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Bulletin of the Netherla nds S ociety for Tropical Medicin e and In ternational Health volume 50 | 1 March 2012 Editorial 1 Ladies and gentlemen Practical Papers 3 Obstetric audit: why and how? Lessons from Thyolo, Malawi Conferences Symposia 5 Safe Motherhood Revisited and Thesis 6 The female condom: what takes us so long? photo: ACMS/UAFC Cases 8 Fundal uterine rupture of an unscarred uterus in a granda multipara. Editorial comment Consult Online 10 Paresis of the legs in a Maasai girl Reflections 13 Home deliveries in underdeveloped settings Tropical doctor: altruism or self-interest? Ladies and gentlemen The theme of this issue of Medicus Tropicus is Safe Motherhood. In 2012, the Safe Motherhood Initiative is celebrating its 25th anniversary. One could question whether there is anything to celebrate. Recent estimates show that every year approximately 80 million pregnancies are unintended. An estimated 356,000 women die every year from complications associated with pregnancy and childbirth, with unsafe abortion accounting for a high percentage of maternal deaths. Many women lack power over sexual decisions; they are not in a position to ask their partners to abstain from sex with others or to use male condoms. An estimated 215 million women wish to delay or space their pregnancies but do not have access to modern contraceptives. On the other hand, we have seen that many countries have been able to improve the health and well-being of mothers and newborns over the last 20 years. However, countries with the highest burden of mortality and illness have made the least progress, and inequalities between countries are increasing. In many places, inequalities within countries are increasing too, between those who live in better conditions and have access to care, and those who for a variety of reasons are excluded. Inequalities in reaching quality obstetric care, strategies to be used to improve services and to learn from mistakes and a strategy to enable women to exercise power over their own sexual health are described in this issue of Medicus Tropicus. Editorial Language editing Elsa van Gelderen Editorial secretariat Lies Laumans Postbus 5032 1200 MA Hilversum Tel: 0031(0)6-34306672 E-mail: [email protected] www.nvtg.org Design Atelier GrotesQue & Françoise Nick, Amsterdam The contributions from Gerstel and Lagro show how lively our Society is. The well visited symposium entitled “Strong past, healthy future”, organized to celebrate the 130th Netherlands Course in Tropical Medicine and Hygiene (NTC) showed the never ending enthusiasm of many young doctors who are willing to spend at least some years of their career on working in difficult areas of the world where those who are often excluded from access to care live. This has not changed in the past 50 years. Many of those doctors who come back (or not) to the Netherlands after a period of working in low-income countries have lost their hearts to obstetrics and Safe Motherhood and become members of the Working Party on International Safe Motherhood and Reproductive Health. The Working Party will celebrate its 25th anniversary in 2012, just like the Safe Motherhood Initiative, with a symposium entitled ‘Safe Motherhood revisited’. You are all welcome to attend! The symposium will be about 25 years of Safe Motherhood Initiatives and about what has been reached and which lessons have been learned. It also creates a platform to design strategies to reach goals for the years to come. Unfortunately the fifth (and fourth) millennium development goal will not be reached because of the unsatisfactory results of initiatives to improve reproductive health services. The scandal of our time, which is that still every day about 1,000 women die from a condition which can be classified as maternal death and which in almost all cases could have been prevented or treated, is ongoing. This simply means that the right to sexual and reproductive health is still systematically violated. In line with (political) democratisation processes in some African and Arabic (low-income) countries, hopefully women movements will gain strength to fight this injustice. Women themselves have to mobilise their forces and increase pressure on politicians to have their (sexual and reproductive) rights respected. We should find ways to support such initiatives. . Jurgens Editorial board Claudia Bijen Frits Driessen Esther Jurgens Steven Smits Hans Wendte Ed Zijlstra Doornbos and de Ridder describe a case from rural Ethiopia of a mother of 6 children who could have died, but only just survived, from a complication of childbirth: a uterine rupture caused by prolonged and probably obstructed labour and delay in receiving adequate care. The case history clearly shows delay in decision making at home (24 hours of ‘pushing down pains’ at home), delay in reaching the hospital (travelling for 8 hours) and delay in receiving adequate care after reaching the hospital (wrong diagnosis at first). Unfortunately, the baby died. Such cases happen in sub-Saharan Africa every day and are easily preventable by high-quality obstetric services in well-functioning health systems. Van den Akker encourages health workers working in district (and other) hospitals to not only spend time within the hospital on saving lives, but also to try to understand why so many cases of severe acute maternal morbidity and mortality are to be dealt within the hospital. By using the tool of medical audit care can be improved. If van den Akker had worked in the Chicago Maternity Centre in the thirties and fourties of the 20th century, he could have met the American science reporter Paul de Kruif, who wrote a book, which was even quoted in Anne Frank’s diary, about how maternal mortality decreased in Chicago in that period. Jan Peter Verhave in his article about home deliveries in underdeveloped settings informs us about this and comes to conclusions which are still very valid: keep your records, improve by discussing failures (audit!!!), be prepared to face a critical journalist and put him/ her on the bloody spot. Jurgens and co-authors submitted an article about the female condom, which is the only female initiated method that provides protection against STIs and mistimed or unwanted pregnancies. Free and universal access to female condoms can enable women to exercise power over their own sexual health which helps to reach the goal of safe motherhood. Jelle Stekelenburg gynecologist Chair Working Party on International Safe Motherhood & Reproductive Health Photos: E Bulletin of the Netherlands Society for Tropical Medicine and International Health ISSN 0166-9303 volume 50 | 1 [email protected] March 2012 Practical Papers Obstetric audit: why and how? Lessons from Thyolo, Malawi Working in an overburdened facility with limited resources, one easily becomes discouraged from any effort to improve care. This practical paper is meant particularly for those of you who are providers of obstetric care in settings with high maternal and perinatal mortality. If you seek to improve peripartum services in your clinic, a ready-to-use tool is available to assist you: obstetric audit. You may find that fighting maternal and perinatal mortality is indeed not a useless effort, even if the odds appear to be against you. Background Audit may be defined as ‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria, and the implementation of change’.1 At the busy Thyolo District Hospital in rural Malawi, several managers, midwives, and clinicians including myself were concerned about the high incidence of maternal and perinatal morbidity and mortality. In order to improve pregnancy outcome, we decided to start obstetric audit, in a manner suitable for the local setting. During a two-year-period, between 2007 and 2009, we registered 386 women who sustained severe maternal complications, 46 of whom died (case fatality rate 12%). Complications included (severe pre-) eclampsia, major hemorrhage, severe infection and uterine rupture. Obstetric audit involving local staff was performed on 45 cases. During the study period, the number of severe maternal complications reduced from 13.5 to 10.4 per 1000 facility deliveries.2 We think that this improvement was, for a considerable part, due to audit and feedback. Audit became a valuable instrument, recognized as such by the health workers.3 In this paper, some of the lessons learned from the application of this instrument in Thyolo are summarized. How to start auditing? A simple form of audit may be implemented anywhere at any time. Starting an audit does not require extensive formal training by anyone involved, as long as a few basic principles are observed. The first principle is that audit must be understood as a cyclical process. The cycle starts by agreeing upon an acceptable standard of care, for instance the local government protocol or a WHO guideline. In so-called ‘critical incident audit’, the care provided in