WORLD HEALTH ORGANISATION ·i( ~,
REGIONAL OFFICE FOR THE WESTERN PACIFIC ., TECHNICAL DISCUSSIONS , (. to.
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REGIONAL COMMITTEE r Sixth Sassion • Singap9,reL.. . . , 13-19 September 1955 l
'WP/RC6/TD5 116 September 1955 ORIGINAL: ENGLISH
15 September 1955, 8.30 a.m. GROUP A Dr. Abel Simoes de Carvalho (Portugal) Chairman Dr. Mam-Komsann (Cambodia) Dr. Leng Pao (Cambodia) Dr. M. Demange (France) Dr. Nguyen· van Hong (Vietnam) Dr. Oudom Souvannavong (Laos) Dr. Thonphet (Laos)
DlSCUSSION GROUP REPORTS
Group A preferred to examine the subject-matter of the technical discussions at a purely practical level, namely domiciliary midwifery in rural areas not provided with health units or qualified staff. The group consiger,s that there are in the villages (village midwives) whose training is empirical but whom it is necessary at present to use, after giving them a cursory education in hygiene. I(matron~s"
The traiping of·"rural midwives" seems to the 'group to offer a quick solution to the problem of deliveries in the country. The term "rural midwife'''' (ace~ucl1euse rurale) would apply to women. who .. hav.e acqUired some idea of f) 'obstetrics,.hygiene, child-welfare, epidemiology, firstaid, but have not attained the qualifications of the midwife .p~oper (sage-femme). These persons would be recruiwd with the help of local authorities and would return to serve in their original Village. They would receive a salary and would be provided with the equipment necessary for. their work. They would be regularly supervised and made to undergo refresher' courses. It is certain that recruitment and maintenance of such a service will raise numerous difficulties at the material and technical level.
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It seemed to the members of group A that the "rural midwives" could have a greater influence on the people at the present juncture. They would form a transitional group until such time as the number of thoroughly qualified midwives would be sufficient and would thus enable countries lacking qualified staff to face up to the present situation.
GROUP B Miss M. Chalmers (WHO) *Dr.S. S. De (FAO) Dr. Clemente Gatmaitan Mr. P.K. Hernon (WFUNA) Dr. T. C. Hsu (China) *Dr. G. Loison (SPC) *Observer The meeting of Group B was opened by the Chairman, . Dr. Gatmaitan, who announced that the guideline for the discussion would be the topics brought out in the summary of the opening session, and asked for the opinions of the group as to how best to proceed to obtain the most thorough examination of the subject., After considerable discussion the following definitions were agreed to; 1.
Miss ~. Ludgate (WHO) Dr. Masay03hi Yamaguchi (Japan) Dr. A. S. Osborne (US) *Mrs. Perera (Singa~ore) *Dr. Ram (Singapore) Dr. K. C. Yeo (UK)
Domiciliary midwifery is taken to mean the delivery of a child within the home of the woman The midwife is 'someone trained in the care of the woman during childbirth. (It was debated whether or not the term should include a.physician attending a delivery, but it ',vas agreed that this should not be d o n e ) . , . ,
2.
Af.tercanvassing the group, a list ot' questions and statements was compiled as a guide for discussion. 1. 2. What area and population could be considered a unit for a midwife What services or functions should a midwife perform What services outside her immediate field should she give What is the responsibility of the local health authority in the supervision of midwives
3.
4.
WP/RC6/TD5 Page 3 5. 6. What training should a midwife have Regarding the question of recruitment of persons for training what phould be the requirements Domiciliary midwifery as an approach to the people in the development of R~al Health Services is of limited value compar~d to any other approach.
7.
It was decided that area and population were not sufficient factors for the assignment of midwives. Importance had to be given to the concentration of population and the accessibility of the area, Although it was impossible to lay down hard and fas~ rules a midwife's territory should be small enough so that she would not need to travel more thdn one hour by the usual means to attend a patient. Her work load' should be in the vicinity of 75 cases annually. In compact areas there should be one midwife per 2000 population with the special pattern of one health centre containing other services every 10,000. The normal functipns of a midwife, and the services she should perform in connection with her work should be ante, intra, and post-natal care. She should be able to give informed opinions on anything she has learned; she should be able to recognize the normal; and in cases of abnormality should be able either to advise on some action, or should report it to the proper authority. With regard to selection for training girls should be between the ages of 17 and 35;' and should preferably come from the area in which they will practise. They should have had at least six years of schooling and should have personality characteristics which would make them readiiliy acceptable within the community. Formal training for midwives should be a minimum of two years. The theoretical course should include instruction in the fundam3ntals of anatomy, physiology, bacteriology, personal and envir~nmental hygiene, nutrition, first aid, materia medica, ethics, human behaviour, the history of nursing, communicable diseases, basic nursing, maternal and child care, the legal requirements of registration, and obstetrics. The number of deliveries attended during training is not in itself important. The student should spend some time in the labour ward, but most of her practical training should be in domiciliary work in the company of a trained person.
