prevalence of a disease, is the percentage of the people in a community who have it at any particular time. For example ‘the prevalence of HIV is 45%’ means that 45 people in 100 are HIV positive. The incidence of a disease is the number of new cases of it in a given time, for example a year. For example, the incidence of HIV might be 15 new infections per 1000 people per year.

Demography studies populations (the people in a country), and counts people. The rate of something is a measure of how often it happens in a given time. For example, the mortality rate (or the death rate), is the number of people who die in every thousand people in a year. The birth rate is the number of children born in a year for every thousand people. Population control is trying to make sure that there are not more people than the land can support.

Fertile has two meanings. For a piece of land it is being able to grow crops. For a mother it is being able to have children. A fertile woman is able to produce ova (eggs) For a man it is being able to father a child. To be infertile is to be unable to have children. The total fertility rate (TFR) is the average number of births a mother has by the time she reaches her menopause (aged about 45), if she was as fertile when she was young as younger mothers are now. If the TFR is very low it is 2 children or less per mother, if it is very high, it is 6 children or more. The TFR of a 1-child world would be one.

Replacement fertility is the number of children the average mother must have if she is to replace herself and her husband when they both die, and the occasional child who dies. It is usually about 2.1 children per mother (Figure 2-1). If all mothers in a young population were to suddenly have only 2.1 children (reach replacement fertility) the population would still continue to grow for many years. This is because its many children would want to have children themselves when they grew up. This continuing growth is population momentum (‘movement’, 2.5). The desired fertility rate (DFR) is the number of children mothers say they want to have (5.17). It is usually less than the total fertility rate, because mothers have some children they don’t want. When populations with high birth rates and high death rates change to having low birth rates and low death rates, they have a fertility transition (fertility change). This is also called the demographic transition. Entrapment is being trapped (caught). If there are more people in a district than the land will support, they starve. Disentrapment is getting out of the demographic trap. Coercion is the incentives (rewards) for having a small family, and disincentives (punishments) for having a large one. Thomas Malthus was worried about population increasing faster then food, so that people starve. A Malthusian is someone who is worried about this. We are Malthusians but we are trying to do something about it.

Communicate kindly!

The KNOWLEDGE ENGINEER helped put this book together, its faults are his!

1.10 Customs, culture, community

Customs are the ‘rules’ for what people do, like eating with their fingers or with a knife and fork, or how to make love and marry. Children mostly learn these rules from their parents as they grow up. Culture is all the customs, beliefs, attitudes, values, laws, and traditions of a people. It is also their ethics (what they think they ought to do). It includes their language and their art, as well as everything they make, from a stone axe to a space ship. The world has many different cultures. We are each of us born into our own culture. We need to understand other cultures. Cultures can change. People who share a culture belong to the same society. A community is the people who live and work in the same place. The longer they have lived there, and the more they know one another and work together, the stronger that community is. People in a society become a community when they know one another and do things together. For example, we speak of West African society (all West Africa), but the community of one of its villages.

A taboo is something which is forbidden by a culture, or something which we put out of our minds. For example, many cultures have taboos on discussing sex in front of strangers, or children, or even discussing it at all. There is a taboo, called the Hardinian taboo, on discussing the most difficult population problems, especially demographic entrapment! A Demon is an evil spirit. In this book, Demons are the reasons why demographic entrapment is so taboo. Our ancestors are our mothers and fathers and their mothers and fathers, and everyone before them. A generation is the time it takes for a baby to have babies. It can be as short as 12 years, or as long as 45 years. It can range (vary) between these two. One generation is about twenty-five years.

The countries of the world are commonly divided into: industrial countries, or the North, such as Germany, Great Britain and America, and developing countries or the South, including India and all countries in Africa. This is a book for the South. When we say the West we mean modern ‘scientific ideas’. When we say Africa we mean Africa south of the Sahara desert (subSaharan Africa). The traditional parts of a culture are its oldest parts, before Western culture came. Traditional beliefs (what people think), and practices (what they do) are what people thought and did before Western culture came.

1.11 Physiology and anatomy

Hormones are substances made in one part of the body, which go round the body in the blood and cause changes in another part. For example, the ovaries make two hormones, oestrogen and progesterone which cause changes in the uterus. The hormones used in family planning Pills are slightly different and are called oestrogens and progestogens. A reflex is something which happens in the body in response to a stimulus without a person deciding to do it. For example, if a baby sucks (sucking is the stimulus), there are reflexes which cause his mother’s breasts to make more milk.

A mother’s genital organs are the parts of her body that are used for sex and birth - her genitalia. Her uterus (pleural uteri) is the hollow organ in which babies grow. The uterus has a body and a cervix or neck. Internal is inside, external is outside. So her cervix has an internal os (mouth) and an external os. If you are a woman you can feel your cervix. Reach upwards and forwards in your vagina. Your cervix feels round, smooth and hard, and has a small hole in it which is its external os. An incompetent cervix is one which will not hold a baby normally and lets him abort (fall out). The top of a mother’s uterus is her fundus. The inside of her uterus where her baby grows is its cavity. This is lined (covered inside) with endometrium, which is a special kind of mucosa. Mucosa is the soft wet red ‘skin’ inside her uterus, her bladder, her rectum, and the rest of her gut. Each of these organs has mucosa of a different kind. We usually call the soft wet skin inside the mouth and the vagina mucosa, but it is thicker, stronger, and more like ordinary skin, except that it does not have the tough outer layer (stratum corneum). Her broad ligaments are two folds of peritoneum (the lining of the peritoneal cavity) at the sides of her uterus. Her round ligaments are two more folds of peritoneum towards the front of her uterus that fix it to the inside of her the anterior abdominal wall.

