WORLD HEALTH ORGANIZATION REGIONAL COMMITTEE Sixth Session Singapore 13-19 September 1955
REGIONAL OFFICE THE l:\fESTERN PACIFIC TECHNICAL DISCUSSIONS WP/RC6/Tr/M1n/l 16 September 1955 ORIGINAL: ENGLISH
MINUTES OF THE FIRST GENERAl, SESSION OF THE TECHNICAL DISCUSSIONS
14 September 1955, 2:30 pm The Chairman stated that the technical discussion was composed of the representatives and observers attending the regional committee meeting and was essentially an informal group. He also pOinted out that those participating in the technical discussions should consider themselves as individuals rather than representatives of a particular government or organization. He reminded the group the topic under discussion was "Domiciliary Midwifery as an Approach to the People in the Development of Rural Health Services." The Chairman stated further that as a result of the 'formation of a sub-committee on programme and budget many mem~ers had been drawn away from the Technical Discussions. It was therefore thought there should oe only three instead of-four discussion groups. As Dr. Bierdrager, one of the discussion leaders,'was occupied on the other subcommittee, Dr. CarvalhO had kindly consented to serve in his place. 'Ni th regard to techniques and :procedures the Chairman indicated that further remarks were unnecessary, except to say that there would be three sessions, and that the first session would be divided in two phases. He hoped that this method would result in introducing ideasto members for further discussion amongst the groups. Dr. Peter Tak-Kien Pau, Senior iilJHO Adviser, WHO/UNICEF - Assisted Rural Health Project, Federation of Malaya, was next called upon for his presentation. Dr. Pau pOinted out that: Almost fiftY,years ago, the Health Organization of the League of Nations organised a European Conference on Rural Hygiene at Geneva under the presidency of Professor Pittaluga, and in 1937, the Health Organization organised an Inter-governmental Conference for Far Easte rn
WP/RC6/TD/Min/l Page 2 Countries on Rural Hygiene at Bandoeng. In 1939, a European Conference on Rural Life was organised by the Assembly of the League of Nations, but the meeting was not convened because of the outbreak of the second world war. On the proposal of the Yugoslav Delegation, the subject "Public Health Problems in Rural Areas" was accepted for the Technical Discussions at the Seventh World Health Assembly. In discussing this subject, it is best to have in mind the definitions of terms suggested at previous international conferences. The word "Hwalth" is used in its widest sense and ref~rs to "a s-cate of complete physical, mental and social well-being, and not merely the absen-ee of disease or infirmity". The term "Public Health" is used in the sense suggested by Professor Winslow of the Yale University ,and the term "Rural Population" is used in the sense suggested by Professor A. Stampar. The moral justification for the provision of rural health services is set forth in Article 25 of the "Universal Declaration of Human Rights" proclaimed by the General Assembly of the United Nations on 10 December," 1948. The obstacles to the advance of medical science in less developed countries are poverty, ignorance and tradition. Poverty prevents the rapid dissemination of knowledge and the eradication of traditions serving no us~ful purpose, while the weight of ignorance and tradition prevents any rise in the living standards. Only an adeQuate approach to the people will lead to any advance. There are five aspects of approach to people. These may be desi~nated~ (I) "Economic, (2) Executive, (3) Educational, (4) Ethnological, and (5) Evolutional. The economic aspect is the simplest to initiate, most difficult to administer, and impossible to perpetuate. It consists in attempting to cut the Gordian knot by removing the obstacle of poverty from the rural scene. It must be remembered that when large sums are placed at the dis~osnl of various territories, they are made principally for the-purpose of priming the pumps; while in the case of national units within a perimeter of defence, the flow of funds and personnel can hardly be kept up .indefinitely if the stress and strain of internat~ ional relations become somewhat easier. Efforts should thus be made at the first opportunity to institute self-help programmes and to mobilise local leadership to expand community development projects. The exedutive aspect entails the careful study of the assumptions, principles and practice of public health administrations, and a survey of the structure of the health services in relation to the socio-economic and ethnological development of the country. It seeks to identify the bottlenecks in the administrative framework, .to adjust priorities
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needs in accordance to felt/ and national pride, and to revise training and development programmes in the light of recent advances. The educational aspect attempts to help people to achieve health by their own efforts, and aims to develop a sense of responsibility for their own health betterment as individuals, families and communities; while the ethnological aspect recognises the importance of understanding the framework of a country's culture before planning or revising any programme, as all activities inducing changes in folk practice will be resisted with varying degrees of urgency. The evolutional aspect of approach takes into account the natural unfolding of self-determinism and the gradual infiltration of modern scientific practices in under-developed areas. It recognises the faulty adjustments made in the wake of such advances, and suggests measures to reduce the tensions created. From the economic aspect, a~domiciliary midwifery