Burundi childbirth in a develo by pengtt



Burundi: childbirth in a developing country
                        Pregnancy and childbirth vary throughout the world and in many developing countries they are influenced by
                        traditional practices. Sue Chadney describes some such observations from the time she spent working in Burundi.
                        Throughout the world women experience pregnancy and different categories of nurses who have received between
                        childbirth. The care they receive is a product of many                 two and three years training and ‘aide-infirmieres’ who
                        factors including the culture of their country, especially             perform many of the institutional deliveries and have
                        when healthcare provision is supplied by traditional                   received one year’s training.
Sue Chadney             birth attendants who invariably apply age-old practices                   Burundi has a total fertility rate of 6.3 per 1000 and a
is a midwife working    to maternity care. This subject has been extensively                   maternal mortality rate of 1300 per 100 000 live births
with Médecins Sans      explored, for example by LeFeber and Voorhoeve (1998).                 (United Nations, 2001), although the potential inaccura-
Frontières              Professional practice is also dictated by factors of                   cy of the data, due to the civil disorganisation as a result
                        culture, geography, socio-economic phenomena and                       of the war and the factor of unregistered domiciliary
                        history. What follows is an account of some of the clini-              births, is acknowledged. The Institut de Statistiques et
                        cal procedures and beliefs practised by professionally                 d’Etudes Economiques du Burundi (2003) states that
                        trained healthcare workers in an area of Great Lakes                   71% of births are unsupervised by trained personnel and
                        Africa, as observed and discussed while working with                   take place in the home by registered or unregistered
                        Médecins Sans Frontières (MSF) for a                                                       traditional birth attendants. The
                        basic healthcare project in the province                                                   remainder take place either in poorly
                                                                      A mother with her baby in the maternity ward
                        of Kayanza in Burundi.                        at Musema Hospital, Burundi                  staffed and equipped rural clinics, in
                           Burundi is classified by aid agencies                                                   small hospitals supported by religious
                        as a ‘post-conflict situation’ (Médecins                                                   orders or in larger, but only marginally
                        Sans Frontières, 2005). It is a small                                                      better equipped, regional hospitals.
                        country in the Great Lakes area of                                                         The infant mortality rate is high, with
                        central Africa that underwent coloni-                                                      the principle causes of death being
                        sation briefly by the Germans, then by                                                     malaria and diarrhoea.
                        Belgium, before gaining independence                                                          While practices inevitably differ
                        in 1963. The population consists of                                                        between workers and institutions in a
                        two main ethnic groups – the Hutus                                                         country with unsupervised clinical
                        who form 85% and the Tutsis who                                                            standards, certain commonly-held
                        form 14%. An ethnic minority group,                                                        clinical beliefs were observed and are
                        Twa pygmies, make up the remaining                                                         recounted below, beginning with the
                        1% of the population.                                                                      management of problems in early
                           From 1965 onward, Burundi has                                                           pregnancy and ending with aspects
                        endured waves of ethnic-based violence, culminating in                 of neonatal care.
                        the civil war of 1993 to 2003 during which an estimated                   Women with threatened abortion frequently present at
                        100 000 people died in a ‘slow trickle genocide’                       clinics, many caused by malaria. Burundi lies within an
                        (Jennings, 2001). This ten-year conflict has left behind a             endemic malaria zone giving rise to recurrent bouts of
                        legacy of psychosocial and economic damage. Healthcare the parasitic disease in patients with lowered immunity,
                        facilities have been destroyed and access to medical care              such as pregnant women. Another contributory factor is
                        significantly reduced through continuing insecurity and                the high incidence of untreated sexually transmitted
                        poverty (Médecins Sans Frontières, 2004; World Bank,                   diseases among the population. In addition to prescrib-
                        2004). The civil war interrupted the training of health-               ing medication for any suspected underlying infection –
                        care professionals and caused the deaths of countless                  although diagnoses remain largely unconfirmed due to
                        trained personnel, which has resulted in the number of                 lack of laboratory facilities – the nurses who staff the
                        doctors per inhabitant falling from 1:25 000 in 1990 to                clinics routinely prescribe oral hyoscine butylbromide
                        1:35 000 in 2002 (Médecins Sans Frontières, 2004).                     (Buscopan). This treatment is based on the known
                           Most healthcare professionals prefer to either work                 smooth muscle relaxant properties of this compound
                        in other countries or in the capital. There are fewer                  that practitioners believe diminish uterine contractions,
                        facilities, including the basics of running water and                  hence arresting the progress of a threatened abortion.
                        electricity in provincial hospitals and rural areas, and                  Pharmacology formularies such as the British national
                        there is a higher level of insecurity and rebel group                  formulary (BNF) (British Medical Association and Royal
                        attacks. There is no tradition of specifically trained                 Pharmaceutical Society of Great Britain, 2004) do not
                        midwives in Burundi – maternity care is carried out by                 support this hypothesis and neither do clinical guidelines

