HEALTH CARE * LES SOINS
We could learn a lesson from Kenya's midwives John Kinahan
During a 2-month elective period in 1989, John Kinahan studied obstetrical care in urban and rural parts of Kenya. Now a fourth-year medical student, he focused on the role of trained professional midwives and returned to Canada with definite views on the role they should play in this country. He is convinced that proper training of midwives is needed here and thinks Kenya might serve as a model. The following is an excerpt from a more detailed research paper prepared after his return from Kenya. e~spite Canada's resistance to universal midwifery During an average night shift at the Pumwani Hospital, 40 .to 60 babies are born. care, midwifery is accepted internationally as a safe and effective form of obstetrical care. I but includes some private and se- born per year, compared with the learned a great deal about it dur- mi-private hospitals in Nairobi roughly 6000 born at KNH. ing 2 months in Kenya in 1989 and Mombasa. The government [About 390 000 babies were born and think this country could learn system provides adequate service in Canada last year - Ed.] To the midwives who work in 90% of urban and 60% of rural something, too. I spent time in hospitals, areas and is augmented by private there, this provincial hospital is health centres and rural clinics, and church-run clinics. Most Ken- known affectionately as "an incompleting a rotation in obstetrics yans use the government and dustry". It has 296 "official" beds and gynecology and researching church-run facilities, although but about 360 actual ones, and the midwifery training, regulation and roughly 10% can afford private 20 official cots for newborns actually number 137. Although it is use. The facilities I visited ranged care. Nairobi's bustling KNH has a chronically underfunded and unfrom the 1200-bed, governmentrun Kenyatta National Hospital complete obstetrics and gynecolo- derstaffed, Pumwani does an ex(KNH) to the Kabiro Clinic, lo- gy ward and outpatient clinic and cellent job. During my week there serves as a tertiary referral centre I was impressed by the efficiency cated in a Nairobi slum. Health care in Kenya is pro- for complicated cases. The gov- and speed with which labour and vided by a government-run sys- ernment has tried to discourage deliveries were handled. Provincial hospitals, which tem based on the British model, its use for uncomplicated deliverhandle births and general health ies by establishing the Pumwani also serve as training problems, in Nairobi. John Kinahan is a fourth-year medical Maternity Hospital for nurses and midhospitals student at the University of British Colum- This is a busy, stunning place A below them are step wives. are babies 000 35 where up to bia. D
CAN MED ASSOC J 1990; 143 (12)
1353
district hospitals, which are smaller and often mission-run, and at the next level are subdistrict hospitals and clinics. Villages are served by health centres, and there are also dispensaries run by medical officers of health. They provide the lowest level of government-sponsored care. Traditional birth attendants, who have no formal training, provide basic obstetrical services in many villages. Prenatal and postnatal care is provided at all levels, while labour and delivery care is provided at the subdistrict level but rarely at health centres. At that level, most births take place at home under an attendant's care.
Private obstetrical care - its quality is on a par with our own - is available but is generally expensive, at least by Kenyan standards. Nairobi has the major concentration of private hospitals and I studied two of them, the 200-bed Mater Misericordiae and 190-bed Aga Khan. Mater is the only private hospital to offer a midwife-training program, while the Aga Khan provides a good example of how midwives are employed in a Western-style hospital. Kenya has two types of midwives. Enrolled midwives serve in rural clinics and small hospitals, while registered midwives tend to work in large hospitals and private centres. Applicants, who must have nursing training, can receive midwifery training in at least six locations. The Nurses' Council of Kenya determines standards of education and sets the syllabus and examinations, although these can be altered slightly by individual schools. For example, Mater is a Roman Catholic hospital and emphasizes medical ethics, prayer and natural family planning in its teaching. The number of graduates ranges from 50 to 80 enrolled midwives and 50 to 70 registered midwives annually and this production supplies current demand 1354
CAN MED ASSOC J 1990; 143 (12)
Kenya's traditional birth attendants Manv developing nations rely on birthing methods that are based looselv on tradition. In rural areas of Kenya elderlv. respected women guide younger women through pregnancy and childbirth. Much of their work is supportive, but often they have great experience depending on the region. these traditional birthing attendants are estimated to deliver 10% to 70% of the countrv's babies. In Nairobi the 10% estimate probably applies, while in the Turkana region 70% to 80% is a reasonable estimate. Kawangaware is a sprawling Nairobi slum that houses more than 90 000 transient labourers. The village of Kabiro forms one part of it and the Kabiro Clinic serves its 3000 residents as best it can. O)nc} midwife. Erorii Nakagxvsa wo3rks here. She attends home births btut cannot serve all of Kawangaware, so she teaches and provides umbilical iCord kits" to birthing attendants in the region She has
