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WHO - Childbirth care
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  CHAPTER 3 III Each year in Africa 30 million women become pregnant,and about 250,000 of them die from pregnancy-related causes.One third of nearly one millionstillbirths occur during labour,and approximately 280,000 babies die of birthasphyxia soon after birth.These figures are closely linked.Skilled care atbirth and immediately thereafter would save the lives of many mothers andbabies and prevent countless complications.Yet almost 60 percent of African women givebirth without a skilled attendant – 18 million a year at home – and during the last 10 years,the average coverage of births with a skilledattendant on the continent has not increased significantly.Two in three women who need emergency obstetric care do not receive it.Scaling up skilled attendance and emergency obstetric care is fundamentalto reaching Millennium Development Goal (MDG) 5 for maternal health,andscaling up careduring childbirth will also contribute to MDG 4 for childsurvival.How can progress be accelerated? How can newborn care bestrengthened while skilled careis scaled up?What canbe done in the shortterm,medium term,and longterm,bearing in mind that the poorest,most isolated women,who often experience birth complications,arelast to receive skilled care during childbirth? Childbirth care Luwei Pearson,Margareta Larsson,Vincent Fauveau,Judith Standley  64 Opportunities for Africa’s Newborns Problem Newborn health and survival are closely linked to care the mother receives before and during pregnancy,childbirth,and the postnatal period.Throughout the continuum of care,the period with the highest risk of death and disability for both mothers and newborns is labour,birth,and the first few hours after birth.Complications and lack of care at this crucial time has consequences for mothers and babies. Pregnant women  –Each year in Africa,an estimated quarter of a million women die of problems relatedto pregnancy,while nearly half die around the time of childbirth and during the first week after birth,mainlyof causes directly related to childbirth. 1 Bleeding,obstructed labour,eclampsia,and infections make up thelargest causes of mothers’ deaths,accounting for two thirds of maternal deaths in sub-Saharan Africa. 2 Haemorrhage alone accounts for one third of all maternal deaths in Africa,yet many of these deaths arepreventable.Obstetric fistula resulting from obstructed labour is a long term complication suffered by asmany as two million women.About 15 percent of all pregnant women have childbirth complications thatrequire emergency obstetric care (EmOC),yet few are able to access such services.The costs of acaesarean section in some African countries can bankrupt the family. 3 Stillbirths and newborns  –Babies are vulnerable during childbirth,and intrapartum complications result inamuch higher risk of death than pre-pregnancy or antenatal complications.At least 300,000 babies in Africadie as intrapartum stillbirths – dying during childbirth from childbirth complications such as obstructedlabour.Among babies born alive,another 290,000 die from birth asphyxia,also primarily related tochildbirth complications.Some of these deaths could be prevented by skilled care during pregnancy,childbirth,and the immediate postnatal period.For every baby who dies,an unknown number develop longterm disabilities.Although most babies breathe spontaneously at birth,up to10 percent of newbornsrequire some assistance to initiate breathing,with less than one percent needing extensive resuscitation. 4 Failure to breathe at birth may be due to preterm birth or to birth asphyxia.An estimated four million lowbirthweight (LBW) babies are born in Africa each year.These babies are particularly vulnerable and withoutextra care are more likely to die from avoidable causes,such as hypothermia (cold),hypoglycaemia (lowblood sugar),or infections.The ability of families and communities to recognise and access carequicklyin case of an emergencydetermines the survival and health of both mother and baby.For some obstetric complications,particularlyhaemorrhage,the window of opportunity to respond and save the life of the mother may be measured inhours.For the baby,either in utero or just born,death can come even more quickly.Any delay may havefatal consequences (Box III.3.1). BOX III.3.1 Deadly delays Three delays in care seeking affect the survival of both mothers andnewborns.1.Delays in recognising problems and deciding to seek careãComplications not recognised as seriousãFamily members delay care seekingãSpiritual or cultural beliefs may reinforce delays or result in othertreatments2.Delays in transportation to reach appropriate care ãLack of transport and/or fundsãDistance and travel time to reach health facilities 3.Delays in receiving appropriate care at the health facilityãLack of appropriatelytrained staff and negativeattitudes of health workersãLack of essential equipment,drugs and supplies Source:Adapted from reference 5  Opportunities for Africa’s Newborns 65 III The first two delays reveal questions about seeking care atthe family and community level. Are families equipped tomake healthy choices? Can the family and community support women when transportation and emergency costsare necessary? In many cultures, a woman must receivepermission and money from her husband or other family members to seek care when complications take place.Long distance, high cost, and poor quality of care alsocontribute to the first and second delays.The third delay is related to health care providers, thefacility, and the health system. 