case of a mortality or severe morbidity is then measured against this standard. Areas of substandard care are identified March 2012 volume 50 | 1 and recommendations for improvement put forward. These recommendations must be shared with all relevant obstetric care providers. In other words, feedback is a critical part of the audit process. The cycle will repeat itself as new standards are set and additional cases are audited. Thomas van den Akker gynecologist Thomas worked as a medical officer in Thyolo District from 2007 to 2010. He recently obtained his PhD from the VU University of Amsterdam, the Netherlands. Obstetric audit formed one of the main themes of his thesis entitled ‘Medical mirrors: maternal care in a Malawian district’. Secondly, the type of audit must be appropriate for the setting. In high-income settings, audit may take on the form of a National Enquiry. These national enquiries are most often used to analyze cases that have become a rarity at the provincial or district level, for instance maternal deaths. At the local level in such affluent settings, it is relevant to audit morbidity such as peripartum hemorrhage or pre-eclampsia. In poorer countries on the other hand, where mortality is still shamefully frequent, a mortality audit may be more suitable, since this type of audit could reveal considerable information about the circumstances around maternal or perinatal deaths in the catchment area of even one single facility. Thirdly, the manner in which an audit is conducted must take into account local customs. The way of discussing sensitive issues may differ between individuals and populations. In an audit such differences may be useful and complementary, given there is mutual respect and a basic understanding between participants. It is crucial that all participants are aware of the objective of audit: to improve care. The emphasis is on learning. Audit is not about assigning blame. A udit became a valuable instrument Fourthly, the conditions that are audited must be representative of the pattern of disease in a given area. If it is unclear what the commonest conditions are, one way in which to start an audit is by simply starting to count. In the case of Thyolo, uterine rupture was exceptionally frequent. Soon after the extent of the problem became known from a morbidity count, it was decided to specifically audit cases of uterine rupture. Within a year, the incidence of uterine rupture declined from 19.2 to 6.1 per 1000 hospital deliveries.4 Practical Papers A safe envi ronment is an environment in which people are free to express their doubts and fears Which cases to audit? From the pool of cases that are potentially useful to review, the number and type of cases that are actually audited may be decided upon in different ways. All staff could be given the opportunity to suggest cases for audit. It could also be agreed to have an audit team, ideally consisting of different cadres, putting cases forward. In many clinics in low-income countries, it is simply decided to audit all maternal deaths. Sometimes, this mortality audit is only done because it is a minimum requirement by the government, often resulting in poorly performed audits. One may question whether performing mortality audits alone is the way to go. In Thyolo, we found that auditing maternal morbidity had tremendous added value for several reasons. First, morbidity audit may be less harmful and even beneficial to staff morale, since ‘survivors’ of complications may be seen as ‘great saves’ rather than ‘near-misses’. Second, morbidity audit may reveal additional information obtained from the woman who survived a complication. What is needed for an effective audit? Starting an audit does not require much money. The initiators of the audits in Thyolo strongly felt that the attendance of audit sessions did not need to depend on financial incentives. The motivation to take part should be the willingness to learn. We estimate that part of the success of the Thyolo audit could be attributed to a general willingness among health workers to share ideas about patient management. In this respect, a supportive management is essential, and involvement from different cadres involved in patient care (including logistics, lab and pharmacy staff) is much desirable. All these elements are promoted by creating a ‘safe’ environment for audit. A safe environment is an environment in which people are free to express their doubts and fears. Negative consequences for health workers taking part in audit should be avoided. In some Latin American countries, audit results have been used to penalize health workers. No doubt that in such situations staff are not eager to take part in audit. Paradoxically, in other countries almost no measures are taken to ensure appropriate professional behaviour. In many sub-Saharan African countries, for instance, court cases against health workers are rare and quality assurance by governments is virtually non-existent. In these places, audit may serve as an alternative instrument to promote accountability and uphold professional standards. In Thyolo, a few staff members had the courage to openly doubt the clinical management they had chosen in a certain case. This encouraged others to do the same. In general, it was much appreciated when those health workers that had been involved in the critical case management participated in the audit. A safe environment facilitates this participation. High attendance of staff prevents a situation where audit depends upon only a few individuals. This ensures the sustainability of audit in that given setting. Closing remarks: obstetric audit in practice In the case of Thyolo, audit and feedback sessions were performed every two or three weeks at the district hospital. All sessions were conducted in a similar manner, with one or two case reports selected and summarized by a responsible maternity staff member. The sessions were open to everyone, but for a session to take place at least one member of all professional cadres had to be present, including a member of the management. Usually between 25 and 50 staff attended. Provided care was measured against benchmark district protocols that followed WHO recommendations. At the end of the session, all participants were asked to complete a form guiding them to assess care as standard or substandard, and give recommendations for improvement of care. Tasks related to these recommendations were assigned to specific individuals, who were required to report on progress made during subsequent sessions. In conclusion, audit is a useful instrument to improve obstetric services, particularly in places with high maternal and perinatal mortality. The question is not whether to audit, but rather how to do it. Anyone working in a clinic where obstetric audits are poorly done or not performed at all, should take this message to heart. You may be the one to start an effective audit and make a positive difference for future patients seeking care at your clinic. [email protected] References 1 | http://en.wikipedia.org/wiki/Clinical_audit; accessed 19-02-2012. 2 | van den Akker T, Van Rhenen J, Mwagomba B, Lommerse K, Vinkhumbo S, van Roosmalen J. Reduction of maternal mortality and severe maternal morbidity in Thyolo District, Malawi: the impact of obstetric audit. PLoS One 2011;6(6). 3 | Bakker W, van den Akker T, Mwagomba B, Khukulu R, van Elteren M, & van Roosmalen J. Health workers’ perceptions of obstetric critical incident audit in Thyolo District, Malawi. Trop Med Int Health 2011;16:1243-50. 4 | van den Akker T, Mwagomba B, Irlam J, van Roosmalen J. Using audits to reduce the incidence of uterine rupture in a Malawian district hospital. Int J Gynaecol Obstet 2009;107:289-94. volume 50 | 1 March 2012 Conferences and Symposia Symposium ‘Safe Motherhood Revisited’ 25 years Working Party on International Safe Motherhood & Reproductive Health How it all started The Safe Motherhood Initiative was launched 25 years ago at an international conference in Nairobi, Kenya. Its aim was to draw attention to the death of half a million women worldwide from pregnancy-related causes. In that same year 1987 some Dutch gynecologists with working experience in low-income countries established the Consultancy for Safe Motherhood & Family Planning. They used their expertise to advise (non) governmental organizations about reproductive health in low-income countries. A quarter of a century later, the Consultancy has changed its name into Working Party on International Safe Motherhood & Reproductive Health (ISM&RH) and broadened its objectives while individual members still act as consultants. Looking back The symposium ‘Safe Motherhood Revisited’ will reflect on 25 years Working Party ISM&RH (Jelle Stekelenburg) and the results of 25 years Safe Motherhood Initiative for maternal and perinatal health (Esther Scheers and Patrick van Rheenen). From these reflections we will learn what has been achieved, but also what still needs to be done. The morning session will therefore close with a future-oriented view by Staffan Bergström on how obstetric services can be implemented in-low income countries. can strengthen health systems. Professional photographer Joni Kabana will talk about and show pictures of the way fistula prevention and repair is addressed in Ethiopia. The third phase of delay takes place at the health care facility. Tanzanian gynecologist Angelo Nyamtema studied the use of audit to improve the quality of obstetric care, Ellen Nelissen will focus on maternal near miss and mortality in Tanzania and how this can be used to improve maternal health services, followed by Marcus Rijken who worked on the Thai-Burmese border and investigated the use of ultrasound in antenatal care. The last speaker is special guest Projestine Muganyizi, gynecologist and president of the Association of Gynecologists and Obstetricians of Tanzania (AGOTA) Rates (dinner&party included) which is the twin partner of the Netherlands College of Obstetrics and > Students: 50 Euros Gynecology (NVOG). He will look at > Aios/Taio: 75 Euros predictors of extra care for eclamptic > Gynecologist/Midwife/Other: 125 Euros patients. 