The Assessment of Quality of Care in Prenatal Services In Irbid, North Jordan:

Women's Perspectives

Salah Mawajdeh, Ra'eda Al-Qutob, and Firas Bin Raad

Summary: This paper focuses on an assessment by 289 pregnant women receiving prenatal care from maternal and child health (MCH) centres in Irbid, Jordan, of the quality of available reproductive health services. Women's perceptions of service quality, as well as their level of satisfaction with the care received, were validated with independent observations of the service delivery process. The study showed that, in general, women were dissatisfied with the patient–provider relationship and with the extent of information exchange between themselves and their care providers. On the other hand, the women were modestly satisfied with the technical competence of providers and were highly satisfied with the management of the health care facilities. This study highlights the relevance and value of women's reports as credible data sources for quality of care assessment. Health care systems that aim to provide services that transcend the traditional emphasis on technical competence of providers as the sole measure of quality of care ought to be attentive to women's inputs into the health care delivery process.

Introduction

Maternal health services directed toward improving women's health are finally receiving due attention. This new focus, driven by recent research, emphasizes the close tie between women's health status and the overall well being of the entire family. This link is most apparent in studies that have demonstrated higher risks of infant and child mortality following maternal death and the tangible benefits of birth spacing for both the mother and child.

Increased attention to the health status of women is evidenced in the movement of the international community toward improving legislation and services directed to women. The Safe Motherhood Initiative of 1978 in Nairobi and 1988 in Amman stressed the need for strategies that tackle the root causes of maternal morbidity and mortality. The initiative also highlighted the need to set measurable goals and targets. In addition, one of the precongress workshops of the World Health Organization/FIGO which took place within the context of the XIII World Congress of Gynaecology and Obstetrics in Singapore in September, 1991 stated the following as a specific objective:

To develop approaches for the participation of women and women's organizations in collaboration with Ob/Gyn and midwifery societies and other relevant groups, in sensitizing decision makers to women's health needs and perspectives and to encourage women's participation, especially in reproductive health (WHO/FIGO 1991).

The other significant trend in maternal health services research has been a realization of the necessity to assure and improve the quality of these services. This trend has led to new quality assessment approaches for reproductive health services that examine service delivery in a comprehensive manner, thereby transcending traditional assessment methods which were merely concerned with the technical competence of providers (Bruce 1990). The new approach examines quality of services at a structural level and describes how high-quality services are actually delivered (process). It also relates these services to outcomes of care that extend beyond the usual physical indicators, such as mortality and morbidity rates, to include behavioural and attitudinal indicators. This comprehensive approach to assessing quality of care relies on the points of view of providers, managers, and users.

One of the pre XIII World Congress of Ob/Gyn workshops stated that

Paternalism (or maternalism) approaches to health care must be replaced by a partnership approach in the provision of quality of care to the whole woman, including assistance in dealing with personal sexual problems. Care must be provided with compassion, dignity, confidentiality, continuity, and informed choice. Women should have general access to fertility regulation and pregnancy services with as comprehensive a reproductive health system as possible. Recognition must be given to the poverty status of millions of women throughout the world, and more generally, to the devastating economic situation in the poorer countries of the world (WHO/FIGO 1991).

The need to involve and incorporate women in national development cycles is gaining greater attention, and some countries have instituted Ministries for Women's Affairs. In a well known study, Carol MacCormack (1992) provides a theoretical framework for linking planning to the evaluation of women's participation in primary health care, and thus offers a mechanism for assessing the status of countries' efforts to incorporate women's views and perceptions in primary health care.

A study of the interaction between women and health care providers may uncover problems in the delivery of high-quality care. However, this assumption could raise some arguments; at the individual level, medical professionals tend not to rely heavily on patient reporting as part of the management process. This aspect of medical care, along with other clinical skills, is being replaced by more elaborate diagnostic techniques. This tendency is greater for certain disease conditions, such as reproductive morbidities, which may be asymptomatic in some women. In addition, some contend that poorer, illiterate women may be unable to describe adequately what they are suffering. The latter may also be the case in facilities providing services of inferior quality.

Reliance on women's reporting to assess the quality of care builds on the experience of earlier research (Bang et al. 1989; Wasserheit et al. 1989; World Health Organization 1989; Campbell and Graham 1990; ) which obtained information on reproductive morbidity through survey methods and clinical and laboratory examinations. Despite their known shortcomings, these community cross-sectional surveys provide a viable methodological approach (Campbell and Graham 1990).

In their study of two villages in the Giza Governorate of Egypt, Zurayk et al. (n.d.) compared women's reports of reproductive morbidity symptoms with the results of medical diagnoses. The authors demonstrated a relatively strong correlation, reporting a specificity and sensitivity of 76% and 50%, respectively.

As part of a larger 1990 study that assessed the quality of prenatal care services in public maternal and child health (MCH) centres in Irbid, Jordan, this study aims to assess quality of care as perceived by the women receiving the care, as well as to validate the women's reporting with observations made by the research team in the centre.

Assessing Quality of Care in Irbid, Jordan

In Irbid, MCH centres are uniformly distributed and provide prenatal services at affordable costs. The primary users of prenatal care at MCH centres are women of middle and low socioeconomic classes. Unlike health centres in the city, MCH centres in the surrounding villages provide services to well-defined geographic areas, and the services are integrated within primary health care centres. The original study (Al-Qutob and Mawajdeh 1992) assessed the quality of prenatal care in MCH centres in Irbid using three methods:

· Interviews with health providers and managers of all MCH centres in Irbid governorate (n=31);

· Observations in 10 randomly selected MCH centres representing both the city and its surrounding areas; and

· Home interviews with 289 pregnant women who had used these services.

This paper presents the results of the assessment of the quality of care as perceived by the women.

Methods

The manner in which women assess the quality of prenatal care was studied by examining their reports on the structure and process of care delivery, as well as their satisfaction with the care received.

The conceptual framework adopted by this study is currently under publication. The framework transfers and adapts Bruce's (1990) framework for the assessment of quality of prenatal care and constitutes five main elements: the pregnant woman–provider relationship, the technical competence of providers, information exchange, continuity and follow-up measures, and management.

Assessing quality of prenatal care comprehensively requires the examination of these five elements at all three levels of the health continuum: the structure, process, and outcome (described by Donabedian 1980). For the measurement of quality as perceived by women, specific indicators were identified for each element (see Appendix).

Names and addresses of 300 women who had received prenatal care from the 10 selected MCH centres in Irbid were obtained. The research team was unable to locate the houses of 11 women. A total of 289 women were successfully interviewed at home within 1 month of their last prenatal visit, to obtain information on the structural and process indicators of prenatal care. This process was carried out using a multistructured, open-ended questionnaire that was revised and pretested several times (Al-Qutob and Mawajdeh 1992/3). To avoid biased answers, the interview questions were phrased in both positive and negative directions. For purposes of data analysis, the scores of negative phrases were reversed for ease of data interpretation. The interviews were conducted by anthropology and public health graduates trained in the field. The authors of the study provided supervision to ensure reliability and validity of responses.

The structure and process of prenatal care delivery in 10 MCH centres was also observed by a medical observer who visited each centre twice within a month and attended the prenatal clinics from start to finish. The observer used a pretested checklist to obtain information on several indicators related to the five elements of quality prenatal care at the levels of both structure and process.

Pregnant women in all stages of pregnancy, regardless of parity or status (new registry or follow up), were observed. The observer also recorded all events not included on the checklist which took place during the transaction process. The observation of the health facilities preceded the interviews.

The results of the women's reports on the indicators of the quality of care and their satisfaction were then validated with the observations.

Results

Women's Interviews

All interviewed women responded to the questionnaire, although some were undecided about a few of the indicators. The average woman was 26 years old. Eleven percent were illiterate, while 46% had received less than 10 years of schooling. The majority (95%) were housewives. In all, 27% were primiparas; 15% of the multiparous women had more than seven children. On average, 3.1 prenatal care visits were made. New registries constituted almost 40% of the study group. For 90% of the women, routine prenatal care was the reason for visiting the MCH centres; only 6% had physical complaints at the time of their visits (Al-Qutob and Mawajdeh 1992/93).

Results of the women's reports on the quality of care indicators are shown in Table 1. The results demonstrate variations in the responses reported based on the elements and the indicators studied. For instance, it appears that a much lower percentage of women sensed a close relationship with the providers compared to their reporting on indicators of provider technical competence. In addition, a lower percentage of women reported receiving information on pregnancy-related issues compared to their reports on indicators of the management entity.

The study demonstrated that 64% of the women reported being satisfied with the care provided all or most of the time (data not shown). Analysis of the satisfaction of women who reported positively on the different elements and indicators of the quality of care showed that the majority were satisfied with the services they had received, across all elements and indicators studied. However, between a minimum of 6% and a maximum of 30% reported being unsatisfied to some degree with the care received.

With regard to administrative management, one notices that although the majority of women reported the working hours as convenient and the waiting time as short, more women were satisfied with the working hour schedule than with the waiting time.

As shown in Table 2, 66 women reported that communication took place between themselves and the health care providers. Among these women, 32% were not satisfied. Among the 34 women who felt that the providers understood their problems and issues, the majority (94%) were satisfied with the service received. The highest rate of dissatisfaction was related to the lack of a private atmosphere for service delivery.

The data in Table 2 also demonstrate which indicators of the structure and process of care are major contributors to women's satisfaction. For instance, although women varied in their assessment of indicators related to provider competence, almost 70% were satisfied with the quality of service provided. In addition, 19% of the women received information on breast-feeding advantages and the hazards of smoking. However, their satisfaction with these elements varied by content area. More women were dissatisfied with information received on breast feeding, than on the hazards of smoking. The results of women's satisfaction with continuity indicators indicate that women were generally satisfied, although only a third were told to come back at the scheduled time.

Centre Observation

Structure

Most of the observed health care facilities were conveniently located in the centre of Irbid and its surroundings. One other facility was on a hill and another further from the city. Three of the facilities were newly built. All but two of the older buildings were well-ventilated and illuminated. Each of the MCH facilities consisted of a main examination room and a maternity room in which both mothers and children were cared for by the midwife. In addition, each of the centres had a bathroom, a kitchen, and a waiting room with 8–10 chairs.

In each of the facilities, the maternity room was equipped with an examination couch, a sheet to cover the women, a stethoscope, a fetoscope, a sphygmomanometer, and a weighing scale. Each also featured a small desk, a few wooden chairs, a filing cabinet, and a cupboard for keeping iron and vitamin supplements. The majority of the maternity rooms were provided with screens. In nine of the rooms, stools and height scales were missing or out of order. On the walls of maternity rooms, a maximum of three educational posters were displayed, one of which was related to pregnancy. A mini-lab was available in two facilities for urine analysis, hemoglobin, blood grouping, and Rh factor determination. A pharmacy was available in only one setting.

The staff responsible for the provision of prenatal care consisted of a physician (male in 8 of 10 facilities), a midwife, a nurse, and an aid. A lab technician and a pharmacist were present when a laboratory or a pharmacy was available at the facility. In addition, one laboratory dispatch common to all centres collected blood and urine samples on scheduled days, to be processed at the Ministry of Health's district laboratories.

Nine facilities had established days for prenatal care: one day allocated to newly registering women, chosen when both the physician and laboratory dispatch were available; and one day reserved for follow-up cases. The 10th facility encouraged pregnant women to visit on any day.

During the prenatal clinic days, reservations for appointments were not given; women were cared for on a "first come, first served basis." Most women were seen between 8:30 a.m. and noon, which prevented some from submitting samples at the appropriate time for processing at the central laboratory.

The length of time required to receive an appointment for a follow-up visit depended on the location of the facility and on the type of provider. This waiting time was longer at facilities located in the city and when a midwife was required; this was probably due to the urban midwives' heavy work loads, as compared to the lighter ones handled in the city's surrounding areas. In both locations, however, waiting for the physicians lasted for a shorter period of time, since they handled primarily newly registered women and complicated cases referred by the midwives. The waiting time for to see a physician ranged from 10 to 90 minutes in the city and from 10 to 45 minutes in the surrounding areas.

According to the midwives, the difference in waiting time could be due to the location of the facilities and to the availability of easy transportation. For example, in one village where the MCH facility was conveniently located, there was no suitable transportation since the vehicle travelled all the way to the city without stopping. Thus, as stated by a midwife in the village health facility, women would rather shop in the city, visit the MCH facility, and then return home. "The absence of a defined target area makes it difficult for us to deny prenatal care to any woman seeking it wherever she comes," reported another midwife in the city facility.

Women newly registering for prenatal care services were first seen by the midwife and the nurse aid, who were trained to record the sociodemographic, obstetric, and family histories in a register. Laboratory tests, namely urine analysis, measurement of blood hemoglobin, blood type, and Rh factor, were then performed. Afterwards, the physician provided care for the pregnant women. Follow-up visits were usually handled by the midwife, except when the women was judged to be in need of a physician or requested it. The research team observed that the nurse aid took charge of new and follow-up cases during the absence of the midwife in four of the facilities. Complicated pregnancies were usually referred to the hospital with a note from the physician.

Process of care delivery

On entering the facility, pregnant women (along with their children) were registered and cared for in the maternity room; hence, the room was always crowded, with an average of 5 to 10 people including the personnel. As expected, this chaos triggered an uneasiness felt particularly by the midwife. At times she was forced to raise her voice in the lounge. Otherwise, women were generally welcomed and treated in a kind and respectful way.

Newly registering women were seen by both the midwife and the nurse aid, and were then examined by the physician and the midwife in sequence. For each newcomer, a new record was allocated and filled in by the midwife and/or nurse aid. Answers to questions on the obstetric card were recorded as reported, although a few items such as measurements (namely height) or physical examinations required checking by the physician. Included in this pregnant woman–midwife exchange were the condition of teeth, nipples, breasts, and the presence of varicosities and vaginal discharge.

Questions on the obstetric card were asked as a formality without further inquiry into the substantive causes of illness or death among members of the family when reported. Moreover, when the pregnant woman volunteered to give a detailed answer about a certain question, she was not given a chance to be heard, nor were her relatives. In one instance, for example, the mother of an 18 year old pregnant woman was aggressively cut short by the midwife when she tried to state that her husband had diabetes: "I am addressing the pregnant woman and not you."

Furthermore, women were not invited to be seated while information was added to the card, possibly as a result of the overcrowding of the maternity room. When a seat was vacant, women still asked permission to be seated; otherwise, they were kept standing for about 10 minutes, holding their crying babies while waiting for the provider to record needed information. In another setting, a tired expecting mother was observed sitting on the floor with her sleeping baby.

While completing registration or preparing for a physical exam or laboratory test, women were rarely asked about their motivation for visiting the facility, the purpose of their current check-in, or whether there were any specific complaints.

Each of the pregnant women registering at the facility for the first time was examined by both the physician and the midwife. Only five physicians were actually observed at work, two of whom were female. In the physicians' room, women were generally received kindly and were seated. The physician then estimated the number of weeks of gestation and carried out a physical exam. The heart beats of both the mother and the fetus were heard, the abdomen examined, and the legs checked for edema in most of the women. However, other organs such as the lips and gums, the thyroid gland, the breasts and nipples, and the varicose veins in legs were not examined. Vaginal exams were not performed for women at any of the facilities observed.

The facilities observed showed a wide variation in prescribing iron and vitamin supplements to this particular group of women; the provision of these supplements was based on the midwife's own judgement at times and, at others, on the pregnant woman's request.

After being examined, the women were given cards that showed the time of their next appointment; these appointments were spaced 1 month apart until the end of the 32nd week of gestation, after which they were more frequent. The relevance of this schedule was seldom explained. The follow-up cases were the sole responsibility of the midwife and nurse aid, except when referral to the physician was judged necessary by the midwife, or upon the request of the pregnant woman.

Follow-up cases were treated much the same as the new cases, particularly with respect to interpersonal relations, information transmission, and continuity measures. Medical care offered to follow-up patients, however, consisted mainly of answering chief complaints, examining the size of the uterus, and of checking heart beats, fetal presentation, and leg edema. Laboratory investigations were independent of the stage of pregnancy or parity, but depended primarily on the midwives' clinical judgement. This judgement was noted to vary considerably. The transmission of information was inadequate, lacked privacy, and was not tailored to women's needs (Donabedian 1980).

Generally, the care provided to follow-up cases did not differ by parity, gestational age, or the woman's appearance. In the city, however, it was noted that women who looked better received better communication and information from the clinic staff. Otherwise, the interpersonal relationships and the process of communication did not differ significantly between users in the city and those in surrounding areas.

Comments on the Pregnant Woman–Provider Relationship

Although pregnant women were welcomed and treated cordially by the health care providers, in many cases they received only a share of the providers' actual attention. In one facility, it was observed that the midwife obtained obstetric information from the pregnant woman while keeping her back turned. In another facility, the midwife talked sarcastically to a primipara who was breast feeding her 8 month old baby. Most communication took place with the women standing and holding their crying babies. This was particularly obvious in the urban facilities, where client-provider communication took place in the presence of five or more people.

The pregnant woman–provider relationship in all facilities lacked privacy, and the women were rarely involved in discussions about their social and psychological well-being. Providers were observed to listen only partially to the pregnant women when they expressed ideas or revealed fears, and seldom did they encourage the women to join in a discussion to find appropriate solutions to their problems. This neglect was apparent in the passivity of the women observed and their acceptance of whatever information they received.

For example, in one case, a multipara woman in her 7th month of gestation visited a facility and expressed a fear of vaginal bleeding that had started five days earlier. She was blamed by both the midwife and the physician for not having reported the bleeding earlier. The woman looked depressed and said: "I did not know that this could be dangerous," despite the midwife's statement to the contrary, and added, "Anyway, it was not a planned pregnancy. I don't want this baby and I don't care if it dies." None of the providers reacted to this attitude, nor did they discuss with her any social problems which could have been related to her reaction. There was also no attempt to alleviate her pain nor to support her emotionally.

The physical exam performed by the physician was more private than that performed by the midwife. The screen was always pulled, the door closed, and no strangers were permitted in the room. During physical exams performed by midwives in the maternity room of three different facilities, screens where not used, the doors were kept open, and people were present at all times.

This lack of privacy was observed more frequently in the cities than in the surrounding areas. In one facility, for example, although the door of the maternity room was closed, it was suddenly opened by the physician in the midst of a midwife's examination of a 40 year old pregnant woman, resulting in the immediate embarrassment of the woman and her attempt to cover herself. Discussions from behind the screen were heard clearly by all strangers in the room, including exchanges about the care of breasts and nipples, personal hygiene, and inquiries about vaginal discharges and sexual activities.

Women were asked to get on the examination couch without the assistance of stools or without the help of the providers, and were only supplied with a covering sheet when one was available. At times the pregnant women laid on their backs for 10 minutes or more, and were not told that they might feel pain during the abdominal exam. In four facilities, women's faces turned red and gestures of pain were observed. Neither emotional nor physical support was given to the pregnant women, who were then asked to step down from the couch on their own.

During the physical exam, new registries were not given proper instructions about standard procedures. In one facility, a new primipara was talking while being examined by the midwife. She did not keep her face turned aside as requested, leading the provider to adjust the position of her head in a harsh manner and say angrily: "You bothered me with your breath. Now, keep your face turned aside." A similar incident was observed in another facility while the woman was trying to express her pain with hand motions.

Despite the availability of sinks with soap and running water in all facilities observed, not one provider washed his/her hands, neither before nor after performing a physical examination. One exception to this observed trend was a midwife who felt especially disgusted after examining a "dirty" case, as she called it.

The results of the different observations therefore indicated strong agreement between how women reported the quality of care they received and how outside observers observed that same quality of care.

Discussion

The main objective of the study was to examine women's assessment of and satisfaction with the quality of prenatal care they received based on a certain set of indicators validated by centre observation. The study results showed that women were aware of the quality of care they received. Variability in their responses as to whether certain elements of care took place and their varied responses to different indicators within the elements suggest that women pay attention to the minute details of care they are offered. The extent of agreement between women's reports and the observations supports this suggestion, and indicates that women are able to judge the kind of care they receive.

Despite some women's dissatisfaction, the majority of women who acknowledged receipt of these services were satisfied with the quality of care received. This selectivity in satisfaction may reflect many factors, including women's expectations of care, previous experiences, their perceptions of the role of the formal health system, and their personal culture and values. Each of these factors has been shown to shape their perceptions, views, and assessment of the quality of care received.

One aspect with which the bulk of the women were dissatisfied was the client–provider relationship. For instance, about half of the women were found to be dissatisfied with the degree of privacy, and one third were dissatisfied with the lack of communication and interaction between themselves and the care providers. The results of the observation support this dissatisfaction with specific incidences which may have affected not only the concerned woman, but also other women who witnessed the particular situation.

Analyzing women's satisfaction with care can pinpoint for the service providers what aspects of care really matter to women. For instance, although many women reported that the waiting time was short, not all of them were satisfied. Even though this information may contradict the facts, it is important to note the cultural context in which care is provided. In fact, these women, who are housewives with moderate education, may be taking advantage of their prenatal visit to socialize together. Thus, the long waiting would not annoy them. The observation results also support this finding. A similar comment on waiting time was raised by Leslie et al. (1989) about the so-called "long waiting time," a term which the author suggested may be culturally biased, and may not be relevant in all settings.

The majority of women were satisfied with indicators of provider competence. However, it is possible that the dissatisfied women may be able to differentiate between particular aspects of adequate and inadequate competence. This knowledge, despite being technical in nature, may help orient program mangers and providers to the service gaps which can be improved. The findings gained from analyzing women's satisfaction with the care received may also suggest to program managers and services providers areas where women need further education.

One example is that of the follow-up schedule. Almost 80% of the women were satisfied with the return visit schedule made by the midwife. However, had they known the relevance of timing and the advantages of the timed follow-up visit, their satisfaction level may have improved. Also, their dissatisfaction could be related to the observation made that when the midwife asked the women to come back within a month, she did not make any effort to check whether the date or the timing was convenient to them. She also did not explain to the women the exact scheduled date and the reason for their return visit.

Women's participation in the assessment of the care they receive is expected to contribute to the democratization of the health service delivery system (Bruce 1990; Leslie 1989). The call for improving women's health, increasing their empowerment, and fostering involvement in the development process that activated many international programs such as the Safe Motherhood Initiative can be initiated through involving women at the grass roots level by assessing the care that is delivered to them. This involvement can enhance their participation in prioritizing, planning, monitoring, and evaluating services in a way that meets their values, needs, and expectations. Anrudh (1989) suggested that women's assessment of the quality of family planning services could be used as a means of measuring family planning program performance. In this way, women will be incorporated into the health system, allowing them to improve their own health, reduce gender disparity, improve gender sensitization, and improve their status and self esteem.

Involving women in the assessment of care by incorporating representatives of the community they serve will make quality of care assessment more applicable to the sociocultural expectations of users than that of health providers, who are usually imported into the community (Leslie 1989). For the formal health system, it may be easier to modify the services to meet users' needs rather than trying to induce social change in an effort to increase the utilization of these services.

To summarize, the study results have clarified two major issues: women's awareness of the elements of the quality of care, and their ability to distinguish between satisfactory and unsatisfactory care. In addition, women's views of the quality of services provided were supported by qualitative measures and professional judgement on how the services meet the users' needs.

In conclusion, this study reveals the strong correlation between how women perceive quality of care and how it is observed by independent observers. Furthermore, the study calls for greater women participation in the evaluation and programming of reproductive health care services.

References

· Al-Qutob, R.; Mawajdeh, S. 1992/93. Assessment of the quality of prenatal care: The transmission of information to pregnant women in maternal and child health centres in Jordan. International Quarterly of Community Health Education, 13(1), 47-62.

· Anrudh, J. 1989. Fertility reduction and the quality of family planning services. Studies in Family Planning, 20(1), 1-16.

· Bang, R.; Bang, A.; Baitule, M.; Choudhary, Y.; Sarmukaddam, S.; Tale, O. 1989. High prevalence of gynecological diseases in rural Indian women. Lancet, 1, 85-88.

· Bruce J. 1990. Fundamental elements of the quality of care: A simple framework. Studies in Family Planning, 21(2), 61-91.

· Campbell, O.; Graham, W. 1990. Measuring maternal mortality and morbidity: Levels and trends. London: Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine.

· Donabedian, Avedis. 1980. Explorations in quality assessment and monitoring (vol. 1.)

· Leslie, J.; Gupta, G. 1989. Utilization of formal services for maternal nutrition and health care in the Third World. International Center for Research on Women, March.

· MacCormack, C. 1992. Planning and evaluating women's participation in primary health care. Social Science and Medicine, 33(6), 831-837.

· Wasserheit, J.; Harris, J.; Chakraborty, J.; Kay, B.; Mason, K. 1989. Reproductive tract infections in a family planning population in rural Bangladesh. Studies in Family Planning, 20(2), 69-80.

· WHO (World Health Organization). Measuring reproductive morbidity: Report of a technical working group. WHO, Geneva, Switzerland.

· WHO/FIGO (World Health Organization/FIGO). 1991. Women's perspectives and participation in reproductive health. Report of a pre-congress workshop organized by the Joint WHO/FIGO Task Force. Singapore, 11-12 September 1991.

· Zurayk, H.; Khattab, H.; Younis, N.; et al. A comparison of woman's reports and medical diagnosis of reproductive morbidity conditions in rural Egypt. Submitted to Studies in Family Planning.

