Int J Gynaecol Obstet 17: 135-138, 1979

The Use of Paramedics in Family Planning Services in Iran F. S. Ghorbani Farah Maternity Hospital, Institute for Protection of Mothers and Newborn, Tehran, Iran

ABSTRACT Ghorbani FS (Farah Maternity Hospital, Institute for Protection of Mothers and Newborn, Tehran, Iran). The use of paramedics in family planning services in Iran. Int J Gynaecol Obstet 17: 135-138, 1979 In the Family Planning Department of Farah Maternity Hospital, from 1968 to 1976, paramedics were trained to administer all reversible methods of family planning and pregnancy termination up to ten weeks and to perform a limited number of abdominal and vaginal tubectomies (1). From 1974 to 1976, all the above methods, except tubal ligation, were performed satisfactorily on 460 417 acceptors at a clinic not located in the hospital. The complication rate of l%-5% was the same whether the procedures were performed by paramedics or by physicians. The project has been economical. It has been accepted by both patients and paramedics and has freed doctors to carry out other work.

INTRODUCTION Farah Maternity Hospital is a large maternity hospital with an annual average of 40 000 deliveries and 8 000 incomplete and spontaneous abortions. It serves women of lower socioeconomic status in the city of Tehran. Sixty percent of women, generally multiparae, are admitted as emergencies. T h e mother and baby are observed for a few hours after delivery and sent home by ambulance. Family Planning Services started in 1959, eight years before population control was adopted by the government, in response to a demand from multiparous mothers. T h e methods offered initially were foam tablets and barrier contraceptives. A great majority of acceptors were mothers of many children. It was not until 1964, when contraceptive pills and intrauterine devices (IUDs) were introduced, that the number of acceptors began to increase. It took another four years for family planning to become acceptable as a means of protecting the mother

and the child's health. Women were given family planning counseling during their stay in the hospital for the confinement and encouraged to space their deliveries. In 1968, the start of the postpartum program for educating and motivating mothers resulted in a dramatic increase in new contraceptive acceptors and an increasing number of old acceptors (Fig. 1). Farah Maternity Hospital's continuing program of family planning education necessitated an increase of staff, particularly in the n u m b e r of doctors. There is a great shortage of doctors in Iran. It was reported in 1976 that there was one doctor to 2699 population (3), and of all the doctors in Iran, only 8% were women. T o help solve both these problems, four midwives from the maternity unit were selected for work in the family planning unit. They were experienced midwives between the ages of 30 and 40 years, experienced in pelvic examinations a n d the examination of obstetric cases in antenatal a n d postnatal clinics and work in the delivery room. After preliminary lectures on contraceptives, these midwives examined all family planning patients with the doctor. Appropriate contraceptive methods were discussed, and at the same time the indications and contraindications, management and treatment of complications were described. Each new method was described, demonstrated and supervised a few times by the doctor until the midwives were competent to perform it independently. After an average of three months' training, the midwives were able to work without supervision, but could always consult the doctor in the clinic if necessary. T h e rate of consultation with the doctor in family planning cases declined from 5% to 1% within one year of work.

MATERIALS A N D M E T H O D S From October 1, 1978, to September 1, 1976, 460 417 old and new family planning patients were

Int J Gynaecol Obstet 17

136

Ghorbani

8000 r

7000 -

6000 -

5000

4000 -

3000 -

2000 -

1000 -

1962

1963

1964

1965

1966

1967

1968

March

Fig. 1 . Number of contraceptive acceptors at the Family Planning Center of Farah Maternity Hospital from March 1962 to March 1968.

Table I. Type of work performed by midwives, 1 9 6 8 1976. Type of Work Distribution of hormonal contraceptives to new acceptors IUD insertion Distribution of barrier methods and local spermicides to new acceptors Menstrual regulation and pregnancy termination* 1 Tubal ligation"

No. of Patients 52 647 8 071 10 213 263 24

Follow-up visits, including smear, for all methods and revisits of patients seen on admission by doctors

389

Total

4 6 0 417

199

Table II. Type and number of lUDs inserted, 19681976. Type of IUDa

No. Inserted

Lippes Loops C and D Ghorbani IUD Copper-7 Dalkon Shield Multiload 250 Scoy Other

7392 300 150 102 78 15 39

Total

8071

8

Manufacturers of the following lUDs are indicated in parentheses: Lippes Loops C and D (Ortho Pharmaceutical Corporation, Raritan, NJ, USA), Copper-7 (G. D. Searle and Co, Chicago, IL, USA), Dalkon Shield (A. H. Robins Co, Richmond, VA, USA), Multiload 250 (Multilan SA, Fribourg, Switzerland).

"Since 1974. " Discontinued because of legal difficulties.

seen by midwives at the Family Planning Center of Farah Maternity Hospital, and a total of 118 655 Papanicolaou smears were taken (Tables I and II). M a n y different combinations of hormonal contraceptives, differing in dosage and constituents, were used in the program, but none was given by injection. New pill acceptors were selected after considering their medical, obstetric and gynecologic histories.

