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www.lostetricainforma.it
www.lostetricainforma.it Uno studio negli USA Data: Mercoledì, 27 dicembre @ 23:54:18 CET Argomento: Continuità dell'assistenza Uno studio americano su 11.814 parti nelle case maternità extraospedaliere, condotte da ostetriche riporta i seguenti risultati: nessuna mortalità materna, 1.3 per mille di mortalità perinatale Uno studio negli USA - Verena Schmid, Ostetrica Uno studio americano su 11.814 parti nelle case maternità extraospedaliere, condotte da ostetriche riporta i seguenti risultati: nessuna mortalità materna, 1.3 per mille di mortalità perinatale, punteggio di APGAR e bambini di basso peso erano uguali o migliori dei centri ospedalieri corrispondenti, la soddisfazione delle donne era al 99%, il 63% delle donne aveva vissuto un incremento dell'autostima verso il 18% delle donne nei parti ospedalieri. Il 99% dei parti erano spontanei verso il 55% in ospedale. Meno del 4% dei parti venivano indotti contro il 40% dei parti in ospedale, il tasso di TC era inferiore al 5% contro il 21% dei parti ospedalieri (Stephenson et al.1995). Una ricerca su 8556 parti extraospedalieri della Germania (Qualitaetssicherung in der ausserklinischen Geburtshilfe, BDH e. V., BfDH e. V.1999) rileva: mortalità perinatale 2 per mille, bambini con APGAR superiore a 7 il 98,6%, a 10 minuti 99%, esiti fetali: 90% ottimo, 3,6% buono, 4,8% trasferimento in pediatria (immaturità, ipossia, problemi cardiaci, osservazione), parto spontaneo 93,5%, TC 3,4%, parto vaginale operativo 2,1%; prematurità (prima della 36a settimana) 0,2%, durata del periodo espulsivo: inf. a 15 minuti nel 53,9%, tra 15 - 60 min. 31%, numero di trasferimenti in ospedale 12,9%, di cui il 90% con calma e l'8,1% con emergenza. 11 dei parti erano gemellari, con esiti buoni, senza trasferimenti. Susanne Houd, maestra ostetrica danese opera in una comunità Inuit nel nord del Canada, dove l'ospedale più vicino sta a 5/6 ore di trasporto con l'aereo, non ci sono strade tra i distantissimi villaggi. Le donne vogliono partorire a casa perché considerano il bambino nato lontano un bambino senza famiglia. Attraverso un'accurata selezione in gravidanza il 25% delle donne viene inviata all'ospedale e il 75% può restare a casa. Nei parti a casa, finora non c'è stata nessuna mortalità materna né neonatale, il tasso di TC per tutta la popolazione è del 3%(esperienza riportata da S. Houd) Poi c'è l'esperienza del Professor Rockenschaub, primario della clinica universitaria di Vienna fino al 1984, studioso e osservatore della fisiologia. Nel suo reparto ospedaliero non veniva applicata la cardiotocografia, non ha mai fatto un cesareo per indicazione fetale, il suo tasso di cesarei era del 2% con risultati di mortalità e morbilità neonatale migliori rispetto agli altri ospedali della città (A. Rockenschaub, Gebaeren ohne Aberglauben, Aleanor Verlag, 1998). La tecnologia medica non ha migliorato gli esiti materni e fetali negli ultimi 20 anni nei paesi sviluppati. OMS (1996): "L'epidemia mondiale di parti operativi merita maggiore attenzione, poiché donne e bambini possono essere danneggiati da interventi inutili. Questi interventi possono essere evitati quando l'assistenza professionale è affidata a persone che non sono qualificate a eseguire interventi operativi, ma che lavorano per mantenere situazioni fisiologiche". La continuità di assistenza con supporto costante e il tuo coinvolgimento attivo nelle scelte assistenziali quindi offre maggiori garanzie per un buon esito per madre e bambino, in presenza di gravidanza fisiologica. Uno studio americano su 4 milioni di nascite dimostra una notevole differenza nella mortalità infantile, neonatale e IUGR (ritardo di accrescimento intrauterino) tra gruppi di donne a basso rischio assistite dal medico e assistite dall'ostetrica. I gruppi seguita dall'ostetrica dimostravano il 19%di mortalità infantile meno, il 33%di mortalità neonatale ed il 31% di IUGR meno rispetto al gruppo assistito dal medico (MacDorman '98). Non esiste una sola ricerca che dimostri un outcome peggiore con l'assistenza dell'ostetrica rispetto a quella del medico per donne a basso rischio. Tutte le ricerche comparative tra assistenza del medico e dell'ostetrica dimostrano una maggiore soddisfazione della donna e una maggiore autostima nelle donne seguite dall'ostetrica, un dato sempre più considerato negli esiti. www.birthinternational.com The outcome of perinatal care in Inukjuak, Nunavik, Canada 1998-2002 by Susanne Houd Susanne is a Danish midwife with wide experience of working in both western settings and in developing countries. As a consultant for the WHO, she has worked on Safe Motherhood projects in African countries. Having recently completed revamping the Danish Midwifery Education program, she is currently working with Inuit communities in Greenland where birth has been returned to the people in their own communities. Houd S , Qinuajuak J , Epoo B 1 2 2 1 The Midwifery School in Copenhagen, University College, Oeresund, Denmark 2 Community Midwives, Nursing station, Inukjuak, JOM IMO Nunavik, Quebec, Canada ABSTRACT Introduction. From the 1950s women in Nunavik were transferred to South Quebec to give birth. Since 1986 women have had the opportunity to give birth in Povungnituk, Nunavik, and the education of community midwives began. Inukjuak, a small community in Nunavik, was included in the project in 1998. There is no possibility for caesarean section or transfer during birth, in any of the places. Women can be transferred in pregnancy or post partum to the small hospital in Povungnituk or to a specialist obstetrical unit in Montreal. Study design. A5-year retrospective survey of the perinatal care in Inukjuak. Method. Data were collected from 1. Birth registrations. 