From pre-history to PHC In the context of maternal and child health, primary health care represents a return to the traditions of community and family- based care, but now it is much more scientifically founded and socially sustained by Mark Belsey The forty years of the World Health Organization have brought as much change and hope for the health of women and children as the preceding 4,000 years. Yet those 4,000 years were not without reason and wisdom. By taking the best that the two worlds of traditional and modern science can offer, WHO has served the world's women and children well . If we were to look back at a birth some 4,000 years ago , the scene would be the same as it had been for millennia before and would be for millennia to come. It was repre- sented in the pottery of pre-Colom- bian Peru, in the descriptions of childbirth in Roman times and in Renaissance times, and it is to be found in the anthropological de- scriptions of nearly all pre-industrial societies. Women delivered their babies from a squatting, kneeling or even standing position. They were supported from behind by another woman, and were often as- sisted in the delivery by a relative. The birthing place was often a closed, indoor place, free from draughts , often with a fire burning and possibly water heating. Yet traditional practices were not enough. In the best of ages, nearly one in a hundred pregnant or partu- rient women failed to survive ; in the worst of circumstances, several times more of them would die. Women were aware of the dangers and risks, sometimes seeking erro- neous solutions to real problems. Fear that too large a baby would lead to a difficult delivery led to food taboos or restrictions that may have been harmful to the woman's own health and to the growth and development of the unborn child. Dr Mark Belsey is Chief of the Maternal and Child Health unit in WHO's Division of Family Health. In recent times, professional con- venience and organized maternity services demanded that women should deliver their babies while lying on their backs. Adherence to aseptic techniques, and once again the convenience of hospital rou- tines , precluded the presence of friends or family members . It was the presumed price to be paid for a safe delivery. But there was wisdom in some of the traditional practices. We now know that the pelvic bones open wider during delivery, and the force of a woman's contractions are greater when she is upright than when she is fiat on her back during labour and delivery. The presence of a friend, relative or sympathetic person for social support cuts in half many of the complications and the need for operative assistance . Yet not all that was traditional in maternal and child health was ben- eficial. Fear of " bad airs" at a tra- ditional delivery might have wisely cut down the danger to the new- born infant of draughts and chill- ing; but the risks of pneumonia Early pottery from Peru shows the tra- ditional way in which women were helped to give birth. Photo WHO W oRLD HEALTH, Jan./Feb. 1988 Today, professional convenience re- quires that women deliver their babies while lying down, and that they con- form to hospital routines. Photo WHO/E. Rice increased when tight swadding im- peded adequate breathing move- ments or when the baby was ex- posed to the irritants of a closed , smoke-filled environment. Many societies failed to understand the importance of that first flow of breast secretion , colostrum, as a unique protective substance. Birth itself was so chancy that the naming of newborn infants was delayed un- til there was a reasonable certainty of survival - sometimes for ten days , beyond the risk of tetanus , often 30 or 40 days , beyond the hazards of newborn infection and the risks to premature infant survival. The rapid social changes and the resultant social and environmental circumstances that accompanied the growth of cities and the later in- dustrial revolution of the 19th cen- W oRLD HEALTH, Jan./Feb. 1988 tury in Europe and North America left little room or time for tradition- al technologies to evolve and adapt. Often, independent of the tradi- tional patterns of health care, tech- nological advances both within and outside of the health care sector have had a great impact on the health of mothers and children. Im- provements in food production and distribution , the availability of schooling, particularly of women, and environmental improvements in water, sanitation and housing have had a beneficial effect on health. Science flourished and new knowledge in maternal and child health rapidly accumulated. Awareness of the nutritional re- quirements of infants and children, developments in immunology and vaccine development , and an un- derstanding of the epidemiology and management of infectious dis- eases of childhood are but a few examples of the rapid strides in research. In some instances the "best " temporarily became the enemy of the "good" , Thus the knowledge of the electrolyte and fluid imbalances of diarrhoea and dehydration initially led to highly complex calculations and a vari- ety of fluid solutions for clinical management, and this posed an obstacle to the management of the problem on a community-wide scale. By the late 1950s, Maternal and Child Health (MCH) technologies had rapidly evolved. Well-defined packages of care emerged; ante- natal care included the detection of pre-eclampsia, anaemia , syphilis screening and Rhesus factor typing. Similarly , child health technologies evolved in such areas as immuniza- tion , growth monitoring , infant and child feeding , or early diagnosis of handicapping conditions. But if it had not been for WHO, much of this knowledge and most of the technol- ogies would have diffused only slowly from the bound volumes of medical journals, remaining beyond the reach of the vast majority of the women and children of the world. 