20 april 2012 Amstelzaal, VU Medical Center Amsterdam > Dinner&Party only: 25 Euros Fresh and outside the box Looking forward New developments in research on how to reduce maternal morbidity and mortality feature in the second session. The overlying theme: the three phases of delay in acquiring quality (obstetric) care. Petra ten Hoope-Bender, midwife and contributor to the UNFPA report ‘Delivering Health, Saving Lives’, will open this session with an introduction to the ‘model of three delays’ and the role of midwifery in improving obstetric health services. Recognizing danger signs and the decision to seek care are the first phase where delay occurs. Yadira Roggeveen and David Urassa will talk about community-based approaches to tackle this problem in Tanzania. Delay in reaching a health care facility is the second phase of delay. Use of modern technology like mobile phones and internet can provide ways of improving access and the quality of health care. Caroline Mbindyo, eLearning Programme Manager for Amref, will present how new technology March 2012 volume 50 | 1 Information and registration: In the afternoon young researchers are given the opportunity to present [email protected] results from their studies about safe or www.safemotherhood.nl motherhood in low-income countries. The Working Party always strives to Payment look outside its own field of work. to bankaccount 48.93.36.965 (ABN/AMRO) The lustrum symposium ‘Obstetric of Stichting Steun Internationale Verlos Ectoscopy’ in 2007 was an example of this. This year we have invited kundige en Gynaecologische Zorg stating architect Antoni Folkers to talk ‘Symposium Safe Motherhood Revisited’ about architecture and health care in Africa. He has more than twenty years of working experience in different countries in Africa. Jos van Roosmalen, one of the founders of the Working Party ISM&RH and Professor in aspects of national and international Safe Motherhood will officially close the symposium. That is, however, not the end of the day: we will continue with drinks, dinner and dance at The Basket until at least midnight! Thesis The Female Condom: what takes us so long? Esther Jurgens consultant international health Marie Christine Siemerink Programma Coordinator UAFC Photos: E. Jurgens Ciska Kuijper Project Officer UAFC Accelerating the access to female condoms worldwide “A condom! I’m not ill, am I?” is what Seyi Jemoh often hears when she is promoting the female condom (FC) at her hairdresser’s in Nigeria. Seyi Jemoh is HIV positive and has been involved in the Nigerian component of the Universal Access to Female Condoms (UAFC) Joint Programme since spring 2011.1 Seyi Jemoh is passionate when she talks about the FC. “People must use condoms. I tell young girls above all. I tell them that they should use a condom, if they are unwilling to say no. Abstinence is better, but I’m not a fool, I know that is unrealistic.” Haircuts and condoms: an odd combination at first sight. Over the past three years, the UAFC Country Programmes in Nigeria and Cameroon have shown a steady increase in demand for and sales of female condoms, both good indicators of its acceptability on the ground. As the female condom is a relatively new product, raising awareness among the general public and peer education are essential instruments in the promotion of the condom. This requires creative, and sometimes, innovative approaches, such as the involvement of hairdressers, barbers and pharmacies, strategies that seem to be paying off, as findings from the End of Term Evaluation of the UAFC Joint Programme illustrate.2 Recent evidence from the UAFC Programme in Nigeria and Cameroon demonstrates the demand for female condoms on the ground, and reinforces the importance of popular and peer education, provided there is easy and sustained access. As Odilia Bessum Kum, owner of a hairdresser’s in Buea, Cameroon who receives women from various social and economic backgrounds, illustrates: “Some rich and influential women also buy from me. They don’t want to buy them in public so they come to my salon, and while doing their hair, they buy their female condoms. I have even been nicknamed “Mammi Protectiv”. (In Cameroon the brandname for the female condom is ‘Protectiv’.)8 When the price is right In spite of the demand, the high price of the female condom – some 0.62 USD, compared to 0.03 USD for a male condom9 – impedes the process of making them widely available, affordable and accessible. A situation that is unlikely to change, given the limited production and competition in the market. Currently FC2 is the only condom approved for bulk procurement, mainly through the United Nations Population Fund and USAID. The UAFC Joint Programme has initiated research in which three newer types of condom are tested in field trials in China and South Africa. The study supports the manufacturers in completing their information for the WHO approval of their products. Results from the studies are expected in spring 2012. Since the mid 1990s female condoms have been distributed, predominantly in the public sector as part of HIV/AIDS reduction programmes, and as an alternative to male condoms.3 The female condom has been on the market for quite some time, albeit only a few different types4 are distributed in a limited number. Some 22 million female condoms are being shipped annually, a small proportion of the almost 2 billion male condoms that are being transported globally (2011 figures).5 Many doubt its demand, an argument often used by manufacturers. To date few have invested in producing the product on a large scale, negating evidence on increased interest and demand from (potential) users. A 1997 WHO review of female condom acceptability studies, conducted in 40 different countries around the world, found that 37% to 96% of female condom users rated the product as positive and acceptable.6 The review acknowledged that acceptability may be determined as much by how the technology is introduced as by its physical characteristics. A prerequisite for acceptability appeared to be education, training and the support that accompanied the introduction of the condom, and whether they were sustained.7 15 years lost… Given the sexual and reproductive health needs of men and women worldwide and despite their huge potential, it is quite surprising why female condoms are still not yet widely available and accessible. They are accepted by diverse users in a variety of settings and provided correct use they are efficacious in preventing pregnancies and STIs, including HIV.10 The female condom helps to increase the number of protected volume 50 | 1 March 2012 Thesis sex acts, in part because it can be inserted in advance. Anecdotal evidence from the 2011 End of Term Evaluation11 and other qualitative studies12 support the assumption that women value the female condom as a means of enhancing their ability to negotiate condoms for safer sex within the relationship, enabling them to exercise power over their sexual health. Men value its comfort, as Chiwechu Nwaokor’l, a motor taxi driver in Nigeria testifies: “Much better than a male condom. The condom doesn’t burst, it’s stronger. And it’s wider, the size of the penis no longer matters, it always fits.” So why are donors and governments hesitating? Why are investments in research, development and programming lagging behind? In 2009, donor support for female condom commodities represented only 0.38 per cent of the total donor expenditure on global HIV/AIDS, despite the substantial unmet need for condoms.13 Furthermore, few parties (donors, government, private companies) are investing in social marketing and other effective/comprehensive programming, which is essential for creating demand and enabling sustained use. Possibly donors are hesitating because of