service will reduce costs to the mother, but unless the trained midwives are present at the deliveries of all booked cases, the traditional midv'ives will have to be retained for the actual delivery of the baby, if for nothing else. Adequate transport ~'_nd housing for midwives are thus necessary. vVhere UNICEF milk has been requested and made available to mothers,breast feeding is more often successful, and nutritional and gastro-intestinal upsets so costly in lives and money have been largely eliminated. Moreover, no under-developed country can afford to build enough hospitals or employ personnel for institutional deliveries :for all births. '. From the executive aspect, there is the choice of staffing the domiciliary service with highly qualified nurse-midwives and operation in a small area, or expanding the service rapidly with thehelp of midwives with no nursing training, or even vlith traditional midwives with -limited extension training and supplied with UNICEF equipment after a simple examination. The policy adopted depends on the economic and educational resources of the country. From the educational point of view, domiciliary midwifery offers unusual opportunities for health education if the structure of the co~munity is understood, as. pregnancy and childbirth entail a series of episodes claiJjJ.ing the interest of members of the family and of large groups of neighbours. From the 8volutional angle, the significant fact is that all societies are now in rapid transition, in which the young daughter-in-law aften developes -the worse tensions. She is therefore less particular regarding the source of any advice or assistance which will offer her some protection, and tends to be more receptive to ,
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WP/RC6/TD/M1n/l Page 4 ideas based on modern science, especially if she will continue to have limited status in the new family group until she gives birth to a male child. The development of a domiciliary midwifery service in the rural areas thus gives many useful points of contact with the people, a.nd can be used as a highly desirable type of approach in rural health matters. But such development will need considerable resources in personnel and material, and it is hoped that these will be provided by those countries best able to offer technical assistance, so that the resurgent peoples and emergent nations in the Pacific region may live in health and happiness.
The Chairman thanked Dr. Pau for his most comprehensive 9resentation, and then called upon Miss Margaret Chalmers, WHO Nurse-Midwife Tutor in Singapore to conduct an interview with three selected local midwives about their activities and problems. Miss Chalmers be~an by introducing the midwives, all of whom she stated were closely associated with the practice of domiciliary midwifery. The midwives were= Sister Nalpon, Sister Aw and Staff Midwife Khadijah. Before commencing the questions, Miss Chalmers explained to the midwives that the meeting was interested in their special problems. She stated that every cultural group has its own pa~ti9ular traditions and beliefs, and she would ask them questions as to their own experiences amongst the people with whom they worked. In reply to her question on particular dietary habits of Malay, Chinese and Indian mothers-to-be, all the midwives agreed that the diet consisted mainly of rice, dried fish and soupo They stated that vegetables and eggs also constituted part of the diet, but although most . mothers realised the value of proteins, they found foods containing these beyond their means. The questioner then enquired if any panticular foods were forbidden under local customs, but the answer in regard to each race was in the negative. As in Singapore many of· the younger women no longer observe the old customs. The midwives were asked if there were any particular customs in regard to labour itself, and they answered that occasionally patients objectedto the hygiene techniques, such as white gowns and masks, which signified mourning to the Chinese. Also when complications arose many mothers refused to be taken to hospital, as they preferred to be with their own people in familiar surroundings. Many local ceremonies also eXisted, but these did not interfere with the well-being of the :patient, and they all
WP/RC6/TD/Min/l Page 5 agreed that they did their best to comply with these beliefs and customs, and suspicion was usually overcome by friendly and helpful attitude on the midwives part. Asked about yroolems in the lying-in period, they stated that these were not great, but one in particular amongst the Indian mothers-to-be was difficult to overcome. These mothers like to starve for about a week, and their job l,~ras to convince them that they would have to take liquids in order to be able to feed their babies. Many Mellay mothers like to anoint their babies with herbs, etc. but the midwives did not think any of these local customs did any harm to either the mother or the child. Hiss Chalmers asked the midwives if they received sufficient knowledge in regard to these customs during their training, and it was agreed that it was most helpful to midwives to learn of the particular racial beliefs. In reply to a question it was stated that most Malay, Chinese, and Indian fathers too~ a great interest in the welfare of the baby once it had been delivered, but it was thought that more fathers-to-be should learn about ante-natal care Asked about untrained midWives, the midwives said that there were many of these in the rural areas and mothers many times preferred to have them, as they were usually members of the community and much older. In Singapore, trained midwives were constantly changing in each area, and mothers did not have