Appendix: Elements and Indicators of Conceptual Framework for Quality of Prenatal Care

Woman–provider relationship UnderstandingDid the providers discuss with you anything that bothered you apart from physical ailments? Communication Did health providers listen to you when you tried to talk about you complaints or things that bothered you? Privacy* Did it bother you that there were people in the room other than the providers of care, including relatives? Technical management Comprehensiveness of exam Do you think that the physical examination was comprehensive? in other words "did they examine your eyes, chest, breasts, abdomen and legs?" Examined for leg edema Did they examine your legs to see if they are swollen? Iron supplements given Were you given multivitamins or iron tablets? Information exchange Breast feeding Did they discuss with you issues related to breast feeding and its advantages? Smoking Did health providers discuss with you hazards of smoking during pregnancy? Continuity Scheduling Did they schedule an appointment for you? Provider sincerity Did you feel that providers care if you come back? Management Working hours Do you think that the working hours are convenient? Waiting time* Was there a long queue? "Did you wait for a long time?" * Negative answers were rescored in the analysis.

Salah Mawajdeh is with the Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; Ra'eda Al-Qutob is with UNFPA/WHO, Amman, Jordan; and Firas Bin Raad is with UNICEF, Amman, Jordan.

Vesicovaginal Fistula (VVF): Only to a Woman Accursed

Kikelomo Bello

Introduction

This paper examines the various factors that contribute to the incidence of vesicovaginal fistula (VVF), a condition that arises from obstetric complications. The goal is to present the gender-based factors that lead to VVF, as well as a comparison of the client–provider relationship within two existing health systems, the modern/orthodox system and the traditional health system, in terms of accessibility, acceptability, and adaptability.

Causal Factors for Vesicovaginal Fistulae

VVF is a health condition caused by the interplay of numerous physical factors and the social, cultural, political, and economic situation of women. This interplay determines the status of women, their health, nutrition, fertility, behaviour, and susceptibility to VVF (WHO 1989).

Physical Causes

The physical factors that influence the incidence of VVF include obstructed labour, accidental surgical injury related to pregnancy, and crude attempts at induced abortion. Obstructed labour leads to VVF when prolonged and unrelieved pressure on the woman's pelvic wall causes a puncture in the bladder.

Surgical procedures that cause VVF are of two types. The first, which may be termed orthodox medical accidental injury, refers to injury caused to the bladder during obstetric operations performed within the formal/modern health care system, such as the hospital. Such procedures include caesarean sections and difficult forceps delivery.

A table prepared for a comparative report by Kelly (1979) presented the cause of fistulae in 161 patients in Africa, particularly Ethiopia, and in Britain. Some subjects became VVF patients as a result of operative delivery performed in orthodox hospitals. Table 1 shows a breakdown of the causes.

A study carried out by Mustafa and Rushwan (1971) in Khartoum in the late 1960s confirmed that the major cause of VVF is prolonged, obstructed labour which is often followed by instrument delivery (mainly forceps) and gynecological operations. Between 1966 and 1968, 91 (74.8%) of the women studied demonstrated VVF resulting from obstructed labour, 25 (20.5%) from instrument delivery, and 6 (4.7%) from gynecological operations.

The second form of surgical procedure that may lead to VVF is performed within the traditional health care system. These procedures are commonly employed during pregnancy and labour, and lead not only to VVF, but may also cause hemorrhages and sepsis. Examples include female circumcision, the Gishiri cut,1 and Angurya, a traditional practice in which tissue is removed from the vagina by traditional surgeons for the treatment of coital pain, infertility, obstructed labour, amenorrhea, dyspareunia, vulva rash, goitre, and generalized body aches and pains (Sambo 1990; Tahzib 1985; Harrison 1985).

In an unpublished paper, Darrah and Froude (1975) estimated that some 40% of the patients attending Zaria hospital (Nigeria) with VVF had received Gishiri cuts. This finding is substantiated by a study conducted by Tahzib (1983) involving 1443 VVF patients at the Ahmadu Bello University Teaching Hospital, Zaria, between January 1969 and December 1980. In a table titled "Aetiological factors leading to fistula," Tahzib showed that 1209 (83.8%) of VVF resulted from prolonged labour, 188 (13.0%) from Gishiri cuts, 14 (1.0%) from surgical trauma, 10 (0.7%) from infections, and 22 (1.5%) from "other" causes including congenital injuries, insertion of caustic materials into the vagina, and so on.

Sociocultural Factors Affecting the Prevalence of VVF

The World Health Organization (WHO) argues that poor socioeconomic development is the basic underlying factor responsible for maternal ill-health, including the prevalence of obstetric fistulae. It further argues that the standards of health in developing countries are low and that natural hazards such as malnutrition and infections remain largely unchecked. The situation worsens where health services are deficient or absent, particularly in isolated rural areas. Logistic problems compound the problem, including the failure of existing health systems to provide appropriate health care that is accessible, acceptable, and adaptable; the sole development of urban areas to the marginalization or total exclusion of rural areas; unequal distribution of government resources; and the lack of appropriate basic infrastructure such as roads, water, health centres, schools, and electricity (WHO 1989).

Marriage and Child Birth

The sociocultural factors that contribute to the prevalence of VVF in women focus on their status in society. For example, girls are given in marriage at very young ages in some cultures, often before or during the process of puberty, and childbearing is seen as an indicator of the attainment of "married woman" status. This helps to explain why VVF sufferers are often very young girls.

Study results on VVF vary geographically. In Africa, where the problem appears to be most prevalent, studies have shown that at least 70% of women with fistulae are aged 30 years and under. Tahzib's 1983 study, in fact, showed that 5.5% (80) of VVF sufferers were under 13 years of age (see also Murphy 1981; Mustafa and Rushwan 1971; Tahzib 1985; Harrison 1985). In some parts of the continent, therefore, children beget children. Another finding of these case studies is that women often develop VVF during their first pregnancy.

In Asia, the same trend holds true, except that a greater concentration of women with VVF fell within the 20 to 24 year age group (except in Bangladesh, where almost half were under 20 (Begum 1989)). This suggests that the age of marriage in Asia is generally higher than it is in Africa (WHO 1991).

The case is different in Latin America, in that VVF has only been reported in Ecuador. A study by Calle (1989) indicated that 75% of the women with fistulae were primiparous, but the numbers were reported to be so small as to make the findings inconclusive.

It is possible that there are more women and children with VVF than appear in the data. This possibility is supported by a 1991 WHO statement that data used in most analyses, except those of Murphy (1981), were obtained from hospital records (WHO 1991). It can be argued that these hospital records show only the incidence of VVF which were actually treated in hospitals.

Malnutrition

In areas where malnutrition is an indicator of a community's nutritional status, women have been noted to be more acutely malnourished than men due to differential feeding practices for boys and girls from birth. This reflects a fundamental undervaluing of girls and women which leads to discrimination and their neglect. The effects of malnutrition contribute greatly to the underdevelopment of women's physiology, and eventually to some of the physical problems addressed earlier (Royston and Armstrong 1989). Evidence to support this is found in Murphy and Baba Tukur's 1981 study.

Education

With respect to education, Murphy and Baba Tukur's study also demonstrated that only boys attend school in Zaria (this research coincided with Universal Primary Education in Nigeria). Girls were seen hawking foodstuffs and other goods prepared by the women, who were confined to their compounds. Adult education for women was not fully accepted. In three villages, home economics was the only course offered to girls, while in six villages, adult literacy classes were for men only.

In many instances, a lack of health education hinders VVF prevention. Most rural dwellers see obstetric complications either as a result of the pregnant woman's sin, the anger of the gods, a curse, evil spirits, or heredity. For example, studies conducted across West Africa by the Prevention of Maternal Mortality Network (1992) demonstrated that certain behaviour, including infidelity and disregarding the authority of one's husband or elders, is believed to lead to obstructed labour and hemorrhage.

According to the study, women in Accra (Ghana), Benin, Calabar (Nigeria), and Freetown (Sierra Leone) reported that when complications arose, oracles were consulted. If the oracle confirmed insubordination, the pregnant woman was forced to apologize and to preform cleansing rites before she was taken for treatment. Similarly, in Bo, Sierra Leone, complications determined to have arisen from infidelity led to forced confessions of sin and the husband spitting water on the woman's abdomen to appease the gods. Only then was further help sought in hospitals, and only if the complication was thought to be serious enough (The Prevention of Maternal Mortality Network 1992).

Illiteracy is also a factor which determines what kind of medical help is sought (Mustafa and Rushwan 1971; Murphy 1981; Harrison 1983). Illiteracy deters people from attending hospitals, particularly when they are made to feel stupid and when hospital staff come from an alien culture with differing traditions, customs, and language (Murphy 1981; Murphy and Baba Tukur 1981; Prevention of Maternal Mortality Network 1992).

According to Edström (1992) and Royston and Armstrong, (1989) education gives young women better access to profitable employment alternatives. It also reduces the incidence of high-risk pregnancies, unwanted pregnancies, and abortions by increasing contraceptive use and reducing fertility. As girls stay in school longer, the average age at marriage tends to rise, as does the average age at first birth, especially when family planning services are promoted, readily available, and accepted by the women (Royston and Armstrong 1989; Edström 1992).

Decision-making

Another social contributor to VVF is the lack of decision-making power available to women, even in decisions pertaining to their own health. This situation has been found to be particularly true for women in seclusion or "purdah" 2 (Prevention of Maternal Mortality Network 1992). The existence of this problem is a major determinant in the health seeking behaviour of women. For example, if labour becomes obstructed and all local methods fail, a woman may be taken to hospital only if consent is given by either her husband, the village chief, or sometimes her mother-in-law. Most times the decision comes too late. Depending on the distance to the nearest hospital, such women and/or their babies may not make it alive; if they do, permanent damage to the internal organs would have occurred (Harrison 1985). This situation is reported in Margaret Murphy's research in Zaria (1981), where it is characteristic for VVF patients to come from rural areas. In her study, part of which involved 100 fistula patients, 71% of the new patients at the clinic came from distances of at least 100 km. The greatest number of new patients came from distances of between 100–199 km from Zaria. Eleven new patients even came from as far away as 800 km to attend the clinic (Murphy 1981).

The timing of decisions to go to a hospital has been linked to knowledge of the possible complications and a mistrust of orthodox or modern health care services (WHO 1991). One such mistrust arises from the fact that most of the women are examined by male doctors (Ojanuga 1992).

Economic Factors Contributing to the Prevalence of VVF

The single most important economic factor contributing to the prevalence of VVF is poverty, especially poverty in rural areas. According to the WHO 1991 Report on Obstetric Fistulae, women with fistulae come almost exclusively from poor families and communities. In her 1981 Zaria study, Murphy indicated that her data pointed to the fact that fistula patients usually come from poor subsistence farming backgrounds (Murphy 1981; Murphy and Baba Tukur 1981).

Poverty also serves as a disincentive or deprives fistulae patients from using modern health facilities in two ways: personal costs incurred as a result of attending these facilities, and cuts in services and provisions at these facilities as a result of insufficient funding or budget cuts. Examples of the first type of cost include costs of transportation to the hospitals, costs of medication, hospital fees, costs of bandages and sutures, and costs associated with feeding both the patient and those who accompany her. Examples of the second type of costs include lack of sufficient hospital beds, inadequate numbers of staff, and a poorly equipped establishment (Ojanuga 1992; Prevention of Maternal Mortality Network 1992).

Health and Social Consequences of VVF

With some of the causes of VVF established, it is important to demonstrate their impact on women. Women with VVF suffer from urinary incontinence which, if not managed properly, causes them to smell of urine. This continuous urine leakage makes them vulnerable to urinary tract infection, vaginitis, and excoriation of the vulva (that is, injury to the surface of the skin or a mucous membrane caused by physical abrasion, such as scratching). Stricture of the vagina (vaginal stenosis), whereby the vagina narrows, secondary amenorrhea, possible future inability to carry a child even after obstetric repair of VVF, and a low child survival rate are also conditions related to VVF (WHO 1991).

The most traumatic aspects of VVF from the social point of view are the resulting incontinence, childlessness (which may lead to marital breakdown and eventually divorce), and social excommunication (Murphy 1981; Harrison 1983). Data from Murphy's study revealed that 14% of the new patients were divorced as a direct result of their illness, while 42% were still living in their husband's compound. When the condition persisted, the proportions changed (28% and 11%, respectively).

According to Murphy, no women in control groups A or B were divorced or living apart from their husbands. By contrast, only 11% of the long-term fistula patients were living with their husbands and 77% had been living apart for at least 2 years. Of the 22 cured patients interviewed during a subsequent confinement in the hospital, 16 were still married to the same husband as when they first developed fistulae. More childless women were divorced by their husbands as a result of their disorder, than were women with living children (36% and 14%, respectively). Childlessness, therefore, is obviously an important factor in marital breakdown, but so too is the fact that the illness is regarded as incurable (Murphy 1981).

It seems that excommunication would be the hardest consequence to bear psychologically for women with VVF. This is indicated by a lack of support not only from society but also from their own families. These women for example, are not welcome in society because they smell. They are not permitted to live in the same house as their families or husbands, neither are they allowed to handle food, cook, or pray. Murphy (1981) observed that women hospitalized for fistula repair enjoyed less support and interest from their husbands than other patient groups, and the amount of practical support provided by family members diminished with prolongation of the illness. Interviews with women with this condition also revealed that patients felt they were a social disgrace to their families and so deserved to be outcasts (Murphy 1981). These women had developed psychological self-labelling and self-esteem problems.

Treatment

Vaginal fistulae are repaired through orthodox surgical correction; a successful repair is gauged by whether the woman is continent of urine. The study by Mustafa and Rushwan (1979) revealed the types of surgical procedures used to repair VVF in 122 cases treated in the Khartoum Teaching Hospital between 1966 and 1968. These are presented in Table 3.

Repairs are generally successful, depending on the extent of damage and duration of condition before medical attention was sought. Kelly (1979) reports that 100 of 128 African women (78%) were cured at the first attempt. Of 33 British women, 31 (91%) were cured, while 2 (6%) faced continued stress incontinence.

Given the causal factors addressed above, the health of women in VVF endemic areas depends greatly on prevention, which itself is an indicator of social change. To be effective, social change must include an improvement in the status of women, as stated by the WHO's Maternal Health and Safe Motherhood Programme:

[o]bstetric fistula lies along a continuum of problems affecting women's reproductive health, starting with genital infections and finishing with maternal mortality. Because of its disabling nature and dire consequences - social, physical and psychological - it is the single most dramatic aftermath of neglected childbirth. As with all of these problems, its prevention must ultimately lie in a profound change in the status of women. This change must involve, among other things, recognition of women's value, starting with adequate nutrition in childhood and continuing with access to primary education as a very minimum. It must include the eradication of harmful traditional practices and raising the age of marriage, giving women other ways of achieving social status than early child bearing. These are long-term goals, not easy to achieve, but vitally important to women's health and lives (WHO 1991).

In Nigeria, the National Council of Women's Societies of Nigeria (NCWSN) launched an exemplary program in 1989, selecting the prevention and treatment of fistulae as one of their top priorities. One interesting feature of this program is the provision of physical, psychological, and social rehabilitation to women recovering from fistula repair to facilitate reintegration into their social group (Murphy 1989).

It is encouraging that women are now raising awareness of this issue, and are trying to make real changes. Given that VVF is solely a woman's problem, this issue will remain unresolved far into the future without the active participation of women.

Analysis of Issues Affecting Provider–Client Relationships

This section of the paper will analyze VVF provider–client relationships in the modern health sector using three indicators: accessibility, acceptability, and adaptability.

Accessibility (Distance, Time, and Cost)

The literature states that the geographic distance to the nearest hospital is an important factor in accessibility. With most hospitals established in urban areas, people in rural areas are marginalized in terms of health provisions, health infrastructures including local health centres, good roads, and experienced health personnel. This has been established as a disincentive to using modern health facilities.

The travel distance is also a direct variant of the time spent. Most rural dwellers, particularly pregnant women, consider it a waste of time to travel long distances to visit clinics for just a few hours. To most rural dwellers, particularly those who work on family farms, time management is very important. Time waste does not encourage women to go to hospitals (Leslie 1992). The costs of going to and receiving health care in hospitals or health centres is also too dear for women, including those with VVF.

With regards to accessibility, then, it can be concluded that modern health care is not accessible to most potential VVF patients.

Acceptability (Cultural Practices, Status of Women, Faith in Modern Health Care)

The issue of acceptability is an extremely important indicator when examining health service use by VVF patients. It determines in part what happens when there is an obstetric emergency, and how quickly VVF patients or their family members will respond.

The literature states that cultural practices pose the greatest danger to both potential VVF patients and to those with the condition. Within most VVF-endemic cultures, women are subordinate to men. Two results of this gender-determined hierarchy are that many women live in seclusion, and that cultural attitudes toward women with obstructed labour endangers their lives. Women must ask for permission to visit modern, orthodox medical centres, they need permission to leave the house (as is the case with women in purdah), they need permission to go ahead with measures that concern their own health. Women in these cultures lack decision-making power. These women's health needs appear on their husband's or family's list of opportunity cost, as all finances are controlled by the males.

This is a great reflection of the status of women in these cultures. It implies that husband and community decisions and needs supersede and override a woman's right to safe health. How else could one explain marrying a 12–13 year old girl? Women's bodies are possessions and are controlled without their permission. Women are not permitted to visit hospitals because their culture does not allow them to expose themselves to a male doctor. Thus, only their husbands and other women may see them naked, even when their lives are in danger.

None of the above arguments against acceptability of modern medical health care helps when women cannot trust the system that is supposed to take care of them. In studies carried out in some West African countries by the Prevention of Maternal Mortality Network (1992), focus groups demonstrated that community members were acutely aware of problems within the health care system, such as administrative and management problems (lack of supplies, attitude of staff, and waiting time), inadequate staff, hospital fees, and the fear of seeing a male doctor. A combination of these factors contributes to maternal deaths in developing countries.

A difference in medical cultures, whereby women encounter behaviour to which they are not accustomed, also contributes to a lack of acceptability. Women are sometimes verbally abused by nurses. The intolerance of medical cultures is clearly demonstrated when nurses and patients do not have an understanding and respect of each other. For example, in Ilorin, Nigeria the nomadic Fulani women reported that the health facility staff (who are largely Yoruba) insult them and tell them that they behave like the cows they herd. When interviewed, the staff complained that the Fulanis do not come to the hospital until they are in serious condition, and that they resist buying supplies (Prevention of Maternal Mortality Network 1992). These women are also faced with having to tip staff before they can actually see the appropriate medical personnel.

It appears, therefore, that modern health care is not acceptable to most potential VVF patients, nor those with the condition. Neither their status within their cultures, nor the way they are received in hospitals, encourages them to visit hospitals which are the only source of VVF repair.

Adaptability

In this section, we examine how the modern health sector is trying to incorporate VVF patients to make them more comfortable in the hospital environment. Apart from performing surgical operations, hospitals represent a hierarchical structure, both in terms of a health structure and in terms of a health personnel pyramid. It is similar to other bureaucratic institutions, with many rules and red tape procedures consuming a lot of time before anything is accomplished. It has rigid guidelines and is criticized as impersonal and sometimes inhuman. Most women coming for VVF repair are not used to this kind of structure and are not used to impersonal relationships.

In Nigeria, for example, the medical structure is such that the teaching hospitals stand at the pinnacle, followed by state hospitals, health centres in local government areas, and comprehensive health centres and dispensaries at the bottom. Similarly, in the medical personnel structure, doctors are seen as the most important, then other professionals such as pharmacists and biomedical researchers, followed by nurses and technical staff. At the very bottom may be the janitors and gatekeepers. Most of the doctors are of course men, who VVF patients refuse to see.

In terms of health participation, hospitals have not done much to encourage patient participation. Rather, they have indirectly continued to encourage discrimination against these women. This is sometimes due to a lack of funding or lack of interest. Prevention in the form of intensive health education for current and potential VVF patients and their family members should be a hospital initiative. Hospitals do not have efficient follow up systems to ensure that patients are reintegrated into their communities.

One of the critiques against modern health care systems is their focus on curative rather than preventive health care. Curative health does not eradicate the problem, it only soothes it. It is a "band aid" measure against the problem of poor health, especially in rural areas. With most of the hospitals located in urban areas, health coverage remains minimal in most countries, particularly those in the developing world. Preventive health care, on the other hand, encourages participation of the potential users of health care, as it involves intensive health education of women and men. It involves health care representatives discussing the problems of health in their communities with the people, and suggesting how they can participate in solving them.

The establishment of hospitals in the urban centres encourages discrimination across socioeconomic lines. It means that a person living in an urban area has a better chance of receiving hospital care and social amenities than those living in rural areas. This in turn suggests that data on the actual numbers of women with VVF are inaccurate.

Given this situation, it would appear that traditional health systems are more accessible and acceptable to VVF patients. Most of the patients who are eventually taken to hospitals have previously contacted either traditional healers or faith healers, who are found in their communities and who have a better understanding of their culture and cultural practices. These healers have won the respect of the community and vice versa. As a result, there is a better understanding in the client–health provider relationship.

Adaptability of the traditional health system is an indicator that is by itself not adequate. Most of the techniques administered by traditional healers to women with VVF further endanger the women's lives and leave them more susceptible to permanent disability or maternal death.

In most societies, cultural and spiritual aspects of pregnancy and childbirth have a strong influence on behaviour. It is important that [modern] health care providers are aware of these aspects so that they can organize services that are appropriate and acceptable to the people. Unfortunately, there are usually limited opportunities for [modern] health personnel to explore the sociocultural context of childbirth (Royston and Armstrong 1989).

Recognizing the limitations of both systems, WHO, United Nations Fund for Population Activities (UNFPA), and the United Nations Children's Fund (UNICEF) have over the past 15 to 20 years established a collaborative effort between national governments to deal with the training of traditional birth attendants (TBAs) so that they may be incorporated into the orthodox health care system (Royston and Armstrong 1989; WHO 1992). The term partnership may, however, be preferable to the word incorporated, because each system has a status of its own. The former makes it appear as if TBAs are a mere bonus to the existing formal system.

One of the most important arguments in favour of greater "collaboration" is that it serves as a means of bridging the gap between the medical cultures of the two systems. As a result of this collaboration of organizations and governments, TBAs have been, and continue to be, trained. This initiative has given rise to many positive results. It has ensured safer and faster delivery of health care to certain communities. It has increased the participation of women in the health of their families. It is cost effective in that it promotes health prevention and health education, thereby saving more lives by encouraging people not to wait too long to seek help. TBAs are trained to be accountable for the health of their communities, and as such are responsible for safer deliveries under cleaner conditions. They are also trained to recognize and refer obstetric complications within the community to the first referral level, the health centre, or to hospitals directly.

Trained TBAs could contribute much to the prevention of VVF in rural areas. This statement is based on deductions and assumptions from both personal analysis and the literature. Their services will be more accessible, acceptable, and adaptable as most trained TBAs are women from within the same community as the patients, with an understanding of the culture. This way women do not have to fear exposing themselves to men other than their husbands. As well, trained TBAs will be in a good position to educate their community against early marriages. They will be able to teach hygiene to pregnant women, and speak against unhealthy behaviour that endangers the lives of pregnant women and their children. In other words, trained TBAs will approach health care in the communities from a holistic approach.

Observations, Criticisms, and Suggestions

While researching this paper, it became evident that there has not been much literature on the sociocultural aspects of VVF. Rather, the majority of papers have focused on the medical aspects of the condition. To further compound the issue, most literature concerning VVF are full of medical terminology that require frequent consultations of the medical dictionary to be able to follow the flow of thought. I realize that the terms are medical, but they also have simple meanings. It would benefit a reader if there were appendices with the meaning of the terms. In addition, I did not come across any paper written on the role of TBAs or traditional midwives in the prevention of VVF.

I also observed that most literature on VVF approach the issue from a curative aspect. Most authors are doctors working within urban hospitals and who are more involved with repair of fistulae. Preventive measures were most times omitted.

Appendix 1: Definition of Medical Terms (Dorland's 1981)

Amenorrhea

Absence or abnormal stoppage of the menses

Dyspareunia

Difficult or painful coitus

Dysuria

Painful or difficult urination

Morphology

The science of the forms and structure of organisms

Necrosis

The sum of the morphological changes indicative of cell death and caused by the progressive degrative action of enzymes

Pathogenic

Giving origin to disease or to morbid symptoms

Primiparous

Bearing or having borne but one child

Sepsis

The presence in the blood or other tissue of pathogenic microorganisms or their toxins

References

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· Bhatia, S. 1981. Traditional childbirth practices: Implications for a rural MCH program. Studies in Family Planning, 12 (2), 66–75.

· Calle, A. 1992 unpublished. Fistula de origen obstétrico. Quito, Ecuador.

· Darrah, A; Froude, J. 1975 unpublished. Hausa medicine for western doctors. Departments of Sociology and Medicine, Ahmadu Bello University, Zaria.

· Dorland's illustrated medical dictionary. 1981. 26th edition W.B. Saunders Company, Philadelphia, PA, USA.

· Edström, J. 1992. Indicators for women's health in developing countries: What they reveal and conceal. Institute of Development Studies Bulletin, 23(1), 38–49.

· Harrison, K.A. 1983. Obstetric fistula: One social calamity too many. Commentary British Journal of Obstetrics and Gynaecology, 90, 385–386.

· Harrison, K.A. 1985. Child-bearing, health and social priorities: A survey of 22,774 consecutive hospital births in Zaria, Northern Nigeria. British Journal of Obstetrics and Gynaecology, 92 (supplement 5),1–117.

