Mother craft clinic-an experiment in obstetrics.
A perinatal mortality survey (1977-1979) in India, carried out by the Federation of Obstetrics and Gynaecological Society of India (FOGSI) revealed that the average perinatal mortality rate was 66.3 per 1000 births, the highest being 14.7 per 1000 births in some centres.
This paper deals with the results of a study designed to improve the maternal care and to reduce the perinatal mortality in Malavani, a village with a population of 70,000, near the city of Bombay, adopted by the K.E.M. Hospital, run by the Municipal Corporation of Greater Bombay (MCGB) for comprehensive health care. The details of this comprehensive health programme have already been described earlier. We discuss in this paper the work done by the Mother Craft Clinic of the Malavani Health Centre.
A Mother Craft Clinic was started at the Malavani Health Centre in 1981 and it gave service to 2706 pregnant women till April 1983. Information about this clinic was disseminated in the community of Malavani through the villagers attending the centre, and by conducting a pregnancy survey in the village. Pregnant women were encouraged to enroll at the clinic as early as possible. They were registered and their records were maintained till term.
This Mother Craft Clinic offered, to the registered patients, the standard services of an antenatal clinic such as examination by a doctor, urine examination, hemoglobin determination, patient education, distribution of iron tablets, treatment of any medical problem when detected and immunization against tetanus. Over and above these, the clinic concentrated en the following items of education of pregnant women and their husbands.
(1) At their first visit, the women were shown mounted specimens of foetuses of different gestational ages; the causes of foetal death at different gestational ages were discussed with them.
(2) They were told about the importance of regular and frequent visits to the clinic and of repeated blood and urine tests.
(3) The women were taught to examine their urine for albumin and sugar under supervision at the centre. This increased their involvement in their own health care.
(4) They were taught to read their own weights at the centre.
(5) Forty per cent of their time at the centre was devoted to health education. This was done by dividing the pregnant women into homogenous groups according to period of gestation, and explaining to them all aspects of pregnancy, labour and child care in 5 to 6 antenatal sessions. Special stress was laid on nutrition during pregnancy. The education was imparted not by doctors but by the medico-social workers and nursing students who mixed. freely with the expectant mothers and who were accepted by the latter as one of them. Initially, they were asked questions to assess the level of their knowledge and then the group was gently led into health discussions.
(6) The women performed antenatal exercises in a group under the supervision of medicosocial workers and nursing students.
(7) Every day, the doctor gave to the social worker names of high risk women he/she had seen on that day, and the social worker kept a close surveillance of these patients thereafter.
(8) The husbands of all the registered pregnant women were encouraged to come to the clinic at their convenience and meet the doctor. They were then taught about their, role in the successful outcome of the pregnancy and about family planning. The details of this work forms the subject of a separate paper.
Although the entire staff of Malavani Health Centre was involved in running the Mother Craft Clinic, the brunt of work was borne by the medico-social worker.
The performance of the Mother Craft Clinic during the period 1981-83 was assessed by comparing the following parameters of the women attending the clinic, with the published information on the same parameters in the pregnant women attending the antenatal clinic of the Department of Gynaecology and Obstetrics of a teaching hospital in the City.
(a) The number of antenatal visits,
(b) The period of gestation at the first visit,
(c) Haemoglobin at the first visit and at term,
(d) The outcome of pregnancy,
(e) Perinatal mortality rate.
Finally, the perinatal mortality rate was compared with that recorded by the FOGSI report in different types of maternity services in the country. All the pregnant women registered at the Mother Craft Clinic during the period under study were evaluated, and no sample was derived.
Out of 2706 women registered with the Mother Craft Clinic, 40.85% were Hindus and 57.16% were Muslims. Literacy rate was 42%. The average per capita monthly income of the families of 68.8% patients was less than Rs. 100. 14.8% of the women were para 3 and above.
[Table - 1] shows (a) the number of antenatal visits paid by the different patients to Malavani Health Centre and a Teaching Hospital, and (b) the period of gestation at the first visit.
[Table - 2] shows the haemoglobin status of patients of Mother Craft Clinic of Malavani at their first visit and at term.
[Table - 3] compares the outcome of pregnancy in Malavani Health Centre and a Teaching Hospital.
100% of the women who were eligible for sterilization by being 3rd or higher para, as well as some lower paras, from Malavani Health Centre accepted post partum sterilisation whereas only 66% of the corresponding group in the Teaching Hospital accepted it.
[Table - 4] shows perinatal mortality rates from all over India in different health care set ups.
No death due to neonatal tetanus was seen in the newborns at the Malavani Health Centre whereas, on an average, it was seen in 2 per 1000 live births in the City of Bombay.
The study brings out what can be done by meticulous antenatal care even in a largely illiterate and low socio-economic section of the population. The first result of the close contact between the clinic staff and the pregnant women was the more frequent visits to the clinic and everything else probably was the outcome of this better antenatal attendance. It will be seen that the pregnant women attended the centre much earlier than in the case of a teaching hospital. This is again probably the result of better rapport between the Malavani Health Centre and the community it serves. Although nearly 50% of women had haemoglobin of less than 10 gm%; at their first visit, this figure was reduced to about 18% at term. This speaks highly of the patient compliance, again probably the result of close rapport and the health education of the pregnant women. A major contribution of the health education of the family unit was probably the involvement of the husbands of the pregnant women. This has been discussed in detail in a separate paper. The most important feature of the outcome of pregnancy was zero maternal mortality in the Malavani Health Centre and the much lower perinatal mortality in this centre than in a teaching hospital. However, a part of the maternal and perinatal mortality in the teaching hospital can be attributed to the fact that 14.7% of pregnant women came there as emergency cases for labour. Many of these patients were referred to the teaching hospital by other smaller centres as complicated cases. Whereas 14.8% of pregnant women attending our centre were eligible for post partum sterilisation (being third or later para), in fact 15.3% of the women accepted post partum sterilisation; the corresponding figures for teaching hospital were 26.8% and 17% respectively. Finally, there was no case of eclampsia, nor of neonatal tetanus in this series. This study illustrates what close rapport between the medical and paramedical staff on one side and the pregnant women and their husbands on the other side, and better education of pregnant women can do in improving the health care during pregnancy. It is hoped that this will serve as a model for obstetric and antenatal care for reducing maternal and perinatal mortality in the country. The 100% acceptance of postpartum sterilisation by the eligible women will further make it a model for family planning programme.
We are thankful to the Dean, Seth G.S. Medical College and K.E.M. Hospital, Bombay, for allowing us to publish the hospital data. Thanks are also due to Dr. Smt. Manda Purandare and Dr. Smt. Saroj Palav for their kind help.