the opportunity to become familiar with them. Miss Chalmers asked if in the course of their ViSits, the midwives found that they were able to give any additional advice in regard to hygiene and disease-preverition in the homes. The midwives said that during the visits to the ante-natal centre, expectant mothers were given advice, and during the later visits of the midwives to the homes to bathe the babies, any unsanitary conditions were noticed and help offered in regard to diet,cleanliness, care of other members of the family, referral of tuberculosis and leprosy patients, etc. Miss Chalmers asked if midwives were taught to recognize diseases, and if any further training was required in this respect. All the midwives recognized the need for some training. They also needed to 'know how to refer patients to other agencies for assistance and advice which they were not qualified to give. Asked what difficulties they'encountered in the performance of their vlIOrk, the midwives agreed that transportation was one of the greatest problems, due to long distances and bad roads. The question of flying squads was discussed, but it was agreed that in most cases delay
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WP/RC6/TD/Min/l page 6 resulting from notification and arrival would not permit these to function. In most cases it would be quicker to take complicated cases to a hospital. In reply to a question as to what form of transport the midwives had, it was stated that private cars were used, and these were paid for by the patients themselves. All agreed that the roads were bad, which made visiting, especially in the jungle, very arduous. They also said that as a result of difficulties of transportation many babies were born before their arrival, and in these cases the deliveries 'l'lere attended by neighbours or relatives. Another difficulty was the refusal of patients requlrlng blood transfusions to be taken to hospitals for this purpose, and many had prejudices against using other people's blood. '),uestions were then called for from the meeting, and one of the observers asked how many cases were attended by each individual midwife in a particular month. Sister Aw replied that in her area the population was around 30,000, and she attended approximately 200 cases a month. There were eight trained midwives in this particular area, but that there were many additional private midwives who attended the mothers when called upon. Many mothers preferred these private midwives as they were considered more respectful of local customs, and 'were more readily available. VVhen asked if family planning advice was ever sought, the reply was that many mothers asked for advice regarding family limitation and in such cases they were referred to the local medical officer. Asked if private midwives received any payment for their services, the reply vras that these midwives were usually friends or relatives and did not depend on this work for their livelihood. Usually presents were given in payment for their assistance. In reply to a question as to whether there were any local prejudices in regard to consumption of milk, the midwives stated that cow's milk was not normally taken by Chinese mothers-to-be, chiefly because of the odour, and also due to religious beliefs. Mother's milk did not come under this belief, and there were few other food pre judices. At the conclusion· of the interview, Miss Chalmers told members that the midwives would welcome other queries and would be happy to discuss their problems informally during tea time. After thanking Miss Chalmers and the midwives, the Chairman adjourned the meeti~g for tea.
wP/RC6/TD/Min/l :page 7 Following tea the Chairman invited Dr. C. Elaine Field, Paediatric Specialist, Singapore Medical Service, to moderate a review of the session by Dr. Pau and Miss Chalmers. Dr. Field asked Dr. Pau and Miss Chalmers questions which she considered were provocative and had arisen from the session thus far. As the discussion prodeeded Dr. Field suggested that these questions might serve as points of departure for the group discussions. The questions discussed were: Can the untrained women who at present practise midwifery be taught to give health education? Is a higher level of education necessary or can they be taught simple rules of health? How should women be recruited and selected for midwifery training? Should those who have failed nursing exam:i.nat±ons be accepted? Vlhat -' should be the standard of education? Is prestige in the village important? Is domiciliary midwifery preferable t 0 ho.spi tal services? Should "devel oped" countries reverse the trend toward hospitalization? Does a midwife who is to practise in rural homes need to receive any training in hospital? If so, how much? If midwives are trained in cities how can they be induced to go back to the villages? What kind of training does the midwife need? Is there need for more emphasis on the public health and social aspects of the work? If midwi ves are given t his type of education, should midwives and public health nurses be trained separately? To what extent can the midwife conform to the customs of the people whom she serves? Should she ever take a firm stand against these? In the open discussion which followed one of the requested information on midwifery training programmes in other countries in the region and six replies were given. represent~tives
The session concluded with a flip chart presentation on behaviour during group discussions, covering expectations, the use of ideas and experience, group partiCipation and leadership, and roles played by individuals in the various groups. After expressing appreciation to those participating in the programme the Chairman adjourned the meeting.