196 Midwives           The official journal of the Royal College of Midwives                                                           Vol 9 No5 May 2006

written for use in developing countries             Various factors conspire against the achieve-                     no prostaglandin preparations available,
(Pinel, 2002; Blok, 2003). The latter recom-        ment of this goal by healthcare workers in                        cervical ‘ripening’ is effectuated in primi-
mends Buscopan solely to reduce the muscle          Burundi. As 25% of women only present for                         parae by the insertion of a large-size Foleys
spasms caused by diarrhoeal disease and             one antenatal consultation and that, from                         catheter into the vagina with the tip, that is,
gastrointestinal tract infestations. The same       personal observation, is at approximately 36-                     the balloon, inside the cervix. The balloon
texts warn against the use of Buscopan in late      weeks’ gestation, the likelihood of them                          is filled initially with the amount of water
pregnancy. In Burundi it is widely used in the      receiving the two necessary doses is low.                         recommended by the manufacturer, then
third trimester for lumbar and ligamental           Additionally, in a resource-poor country                          additional millilitres are added over 24
pain, instead of giving simple analgesia or         such as Burundi, the cold chain frequently                        hours. When the catheter falls out, it is
physiologically-based lifestyle advice. It          breaks down, perhaps due to lack of petrol                        either due to the balloon bursting or to
remains, however, a cheap and easily available      for the fridge or insecurity preventing a trip                    initial cervical effacement and dilatation. I
drug and will no doubt continue to be                                                                                 have observed this method being unexpect-
prescribed for these pregnancy problems in                    An education session for traditional birth attendants   edly effective!
Burundi, despite the lack of a pharmaceutical                                                                            Where pharmacological induction of
evidence base.                                                                                                        labour is deemed necessary and in the
   With no availability of intensive neonatal                                                                         absence of oxytocics, medical practitioners
care in Burundi, nor of medication to                                                                                 in this area of Africa are reported to use
promote lung maturity, healthcare staff are                                                                           intravenous quinine. Oral and parenteral
acutely aware of a poor prognosis for any                                                                             quinine is used routinely for the treatment of
preterm baby, hence the need to arrest                                                                                malaria caused by the parasite Plasmodium
preterm uterine contractions. Western medi-                                                                           fulciparum, however, I have found no clini-
cine provides a selection of tocolytics with                                                                          cal or pharmaceutical text to reveal any
continuous clinical studies to realise the most                                                                       reference to its use as a uterine stimulant
effective pharmacology. In countries with few                                                                         (British Medical Association and Royal
resources, the beta 2-agonist Salbutamol is                                                                           Pharmaceutical Society of Great Britain,
readily available and so is the tocolytic of                                                                          2004; Pinel, 2002). However, the
choice by default. This is prescribed in the                                                                          International Union for the Scientific Study
rural clinics as an oral medication for use at                                                                        of Population (1998) and the Marxists
home for five to seven days, despite the                                                                              Internet Archive (2004) have documented
recommendation of intravenous administra-                                                                             the 19th century use of quinine as an
tion for 48 hours as an effective treatment                                                                           abortificant. The administration of high
(British Medical Association and Royal                                                                                doses produced toxicity causing cardiac
                                                    Testing a pregnant woman for malaria
Pharmaceutical Society of Great Britain,                                                                              arrhythmias and convulsions, which in turn
2004; Pinel, 2003). For the few women who                                                                             provoked an abortion. I presume this to be
are transferred to hospital and can pay for         Mothers and babies outside the maternity ward                     the clinical basis for its use to stimulate
treatment, intravenous Salbutamol is invari-                                                                          labour, albeit at an unknown cost to mother
ably followed by five days oral supply.                                                                               and baby.
Prolonged therapy is advised against in the                                                                              Once a woman presents in spontaneous
BNF (2004) as it increases the risk of side-                                                                          labour at a clinic or hospital, little monitoring
effects to the mother and does not have                                                                               of mother or fetus takes place. There is an
proven clinical effectiveness. There is little                                                                        official ‘partogramme de Burundi’ that is
recording of outcomes from hospitals or                                                                               seldom available or used. Pinards stetho-
clinics, so neither the clinical effectiveness of                                                                     scopes are widely used, often having been
this drug strategy nor cases of side-effects can                                                                      donated by a charity, church or aid agency,
be assessed.                                                                                                          with the fetal heart noted as simply positive
   Tetanus, caused by the toxin of                  to the vaccine store to replenish supplies –                      or negative – the relevance of rate and rhythm
Clostridium tetani, is responsible for 50% of       thus often vaccines are unavailable even                          are not taught as being significant. When
infant deaths in Africa (Blok, 2003).               when women attend correctly and in time.                          there is no progress to a normal delivery
Neonatal tetanus is entirely preventable by           Although many rural Burundian women                             following full dilatation with the presenting
vaccination of the woman during pregnancy.          are unaware of the date of their last                             part in low cavity with expulsive contractions
The administration of the anti-tetanus              menstrual period, or perhaps have not                             and maternal effort, practitioners employ
vaccine is a priority during antenatal consul-      menstruated since their previous delivery,                        fundal pressure to achieve a vaginal delivery,
tations in Burundi with the aim of adminis-         there are occasional clinical indications to                      mainly when there is no option of operative
tering at least two doses, with an interval of      induce labour. These may include a known                          delivery or transfer. In the Great Lakes area,
at least four weeks. This results in a neonatal     post-maturity and intrauterine death where                        among French-speaking professionals, this is
protection rate for three years of over 85%.        labour does not spontaneously begin. With                         called the ‘manoeuvre de chrystalline’ – I was

