Alpha Omega Alpha Honor Medical Society

2013 Research Abstract

Implementation of a Teaching Program for Midwives in Rural Guatemala and Its Impact on Postgraduate Education

Investigator: Victoria Mui, MD (AΩA Jefferson Medical College, 2011)

Mentor: Amr Madkour, MD

Background
According to the World Health Organization (WHO), approximately 358,000 women die from pregnancy and childbirth a year, and 99% of all maternal deaths occur in developing countries. The WHO cited maternal health as one of the eight Millennium Development Goals (MDG) in 2000, in which maternal mortality would be reduced by 75% by 2015 compared to 1990. At this time, maternal mortality has decreased by 47% with a rate of decrease of 3.1% per year, approximately 1.9% lower than the rate required to meet the 2015 MDG.

The maternal health disparities are readily apparent. The rate of maternal death in developing countries is approximately fifteen times higher than in developed countries. A woman’s lifetime risk of maternal death in a developing country is twenty-five times higher than in a developed country. The most vulnerable population is poor women in remote areas of developing countries, as they have the most difficulty accessing adequate health care. One-half of all pregnant women in developing countries receive at least one prenatal visit and only 46% of deliveries are attended by a trained provider, including a midwife, physician or nurse. The WHO has identified four factors that contribute to this barrier: poverty, distance, lack of education and unavailable services.

There are a number of factors contributing to maternal morbidity and mortality, yet the most common causes of maternal death are preventable with simple interventions. In fact, hemorrhage, particularly postpartum hemorrhage, sepsis, pre-eclampsia and eclampsia, and septic abortions make up 80% of all maternal deaths. These complications can be prevented with appropriate access to all aspects of the pregnancy timeline, including consistent antenatal care, a skilled provider at delivery, and appropriate postpartum follow-up. As such, the WHO has compiled multiple education tools to aid in prevention of such complications with the intention of implementation and sustainable systemic improvements in developing countries.

Santiago Atitlán, Guatemala, is one such impoverished area with a need for improvement in maternal health. A majority of women do not receive prenatal care and approximately 60% of deliveries occur at home. Most home deliveries are attended by a midwife or birth attendant, neither of whom is trained in evidence-based medicine. Many maternal deaths are preventable, as a result of postpartum hemorrhage and infection, and many neonatal disabilities and deaths have occurred as a result of obstructed or difficult labors. Prior to 2005, before a small hospital was built in the town, the nearest hospital for emergencies was three hours by car. By the time a woman could make it to the hospital for a cesarean delivery, if they had the means to do so, the infant would have died.

Since it’s opening, the hospital has provided medical services to 22,000 pregnant women. It currently serves a population of 75,000 women and provides a full-range of preventative and clinical health services. It has the capabilities for 24/7 emergency and obstetrical care and it the only hospital within a two hour radius. In Guatemala, generalists are predominantly responsible for prenatal care, labor and delivery, and postpartum care. There is one obstetrician/gynecologist who provides women’s health care twice a week. Even with these limited resources, there has been a slow improvement in maternal morbidity and mortality since the hospital began providing obstetrical and gynecological care. However, the hospital and region continues to need expanded coverage by skilled providers, which can be accomplished by both providing direct care through volunteering and adequately training the birth attendants who serve the community.

The project had two goals. The first was to address and improve maternal morbidity and mortality in an underserved and resource-poor area. The training program provided to the lay-midwives provided a basic foundation for management of obstetrical emergencies, as well as cultivate a trusting relationship between the community and hospital. If successful, the training program can be implemented in other regions of Guatemala and/or other developing countries.

Secondly, this project aimed to fill a gap in postgraduate education. There is a growing interest in global health and as such, postgraduate education demands opportunities for resident physicians to gain first-hand experience. This collaboration between GWU OB/GYN and the hospital will provide consistent care to a community in need, as well as provide an opportunity for every OB/GYN resident to have a valuable experience in practicing medicine in a resource-poor setting. A long-lasting relationship between hospitals and an established curriculum will lay the foundation for future careers in global health.

Discussion
The implementation of a training program provides the opportunity to standardize obstetrical care in a rural setting where there is no organized education. The lecture/simulation format allows for those without or with minimal literacy to learn the necessary clinical skills. Through acting out clinical scenarios with other colleagues, lay-midwives gain the experience and comfort with specific steps and techniques that may be required in an emergency setting.

This project allows for many opportunities to expand. First, it would be beneficial to follow these participants at 6- and 12- months after the program to evaluate the long-term impact. The short term success is evident; however, because postpartum hemorrhage, shoulder dystocia and preeclampsia are uncommon, retention of these skills will likely diminish. Secondly, these sessions can be expanded to include other obstetrical scenarios and gynecologic emergencies. The unlimited list of topics provides the opportunity for future resident physicians to volunteer direct patient care as well as an educator. The George Washington University OB/GYN department now offers this global health elective annually and there will be three residents in the coming year to continue this project.

Updated on December 23, 2014.


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