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· Kabeer, N; Raikes, A. 1992. Gender and health: An introduction. Institute of Development Studies Bulletin, 23(1), 1–3.

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· Leslie, J. 1992. Women's time and the use of health services. Institute of Development Studies Bulletin, 23(1), 4–7.

· Murphy, M. 1981. Social consequences of vesico-vaginal fistula in northern Nigeria. Journal of Biosocial Science, 13, 139–150.

· Murphy, M. 1989 unpublished. Medical Social Welfare Services Department, A.B.U. Teaching Hospital Zaria. Craftwork programme with patients suffering from vesico-vaginal fistulae. Zaria.

· Murphy, M; Baba, Tukur M. 1981. Rural dwellers and health care in northern Nigeria. Social Science and Medicine, 15A, 265–271.

· Mustafa, A.Z.; Rushwan, H.M.E. 1979. Acquired genito-urinary fistulae in the Sudan. Journal of Obstetrics and Gynaecology, 78, 1039–1043.

· Ojanuga, N.O. 1992. Education: the key to preventing vesicovaginal fistula in Nigeria. World Health Forum, 13, 54–56.

· Prevention of Maternal Mortality Network. 1992. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Studies in Family Planning, 23(5), 279–291.

· Royston, E.; Armstrong, S. (ed.). 1989. Preventing maternal deaths. WHO, Geneva, Switzerland.

· Sambo, A.E. 1990 unpublished. First national workshop on causes and prevention of vesico-vaginal fistula in Nigeria. Organized by the National Council of Women's Societies of Nigeria, Kano State Branch.

· Tahzib, F. 1983. Epidemiological determinants of vesico-vaginal fistulas. British Journal of Obstetrics and Gynaecology, 90, 387–391.

· Tahzib, F. 1985. Vesicovaginal fistula in Nigerian children. Lancet, 1291–1293.

· WHO (World Health Organization). 1989. The prevention and treatment of obstetric fistulae. Report of a Technical Working Group, Geneva, 17–21 April 1989. (WHO/FHE/89.5)

· 1991. Maternity mortality and morbidity: Obstetric fistula. Women's Global Network for Reproductive Rights. 37 (Oct.–Dec.) pp. 8–9.

· 1991. Obstetric fistula. Maternal Health and Safe Motherhood Programme (WHO/MCH/MSM/91.5).

· 1992. Traditional birth attendants: A joint WHO/UNFPA/UNICEF statement.

Kikelomo Bello is with the International Development Studies Department, Saint Mary's University, Halifax NS, Canada.

The Adverse Affects of Kala-Azar (Visceral Leishmaniasis) in Women

Jharna Bhattacharyya and A.K. Hati

Summary: West Bengal, India, is an area endemic to kala-azar (KA). Between 1980 and 1993, almost all of the 100 parasitologically confirmed cases of KA were admitted to Calcutta hospitals through the recommendations of the West Bengali government and nongovernment organization (NGO) health providers. Of the patients suffering from the disease, 45% were women; this figure is proportionately higher than that for other parasitic diseases such as malaria, for which the ratio of male to female patients was 68:32. The enormous burden this particular disease places on women may be due to the fact that it has largely become a household disease transmitted by sandflies (Phlebotomus argentipes). In the Hindu community, 41.2% of the females were affected, as were 60% of the women in the Muslim community.

Female sufferers were more undernourished than males. The percentage of females having body mass index (BMI) value below 16 was higher (57.7%) than that of males (40%). Lower values of BMI in females were evidenced in all age groups. Death rates resulting from KA were also higher among the female population than among males, at 17.7% and 5.5%, respectively.

Women's admission to the hospital was usually delayed, in spite of health providers' best efforts. Within the first 6 months after KA detection, 73% of the males had been admitted to the hospitals, compared to 62% of the females. The trend was reversed over the next 6 months (males 16%, females 24.4%). Hospital stays were also longer for the males than for the females. This trend created many difficulties during treatment, producing more nonresponsive cases among the females than among the males.

The reasons given for both delayed admission and the short hospital stay of the females included: the reluctance of the women to divulge their disease condition fully to family members or to health providers; their child-rearing duties; the lack of proper medical attention provided for women; and the importance placed on them remaining with the family to carry out essential household duties. The women also became easy victims of superstition and unscientific propaganda promoted by others for their own interests.

In the endemic area, more than one person was affected in each of seven families, for a total of 24 patients. Of these, 14 were males and 10 were females, with a 7% death rate among males and a 30% death rate among females. The incubation period seemed to vary from 14 days (minimum) to 6 months (maximum). It was interesting to note that six males and five females were simultaneously affected with malaria and KA; among the five female patients, one also suffered from hemoglobin E thalassemia.

Anemia was more common among the females than among the males. A high rate of reticulocytes among the females indicated more hemolysis; leucopenia was also more pronounced in females than in males, demonstrating that the resistance to the disease was lowered in females. A red cell morphology study revealed that anisocytosis, hypochromia, poikilocytosis, and spherocyte levels were higher in females than in males.

In so far as clinical signs and symptoms were concerned, no marked differences were noticed between the male and female patients, although anorexia, swelling of the face, weight loss, weakness, diarrhea, edema of the feet, and jaundice were found in greater numbers among the females than the males. Surprisingly, liver function tests showed practically no difference between females and males, although hypoproteinemia and hyperglobulinemia were found to be more pronounced in females than in males.

Haptoglobin status in males and females showed no difference, although in both male and female KA patients significant increases of ahaptoglobinemia (HP 0-0) were observed through polyachrylamide gel electrophoresis (PAGE). Treatment resulted in negative indications, demonstrating that functional haptoglobinemia was due to the hemolytic effect of KA.

Oxidative metabolism of red cells of KA patients showed a significant decrease in the erythrocytic reduced glutathion level and its stability. Glutathion reductase activities were much more pronounced in female than in male patients. In addition, a significant increase in the methemoglobin level was noticed in females, but not in males. Hence, it can be said that KA infection adversely effects the oxidative metabolism of red cells, particularly in females, and thereby increases the risk of anemia.

Introduction

Kala-azar (KA) occurs in certain endemic areas of West Bengal (9 of 17 districts), among socially and economically disadvantaged population groups. Women constitute about 50% of this population. This study was conducted to determine the differential impact of KA on female clients compared to male clients, and the nature of the health services they receive through various health providers.

This paper documents the status of 100 parasitologically positive KA patients who were admitted to the Carmichael Hospital for Tropical Diseases (Calcutta), the Medical College and Hospital (Calcutta), or the Nilratan Sirkar Medical College and Hospital (Calcutta). Each of the patients came from an endemic zone of the district of North 24-parganas, West Bengal state, India, and was admitted to the hospital between 1988 and 1993.

The sex, age, and religion of the patients were taken into account. The body mass index (BMI) of each patient was noted and analyzed according to sex and age. Responsive and nonresponsive cases among males and females who died or relapsed were also documented.

The respective times required for male and female KA patients to reach health providers and the length of their hospital stay were recorded. Certain hematological parameters, liver function tests (LFT), some aspects of oxidative metabolism of red cell, and haptoglobin and hemoglobin electrophoretic patterns were studied in these KA patients and analyzed according to sex. Occurrence of KA in more than one family member was analyzed. Prevalence of malaria among these KA patients was also recorded.

Results

Age and Sex Gradation

Of the 100 KA patients admitted to the hospitals, 55 were males (age varying from 5–60 years) and 45 were females (age varying from 8–50 years). Age gradation of the KA patients is shown in Table 1.

Historically, it has been understood that females are usually less affected by the insect-borne diseases than are males, as females are usually covered (and therefore protected) by more clothing than are males. This study, however, demonstrates that 45% of infected persons admitted to health care facilities were females, which indicates that the burden of this disease on women is enormous. The greater degree of transmission to women may be due to the fact that KA is transmitted at the household level by sandflies (Phlebotomus argentipes). In an early field study, 38.5% of the women suffered from the disease (77 out of 200) (Hati et al. 1985). Those aged up to 30 years bore the brunt of the disease, thereby hampering community development. It is important to mention that in this present study, 30% of cases occurred in the above 30 age groups (27% among the males and 33% among the females).

BMI Status of KA Patients

This study was undertaken to assess the degree of individual undernutrition among the 100 KA patients in relation to age, sex, duration of illness, drug responsiveness, and mortality, using body mass index (BMI) as the parameter. Agewise body mass index (BMI) of males and females is shown in Table 2.

The differences between the mean and range of BMI in males and females are obvious. It is quite evident that females in all age groups were much more malnourished than were the males. As age increased, a higher value of BMI was obtained. In all age groups, females had lower BMI values than males. This reflects the socioeconomic condition of the community, where the position of the female is always inferior to that of the male, and where females receive less food and/or food of a poorer quality than do the men.

The mean BMI values and the ranges of 100 KA patients in different clinical groups are shown in Table 3. A BMI value under 16 was taken as a marker for severe undernutrition (Edwards and Bouchie 1991). Patients in the age group below 15 years had lower BMI values than those above 15 years of age, both for males and females, although females always demonstrated lower BMI values than did males. The difference in BMI values between the two groups (below 15 and above 15 years) was statistically significant both for males and females.

Comparison between groups demonstrated the following:

C vs KA S(P < 0.05)

C vs KA < 15 years S(P < 0.05)

C vs NR S(P < 0.05)

KA < 15 years vs > 15 years S(P < 0.05)

KA R vs NR S(P < 0.05).

Male and female patients then were classified according to BMI unit. Five males and three females fell under the BMI unit 5.0–10.9. When the BMI unit was raised to 11.0–15.3, the number of corresponding males and females was 22 and 26, respectively. Between BMI units 16 and 19.3, there were 26 males and 16 females. Two males had BMI values between 20–21.3; no females were represented in this category. From this, it can be seen that undernutrition is generally more prevalent in females than in males. However, the degree of undernutrition demonstrated no significant relation to the duration of disease before treatment in either males or females.

BMI and Responsive and Nonresponsive Cases of KA

Of the 37 nonresponsive cases, 19 were female and 18 were male. Thus, 41.6% of the total female group, and 32.7% of the total male group, did not respond to drug treatment. The relationship between BMI and responsive and nonresponsive cases of KA is shown in Table 3. The mean BMI of nonresponsive cases was much lower than that of responsive cases; the difference in the two mean BMI values was statistically significant for both males and females.

In the majority of the nonresponsive female KA patients, BMI values were less than 16, indicating that these women were severely undernourished. This might have resulted from their immunocompromised state (as a result of KA infection), which in turn favoured more frequent intercurrent infections. However, it is also possible, as the BMI values in the control group might suggest, that the subjects were already undernourished and hence immuno-compromised, and subsequently became drug nonresponsive after developing KA.

BMI and Mortality in KA Patients

The incidence of death among KA patients is shown in Table 3. Eight females (17.7%) and three males (5.5%) were in this group. BMI values of the eight females who died as a result of KA had a mean of 10.2, and a range of 8.2–12.6. The corresponding values for the three males were a mean of 11.3, and a range of 10.0–12.6. It could be postulated that the lower BMI values among the females contributed to their increased number of deaths.

However, the most important finding was that the female drug nonresponsive cases were more severely undernourished than were the males. This, again, may have been due to their immunocompromised state, which favoured more frequent intercurrent infections. This supposition is supported by Chandra (1973), who stated that undernourished, and hence immunocompromised, subjects could be predisposed to develop drug nonresponsive VL (visceral leishmaniasis).

Although the mechanism of drug nonresponsiveness in VL is complex, it appears worthwhile to see the effect of improving the nutritional status from the very beginning of treatment by dietary protein supplements or by other means (i.e., plasma or blood transfusion) on the drug-responsiveness, which may possibly be achieved at least in some patients from improvement of immunocompetence (Chandra 1973).

Time Taken for KA Patients to Reach Health Providers

The details about the time taken for KA patients to reach health providers are shown in Table 4. Delay in admission was more pronounced for female patients than it was for male patients. As a result of this unnecessary, unusual delay, deaths among female patients were exaggerated.

Adequate and proper treatment with the exact doses of sodium antimony gluconate (SAG) is of prime importance. This is often ignored, more so in the treatment of females, creating a high number of nonresponsiveness towards SAG.

Clinical Features of the KA Patients

Routine clinical examinations were performed with standard techniques. Diagnosis of KA was confirmed by the presence of LD bodies in either the bone-marrow or splenic aspirates of the patients. Clinical features of the KA patients are shown in Table 5.

Complications and Associations

Associated infections in this series of KA patients included bacterial pneumonia in four males and seven females, and enteric fever in one male. One female patient developed colour-blindness, while another suffered from menorrhagia and weakness in all limbs. The latter patient developed bilateral foot drop G.B. Syndrome. One male patient was also a diabetic.

Association of Malaria and KA

Six males were affected with malaria (Plasmodium vivax) at the same time as KA (Leishmania donovani). Among them, one was nonresponsive to sodium antimony gluconate (SAG) and pentamidine, and two were only SAG nonresponsive. There were also five females affected with malaria during their KA infection; among these patients, one was SAG nonresponsive and another was a Hb-E thalassemia patient infected with both Plasmodium vivax and Leishmania donovani simultaneously.

Motivation

Motivation is one of the essential factors for the admission and proper treatment of women in the hospital. When women are suffering from a prolonged fever which is not amenable to antimalarial or other treatment, they usually go to village healers and/or follow traditional healing methods. Superstition is rampant; worship to a village god may be offered. Sometimes "holy water" is thrown on the patient, or a small plate may be placed on her back while the village healer chants a hymn. Potentially harmful healing practices, such as touching a red hot iron or placing an irritating plant on the left side of the abdomen (over the enlarged spleen), are often practised. Going to the village healers and priests is now almost exclusively practiced by females. Males usually go to the primary health centres or hospitals for modern treatment, particularly when they are informed about the healing power of modern medicine or when they observe their friends and relatives being cured by the treatment.

Many factors prevent women from coming to the hospitals in proper time to receive modern treatment.

· They usually do not want their family members to know about their illness.

· Their health is not given the same attention by the family as is the health of male family members.

· The woman is responsible for providing care for the family, so it is very difficult for her to find time to go to the hospital or PHC.

· Women tend to follow more closely local superstitions and believe in the power of village healers or priests.

· Women often ignore their own health, which results from the inferiority complex which they suffer from an early age.

· Financial difficulty is more evident among women than among male family members.

· Women appear to be more attracted to unscientific propaganda, especially when made by competent medical persons who may have personal and/or vested interests. They sometimes believe that one drop of blood taken from a finger will be enough for conclusive diagnosis (bone-marrow/splenic smear examinations in the field or in the hospitals and splenic smear examinations in the hospital are often not liked and resisted by the patients).

Faced with these difficulties, health personnel from both the government and NGOs continued their sustained effort to locate new cases of KA emerging in the area. Attempts were made to admit all patients in the hospitals for better treatment facilities. Even then, late admission among the female patient group was noted. The female patients also did not want to stay in the hospital to receive full treatment; their average hospital stay (20.8 days) was shorter than that of the males (30 days).

Infection of More than One Person in a Family

Seven families in the endemic zone presented more than one KA patient. In two families, two persons were attacked with KA; in two other families three persons suffered from KA; in one family five persons had KA; and in one family seven persons suffered from KA (Table 6). The total number of males affected was 14, and the total number of females was 10. Among them, one male and three females died of KA.

The second patient in family no. 7 (Table 6) was in good health before she came to the house of her younger sister on 7.1.90. She began to suffer from fever on 25.1.90. Hence, in her case the maximum incubation period seemed to be 14 days.

The female patient in family no. 1 (Table 6) suffered in her home for 2 years before she was admitted to the hospital. Twenty-three days after admission, she died. This was a prime example of the impact of negligence and delayed admission.

In family no. 6 (Table 6), a gap of six months was noticed between the onset of disease symptoms among the first three patients; this suggests that the maximum incubation period might be 6 months. Therefore, attempts to estimate incubation periods within a family affected with KA have been made, and were placed between 14 days and 6 months.

Hematological Studies

Hematological parameters of the 100 KA patients were studied with standard techniques (Dacie and Lewis 1975). They showed that anemia was more severe among females than it was among males (Hb in females: mean 7.1 g%, range 3.5–9.9 g% and in males mean 8.8 g% range 6.0–11.5 g%). Packed cell volume (PCV) was also lower among women (mean 24.3%, range 14.0–32.0%) than among men (mean 27.3%, range 16.0–37%). The reticulocyte count was higher in females (mean 4.54%, range 2.5–10%) than in males (mean 3.62%, range 3.0–9.4%). This indicated more hemolysis in females than in males, thereby creating more anemia in females. Leucopenia was also more pronounced in females than in males, showing that females enjoyed less resistance to the disease than did the males.

Electrophoretic Study of Hb of all KA Patients

To determine abnormality in hemoglobin (Hb) type, if any, associated with KA, hemoglobin electrophoresis study was performed with the standard techniques (Dacie and Lewis 1975) using filter paper strips. All cases except one showed normal band for Hb electrophoresis, indicating no abnormality in Hb type in these cases.

One female aged 14 years who suffered from KA and was infected with Plasmodium vivax showed two bands on Hb electrophoresis, one at E region and other at F region, and was diagnosed as Hb-E thalassemia. Her RBC morphology showed hypochromia, anisocytosis, and poikilocytosis. Her reticulocyte count was also high. Hepatosplenomegaly was present, and the fetal hemoglobin (HbF) level was high (15%) during infection.

The association between KA, malaria, and Hb-E thalassemia is a new finding, and is therefore reported here. This provides another example that females are more susceptible to infection than are males.

Haptoglobin Studies in KA Patients

The haptoglobin status of 100 patients admitted to the hospitals was studied through the polyacrylamide gel electrophoresis (PAGE) method as described by Clarke (1964) and Smithies (1959), with a slight modification.

Significant increase of ahaptoglobinemia (HP 0-0) was encountered in KA patients, when screened before treatment. Most of the patients had also been screened for HP after treatment, and the incidence of HP 0-0 was found to be negative. It is suggested that the functional ahaptoglobinemia (HP 0-0) was due to the hemolytic effect of KA. The phenomenon was found to be the same in both males and females.

Studies on Oxidative Metabolism of Red Cells of KA Patients

As hemolytic anemia is one of the hallmarks of KA, the status of some enzymes and other factors involved in maintaining the integrity of red cells under stress was studied. The parameters studied were as follows:

· methemoglobin (Met Hb) level by the method of Evelyn B Malloy (1938);

· level of the erythrocytic reduced glutathione (GSH), by the method of Beutler et al. (1963), and GSH stability by the method of Beutler (1957) on the basis of incubation of erythrocytes with Acetyl Phenyl Hydrazine (APH);

· activity of the erythrocytic enzyme Glucose-G-Phosphate Dehydroglucose (G-6-PD) by screening test (method of Bernstein 1962) as well as by quantitative assay according to the method of Kornberg and Horekar (1955) as modified by Marks (1958), using Tris-HCl buffer at pH 8.0; and

· activity of erythrocytic enzymes Glutathione Reductase (GR) and Glutathione Peroxidase (GSH-Px) by the methods of Racker (1955) and Gross et al. (1967), respectively.

Results of Oxidative Metabolism of Red Cells

Results were analyzed by sex for all 100 KA patients (Table 7).

Level of GSH

Compared to the corresponding controls, the level of erythrocytic GSH in KA patients (both male and female) was reduced by a statistically significant amount (P < 0.05). The level of GSH was below 30 mg/100 mL RBC in six females and three males. Values of GSH in females was much lower than in males.

GSH Stability

In normal subjects, the unstable pattern of GSH after incubation with APH (i.e., value below 30 mg/100 mL RBC) was not found. In KA patients, however, the GSH level dropped below 30 mg/100 mL RBC in 18 female cases (of 45) and in 13 male cases (of 55), showing instability of GSH in those cases. Here also GSH instability was more pronounced in females than in males (Table 7).

G-6-PD Activity

G-6-PD activity was slightly lower among both male and female KA patients than it was among the controls; the mean values were not statistically significant (P > 0.05) (Table 7). This suggests that there is no significant change in G-6-PD activity during KA infection.

Activity of GR

There was a marked depression in the activity of GR in KA patients as compared to controls. In two cases, enzymic activity was less than 2 units/100 mL RBC/min (females) (Table 7). A significant decrease in GR activity, particularly among females, therefore occurs during KA infection.

Met Hb Level

Comparison of data from normal and KA patients showed that there was a marked increase in the level of met Hb in female KA patients.

Activity of GSH-Px

No significant difference in the activity of GSH-Px during KA infection was detected (Table 7).

Conclusion

From the results of this study, it appears that during KA infection, the following significant changes take place in the host red cell.

· There is a significant decrease in erythrocytic GSH level and stability, particularly among female patients.

· There is a significant decrease in the activity of the enzyme GR, which is also more pronounced in females.

· Activity of erythrocytic G-6-PD and GSH-Px is not affected adversely in either males or females.

· Met Hb levels increase significantly in both males and females, but more so in females. Therefore, it can be said that KA infection affects the oxidative metabolism of red cell more adversely in females.

It can be safely stated that Leishmania donovani infection somehow exerts an inhibitory effect on red cell enzyme GR activity, which ultimately affects the GSH level and its stability. This results in disturbances of red cell integrity with subsequent predisposition to hemolysis. This may be one of the causes of severe anemia in KA, particularly among females.

Liver Function Tests (LFT) in KA Patients

Liver function tests were studied in 100 KA patients. The results are shown in Table 8. This table shows practically no difference between female and male patients, although hypoproteinemia and hyperglobulinemia were found to be more pronounced in females.

The Role of Health Providers

Health providers (both government and nongovernment) play a very vital role in West Bengal, searching for KA patients and admitting them to hospitals. Yet they must be motivated more thoroughly to avoid the biases of gender, so that female patients will also be admitted quickly to the hospital, receive early treatment like their male counterparts, and be cured.

References

· Beutler, E. 1957. The glutathione instability of drug sensitive red cells. A new method for the in vitro detection of drug sensitivity. J. Lab. Clin. Med., 49, 84–95.

· Bernstein, R.E. 1962. A rapid screening dye-test for the detection of glucose- 6-phosphate dehydrogenase deficiency in red cells. Nature, 194, 192–193.

· Beutler, E.; Duron, E.; Kelly, B.M. 1963. Improved method for the determination of blood glutathione. J. Lab. Clin. Med., 61, 882–888.

· Clarke, J.T. 1964. Simplified disc. polyacrylamide gel electrophoresis. Ann. N.Y. Acad. Sci., 121, 428–436.

· Chandra, R.K. 1973. Nutrition immunity and infection. New York. Plenum Press.

· Dacie, J.V.; Lewis, S.M. 1975. Practical hematology (5th ed.). J.A. Churchill, London, UK

· Evelyn, K.A.; Malloy, H.T. 1938. Microdetermination of oxyhemoglobin, methaemoglobin and sulfhaemoglobln in a single sample of blood. J. Biol. Chem., 126, 655–662.

· Edwards, C.R.W.; Bouchier, I.A.D. (ed.). 1991. Davidson's Principles and practice of medicine, 16th ed. (ELBS). Churchill, Livingstone, London, UK.

· Gross, R.T.; Brucei, R.; Rudolph, N.; Schroder, E.; Kochen, J.A. 1967. Hydrogenperoxide toxicity and detoxification in the erythrocytes of new born infants. Blood, 29, 481–493.

· Hati, A.K.; Nandy, A.; Choudhury, A.B. 1985. An epidemic outbreak of kala-azar in a District in West Bengal, India. WHO/VBC/85 22, 1–9.

· Kornberg, A.; Horekar, B.L. 1985. Glucose-6-phosphatedehydrogenase. In Colowick, S.P.; Kaplan, N.O. (ed.). Methods in enzymology (vol 1). Academic Press, New York, NY, USA. Pp. 323–326.

· Marks, P.A. 1958. Red cell glucose-6-phosphate dehydrogenase and 6-phosphogluconicdehydrogenase and nucleotidephosphorylase. Science, 127, 1338–1339.

· Racker, E. 1955. Glutathionereductase (liver and yeast). In Colowick, S.P.; Kaplan, N.O. (ed.). Methods in enzymology (vol 2). Academic Press, New York, NY, USA. Pp. 722–725.

· Simithies, O. 1959. Zone electrophoresis in starch gel and its application to serum protein. In Antinex, C.B.; Anson, M.C.; Baily, K.; Edsall, J.T. (ed.). Advance protein chemistry (vol. 14). Academic Press, New York, NY, USA. P. 65.

· Snedecor, G.W.; Cochrane, W.G. 1967. Statistical methods (6th ed.). Oxford and IBM Publishing Co. P. 258.

The authors of this paper are with the Calcutta School of Tropical Medicine, Calcutta, India.

Genero, Cliente Femenino y los Proveedores del Servicios de Planificación Familiar en Quito

Nelly Idrobo B. y Amparo Lopez

Summary: This paper is based on a study of 162 urban residents of Quito, Ecuador (97 men and 65 women), and focuses on gender differences in the use of family planning and determining factors, the role of the couple in decision-making, and gender inequalities in the attitudes of family planning providers to their clients. The study found that males dominated in decision-making regarding reproduction and the number of children that the couple had, while females were responsible for meeting these goals through appropriate reproductive behaviour, including family planning. Men were especially dominant in cases where women's activities were confined to the domestic environment.

The attitudes of health providers reinforced gender roles, by perceiving the female to be primarily responsible for family planning. They gave information on contraception to the woman after she had given birth, rather than to the man or to the couple in more neutral situations. Women in the study were satisfied with the health services they received and did not question the gender bias expressed therein. Moreover, women did not question their responsibility for family planning and the provision of care to their children.