5 In South Africa, data collected for the national perinatal problem identificationprogramme, which now covers over one third of South Africa’s births, show that while the majority of avoidablefactors for stillbirths and neonatal deaths are related topoor maternal care during labour and the immediatepostnatal period, about one third are due to delays athome and in transportation 6 (Box III.3.2). BOX III.3.2 Top10 preventable delays associated with perinatal deaths in ruralareas of South Africa,according to confidential enquiry of maternal death 1.Inadequate facilities and equipment in neonatal units and nurseries 4.9% of deaths2.Non-existent or poor antenatal care 3.5%3.Poor intrapartum fetal monitoring 3.2%4.Patient delay in seeking medical attention during labour 2.4%5.Prolonged second stage of labour with no intervention 1.4%6.Inappropriate response to rupture of membranes 1.2%7.Lack of transport from home to the health facility 1.2%8.Poor progress in labour and incorrect use of partograph 0.9%9.Delayin medical personnel calling for expertassistance 0.8%10.Inadequate neonatal management plan 0.8% Source:Adapted from reference 7 This chapter will outline the package for careinchildbirth, including skilled attendance at birth andemergency obstetric and newborn care. We then describethe current situation for childbirth carein Africa andexplore opportunities to integrate and strengthennewborn interventions, suggesting practical steps to scaleup skilled careand address key challenges, particularly the18 million women who currently give birth withoutskilled care. Package New analysis presented throughout this publicationsuggests that high coverage of care during childbirth,including skilled maternal and immediate newborn care,EmOC, and additional interventions, such as antenatalsteroids for preterm labour, could avert up to 34 percentof neonatal deaths. This means that out of Africa’s1.16million newborn deaths, between 220,000 and 395,000newborn lives could be saved if over 90 percent of  women and babies received skilled childbirth care. Thelives that can be saved aremorethan the newborns dying from birth asphyxia, since skilled carealso reduces deathsdue to preterm birth complications and infections. Inaddition, countless maternal lives would be saved andintrapartum stillbirths prevented. (For moreinformationon this analysis, see data notes on page 226) Inindustrialised countries, virtually all women haveaccessto skilled careat birth and EmOC as well as emergency neonatal care. The reality in most African countries,however, falls far short of universal coverage of skilledcare. Skilled care, including essential newborncarefor all births The birth of a new baby is a natural process and animportant and joyful social event both for the individualfamily and the wider community. Most womenexperience normal childbirth, and most babies are bornhealthy.Complications during childbirth, however,cannot be predicted. For this reason, all women andbabies require access to childbirth care from skilled careproviders. 8 Timely recognition and management of complications during childbirth is important, as isavoiding unnecessary medical interventions.  66 Opportunities for Africa’s Newborns The who, where  ,and what  ofskilled care during childbirth can be summarised as follows: Who?  Skilled care at birth is defined as care provided by a health worker with midwifery skills, also called a skilledattendant. Skilled attendants are accredited healthprofessionals such as midwives, doctors, and nurses whohave been educated and trained to proficiency inmanaging normal (uncomplicated) pregnancies,childbirth, and the immediate postnatal period and canidentify, manage, and refer complications in women andnewborns. 9 Where?  Childbirth should take place in a setting with thenecessary equipment, supplies, drugs, and support of a functioning health system, including transport andreferral facilities for emergencies. This is sometimes calledan enabling environment. In countries with poorcommunication and transport networks, it is challenging for skilled attendants to provide effective childbirth careat home, and in most of Africa, skilled attendants aremainly based in health facilities. What?  Key interventions during labour and birthinclude: ãRoutine infection prevention practicesãMonitoring of labour using a partograph as an effectivetool for monitoring the progress of labour. Thepartograph helps identify problems such as slow progress and prolonged labour (Box III.3.3)ãActive management of the third stage of labour ãHygienic cutting and tying of the cordãResuscitation if neededãEssential newborn care (warmth, early and exclusivebreastfeeding, and cleanliness)ãPrevention of mother-to-child transmission (PMTCT)of HIV ãIncreasing client satisfaction and comfort, for exampleproviding privacy, limited vaginal exams, permitting freemovement, food and drink intake, encouraging use of a social companion at birth, and establishing a supportiverelationshipImmediate newborn care includes assessing the baby,recording the birth weight, and providing eye care toprevent gonococcal eye infections where this is localpolicy. Resuscitation should be started if the baby doesnot breathe within 30 seconds after birth. Recent reviewshave concluded that adequate ventilation with a bag andmask (“ambubag”) device and room air is just as efficientas oxygen for initial resuscitation. BOX III.3.3  When a piece of paper can save a life:using the partograph to monitor labour When the partograph has been used to manage labour,research has shown improvements in fetal andnewborn survival as well as significant reductions in unnecessary interventions.Data and experience acrossAfrica suggest that although the partograph is a well-known intervention,it is often not used or not usedcorrectly.There are varying reasons for this,including:ãLack of human resources and time pressure.One midwife working in a labour ward of a large Africanteaching hospital remarked,“There is no time to chart the partograph unless there are students around.Onenurse is looking after too manymothers,therefore she does not have time.” ãStock-outs of copies of the printed partographãInadequate monitoring of maternal and fetal keyindicators,particularly the fetal heart,as the traditionalPinard stethoscope may be incorrectly used andDoppler ultrasound monitors are not widely available 12 ãInformation may be collected but is not always used tochange procedures,or there may be delays inundertaking emergency care,particularly caesareansection 13

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Jul 23, 2017
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