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During the course of the discussion the question was raised as to whether a midwife should be allowed to perform vaccinations and immunizations. It was the opinion of the group that this should be allowed only if these services did not exist in the area, and only after the midwife had received special instruction in this field. It was agreed that domiciliary midwifery was only .ne of the personal services that had grown up since the turn of the century, and since it took into consideration only two members of the family, wheras other services looked after the ent ire community, 8.8 in the "village improvement" scheme, domiciliary midwifery had only a limited value as an approach to the people in the development of rural health services. It was also agreed that where untrained midwives were practising, they should be allowed to continue to do so, but should be replaced by trained personnel as they retired. On the ~u~stions raised in the summary of the opening session the group held the following opinions: The midwife must have some hospital experience. but her training should be slanted to the home, with special emphasis on antenatal and postnatal care, and the, p~blic health aspects of her speciality. 'Midwives could be encouraged to serve in rural areas by offering them inducements in the form of amenities, piped water, electricity and a home suitable for themselves and their families. Their prestige must be built and . maintained apd they must not be allow~d to feel that they have been left out of things by serving i~ a rural area. The midwife may give way to local customs which are not harr.~ful, but should oppose those which are. This cpposition should not be by strong methods, but by health education. The ide~. of the public health team should be a part of her training. There should be separate training for midwives and for public health n~rses. Their functions do notooverlpp. The ~uestion of whether domiciliary midwifery services should be expanded in "developed" countries was not really a point for discus~ion. In general the answer was no in developed countries the pattern had already been established, and the more developed the country, the less the need for domiciliary midwifery.
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GROUP C Richmond K. Anderson (Rockefeller Found) *Brigadier D. Bluett , (ICMM & p) Dr. F. Field (SingapOrej Dr. Eung Soo Han (Korea Mr. Young Kee Kim(Korea Dr. Le van Kai (Vietnam *Madame Nooi Ah Kuan (ICN) Dr. K. C. Lee (US) Chairman Dr. C. Mani (WHO)
*Dr.
Mr. *Dr. *Dr. Dr. Mr. Dr. Dr. Dr.
Takao Matsuo (Japan) E. B. M. Murphy (WFMH) F.A.C. Oehlers (IDF) Jose Ne Rodriguez (PI) A. Sait& (Japan) P. Fau (WHO) C. H. Yen (China) E. C. Vardy (UK)
*Observers.
On the opening of the meeting, the Chairman called attention to the theme for the discussion of the group keeping in mind domiciliary midwifery services as a means to be used in the development of rural health. The rapporteur was selected by the group. On the develf'pment of the subject and in the group's endeavour -to finalize some concepts for it's report, the following are the results of it's discussion. 1. It was agreed that rural health services can be carried .ut without midwifery services. However, domiciliary midwifery can be an,d is an important, practical y and useful spearhead or means for the development of rural health services particularly in lessdev~loped countries. 2. Midwifery included that service rendered by one who had training in this practice. It mayor may not be carried out in an organized manner. It was agreed that midwives should be trained and used for other health services beyond the practice of midw~fery in areas of the world where there are great shortages of pr~fessional health workers. The practising midwife <Jan become a more respected and useful health worker in her co~nunity by providing her with additional training and giving her more responsibilities as she is able to absorb these duties. In giving the midwife additional health responsibilities, she becomes known in the community she serves as one who does more t~an delivery services alone.
3.
4.
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It was agreed that the ultimate objective of " the training of midwives was in the preparation of nurse-midwives as ideal heal th workers in a rura.l area. It was recognized however, that it will take a long time, if ever, to accomplish this. objective. Meanwhile, it was necessary to have a class of assistant nurse-midwife to carryon '.the needed health services and these workers must be. helped with adequate supervision. In the matter of superstition, customs and traditions, it was agreed that they cannot be ignored. In fact, it was felt that an attempt be made to understand and accept some of these beliefs and use them as an aid to promote health and educational programmes. But when it is certqin that these beliefs are harmfUl to the child, mother, the family, or the community, we must and should take steps to correct and change these improper health habits as quickly and as effectively as possible. Gaining the confidence of the people early, was very necessary before endeavouring to change people's habits and customs. ~ Taking into account the educational l~vel of a people, the economic, human, and physical resources domiciliary miJwifery is the preferable choice of approach to the development of good maternity care in rural areas, rather than building more maternity homes and hospitals. It wasfelt however, that provision and plans should be made for the handling of difficul t or abnormaL rna terni ty cases. It was concluded that ante-natal care was an important aspect of good maternity care. TIhis health service was more effective and economically managed at ante-natal clinics rather than home visits. It was agreed, however, that a certain numbe~ of antenatal home visits must be made in order to learn about the conditions and~acilities in the home. The group. b'elieved that at the ante-natal clinics the resources for teaching and giving ante-natal care was more adequate than in th3 home. In add,ition, . the mother and her family· can be served by other health programmes~ ~.
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8.
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9. Training of midwives should be given in the hospitals and in the homes. Public health learning and experience should be provided a midwife in accordance with the needs and demands of the rural communities and the capabilities of the midwife. In summary, Group C believed that domiciliary midwifery was an important means of approach for the development of rural health services. Domicil~ary midwifery must not remain a static type of health programme. It must be expanded and improved by training the midwives so that their services can be utilized for other needed health programmes in our rural communities.
For nex~ year's Technical Discussion, the group suggested one of these two subjects: 1. The Appreach and Management of The Pre-School Child (From 1 - 6 )
2. The Collection and Analysis of Health Statistics. Richard K. C. Lee Chairman Dr. F.S. Han Rapporteur