Mis Apuntes de
Obstetricia y Ginecologia
viernes,
26 de julio de 2013
Luis Vega
PLoS Medicine | www.plosmedicine.org 000 Health in Action
February 2006 | Volume 3 | Issue 2 | e16
The Maria Auxiliadora Hospital (HAMA), a
20-year-old government hospital, serves
about 2 million people living in Southern Lima, the poorest
area of the city and one that is experiencing an explosive growth in
population.
We take care of extremely poor, malnourished patients, who
have had little education and who have poor access to adequate
utilities (two-thirds of homes have no safe water and no sewer).
The rapid population growth in Southern Lima began in the
1970s.People migrated to the city from the Andes, both to flee terrorism
and to participate in the city’s industrial development.
They mostly settled in a desert area with few sources of
water. Although 90% of Southern Lima is now urban, we still have a
few small villages in the mountains, where people are very poor and
make a living from cattle breeding and agriculture.
Working under difficult conditions with insufficient
resources, and facing many other obstacles to improving maternal
health (Box 1), our obstetric and gynecology team has worked hard to
reduce the maternal mortality rate.
In this article, I discuss the resources at our disposal,
the challenges we are facing, and the steps we have taken toward
reaching our goal.
Our Resources
HAMA has a total of 300 beds, 86 of them for obstetrics and
gynecology. We have the infrastructure and technical expertise to perform
highly specialized procedures, such as surgery for pelvic cancer and
laparoscopic and fertility surgery.
Our obstetrics and gynecology staff is composed of 26
gynecologists and obstetricians, 12 residents, 40
midwives, and 15 nurses.
Box 2 gives a detailed picture of the department.
Our department provides health care to 575,000 women of
reproductive age with a fecundity rate of 2.3 children per woman and a high
rate of pregnancy in adolescents. Eighteen percent of our pregnant
patients are 19 years old or younger; this percentage has been
stable during the last eight years.
HAMA is the head of the maternal and perinatal health network of
Southern Lima. This network includes
15 maternal hospitals with staff composed of general physicians
and midwives. These small hospitals are
in charge of low-risk pregnancies and deliveries. Additionally,
there is a 70-bed general hospital (Rezola
Hospital) with 20 beds for gynecology and obstetrics patients
located 150 kmsouth of HAMA, which can carry out Caesarean sections.
Health centers in our network communicate with each other
by phone or radio; every small
hospital has an ambulance to transfer patients with
complications to HAMA. In 2003 our network assisted 21,090 deliveries; 8,539 of
these took place at HAMA (Figure 1), where 70% of patients have regular
prenatal care (60% of pregnant women begin prenatal care before the 20th week
of pregnancy). As shown in Figure 1, the number of deliveries in HAMA has
increased progressively as a result of free maternal and pediatric medical care
to anyone who lives in the hospital’s catchment area. The proportion of
deliveries at HAMA attended by different professionals is shown in Figure 2.
Although the number of deliveries at HAMA has increased, there
has been no increase in the hospital budget or number of health workers or any
expansion of the infrastructure.
Overcrowding of beds is a major problem
Barriers to Improving Maternal Health in
Southern Lima
• Large number of patients and overwhelming workload
• Insufficient economic and human resources
• Bureaucracy and inefficiency in the state health system that
create barriers to hiring new staff and buying new medicines and equipment—the
Ministry of Health is responsible for providing health care to about twothirds
of the Peruvian population, but it has no clear policies on service delivery
and long-term planning.
• Frequent changes in national government cause frequent changes
in health policy. For example, the
government of the 1990s supported the family-planning program,
but with a new government administration in 2000, this support has been scanty
and irregular, reflecting the new administration’s religious, conservative
orientation.
• International assistance and donations sometimes do not
correlate with our priorities and more urgent needs, and they may be culturally
inappropriate.
• Poor social status of women.
• A mismatch between how doctors are trained (according to a
curriculum more suited to a developed country) and the actual training that
would be appropriate for addressing Peru’s health problems (such as better
training in family planning, infectious diseases, environmental health, child
health, and women’s health).
• The illiteracy rate is 8.5% in the general population and
13.5% in women.
• Only 4.8% of the national budget is invested in health.
The Obstetrics and Gynecology Department at HAMA has three services: gynecology,
obstetrics, and reproduction, each with their respective chiefs. There are
eleven offices to evaluate ambulatory patients, and the appointments are
scheduled from Monday to Saturday from 8 a.m. to 8 p.m. Three offices are for
gynecology patients, two for low-risk obstetrics, and one each for high-risk
obstetrics, gyneco-oncology, teenagers, evaluation of puerperal patients,
family planning, and ultrasound studies. These offices are run by specialized
doctors and
residents-in-training.