The study concludes that gender bias remains strong in Quito, not only among women and men, but also in the health services which evidently do not consider men as jointly sharing responsibility for the welfare of the family. The researchers recommend that health care personnel should be taught not only about sex-related differences in reproductive health, but also about inequal gender roles. These inequal roles not only burden women with the responsibility of bearing children, but also fail to empower them to make reproductive choices. The researchers suggest that "male" contraceptive methods, such as the condom and vasectomy, in addition to "female" methods, should be promoted in family planning clinics, and that gender-sensitive services should be extended to rural areas where the problems of gender discrimination are even more pronounced.

Antecedentes

Numerosos estudios realizados en Latinoamérica, nos muestran que existe un alto porcentaje de mujeres que son asiduas clientes de los servicios de planificación familiar puesto que ellas son las que mayormente se ven afectadas al no desear más hijos que los que tienen, espaciamientos inadecuados entre sus embarazos, abortos a repetición y en otros indecisión que a lo largo van mermando la salud de la mujer (Viel y Pereda 1991; Kizer et al. 1989; Martinez et al. 1992; Population reports 1987).

Las necesidades de practicar la anticoncepción son altas, sin embargo, existen limitaciones en la práctica y en el uso de los servicios de planificación familiar, dadas no sólo por la diferenciación biológica, sino también expresada por relaciones estereotipadas dentro de la necesidad insatisfecha de utilizar medios anticonceptivos eficaces, consejos que orienten la fecundidad compartida entre hombre y mujer, actitudes que deben ser apoyadas por los servicios de salud (Banco Mundial 1993).

Si se satisfaciera el deseo de las mujeres o su pareja de espaciar los embarazos, se calcula a nivel de las Américas se evitaría cada año hasta 100.000 muertes maternas y 850.000 muertes de niños menores de cinco años (Prada 1992). Desde siempre, el perfil de comportamiento sexual, ha puesto en evidencia el dominio del hombre en la unión sexual, estereotipo que establece la responsabilidad de la regulación de la fecun didad recaiga exclusivamente en la mujer (De los Rios y Gómez 1991; Boletín IPPF 1992).

En el último quinquenio, en el Ecuador, la tasa de fecundidad ha descendido de 6 a 3.8 hijos promedio por mujer en edad fértil, asociado a factores relacionados con la incorporación de la mujer al mercado de trabajo y a la prevalencia del aborto provocado frente a la situación socio económica deficitaria que viven la mayoría de las familias en el país (CEPAR 1989; Rios 1993).

Consecuencia de lo anterior, la demanda de servicios de planificación familiar, han ido creciendo pero integrados al programa materno-infantil, dando por sentado que la mujer está más motivada que el hombre para practicar la planificación familiar, (rol histórico que desempeña la mujer dentro de la reproducción) y que la mayor parte de veces es el hombre quien toma la decisión (Gonzalez et al. 1991; Freeman 1991; CEPAR 1989; CEIMME 1993; CEPAM 1993; OPS 1990).

Este estudio se realizó en la ciudad de Quito capital de la República del Ecuador, que cuenta con 1'200.000 habitantes, (según proyección Censo 1990 INEC), a 2850 metros sobre el nivel del mar, la población en su mayoría es mestiza, la tasa global de fecundidad en el área urbana fue de 3.8 nacimientos por mujer en edad fertil (última encuesta de fecundidad 1989), la tasa de mujeres en edad fértil que utilizan un método cualquiera de planificación familiar fue del 42%, la población casada con necesidades insatisfechas de planificar fue del 24%, (mujeres casadas que desean limitar los nacimientos, o espaciarlos, pero no practican la planificación familiar), el 34% restante no se conoce las tendencias de accesibilidad (demanda potencial).

Los objetivos del estudio fueron:

· Caracterizar las diferencias de género en el uso de la p. familiar, sobre todo de la mujer, en relación a factores demográficos y culturales.

· Identificar las diferencias de género según factores socio-sicológicos, traducidos por: experiencias, percepciones, expectativas y creencias en la práctica de la anticoncepción y uso de los servicios de p.familiar.

· Identificar el rol de la pareja en la p.familiar, a través de la jerarquía en el hogar, responsabilidad y toma de decisiones en el tamaño de la familia.

· Conocer la desigualdad de género según criterios y actitudes de los proveedores del servicio de planificación familiar.

Hipotesis

La mujer con ocupación no productiva, es mayormente influenciada por el hombre para concurrir al centro de p.familiar, frente a la mujer con ocupación productiva. El sexo del proveedor es decisivo en la asistencia a la p.familiar más que la calidad de la atención.

Materiales y Metodos

Para el análisis de la demanda, se tomó una muestra represen tativa de 162 habitantes de la ciudad de Quito de 15 a 60 años, de los cuales 65 fueron mujeres ( 15 a 45 años ) y 97 hombres (15 a 60 años), según Censo de población de 1990. La diferencia numérica entre mujeres y hombres se debe a la edad de la función reproductiva, frente a la misma función en el hombre y a la prevalencia del uso de anticonceptivos que fue mayor en la mujer que en el hombre, encuesta de fecundidad (CEPAR 1989).

Para el análisis de la oferta de servicios, se tomó una muestra selectiva de 10 establecimientos del sector salud en la Ciudad de Quito, con atención de p.familiar, fueron entrevistados 50 proveedores vinculados directamente con este servicio. Se aplicó un cuestionario que contenía las variables.

Para el análisis se calculó medidas de tendencia central y diferencia entre los datos X2 considerando significativo P < 0.05, para prueba de hipótesis.

Resultados

La media de edad en las mujeres fue de 28 ± 8.3 años; para los hombres, la media fue 29.5 ± 10.8 años. La mayoría 46.9% (n = 76) tuvieron instrucción media, el 27.7% (n = 44) instrucción baja y el restante 25.9% (n = 42) alta o superior.

Existió predominio de raza mestiza con el 94.4% (n = 153). El 50% (n = 81) fueron nativos, el 87.0% (n = 141) de religión católica, la mayoría 84.6% (n = 137) fueron de estrato socio-económico bajo, apenas el 15.4% (n = 25) estrato medio. El 66% (n = 107) fueron casados. El 74% (n = 120) ocupación productiva, frente al 26% (n = 42) no productivos.

El mayor porcentaje, 81.5% (n = 132) de entrevistados, tuvieron su primera relación sexual a la edad de 12 a 19 años, de los cuales el 66.7% (n = 88) hombres,el 33.3% (n = 44) mujeres, el 18.5% (n = 30) restante entre los 20 y más años, de ellos el mayor porcentaje 70% (n = 21) fueron mujeres.

El 85% (n = 138) desearon o desean formar una familia reducida con 2 a 3 hijos como número ideal. El espaciamiento entre los hijos (período intergenésico), en su mayoría fue mayor a los dos años 51.2% (n = 42). El 74.4% (n = 90) fueron hijos deseados. Se cuidaban para no tener hijos el 52.5% (n = 85), de ellos el mayoria lo hacía la mujer con el 52.9% (n = 45), el 31.7% (n = 27) el hombre y el 15.4% (n = 13) la pareja.

Las 85 personas que se cuidaban, utilizaban en mayor porcentaje 77.6% métodos modernos (DIU, píldoras, condónes, esterilización femenina, no hubieron casos de vasectomizados), el 22.3% métodos tradicionales (ritmo, coito interrumpido, calendario).

La fuente de información por la cual conocieron los diferentes métodos fue diferente para los dos sexos asi: apenas el 17.9% (n = 7) de los hombres se informaron por personal de salud, en cambio las mujeres, el 58.6% (n = 27) por personal de salud.

En el Cuadro 1, se identificó el rol de la pareja en la anticoncepción, considerando las jerarquías en el hogar como jefes de familia: el 53.3% (n = 64) el hombre (padre) era el jefe del hogar (patriarcado), el 36.7% (n = 44) la mujer (madre) era la jefa del hogar; respecto a la responsabilidad en el tamaño de la familia, el 64.6% (n = 82) lo asumió el hombre, el 35.4% (n = 45) la mujer.

Por otra parte a pesar del patriarcado en el hogar y mayor responsabilidad masculina en el número de hijos la decisión de concurrir a la planificación familiar, aparentemente fue compartida en el 48.2% (n = 41), el 38.8% (n = 33), asumió la mujer y el 13% (n = 11) el hombre, diferencia significativa según nivel de instrucción y ocupación, P < 0.05.

Se detectó la necesidad de planificar la familia, encontrando en los 162 entrevistados que tanto hombres como mujeres el 61.7% (n = 100) conocían que debían planificar al iniciar la vida sexual activa, sin embargo, en la práctica la mujer planificó después de tener 1 o más hijos, muchos de ellos no fueron deseados.

Por otro lado, apenas 85 personas entrevistadas del grupo total, se cuidaron para no tener hijos, de los cuales apenas el 40.0% (n = 34) concurrieron a los centros de planificación familiar, siendo la mujer la que más concurre, P < 0.05.

El 65.2% (n = 30) mujeres, fueron clientes de los centros de planificación familiar, diferencia que fue más notoría al analizar por ocupación siendo las mujeres no productivas las que más concurrieron.

También se encontró diferencia significativa según estado civil, siendo las mujeres casadas las que más concurrieron, P < 0.05.

En adelante nos referiremos a las 34 personas que concurrieron a los centros de planificación familiar (4 hombres y 30 mujeres), analizando las características socio-sicológicas traducidas por experiencias, actitudes, creencias y percepciones desarrolladas en el uso de estos servicios.

En el cuadro 2, tuvieron una imagen positiva del servicio por el buen trato recibido, la oportunidad de la atención (tiempo de espera corto), la efectividad (métodos efectivos), el 94.1% (n = 32) de entrevistados de los cuales: 28 fueron mujeres y 4 hombres que asistieron a los centros de p.familiar.

Otra actitud analizada fue la confianza que infunde el sexo del proveedor, en este sentido, el 73.3% (n = 22) mujeres, prefirieron ser atendidos por proveedores de sexo femenino, el 100% (n = 4) hombres fue indiferente el sexo del proveedor, No se encontró diferencia significativa según edad e instrucción de los entrevistados.

Entre las espectativas en el uso de los servicios, el mayor porcentaje de mujeres desearon mayor información sobre los métodos, en cambio los 4 hombres que planificaban prefirieron que mejore la calidad de la atención (P < 0.05).

En relación a la oferta, los 25 centros de planificación familiar sujetos al estudio, dieron atención preferencial a las madres, analizando según tipo de establecimiento: público, semipúblico y privado no existió diferencia (Cuadro 3).

Fueron clasificados por edad y sexo los 50 proveedores entrevistados, encontrando 66% (n = 33) mujeres y 34% (n = 17) hombres, las edades estuvieron entre 20 a 51 años, la media fue 39± 8.3 años.Por tipo de proveedor, el 38% fueron médicos y médicas, 18% obstetrices, 10% enfermeras, otras profesiones con el 34% (auxiliares enfermería, educadores de salud, trabajadores sociales y sociólogo). La religión de los proveedores, de preferencia fue católica con el 90% (n = 45).

Independiente del sexo, edad y religión, los diferentes tipos de proveedores tuvieron el mismo criterio sobre diferencias de género. El 96% (n = 48), sostuvieron que la mujer debe planificar la familia, apenas el 4% (n = 2) piensan que deben hacerlo la pareja (Cuadro 4).

En relación a la prescripción de anticonceptivos, como la madre es la principal cliente, los métodos en un 92% fueron para uso exclusivo de ella, aunque se hizo promoción del uso del preserva tivo y la esterilización masculina, pero su demanda suele ser muy restringida. La información de los diferentes métodos, el 100% (n = 50) proveedores, dirigen exclusivamente los consejos a la madre que es la cliente exclusiva de estos servicios.

Respecto a la autorización o consentimiento del compañero o pareja, que la cliente debe presentar cuando va a adoptar un método anticonceptivo, al respecto, se encontró que el 80% (n = 41) de proveedores solicitan esa autorización, porque es "norma" del establecimiento.

Respecto al sexo del cliente que le gustaría atender y que tuviera mayor confianza,no existió diferencias significativas según sexo del proveedor puesto que se prestó atención prioritaría a las madres, situación que difiere de lo mencionado por las clientes que prefieren el sexo femenino del proveedor (Cuadro 5).

Cuadro 5. Sexo del proveedor segun percepciones, experiencias del proveedor del servicio de planificacion familiar, Quito1994. Percepciones y experiencias del proveedorSexo del proveedor MujeresHombresTotal El hombre debe participar en la p. familiar?

Discusion

El término género ha sido muy utilizado en recientes estudios, como una categoría de análisis que permite identificar a través de un proceso de construcción social, la red de rasgos actitudes, percepciones, valores, conductas y actividades que deviene en potencialidades y limitaciones para hombres y mujeres (Fernandez 1994). De las relaciones inter e intra-sexos, emerge un patrón de necesidades, roles, riesgos, responsabilidades y acceso a recursos según sexo.

De acuerdo a los resultados, la variable sexo permitió identificar diferencias significativas de género,(en la demanda real y potencial), en menor número lo hicieron otras variables.

Según características reproductivas de los entrevistados,las diferencias fueron significativas, puesto que el hombre mantiene el predominio en la reproducción, él comienza la vida sexual más precozmente, establece el tamaño ideal de la familia, (hijos deseados, número ideal de hijos) sin que la mujer pueda tomar decisiones sobre su propio cuerpo (Sanceda 1991), adquiere información anticonceptiva por fuentes diferentes a las del sexo femenino, usa menos métodos, manteniendo el estereotipo de su género.

Por otra parte las actitudes y creencias de los entrevistados, han ido cambiando en relación a lo que refieren otros estudios, puesto que existían creencias en las cuales el hombre fue contrario a que la mujer planifique porque podía serle infiel y desobedecer a su marido, sin embargo, la sometian a embarazos a repetición con los consiguientes riesgos que ello implica (Escalante 1983; Gomez 1993).

Actualmente, la mujer es la "que tiene que cuidarse para no tener hijos", ella es la que debe concurrír a los servicios de p.familiar, diferencia de género que cobró importancia analizando por ocupación, siendo la mujer no productiva (ama de casa, estudi ante), la que probablemente por la situación de dependencia económica que tiene en el hogar, su principal función fue la reproductora (OPS 1992).

Según resultados de este estudio, fue la pareja la que tomó la decisión para que la mujer planifique 48.2% (n = 41), función que la mujer acepta para conservar su estereotipo femenino, cuidando del hogar y de los hijos.La planificación familiar no estuvo entre las percepciones de necesidades especiales de atención del hombre, pero si de la mujer.

Estas prácticas y creencias, son reforzadas por los proveedores, quienes motivan preferentemente a clientes postparto para que se integren a la p.familiar, insuficientemente se ha trabajado en forma preventiva a nivel de grupos en riesgo, mujeres en edad fértil adolescentes, futuras esposas madres y sus respectivos compañeros, sobre todo cuando ellos comienzan su vida sexual.

Otra actitud analizada, demostró las preferencias por el proveedor femenino, sobre todo la madre, cliente directa del servicio de p.familiar, pocas mujeres han ido cambiando esta actitud probablemente influenciadas por las costumbres y prácticas modernas, mayor acceso a la educación y medios de comunicación, en quienes fue indiferente el sexo del proveedor, aparentemente se piensa que se ha logrado vencer los prejuicios o tabues que despierta el mismo sexo inculcados por la cultura machista que ha logrado generalizar conductas distorcionadas que a lo largo constituyen barreras de comunicación.

Por otro lado las experiencias en el uso de los servicios de p.familiar, han formado una imágen positiva de la prestación que se da en estos centros.Sin embargo, las expectativas de las clientes del servicio, estuvieron relacionadas en su mayor parte con la mejor información de los métodos, lo que lleva a una mayor aceptabilidad de la p.familiar y una práctica sostenida de la anticoncepción (Dever 1990; Boletín IPPF 1991; De los Rios 1992).

Por otra parte, se menciona que la existencia de los servicios de p.familiar, se apoya en supuestos como que la mujer es la responsable del bienestar de la familia y que la ayuda que se brinde para lograr un mejor desarrollo de los roles de madre y esposa van a contribuír sustancialmente a conseguir esos objetivos, sumándose, a ello la disposición del mismo proveedor de salud que estimula el mayor acceso promocionando de preferencia métodos para uso de las madres vinculadas estas actividades con el programa materno-infantil, dejando olvidada a la otra mitad que es el hombre (Villareal 1993; Boletín Médico de IPPF 1990).

En consecuencia, los servicios atendieron a madres, en muchos casos no permitió la presencia del compañero o esposo probablemente por no disponer de espacio físico, limitando el acceso del hombre quien debió interesarse por este tipo de actividades que tuvieron que ser compartidas.

Algunas sociedades, entre ellas la nuestra sigue apoyando la posición que el hombre debe controlar la fecundidad de la esposa situación que ha determinado desde el punto de vista legal (en hospitales y casas asistenciales), que la mujer tenga el consentimiento del marido o compañero para someterse a la esterilización o para usar algún método anticonceptivo (Boletín IPPF 1990; Population Reports 1987; Boletín Médico de IPPF 1990).

La mujer estuvo directa o inmediatamente vinculada a la idea de maternidad, de cuidado de los niños, a la práctica de la anticoncepción y uso de los servicios de p.familiar, incluso ella por si misma está convencida que es su responsabilidad, comporta mientos que también fueron estimulados por el sistema de salud de p.familiar manteniendo las brechas entre lo masculino y femenino.

Conclusiones y Recomendaciones

· Persisten las brechas de género en la práctica de la anticoncepción y uso de los servicios de p.familiar, relacionados con variables demográficos, culturales, reproductivas y socio-sicológicas, conservando los estereotipos femenino y masculino.

· Asimetrías de género que los proveedores salud de los servicios de p.familiar, mantienen por su propia formación, asociado a la estructuración y organización del sistema de salud que trata de apoyar a la madre responsable del bienestar familiar, sin dar acceso al hombre para que comparta con la otra mitad de esta obligación.

· Los servicios de p.familiar, deberían implantar estrategias que tomen en cuenta no sólo las diferencias biológicas o el rol de madre reproductora, sino también las diferencias de género entre hombres y mujeres y la forma que ellos se relacionarían con el sistema de salud.

· Se propone extender las coberturas de atención de planificación familiar a los dos sexos, promocionando la paternidad responsable, promoción de métodos anticonceptivos para uso del hombre (condón, vasectomía).

· Extender este tipo de estudio a sectores rurales donde el problema de género debe ser más evidente.

Bibliografia

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· development project planning workshop. Trinidad and Tobago. 11 to 16 October 1992.

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The authors of this paper are doctors with the Instituto de Investigaciones para el Desarrollo de la Salud, Quito, Ecuador.

Intention to Deliver and Delivery Outcome

Godfrey S. Lule and Margaret Ssembatya

Summary: Lack of antenatal care and lack of attendance or attendance by non trained personnel during child birth are important risk factors of maternal and perinatal morbidity and mortality in Malawi related to obstetrical causes. Although many mothers attend antenatal clinics at various health units in Malawi, less than one-quarter of them actually deliver at the health centre. A questionnaire was completed by 390 women who were followed up from an antenatal clinic at Nankumba health centre, Mangochi district, Malawi, to post delivery. About 85% of the respondents had passed their 16th week of pregnancy by their first booking. Over 90% of the women expressed a desire to deliver at the health centre. However, less than 25% of these mothers did actually deliver at this health centre. The majority of those who delivered at home cited long travelling distances and unkind health centre staff as the main reasons for delivering at home. The labour outcome of the mothers who did deliver at the health centre was much better than that of the mothers who delivered at home (Chi square = 16.89, P < 0.001). While it was very encouraging to note that the majority of the mothers desired to deliver at the health centre, the lack of actual deliveries occuring there was very much a cause for concern. Health education on the benefits of trained personnel assistance during labour is urgently required.

Introduction

Every year, an estimated half million women die of causes related to pregnancy and childbirth (WHO 1991). Experience in other countries has shown that strategies most likely to produce a significant decline in maternal morbidity and mortality include the assurance that women in labour can receive the skilled care they require (Safe Motherhood Newsletter 1994). In Malawi, the maternal mortality rate is estimated at 500 per 100,000 births (Chipangwi 1989). A 1989 community study which analyzed maternal death data from 12 hospitals identified many direct causes of this very high maternal mortality, but the primary roots of the problem were found to be much deeper (Chipangwi 1989). One of these is the lack of trained assistance available during the majority of deliveries. It is estimated that at present in developing countries, 45% of births are either not attended or attended by nontrained personnel (Voorheove et al 1987). Awareness of the factors which may bring about this lack of attendance or attendance by nontrained personnel during childbirth is a precondition for improving women's use of health services.

Malawi's health service delivery is based on the National Health Plan 1986–1995 (UNICEF 1993). The main objectives of this health plan include extension of peripheral and community-based health services. This health service system has, however, been constrained by a lack of financial and human resources. Although gravely short of resources to offer optimal health services, the government of Malawi has done all that it can to provide antenatal services to pregnant mothers.

Among the steps taken to improve maternal health care services in Malawi is the training of traditional birth attendants (TBAs). Most TBAs, if not all, are elderly women who are already known to attend to mothers during labour in rural settings. These women are well known in their localities. They are identified, and given a 2-week training course consisting of theory and practice on simple and safe obstetrics. They are taught how to identify at-risk mothers, how to carry out hygienic deliveries, including care of the cord, and how to promote appropriate health education to the mothers. At the end of the course, in addition to the certificates of attendance, they are provided with delivery kits free of charge.

Antenatal clinic attendance in Malawi is good, and many mothers express the wish to deliver in a health unit (Mponda and Mwafulirwa 1993); in reality, the majority of them end up either not being attended or attended by nontrained people (the majority of whom are family members) during delivery. In Mangochi district, not more than 40% of pregnant women deliver in health units or with a TBA (Mponda and Mwafulirwa 1993).

Why do so many women who wish to deliver their babies under the most ideal conditions available end up not doing so? In an attempt to answer this question, this study examined antenatal attendance, intended place of delivery, the actual place of delivery, and the delivery outcome of a cohort of pregnant mothers attending an antenatal clinic at Nankumba health centre in Mangochi district of Malawi.

Subjects and Methods

The study population included all mothers who had attended antenatal clinics at the Nankumba health centre during September and October 1993, and who came from Binali, Chamba, Chilonga, Kala, Makokola, Nankumba, Saidi, or Sosola. These villages were selected through a multistage method (Baker 1982). First, each village in the Nankumba health centre catchment area was put into a cluster based on distances of 10, 20, and more than 20 km from the health centre. The maximum distance was 30 km. Three villages were then randomly selected from each cluster.

Information collected on each woman included name, age, marital status, educational background, gestation age, and expected date of delivery. In addition, the women's addresses were recorded to facilitate after-delivery follow-up.

In April–May 1994, a follow-up was undertaken, and additional information was obtained from the women. This information was collected by means of a questionnaire which had been developed after a pilot study in the same geographic area. Due to the high illiteracy rate among these women, the questionnaire was administered to individual mothers in their homes by the researchers. All the participants were clearly informed that the purpose of the survey was to examine their antenatal histories, places of delivery, and delivery outcomes. In addition, the women were asked to state the reasons for their choice of intended delivery place, and the factors which determined the actual place of delivery. Also included in the questionnaire was an inquiry into the labour outcome, which relates to the mother's and baby's physical condition 24 hours after delivery, as reported by the mother. When delivery took place at the health centre, the mother's reported labour outcome was cross-checked with the health centre's records.

All data were coded and analyzed using the Statistical Package for Social Scientists-x (SPSS-x) and BioMedical Programme (BMDP) software. Following calculation of Mantel Haenszel chi-square statistics, a multivariate analysis was conducted on those variables which had a high statistical significance of association with place of delivery. A logistic regression model was used to determine the independent contribution of these variables to the place of delivery.

Results

Using the addresses provided by the participants, 396 of the 432 women who had been recruited were traced to their homes between September and December 1993. As six had not yet delivered, the questionnaire was completed by 90.3% of those who had been recruited into the study.

The respondents had a mean age of 17.4 years (SD 7.9). Of the respondents, 80% were married or living with a regular partner. Nearly 90% of these women had never been to school, and therefore were illiterate. In all, 85% reported attending antenatal clinics during previous pregnancies. The remainder were primigravidae. The respondents' mean gestational age at first booking was 22 weeks (SD 3.8), with almost 65% at 24 weeks or more. Only 3% of the women were at less than 16 weeks of gestation at first booking.

The reasons given by the respondents for attending antenatal during the present and/or previous pregnancies are shown in Table 1. For both present and previous pregnancies, about 90% of the respondents reported that they had attended the antenatal clinic to either get an obstetric check, for a tetanus toxoid shot, or to ensure that they would not be sent away when in labour. More than 50% of the primigravida women and 40% of nonprimigravida women reported that their husbands had instructed them to attend the clinic. Fewer than one-third of the women in each group attended the antenatal clinic to receive medication, and only 1% of all respondents indicated that they had just followed friends to the clinic.

Almost half of the respondents (47%) had already given birth to five or more children; 5% had delivered 10 or more. The highest parity was 12. Of the women who had delivered two or more children, 83% had not seen any of their children die. Despite the respondents' late booking for the antenatal clinic, more than one-third did not keep all their appointments.