2. Antenatal records in Inukjuak. 3. Records and follow-up of medical evacuations to either Povungnituk or Montreal. Results. Of the 182 women from Inukjuak who gave birth, 72.5% of the women gave birth in their own community. 4.5% women or/and newborn was evacuated for reasons related to birth. The rate of premature birth is 3.3% of all pregnant women from Inukjuak. The PMR is 0.5% of all babies born by women from Inukjuak and 0.7% of all babies born in Inukjuak. Conclusion. Three out of four women can stay in Inukjuak and give birth with a PMR of 0.7% Keywords: Nunavik, Inuit midwives, decentralized perinatal care, arctic perinatal care INTRODUCTION Nunavik is a very remote area in the northern part of Quebec. The population consists of 10,000 Inuits and a few hundred non-Inuits. The health services are quite well developed, with nursing stations in all the villages along the coast, with nurses and at least one doctor and in two villages also midwives. There is a small hospital in Povungnituk with a clinical laboratory and a ward with staff around the clock. From 1960 until 1986 all pregnant women were transported south three weeks before the due date and stayed one to two weeks after the birth. They were alone and surrounded by people who did not speak their language. In 1985 a joint group of the Inuit women’s association, Pauktuutit, together with a multidisciplinary group of health workers decided to make it possible for women to stay up North to give birth using evidence-based guidelines and, at the same time, to start the education of Inuit midwives. This was at a time where official midwifery did not exist in the rest of Canada. Today the maternity in Povungnituk has approximately 125 births per year and 7 women have undergone education as midwives. Six of the midwives have been working at the Maternity since then. Several surveys have been conducted looking at the health status of the population (1,2). In 1997 the Public Health Department in Nunavik issued a report of a survey of infant health and development in Nunavik (3). Compared to the previous period 1979-86 there were far fewer deaths from prematurity and low birth weight. The population is to a certain degree a "high risk" population. Almost 100% of the population smoke and although it is a "dry" community there are alcohol-related problems, problems connected to domestic violence, and problems connected to child abuse and neglect. It was very important for the people in Nunavik to bring birth back to the north in order to be born an Inuit and "with a home", as the old traditional midwife Miko says. In 1996, 92.3% of the women in Nunavik gave birth up north with no possibility for a caesarean section or to transfer during birth. The results have been reassuring. The reasons for the program’s success are: the multidisciplinary approach; a system of education of Inuit women, which is of a high level and is decentralized; the work of the perinatal committee. This Perinatal Committee consists of midwives, nurses, and doctors. At weekly meetings the Committee does an "audit" on every pregnant woman reaching 32 weeks’ gestation. A joint decision and recommendations for each woman are made and followed. Because the other larger village on the coast, Inukjuak, with 1,600 inhabitants, also wanted their own maternity, the training of student midwives in antenatal and postnatal care began in 1993. I arrived in Inukjuak on January 28, 1998, the day the Maternity opened. From the beginning most of the perinatal care has been done by three students midwifes. They each have their own caseload of women, providing care during pregnancy, birth and postpartum. This means the three midwives are on call for their "own women". There is also a senior midwife in Inukjuak responsible for the teaching and evaluation of the students. In addition, this senior midwife is on call to provide backup for births and emergencies. The position as senior midwife rotates among a team of experienced midwives from Canada and myself from Denmark. Over the past five years at the Inukjuak Maternity, the students have attended to 70 to 80 pregnant women a year. During this time 28 to 42 women a year from Inukjuak have given birth – a total of 182 women. Of these women 16 to 33 have given birth in Inukjuak a year – a total of 132 women. Women who did not give birth in the village were referred to Povungnituk Maternity or to Montreal, often by joint decision of the Inuulitsivik Perinatal Committee. During the 5-year period 72.5% of women from Inukjuak have given birth in Inukjuak. The numbers of women who were referred or chose during the pregnancy to give birth in Povungnituk were from a high of 14 in 1998 to a low of 3 in the year 2000. The number of women referred during the pregnancy to give birth in Montreal has been quite stable, between 1 and 4 a year. This means the percentage of women giving birth in Inukjuak has gone from 44.4% in 1998 to 79% in 2002, with the year 2000 showing the most women giving birth in Inukjuak, 86% (figure 1). Figure 1. Place of birth for women from Inukjuak and Medevac for women and babies The jump from 44.4% in 1998 to 74% in 1999 is the most interesting development. In 1998 women having their first baby could not give birth in Inukjuak, but after a discussion in the perinatal committee this policy was changed. Also women going to Povungnituk by choice were a factor that has an influence. In 2002 no women went to Povungnituk by choice. Over the years several women have had more than one child in Inukjuak and most women prefer to stay in Inukjuak to give birth, even at times when the recommendation is to go to Povungnituk. Here is an overview of the reasons for giving birth in Povungnituk or Montreal. 