Vol 9 No5 May 2006                                                                         The official journal of the Royal College of Midwives   Midwives 197

unable to establish the origin of this term.            umbilical cord is tied with two pieces of                 and essential obstetric interventions not
MSF acknowledges this practice as one ‘to be            umbilical twine and a clean piece of gauze is             limited by the ability to pay, rightfully criti-
used with caution, and only in rural and                applied, followed by a cotton bandage                     cise the clinical practice of their colleagues in
isolated situations’ (Pinel, 2003 – transla-            wrapped around the abdomen and tucked                     the developing world who often do not have
tion). The technique employed is directed in            into itself at the back. No lotions are applied           access to such options?
this manual: ‘Using two hands flat on the               to the cord stump and the mother is told to                  Finally, to replace inappropriate or unsafe
fundus, push downwards with moderate                    leave on this dressing for a week. As there is            practices by evidence-based ones requires
pressure at the same time as the woman                  no culture of postnatal care in Burundi, I                standardisation of professional care within
pushes with a uterine contraction’ (transla-            was unable to observe either compliance                   an organised healthcare system. Given the
tion). However, I once entered a delivery               with or effectiveness of this treatment.                  social and political chaos existing in
room in Burundi to find a nurse astride the                The second routine treatment given to                  Burundi, a country emerging tentatively but
woman on the delivery bed, facing the                   neonates is a single application of                       hopefully from a decade of conflict, this will
perineum and exerting fundal pressure with              Tetracycline eye ointment. This protocol is               take time and effort to achieve.
all her weight and might. Sadly, on this occa-          followed to prevent neonatal conjunctivitis
sion, the baby was stillborn.                           and ensuing corneal lesions caused by infec-              References
   The materials and skills appropriate for             tion with Neisseria gonorrhoea or Chlamydia               Blok L. (2003) Guide clinique et thérapeutique
neonatal resuscitation are not easily available         trachomatis during delivery. The incidence of               (cinquième edition révisée). Médecins Sans
to healthcare workers, and the most common              these infections is thought to be high in Great             Frontières: Paris.
practice observed was to stimulate and drain                                                                      British Medical Association, Royal Pharmaceutical
secretions by holding the neonate by the feet            A young mother with her baby attends a family planning     Society of Great Britain. (2004) British national
and slapping the buttocks. When a neonate                consultation in a rural clinic                             formulary. Pharmaceutical Press: London.
does not respond to this action, two further                                                                      Guyard-Boileau B, Grouzard V, Rigal J. (2003)
actions normally take place. Firstly, the baby                                                                      Obstétrique en situation d’isolement (deuxième
is lain down on a table and oro-nasal suction                                                                       edition). Médecins Sans Frontières: Paris.
is performed using a ‘poire d’aspiration’ – a                                                                     Institut de Statistiques et d’Etudes Economiques
rubber device the shape and size of a pear –                                                                        du Burundi. (2003) Etude de base du projet santé
that is inserted superficially into the mouth                                                                       maternelle et infantile. Population Services
and nostrils and compressed manually to                                                                             International: Bujumbura, Burundi.