The majority (86%) of the mothers walked to the health centre, while the remaining 14% were carried by their husbands on bicycles. The mode of transport appeared unrelated to the distance one had to travel to the health centre, to gestational age, or to the mother's parity. The respondents spent a mean time of 7.7 hours (SD 4.3) travelling from home to the health centre and back. The time spent was directly related to the distance from the health centre, with those who had to travel over 20 km spending well over 10 hours.

NS = difference not statistically significant.

Most (95%) of the respondents indicated that they wanted to deliver at the health centre; 4% preferred to deliver at a trained TBA's place. Only 1% stated that they would like to deliver at home. Of those who indicated that they liked to deliver at the health centre, two-thirds said that it was because they could be quickly referred to the hospital in case of complications. Only four respondents indicated that they would deliver at the health centre because the nurse said to (Table 2). On the other hand, all the mothers who preferred to deliver at a trained TBA's place gave the long distance to the health centre as the reason for saying so.

Regarding the actual place of delivery, only 90 (23%) women delivered at a health institution. Eighty-four delivered at the health centre, and six delivered at Mangochi District Hospital where they were referred due to labour complications. Of the remaining 300 mothers (77%) who delivered outside a health institution, 68% were not attended to or were attended to by nontrained personnel during child birth; the other 32% were attended to by trained TBAs. Taken as a whole group, 52% of all respondents were not attended to or were attended to by non trained personnel during child birth. This included 11 primigravidae and five women who had delivered 10 or more children.

The reasons given by the 300 women for delivering at home are shown in Table 3. The majority (53%) said that by the time they realized they were in labour, they could not make it to the health centre or to the nearest trained TBA's place in time. A surprisingly large percentage (21%) indicated that they delivered their children at home because their own experience or that of others had shown that certain midwives were very unkind to mothers during labour. Another 10% mentioned that an old female relative had refused to let them go to the health institution or to a TBA's place when in labour.

The number of mothers who delivered at the health centre was indirectly related to their distance from the health centre. For example, 90% of those who lived within 1 km of the health centre delivered there, while only 10% of those who lived more than 20 or more km away did the same. Similarly, the number of mothers who presented at the health centre during the second or third stage of labour increased proportionately with the increase in their distance from the health centre.

Labour outcome was best for those mothers who delivered at the health centre, compared with those who delivered with trained TBAs, and to those who delivered at home (P < 0.001). Of the 36 mothers who reported to have had a poor labour outcome, one delivered with a midwife at the health centre, six with trained TBAs, and 29 at home. Regarding the babies' reported physical condition 24 hours after delivery, there were two stillbirths (one delivered at home and the other at the health centre), and one baby was reported as having been in poor condition. This latter child was delivered at the health centre.

A logistic regression model was established using eight variables which showed a significant association with a mother being assisted by a trained personnel during delivery. Table 4 shows that five of the variables emerged as being independently associated with a mother being assisted by a trained personnel during delivery. The strongest association was a positive attitude to the health centre staff. Patients who approved of the behaviour of the health centre staff were 2.8 times more likely to have delivered at the health centre or at a TBA's place than those who did not.

Discussion

Although the sample size in the study was relatively small, and limited to a catchment area around one rural health centre in Malawi, it was sufficient to fulfil the objectives and to provide reliable information. The findings of this study bring out some important points that can be of value in the future planning and management of maternity services, particularly as regards the factors which facilitate or inhibit women's use of the health services during labour in Malawi as a whole, and in the Mangochi district in particular.

The loss to follow-up was due to several factors. Some mothers had emigrated from the villages, while others were farmworkers and were, therefore, not known by the indigenous members of the villages.

The great majority of the respondents appeared well aware of the reasons why one should attend an antenatal clinic. However, while about 90% indicated that they attended the clinic for an obstetric check, only 1% was influenced by her peers. The other reasons given for attending the clinic, such as securing a place so that they could be attended to when in labour, were also reflected in their gestation age at the time of first booking. Almost two-thirds of the respondents' gestation age at first booking was 24 weeks or more, and despite their late booking for the antenatal clinic, more than one-third of them did not fulfil all the appointments given to them. The general lack of knowledge about the benefits of the proper attendance of antenatal clinic needs to be addressed very quickly.

This study demonstrated that antenatal attendance in and around Nankumba Health Centre is good, and many of the mothers expressed a wish to deliver in a health unit. In terms of provision of antenatal care as a means of preventing maternal mortality and morbidity, this relatively high antenatal attendance and the expressed wish to deliver at a health facility gives some ground for optimism, and it is indeed a sign of the success of the antenatal services provided by the Malawi government.

Paradoxically, however, when they were asked to give the reasons for wanting to deliver at the health centre, 90% of the respondents indicated that they could be referred to Mangochi hospital much more quickly. This may be a reflection of lack of confidence by these mothers in the services offered by the health centre during labour.

The finding that almost 95% of the women expressed the wish to deliver at the health centre but only 23% ended up actually doing so is less than the figure for the whole district, which is about 40% (Mponda and Mwafulirwa 1993). The respondents in this study could have had less clearer views on the value of being attended by trained people during delivery, and this may also have been a reflection of the low levels of literacy among the mothers in this study. A majority of those mothers (68%) who delivered outside the health centre ended up either not being attended or attended by nontrained people during delivery. This lack of assistance by trained personnel during delivery continues to provide countless opportunities for an increase in maternal morbidity and mortality, as well as perinatal morbidity and mortality. In this respect, the findings of this study compare very well with the UNICEF report on the situation of children and women in Malawi, in which it was reported that antenatal attendance in Malawi is good, and many of the mothers express the wish to deliver in a health unit (UNICEF 1987). Similarly, in a study of service-related factors contributing to maternal mortality in hospitals in Malawi, it was found that many mothers continue to deliver at home and only come to a health facility when problems have developed (Phoya et al. 1992).

Many of those who delivered at home were either primigravidae or grand multiparas. Although the reasons given for not being attended or being attended by nontrained people during delivery appeared genuine, for example that of the long distances from the health centre, the risks taken particularly by the grand multiparas remain disturbingly high. These mothers who take the trouble to attend the antenatal clinics are among those in the district who should be assumed to have been motivated to use the health facilities. While it appears from the list health education topics given in the antenatal clinics that most of these mothers should have had sufficient knowledge about the signs of the onset of labour, and many of them were multiparas, apparently many of them did not put that knowledge into practice. Indeed, 53% of those who delivered at home said that they did so because by the time they realized they were in labour they were no longer able to walk to the health centre. The health education given at the health centre seems to be failing.

From this study it is clear that the role played by family members and relatives must not be underestimated. Of the women who delivered at home, 13% said that they did so because they had either been forbidden to go to the health centre, or advised to stay at home by an older female relation. This suggests that health education about the advantages of delivering a baby under the care of a trained person should not be limited to only the pregnant women, but through the village health committees to the whole communities. On the other hand, although only two percent of the women who attended the antenatal clinic did so on the instruction on their husbands, it does appear that at least some men have started to realize the importance of the maternity services offered.

Our findings that there was a big difference in terms of the labour outcome depending on the place of delivery is not surprising, considering the maternity knowledge levels of those who assist in the deliveries at home, and the generally unclean environment under which some of these deliveries take place. The trained birth attendants may have fared well with regard to the labour outcome because these trained TBA could have been more selective in the choice of their patients and insisted on sending all problem cases to the health facilities.

Distance from the mothers' home to the health centre affected antenatal attendance and the place of delivery. As a result, of the mothers who lived 8 km or more away from the health centre, only those who had complications during a home "trial of labour" resorted to going to the health centre. This could also explain why the labour outcome was bad for some mothers who delivered at the health centre.

Given the relatively small proportion of mothers who deliver at a health facility, and the possibility that those who go there go after the home "trial of labour" has failed, leading to a poor labour outcome, health education on the signs of the onset of labour and the benefits of delivering in a health facility must be reemphasized. Given that many mothers delivered at a trained TBA's and the labour outcome was relatively good, many more trained TBAs should be made available at the village level.

To its credit, the Malawi Government has already taken steps toward the training of TBAs. However, much more needs to be done at this stage of high maternal mortality and perinatal mortality in Malawi if more mothers are to be attended by trained personnel during child birth.

We were encouraged by the finding that the women who had a positive attitude to the health centre staff were almost three times more likely to deliver their children under the assistance of a trained person. We were similarly encouraged that those who received health education about the advantages of being assisted by a trained person during labour were one and one-half times more likely to be assisted during labour by a trained person. This also suggests that the maternal health public education campaigns have somewhat succeeded in influencing attitudes. On the other hand, one should not forget that 20% of the women who delivered at home did so because they had either from past experience or from being told learned of bad attitudes among the health centre staff toward them.

Our analysis showed that the woman's education was a very important factor in her decision to deliver her baby under good care. This compares very well with other findings and recommendations that to reduce maternal mortality and morbidity one needs to improve female literacy (USAID 1991).

It is, therefore, clear from this study that to improve women's use of the available maternity services during labour, the government of Malawi and private organizations are confronted with serious challenges. It is evident that women's education in general and about the use of health facilities in particular requires considerable emphasis and strengthening in order to reach a broad segment of the female population. Increasing the demand for maternity services through education should go hand in hand with extending access to these services.

References

· Baker, D.J.P. 1982. Practical Epidemiology 3rd ed. pp 37–38. Churchill Livingstone, Edinburgh. UK.

· Chipangwi, J.D. 1989. Maternal mortality in South Malawi-Thyolo District (unpublished draft document).

· Mponda, M.; Mwafulirwa, T.D. 1993. A report on the health status of Mangochi district 1993. Ministry of Health, Malawi.

· Phoya, A.M.M.; Mslomba, R.G.; Chawani, F.S.; et al. 1992. Service related factors contributing to maternal mortality in hospitals of Malawi. Ministry of Health, Lilongwe, Malawi. 27: 13.

· Safe Motherhood Newsletter. 1994. No. 14, March–June.

· UNICEF. 1987. The situation of children and women – Malawi. September 1987. Malawi Government.

· 1993. Malawi: Situation analysis of poverty. Lilongwe, Malawi.

· USAID (United States Agency for International Development. 1991. Malawi girls' attainment in basic literacy and education. Lilongwe, March.

· Voorhoeve, A.M.; Muller, A.S.; Woigo, H. 1987. The outcome of pregnancy. In MCH-Kenya. ed Guinneken, J.K. and Muller, H. Biddles Ltd, UK. Pp 223–240.

· WHO (World Health Organization). 1991. Maternal morality. A global factbook.

Godfrey Lule is with the Department of Community Health, College of Medicine, University of Malawi; Margaret Ssembatya is at Our Lady of Wisdom, Limbe, Malawi.

Dai and Midwives: The Renegotiation of the Status of Birth Attendants in Contemporary Bangladesh

Santi Rozario

Introduction

For some years, World Health Organization (WHO) policy has emphasized the use of traditional birth attendants (TBAs) as the best means of improving the appalling level of maternal and child mortality and illness in much of the Third World. Recently, however, some doubts as to the universal appropriateness of this strategy have begun to surface (Scheepers 1991; Stephens 1992).

My initial research on the question of childbirth and women's health (1991–92) was conducted in several villages in Rupganj (Dhaka district), an area where I had previously carried out research on women, development, and social change (Rozario 1992). In several forthcoming papers (Rozario in press; Rozario forthcoming) arising from this research, I discuss in detail the typical characteristics of childbirth in rural Bangladesh.

These characteristics include the low status attributed to, and the apparent lack of expertise of, TBAs (in Rupganj, these women are usually called dai), the lack of significant antenatal or postnatal care for the mother, and the heavy emphasis placed on birth pollution and vulnerability to spirits (bhut). This pattern is essentially the same as that found by Banchet (1984, 1991) and Islam (1981, 1989) elsewhere in Bangladesh, and by researchers in much of rural India (Jeffery et al. 1988; Stephens 1992).

Childbirth among many other Third World societies, however, is a markedly different process. One could compare, for example, traditional midwives3 among the Maya Indians of Central America (Paul and Paul 1975; Jordan 1980), in rural Jamaica (Kitzinger 1978), or, closer to Bangladesh, among Malay villagers (Laderman 1983). In each of these cases, traditional midwives are respected members of the community whose skills are generally valued and whose right to take charge of the care of the birthing woman is clearly recognized. In addition, their involvement with the birthing mother generally begins early in pregnancy and continues well after the actual birth. None of these things are true for TBAs in rural Bangladesh.4

The "low status trap" in which most rural South Asian TBAs are caught limits the viability of the WHO strategy. In this paper, I explore these issues further on the basis of recent fieldwork (1994–95) in a number of villages in Noakhali in southern Bangladesh, said to be one of the more religiously conservative regions in the country.5 In particular, I want to look at the way in which a small number of Christian-trained midwives seem able to avoid the "low status trap," and to ask whether there is potential for real change in rural Bangladeshi birthing practices.

Identifying the Traditional Birth Attendants

The most common term used to refer to TBAs in rural Bangladesh is dai. However, as Blanchet's (1984) and my findings (forthcoming, 1) show, dai is by no means the only term used to refer to TBAs. Terms such as dhatri and dhoruni (literally, one who catches the baby) are also used variously in different parts of the country. In Noakhali, I found that village women avoided using the term dai, but, although no specific term was used to refer to TBAs, they had no difficulty in identifying those local women who assisted at births. It is these women to whom I refer to in this paper as "TBAs," as distinct from the smaller number of trained "midwives," mostly associated with the mission clinic.

It is worth noting that the term dai is also commonly used in India, although the word itself appears to be of Arabic origin. In North India, the term is used to refer to women, generally of low-caste Hindu groups, but sometimes also Muslim, whose primary function appears to be dealing with and removing the "pollution" associated with birth (see Jeffery et al. 1988).

The reason for the avoidance of the term dai is of interest. For Noakhali villagers, dai were a specific group of women who were historically called in especially to cut the umbilical cord. This is regarded as one of the most polluting aspects of birth, and would not be performed by anyone else.

There was a set fee in cash and kind for the dai who performed this task. Apparently, these dai no longer exist in Noakhali district, although some of the older community members do remember them.6 The task of cutting the umbilical cord has consequently become problematic. Sometimes the birthing mother is made to cut the umbilical cord herself. On rare occasions, the TBA will do it provided she is appropriately paid for the task.7

Women who assist at births in Noakhali today go out of their way to avoid being identified with the despised dai. Thus, most Muslim TBAs I interviewed told me without my asking, "I do not cut the cord." Similarly, when I enquired about the cutting of the cord, a Hindu woman who regularly assists at births told me that she will cut the cord only for her daughter but not for others. She said "if I cut the cord, will I not become a dai?" Her 20 year old daughter, who was present during the interview, said that the dai who used to cut the cord "are a separate jat [caste or subcaste], there are no other jat below them."

The lack of a label given to TBAs in Noakhali8 also indicates that these women do not see delivering babies as a viable profession. It is something they do when people need their assistance. It may also be an irregular source of material gain, but it certainly does not yield a regular or substantial income. For these reasons, I shall avoid the term dai in this paper, and refer to the women who assist at births simply as TBAs.

Options for Birthing Mothers

Assistance with birthing is a problematic issues in the Noakhali region, as indeed it is elsewhere in Bangladesh. Because birth is considered to be extremely polluting, middle class families will generally employ a TBA to deliver the baby, clean up all the birthing substances, and bathe the baby before anyone in the family touches it. However, most rural families cannot afford to employ a TBA to perform these polluting tasks, and thus do not receive any assistance during birth from TBAs, trained midwives, or the hospital. At most they may be assisted by some family members (such as the mother, mother-in-law, sister-in-law, and so on). Sometimes a neighbour may be called in. The number of women who give birth entirely on their own in Noakhali, as elsewhere in rural Bangladesh, is thus significant.9

When expert attention is needed (and can be afforded), rural families have two main options: to call a TBA, who receive little or no payment, have low status and may have been involved in a limited training scheme, or to take the women to the government hospital or to a private clinic in the nearby town. In some areas, including the Noakhali region, there is also a third option: to call one of the few properly trained midwives, most of whom are associated with a clinic run by the Catholic mission.

The Traditional Birth Attendants

The Question of Status and Payment

Although TBAs are readily resorted to by most middle-class rural families, they themselves have very low status within village society. They are called at the onset of the labour pains, and are not looked to for medical advice. They merely come to "catch" the baby, or as the village women commonly use the term, to relieve (khalas) the birthing woman's travails by pulling the baby out. Although it is recognized that the TBAs have reasonable experience in assessing how the labour is progressing, which they do by inserting their left hands into the birthing woman's vagina, the elderly female guardians of the birthing woman do not usually heed any advice the TBAs may provide. It is these guardians who decide, based on the TBA's assessment of labour progression, whether to bring pani para (blessed water), chini para (blessed sugar), homeopathic or allopathic drops to bring on the labour pains, whether to call a trained midwife, or whether to take the woman to the hospital.

When I asked the TBAs about how the villagers regard them, they each had stories to tell to illustrate the point that "dhatris do not even receive honour equivalent to half a paise [a small coin; 100 paise = 2 cents US]." A typical comment was "when in danger they call you, but when the danger is over, get lost." Most of the TBAs linked the issue of status to the lack of any real recognition of their services in the form of payment.

They are usually given a bar of soap and a small bottle of attar (a special perfume used by Muslims before saying prayers), but neither money nor a sari (which is a standard gift in many parts of Bangladesh). The soap is given so that the TBA can purify herself thoroughly after delivering. The attar is given so that the TBA can use it before saying her prayers (namaz) for 45 days after the delivery. Some TBAs may receive a small amount of money, equal to USD 0.25 to 1.25. On the whole, however, they cannot expect to be paid as delivering babies is something they can do to gain spiritual benefit (sowab).10 It is said that the spiritual benefit from 101 deliveries is equivalent to a haz (pilgrimage to Mecca).

In fact, however, only a minority of the TBAs actually said that they do the job because of sowab. Even these, I suspect, said it because they felt it was the right thing to say, especially when speaking in front of other women. Most of the TBAs, on the other hand, vehemently complained about the lack of payment. At one Muslim delivery, several women were discussing how TBAs "should not take money because this is something done for sowab. If they take money for their service, then they cannot have any sowab." This statement was made in front of a Muslim TBA attending the birth, who did not reply directly. Rather, she made her point indirectly by saying "these days a dhatri [TBA] will not come unless she is paid BDT 100 [about USD 2.50]."11 Another Muslim TBA, who was complaining about the rich being particularly stingy, told how one family, who lived in a brick house (which indicates considerable wealth) gave her a mere BDT 10 note, in addition to the customary soap and attar, after she had attended a birth for one of its women. She said "I felt like pushing the baby back into the stomach."

Many other Muslim TBAs told me that they do not or cannot ask for any money, because people say "why do you ask for money, this is something you do for sowab." Hindu TBAs do not fare any better in terms of remuneration. Thus one Hindu TBA, Chenu Rani, told how a woman whose baby she delivered tried to dissuade her husband from giving her any payment by saying, "Has she touched me [dhorey nai] that you should pay her? Has she inserted her hand inside me?" The implication was that the TBA was paid only to compensate for the pollution, and that she had not been polluted enough to require payment. Chenu Rani's angry comment was, "Blood equivalent to a full water-pitcher [kalash] came out, and I delivered the baby, hasn't that any value?" She added "they call me non-stop when in danger, when danger is over they say tumi amar ki bal falaichha [a derisive village idiom implying ´what have you done for me']?"

There is clearly a conflict of interest here, but also a conflict of perspectives. Chenu Rani feels that she should be paid because she delivered the baby, but the mother argues that she should not be paid because she did not have to insert her hand inside her or deal with other specifically polluting aspects of the birth. The implication that the TBA is paid to compensate for the pollution is also present in relation to the conflict over cord-cutting. Most TBAs say they do not cut the cord, which is the most polluting task of all, because they would not be paid the large amount associated with doing so.

There is no doubt that most TBAs attend births in expectation of some form of payment. My understanding is that, even though they generally say that they are not paid at all, they are in fact paid by at least some families. It is clear that these women are in a bind. They need the money, and once a woman becomes acknowledged as an experienced TBA, she usually must be ready and willing to assist a family in delivering if called, because as everyone says in the village "this is the job of sowab." Yet, it is only in time of need that village society is prepared to recognize their value. Beyond the oshot [evil] and oshouch [polluted] ghar [hut, room] where birth takes place, these women have no value.

The rhetoric of gaining sowab from delivering babies and the common practice of handing out of soap and attar to poor TBAs after they attend births but not actually paying them for their services are linked by a simple logic. The rhetoric of sowab prevents TBAs from demanding or even expecting any renumeration; at the same time it justifies the use of their services without payment by the more well-off section of the village society. But every family at least hands out soap and attar, and so reinforces the notion that the TBAs should do deliveries for sowab and not for money.

Problems with TBA-Assisted Births

The medical problems associated with TBA-assisted births can mostly be understood in terms of their low status and marginal position in the birth process.

· No antenatal care is provided by the TBAs nor is it expected of them. The TBA's involvement begins when she arrives for the delivery and ends as soon as the birth is completed.

· At least 90% of the TBAs I interviewed said they do not wash their hands before delivery. When I asked whether they are given soap and water to wash hands before the delivery, they were usually very surprised at my question. Several responded by asking in turn, "Why soap and water before? It is after the delivery that we need to clean ourselves."

· There are usually too many women and children crowding inside the delivery room. Some TBAs complained that it may be difficult to concentrate because too many people are saying too many different things, making the TBA or the birthing woman confused and worried. Yet it is not the TBA's place to decide who comes in and who does not. The common feeling among Muslims is that the presence of many adult women means more courage and more ideas. Also, "who knows with whom the feresta [angel or guardian spirit] will enter the delivery room?" The feresta comes to help relieve the woman's suffering [khalas kara].12 Thus a Muslim woman whom I came to know very well, said "people sometimes say when ´luck has opened up [becomes favourable], the mother has been relieved quickly because a particular woman has entered the delivery hut."

· The TBAs are unable to examine the birthing woman properly. TBAs will not uncover a birthing woman to see the vaginal area as it is considered most polluted and shameful. One woman said "There is a big dabi [demand for money] if a dhatri sees it [the vagina]". She added "it is gunah [sinful]". It is not good for the dhatri or for the birthing woman to see the vagina, and it may be harmful.13 Due to the polluting nature of birth, TBAs use their left hand to assess how labour is progressing and use the right hand only at the last moment to draw the baby out.14

· The cutting and tying of the cord generally takes place under unhygienic conditions. Many said a bamboo slip is used for cutting of umbilical cord, saying it is better than a metal blade. At one birth I attended, a bamboo slip was used and the family did not seem to have a blade anywhere. The thread used was not boiled. The TBAs also smear ash on the navel area of the baby. This is believed to help the area to heal after cutting the cord. As explained previously, the cutting of the umbilical cord, which is seen to be most polluting of all the tasks associated with birth, is in any case not necessarily done by the TBA. Often it is done by the birthing woman herself or by her mother or mother-in-law in order to avoid the large payment associated with this task.

TBA Training Schemes

A few of the TBAs are now receiving training by various government programs and NGOs. In addition to the government's training program, almost all of the NGOs working in the area of family planning in the Noakhali region offer similar training to existing TBAs.

The training involves two or three short courses, each lasting several days. These are followed by refresher courses 1 day each month for 36 months. The training involves giving the TBAs some lectures and information, sometimes with pictorial booklets, on cleanliness (i.e., the importance of washing hands before delivery and the need to boil the blade and the thread), the need for the TBAs to cut the cord, the need to refer women to Family Welfare Visitors, trained midwives or the hospital when they perceive difficulty, and other such issues.

There are no practical components to the training. It is generally believed that the TBAs know how to deliver, and that they need training only about hygiene and how to refer cases to the hospital when they cannot deal with the case. They are usually given delivery kits. This delivery kit plays an ambiguous role in the TBA's career. If a TBA carries a delivery kit with her to a birth, she may be considered as trained; in other words, the delivery kit is a symbol of training and status.15 Yet in many instances a trained TBA will not carry her delivery kit to a birth because "people [will] make fun of me." Another consideration is that if a TBA carries a kit, people may assume that she is paid by the government and fail to give her even the minimal payment she might otherwise receive.

It is worth considering what type of women attend these training courses. I went to a refresher course session attended by some 13 TBAs on a government scheme. Most of the women were in their early 30s, and only three were over 40 years old. Most of them had small children. Two of the women had 4 or 5 years of education, while the rest could only write their names. It was clear to me that they were all very poor and desperate for a job. A few had never delivered a baby before their training. Three of the women were widows, one's husband "had become mad," and three women had two or three co-wives and were therefore not looked after by their husbands. One woman's husband had a tea stall, five women's husbands are rickshaw-pullers. The women were paid BDT 40 (USD 1) per day to attend the course, which seemed to be an inducement in itself.

The TBAs do gain some awareness about hygiene and other matters from their training, which no doubt slightly improves the kind of services they can provide the village women. However, their ability to insist on using the ideas and knowledge they have gained from their training in an actual situation remained very weak.

The amazement of the women at the training session when I sat next to them on a bench brought home to me anew the significance of the rigid status hierarchy in Bangladesh and South Asia in general.16 Society at large does not accord these women any status or honour. Nor do the village people with whom they have to deal with on a day to day basis. The rural society's image of these TBAs as poor, illiterate, women without suitable male guardians, and therefore of lowly status, undoubtedly has a detrimental effect on them.

The situation is not helped when TBAs are only given minimal training, and not paid a proper salary by either the government or the people they assist. These minimal training programs can have little impact by themselves on the traditional birthing practices of the village. The village people must value the TBAs' opinion and judgement; this, however, will not happen because of their poverty and the low status attributed to these women. At present, they are laughed at should they suggest new ideas or even bring their delivery kits. This "low status trap" in which the TBAs are caught is the central problem with TBA-assisted births in the village.