36 women gave birth in Povungnituk during the 5-year period. The main reasons for referral to POV are the following: 1. 2. 3. 4. A history of post-partum haemorrhage: Choice: No senior midwife in Inukjuak: Pre-eclampsia / hypertension: 25% 22.2% 19.4% 11% 14 women gave birth in Montreal during the 5- year period. The main reasons for referral to Montreal are the following: 1. Pre-eclampsia/hypertension: 2. Twins, Vaginal Birth After Caesarean, abruptio placenta, each of these: 3. Remaining reasons for referral: history of cervical tear, stillbirth, breech, Hyperthyroidism, pulmonal stenosis, Each one of these: 21.3% 14.2% 7.1%. Reasons for emergency medical transfer (Medevac) during pregnancy or immediately after birth (woman or baby). In all, 4.5% of the mothers and babies had to have a medical evacuation. The two main reasons for transfer/medevacs were post partum bleeding and premature labour and birth. Post partum haemorrhage (pph.) or a history of pph. is the most common reason for refers to Povungnituk, and the second most common reason for Medevac. In looking at the incidence of pph. it is seen that no primiparas had pph. over 2,000 ml. Altogether 1.5% of the women having pph. had a haemorrhage exceeding 2,000 ml, and 4.7% of the women had pph. between 1,000 ml and 2,000 ml. It is interesting that anecdotal observations from several different midwives in Nunavik indicate that even when a woman has might think. The premature birth rate among the women from Inukjuak is 3.3%. The intervention rate is extremely low: One caesarean section among the women transferred to Montreal (0.5% in total) and one vacuum extraction among the women giving birth in Inukjuak (0.7%). There were no episiotomies among the women giving birth in Inukjuak. Perinatal mortality rate There has been one perinatal death: An unexpected premature birth at home, 1,250 gr. at 29 weeks. The perinatal mortality rate of all births in Inukjuak is 5 per thousand births and of the women giving birth in Inukjuak it is 7 per thousand births. CONCLUSION This analysis has demonstrated that 1) the work of the Inukjuak midwives is outstanding, 2) the way the local Perinatal Committee works is very effective. Nunavik can be proud of its unique Midwifery service as the care is safe, health-promotive and meets the community’s demand for women to stay in their own community to give birth. Acknowledgements Thank you to the people in Inukjuak and especially to the midwives Julie, Brenda, Aileen, Minnie and Miko, from whom I have learned about true Midwifery. REFERENCES Carignan G. Pregnancies and births among the inuit population of Hudson Bay 1989-91. Project Nord, Community Health Department, University of Laval Hospital Centre March 1993. Fletcher C.The Inuulitsivik Maternity: Issues Around the Return of Inuit Midwifery and Birth to Povungnituk, Quebec. Final report submitted to the Royal Commission on Aboriginal Peoples. 1370 Overdale Montreal, Quebec 1993. Hodgins S. Infant Health and Development in Nunavik. Community Health KCRSSS, Kuujuak 1997. Susanne Houd, Principal The Midwifery School in Copenhagen University College, Oeresund Sigurdsgade 24, 2200 N., Denmark Email: [email protected] Midwifery care for every woman, everywhere. by Susanne Houd Susanne is a Danish midwife with wide experience of working in both western settings and in developing countries. As a consultant for the WHO, she has worked on Safe Motherhood projects in African countries. Having recently completed revamping the Danish Midwifery Education program, she is currently working with Inuit communities in Greenland where birth has been returned to the people in their own communities. To be born with a home Women in Nunavik, Eritrea and Greenland want to give birth where they live, with midwives that understand their language and culture and at the same time, who have the knowledge of today’s midwifery care. They want their babies to be born with a home – this means to be born in your own culture, assisted by midwives from your own culture who understand the language, the food habits, and the words to be said or not to be said. To be born without a home was for many years the case for women in Nunavik, North Quebec Canada. They were sent south to give birth alone and among strangers. In 1985 this changed, and birth was brought back to the north. The education of Inuit midwives began, honouring the culture. Today the care in Nunavik is an example for Nunavut and the Northwest Territories and the 10 Inuit midwives in Nunavik takes care of all the perinatal cases in the area. I was part of the return of birth to Inukjuak, a small