We also have an emergency room, attended by two specialists who
do 12-h duty shifts. In the delivery room there are two specialists and one
resident from 8 a.m. to 8 p.m.; they are in charge of attending complicated
deliveries, scheduled and emergency
Caesarean sections, ambulatory treatment of uncomplicated
abortions, and male and female sterilization. After 8 p.m. until 8 a.m., the
emergency and delivery rooms are run by two specialists and two residents.
Additionally, three days a week, from 8 a.m. to 8 p.m., we perform elective
gynecological surgery.
Midwives are in charge of attending uncomplicated deliveries,
identification of newborns, evaluation of women in normal puerperium, and
counseling on family planning in the delivery room. They also are in charge of
educating patients on psychoprophylaxis, prevention of sexually transmitted
infections, and promotion of cervicaland breast-cancer screening. They feed
data into our computerized information system. Our nurses are in charge
of the hospitalized patients and the operating theatres.
In the delivery area, there are three operating rooms for
Caesarean sections and
ambulatory surgery. We have the support of anesthesiologists,
neonatologists, and
specialized neonatology nurses wherever they are required. The
hospital also has a
general intensive care unit with seven beds for severely ill
patients. Our blood bank runs
well and we always can obtain whole blood or its derivates 24 h
a day.
The Health Challenges
A high maternal mortality rate. The maternal death rate at HAMA has decreased gradually from
330 per
100,000 deliveries in the late 1980s to 64.4 per 100,000
deliveries in 2003 (the 2003 rate for the whole network was 28 per 100,000
deliveries). In comparison, the national rates were 350 per 100,000
in the 1980s, 263 per 100,000 in 1996, and 152 per 100,000 in
2003.
The rate at HAMA is higher than the average rate across the
whole network because we take care of patients in the network that have
complications (there are almost no maternal deaths in the other health centers
of our network). We also receive patients with complications from other
areas—these
patients are usually very ill and often need dialysis or
ventilatory support.
Between 1989 and 2003, we had 111 deaths from direct obstetric
causes.
The most frequent causes of death were septic abortion (37
deaths), preeclampsia and eclampsia (35 deaths), puerperal infections (27
deaths), and hemorrhage (12 deaths, related to postpartum uterine relaxation,
ruptured uterus, abruption placenta, and ectopic pregnancy).
Pre-eclampsia and eclampsia complicate 14.5 % of deliveries, and one in ten of these develop
HELLP
syndrome (hemolysis, elevated liver enzymes, and low platelet
count syndrome)
Premature rupture of the membranes is the most important risk factor for
puerperal sepsis, and the
most severe cases arrive at our hospital with established
chorioamnionitis.
Tuberculosis is the most important non-obstetric cause of maternal death
Abortion. Induced abortion is illegal and clandestine in Peru. Safe
backstreet abortions are available, but these are expensive and most of our
patients are too poor to pay for such safe procedures. They risk serious
complications from the cheap, unsafe procedures, but fears of being reported to
the police prevent them from seeking prompt medical attention.
In 2003 we attended 2100 abortions; 90% of these were
uncomplicated abortions and 10% (212) were septic. At HAMA we manage
uncomplicated spontaneous abortions of less than 12-wk gestation as an
ambulatory procedure using manual intrauterine vacuum devices. We manage
incomplete abortions as an ambulatory procedure using a Karman-type catheter
device. We realize that most of these incomplete abortions are induced
abortions (generally induced by misoprostol use), but we do not ask our
patients specific questions about the circumstances of their abortion. We
perform the procedure and after 2 h of
rest the patients leave the hospital. We have adopted this strategy
to encourage patients who have had an induced abortion to seek medical
attention earlier, before complications become
serious. We do not perform elective abortions.
Septic abortion has been a fastgrowing national problem over the last three
years as a consequence
of conservative governmental population policies, which have
affected the regular supply of appropriate information and contraceptive
methods, and because of more complicated and confusing requirements for
obtaining definitive contraception (i.e., male and female sterilization).
In the 1990s, if a woman wanted to be sterilized, she only had
to sign an application form. But since 2000, shenow has to fill out lots of
paperwork, receive at least three sessions of counseling, and undergo a 72-h
period for reflection. Additionally, if she has a partner, he also has to
authorize the procedure. In emergency caesarean sections, a large proportion of
patients arrive at the hospital without having fulfilled these requirements
(and sounfortunately, we miss the opportunityto offer them sterilization).
Caesarean sections. The Caesarean section rate was 31.9% in 2003. The rate has
been increasing across
Peru, which is due to: (1) more health centers being able to
perform Caesarean sections; (2) an increase
in the number of doctors trained to perform them; (3) a
reduction in the rate of postoperative complications;
(4) wide use of partograms with “alert lines;” (4) an
increase in the incidence of pre-eclampsia and eclampsia; and (5) a rise in law
trials for obstetric malpractice cases across the country.