25 From pre-history to PHC Breastfeeding and family planning posters advocate healthy practices to mothers attending a clinic in Lesotho. Photo W HO/N. Durreii-McKenna During this same period, the trend in the care of mothers and children was becoming highly pro- fessional and dependent on more and more complex technologies. Often the community became the passive recipient of care. The skills and knowledge of traditional moth- er and child care were lost. Ante- natal clinics had become crowded, popular demand for care had been created, and with it, dependency. The technologies were not always appropriate ; the resources , skill and infrastructure required to sus- tain them were usually not avail- able in the developing world. Amidst this disharmony, another discordant theme became appar- ent; unregulated fertility was tak- ing a significant toll on the health of mothers and children. In all these currents and counter- currents of social and technological change, what role has WHO played? But for WHO, would the scientific 26 community and the policy-makers have recognised the excesses of technology and rediscovered the beneficial features of traditional practices in maternal and child health, including family planning? Since its infancy and in the constan- cy of its idealism, the Organization has moved from a position of serv- ing as a noble supplier of know- ledge and technical support to countries , issuing pronouncements and technical documents, to the position of a mature activism and outspoken advocacy . In the context of maternal and child health, primary health care represents a return to the traditions of community- and family-based care, but now more scientifically founded and socially sustained. The gaps in knowledge and application have prompted new solutions and approaches: oral rehydration ther- apy for diarrhoea! disease; the widespread application of the risk approach in maternal and child health, including family planning, as a means for redressing inequity and matching resources to needs. The monitoring of the world health situation of women and children has identified disturbing trends and unmet needs: a decline in breast- feeding in many areas of the world; and a level of maternal mortality that is still intolerably high. Increased efforts by WHO and spe- cial programmes in these and other areas have accelerated action. Con- traceptives are being developed and tested ; early warning systems ensure timely intervention in case of nutritional deterioration in chil- dren. The cold chain for maintain- ing vaccines from manufacturer to health centre is being extended . The technologies for managing those common killers of infants and children, diarrhoea! diseases and respiratory infections , are being simplified and more widely dif- fused. And, more recently , the shame of 500,000 maternal deaths a year is being redressed through a sensitive and supportive partner- ship between the health system and the community. We bear witness that these chal- lenges have been and will continue to be met by the World Health Or- ganization on its fortieth birthday and in the remaining twelve years of this century. • W oRLD HEALTH, Jan./Feb. 1988
From pre-history to PHC In the context of maternal and child health, primary health care represents a return to the traditions of community and family- based care, but now it is much more scientifically founded and socially sustained by Mark Belsey The forty years of the World Health Organization have brought as much change and hope for the health of women and children as the preceding 4,000 years. Yet those 4,000 years were not without reason and wisdom. By taking the best that the two worlds of traditional and modern science can offer, WHO has served the world's women and children well . If we were to look back at a birth some 4,000 years ago , the scene would be the same as it had been for millennia before and would be for millennia to come. It was repre- sented in the pottery of pre-Colom- bian Peru, in the descriptions of childbirth in Roman times and in Renaissance times, and it is to be found in the anthropological de- scriptions of nearly all pre-industrial societies. Women delivered their babies from a squatting, kneeling or even standing position. They were supported from behind by another woman, and were often as- sisted in the delivery by a relative. The birthing place was often a closed, indoor place, free from draughts , often with a fire burning and possibly water heating. Yet traditional practices were not enough. In the best of ages, nearly one in a hundred pregnant or partu- rient women failed to survive ; in the worst of circumstances, several times more of them would die. Women were aware of the dangers and risks, sometimes seeking erro- neous solutions to real problems. Fear that too large a baby would lead to a difficult delivery led to food taboos or restrictions that may have been harmful to the woman's own health and to the growth and development of the unborn child. Dr