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close this book07. Health Professionals for Maternity Services: Experiences on Covering the Population with Quality Maternity Care
View the document(introduction...)
View the documentSummary
View the documentHistorical Development of Obstetric Care
Open this folder and view contentsPresent Legal Situation of Health Personnel
Open this folder and view contentsDistribution Problems of Health Professionals
Open this folder and view contentsStrategies to Overcome Unequal Distribution of Professionals
Open this folder and view contentsDifferent Models of Training
View the documentQuality of Obstetric Care by Medical and Non-academic Staff
View the documentThe Costs of Training for Obstetric Emergency Care
View the documentSummary of Present Experience
View the documentProposal for More Equal Distribution of Qualified Obstetric Care
View the documentReferences

Proposal for More Equal Distribution of Qualified Obstetric Care

The different situations of the different countries point to individual and not an uniform strategy. Countries with a high absolute number of medical doctors have different problems assuring maternity care to rural areas than countries where personal is scarce. Scarcity of personnel can also be due to the small training capacity of medical schools, economic constrains, or to migration of health personnel to greener pastures abroad.

Considering the evidence described above, we suggest the following scenarios:

1. Countries with enough capacity of medical personnel concentrated in the main cities.

The clear political will should be formulated, that the coverage of the rural areas with quality maternity care is a priority. It should be obligatory for all health workers to work for a period of at least two years in rural areas, before being allowed to settle in the bigger cities or private practice. We have evidence from developed and developing countries where this is functional (e.g. Norway, holders of state bursaries must work for 2 years in the northern provinces, Burkina Faso, all medical and paramedical staff must work for 2 years in the districts).

2. Countries with few qualified health workers due to emigration.

The most important measure is to make working in the country more attractive than working abroad. There are many possibilities apart from financial incentives. Faster advancement in the hierarchy of health services, higher salary grades, public acknowledgement of work, upgrading of training and preferential admission to courses are some examples.

3. Countries with few qualified personnel due to limited training capacities or economic constrains.

Up-grading training for existent staff is the first possibility. As we can see from the experience in Ethiopia, South Africa and others, whole groups of personnel are working without enough background training and practical skills. They are willing and able to learn surgical skills and perform well. Delegation of tasks to other cadres of health personnel is another possibility. On-the-job training of nurses in DRC proved to be very successful and sustainable. The creation of a new cadre is the solution for countries where the official policy supports training non-academic personnel and allows them to perform specific tasks independently (Table 2). Tanzania and Burkina Faso have here advanced experiences and others can learn from their experiences.

Table 2. Suggestions for a better coverage of emergency obstetrics

Main actors for emergency obstetric care

Better coverage of emergency obstetrics

Referral level (dispensaries, health centres)

I. Referral level (dispensaries, health centres )

nurses
midwives
auxiliary staff

lifesaving skills for nurses and midwives; e.g. manual evacuation of the uterus, bimanual compression of the uterus, repair of lacerations and episiotomies, perfusions, oxytocin post-partum

Referral level (district hospital)

II. Referral level (district hospital)

general practitioner
nurses
midwives

a) training of general practitioners in surgical procedures for frequent emergency events (caesarean section, strangulated hernias) e.g. Ethiopia, Australia
b) training of non-academic cadre in surgical procedures and anaesthesia (e.g. AMO in Tanzania, nurse-surgeon and nurse-anaes-thetist in Burkina)
c) up-grading training for nurses and midwives in surgical procedures and anaesthesia (e.g. on the job training of surgical nurses in DRC, assistant medical anaesthetist in Malawi, surgical technicians in Mozambique)

Referral level (regional and national hospital)

III. Referral level (regional and national hospital)

specialist in obstetrics and gynaecology
senior medical doctor
general practitioner

integration of specialists and senior medical staff in practical training and supervision of 2. referral level staff.