a hampering supply chain in many developing countries, because of weakened public health systems, enhancing the risks of irregular supplies and stockouts. In addition, as indicated in several studies14 and by the WHO, because of the high cost of the female condom compared to male condoms the female condom has achieved only limited distribution in countries hardest hit by the HIV/AIDS epidemic.15 The UAFC Joint Programme is one of the few programmes in which funding for programming and procurement are combined, which is considered a prerequisite for ensuring access, creating demand and stimulating use. In addition, the UAFC Joint Programme addresses the cost and choice issues by promoting entry of new types of female condom onto the market. Male involvement “The female condom is regarded more as a woman’s thing”, as Victoria Archebong, programme staff from the Society for Family Health, the Nigerian partner of the UAFC Joint Programme partner, explains. “Some men may feel threatened as the female condom will empower women in demonstrating their sexual and reproductive health rights. For female condom programming, programmers have to be more creative and strategic.” The strategy of SFH therefore invested in allowing both men and women to become familiar with the product. SFH made a deliberate move to reach out to men through mass media campaigns, and to actively involve them as male trainers and promoters. Such as Chiwechu Nwaokor, a motor taxi driver and FC educator: “I talk about female condoms with my friends. Even when watching a football match. I’m a Chelsea fan. When there’s a match we all go to the video centre. We talk before the match, and I tell them about the female condom. Really, they listen. We are Africans, seeing is believing. So I always bring a demonstration model along. Once they see it they say: ‘Give me one.’ And they want to use it.” Another success of the country programme in Nigeria was the involvement of an Anglican bishop, one of the key religious leaders in the country, who openly speaks out about the female condom and promotes it among his constituency, thereby helping in breaking down possible cultural barriers to female condom use. Currently the UAFC Joint Programme is entering its second phase, including a continuation of the country programmes in Nigeria and Cameroon, possibly expanding to other countries provided there is an interest from governments and donors. References 1 | In 2009 a large-scale female condom programme started in Nigeria and Cameroon as part of the Universal Access to Female Condoms (UAFC) Joint Programme. Other components included: Research and Development; International Advocacy, Linking and Learning, Communication; and Governance. 2 | ACE Europe. End of Term Evaluation of the UAFC Joint Programme. December 2011. 3 | WHO (2007). Report of the Female Condom Technical Review Committee (WHO/RHR/07.18). 4 | The Female Condom (FC1 and FC2), the VA w.o.w. Feminine Condom (also known as the ‘Reddy condom’), Cupid Female Condom, and the Women’s condom (an innovative model developed in close collaboration with women and couples). To date only type FC2 received approval from USFDA (in 2009) and from the WHO pre-qualification system. Reddy and Cupid have been granted a consumer safety mark for distribution in the European Union. 5 | Statistics from the Reproductive Health Coalition: http://rhi.rhsupplies.org, accessed February 20, 2012. 6 | Center for Health and Gender Equity. Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health. Washington, DC: Center for Health and Gender Equity, 2011. 7 | Idem. 8 | UAFC, information leaflet 2011. 9 | Male condoms: more than 1,8 billion shipments globally representing $ 57 million USD. Female condoms: more than 22 million condoms representing some $ 13 million USD (January-December 2011). Source: http://rhi.rhsupplies.org, accessed February 20, 2012. 10 | Center for Health and Gender Equity. Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health. Washington, DC: Center for Health and Gender Equity, 2011. 11 | ACE Europe. End of Term Evaluation of the UAFC Joint Programme. December 2011. 12 | Center for Health and Gender Equity. Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health. Washington, DC: Center for Health and Gender Equity, 2011. 13 | Idem. 14 | Idem. 15 | WHO (2007). Report of the Female Condom Technical Review Committee (WHO/RHR/07.18). March 2012 volume 50 | 1 Universal Access to Female Condom (UAFC) Joint Programme The UAFC Joint Programme started in 2008 aiming to make female condoms accessible, affordable and available to all. The overall objective of the Programme is to decrease new HIV-infections and STIs, to prevent mistimed and unwanted pregnancies and enable women to exercise power over their own sexual and reproductive health. UAFC is an initiative of four organisations in the Netherlands: Oxfam Novib, Rutgers WPF, i+ solutions, and the Netherlands Ministry of Foreign Affairs. For more information contact Ms.M.C.Siemerink, the Programme coordinator UAFC Joint Programme at: MarieChristine.Siemerink@ oxfamnovib.nl, or visit the website: www.condoms4all.org. Cases Fundal uterine rupture of an unscarred uterus in a granda multipara Iris de Ridder Resident tropical medicine at OLVG hospital in Amsterdam Hans Doornbos Gynaecologist in St Luke hospital in Wolissa, Ethiopia A case report from Ethiopia Case description This case is set in St Luke Hospital: Wolisso town, Oromia regional state, Ethiopia. St Luke is a general, referral hospital with a training college for nursing and midwifery care. The hospital has a catchment area of over 1 million people. It has 192 beds and annually 2900 deliveries, 450 caesarian sections and 30 uterine ruptures (2011 numbers). The obstetric and gynaecology ward is staffed with one (Dutch) gynaecologist, six first and second year Master Health Officers and numerous obstetric nurses, midwives and trainees from the nursing school. The health officers and midwifery staff speak mostly Amharic and reasonable English. The patients, however, mostly speak the local languages, so there is often a communication problem. The hospital does not have a diagnostic ultrasound. The patient was a multigravida with six living children, all of them spontaneous home deliveries. She was admitted to our hospital with a history of long labour at home (‘pushing down pains’ for more than 24 hours). After the pains had subsided she travelled over 8 hours on foot to the local health center. The health worker at the health center, who spoke the local language, sent the patient to St Luke hospital by car with a very short referral letter, only saying: ‘uterine rupture?’. In St Luke she was first seen by the Master Health Officer on duty who did not speak her language. History taking was difficult due to this language barrier. However, there appeared to be no history of caesareans, other abdominal surgery, curettages or any chronic illness. She had not received any prenatal care and she was unsure of her gestation. On examination the patient was stable, with normal blood pressure and pulse and no fever. The conjunctivae were pale. On inspection the abdomen was distended and no scars of previous operations were seen. On auscultation the bowel sounds were sparse and no fetal heart beat could be heard with a fetoscope. On percussion there was meteorism and slight tenderness. On palpation the uterus was conform 24 weeks’ gestation and somewhat hypertonic. The lower uterine segment was not tender. On vaginal examination there was slight bleeding but the cervix was closed. The urine was clear. This was not a classical presentation of uterine rupture and the diagnosis made by the Master Health Officer was intrauterine fetal death with impending labour. However, laboratory examination showed an Hb of 3.0 mmol/l which did not fit the picture, so the gynaecologist was consulted and one hour later he examined the patient again: on palpation fetal parts were felt outside the uterus in the abdominal cavity and the diagnosis uterus rupture was made. An emergency operation was arranged within 15 minutes. The laparotomy was performed by the Master Health Officer under senior supervision. At laparotomy, a first degree macerated full term child with its placenta and 2.5 litres of blood were found in the abdomen. In the fundus of the uterus was a star-shaped, actively bleeding rupture. A supravaginal hysterectomy was performed. The patient made a full recovery without further complications and was discharged on the sixth day postoperatively. Background Rupture of an unscarred uterus, which is a rare event in the developed world, is unfortunately common in developing countries.1 In Ethiopia it is also still a major obstetric problem.2 Obstructed labour and delayed intervention are the main reasons that uterine rupture is still a frequent life-threatening obstetric complication in the developing world.1,2 Uterine ruptures are usually in the lower uterine segment, but in this