exert suction. The ‘poire’ is washed out with                                                                     International Union for the Scientific Study of
chlorhexidine solution between uses, but not                                                                        Population. (1998) Policy and research paper
sterilised, so the risk of cross infection,             Lakes Africa, and, in the absence of antenatal              number 15: Abortion and women’s health and
notably the transmission of HIV, is evident.            screening, diagnosis and treatment, preven-                 fertility. See: www.iussp.org/Publications_on_
   The second intervention is for the health-           tion forms part of normal health care.                      site/PRP/prp15.php (accessed March 2006).
care worker to put some pure alcohol in her                Working as a midwife in developing                     Jennings C. (2001) Across the red river:
palms and rub this on the neonate’s abdomen             countries provides a fascinating opportunity                Rwanda, Burundi and the heart of darkness.
and back. When asked to explain the reason              to observe and discuss differing clinical                   Phoenix: London.
for this action, the universal reply was that it        practices. Some of the above practices are                LeFeber Y, Voorhoeve HW. (1998) Indigenous
stimulated respiration. There is an obvious             appropriate responses to the clinical needs                 customs in childbirth and childcare. Van
clinical logic to the tactile stimulation,              of the continent, such as vaccinating against               Gorcum: Netherlands.
perhaps also to the application of cold alcohol         tetanus and preventing neonatal conjunc-                  Marxists Internet Archive. (2004) Abortion – the
shocking the baby into breathing, but I also            tivitis. Others appear to be rooted in clinical             pioneers. See: www.marxists.org/archive/
discussed this common practice with a                   beliefs that are either misplaced or applied                widgery/1975/07/abortion.htm (accessed
European doctor who had worked for many                 in inappropriate contexts, such as the use                  March 2006).
years in Africa. He related that in developing          of alcohol to aid neonatal respiratory effort.            Médecins Sans Frontières Belgium. (2004) Access
countries without sophisticated health care             I remember the practice of holding the baby                 to health care in Burundi: results of three
and lacking most medications, patients with             up by the feet at birth being standard                      epidemiological studies. Médecins Sans
pulmonary oedema and asthma may be                      practice at the start of my midwifery career                Frontières: Brussels.
treated with inhalations of alcohol that engen-         in Scotland! Of most concern are those                    Médecins Sans Frontières. (2005) Country profile
der a bronchodilating effect. This practice has         practices that potentially or actually harm                 for Burundi. Personal communication.
become internalised and applied routinely to            the mother and/or baby, specifically incor-               Pinel J (Ed.). (2002) Médicaments essentiels
other respiratory problems, including lack of           rect prescribing and manoeuvres such as                     (troisième edition révisée). Médecins Sans
respiratory effort in neonates, in the belief           fundal pressure.                                            Frontières: Paris.
that the alcohol will be absorbed through the              However, can professionals in the devel-               United Nations. (2001) Abortion policies: a global
skin and aid respiration.                               oped world, practising within an organisa-                  review. United Nations: New York.
   Immediate neonatal care in health struc-             tional framework that provides emergency                  World Bank. (2004) Burundi at a glance. World
tures follows certain procedures. The                   transfers by ambulance along tarmac roads,                  Bank: New York.

198 Midwives             The official journal of the Royal College of Midwives                                                                  Vol 9 No5 May 2006

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