IntJ Gynaecol Obstet 17

During subsequent visits, they were examined for signs that might necessitate discontinuation of hormonal contraception, such as evidence of liver d a m age, excessive weight gain, raised blood pressure a n d thrombophlebitis. Changes of dosage and composition of the pill were made when there was breakthrough bleeding and other bleeding irregularities. There were no known cases of perforation at the time of I U D insertion by midwives, although 32% of the patients were at 4-6 weeks postpartum. T h e one case of perforation at the time of I U D insertion

Family planning paramedics in Iran

by a doctor occurred in a patient in whom a midwife had failed to insert an I U D because of stenosis of the cervical canal. Menstrual regulation and pregnancy termination in cases of failed contraception were initiated on a limited scale from 1973 onwards, first by doctors and then later by midwives. With the liberalization of abortion laws in early 1976, terminations of pregnancy in cases of up to ten weeks' gestation were performed on demand by midwives. There were no cases of cervical laceration, heavy bleeding, severe shock or infection, and no patients required hospitalization immediately after evacuation of the products of conception. (Eight complications resulting from 263 menstrual regulation procedures performed by paramedics are shown in T a b l e III.) Beginning in 1973, tubal ligations were performed by paramedics selected from a younger group of nurse-midwives who had special operating-room training, had worked as scrub nurses and had shown an interest in learning to perform the operation. After assisting in a number of operations, they were instructed in the details of the tubal ligation procedure. (The operations performed at that time at the Farah Family Planning Department were postpartum tubal ligation via small abdominal incision and interval ligation via the vaginal route. T h e latter operation has now been abandoned in view of its higher incidence of infection and has been replaced by minilaparotomy and peritoneoscopy.) After 1015 weeks, paramedics motivated by operating became confident enough to operate without direct supervision. There were no complications recorded for the limited number of operations performed by paramedics. To the disappointment of doctors and paramedics, paramedics could not continue to perform tubal ligations because of legal difficulties, and the number performed was not large enough to make valid comparison with those done by doctors. But, if circumstances permit and the need arises, the knowledge may still be used. The Family Planning Department of Farah Ma-

Table III. Complications of menstrual regulations performed by paramedics on 263 patients. Complication No. Shock requiring up to 1 - 2 hours of rest Retained placenta requiring dilatation and curettage Failure to evacuate uterus, with pregnancy continuing None

3 3 2 255

137

ternity Hospital is a training center for doctors, midwives, nurses, medical students and midwifery and nursing students referred from various organizations. After instruction in theory a n d an introduction by doctors, they receive their practical training in all contraceptive methods, except sterilization techniques, from the midwives in the Family Planning Unit.

COMMENT In Family Planning Units, the examination of patients, discussion of suitable contraceptive methods with patients, insertion of IUDs, pregnancy termination up to ten weeks and treatment of complications constitute the greater part of work. In some developing countries, a male gynecologist is not accepted, even in a grave obstetric or surgical emergency, and so a female practitioner is preferred and welcomed for family planning advice. U n d e r these circumstances, employment of midwives in Family Planning Units has several advantages: 1. Their work is similar to that done by doctors and, in some cases, there are fewer complications (possibly because difficult cases are referred to doctors) . 2. T h e work of midwives is more acceptable to women patients because they can discuss their sexual and contraceptive problems freely. 3. T h e work is satisfying to midwives a n d gives them a sense of importance and continuity of maternal and child health care. 4. It saves doctors' time, which can be used for other work. 5. In Iran gynecologists are all working in cities (4) where the birth rate is low compared with rural areas. Yet, in many parts of these rural areas where all deliveries are performed by midwives, there exists some kind of obstetric facilities, which can be used to administer contraceptives and perform early abortion in static or mobile units, thus taking the service to those places where it is most needed.

ACKNOWLEDGMENT T h e author wishes to thank the International Fertility Research Program and the Office of Population, U S Agency for International Development (AID/csd-2979), for their assistance in training the tutors of the Nursing and Midwifery School in Menstrual Regulation; and Miss F. Mahini, Head of the Nursing and Midwifery School, for her co-

IntJ Gynaecol Obstet 17

138

Ghorbani

operation in selecting suitable candidates for training.

4. Statistical Journal of Iranian Medical Association, p 23. 1976.

REFERENCES 1. Ghorbani FS: Iranian nurse midwives train for tubal ligation. Newsletter International Project Association for Voluntary Sterilisation, p 2, Fall 1974. 2. Statistical Journal of Iranian Medical Association, p 1, 1976. 3. Statistical Journal of Iranian Medical Association, graph II, 1976.

¡nl J Gynaecol Obstel 17

Address for reprints: F. S. Ghorbani Farah Maternity Hospital Institute for Protection of Mothers and Newborn Tehran Iran

The use of paramedics in family planning services in Iran.

In the Family Planning Department of Farah Maternity Hospital paramedics were trained to administer all reversible forms of family planning and pregna...
247KB Sizes 0 Downloads 0 Views