patient the rupture was in the uterine fundus which is rare. In St Luke hospital it was the first recorded case. Normally, the uterine wall is at its strongest at the fundus, especially during labour.3 In literature a number of possible reasons for the uterus to rupture at the fundus are cited such as high parity, prolonged labour and previous damage to the uterine wall due to curettage5, manual removal of a morbidly adherent placenta or other intrauterine instrumentation.4 Other causes for uterine rupture are uterotonic drugs and the use of cocaine.6 In the presented case, we hypothesize that the combination of prolonged labour and multiparity (repeated stretching from previous pregnancies) caused the rupture. It is also possible that fundal pressure was repeatedly applied by a traditional midwife at the patient’s rural home. A literature search revealed no systematic reviews focusing on uterine rupture in the fundus specifically, probably because it is a rare phenomenon in the developed world.7 However, several facility based studies suggest that in the developing world a rupture in the volume 50 | 1 March 2012 Cases fundal region might not be so uncommon. For instance a facility based study in Pakistan finds that 20% of its uterine ruptures were in the fundal region8 and a Turkish article finds that even 37% of its ruptures were in the fundus of the uterus.9 These numbers differ greatly from studies based in the Western world. In a population based cohort study in the Netherlands they find that only 1% of the uterine ruptures were in the fundal region. But 87% of all the women with a rupture had a uterine scar and all but 2 (1%) of them had a lower uterine segment rupture. But in the group without a uterine scar, 16 % had a rupture in the fundus, and the anterior and posterior wall being the most common place of rupture (each 25%).7 Since most ruptures in the developed world occur in a scarred uterus it is logical that the usual side of rupture is the lower uterine segment. In the developing world, however, it is not the scarred uterus but obstructed labour and delayed professional medical help, that are the biggest risk factors for a uterine rupture. And as stated before, these are also thought to be risk factors for fundal uterine rupture. Therefore the incidence of fundal uterine rupture is higher in the developing world. The clinical picture of the fundal uterine rupture can differ significantly from the classical signs and symptoms present in cases of the lower uterine segment rupture.5 Intra-abdominal blood loss might be less profuse and as the lower uterine segment is intact, the patient will present without lower abdominal tenderness. In our case, where the patient was stable and without signs of acute abdomen, the vaginal examination initially led to an incorrect diagnosis. Different modes of management are practised when dealing with uterine rupture. When the damage is not extensive, as is sometimes the case with lower uterine segment rupture, often the quickest procedure is repair. In this case the actively bleeding wound in the fundus was difficult to repair which resulted in the decision to perform a hysterectomy*. Conclusion Fundal uterine rupture is a relatively unknown phenomenon. The clinical presentation might be confusing, but careful history taking and physical examination can clarify the diagnosis and prevent unnecessary further delay of laparotomy. As stated earlier, the history of women from rural areas is often difficult to obtain. In cases of uterine rupture the history is most essential, so the suggestion of the health professional in the health centre (speaking the local language) should have had more influence on the decision making. [email protected] References Literature 1 | Wang YL, Su TH. Obstetric uterine rupture of the unscarred uterus: a twenty-year clinical analysis. Gynecologic and Obstetric Investigation 2006;62:131–135. 2 | Amanael Gessessew, Mengiste M Melese. Ruptured uterus - eight year retrospective analysis of causes and management outcome in Adigrat Hospital, Tigray Region, Ethiopia. Ethiopian Journal of Health Development. 2002;16(3):241-245. 3 | Buhimschi CS, Buhimschi IA, Malinow AM, Weiner CP. Myometrial thickness during human labor and immediately post partum. American Journal of Obstetrics & Gynecology; 2003 Feb;188(2):553-9. 4 | E. Nkwabong, L Kouam, W Takang. Spontaneous uterine rupture during pregnancy: case report and review of literature. The African Journal of Reproductive Health; 2007 Aug;11(2):107-12. 5 | David Chelmow, Gerard G Nahum. Uterine Rupture in Pregnancy. Medscape. 6 | Agarwal R, Gupta B, Radhakrishnan G. Rupture of intrapartum unscarred uterus at the fundus: a complication of passive cocaine abuse? Archives of Gynecology and Obstetrics 2011 Mar;283 Suppl 1:53-4. Epub 2011 Feb 17. 7 | Zwart JJ, Richters JM, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Uterine rupture in the Netherlands: a nationwide populationbased cohort study. British Journal of Obstetrics and Gynaecology. 2009 Jul;116(8):1069-78. 8 | Sameera Khan, Zahida Parveen, Shamshad Begum, Iqbal Alam. Uterine rupture: a review of 34 cases at Ayb Teaching hospital Abbooaba. The Journal of Ayub Medical College. 2003;15(4):50–52. 9 | Kara M, Töz E, Yilmaz E, Oge T, Avci I, Eminli I, Sentürk S. Analysis of uterine rupture cases in Agri: a five-year experience. Clinical & Experimental Obstetrics & Gynecology. 2010;37(3):221-3. Editorial comment Although the authors do not specifically say so, three clinical features of this patient made a correct diagnosis initially difficult. Firstly, the blood pressure and pulse were reported to be normal, secondly no fetal parts were felt outside the uterus on abdominal palpation and thirdly the cervix on vaginal examination appeared closed. A few comments are in order. March 2012 volume 50 | 1 No values are given for the patient’s blood pressure and pulse rate. This is unfortunate because I find it hard to believe that a patient, who is severely anaemic as the result of a recent bleed of two and a half litres, has a normal pulse rate. Identifying fetal parts outside the uterus by abdominal palpation is often not as easy as it may seem. Photos: I. de Ridder * | In the medical colleges in Ethiopia the gynecologists always prefer to do a hysterectomy in cases of rupture for reasons that are not very clear. Frits Driessen formerly gynecologist in Africa Cases - Consult Online The abdominal wall may be tense or the fetus is somewhere deep in the abdomen, away from the anterior wall. After the uterus has delivered its contents into the abdomen, the cervix tends to shut down and may no longer be felt to be widely dilated as one expects at the end of the first stage or during the second stage of labour. However, careful palpation will reveal that it easily admits two or three fingers. After normal labour this situation persists for several days. One wonders whether whoever examined this patient fully appreciated this fact. If, however, the cervix was indeed firmly closed as it is during pregnancy, this would shed a completely different light on the course of events. In that case one has to assume that the uterine rupture occurred before the onset of labour. In this, admittedly unlikely, scenario other causes of rupture need to be thought of. A uterine scar, for example, due to an unskilled abortion in an earlier pregnancy is one possibility. Particularly in countries where abortion is illegal or not culturally acceptable, such an event is often hidden by the patient. However, external injury to the abdomen and uterus in the present pregnancy is also possible. Supposedly, an unskilled attendant may have attempted to deliver the baby by applying force before the patient was in labour. More likely would be, however, that the abdomen was severely beaten maliciously. Such external injury although uncommon, is certainly not unheard of and may not be revealed to the medical attendants. It can be important to bear this latter possibility in mind in the patient’s interest and for medicolegal reasons. Presumably, in this patient we will never know. No ultrasound was available for the examination of this patient. Had it been available, what might it have contributed? Most importantly, it would have shown the presence of a large amount of fluid in the abdomen and this, in combination with the low haemoglobin would have been extremely suggestive of a large haemoperitoneum. Of course, it would also have confirmed the baby to be dead. However, determining by ultrasound whether a fetus is inside or outside the uterus can at times still be difficult. Fortunately, in this patient the baby was felt by palpation to be outside the uterus and thus, the need for laparotomy became obvious. As Shakespeare wrote: “All’s well, that ends well!” 1 In the medical colleges in Ethiopia the gynecologists prefer to always do a hysterectomy in cases of rupture for reasons that are not very clear. Consult online - case report Floor Peters