Customs, culture, community, physiology, anatomy

Normally, her uterus is anteverted or pointing forwards, so that her cervix points backwards towards the posterior (back) wall of her vagina. Sometimes, her uterus is retroverted and points backwards, so that her cervix points forwards towards the anterior (front) wall of her vagina. See Fig. 8-11. Knowing which direction her uterus is pointing is important, because you cannot put instruments into it safely unless you know this. Her bladder is in front of her uterus and her rectum is behind it. During labour her uterus has two parts, a thick contracted upper segment, and a thin stretched lower segment. Oxytocic drugs or hormones make her uterus contract.

She delivers her baby through her vagina, which is the place where her husband puts his penis and leaves his sperms. He leaves them near her cervix; his penis does not go into her uterus. Her uterus and vagina are her birth canal (passage). The parts of her vagina around her cervix are called her fornices. She has an anterior (front), a posterior (behind), and a right and left lateral (at each side) fornix. Her peritoneal cavity comes down close to her posterior fornix to make a pouch called the pouch of Douglas. This pouch sometimes fills with pus or blood. When it is full you can feel it through her posterior fornix. When we do a culdocentesis, we put a needle into it through her posterior fornix. (13.1) Her adnexa are her ovaries and tubes as you examine them through her vagina. Normally, you cannot feel them, but they are tender when you compress them. Adnexal tenderness is abnormal tenderness. Abnormally, you can sometimes feel an adnexal mass (lump) or increased tenderness.

At the bottom of her vagina is the introitus (entry place) for her husband’s penis in the middle of her vulva. On either side of this there are two lips, her labia majora (large lips), and inside them her labia minora (small lips). At the back these join at her posterior fourchette (fork). Her urethra opens in front of her introitus to let her urine escape. In front of her urethra, where her two labia minora join, there is a small structure called her clitoris. This is the most sensitive part of her sex organs. The opening from her vulva to her vagina may be partly blocked by a piece of very thin skin with a hole in it called her hymen. This may be strong or weak, and the hole may be large or small. When she makes love for the first time her husband’s penis enlarges it. Some girls are born without a hymen. There are two small Bartholin’s glands beside the lower end of her vagina. When she makes love and is aroused (has pleasant sexual feelings) these secrete a watery fluid called arousal fluid. Her perineum is the part of her body between her legs, her anus and her vulva.

Figure 1-9 THE UTERUS AND OVARIES. Each month an ovum (much smaller than shown here) is released from one or other ovary, and goes into a fallopian tube. If it meets a sperm it is fertilized and becomes an embryo. An embryo goes down a tube into the uterus where it implants and grows to become a foetus (baby). The uterus is not empty, as shown here. The front and back walls touch.

Her pelvis is the ring of bones in Figure 1.13. Her pubis or pubic symphysis is the hard bony place at the bottom of her abdomen where her two pubic bones join in her symphysis pubis. You can feel this joint under your own pubic hair. The bone at the back is her sacrum. The joints between it and the bones on each side (her right and left ilium) are her sacroiliac joints. The top of her pelvis is its brim or inlet, and the bottom is its outlet. The inside of her pelvis is its cavity. Half way down her pelvis are two pieces of bone called her ischial spines. When you do a vaginal examination you can feel how far her baby’s head is above or below these spines. An (anatomical) landmark is an easily found part of the body which help you to find your way to other less easily found parts. The ischial spines and the pubic symphysis are useful landmarks.

1.12 Making love

To caress someone is to stroke (touch) them gently so as to cause pleasure. Love has several meanings. We use two of them: Really caring for another person and wanting what is best for him or her. There is no sex in this kind of love. Sexual love which is also called ‘making love’, ‘love-making’, ‘having sex’, coitus, ‘sleeping together’, and sexual intercourse. These are all words for the same thing that begins with ‘foreplay’ (touching each other and getting sexually aroused), and usually ends with the man putting his penis into her vagina. Making love’ is much the most beautiful word. To really ‘make love’ you must really care for the other person. So ‘making love’ has the first meaning of love in it too. Two people making love are lovers, or sexual partners, or a couple. To bond two things is to join them together. The bond of properly ‘making love’ (4.9) joins two lovers. A child and his mother are also bonded by the love between them (20.3). A prostitute (sex worker) is someone who sells sex for money.

Pre and ante means before. Post means after. Antenatal is before birth, postnatal is after birth. An ANC is an antenatal clinic. Postcoital means after sex. Some family planning methods are regular (used before or during sex) and others are postcoital (used after sex). Being sexually active is having sex. Abstinence is not having sex.