The Hospital

The local government hospital in Noakhali was built during the period of Pakistani rule, but inaugurated in the early 1970s. Although it apparently had a good name in its early years, its reputation now is very poor. Many of the TBAs told me stories of their experiences when they accompanied a complicated delivery case to the government hospital. Not a single person - TBA, trained midwife, or any of the village people in general - had anything positive to say about the place. People referred to it as the "slaughterhouse." No one wanted to take their birthing women there unless it was absolutely unavoidable.

I visited the delivery section17 of the government hospital on several occasions. What I saw was simply horrific. It is overcrowded, mattresses are placed directly on the floor, the ward is littered with old bandages. Only a very small minority of women are taken to the hospital before a TBA or and/or a trained midwife has been tried at home. The vast majority arrive when the TBA (or the trained midwife) decide they cannot handle the birth at home.18 Problems with the hospital centre around the expense involved in making use of it, and the mistreatment and lack of treatment of patients.

Expenses Associated with Using the Hospital

The government hospital is supposed to be free for the patients: bed, services, food, and medicine are all supposed to be provided without charge. In reality, the case is otherwise. I have numerous stories of people telling me how much it cost them when they took their birthing women or other patients to the hospital. A trained midwife told me, "It is as if every brick of that hospital building opens its mouth for money."

The cumulative costs incurred from entering a hospital and being treated by doctors and nurses are very high in village terms. Some of these costs, none official, are: the entrance fee to the hospital, medicine, charge for doctor, charge for nurses, and charge for ayah. To this must be added food for relatives staying with patients 24 hours a day (up to three per patient are necessary since the hospital itself provides no services), travel back and forth to the hospital by relatives, and so on.

Entrance Fee

A family may arrive at the hospital at any time with a serious delivery case. They will not be allowed to pass the main gate of the hospital building unless an entrance fee is paid. As this entrance fee is not official, the guard charges whatever he thinks fit from clients, from BDT 5 to 50 [12 cents to $1.25 US].

Medicine

A major cost that no one can avoid is that for medicine. Patients are given prescriptions and their guardians are expected to go to one of the numerous pharmacies immediately outside the hospital gate to get the medicine at their own cost. Many villagers commented that the pharmacies are owned and run by the hospital doctors, and that the medicine on their shelves usually comes from the hospital stock (which is supposed to be distributed freely to the patients). Although I have no evidence to support these statements, it was interesting that when I took some photographs of these pharmacies I was confronted by a shopkeeper who enquired whether I was a journalist and asked why I was taking photos. His suspicion about me made me think there may very well be some truth in what village people say.

Doctor's, Nurses' and Ayah's Charges

If the delivery entails a Caesarian section or other surgical procedure, the doctor apparently makes a contract with the birthing woman's family as to the amount he will be paid, which can vary from BDT 4000 to 12,000 (USD 100 to 300). Again I do not have any evidence to prove what village people told me, but such statements were made by numerous people, including TBAs and trained midwives, as well as village people, which makes me think that there is some truth in the rumour.

Even when a straightforward delivery does not entail a direct charge for the doctor, there are various other costs. The doctor does not usually handle normal deliveries; these are handled by the ward nurses who are fully trained, including a year of midwifery. A certain amount has to be paid to the nurses who attend the delivery and mind the ward. In addition, payment has to be made to the ayah who is supposed to do the general cleaning after the delivery, as well as washing the birthing woman's clothes and changing the sanitary pads. She will not lift a finger until she has been paid in advance for each of these tasks.19 When I asked the birthing women's female relatives, they did not know exactly how much was being paid, but they knew that something would be paid to the nurses and the doctor, including providing several morning and afternoon teas (with snacks of savouries and sweets).

Travel

The costs for village people also include trips back and forth from their home to the hospital on a daily basis. Because no services are provided by the hospital staff except for the actual delivery, every patient needs at least two to three people to attend her all the time. These relatives have to buy their own food from the food stalls outside, which can cost quite a lot of money, especially in cases when a patient needs to remain at the hospital for a long period of time.

Mistreatment of and Lack of Treatment for Patients by Hospital Staff

Here I summarize my observations from my first day at the hospital, which proved, from subsequent visits and from the numerous stories I heard from patients, to be quite typical. I arrived at the women's ward at 9:30 a.m. and found a woman, who was brought into the hospital about midnight and had a forcep delivery. She was half-sitting on a bed on the floor and looking lost. She had her mother with her. They were wondering what they should do with the baby, whether to feed it or not. At home, they normally would have used some honey or mustard oil, neither of which they had with them. The two women were feeling quite lost, and were waiting for the birthing woman's father to arrive with some mustard oil. They were afraid to ask the nurse for anything.

The birthing woman was in pain and needed to go to the toilet. She was wondering whether she should get up to walk to the public toilet. I volunteered to ask the nurse in charge whether it was all right for the woman to go to the toilet. The nurse said yes. After the woman's mother and I helped her to walk to the toilet she nearly fainted on the toilet seat. She needed to be changed, including her sanitary pads, but no one was there to help her, so I helped her. Then I went to the nurse again to ask for a bed pan. She told the ayah to give us one. Without prompting, the birthing woman and her mother started to complain how rude the nurses were, how they refused to talk to them, and so on. I again went to ask the nurse what is to be done with the baby. The first time she ignored me. I asked again and then she turned around to the new mother and said she should feed the baby, "It is their fault, why come so late to the hospital, we had to use forceps; of course it will be difficult for the baby."

Then the doctor came to do his rounds - it took him about 10 to 12 minutes, no more, to go around 26 patients. His rounds consisted of merely making a hand gesture to the attending nurse with a few words like "discharge this one," "let her be for another day," or taking an old bandage off Caesarian patients and putting on a new one, throwing the old one on the floor. There was hardly any interaction with the patients. Sometimes patients would call to him as he turned away, but he simply continued to the next patient. A few patients I spoke to before the doctor arrived had many questions they wanted to ask the doctor, but they could not. The women were overwhelmed, clearly feeling out of place.20 I was told that if a patient's guardians pay a large sum of money to the doctor and the nurses, they usually keep an eye on the patient. Otherwise there is no guarantee that the patient is going to be attended to when needed.

Both trained midwives and TBAs had numerous stories to tell me. When they take patients to the hospital, the women were often left on their own in the delivery room. There were cases where the baby was born more or less by itself, and nearly fell onto the floor.21

Well over 50% of the patients in the hospital had Caesarian deliveries. Many also had eclampsia. This was largely because women are brought to hospital in emergencies, when there is a need for a Caesarian delivery, or because they have high blood pressure or other symptoms of eclampsia.

The infection rate after Caesarian is quite high, which may be linked to the unhygienic situation of the hospital. The toilets often do not have water for women to clean themselves, and both the toilet and the delivery ward floor are littered with old bandages.

Every patient has two other women staying with them who must bring their own bedding and sleep on the floor. The patients themselves are provided only with minimal bedding; some of their bedding, such as a quilt, will also be brought from home.

The impression I got of the women being treated in the hospital was that they were in limbo. They thought they were in the hands of the experts, and that they could leave all decisions to them, but this was not the case. Each woman I spoke to had many questions for the doctors and because the doctor would not even listen to them, they asked me, who knew no better! It is not surprising that no one wants to go to the hospital if they can help it. The TBAs do not want to go there because they are always accused of doing something wrong by the hospital staff - usually for not bringing women to the hospital before they tried to deliver themselves.

There are several private clinics where the service is much better. However, the charge is much too high for anyone except for the very rich. In fact, because of the very high costs involved, most of the women brought even to the government hospital for delivery-related reasons are also from middle to upper middle class background. The very poor cannot afford the hospital or the clinic. Emergency or no emergency, they have no choice but to rely on the good will of God.

The Trained Midwives

Trained midwives (TMs) are perhaps the most hopeful element in this generally very discouraging situation. The midwives in this region were trained by the nuns from the missionary clinic system. Most received their training some 30 to 40 years ago; new midwives have been trained for at least 15 years. Women trained under this system have spent at least 18 months at a missionary training centre, receiving getting practical and theoretical training on midwifery.

There are several missionary clinics around the country, usually part of a Catholic church complex. Clinics are usually also run by the nuns (as in the case of Rupganj, where I did my previous fieldwork). In Noakhali, however, the clinic (the Moriam Health Centre) is run by a lay midwife, Ivy, who was trained by a nun–midwife some 35 years ago. The mission had trained many other women (Hindu, Muslim, and Christian), some of whom still practice in the region. The Noakhali clinic used to be staffed by several nurses until some time in the 1980s. Because of lack of funding, most were retrenched.

There are also a few TMs who received their training by working with Bangladeshi doctors in their private clinics. Their experience in these clinics lasted between 6 months to 10 years. For various reasons, they took up midwifery as a profession after leaving the clinic.

Some of the TMs have finished matriculation, while others have had at least 7 to 8 years of education. The most highly regarded midwife is Ivy, the chief midwife at the missionary clinic, who also has paramedical training. People usually pay her BDT 500 (USD 12.50) per delivery. In addition to the payment, some families may also give a sari to these midwives.

The Moriam Health Centre: The Catholic Mission Clinic in Noakhali

Within the present scenario, the Catholic mission clinic (Moriam Health Centre, henceforward MHC) is the only place where women can expect to receive good attention and health care during pregnancy at a relatively cheap price. Whereas a visit to a private doctor's chamber may cost anywhere between BDT 70–100 (USD 1.50 to 2.50), plus costs of medicine, the MHC charges no fee, only the cost of medicine.22

The usual practice is for women to start visiting the MHC clinic as soon as they can after they become pregnant. They can visit the clinic every month on a Wednesday to have regular check-ups. The cost to them is a single admission fee of BDT 30 (USD 0.75) which covers all their visits throughout the pregnancy. They also have to pay for whatever medicine, including vitamin and calcium tablets, they receive. Of course, women living a long distance from the MHC often have to resort to hiring a rickshaw, an additional cost.23

I observed these midwives at work, and felt they were very thorough and caring in the way they treated the women. At every visit, each woman receives a series of tests to determine if everything is progressing smoothly with the pregnancy.24 Toward the advanced stage of pregnancy, the woman is usually told whether she can expect to have a normal delivery or whether she should seek expert help by going to a hospital or a private clinic.25

Only some of the women who attend the MHC clinic will eventually call Ivy to attend the birth. Her charge for a delivery is BDT 500 (USD 12) and very few can afford her services. The clinic staff only receive a nominal salary from the mission for their services and their charge for attending deliveries somewhat makes up for a lack of full salary.26 In any case, as Ivy's services at the clinic are relatively cheap, these are more accessible to women who at least are told beforehand whether they can have a home delivery with a TBA or a TM, or whether they should consider seeking more expert help.

The village women living within several miles of the MHC thus have access to regular check-up during pregnancy (including urine tests, blood pressure, and general physical condition), and advice from Ivy on how to manage oneself during pregnancy. Moreover, through weekly EPI (Expanded Programme on Immunisation) sessions at the clinic, run by the government, and funded by UNICEF, women and babies also have access to immunization as a safeguard against eclampsia, and various infants' diseases such as diptheria, tuberculosis, polio, measles, and whooping cough.

Some Points of Contrast between TBAs and TMs

It may be useful to summarize some of the differences between the services provided by the TMs and the TBAs.

· If women go to the clinic beforehand, they receive regular prenatal care. TMs usually visit the new mothers and babies for several days after birth.

· The TMs are much more competent. They recognize the importance of hygiene in birth care and perform their deliveries accordingly. They carry their own delivery kits with the relevant implements. They wash their hands and use gloves, and change the birthing woman into clean clothes.

· TMs use both hands for delivering, not only the left hand employed by the TBAs.

· Although TMs, being local women, are sensitive to the modesty rules and avoid taking off all of the birthing woman's clothes, they take off her sari and place it over her bosom. More importantly, they carry out a pelvic and vaginal examination in order to assess the labour situation. We have seen that this is not done by TBAs.

· TMs perform enemas (douche) on the birthing woman and check her blood pressure. Again, TBAs are not in a position to do this.

· Because often Ivy may be called after the birthing mother has been in labour for 2 days or so, if she feels the case is complicated and needs clinical attention, she tells the woman's guardians to arrange to take her to the hospital. Often she may accompany them. In contrast, most TBAs would find it difficult to establish the causes of long labour and by waiting in ignorance may endanger the lives of the birthing mother and the baby.

· Most TMs, especially Ivy, do not allow too many women and children to crowd around the delivery room. However they allow one or two women (mother, mother-in-law or sister-in-law) to stay and help.

· TMs cut the umbilical cord as a matter of course after delivering a baby. They use scissors which they carry in their delivery kit and which they boil before and after each usage. They also carry sterilized thread in their delivery kit.

· Ivy gives a warm bath to the baby, sponges the mother, and puts on a sanitary pad or uses the pieces of clean old sari to make into a pad. (She says she does not do the cleaning.) She also goes for follow-up visits to see how the baby and the mother and progressing. However, she admitted that because they are so busy at the Centre, she cannot always go back regularly.

How do the Trained Midwives Fare in Terms of Status?

From the above list we can see that Ivy, the MHC clinic midwife, and other TMs perform their task of delivery quite differently than do the TBAs. In particular, TMs use both hands for deliveries, uncover the woman for internal examinations, and cut the umbilical cord. If TBAs did the same thing, they would risk polluting themselves unnecessarily and committing gunah [sin].

Ivy was not at all concerned about these issues, and yet she clearly commanded much respect from the village society. For example, she was away on holidays for a few weeks and when she returned everyone seemed very pleased to see her. When she went to the schoolyard, some young mothers came and touched Ivy's feet asking for her blessings, a common way of showing respect to older women in this culture. Walking on the streets with her, I observed that the menfolk (of all religious backgrounds) stopped to speak to her, ask about her well-being and so on. Although all TMs enjoyed higher status than the TBAs, no one commanded as much respect as the clinic-based midwife Ivy. This was also reflected in the different amounts paid by families to different TMs. Ivy's rate was BDT 500 (USD 12.50), while others could earn anything from BDT 150 to 500 (USD 3.75 to 12.50).

Conclusion

In considering the relationship between TMs and TBAs, a good starting point is the question of Ivy's high status in the community. How can we explain Ivy's status? She carries out all the "polluting" tasks, including the most polluting one of all, cutting the cord, yet she enjoys higher status than the TBAs who avoid doing these tasks. Is it because of her education (matriculation), her training, and her association with the mission clinic? Is it because she has a continuing relationship with the women through the antenatal services at the clinic? Is it because her expertise, including her paramedic training, is sufficiently recognized and her services enough in demand to enable her to charge BDT 500 for a delivery, a quite considerable sum in local terms?

I think that all of these factors play a part. However, there does not seem to be a stream of educated and middle class women ready to follow in Ivy's footsteps. In part this is because the mission system which supported her training no longer has the resources or (in postcolonial Bangladesh) the political strength to maintain its training programme. There are, however, other ways to obtain training if women are determined.

A key issue is the lack of payment, which ensures that only very poor and uneducated women with no real alternative will take up this career. Undoubtedly, if TBAs received a government salary, or if they were able to demand a reasonable fee from the families they assisted, this would help. Thus in the past, nursing was an occupation which was taken up by women in marginal situations (particularly Christians), while these days increasing numbers of women from all religious groups are taking up this profession as it commands a respectable salary in the present times of economic crisis. Again, women from middle class families who work with family planning NGOs now travel wearing a veil and walk long distances. A few years ago, this would not be done by a middle class woman. The low status of the village TBAs is closely tied up with the lack of payment for their services. If they received a respectable salary in local terms, I have no doubt that the job would become much more attractive and its status would rise.

So it seems that there is room for change, provided the government and relevant NGOs are prepared to take sufficient notice of the need for it. However, as long as TBAs are the poorest women in the community, exploited for little or no payment, there is unlikely to be significant change. Here the ideology of sowab continues to play an important part, legitimating the exploitation of TBAs by the wealthier villagers, and maintaining their low status. It would be useful if Islamic authorities could come out against this ideology, as they have in the case of traditional opposition to family planning. This might be an important step in restructuring the whole network of social relations which keeps TBAs locked in a "low status trap". It is only if TBAs somehow gain the status and the income appropriate to the vital work they perform that the work will gradually attract young and educated women who will in their turn be able to make a real impact for the better on the nature of the birthing process in rural Bangladesh.

References

· Blanchet, T. 1984. Women, pollution and marginality: meanings and rituals of birth in rural Bangladesh. University Press, Dhaka, Bangladesh.

· T. 1991. Maternal health in rural Bangladesh: an anthropological study of maternal nutrition and birth practices in Nasirnagar, Bangladesh. Save the Children, Dhaka, Bangladesh.

· Islam, S. 1981. Indigenous abortion practitioners in rural Bangladesh. Women for Women, A Research and Study Group, Dhaka, Bangladesh.

· 1989. The socio-cultural context of childbirth in rural Bangladesh. In Krishnaraj, M.; Chanana, K. (ed.). Gender and the household domain: social and cultural dimensions. Sage Publications, New Delhi, India.

· Jeffery, P.; Jeffery, R; Lyon, A. 1988. Labour pains and labour power: women and childbearing in India. Zed Books, London, UK.

· Jordan, B. 1980. Birth in four cultures. Eden Press Women's Publications, Montreal, Canada.

· Kitzinger, S. 1978. Women as mothers. Fontana/Collins, London, UK.

· Krauskopff, G. 1989. Maitres et possedes: Les rites et l'ordre social chez les Tharu (Nepal). Éditions du CNRS, Paris, France.

· Laderman, C. 1983. Wives and midwives: childbirth and nutrition in rural Malaysia. University of California Press, Berkeley CA, USA.

· Paul, L.; Paul, B.D. 1975. The Maya midwife as a sacred specialist: a Guatemalan case. American Ethnologist, 2(4), 707–725.

· Ram, K. (forthcoming). Maternity as order and disorder in women's experience: female spirit possession, embodiment and narrative in southern India. In Kalpana Ram and Margaret Jolly (ed.). Modernities and maternities: colonial and post-colonial experiences in Asia and the Pacific.

· Rozario, S. 1992. Purity and communal boundaries: women and social change in a Bangladeshi village. Zed Books, London, UK.

· (in press). TBAs (traditional birth attendants) and birth in Bangladeshi villages: cultural and sociological factors. International Journal of Gynaecology and Obstetrics.

· (forthcoming). The dai and the doctor: discourses on women's reproductive health in rural Bangladesh. In Kalpana Ram and Margaret Jolly (ed.). Modernities and maternities: colonial and post-colonial experiences in Asia and the Pacific.

· (forthcoming). Boundary as predicament: the case of the dai in rural Bangladesh. In Renuka Sharma (ed.). Representations of gender in identity politics with reference to South Asia. Indian Book Centre, New Delhi, India.

· Scheepers, L.M. 1991. Jidda: the traditional midwife of Yemen? Social Science and Medicine, 33(8), 959–962.

· Stephens, C. 1992. Training urban traditional birth attendants: balancing international policy and local reality. Social Science and Medicine, 35(6), 811–817.

Santi Rozario is with the Department of Sociology and Anthropology, University of Newcastle, NSW, Australia.

Malaria Prevention During Pregnancy: An Antenatal Intervention Strategy Whose Time Has Come

Linda J. Schultz; Richard W. Steketee; Monica Parise; Jack J. Wirima; Aggrey Oloo; Bernard Nahlen

Summary: In sub-Saharan Africa, infection with Plasmodium falciparum during pregnancy is a major contributor to both maternal morbidity and perinatal morbidity and mortality. However, because maternal malaria infection is one of the few contributors to morbidity and mortality that is amenable to intervention once a woman becomes pregnant, effective antimalarials should be provided as part of an antenatal care package. In Malawi and in the Kisumu district of western Kenya, women's knowledge and attitudes, delivery of services at antenatal clinics (ANCs), and utilization of ANCs to assess the opportunities for and obstacles to delivery of antimalarials and other selected interventions were examined. In both settings, approximately 90% of women perceived malaria as a health threat during pregnancy and believed that antimalarials could be an effective treatment. In Malawi, where the antenatal program included weekly chloroquine (CQ) prophylaxis, over 25% of women reported that they had not received any CQ. Antimalarials were not routinely delivered through ANCs in Kenya, resulting in 96% of women not receiving CQ. Delivery of other key antenatal interventions, including tetanus toxoid (TT), hematinics, and syphilis testing and treatment, was also poor, despite the finding that over 85% of pregnant women attended ANCs at least twice during their pregnancy. Pregnant women are therefore accessing ANCs, yet health care systems are failing to deliver appropriate interventions. Efforts to improve antenatal care must concentrate on the delivery of interventions known to be effective.

Introduction

Approximately half a million women die each year during pregnancy or childbirth. Of these deaths, 99% occur in developing countries (WHO 1991). Pregnant women in sub-Saharan Africa experience the highest risk, with reported maternal mortality rates ranging from 500 to 700 per 100,000 live births, a rate approximately 200 times that for women in developed countries (WHO 1991). Similarly, stillbirths and neonatal deaths (deaths within the first 28 days of life) are common and occur disproportionately in developing countries; reported perinatal mortality rates in sub-Saharan Africa range from 45 to 75 deaths per 1000 births (Greenwood et al. 1987; Nordbeck et al. 1984; Steketee et al. 1994) compared with about 9 deaths per 1000 births in developed countries (Booth 1979; National Center for Health Statistics 1992). Reduction of maternal and perinatal morbidity and mortality needs a focused effort to deliver effective antenatal care, which is one of the four critical strategies of the Safe Motherhood Initiative (Mahler 1987).

In sub-Saharan Africa, Plasmodium falciparum malaria is an important contributor to maternal morbidity and perinatal morbidity and mortality. During pregnancy, particularly among primi- and secundigravidas, women are at increased risk of malaria parasitemia, malarial illness (McGregor 1984; Steketee et al. 1988; Keuter et al. 1990), and anemia (Gilles et al. 1969; Kortmann 1972; Fleming et al. 1986). Furthermore, maternal P. falciparum parasitemia may result in placental parasitemia, which in turn can compromise placental function and increase the risk of low birth weight (LBW) (MacGregor and Avery 1974; Brabin 1983; Steketee et al. 1994). Neonatal and early infant mortality is a common consequence (McCormick 1985).

Effective antimalarials have recently been demonstrated to reduce the effects of malaria infection during pregnancy (Steketee et al. 1984; Greenwood et al. 1989; Schultz et al. in press). In sub-Saharan Africa, where women often do not seek antenatal care until mid-pregnancy, administration of antimalarials represents one of the few interventions which could be given during the second and third trimesters, still effectively promote maternal health, and reduce the incidence of LBW and prematurity (Steketee et al. 1984).

Similar to other interventions which should be included in the package of antenatal care services (such as tetanus toxoid, syphilis testing and treatment, and iron and folate supplementation), antimalarial intervention requires appropriate patient behaviour and beliefs, proper utilization of services, and adequate service delivery to ensure program effectiveness. To support this assumption, we examined client and health worker practices and health system support in Malawi and Kenya to identify opportunities for and obstacles to delivery of an antimalarial intervention within antenatal service packages.

Background

Studies document lower maternal and perinatal mortality rates among women receiving antenatal care (US Congress 1988; Greenberg 1983). Early onset of antenatal care and appropriate frequency of visits is also associated with improved pregnancy outcome (Gortmaker 1979; Ryan et al. 1980). A minimum number of services have been accepted as standard practice for developing countries. Figure 1 and Table 1 provide an example of service delivery.

Table 1. Key services that should be available to pregnant women in sub-Saharan Africa. ServiceVisits requiredComments Maternal risk assessmentEach visitScreening for small pelvis, high blood pressure, twins, abnormal presentation, etc. Risk managementVariableShould include referral to facility for delivery for primigravidas, grand multigravidas (5 or more pregnancies) and other high-risk pregnancies Tetanus toxoid (TT)TwiceDose 1, first visit; dose 2, 1 month later (if previously vaccinated, one dose at first visit) Ferrous sulfate/folate (Fe/fol)MonthlyMonthly supply dispensed for daily self-administration at home Syphilis testing and treatmentTwiceTest, first visit; treat positives, second visit AntimalarialTwiceDose 1, first visit; dose 2, 1 month later Record keeping (ANC card)Each visitStandard recording form recommended Patient educationVariableRotating schedule of messages is often provided. Identified high-risk patients should be counseled individually about their condition and delivery at a health facility

For an antenatal intervention to be effective, services must be available and women must use ANCs. Assuming the first visit occurs at the beginning of the second trimester, women should complete a minimum of five visits to ensure that they receive the full antenatal care package. Many countries in sub-Saharan Africa do have high rates of ANC attendance; for instance, ANC attendance has been reported to be as high as 95% in Tanzania (Moller et al. 1989), and greater than 80% in Zambia (Ratnam et al. 1982), The Gambia (WHO 1991), Togo, and Zaire (Steketee et al. 1994). Service delivery, however, is often inadequate. It was discovered during one study in Zambia that fewer than half the women were screened for anemia, and only one-third of the anemic women received iron supplements (Ransjo-Arvidson et al. 1989). Although high-risk women should be identified at ANC visits and referred to facilities for delivery, home delivery rates are often as high as 73% (Voorhoeve et al. 1984), with more than 60% delivering at home without the assistance of trained personnel (WHO 1991). The high proportion of home deliveries may be due to a variety of determinants, including distance from the facility and sociobehavioural factors.