MD, tropical doctor Endulen Hospital Tanzania Paresis of the legs in a Maasai girl Setting Endulen Hospital is still the only hospital in the Ngorongoro Conservation Area serving a population of at least 70,000 scattered in an area of some 8300 km2. The hospital has developed to the current status from a tuberculosis treatment center in the early seventies to the current seventy-two bed general hospital. This was done throughy the effort of both the church and the Austrian Government. The hospital offers all the essential services, serving mostly the pastoral Maasai in the area. Medical staff consist of local nurses and nurse-midwives, together with four clinical officers and two medical officers (one Tanzanian and one Dutch medical officer) Claudia Bijen MD, PhD resident in tropical medicine Photo: F. Peters Josien Westendorp MD resident in tropical medicine 10 Case report A 13-year-old Maasai girl presented at Endulen Hospital with complaints of initial difficulty in walking that volume 50 | 1 March 2012 Consult Online Laboratory analysis revealed a slightly elevated erythrocyte sedimentation rate (ESR) of 15 mm/hr. All other laboratory results, including haemoglobin, white blood cell count and leucocyte differentiation were in the normal range. The Brucella agglutination test was positive. VDRL and HIV testing was negative. No X-rays were made and a lumbar puncture was not performed. In order to discuss differential diagnosis and treatment possibilities, professional advice from consult online was requested. The online consultation service aims to offer support for tropical doctors confronted with rare or complicated cases. Any colleague in need of advice on a particular clinical problem is invited to log on to www. tropenopleiding.nl. After registration as a member (free of charge) cases can be presented by e-mail. When requesting a consultation, please provide all necessary information (Box). While striving to provide the best possible advice, the online consultation service and the specialists who are consulted accept no legal responsibility for the patient’s outcome. The requesting doctor remains fully responsible for the care of the patient. In the meantime, the girl was treated with medication against Brucellosis according to local protocol (gentamycin intravenously and co-trimoxazole orally during two weeks according to local paediatric protocol) and physiotherapy was started. March 2012 volume 50 | 1 Four Dutch paediatricians responded and one neurologist. The first paediatrician replied within two days and the last within one month. The differential diagnosis of the expert panel varied from: 1 Spinal cord disorder (Konzo, Tabes Dorsalis, Poliomyelitis) 2 Peripheral neuropathy (Guillain Barré) 3 Muscular disorder (Duchenne Muscular Dystrophy, Myopathy) 4 Musculoskeletal disorder (Juvenile Idiopathic Arthritis, Acute Rheumatic Fever, Osteomyelitis) The situation of the patient improved visibly on treatment. In three weeks she was able to walk 50-100 metres, first along the barrier then with a stick. After five weeks of rehabilitation the patient was discharged home. No follow-up appointment was made. Because of the fast and complete recovery we thought Guillain Barré syndrome would have been the most obvious diagnosis. Referring physician Medical field in which the consultation is required had progressed to a paresis of both legs over a period of six weeks. She was complaining of progressive pain and weakness in both legs from her hip to her ankles and of lower back pain. The complaints started without pre-existing fever or trauma. There was no incontinence for urine or faeces. Before the onset of her illness she had no complaints of her legs or back and she could walk normally. She had had a normal development and completed all her vaccinations according to scheme (including polio). Her family history mentioned no other members with similar problems. The nutritional status of the patient was fair, and no cassava was consumed. On physical examination the girl looked healthy. The skin of the legs looked normal, joints were not swollen or red and there was overall minimal muscle atrophy. The girl was hardly able to move her legs actively. There was slight loss of sensation to light touch and pin prick. Joint position sense was normal. The deep tendon reflexes of the legs were lively, symmetrical, with a tendency to clonus. Babinski reflex was absent. Strength in both arms was normal. Auscultation of the heart and lungs was normal. On palpation of the spine, no swelling or pain was felt. Training, years in practice Hospital facilities and possibilities of referral Patients data Age and gender Previous disease, HIV status: positive/negative/unknown Present complaints Findings on physical examination Laboratory and other findings (X-ray, ultrasound et cetera) Treatment given so far Specified question relating to diagnosis, therapy or something else However, after three months the girl returned to the hospital with recurrence of her paresis. This time the paresis was also accompanied by urine and stool incontinence. The Brucella test was positive again. Other laboratory findings were normal. Neurobrucellosis, an uncommon complication of brucellosis involving the central nervous system, became more plausible. Therefore, we decided to treat the girl again with anti-brucellosis treatment; this time for a period of three months.1 Because of the high prevalence of tuberculosis and a differential diagnosis with spinal tuberculosis, antiTB-treatment with RHZE (Rifampicin, Ethambutol, Isoniazide and Pyrazinamide) was started as well. In literature some authors state that the Guillain Barré syndrome could have been the manifestation of neurobrucellosis in the first episode.2,3,4 Alternatively, it might be possible that her initial treatment period for brucellosis was too short. 11 Consult Online Background Brucellosis is a zoonotic disease. B. melitensis (goat,sheep), B. abortus (cattle), B. suis (swine) and B. canis (dog) are the most common organisms causing disease in humans. These organisms are small, aerobic, non-spore forming, non-motile, gram-negative intracellular coccobacilli. Humans are accidental hosts. They can acquire the disease through direct contact with infected animals (e.g. handling of animal placentas) or consumption of products of an infected animal (Figure 1). Much of the Brucellosis in humans is food-borne and is associated with consumption of unpasteurized milk products and raw or under-cooked meat. Risk of getting infected depends upon the immune and nutritional status of the host and the way of transmission. Furthermore the different species of Brucella have a different virulence.5,6 abortion unpasteurized milk products airborne transmission mating shedding in milk Brucellosis exists worldwide and is an endemic disease in Tanzania.7 Maasai people are pastoralists that still live traditionally, in very close contact with their herds. Inside the Ngorongoro Conservation Area (NCA), inhabitants are not allowed by government regulations to grow their own crops, because this is a conservation area. Maasai diet consists of maize porridge, milk, meat, animal fat and traditionally some animal blood is being consumed. can be involved to some extent.8-11 The incidence of neurological complications ranges between 0-25% in adult patients. It is rarely seen in children.8-13 Neurological complications have marked clinical importance for their severity and important morbidity. Brucella bacteria may affect the nervous system directly or indirectly, as a result of cytokine or endotoxin on the neural tissue.14 Direct involvement of the brain or spinal cord with the Brucella organism leads to encephalitis or myelitis. The myelopathy typically involves the corticospinal tract, thus producing an upper motor neuron syndrome. The peripheral nerve lesions probably occur within the intrathecal portion of the peripheral nervous system, which leads to radiculopathy or polyradiculopathy. Characteristically, the legs are more involved than the arms.15 As a diagnostic tool, the serum agglutination test is most widely used but it cross-reacts with other Gram-negatives. In diagnosing Brucellosis the bacteria isolation from serum and other specimens is the gold standard, but culture positivity may be less than 50% in many reports.8-11 A treatment regimen for patients with Brucellosis is doxycycline (for 6 weeks) plus either streptomycin (for 2-3 weeks) or rifampicin for 6 weeks. Relapse occurs in approximately 10 percent and should be treated with the same regimen. The combination of ciprofloxacin and ofloxacin plus either rifampicin or doxycycline may be an alternative. Rifampicin, co-trimoxazole and gentamycin are useful in children and pregnancy.5 Those patients who present early usually respond quickly and completely to treatment. Those who present later may suffer significant neurological sequelae related to demyelination, infarction or haemorrhage in the central nervous