Ladies and gentlemen

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.
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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,
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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]
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