trained 20 of them in the basics of cleanliness, cord care and childbirth problems and works diligently to discourage some traditional practices - smearing cow dung on the umbilicus. for instance, or practising pica - eating dirt or foreign objects during pregnancy. Through an interpreter I interviewed Sarah Nyeri, a 55-year-old birthing attendant who had delivered 16 babies in the past 3 years. She walks some pregnant mothers, including all primigravidas, to hospital for delivery, and no longer uses her traditional herbs on the umbilicus. She is paid either a nominal fee or by barter. Attempts to train these women have begun in earnest in Kenya, where it is hoped they can be integrated into the coun tn's health care systenm They are closer to the ideals held bv midwifery than most Kenvan hospital midwives, if only because of the increased continuity of care they provide
adequately. I reviewed the 12-month course for registered midwives and found it thorough and well organized, with lectures covering everything from basic anatomy to obstetrical procedures and drugs. There is also extensive clinical teaching totalling 44 weeks, including 14 weeks in the labour ward and theatre and 8 in the postnatal ward. The nurses' council is the registering and disciplinary body; once licensed, a midwife is governed by the Nurses, Midwives and Health Visitors Act. However, the council does not control the significant number of traditional birthing attendants, In one hospital, 35 000 babies are born unlicensed and untrained women each year. who continue to deliver babies
in rural villages and urban slums. Most Kenyan hospitals employ several enrolled or registered midwives. The reason is simple: obstetrics is big business there, much bigger than here. The annual birth rate has been as high as 160 births per 1000 people, compared with the Canadian rate of about 15 per 1000. At the Pumwani Maternity Hospital, staffing is a constant problem. Operated by the Nairobi city council, the hospital relies on one consultant obstetrician, three "registrars" in obstetrics, one consultant and three registrar pediatricians, five medical officers of health and five medical officers of anesthesia. It also employs 20 registered midwives and 89 enrolled ones. To a Canadian visitor, the workload is astonishing. In the first 6 months of 1989, 14 016 babies were born at the hospital, 955 by cesarean section. [The perinatal death rate at the hospital was 21.6/1000; in 1986 the Canadian rate was 7.9/1000 - Ed.] The Pumwani is so busy that it has 29 beds in the labour and delivery ward, but at least 35 are needed most of the time; up to 10 women will endure the first and second stages of labour on benches as they wait for beds to be cleared. During an average night shift 40 to 60 babies are born, with almost all care being provided by about 10 midwives. Physicians are called in for the occasional difficult forceps delivery or to perform a cesarean section. Midwives and student midwives at the Pumwani handle spontaneous vaginal deliveries, episiotomies, artificial rupture of membranes and all breech and twin deliveries. A duty doctor is available on the labour ward at all times and usually does rounds twice per shift. The doctor examines all new arrivals and performs all cesarean sections. In the morning, all episiotomies are repaired
Midwives provide most obstetric care in Kenya
by the physician; midwives are rarely expected to do suturing. The importance of the midwife in Kenyan obstetrics should not be underestimated. Midwives here have repeatedly earned the respect they deserve because of their competence, experience and cost-effectiveness; midwives seem to work best where funds are limited. Outcomes are not affected adversely by their involvement. A 1981 study, the Nairobi Birth Survey, investigated 5293 births that took place during a 7-week period and found that, in terms of perinatal deaths, midwives performed well when compared with physicians. It was acknowledged that higher-risk births are generally referred to physicians. Although many Canadians still oppose midwifery, this opposition is rarely based on fact much of our distaste stems from inadequate laws and training. Many physicians oppose their involvement in obstetrical care, with some general practitioners fearing they will lose patients. Interestingly, some 70% of Ontario GPs now refuse to practise obstetrics. Regardless, midwives still practise in Canada, but as with
any unregulated profession the potential for abuse exists. Throughout the world, whether in affluent Holland or developing Kenya, competent and devoted midwives consistently do fine work. Canada is privileged to have some midwives of this calibre practising here, but to date they remain largely a squandered resource. If midwifery is to take hold in Canada, compromises will be needed from both opponents and proponents. Home births must be discouraged, especially in rural areas, and midwives should be university trained. They could be independent practitioners, although they must be willing to work closely with physicians. Legislation is needed badly and education, licensing and surveillance programs must be put in place. Canada is a large country whose obstetrical care needs cannot be met by physicians alone. Kenya is also a large country and it has developed a system of obstetrical care based on mutual trust and cooperation between well-trained, competent midwives and physicians. I think Kenya offers a lesson that Canada would be wise to learn.u CAN MED ASSOC J 1990; 143 (12)