Despite recommendations by WHO that pregnant women living in P. falciparum endemic areas should receive an initial treatment dose followed by regular prophylaxis with an effective and safe antimalarial drug (WHO 1986), few African countries have a formal policy concerning maternal malaria control. Even fewer have operational programs for the delivery of antimalarials through ANCs (USAID 1994). This programmatic inertia may be attributable in part to the emergence and spread of chloroquine (CQ) resistance, resulting in difficulties in identifying an efficacious, safe, and affordable antimalarial for use during pregnancy.

Studies in Malawi have established that a highly efficacious antimalarial administered during the second and third trimesters of pregnancy significantly decreased LBW among primi- and secundigravidas (Steketee et al. 1994). More recent work has demonstrated that an antimalarial regimen, consisting of two doses of sulfadoxine-pyrimethamine (SP/SP), the first administered during the second trimester and the second administered at the beginning of the third trimester, was highly efficacious in reducing the prevalence of peripheral and placental parasitemia, well-tolerated (Schultz et al. in press a), and more economical than the commonly recommended regimen of CQ in both total cost and cost per infant death prevented (Schultz et al. in press b). Similarly, in The Gambia, chemoprophylaxis with another sulfapyrimethamine combination (Maloprim 27) was efficacious in preventing placental malaria, decreasing LBW, and was well tolerated (Greenwood et al. 1989). When viewed together, these studies identify antenatal antimalarial strategies that are efficacious, safe, affordable, and practical to deliver.

Methods

In Malawi and in the Kisumu district of western Kenya, a series of investigations was conducted to examine women's knowledge, attitudes, and practices regarding malaria illness, treatment, and prevention; evaluate the opportunity for delivery of an intervention within the current ANC system; and examine women's utilization of the current ANC programs in Malawi and Kenya.

Malaria Knowledge and Attitudes

In 1992, a nationwide survey examining malaria knowledge, attitudes, and practices (KAP) was conducted in Malawi. A modified Expanded Program for Immunization cluster-sampling method (Henderson and Sundaresan 1982) was used to select a total sample of 1531 households, in 30 clusters of 51 or 52 households. One section of the survey focused on women who had completed a pregnancy within the past 5 years. Questions regarding ANC use, services received, and place of delivery were asked, in addition to those on malaria treatment and prevention. A similar survey focusing strictly on women pregnant within the past 5 years was conducted in the Kisumu district in 1994. A total of 216 women in 30 clusters of 7–8 women each were interviewed. In both surveys, interviews were conducted by female nationals of childbearing age and efforts were made to conduct the interviews in the first language of the woman interviewed. When this was not possible, interviews were conducted in the national language.

Delivery of Antenatal Services

As part of the KAP surveys, women were asked about services received during ANC visits. Reported rates of TT immunization and administration of Fe/fol and CQ were compared with antenatal care record cards, among the women still possessing them, to verify reporting accuracy. Facility assessment was performed to verify available supplies and medicines. A sample of women attending ANC was followed through the clinic, and health care worker practices were recorded.

Utilization of Antenatal Clinics

Using reported initial and return ANC attendance rates, estimates were made of the proportion of women available for delivering various interventions to pregnant women. We examined ANC use and place of delivery for high-risk women to assess the need for more effective referral. For Malawian women, age categories were used as a surrogate for parity. Previous studies documented that 89% of women less than age 18 years at delivery were primigravidas, while 93% of women at least 35 years old were grand multigravidas (5th pregnancy or greater) (Steketee, personal communication). We defined women in these age groups as high risk and compared them with women delivering at 20 to 34 years of age. Kenyan women were classified as high risk on the basis of parity. The number of women available to receive the full benefit of antenatal services and referral for hospital delivery was estimated.

Results

In Malawi, 809 recently pregnant women were interviewed. The mean age of the Malawian women was 29 years, and 669 (83%) reported being currently married. In Kisumu district, the mean age of the 216 interviewed women was 27 years, of which 118 (87%) reported being currently married. Figure 2 shows further demographic characteristics of the pregnant women in the two countries. Most women in Malawi reported their principal occupation as farming, and most had little formal education.

Malaria Knowledge and Attitudes

Malaria was considered a problem during pregnancy by 87% and 96% of pregnant women in Malawi and Kisumu, respectively. Detrimental health effects of malaria reported by respondents in both countries included maternal illness, spontaneous abortion, and illness in the baby. Antimalarial medication was perceived to be potentially harmful to a pregnant woman or her unborn child by 37% and 74% of women in Malawi and Kenya, respectively. Most women in both countries reported that antimalarials were effective for treatment and prevention of malarial illness.

Delivery of Services

Over 95% of ANC attenders reported receiving an ANC card; however, only 26% of Malawian attenders and 13% of Kenyan attenders could produce a ANC card for examination. Correlation between reported number of visits and number recorded on the ANC card, when available, was high (Schultz et al. 1994). Reported receipt of TT immunization was common in both countries. Among primigravidas, however, fewer than 80% in Malawi and 60% in Kenya reported receiving two doses TT. More than 70% of women in Malawi and more than 90% in Kenya reported having received Fe and/or fol from the ANCs. With prevalence of anemia (defined by WHO as haemoglobin level below 11 g/dL) as high as 82% and 79% in the study areas (Brabin 1983), coverage with Fe and fol is important. Syphilis testing was not routinely available in Malawi (Steketee et al. 1994). In Kenya, a policy existed for syphilis testing; however, testing was often unavailable for months at a time because of shortages of reagents (Schultz, unpublished). Reflective of the difference in malaria control policy between the two countries, 73% of Malawian women reported receiving CQ, compared with 4% of Kenyan women. Of the Malawian women, however, only 61% of those receiving CQ reported taking the recommended dose of two tablets weekly.

Utilization of Antenatal Clinics

In both Malawi and Kenya, over 90% of women reported attending an ANC at least once. The total number of reported visits was similar in Malawi and Kenya, with 87% and 92%, respectively, attending two or more times. More than 40% of the women in both countries reported attending five or more times. ANC attendance rates were applied to the model in Figure 3 to estimate the proportion of women available for interventions during pregnancy. In both Malawi and Kenya, more than 85% of pregnant women were available to benefit from a two-dose antimalarial regimen, coverage with two-dose TT, syphilis testing and treatment, initial Fe/fol supplementation, and risk assessment with one follow-up. In contrast, fewer than 45% were available for continued risk management and Fe/fol coverage throughout their pregnancy.

Fifty-six percent of Malawian women and 37% of Kenyan women delivered in a hospital or clinic setting (Figure 4). In both countries, women who attended ANCs were significantly more likely to deliver at a hospital or clinic than women who had never attended an ANC. For those delivering at a health facility, 68% of Malawian women and 52% of Kenyan women walked to the facility; 80% of Malawian women and 95% of Kenyan women reported waiting until the onset of labour to travel to the facility. Only 55% of women with high-risk pregnancies in Malawi and 33% in Kenya gave birth in a health care facility. In both countries, rates of ANC attendance and hospital delivery were similar among high- and low-risk pregnancies.

Discussion

The recent identification of an efficacious, safe, affordable, and cost-effective antimalarial intervention represents a technologic advancement for improving maternal and infant health. However, its identification alone does not ensure its delivery. Malaria has long been recognized as a health problem during pregnancy, yet few African countries have implemented an antimalarial strategy with wide coverage among pregnant women. Our study showed that in Malawi, which has a national policy of administering CQ during pregnancy, more than 25% of women attending ANC failed to receive CQ. Many more received it irregularly or at an inadequate dosage. In Kenya, where a clear policy does not yet exist, only 4% of women received an antimalarial drug. These findings are consistent with community-based surveys of seven regions in four other sub-Saharan African countries which showed that although 34–68% of women reported attending ANCs, only 1–18% reported using weekly antimalarial prophylaxis (Steketee et al. 1994). These findings suggest that a clear policy for antimalarial use in pregnancy is needed but is not sufficient to ensure appropriate antimalarial drug use in pregnancy.

In recent years, antimalarial interventions may not have been actively promoted because of the lack of an identified efficacious and safe drug in the face of widespread CQ-resistance. However, prevention of malaria is not the only intervention that is not being delivered to pregnant women. Although most women in sub-Saharan Africa appear to be using ANCs, the health care system is failing to provide uniformly basic services which could greatly reduce the risk of pre- and perinatal complications. We observed that 16–38% of primigravidas failed to receive two doses of TT, and that few women underwent testing and treatment for syphilis, despite visiting an ANC two or more times. Similar findings have been reported elsewhere: in Zambia, although the mean number of ANC visits was more than five, only 50% of the primiparous women received two doses of TT (Ransjo-Arvidson et al. 1989); 72% were tested for syphilis, and almost 25% of women testing positive for syphilis did not receive appropriate treatment (Henderson and Sundaresan 1982).

Our investigations in Malawi and Kenya identified certain opportunities for the delivery of antimalarial interventions. The finding that women recognize malaria as a health threat during pregnancy and believe medicine is capable of preventing malarial illness will help to ensure acceptance of an antimalarial intervention. Although compliance with antimalarial home-dosing has limited program effectiveness for previous regimens (Heymann et al. 1984), the recent identification of a two-dose SP regimen which can be administered during ANC visits in the second and third trimesters should eliminate the obstacle of low compliance. An additional opportunity exists in linking the two-dose SP regimen to an existing program, such as tetanus toxoid immunization, that has similar timing for its two-dose schedule among primigravidas. The existing widespread support of immunization programs for antenatal packages could offer the necessary support for a linked delivery program with antimalarials.

The provision of high-quality antenatal care is one strategy aimed at reducing the high risk of maternal mortality among African women and perinatal mortality among their infants (WHO 1991). Although further efforts to find new or improved methods of promoting both maternal and infant health should continue, the fact remains that a package of antenatal services already exists which is not being delivered. For sub-Saharan Africa, this package includes providing effective antimalarials. Understanding specific health problems, the necessary interventions, patient attitudes and behaviours, and the ability of the ANC system to deliver interventions is essential to design and implement a successful antenatal care package. Data that identify opportunities for delivery of antenatal interventions, such as these presented here, should enable programs to better focus efforts at improved antenatal care. Program effectiveness can, in part, be judged by our ability to provide and women's choice to use these services. Application of current technology can decrease maternal and infant mortality through affordable, effective, and deliverable antenatal interventions - and pregnant women are accessing the health care system. We must seize the opportunity to improve the delivery of antenatal services lest we fail to reach women at the threshold of safe motherhood.

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· Greenwood, A.M.; Greenwood, B,M.; Bradley, A.K.; Williams, K.; Shenton F.C.; Tulloch, S.; Bypass, P.; Oldfield, F.S.J. 1987. A prospective survey of the outcome of pregnancy in a rural area of The Gambia. Bulletin of the World Health Organization, 65, 635–643.

· Greenwood, B.M.; Greenwood, A.M.; Snow, R.W.; Byass, P.; Bennett, S.; Hatib-N'Jie, A.B. 1989. The effects of malaria chemoprophylaxis given by traditional birth attendants on the course and outcome of pregnancy. Trans R Soc Trop Med Hyg, 83, 589–594.

· Henderson; R.H.; Sundaresan, T. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. Bulletin of the World Health Organization, 60, 253–260.

· Heymann, D.L.; Steketee, R.W.; Wirima, J.J.; McFarland, D.A.; Khoromana, C.O.; Campbell, C.C. 1984. Antenatal chloroquine chemoprophylaxis in Malawi: Chloroquine resistance, compliance, protective efficacy and cost. Trans R Soc Trop Med Hyg, 496–498.

· Hira, S.K.; Bhat, C.J.; Ratnam, A.V.; Chintu, C.; Mulenga, R.C. 1982. Congenital syphilis in Lusaka II: Incidence at birth and potential risk among hospital deliveries. East Afr Med J, 59, 306–310.

· Jelliffe, E.F.P. 1968. Low birth weight and malaria infection of the placenta. Bulletin of the World Health Organization, 38, 69–78.

· Keuter, M; van Eijk, A.; Hoogstrate, M; Raasveld, M; van de Ree, M; Ngwawe, W.A.; Watkins, W.M.; Were, J.B.O.; Brandling-Bennett, A.D. 1990. Comparison of chloroquine, pyrimethamine and sulfadoxine, and chlorproguanil and dapsone as treatment for falciparum malaria in pregnant and non-pregnant women, Kakamega district, Kenya. Brit Med J, 301, 466–470.

· Kortmann, H.F.C. 1972. Malaria and pregnancy. M.D. Thesis, University of Amsterdam.

· MacGregor, J.D.; Avery, J.G. 1974. Malaria transmission and fetal growth. Brit Med J, 3, 433–436.

· Mahler, H. 1987. The safe motherhood initiative: A call to action. Lancet, 2, 668–670.

· McCormick, M.C. 1985. Contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med, 312, 82–90.

· McGregor, I.A. 1984. Epidemiology, malaria and pregnancy. Am J Trop Med and Hyg, 33, 517–525.

· Moller, B.; Lushino, O.; Meirik, O.; Gebre-Medhin, M.; Lindmark, G. 1989. A study of antenatal care at village level in rural Tanzania. Int J Gynecol Obstet, 30, 123–131.

· National Center for Health Statistics. 1993. Health, United States, 1992. Public Health Service, Hyattsville, MD, USA. pp. 35.

· Nordbeck, H.J.; Voorhoeve, A.M.; van Ginnekin, J.K. 1984. Use of perinatal mortality data in antenatal screening. In Van Ginneken, J.K.; Muller, A.S. (ed.). Maternal and child health in rural Kenya: An epidemiological study. Croom Helm, London, UK. Pp. 241–256.

· Quick, J.; Greenlick, M.; Roghmann, K. 1981. Prenatal care and pregnancy outcome in an HMO and general population: A multivariate cohort analysis. Am J Public Health, 71, 381–390.

· Ransjo-Arvidson, A.B.; Christensson, K.; Darkwah, G.; Lungu, F.; Kakoma, C.; Chikamata, D.; Diwan, V.K.; Sterky, G. 1989. Maternity care routines in a teaching hospital in Zambia. East Afr Med J, 7, 427–436.

· Ratnam, A.V.; Din, S.N.; Hira, S.K.; Bhat, G.J.; Wacha, D.S.O.; Rukmini, A.; Mulenga, R.C. 1982. Syphilis in pregnant women in Zambia. British Journal Venereal Disease, 58, 355–358.

· Rooney, C. 1992. Antenatal care and maternal health: How effective is it? A review of the evidence. World Health Organization, Geneva, Switzerland. Document WHO/MSM/92.4.

· Rooth, G. 1979. Better perinatal health: Sweden. Lancet.

· Ryan, G.; Sweeney, P.; Solola, A. 1980. Prenatal care and pregnancy outcome. Am J Obstet Gynecol, 137, 876–881.

· Schultz, L.J.; Steketee, R.W.; Chitsulo, L.; Macheso, A.; Nyasulu, Y.; Ettling, M. 1994. Malaria and childbearing women in Malawi: Knowledge, attitudes, and practices. Trop Med Parasitol, 45, 65–69.

· Schultz, L.J.; Steketee, R.W.; Macheso, A.; Kazembe, P.; Chitsulo, L.; Wirima, J.J. The efficacy of antimalarial regimens containing sulfadoxine-pyrimethamine and/or chloroquine in preventing peripheral and placental Plasmodium falciparum infection during pregnancy. (in press, Am J Trop Med Hyg).

· Schultz, L.J.; Steketee. R.W.; Chitsulo, L.; Wirima, J.J. Antimalarials during pregnancy: A cost-effectiveness analysis. (in press, Bull World Health Organ).

· Steketee, R.W.; Breman, J.G.; Paluku, K.M.; Moore, M.; Roy, J.; Ma-Disu, M. 1988. Malaria infection in pregnant women in Zaire: The effects and the potential for intervention. Ann Trop Med Parasit, 82, 113–120.

· Steketee, R.W.; Wirima, J.J.; Slutsker, L.; et al. 1994. Malaria prevention in pregnancy: The effects of treatment and chemoprophylaxis on placental malaria infection, low birth weight, and fetal, infant, and child survival. African Child Survival Initiative - Combatting Childhood Communicable Diseases. Project Document 099-4048. Atlanta, Ga.

· USAID (United States Agency for International Development). 1994. Controlling malaria in Africa: Progress and priorites. African Child Survival Initiative - Combatting Childhood Communicable Diseases Project Document 099-4050. Atlanta, Ga.

· US Congress, Office of Technology Assessment. 1988. Healthy children: Investing in the future. OTA, Washington, DC, USA. OTA-H-345. Pp. 73–90.

· Voorhoeve, A.M.; Kars, C.; Van Ginneken, J.K. 1984. Modern and traditional antenatal and delivery care. In Van Ginneken, J.K.; Muller, A.S. (ed.). Maternal and child health in rural Kenya: An epidemiological study. Croom Helm, London, UK. Pp. 309–322.

· World Health Organization. Expanded Program on Immunization. 1986. Prevention of neonatal tetanus through immunization. World Health Organization, Geneva, Switzerland. Document WHO/EPI/GEN/86.9.

· World Health Organization. WHO Expert Committee on Malaria. 1986. World Health Organization, Geneva, Switzerland. WHO Technical Report Series no 735. pp. 57–59.

· World Health Organization. 1991. Maternal mortality: A global factbook. WHO Division of Family Health, Geneva, Switzerland. Pp. 1170–1172.

Linda J. Schultz, Richard W. Steketee, Monica Parise, and Bernard Nahlen are with the Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Jack J. Wirima is at the University of Malawi, Blantyre, Malawi; Aggrey Oloo and Bernard Nahlen are with the Kenya Medical Research Institute, Kisumu, Kenya.

An Epidemiological Study of Gynecological Morbidity in a Rural Community of Haryana, India

Alka Sehgal, Amarjeet Singh, Rajesh Kumar, and Indu Gupta

Summary: A cross-sectional, population-based study was conducted among rural women in two villages of Haryana State (India) to determine the prevalence of gynecological morbidity. A total of 225 women underwent complete general and gynecological examinations. Of these, only 55% reported complaints related to sexual organs, although 72.7% were found to be suffering from some form of gynecological disease. Menstrual irregularities and genital tract infections were two major causes of gynecological morbidity. Of the women, 82% believed that their family planning method was the root cause of their ill health; 60.4% felt that their problem was an abnormal phenomenon, although their perception of the cause of their disease was unscientific. Consultation is sought infrequently for gynecological problems; when it is sought, health personnel often have little knowledge of gynecological disease. The majority of patients seek no treatment or undertake only partial treatment, which may be nonspecific in nature. Concentration on obstetric care to the neglect of nonpregnant reproductive health has compounded gynecological morbidities in rural areas.

Introduction

Maternal and child health care is one of the eight basic components of primary health care in the Alma-Ata Declaration, and its provision to the community is an essential perquisite for "Health for All by the Year 2000" (W'HO and UNICEF 1978). Because of the continued high maternal mortality rate in developing countries, including India (Sai 1987), there is increasing international concern about the provision of health care during pregnancy and child birth (Conable 1987). The Safe Motherhood Program is currently in the process of upgrading maternity care services in India. This indicates the high priority that national and international agencies are placing on the prevention of maternal mortality.

In comparison, scant attention has been paid to the reproductive health of nonpregnant women. In India and other Third World countries, women usually do not consult physicians or gynecologists, due to inhibition or to a lack of perception of causes of disease. Their only contact with the health care system is through health workers for family welfare programs (Bang 1987).

The lack of concern of health care planners for the prevention of gynecological abnormality can be traced to a lack of adequate information about rural health problems. Most data on morbidity among nonpregnant women are either hospital based (Wahi et al. 1972; Mali et al. 1984) or selective for a particular disease (Bali and Bhujwala 1969; Sharma et al. 1984). Occasional studies among the rural population in India have pointed out that gynecological morbidity may be present in 92% of the women (Bang et al. 1990).

In the present study, we sought to determine

· The prevalence of gynecological diseases among rural women of reproductive age,

· The awareness and perception of women regarding causes of disease, and

· The current role played by health workers in management of such complaints.

Materials and Methods

Study Area and Sample Population

The study was carried out in two villages of Haryana State (North India). These villages were a part of the Raipur Rani community development block in the district of Ambala. The first village, Ramgarh, had a population of 3000, of which approximately 550 were females 15 to 45 years of age. This village had a health subcentre. The second village, Kot, had a population of 1290, of which about 280 women were of reproductive age. This village has a Primary Health Centre (PHC) with a female doctor as a medical officer. Both villages are about 20 km from the state capital town of Chandigarh, and are connected to it by paved roads.

Investigations

Field camps were set up in both villages (on different days) after repeated visits and distribution of pamphlets by local health workers regarding the date of camp. All patients coming for check-ups were interviewed by female doctors specialized in the field of obstetrics and gynecology.

Detailed histories, including personal details, socioeconomic status, education, perceptions of disease, practices regarding gynecological symptoms, any treatment taken (obstetric and gynecological), and sexual histories, were noted. A complete general physical examination, including hemoglobin and urine analysis, was completed for each patient. A pelvic examination, including a perspeculum examination, was also conducted. Cervical smears were taken from 100 patients. Patients requiring special investigations or treatment were referred to the Postgraduate Institute of Medical Education and Research, Chandigarh, the Civil Hospital, Ambala, or the Civil Hospital, Naraingarh. At a later date, the women were followed-up at home or at the subcentre/PHC with the help of a local leader or the health workers.

Results

A total of 225 women were interviewed and screened for gynecological problems: 155 were from Ramgarh, and 70 were from Kot. On average, the women attending the camps were aged 29 years - 41% were illiterate and 62% were of low socioeconomic status.

Overall, 55% of the women had gynecological complaints. Most of the complaints were related to menstrual irregularities (32.4%); the other common complaint was vaginal discharge (11.1%). Other complaints are outlined in Table 1.

Some 40% of the women accepted their ill health as a normal phenomenon, whereas almost 50% felt they did not require any treatment. The women's perceptions of the causes of their diseases were very unscientific, with most attributing their condition to their use of contraception (see Table 3).

It was observed that patients seek consultation for general complaints more often than for gynecological disease: 63% of the women sought consultation for general complaints, whereas only 47.2% sought consultation for gynecological diseases. The majority of women sought consultation from an unqualified local practitioner or from a health care clinic. The nonavailability of a female doctor was the most common reason given for not seeking consultation (Table 4).

Only 54% of the women took any form of treatment for their disease; of these, only 52% completed the full course of treatment. The reasons given for not completing treatment are given in Table 5.

Discussion

Our study may not reflect the actual prevalence of gynecological morbidity in the community, as only 25% of the females of reproductive age attended the camps. In addition, the majority of women attending the camps came with more gynecological complaints than general complaints. This may be due to their motivation, to their less-orthodox character, or perhaps to the posted advertisement regarding the camps, which offered women a chance to receive specialist medical advice.

The number of women who presented gynecological complaints was actually less than those who actually had problems on examination. This may be due to the women's perception of the problem, as up to 40% of the women considered their problems to be a normal phenomenon. This discrepancy is obvious in women complaining of vaginal discharge and menstrual irregularities.

Some 40% of the women had no specific perception of disease causation, while the rest related it to some abnormality. Fifty percent of the women thought that no treatment was required for these problems. Concepts of hygiene were very poor. Scanty periods were deemed to be an important issue, as the washing away of "bad blood" (menstrual blood) is believed to be a prerequisite for good health. On the other hand, post-menopausal bleed was thought to be a normal part of sexual activity. One alarming finding was that 82% of women blamed the use of contraception directly or indirectly for their disease(s), irrespective of the type of contraception adopted and the duration of its use. This percentage is higher than in previous reports, in which 66% of women attributed their problems to contraceptive use (Bang et al. 1990).

Very few women blamed supernatural powers for their complaints. This may be attributed to awareness created by health workers. However, one cannot overgeneralize this finding: orthodox women may not have attended the camps. Menstrual problems and vaginal discharge are commonly associated with food habits.

Fewer than half the women in villages sought consultation for their problems. The majority went to either unqualified village practitioners (22%), auxiliary nurse midwives (42.8%), or to private doctors (23.3%), all of whom have limited knowledge of gynecological problems. Only 4% of such women received a vaginal examination. The reasons for this lack of consultation are many: lack of proper health facilities and nonavailability of female doctors. Even in the village where a female doctor was available, however, a lack of motivation and lack of proper examination made the facility redundant.

Of the 47.7% women who took consultation, only 54% were prescribed or took treatment; of these, only 52% completed the course. The most common reason given for not completing the course was the expense. The majority of the prescription slips which could be screened were either for medication that was nonspecific or for symptomatic relief.

Some glaring examples of nonspecific treatment prescribed included hematinics for cases of cervical and uterine cancer with bleeding. Nonspecific hemostatics were also given for cases of fibroid uteruses with excessive bleeding. In one case, ovarian cancer resulting in a distended abdomen was managed as a pregnancy. Local steroids were prescribed for condyloma lata, cephalosporins for vaginal discharge, and so on.

References

· Bali, P.; Bhujwala, R.A. 1969. A pilot study of clinico-epidemiologic investigations of vagina discharges in rural women. Ind J Med Res, 5, 7-12.

· Bang, R.A. 1987. Counselling and choice in family planning. Paper presented at international conference on better health for women and children through family planning. Nairobi, October 5-9.

· Bany, R.A.; Bang, A.T.; Baitule, M.; Choudhary, Sarmukaddam, S, Tale, 0. 1990. High prevalence of gynaecological diseases in rural Indian Women. Lancet, 1, 85-87.