Mark Belsey is Chief of the Maternal and Child Health unit in WHO's Division of Family Health. In recent times, professional con- venience and organized maternity services demanded that women should deliver their babies while lying on their backs. Adherence to aseptic techniques, and once again the convenience of hospital rou- tines , precluded the presence of friends or family members . It was the presumed price to be paid for a safe delivery. But there was wisdom in some of the traditional practices. We now know that the pelvic bones open wider during delivery, and the force of a woman's contractions are greater when she is upright than when she is fiat on her back during labour and delivery. The presence of a friend, relative or sympathetic person for social support cuts in half many of the complications and the need for operative assistance . Yet not all that was traditional in maternal and child health was ben- eficial. Fear of " bad airs" at a tra- ditional delivery might have wisely cut down the danger to the new- born infant of draughts and chill- ing; but the risks of pneumonia Early pottery from Peru shows the tra- ditional way in which women were helped to give birth. Photo WHO W oRLD HEALTH, Jan./Feb. 1988 Today, professional convenience re- quires that women deliver their babies while lying down, and that they con- form to hospital routines. Photo WHO/E. Rice increased when tight swadding im- peded adequate breathing move- ments or when the baby was ex- posed to the irritants of a closed , smoke-filled environment. Many societies failed to understand the importance of that first flow of breast secretion , colostrum, as a unique protective substance. Birth itself was so chancy that the naming of newborn infants was delayed un- til there was a reasonable certainty of survival - sometimes for ten days , beyond the risk of tetanus , often 30 or 40 days , beyond the hazards of newborn infection and the risks to premature infant survival. The rapid social changes and the resultant social and environmental circumstances that accompanied the growth of cities and the later in- dustrial revolution of the 19th cen- W oRLD HEALTH, Jan./Feb. 1988 tury in Europe and North America left little room or time for tradition- al technologies to evolve and adapt. Often, independent of the tradi- tional patterns of health care, tech- nological advances both within and outside of the health care sector have had a great impact on the health of mothers and children. Im- provements in food production and distribution , the availability of schooling, particularly of women, and environmental improvements in water, sanitation and housing have had a beneficial effect on health. Science flourished and new knowledge in maternal and child health rapidly accumulated. Awareness of the nutritional re- quirements of infants and children, developments in immunology and vaccine development , and an un- derstanding of the epidemiology and management of infectious dis- eases of childhood are but a few examples of the rapid strides in research. In some instances the "best " temporarily became the enemy of the "good" , Thus the knowledge of the electrolyte and fluid imbalances of diarrhoea and dehydration initially led to highly complex calculations and a vari- ety of fluid solutions for clinical management, and this posed an obstacle to the management of the problem on a community-wide scale. By the late 1950s, Maternal and Child Health (MCH) technologies had rapidly evolved. Well-defined packages of care emerged; ante- natal care included the detection of pre-eclampsia, anaemia , syphilis screening and Rhesus factor typing. Similarly , child health technologies evolved in such areas as immuniza- tion , growth monitoring , infant and child feeding , or early diagnosis of handicapping conditions. But if it had not been for WHO, much of this knowledge and most of the technol- ogies would have diffused only slowly from the bound volumes of medical journals, remaining beyond the reach of the vast majority of the women and children of the world. 25 From pre-history to PHC Breastfeeding and family planning posters advocate healthy practices to mothers attending a clinic in Lesotho. Photo W HO/N. Durreii-McKenna During this same period, the trend in the care of mothers and children was becoming highly pro- fessional and dependent on more and more complex technologies. Often the community became the passive recipient of care. The skills and knowledge of traditional moth- er and child care were lost. Ante- natal clinics had become crowded, popular demand for care had been created, and with it, dependency. The technologies were not always appropriate ; the resources , skill and infrastructure required to sus- tain them were usually not avail- able in the developing world. Amidst this disharmony, another discordant theme became appar- ent; unregulated fertility was tak- ing a significant toll on the health of mothers and children. In all these currents and counter- currents of social and technological change, what role has WHO played? But for WHO, would the scientific 26 community and the policy-makers have recognised the excesses of technology and rediscovered the beneficial features of traditional practices in maternal and child health, including family planning? Since its infancy and in the constan- cy of its idealism, the Organization has moved from a position of serv- ing as a noble supplier of