1355
We could learn a lesson from Kenya's midwives John Kinahan
During a 2-month elective period in 1989, John Kinahan studied obstetrical care in urban and rural parts of Kenya. Now a fourth-year medical student, he focused on the role of trained professional midwives and returned to Canada with definite views on the role they should play in this country. He is convinced that proper training of midwives is needed here and thinks Kenya might serve as a model. The following is an excerpt from a more detailed research paper prepared after his return from Kenya. e~spite Canada's resistance to universal midwifery During an average night shift at the Pumwani Hospital, 40 .to 60 babies are born. care, midwifery is accepted internationally as a safe and effective form of obstetrical care. I but includes some private and se- born per year, compared with the learned a great deal about it dur- mi-private hospitals in Nairobi roughly 6000 born at KNH. ing 2 months in Kenya in 1989 and Mombasa. The government [About 390 000 babies were born and think this country could learn system provides adequate service in Canada last year - Ed.] To the midwives who work in 90% of urban and 60% of rural something, too. I spent time in hospitals, areas and is augmented by private there, this provincial hospital is health centres and rural clinics, and church-run clinics. Most Ken- known affectionately as "an incompleting a rotation in obstetrics yans use the government and dustry". It has 296 "official" beds and gynecology and researching church-run facilities, although but about 360 actual ones, and the midwifery training, regulation and roughly 10% can afford private 20 official cots for newborns actually number 137. Although it is use. The facilities I visited ranged care. Nairobi's bustling KNH has a chronically underfunded and unfrom the 1200-bed, governmentrun Kenyatta National Hospital complete obstetrics and gynecolo- derstaffed, Pumwani does an ex(KNH) to the Kabiro Clinic, lo- gy ward and outpatient clinic and cellent job. During my week there serves as a tertiary referral centre I was impressed by the efficiency cated in a Nairobi slum. Health care in Kenya is pro- for complicated cases. The gov- and speed with which labour and vided by a government-run sys- ernment has tried to discourage deliveries were handled. Provincial hospitals, which tem based on the British model, its use for uncomplicated deliverhandle births and general health ies by establishing the Pumwani also serve as training problems, in Nairobi. John Kinahan is a fourth-year medical Maternity Hospital for nurses and midhospitals student at the University of British Colum- This is a busy, stunning place A below them are step wives. are babies 000 35 where up to bia. D
CAN MED ASSOC J 1990; 143 (12)
1353
district hospitals, which are smaller and often mission-run, and at the next level are subdistrict hospitals and clinics. Villages are served by health centres, and there are also dispensaries run by medical officers of health. They provide the lowest level of government-sponsored care. Traditional birth attendants, who have no formal training, provide basic obstetrical services in many villages. Prenatal and postnatal care is provided at all levels, while labour and delivery care is provided at the subdistrict level but rarely at health centres. At that level, most births take place at home under an attendant's care.
Private obstetrical care - its quality is on a par with our own - is available but is generally expensive, at least by Kenyan standards. Nairobi has the major concentration of private hospitals and I studied two of them, the 200-bed Mater Misericordiae and 190-bed Aga Khan. Mater is the only private hospital to offer a midwife-training program, while the Aga Khan provides a good example of how midwives are employed in a Western-style hospital. Kenya has two types of midwives. Enrolled midwives serve in rural clinics and small hospitals, while registered midwives tend to work in large hospitals and private centres. Applicants, who must have nursing training, can receive midwifery training in at least six locations. The Nurses' Council of Kenya determines standards of education and sets the syllabus and examinations, although these can be altered slightly by individual schools. For example, Mater is a Roman Catholic hospital and emphasizes medical ethics, prayer and natural family planning in its teaching. The number of graduates ranges from 50 to 80 enrolled midwives and 50 to 70 registered midwives annually and this production supplies current demand 1354
CAN MED ASSOC J 1990; 143 (12)
Kenya's traditional birth attendants Manv developing nations rely on birthing methods that are based looselv on tradition. In rural areas of Kenya elderlv. respected women guide younger women through pregnancy and childbirth. Much of their work is supportive, but often they have great experience depending on the region. these traditional birthing attendants are estimated to deliver 10% to 70% of the countrv's babies. In Nairobi the 10% estimate probably applies, while in the Turkana region 70% to 80% is a reasonable estimate. Kawangaware is a sprawling Nairobi slum that houses more than 90 000 transient labourers. The village of Kabiro forms one part of it and the Kabiro Clinic serves its 3000 residents as best it can. O)nc} midwife. Erorii Nakagxvsa wo3rks here. She attends home births btut cannot serve all of Kawangaware, so she teaches and provides umbilical iCord kits" to birthing attendants in the region She has