village on the coast of the Hudson Bay, and we brought education to the students and the community and not the other way around. The health promotion results of this community based perinatal care are impressive and make you wonder why most of the western world wants to centralize perinatal care (1). Eritrea has one of the world’s highest rates for maternal and child mortality. In this area, 998 out of every 100,000 women die in connection with pregnancy and birth and 134 out of every 1,000 children do not reach their fifth birthday. After 30 years of fighting for independence, the war was won in 1992 and the country is now re-building. Traditional midwives do 80% of the perinatal care. That is how the government has decided it should continue, based partly on economy, partly on common sense and tradition. The traditional midwives are educated where they live and are supported in continuing the kind of care they have always given. Now, with new knowledge and easy access to the established system, they form the backbone of the perinatal care system. They work against female circumcision, they educate the women and the women trust them. The care is decentralized and the education goes to the women and not the other way around. I am part of a small team educating the midwives and nurses that train the traditional midwives. We use the concept The House of Learning, which is based on the idea that to learn, is to want to change. It is change that is the hard part. We have trained almost 300 health professionals during the eight years we have been coming to this poor and unknown country. We work closely with Eritrean midwives and nurses and we are supported by the Danish government as one of the few Danish non-governmental organisations in the country. The first white man stepped on the east coast of Greenland a little more than 100 years ago. Only 30 years ago people lived in primitive huts made of stone and earth and the heating was an open and hollow stone filled with seal oil. The Shamans had great power and even today people believe in ghosts and spirits underneath their thin Christian veneer. The Inuits are strong and intelligent, able to survive in a very harsh climate. There is an old tradition of Danish educated midwives working side-by-side with traditional midwives. Today the system favours the centralised point of view, but being so isolated from the rest of Greenland, the women want to stay home and give birth – on the east coast in their villages (2). The women give birth with the help of both Greenlandic and Danish midwives and they do it with power and strength. Birth is a part of daily life and they seldom show the pain. The introduction of ideas from western society has created many problems – they now have a society with the world highest suicide rate, with violence, alcohol abuse and incest. In the middle of all this, birth becomes a very important event, linking the old traditions to the new times. Birth is hope – and hope is needed in this society. Giving birth is a very social event. There are many women at each birth, all offering their silent support, their warm hands and their cry of happiness when the baby is born. I feel very privileged to work in this vast area as the only Danish educated midwife, and I work closely with three Greenlandic midwives. The language is the key to the culture and I am challenged every day – and that is how it should be. Three very different places and yet there are similarities. In all three places the perception of time is circular. Everything take the time it takes, whether it is hunting a polar bear, getting the water from the well or being at a birth. The difference in experience of time by the white man and indigenous people is expressed by a Greenlandic elder: "I think that the white man does not have any understanding of time. They cut it out in little pieces. Sleep a certain amount of time and wake up when the boss has told them to do. They ate at a certain time and always together. They work the amount of time that their Nalagaq (boss) has decided. Just think if we had to live like them? When we hunt the nanok – the polar bear – we are not limited by time. We are without time during the hunt. Does it take some few minutes or the whole day – it does not matter, for us it is only the bear and the hunting that exists. We are never too late for a meal. We eat when we are hungry and until we have had enough food. We sleep when we want and until we are not tired anymore. None of us would ever wake a person that is asleep." Acceptance of this notion, that things take the time it must take, is the lesson I have learned from Nunavik, Eritrea and Greenland. In all three places the women want to stay close to their family and culture when giving birth and the midwife is an important person in the community. The three cultures are fragile, threatened by our western cultural values. We must stop and learn and listen. As a midwife I must make sure that every child is born with a home. References: Houd S., Qiunuajuak J., Epoo B. The outcome of perinatal care in Inukjuak, Canada 1998-2002. International Journal of Circumpolar Health 2004;63 (Suppl. 2): 239241. Bjerregaard P, et al. Inuit health in Greenland. A population survey of life style and disease in Greenland and among Inuit living in Denmark. International Journal of Circumpolar Health 2003;62 (suppl. 1):1-79.