know- ledge and technical support to countries , issuing pronouncements and technical documents, to the position of a mature activism and outspoken advocacy . In the context of maternal and child health, primary health care represents a return to the traditions of community- and family-based care, but now more scientifically founded and socially sustained. The gaps in knowledge and application have prompted new solutions and approaches: oral rehydration ther- apy for diarrhoea! disease; the widespread application of the risk approach in maternal and child health, including family planning, as a means for redressing inequity and matching resources to needs. The monitoring of the world health situation of women and children has identified disturbing trends and unmet needs: a decline in breast- feeding in many areas of the world; and a level of maternal mortality that is still intolerably high. Increased efforts by WHO and spe- cial programmes in these and other areas have accelerated action. Con- traceptives are being developed and tested ; early warning systems ensure timely intervention in case of nutritional deterioration in chil- dren. The cold chain for maintain- ing vaccines from manufacturer to health centre is being extended . The technologies for managing those common killers of infants and children, diarrhoea! diseases and respiratory infections , are being simplified and more widely dif- fused. And, more recently , the shame of 500,000 maternal deaths a year is being redressed through a sensitive and supportive partner- ship between the health system and the community. We bear witness that these chal- lenges have been and will continue to be met by the World Health Or- ganization on its fortieth birthday and in the remaining twelve years of this century. • W oRLD HEALTH, Jan./Feb. 1988
From pre-history to PHC In the context of maternal and child health, primary health care represents a return to the traditions of community and family- based care, but now it is much more scientifically founded and socially sustained by Mark Belsey The forty years of the World Health Organization have brought as much change and hope for the health of women and children as the preceding 4,000 years. Yet those 4,000 years were not without reason and wisdom. By taking the best that the two worlds of traditional and modern science can offer, WHO has served the world's women and children well . If we were to look back at a birth some 4,000 years ago , the scene would be the same as it had been for millennia before and would be for millennia to come. It was repre- sented in the pottery of pre-Colom- bian Peru, in the descriptions of childbirth in Roman times and in Renaissance times, and it is to be found in the anthropological de- scriptions of nearly all pre-industrial societies. Women delivered their babies from a squatting, kneeling or even standing position. They were supported from behind by another woman, and were often as- sisted in the delivery by a relative. The birthing place was often a closed, indoor place, free from draughts , often with a fire burning and possibly water heating. Yet traditional practices were not enough. In the best of ages, nearly one in a hundred pregnant or partu- rient women failed to survive ; in the worst of circumstances, several times more of them would die. Women were aware of the dangers and risks, sometimes seeking erro- neous solutions to real problems. Fear that too large a baby would lead to a difficult delivery led to food taboos or restrictions that may have been harmful to the woman's own health and to the growth and development of the unborn child. Dr Mark Belsey is Chief of the Maternal and Child Health unit in WHO's Division of Family Health. In recent times, professional con- venience and organized maternity services demanded that women should deliver their babies while lying on their backs. Adherence to aseptic techniques, and once again the convenience of hospital rou- tines , precluded the presence of friends or family members . It was the presumed price to be paid for a safe delivery. But there was wisdom in some of the traditional practices. We now know that the pelvic bones open wider during delivery, and the force of a woman's contractions are greater when she is upright than when she is fiat on her back during labour and delivery. The presence of a friend, relative or sympathetic person for social support cuts in half many of the complications and the need for operative assistance . Yet not all that was traditional in maternal and child health was ben- eficial. Fear of " bad airs" at a tra- ditional delivery might have wisely cut down the danger to the new- born infant of draughts and chill- ing; but the risks of pneumonia Early pottery from Peru shows the tra- ditional way in which women were helped to give birth. Photo WHO W oRLD HEALTH, Jan./Feb. 1988 Today, professional convenience re- quires that women deliver their babies while lying down, and that they con- form to hospital routines. Photo WHO/E. Rice increased when tight swadding im- peded adequate breathing move- ments or when the baby was ex- posed to the irritants of a closed , smoke-filled environment. Many societies failed to understand the importance of that first flow of breast secretion , colostrum, as a unique protective substance. Birth itself was so chancy that the naming of newborn infants was delayed un- til there was a reasonable certainty of survival - sometimes for ten days , beyond the risk of tetanus , often 30 or 40 days , beyond the hazards of newborn infection and the risks to premature infant survival. The rapid social changes and the resultant social and environmental circumstances that accompanied the growth of cities and the later in- dustrial revolution of the 19th cen- W oRLD HEALTH, Jan./Feb. 1988 tury in Europe and North America left little room or time for tradition- al technologies to evolve and adapt. Often, independent of the tradi- tional patterns of health care, tech- nological advances both within and outside of the health care sector have had a great impact on the health of mothers and children. Im- provements in food production and distribution , the availability of schooling, particularly of women, and environmental improvements in water, sanitation and housing have had a beneficial effect on health. Science flourished and new knowledge in maternal and child health rapidly accumulated. Awareness of the nutritional re- quirements of infants and children, developments in immunology and vaccine development , and an un- derstanding of the epidemiology and management of infectious dis- eases of childhood are but a few examples of the rapid strides in research. In some instances the "best " temporarily became the enemy of the "good" , Thus the knowledge of the electrolyte and fluid imbalances of diarrhoea and dehydration initially led to highly complex calculations and a vari- ety of fluid solutions for clinical management, and this posed an obstacle to the management of the problem on a community-wide scale. By the late 1950s, Maternal and Child Health (MCH) technologies had rapidly evolved. Well-defined packages of care emerged; ante- natal care included the detection of pre-eclampsia, anaemia , syphilis screening and Rhesus factor typing. Similarly , child health technologies evolved in such areas as immuniza- tion , growth monitoring , infant and child feeding , or early diagnosis of handicapping conditions. But if it had not been for WHO, much of this knowledge and most of the technol- ogies would have diffused only slowly from the bound volumes of medical journals, remaining beyond the reach of the vast majority of the women and children of the world. 25 From pre-history to PHC Breastfeeding and family planning posters advocate healthy practices to mothers attending a clinic in Lesotho. Photo W HO/N. Durreii-McKenna During this same period, the trend in the care of mothers and children was becoming highly pro- fessional and dependent on more and more complex technologies. Often the community became the passive recipient of care. The skills and knowledge of traditional moth- er and child care were lost. Ante- natal clinics had become crowded, popular demand for care had been created, and with it, dependency. The technologies were not always appropriate ; the resources , skill and infrastructure required to sus- tain them were usually not avail- able in the developing world. Amidst this disharmony, another discordant theme became appar- ent; unregulated fertility was tak- ing a significant toll on the health of mothers and children. In all these currents and counter- currents of social and technological change, what role has WHO played? But for WHO, would the scientific 26 community and the policy-makers have recognised the excesses of technology and rediscovered the beneficial features of traditional practices in maternal and child health, including family planning? Since its infancy and in the constan- cy of its idealism, the Organization has moved from a position of serv- ing as a noble supplier of know- ledge and technical support to countries , issuing pronouncements and technical documents, to the position of a mature activism and outspoken advocacy . In the context of maternal and child health, primary health care represents a return to the traditions of community- and family-based care, but now more scientifically founded and socially sustained. The gaps in knowledge and application have prompted new solutions and approaches: oral rehydration ther- apy for diarrhoea! disease; the widespread application of the risk approach in maternal and child health, including family planning, as a means for redressing inequity and matching resources to needs. The monitoring of the world health situation of women and children has identified disturbing trends and unmet needs: a decline in breast- feeding in many areas of the world; and a level of maternal mortality that is still intolerably high. Increased efforts by WHO and spe- cial programmes in these and other areas have accelerated action. Con- traceptives are being developed and tested ; early warning systems ensure timely intervention in case of nutritional deterioration in chil- dren. The cold chain for maintain- ing vaccines from manufacturer to health centre is being extended . The technologies for managing those common killers of infants and children, diarrhoea! diseases and respiratory infections , are being simplified and more widely dif- fused. And, more recently , the shame of 500,000 maternal deaths a year is being redressed through a sensitive and supportive partner- ship between the health system and the community. We bear witness that these chal- lenges have been and will continue to be met by the World Health Or- ganization on its fortieth birthday and in the remaining twelve years of this century. • W oRLD HEALTH, Jan./Feb. 1988