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Burundi: childbirth in a developing country.

Throughout the world women experience pregnancy and childbirth. The care they receive is a product of many factors including the culture of their country, especially when healthcare provision is supplied by traditional birth attendants who invariably apply age-old practices to maternity care. This subject has been extensively explored, for example by LeFeber and Voorhoeve (1998). Professional practice is also dictated by factors of culture, geography, socio-economic phenomena and history. What follows is an account of some of the clinical procedures and beliefs practised by professionally trained healthcare workers in an area of Great Lakes Africa, as observed and discussed while working with Médecins Sans Frontières (MSF) for a basic healthcare project in the province of Kayanza in Burundi. Burundi is classified by aid agencies as a ‘post-conflict situation’ (Médecins Sans Frontières, 2005). It is a small country in the Great Lakes area of central Africa that underwent colonisation briefly by the Germans, then by Belgium, before gaining independence in 1963. The population consists of two main ethnic groups – the Hutus who form 85% and the Tutsis who form 14%. An ethnic minority group, Twa pygmies, make up the remaining 1% of the population. From 1965 onward, Burundi has endured waves of ethnic-based violence, culminating in the civil war of 1993 to 2003 during which an estimated 100 000 people died in a ‘slow trickle genocide’ (Jennings, 2001). This ten-year conflict has left behind a legacy of psychosocial and economic damage. Healthcare facilities have been destroyed and access to medical care significantly reduced through continuing insecurity and poverty (Médecins Sans Frontières, 2004; World Bank, 2004). The civil war interrupted the training of healthcare professionals and caused the deaths of countless trained personnel, which has resulted in the number of doctors per inhabitant falling from 1:25 000 in 1990 to 1:35 000 in 2002 (Médecins Sans Frontières, 2004). Most healthcare professionals prefer to either work in other countries or in the capital. There are fewer facilities, including the basics of running water and electricity in provincial hospitals and rural areas, and there is a higher level of insecurity and rebel group attacks. There is no tradition of specifically trained midwives in Burundi – maternity care is carried out by different categories of nurses who have received between two and three years training and ‘aide-infirmieres’ who perform many of the institutional deliveries and have received one year’s training. Burundi has a total fertility rate of 6.3 per 1000 and a maternal mortality rate of 1300 per 100 000 live births (United Nations, 2001), although the potential inaccuracy of the data, due to the civil disorganisation as a result of the war and the factor of unregistered domiciliary births, is acknowledged. The Institut de Statistiques et d’Etudes Economiques du Burundi (2003) states that 71% of births are unsupervised by trained personnel and take place in the home by registered or unregistered traditional birth attendants. The remainder take place either in poorly staffed and equipped rural clinics, in small hospitals supported by religious orders or in larger, but only marginally better equipped, regional hospitals. The infant mortality rate is high, with the principle causes of death being malaria and diarrhoea. While practices inevitably differ between workers and institutions in a country with unsupervised clinical standards, certain commonly-held clinical beliefs were observed and are recounted below, beginning with the management of problems in early pregnancy and ending with aspects of neonatal care. Women with threatened abortion frequently present at clinics, many caused by malaria. Burundi lies within an endemic malaria zone giving rise to recurrent bouts of the parasitic disease in patients with lowered immunity, such as pregnant women. Another contributory factor is the high incidence of untreated sexually transmitted diseases among the population. In addition to prescribing medication for any suspected underlying infection – although diagnoses remain largely unconfirmed due to lack of laboratory facilities – the nurses who staff the clinics routinely prescribe oral hyoscine butylbromide (Buscopan). This treatment is based on the known smooth muscle relaxant properties of this compound that practitioners believe diminish uterine contractions, hence arresting the progress of a threatened abortion. Pharmacology formularies such as the British national formulary (BNF) (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2004) do not support this hypothesis and neither do clinical guidelines Pregnancy and childbirth vary throughout the world and in many developing countries they are influenced by traditional practices. Sue Chadney describes some such observations from the time she spent working in Burundi.