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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.