Unprotected sex is sex without any kind of family planning. Penetrative sex is putting the penis inside the other person’s body. Non-penetrative sex or sex play is making love without putting the penis in the vagina, or any other part of the body. Dyspareunia is painful sex. A virgin is a person (man or woman) who has never had sex. Chastity is no sex before marriage and only sex with your husband or wife afterwards. Polygamous means having many wives. Being monogamous or being faithful is having sex with one partner only.

Fidelity is having sex with one partner only. A promiscuous person ‘sleeps around’ and has many sexual partners. Desire or libido is the wish to have sex. An orgasm is a strong feeling of sexual pleasure. A man has an orgasm when he ejaculates his seminal fluid. Women can also have orgasms. Petting is causing sexual pleasure in another person, even to orgasm (heavy petting) without putting the penis into the vagina. Heavy petting is also called outercourse. Incest is sex in the family except between husband and wife; usually sex between father and daughter. All culures consider this wrong.

The CPR is the contraceptive prevalence rate (users of family planning)

Making love

1.13 Conception

The changes that happen in a woman’s uterus (and the rest of her body) each month are called her menstrual cycle. The times that she bleeds each month are her periods. Premenstrual is the time just before her periods. Mid-cycle is in the middle of a cycle between two periods. If she has no periods, she has amenorrhoea. Painful periods is dysmenorrhoea. A tampon is a piece of compressed cloth that a woman puts into her vagina to catch her menstrual blood. ‘Spotting’ is a few drops of vaginal bleeding. A woman has two ovaries, one on each side. These contain her ova (eggs). The release of eggs is called ovulation. She ovulates bout 14 days before the first day of her next period. If her cycles are 28 days, this will be about half way between two menstrual periods. Her ovaries release one ovum each month from the time her periods start (her menarche) until the time they stop (her menopause). Puberty is the time of the menarche when girls become women, and boys become men. A woman’s reproductive life or her child bearing age is the years between 15 and 45 during which she can have children. Spermatozoa or sperms are a husband’s seed; they are in his seminal fluid or semen. A spermicide is a chemical for killing sperms.

See Figure 4-3!! Her ova are her eggs. One egg is an ovum. A follicle is a bag of cells round an ovum. Fertilization or conception is a sperm joining with an ovum. This happens near the ovary. The fertilized ovum (zygote) is then picked up by the fimbrial end of a Fallopian tube (‘her tubes’). One end of a tube opens into her peritoneal cavity near an ovary. The other end opens into the cavity of her uterus. The ovum then goes down its tube until it reaches the cavity of her uterus. It then implants (goes into) the specially prepared lining (endometrium) of the uterus called the decidua. This is endometrium that has been made thick and full of nutrients by the hormones that her fertilized ovum makes. Implantation takes about two weeks. As a fertilized ovum develops (grows and changes) it becomes a zygote, then an embryo, and then a foetus or fetus (baby).

An ectopic pregnancy is a foetus which is not in its normal place in her uterus. The products of conception (POC) are the embryo, the placenta and the membranes. (see below).

1.14 Contraception

Family planning (FP), contraception, and birth control, mean nearly the same thing. They are all words for having children only when you want to have them. A contraceptor is a person who uses family planning methods. Contraceptives (family planning supplies) are the Pills, condoms, etc. that couples need. A contracepting society is one in which most people use family planning (contraceptive) methods. A non-contracepting society is one where most people don’t use them. Family building (2.12) is deciding how many children you are going to have, and then having only them. The birth interval is the time between two births in a family. Birth spacing is making sure there is enough time (usually at least 2 years) between children. It is birth intervals which are long enough. Precoital family planning methods are used before sex (coitus). Postcoital methods are used after sex. The POC (Products Of Conception) are the early fetus, placenta, and membranes. The postcoital methods remove them. An MSP (Marie Stopes Procedure) is a method of removing the POC (also called menstrual regulation). An NSV is a non-scalpel vasectomy (8.14). Eligible couples or couples of reproductive age are those who could be using family planning. This is all married couples when the wife is between 15 and 45. It does not include sexually active unmarried people.

Figure 1-11 PRESENTATION AND LIE. A baby’s presentation is the part of him which is born first. This is normally his vertex (the top of his head). So a vertex presentation is normal, and all other presentations are abnormal. His lie is the way he is placed in her uterus. If he lies up and down it, he has a normal or longitudinal lie. If he lies across it, he has an abnormal or transverse lie.

The CYP (pronounced sip) is the couple year protection. It is a method of measuring family planning, and is the number of couples who are protected from pregnancy for one year. Each method prevents pregnancy for a different time. For example, one condom protects a couple during one love-making. 100 condoms provide one CYP.

The CPR is the Contraceptive Prevalence Rate, or the percentage of eligible couples who use family planning at a particular time (5.17). The CPR is the most useful way of measuring family planning. The demand for family planning is the percentage of eligible couples who want it. The unmet demand is the percentage of eligible couples who want family planning but cannot get it. The need for family planning is the number of people who should be using it, but are not. The demand is always less than the need.

If you help a mother to use family planning, you