Our main Postoperative complication is puerperal
infection (endometritis). We have not had
anesthtetic complications in the last 15 years, but in reviewing
our maternal deaths, we found that 34.4% of ourmaternal patients who died had
had a Caesarean performed.
Contraception. Unfortunately, there has been a decline in the proportion of
hospitalized patients being discharged with adequate contraception. Before
2000, 80% of our hospitalized patients left the hospital with some
contraceptive method, but in 2004 this figure was only 50.6%. This decline
occurred because of the lack of support for family planning from the Ministry
of Health, which has led to an irregular supply of contraceptive devices and
bureaucratic barriers to obtaining them.
Action to Reduce Mortality
I believe that the most important factor in the fall in maternal
mortality rate (both at HAMA and nationally) has been governmental support,
which was intense in the 1990s, with the implementation of two crucial projects
aimed at lowering the death rate—Project 2000, and Ten Steps for a Safe
Motherhood.
There were several components to these two initiatives that
helped to improve the maternal mortality
rate, including a program of national hospital recertification,
as well as strengthening of those hospitals
selected as training centers (including HAMA). These training
centers were equipped with modern medical
equipment, e-mail, and other facilities.
There was increased training of health personnel in these
centers, including training in health quality improvement and in information
processing. The training was extended to physicians,midwives, and nurses from
outside these designated training centers— these professionals came to the
training centers and learned while they worked with us. The training hospitals
were permanently interconnected with other maternal hospitals in the country by
e-mail, making it possible to share experiences. For example, staff from
the training hospitals could suggest diagnostic procedures and
treatments for patients with complications from
other hospitals.
The two projects also involved giving strong support to the
Family Planning Program with publicity campaigns and regular supply of
contraceptive devicesand information distributed free of charge. (This support
has declined with the arrival of a new government administration in 2000.)
Sterilization procedures were also offered free of charge, and sterilization
campaigns were extended across the whole
country, even in small towns, with portable mini-hospitals.
Other components that have helped to contribute to the reduction
in maternal deaths are:
(1) Ambulatory management of uncomplicated, spontaneous
incomplete abortions;
(2) Free maternal and pediatric medical care, free
medicines and transportation for patients with complications from the provinces
to well-equipped health centers such as HAMA;
(3) Creation of networks for maternal and perinatal
care;
(4) Creation of a portable maternal medical record, used
by all the hospitals in the country through a unified patient-information
system;
(5) Development of care protocols with the participation of
personnel from the network; (6) review and discussion of each maternal death in
the network, to find out the factors that contributed to the patient’s death
(professional and administrative personnel are invited to these meetings).
In sum, we learned to work together, to exchange experiences, to
improve permanently the quality of our work, to process information and to draw
conclusions from it, and to appreciate the experiences at small hospitals.
The Challenges Ahead
Despite the strides we have made against the high maternal death
rates, there are many reasons why
we cannot afford to be complacent.
The Ministry of Health does not have long-term plans for
maternal health. Short- and long-term plans—for
maternal health as well as for family planning—are politically
influenced, and they could change when the
government changes.
The department has three services: gynecology, obstetrics, and
reproduction, each with their respective chiefs. There are eleven offices to
evaluate ambulatory patients, and the appointments are scheduled from Monday to
Saturday from 8 a.m. to 8 p.m. Three offices are for gynecology patients, two
for low-risk obstetrics, and one each for high-risk obstetrics,
gyneco-oncology, teenagers, evaluation of puerperal patients, family planning,
and ultrasound studies. These offices are run by specialized doctors and
residents-in-training.
We also have an emergency room, attended by two specialists who
do 12-h duty shifts. In the delivery room there are two specialists and one
resident from 8 a.m. to 8 p.m.; they are in charge of attending complicated
deliveries, scheduled and emergency
Caesarean sections, ambulatory treatment of uncomplicated
abortions, and male and female sterilization. After 8 p.m. until 8 a.m., the
emergency and delivery rooms are run by two specialists and two residents.
Additionally, three days a week, from 8 a.m. to 8 p.m., we perform elective
gynecological surgery.
Midwives are in charge of attending uncomplicated deliveries,
identification of newborns, evaluation of women in normal puerperium, and
counseling on family planning in the delivery room. They also are in charge of
educating patients on psychoprophylaxis, prevention of sexually transmitted
infections, and promotion of cervicaland breast-cancer screening. They feed
data into our computerized information system. Our nurses are in charge
of the hospitalized patients and the operating theatres.
In the delivery area, there are three operating rooms for
Caesarean sections and
ambulatory surgery. We have the support of anesthesiologists,
neonatologists, and
specialized neonatology nurses wherever they are required. The
hospital also has a
general intensive care unit with seven beds for severely ill
patients. Our blood bank runs
well and we always can obtain whole blood or its derivates 24 h
a day.