· Conable, B.B. 1987. Safe motherhood. WHO Forum, 8, 115-160.

· Mali, S.; Wahi, P. N.; Luthra, U.K. 1968 Cancer of the uterine cervix. Ind J Cancer, 269-273.

· Sai, F.T. 1987. Safe motherhood initiative: A call for action. IPPE Bull, 21, 3.

· Sharma, R.S.; Dutta, K.K.; Gupta, J.P.; Mahelldra, Dutta. 1984. A longitudinal study of morbidity pattern among housewives in rural Rajesthan. Indian Journal of Public Health, 28.

· Wahi, P.N.; Luthra, U.K.; Mali, S.; Shamkin, M.B. 1972. Prevalence and distribution of cancer of uterine cervix in Agra district, India. Ind J Cancer, 30, 720-725.

· WHO (World Health Organization); UNICEF (United Nations Childrens' Fund). 1978. Primary health care: Report of the international conference on primary health care. Alma-Ata, September. WHO, Geneva, Switzerland.

The authors of this paper are with the Departments of Obstetrics and Gynaecology and Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Problems of Utilization of Nutritional Rehabilitation Services by Mothers of Malnourished Children in N'Djamena (Chad)

Kaspar Wyss and Monique Nandjingar

Summary: This paper reports on a study that explored the difficulties mothers of malnourished children face in using nutritional rehabilitation services in N'Djamena, Chad. The objective, using focus group discussions, was to understand perceptions of malnutrition, to gather information on interactions between the health care workers and the women, and to determine the reasons women abandon the services. We then suggest ways to improve the utilization of nutritional rehabilitation services by mothers.

Most women identify diarrhea and vomiting as the principle causes of malnutrition illness. Quantity and quality of food are rarely mentioned as important elements of health. Other factors mentioned in connection with malnutrition are repeated pregnancies, bitter milk, teething, inflammation of the uvula, and measles; witchcraft and evil spirits are also implicated. Mothers choose multiple treatment options, and often use both "traditional" and "modern" health care, either in parallel or consecutively.

The length of the rehabilitation program (3 months) was rarely mentioned as a problem. On the other hand, long waiting times and the time of day when nutritional supplements are provided are seen as major obstacles to utilization, since the women feel that it takes too much time away from their other essential tasks. Some appreciate the nutritional supplements, but others complain that the enriched porridge causes diarrhea.

Because the children often need treatment for disease as well as nutritional supplements, the lack of drugs available in N'Djamena is perceived as a major problem. The women also complained about the amount and costs of the prescriptions. Furthermore, the women are dissatisfied with their reception by the health services personnel, and the incorrect distribution of nutritional supplements.

Principle causes for abandoning the services include the social and economic position of women, difficulties with access, the long waiting periods, unsatisfactory contact with the personnel, and the high costs for drugs.

Health services can improve the utilization of nutritional rehabilitation services by making drugs available through the establishment of a cost recovery system, and by promoting participatory approaches that can establish better communication and exchanges between the women and the personnel of health facilities.

Introduction

For several years, food aid - mainly under famine conditions - has been a frequent topic of discussion, debate, and publication. The "drama" of a hunger catastrophe in a Southern country, often related to a situation of crisis or war, attracts public interest in the North and in international organizations.

Apart from these crises, however, persistent malnutrition continues in many countries, particularly among young children. Two anthropometric studies carried out in N'Djamena, Chad, revealed that malnutrition rates were as high as 8.5–10.3% among children aged 6 months to 5 years (Ministère de la Santé Publique 1987, 1989). These studies were carried out during a critical period in the year, just before the rainy season, when the availability of food is low and prices high.

In Chad, as elsewhere, first-level health centres are responsible for delivering a core package of curative, preventive, and promotional services, including the detection and treatment of child malnutrition (Ministère du Plan et de la Coopération 1993). In N'Djamena, the admission of malnourished children to nutritional services began in 1991 in four of the city's 11 health centres.

Children are enrolled in the rehabilitation program when their weight-for-height ratio falls below 80% of the international standard median of NCHS (United States Public Health Service 1976; Waterlow et al. 1977). The duration of treatment is 12 weeks. During the first 6 weeks, the children must be brought to the health centre each day by their mothers. While there, they receive preparations of milk and a porridge enriched with oil and sugar. During the following 6 weeks, if the child's progress is deemed satisfactory, follow-up continues at home. The mother brings the child to the centre once a week for weighing and to receive the nutritional supplements.

During 1992, 542 children were admitted to the nutritional rehabilitation program; 31% were withdrawn from treatment before the end of the program and 14% died during the treatment period (Ministère de la Santé Publique et des Affaires Sociales 1993). Of the children who finished the program, only 31% fulfilled the criteria for a complete cure (weight/height 80% of median NCHS standard) after the 12-week period. Similar results have been observed in other African countries (Beau and Sy 1993; Hennart et al. 1987; Van Roosmalen–Wiebenga et al. 1987).

The relatively high percentage of withdrawal - nearly one-third of the children - indicates that accessibility of nutritional services is only partially guaranteed. What are the problems confronting the mothers of the children using the services? Are they related to the sociocultural acceptability of health centres in general and of malnutrition programs in particular? Or are the barriers tied to the behaviour of health service personnel (reception, communication, and so on)? In this study we set out to answer some of these questions, trying to understand the problems that mothers of malnourished children face in using nutritional rehabilitation services. The objectives were to look at the way women perceive malnutrition in children; to obtain information on the interactions between the health care provider and the patients; to investigate the reasons for the abandonment of rehabilitation services; and to suggest means of improving the accessibility of nutritional rehabilitation services for the mothers of malnourished children.

Methods

To understand women's problems related to the utilization of health services, focus group discussions were used (Basch 1987; Dawson et al. 1992; Khan and Manderson 1992). In focus groups, participants are assembled on the basis of a topic of common interest, with the intention of promoting discussion between them. The interactions within the group are considered to be an important element for comprehending the way they think about the topic.

In all, eight groups were formed, six with women using the centres and two with personnel providing the services. Of the women's groups, two were composed of mothers who had continued with the treatment of their child until it was finished, and two of mothers who had abandoned the treatment. Two groups were heterogeneous, with some women who had terminated treatment and others who had abandoned it.

The discussions took place between December 1992 and March 1993. Mothers of malnourished children were identified by nutritional assistants at the health centres or from the consultation register, and were invited to participate. The discussions were held at a place completely independent of the health centre, usually in the courtyard of the compound where one of the mothers lived. Attempts were made to ensure that there was no direct connection with the health centres - none of the people present during the discussion worked in a centre - and that a stimulating ambience for a free exchange was present. Discussions with the personnel took place at their place of work. In each group, between 6 and 12 women participated. Discussions lasted 1 to 2 hours, and they were conducted in the local languages, Arabic, Sara (or N'Gambaï, a local dialect of Sara), or in other languages. The discussions were later translated into French.

The discussions were guided by a female animator, who raised the questions and tried to ensure a natural conversation. The questions focused on perceptions of children's malnutrition, the centre's treatment program, and the reasons for abandoning the treatment. The animator used a pre-prepared interview guide that was oriented toward the principle questions to be raised during the discussion.

At the beginning of the discussion, the animator showed two photographs, one of a malnourished child and one of a child in good health. The participants were asked to describe what they saw in the pictures. The animator then guided the discussion toward the reasons for abandoning the centres. In addition to the animator and the participants, a woman observer was present during the discussion. Her task was to note the exchanges between the participants (attitudes, gestures) and the principal topics of the discussion. She was also responsible for tape-recording the conversation.

The discussions were analyzed on the basis of the transcription, as proposed by The Focus Group Manual (Dawson et al. 1992): the elements of the text were classified, and the terms or topics used by the participants were identified. The content of the speeches was then examined.

Results

Living Conditions

Women participating in the discussions were living in different neighbourhoods of N'Djamena (principally Farcha, Madjorio, Moursal, Chagoua, Dembé) and in villages around the city. They had different ethnic (Arab, Gabi, Haoussa, Bornou, Ouaddaï, Sara, N'Gambaïe, Lélé, Gore) and religious (Islamic, Protestant, Catholic) backgrounds, and were aged between 18 and 40. The length of time they had lived in N'Djamena was also variable; some were born in the city and others had arrived recently. Most of the women had never been to school, although some had received some primary education.

The women using the nutritional rehabilitation services are confronted with problems common to most women in N'Djamena: the general living conditions are poor and their socioeconomic situation is difficult. The gender division of work - still present even in the urban context - allocates to women domestic tasks and the care of the children. At the household level, the woman has multiple duties: she is responsible for the availability of water, the cleanliness of the household, the organization of marketing, the preparation of food, and the health of the children. "A housewife doesn't lack work."

Furthermore, many women are in a situation where the husband (if there is one) is earning nothing, or not enough to guarantee a minimal basis for existence. The incomes of women, therefore, become indispensable to the functioning of the household. The women have various coping mechanisms; often they engage in petty trade, frequently in the food sector. "If I got a small scale trade, I could give my child what he needs; what his heart desires."

A multitude of extra tasks arise with the illness of one or several of the children. The responsibility for health and care of the children places new demands on the mother. These demands are considerable for severe or long-lasting conditions such as malnutrition. "When a mother has a very sick child, she has no rest day and night."

Although the female staff members of the health centres live and work under similar conditions, they showed little or no understanding of the social and economic situation of the mothers. As one social worker said:

Women like that always have problems. A child gets sick, then maybe they don't sleep peacefully at night; they aren't at their husband's side but are disturbed by that child and preoccupied with it. So they always have a problem - basically, it's all psychological.

The views of the medical staff about the patients are often dominated by the conviction that ignorance is at the root of disease. "The mothers of malnourished children are negligent mothers." There is very little recognition on the part of the health personnel of the mother's functions and obligations.

The Child's Illness

When the photograph showing the malnourished child was presented to the mothers, they recognized the child as being sick, as suffering from the same disease as their own. "That child really has a wicked illness. He is between the hands of death. My child was exactly like this one." Even though the child in the picture was perceived as being gravely ill, the term "malnourished" was never used by the women. In fact, it is a word that does not exist in the vernacular languages of Chad.

Some mothers do talk about nutrition and vitamin deficiency in connection with the child: "It's the hunger. When a child is sick and his mother doesn't give him enough to eat, he will suffer from hunger on top of the illness. That can kill a child." As another mother explains: "But just being hungry doesn't make a child look like that. There has to be diarrhea and vomiting at the same time."

In fact, diarrhea and vomiting are identified by the women as the main causes of malnutrition. The mothers complain that diarrhea and vomiting are accompanied by additional problems. "She had diarrhea and vomiting. She suffers a lot. She's more than a year old, but she's never been healthy. She has all kinds of problems." Other factors such as measles, teething, and inflammation of the uvula are also identified as sources of childhood malnutrition.

Several women said "Bitter milk is my problem; my milk is not good." However, not everyone accepts the idea of "bitter milk." "The women talk about amboula (bitter milk) but in medicine this doesn't exist. The old people say that it is the bad milk that gives the child diarrhea." Sometimes a new pregnancy is seen as the cause of the milk being bitter. "The child has diarrhea and vomits because the milk doesn't belong to it, and because its mother is pregnant with another baby." The negative consequences of frequent pregnancies are connected with malnutrition. "You have a child in your arms, you're pregnant again, and the other child has diarrhea all the time. Repeated pregnancies are bad."

Sometimes the women ascribe malnutrition to supernatural forces: angry spirits of the ancestors, evil spirits, and the effects of witchcraft. They are thought to have a negative influence on the health of the child.

In contrast to the mothers, the health professionals describe the malnourished child as an object, using technical and technocratic expressions. "This child is dehydrated /marasmic/has kwashiorkor. It has edema, it's a malnourished child, dehydrated."

The Quest for Therapy

The women often have recourse to several forms of therapy, and both "modern" and "traditional" forms may be used either consecutively or in parallel. "There are children who are lucky enough to be cured rapidly, and there are others you are forced to take to the marabout. It may be witchcraft." The health personnel confirms that "there are mothers who disappear and then appear again saying 'I did a traditional cure, now I think your porridge is better.'"

The quest for therapy for the malnourished child takes the mothers on a pilgrimage from one health facility to another until they finally arrive at the nutritional service.

This child! I went with him to the Central Hospital - no improvement; to Asiam Vantou - no better; to the Polyclinic - still no improvement. And I was tired. Finally I took him to the nutritional rehabilitation service until he was able to walk. If I had got tired on the road to the porridge, my child would have died.

The mothers of the malnourished children had rarely known about the nutritional rehabilitation services beforehand. Sometimes it was a neighbour who had made the suggestion. "My child was so sick, that he even couldn't sleep at night. One day, one of my neighbours came and advised me take him to the centre. I was accepted at the centre and I went there morning and evening." The referral system between the different health facilities of the city and those offering nutritional rehabilitation services is not well established. "I waited around in the hospitals for several months before I discovered the centre where my child could be treated."

The situation is the same concerning the relationship between preventive consultations for children and the rehabilitation services: malnourished children are not identified and not referred correctly by the city's health services. Finances pose a serious constraint to women who are forced to go from one service to another. They often have to pay for consultations and for drugs.

Every time you have to pay 100 francs for this, 100 francs for that. If you multiply these 100 francs by the number of times you go to hospital, you are not able to find the necessary money. And so we are obliged to make debts.

Admission and Waiting

The 3-month treatment program seems to many staff to be too long, believing that it poses a barrier to some mothers. "This duration of 12 weeks is much too long, because some women live far away." The women, however, rarely criticize the program's duration. Several women, in fact, express the wish to stay longer. "I thought I would be at the centre for 2 years." The women are puzzled that no follow-up is guaranteed after the end of the treatment. "When the centre let us go, all the children got ill again." Relapses are frequent, as has been reported in other studies (Beau and Sy 1993; Hennart et al. 1987; Van Roosmalen–Wiebenga et al. 1987). Several women mentioned that they had stayed twice for 3 months at the rehabilitation service. "After 3 months at the centre the treatment is terminated. But when the child is weighed and he is too weak, we go for another 3 months."

In contrast to the total duration of the treatment program, the time spent each day waiting for the distribution of the porridge and the milk is a frequently mentioned problem. "It's not that it takes so long, but having to wait til 11 o'clock makes it seem a terribly long time." With the women's numerous obligations, waiting poses a series constraint to the morning's smooth organization, and few can afford to wait for several hours. "What we receive is fine. But why so late? We've got other children at home waiting for us. They have to go to school and we have to go to the market." The fact that it is impossible for the women to wait for a long time leads to conflicts with the personnel, who have very little appreciation of the women's daily tasks. "They would like to be here at 8 a.m. to leave again at 9 a.m. for the market. This is their real problem."

The Lack of Drugs and the Quality of the Porridge

One of the most sensitive points for the women is the lack of drugs available through the health services of N'Djamena. "Hospitals were created for the children and when we visit them there are no drugs." The women also make complaints about the prescriptions.

If you don't take your sick child to the hospital, the family thinks you are negligent. And if you go to the hospital, there are plenty of problems. Always a prescription. To go to the hospital and then to come back to purchase the drugs isn't worth the effort.

Women have to spend huge sums to purchase the drugs. Within a context where money is lacking, prescriptions are absolutely not appreciated. "A man to whom you present every day a prescription will get tired. Furthermore, when he has no work..."

The health professionals face a difficult problem: despite the lack of drugs and other materials, they are expected to offer continuous, high-quality care. In the absence of drugs, the staff are doubtful of the efficacy of care they can provide for the malnourished children:

There are women who say "my child is sick; giving him just porridge is not enough, you also have to cure him." The mothers haven't the financial means to purchase the drugs. We can't offer any antibiotics in the health centre and this delays the success of the treatment.

The staff may go to some lengths to satisfy the women.

There are mothers who are satisfied. But sometimes there are mothers who say that their children are sick, and if they don't get any treatment they will be disappointed. Given the porridge without anything, they aren't satisfied. So we take some vitamins and put them into the porridge and the mothers think it's a drug.

The porridge and the milk offered by the nutritional rehabilitation services cannot fill the crucial role played by drugs, to which the women attribute the efficiency of the therapy. Opinions on the quality of the porridge are ambiguous. Some women appreciate it, "My child gulps down the porridge"; others think there is a connection between the consumption of the porridge and the child's diarrhea. "The porridge makes my child swell up and increases the diarrhea." Sometimes the women just speak about the bad taste of the porridge. "My child thought the porridge at the centre was disgusting." Several times the women mentioned the lack of variety of the food.

During some discussions, the mother's demands focused on material assistance. "Because it's cold, the centre has to give us pullovers so that we are able to protect our children." For these women, the nutritional rehabilitation service's purpose is to distribute nutritional, material, and economic handouts.

Relationships with the Health Personnel

The women's feelings about the personnel of the health centres were divided. The reception by the nutritional rehabilitation centre staff is a topic of intensive discussion. Some mothers are satisfied: "There is no problem. We are received kindly, there is an awning to sit down under..it's OK." Other women deplore the attitudes of the health personnel.

The centre is supposed to be here to accommodate the sick children. But then the staff just say mean things. How can the child get better? When we leave the centre we grumble about it on the way home.

The women don't hesitate to accuse the personnel. "Several children have died because of the behaviour of the staff." A woman who spoke the Haoussa dialect said about the attitude of the personnel: "I don't understand either French or Arabic. So how can I understand the insults? I'm going there for my child. Even if they strike and beat me I'll still go, to get the porridge for my child."

The women also complain that service staff show them no respect. They feel that the relationship between them does not correspond to the kind of contract that should exist between one who has the power to cure and one who is asking to be cured. "They are like our godparents, who profit from us."

The personnel, on their side, rarely discuss the importance of the reception of the mothers and their social relationships with them. The person in charge of one centre said:

Concerning the reception, we ourselves are trying to make things better. If the attitudes of the staff have not been good, we will try and improve them. However, no woman has ever left the centre because of the reception.

The strained relations between the mothers and the personnel are aggravated by the fact that some staff members do not hand over all the nutritional supplements to the beneficiaries. They are accused of not providing the right quantity of porridge or tins of sardines (given by the Programme Alimentaire Mondiale (PAM)). The women say that the personnel distribute just a fraction, and that they give the rest to their own family members.

To those they called, they gave four spoonfuls of porridge, but to us they gave just a little bit, just one spoonful. To their family members they hand over masses of tins of sardines, but for us they keep only a few.

The women are aware how much should be distributed to them, and are very observant of any malpractice. "On the day of distribution, the traders come to buy the food in big quantities. To us they hand over just one tin."

During 1992 and 1993, repeated strikes immobilized the health facilities, including the nutritional rehabilitation services. However, this temporary stoppage of health care provision did not arise as an element in the discussions.

Reasons for Abandoning Treatment

The women gave diverse reasons for abandoning treatment: the quality of the porridge, the duration of waiting, the distance to the health centre, the expenditures for drugs, and the socioeconomic obligations of the women.

Sometimes the quality of the porridge is considered to be so bad that it is an argument for abandoning treatment. "I was asked to stay for 3 months. After 1 month my child refused to eat the porridge. I don't know whether she just began to find it disgusting."

During the discussions, the lack of drugs for the treatment of malnourished children appeared as an argument. "When you have got a sick child, no drugs are given, and every day you have to go to the health centre. Then it's normal that you're getting tired. Because of this, some women refused to return."

The situations under which the women live may make it impossible for them to make use of the nutritional rehabilitation services. "We refused to go to the centre because we have too much do at home." The women must consider whether the benefits they hope to gain from using the centre justify the expenditure of time and energy that are badly needed for other essential activities. "I'm a trader and they want that I lose my time at the centre - and meanwhile other children wait at home. My commercial activities are more important."

The personnel confirm that withdrawal is often due to the social obligations of the women:

Generally mothers say that they are busy, that they aren't able to come, that they have to travel or that they are traders. They also say that their business nourishes the whole family and that they cannot neglect all the children just for one.

The staff members also believe that the main reasons for withdrawal focused on the poor geographic access to the services and the long duration of waiting.

The women have to get up early, to prepare the breakfast and then come here and go home again. It really is hard work. They think that all this going to and fro takes so much energy that it's tiring for the child. They think that if they are making all this effort just to get a few spoonfuls of porridge, it would be better to keep the child at home and treat it there. Often the women don't like to stay from 8 a.m. to 11 a.m. every day for several weeks. So they abandon the treatment.

It is interesting to note that the women rarely mentioned distance as a barrier to health centre accessibility. The staff also believed that a preference for "traditional" therapies was a cause for withdrawal by some women from the program. "Some mothers come two or three times, and then say that the illness of their children is not malnutrition. They want to go to the marabout, because they say it's witchcraft."

Conclusions

One of the problems of the nutritional rehabilitation services for malnourished children is, in N'Djamena as elsewhere, that the mothers of malnourished children frequently abandon the centre before the treatment is finished. It is important to understand the reasons for this to increase the effectiveness of the services. In public health and tropical disease research, an increasing interest is being shown in rapid assessment methods (Anker 1991; Manderson and Aaby 1992; Vlassoff and Tanner 1992), and especially in the methodology of focus group discussions (Khan and Manderson 1992). In Chad, focus group discussions have rarely been used. Only one study, in fact, has used this method to investigate the demand for family planning services, the perceived benefits, and barriers against their utilization (Ministère de la Santé Publique 1988). Elsewhere in Africa, focus groups have been used to study problems related to AIDS (Irwin et al. 1991), barriers to the utilization of obstetrical emergency services (Prevention of Maternal Mortality Network 1992), and perceptions of goitre (Andrien et al. 1993).

The discussions in N'Djamena highlighted the difficulty of the domestic situation and the socioeconomic environment of the women utilizing the health centres. The division of work by gender allocates a multiplicity of tasks to them, and they are often also responsible for the family's income. With the illness of a child, the women's obligations increase. Most women identified diarrhea and vomiting as major causes of malnutrition, and realized that they should seek treatment. However, the final decision about whether to use a nutritional rehabilitation service or some other kind of therapy results from the interaction between the desired benefits and a variety of social, spatial, financial, and cultural constraints.

A more detailed analysis of these constraints would require quantitative as well as qualitative techniques. The findings of focus group discussions alone are not a sufficient basis for making a detailed situational appraisal of the problems of women and their malnourished children in the urban context of N'Djamena. A more comprehensive assessment would encompass both quantitative and qualitative analyses, including gender roles, the food available for the household, and living conditions as a whole. Quantitative data could be obtained through household surveys focusing on the social, environmental, and economic situation of women, on gender roles and family structure, and on the food available for children. Qualitative methods (observations, interviews) could supply indepth information on attitudes to child nutrition. It would also be interesting to assess in detail the frequency of relapses in N'Djamena, which are reported from studies in other countries to be quite high, in order to evaluate the efficacy of the nutritional rehabilitation services. Nevertheless, the present study shows that the focus group technique can provide insights into the perception of malnutrition by the mothers of malnourished children, their interaction with health care providers, and the causes for their abandoning treatment.

Although nutritional interventions can be implemented through vertical programs (Pelletier and Shrimpton 1994), they are most effective if they are integrated into the country's PHC provisions. In Chad, the integration of nutritional rehabilitation services into the globality of health care offered is not satisfactory. The detection and referral of malnourished children is the task of first-level health centres, but communication between the curative and preventive services of health centres is weak, and most women have to pass through several different health facilities to find therapy for their child. An operational referral system, including referrals from preventive to curative services, could facilitate the utilization of rehabilitation centres.

The abandonment of treatment once started is another problem. Principle causes in N'Djamena are loss of time, which is needed for other household duties and for economic activity, the behaviour of the personnel, and the availability of drugs. The time of distribution of supplementary food, and the long waiting period are also major problems for the mothers. The 3-month duration of the program is rarely mentioned as a barrier for the nutritional rehabilitation.

The lack of drugs available through the public health services in N'Djamena is perceived as an immense weakness; the women disapprove of the frequency of prescriptions for drugs that they have to buy at great expense from private suppliers, and the staff members are dissatisfied because they are expected to provide health care without being in a position to supply drugs. Some women are satisfied with their reception by the health centre staff, but others find the attitude of the personnel unsympathetic or even insulting.

Improved utilization of nutritional rehabilitation services by women could be achieved by diminishing the daily waiting time, improving the availability of drugs, and promoting better communication between the providers and the women. A reduction of the waiting time could easily be achieved through quicker distribution of the nutritional supplements. Drugs could be made available through the establishment of a cost-recovery system. Finally, communication could be improved through the promotion of participatory approaches. Communication between the providers and the users of health services must to be perceived as a resource and an opportunity that will allow better management of health for all. A rehabilitation centre, where the mothers attend regularly for a long period, offers excellent opportunities to increase understanding and cooperation between the health professionals and the women who carry a large amount of the responsibility for the health of their families.

Acknowledgements

We are most grateful to Miss Solange Adannou and Miss Gueti N'Guinza for their efforts and their seriousness during their work as animator and observer. We would also like to thank very warmly the women and the health personnel participating in the discussions, for their availability and for their welcome. For support in planning this study, comments and propositions we are grateful to: Professor Marcel Tanner, Dr Nick Lorenz, Dr Walter Kessler and Marleen Boelart. I should also like to thank Jennifer Jenkins for her help and suggestions in the preparation of the present version of the report.

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Kaspar Wyss is with the Bureau d'Appui Santé environnement, N'Djamena, Chad and Swiss Tropical Institute, Department of Public Health and Epidemiology, Basel, Switzerland; Monique Nandjingar is with the Ministère de la Santé Publique, Centre National de Nutrition et de Technologie Alimentaire, N'Djamena, Chad.