system. Patients presenting with polyradiculopathy usually recover completely.15 To prevent infection of Brucellosis the following strategies can be used: pasteurization or boiling of milk products, protective clothing for those at risk, screening of livestock by serology or by testing cow’s milk, elimination of infected animals and vaccination of animals in high prevalence areas. Reflection After a variable incubation period (2-4 weeks to months) an acute or insidious onset of fever starts (maybe rigors) with constitutional symptoms. Brucellosis has a wide clinical polymorphism and almost every organ can be affected during the infection. The most common site involved is osteoarticular. Additionally the hematologic system, central nervous system, cardiopulmonary system and genitourinary system 12 Brucellosis continues to be a common and important health problem in developing countries and neurobrucellosis is one of the important complications in Brucellosis. Neurobrucellosis may appear with different clinical manifestations and the diagnosis may be difficult. In unusual neurological disorders Brucellosis should be kept in mind especially in endemic areas. If Brucellosis was the cause of the symptoms in this volume 50 | 1 March 2012 Consult Online - Reflections Maasai girl remains unclear with the limited diagnostic facilities in the hospital. After 6 weeks she showed very slight clinical improvement. We hope with conti- nuing treatment (medication and physiotherapy) she will eventually recover again. [email protected] References 1 | Colmenero JD, Ruiz-Mesa JD, Plata A et al. Clinical Findings,Therapeutic Approach, and Outcome of Brucellar Vertebral Osteomyelitis. Clinical Infectious Diseases 2008; 46:426-33. 2 | Namiduru M, Karaoglan I, Yilmaz M. Guillain Barré Syndrome Associated with Acute Neurobrucellosis. Int J Clin Pract. 2003; 57:919-20. 3 | Stanley R, Rust JR. Neurologic manifestations of Brucellosis. Online available at: http://emedicine.medscape.com/article/1164632-overview#a0104 4 | Goktepe AS, Alaca R, Mohur H et al. Neurobrucellosis and a demonstration of its involvement in spinal roots via magnetic resonance imaging. Spinal Cord 2003; 41: 574-576. 5 | Eddleston M, Davidson R, Brent A et al. Multi-system diseases and infections: Brucellosis. In: Oxford Handbook of Tropical Medicine. 3rd ed., 2008: 696-7. 6 | Behrman, Kliegman and Jenson. Infectious diseases: Brucella. In: Nelson’s Textbook of Paediatrics. Saunders, 17th ed., 2004:939-41. 7 | Pappas G, Papadimitriou P, Akritidis N, Christou L, Tsianos EV. The new global map of brucellosis. Lancet 2006; 6:91-9. 8 | Young JE. Brucella species. Mandell GL, Bennet JF, Dolin R (eds). In: Principles and Practice of Infectious Diseases. Churchill Livingstone USA, 6th ed., 2005: 2669-2674. 9 | Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med. 2005; 352:2325-36. 10 | Colmenero JD, Reguera LM, Martos F, Sanchez-De-Mora D, Delgrado M et al. Complication associated with Brucella melitensis infection: a study of 530 cases. Medecine 1996; 75:195-211. 11 | Shakir AR, Al-Din ASN, Araj F, Lulu AR, Mousa AR et al. Clinical categories of neurobrucellosis. Brain 1987; 110: 213-23. 12 | Pascal J, Combarros O, Polo JM, Berciano J. Localized CNS brucellosis: report of 7 cases. Acta Neurol Scand. 1998; 78:282-289. 13 | Lubani MM, Dudin KI, Araj GF, Manandhar DS. Neurobrucellosis in children. Pediatr Infect Dis J. 1989: 8:79-82. 14 | Bashir R, Faan MZ, Faan EJH, Jinkins J. Nervous system brucellosis: diagnosis and treatment. Neurology 1985: 35:1576-81. 15 | McLean DR, Russell N, Yousuf Khan M. Neurobrucellosis: Clinical and Therapeutic Features. Clinical Infectious Disease 1992; 15:582-90. Home deliveries in underdeveloped settings During the Great Depression, American science reporter Paul de Kruif (1890-1971) became deeply concerned about the unnecessary mortality of mothers and newborns during and after delivery. His Dutch grandparents settled in West Michigan in 1847. He was trained as a bacteriologist, and after his PhD he worked for six years on prestigious research projects. But he made it his life’s calling to inform the public at large about medical science from the past (Microbe Hunters (1926), Bacteriënjagers), as well as his own time. Many researchers and doctors had devoted their lives to understanding infectious diseases and the causes of death. After reading their reports, he interviewed medical specialists on venereal diseases, tuberculosis, polio etc., and he published their stories in popular magazines: the people should know about public health and modern cures for disease. and wrote about his way of working. After safely delivering the well-to-do ladies he used his honorarium to train medical students. He was convinced that a maternity ward should be separate from the main hospital (“a cesspool of infection”) and started a dispensary. From there DeLee brought the interns, students and nurses to the homes of the poor to deliver babies and to learn how to prevent or face eclampsia, hemorrhage, childbed fever, or deal with placenta praevia. It was his drive to offer an alternative to the practices of poor delivery care of midwives and neighbourhood women in backward quarters. He achieved an amazingly low death rate among mothers delivering in dirty homes. The conditions of work must have had similarity with the approach of tropical doctors (if one only exchanges the bitterly cold Chicago winter for the soaking and pouring wet season). One of De Kruif’s historic subjects was Dr. Ignaz Semmelweis who had discovered how women got childbed fever after delivery. It opened many eyes, because even in the 1920s in the United States, obstetrics was not in high esteem among academicians at Medical Schools. One obstetrician in Chicago, Dr. Joseph B. DeLee, brought about a turn.1 De Kruif got in touch with him Then came the economic crisis and the dispensary was closed. DeLee, now an old man, continued, with his own money, and started the Chicago Maternity Center in a drab building surrounded by sooty, desolate slums, from where the birth helpers were called into the dilapidated homes of the poor. His record was 1/1000 mothers dying, compared to the nation’s average of 6/1000. March 2012 volume 50 | 1 Jan Peter Verhave A maternity ward should be separate from the main hospital 13 Reflections T heir rule was: no anaesthe sia and no instruments He hired Dr. Beatrice Tucker, who took the torch from him. With her team De Kruif discussed the underlying causes of maternal death and he went with them into the poverty-stricken rooms. He was there to report on how Tucker and her crew made the filthiest dark room into a focus sterile spot, with the woman in labour put on the table. Their rule was: no anaesthesia and no instruments: 90 per cent of deliveries have a normal course. He assisted and described several emergency deliveries. In an occasional case the forceps had to be used: a healthy girl started crying (no ether had been used!) even before she was completely free. Then, hemorrhage! “Your chronicler couldn’t stand the cascade of blood and went out.” He came in when the mother was packed with yards of gauze. Ten years later, the team had trained 5000 students and delivered 30,000 babies. Here is what Beatrice Tucker told: ‘One day in 1934, Dr. DeLee asked me to work with Paul de Kruif on articles about the Maternity Center. I agreed, little dreaming of the volcanic eruptions which were to shake our cozy world. He came to the Center to learn how we had achieved the lowest maternal mortality rate of any institution in the country. He spent three full months with us, going out on cases, interviewing the doctors, nurses and patients. In those months I learned a great many things from Paul that I had never thought about before. He had a broader viewpoint; he wanted to get at the underlying causes of maternal and infant deaths and wrote, “Why should mothers die?” and “Chicago keeps babies alive.”2 C reate an intelligent demand for good medical care When the first articles appeared, all medical Chicago went into an uproar. I was at my wit’s end and ran to Dr. DeLee screaming, “Why did you do this?” The old professor chuckled and said, “Tucker, you were too comfortable. You are now about to grow up!” His black eyes snapped. “For 40 years I have worked to lower the maternal mortality rate in this country. For 20 years it had stood stationary: one woman dies for every 150 live babies born. Three fourth of these could be saved. De Kruif has a vitally important function: to create an intelligent demand for good medical care.” Paul took hold of the Center when it was all but dead, spent months beating the drum and passing the hat, and raised a public interest that has kept us out of financial hot water ever since. I believe, as Dr. DeLee did, that by creating public demand for good medicine Paul de Kruif has done more than any other man to raise the standards of medical care in this country.’ De Kruif described the story of the Chicago Maternity Center in his book The Fight for Life.3 It was filmed in 1939, again causing irritation of fashionable doctors who had never set foot in the slums. He got a supporter in the Netherlands: shortly before her deportation Anne Frank read the book and wrote in her diary: There is something in the book that has affected me deeply, along the lines that women suffer more pain, more illness and more misery than any war hero just from giving birth to children. And what reward does woman reap for coming successfully through all this pain? She is pushed to one side should she lose her figure through giving birth, her children soon leave her, her beauty passes. Women are much braver, much more courageous soldiers, struggling and enduring pain for the continuance of mankind, than all the freedom-fighting heroes with their big mouths! … I fully agree with Paul de Kruif… when he says that men must learn that birth has ceased to mean something natural and ordinary in those parts of the world we consider civilized.4 Indeed, the more civilized women (certainly in America) wanted unnatural, painless births. Time and public pressure have proved the value of De Kruif’s biting comments on a society that withheld natural birth and life from the poor. The result shows in the tremendous drop in America’s maternal mortality rate in the next decade: from 5.9 per thousand live births in 1934 to 2.3 per thousand in 1944; and for Chicago from 4.3 to the phenomenal low of 1.6! De Kruif would be the last to claim credit for this miraculous change. Much of it is due to new drugs, better hospitals, more clinics and doctors with more modern techniques. But he laid the sorry record of the United States open to public view and shook the standpatters out of their complacency.5 One lesson of this story on obstetrics in an underdeveloped society is: keep your records, improve by discussing failures, train the locals, and be prepared to face a critical journalist or TV reporter, and if necessary, put him/her on the bloody spot! [email protected] References 1 | Judith Walzer Leavitt, Joseph B. DeLee and the Practice of Preventive Obstetrics. Am.J.Public Health 78 (1988), 10, 1353-1360. 2 | Ladies’ Home Journal, March 1936; November 1938; Reader’s Digest, August 1936. 3 | The Fight for Life. New York, Harcourt, Brace, and Company, 1938; part one “The Fight for Life’s Beginning” (Dienaren der Menschheid. Amsterdam, Scheltema, Holkema, 1938). 4 | The Diary of Anne Frank : The Revised Critical Edition. New York, Doubleday/Random House, 2003. 5 | Albert Q. Maisel, Fighter for the Right to Live. Reader’s Digest 49 (1946), 91-96. 14 volume 50 | 1 March 2012 Reflections Lisanne Gerstel Coordinator of the Netherlands course for Tropical Medicine and Hygiene (NTC), Royal Tropical Institute, Amsterdam Photo: Irene de Groot, KIT. During the symposium the attendees participated in a playful question and answer game about medical development work. Tropical doctor: Altruism or self-interest? In December last year the Royal Tropical Institute (KIT) organized a well-visited symposium in Amsterdam entitled “Strong past, healthy future? The role of medical development cooperation in low-income countries.” The symposium covered several issues such as inequity, idealism and sustainability. During the symposium especially the role of medical development cooperation was discussed. The chair of the board of directors of KIT, Mr. Jan Donner, opened the symposium with a positive view on the role of KIT. He is confident that despite the current economic and political climate in the Netherlands, KIT will be able to keep on contributing. Mrs. Prisca Zwanikken, head of the area Education at KIT adds: ‘Also when I followed the Netherlands course for Tropical Medicine and Hygiene (NTC course) many years ago, there were heated discussions about the use of working in the tropics. These discussions are far from new, but it is good that they are repeated periodically. By organizing this symposium KIT hopes to contribute to the debate. No altruism Mr. Martin Grobusch, professor of Tropical Medicine at the Academisch Medisch Centrum in Amsterdam gave an historical perspective of medical development cooperation. Tropical medicine was not born out of altruism, March 2012 volume 50 | 1 T but out of necessity to keep our compatriots healthy during their work in our former colonies. Only later were we also motivated to assist the local population. Although Grobusch sympathizes with the critical views of people like the well-known Zambian economist Dabisa Moyo, he also sees opportunities to contribute to the development of health care in poor countries. ‘These opportunities lie, in my opinion, much more in the field of collaborative research with local scientists. This kind of collaboration can give real sustainable results and doesn’t have all the drawbacks of unilateral and incidental donations of funding,’ says Grobusch. ropical medicine was not born out of altruism Moral duty he richer part of the world has the moral duty to offer assistance Mr. Jelle Stekelenburg, gynaecologist at the Medisch Centrum Leeuwarden and involved in projects in Tanzania, thinks the debate about development cooperation is often too emotional. Also, the economist Moyo involves her own family history in her book ‘Dead Aid’. Stekelenburg’s experience in reducing maternal T 15 mortality in Africa, is that western doctors and organizations can definitely contribute, under the condition of narrow cooperation with local health care workers. He refers to the enormous problems that arise when local health care emigrates - the so called braindrain - with the result that for example more Ethiopian doctors work in Chicago than in Ethiopia. Stekelenburg: ‘Low-income countries invest their scarce resources in the education of health care workers, but high-income countries are the ones that benefit from this. As long as the inequity with regards to health is so big, the richer part of the world has the moral duty to offer assistance.’ Membership of the Netherlands Society for Tropical Medicine and International Health (NVTG) runs from January 1st to December 31st and may commence at any time. Membership will be renewed automatically unless cancelled in writing before December 31st. Membership includes MT and International Health Alerts. An optional subscription to TM&IH carries an additional cost. Non NVTG members can subscribe to MT for € 25 per year by sending your postal address by e-mail to [email protected] From idealist to ‘thrill seeker’ That medical development cooperation is no lucrative business became clear during the presentation of Mrs. Suzanne Viveen, alumna of the NTC course, who sketched her motivation to work as a ‘tropical doctor’. Viveen: ‘I like to make stereotypes, that makes the world much clearer to me. I see three types of tropical doctors: the idealists, the religious people and the ”thrill seekers”. This last group likes to add to their professional experience but also seeks adventure. Viveen started as a pure idealist but soon realized that pursuing utopian ideals often leads to frustration. Currently she is still a bit of an idealist, but she is also motivated by personal adventure. She shared her experiences from working in Colombia where she experienced that local activities do not lead to sustained progress unless there is close collaboration with local authorities. Contributions and announcements (Word document) should be submitted to the editorial office by e-mail: [email protected] Closing date for MT3 2011: May 3, 2012. With the skills of the Master course in International Health that Suzanne Viveen is currently following at KIT, she would like to optimize local health systems and increase access to health care for those groups of the population who are in need of it most. Disclaimer: all views expressed in this journal are of the authors only and are not necessarily shared by the editors of MT. Letters and articles may be edited for purposes of (clarity and) space. Motivated young health care workers All three experts agreed that sustainable cooperation with local scientists, health care workers and authorities is a prerequisite to offer a successful contribution to local health policies and health care systems. During the symposium 19 health care workers received their NTC diploma. Most of them have left to work in Africa in challenging areas like Sierra Leone, Zambia, Nigeria, Somalia and Tanzania. Whatever the role of medical development cooperation may be in the future, it is clear that there are many motivated young health care workers willing to contribute. NVTG: Netherlands Society for Tropical Medicine and International Health President: P. van den Hombergh Secretary: J.F. Wendte Secretariat: E.H. Laumans PO Box 5032 1200 MA Hilversum Tel: 0031(0)6-34306672 E-mail: [email protected] www.nvtg.org [email protected] COTG: Sluiskade Noordzijde 96, 7602 HW Almelo tel. 0031(0)546451765 [email protected] 16 March 2012 volume 50 | 1