trained 20 of them in the basics of cleanliness, cord care and childbirth problems and works diligently to discourage some traditional practices - smearing cow dung on the umbilicus. for instance, or practising pica - eating dirt or foreign objects during pregnancy. Through an interpreter I interviewed Sarah Nyeri, a 55-year-old birthing attendant who had delivered 16 babies in the past 3 years. She walks some pregnant mothers, including all primigravidas, to hospital for delivery, and no longer uses her traditional herbs on the umbilicus. She is paid either a nominal fee or by barter. Attempts to train these women have begun in earnest in Kenya, where it is hoped they can be integrated into the coun tn's health care systenm They are closer to the ideals held bv midwifery than most Kenvan hospital midwives, if only because of the increased continuity of care they provide
adequately. I reviewed the 12-month course for registered midwives and found it thorough and well organized, with lectures covering everything from basic anatomy to obstetrical procedures and drugs. There is also extensive clinical teaching totalling 44 weeks, including 14 weeks in the labour ward and theatre and 8 in the postnatal ward. The nurses' council is the registering and disciplinary body; once licensed, a midwife is governed by the Nurses, Midwives and Health Visitors Act. However, the council does not control the significant number of traditional birthing attendants, In one hospital, 35 000 babies are born unlicensed and untrained women each year. who continue to deliver babies
in rural villages and urban slums. Most Kenyan hospitals employ several enrolled or registered midwives. The reason is simple: obstetrics is big business there, much bigger than here. The annual birth rate has been as high as 160 births per 1000 people, compared with the Canadian rate of about 15 per 1000. At the Pumwani Maternity Hospital, staffing is a constant problem. Operated by the Nairobi city council, the hospital relies on one consultant obstetrician, three "registrars" in obstetrics, one consultant and three registrar pediatricians, five medical officers of health and five medical officers of anesthesia. It also employs 20 registered midwives and 89 enrolled ones. To a Canadian visitor, the workload is astonishing. In the first 6 months of 1989, 14 016 babies were born at the hospital, 955 by cesarean section. [The perinatal death rate at the hospital was 21.6/1000; in 1986 the Canadian rate was 7.9/1000 - Ed.] The Pumwani is so busy that it has 29 beds in the labour and delivery ward, but at least 35 are needed most of the time; up to 10 women will endure the first and second stages of labour on benches as they wait for beds to be cleared. During an average night shift 40 to 60 babies are born, with almost all care being provided by about 10 midwives. Physicians are called in for the occasional difficult forceps delivery or to perform a cesarean section. Midwives and student midwives at the Pumwani handle spontaneous vaginal deliveries, episiotomies, artificial rupture of membranes and all breech and twin deliveries. A duty doctor is available on the labour ward at all times and usually does rounds twice per shift. The doctor examines all new arrivals and performs all cesarean sections. In the morning, all episiotomies are repaired
Midwives provide most obstetric care in Kenya
by the physician; midwives are rarely expected to do suturing. The importance of the midwife in Kenyan obstetrics should not be underestimated. Midwives here have repeatedly earned the respect they deserve because of their competence, experience and cost-effectiveness; midwives seem to work best where funds are limited. Outcomes are not affected adversely by their involvement. A 1981 study, the Nairobi Birth Survey, investigated 5293 births that took place during a 7-week period and found that, in terms of perinatal deaths, midwives performed well when compared with physicians. It was acknowledged that higher-risk births are generally referred to physicians. Although many Canadians still oppose midwifery, this opposition is rarely based on fact much of our distaste stems from inadequate laws and training. Many physicians oppose their involvement in obstetrical care, with some general practitioners fearing they will lose patients. Interestingly, some 70% of Ontario GPs now refuse to practise obstetrics. Regardless, midwives still practise in Canada, but as with
any unregulated profession the potential for abuse exists. Throughout the world, whether in affluent Holland or developing Kenya, competent and devoted midwives consistently do fine work. Canada is privileged to have some midwives of this calibre practising here, but to date they remain largely a squandered resource. If midwifery is to take hold in Canada, compromises will be needed from both opponents and proponents. Home births must be discouraged, especially in rural areas, and midwives should be university trained. They could be independent practitioners, although they must be willing to work closely with physicians. Legislation is needed badly and education, licensing and surveillance programs must be put in place. Canada is a large country whose obstetrical care needs cannot be met by physicians alone. Kenya is also a large country and it has developed a system of obstetrical care based on mutual trust and cooperation between well-trained, competent midwives and physicians. I think Kenya offers a lesson that Canada would be wise to learn.u CAN MED ASSOC J 1990; 143 (12)
1355
