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)
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is performed using a ‘poire d’aspiration’ – a Institut de Statistiques et d’Etudes Economiques
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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.
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198 Midwives The official journal of the Royal College of Midwives Vol 9 No5 May 2006