Provision of a community perinatal service in a developing country.

Abstract

In 1980, a community perinatal service (CPS) facility was developed by the University of Cape Town in South Africa. This Peninsula Maternal and Neonatal Service (PMNS) is a model for understanding the objectives and essential requirements for the provision of a CPS. The goals of a CPS are to 1) use a single authority to provide integrated perinatal and family planning (FP) services for all women in a defined geographic area, 2) reduce infant morbidity and mortality to acceptable levels, 3) promote FP and a 2-child norm, and 4) provide education to staff, patients, and the community. A CPS must have a tiered system of perinatal care which has midwife obstetric units (MOUs) as the first level, secondary hospitals as the second, and tertiary hospitals as the third. The MOUs are centered around midwives, with a doctor available as a consultant to the midwives and as a provider of continuing education (CE) to the staff and patients. Staff CE takes place in perinatal mortality meetings, case discussions, orientation classes, refresher courses, outreach programs, and formal CE programs and journals. A loose-leaf, self-instructional perinatal education program is being developed to provide up-to-date information for every midwife and doctor. The midwives also may attend triennial congresses in Cape Town. The objective of patient education is to develop mothers as monitors of their own health and that of their fetuses and newborns. Patient education is achieved through the use of posters, lectures, and audiovisual programs. A CPS also needs appropriate equipment (a list is available from the World Health Organization). The CPS comprehensive referral system must cover all criteria and be respected throughout the region. The criteria must be updated regularly. Adequate communication channels and transportation facilities are also necessary to insure that a patient is transferred under the best conditions. Regular audits are essential and require accurate record keeping. Finally, a CPS must have the support of its community. During its 18 years of operation, the PMNS has 1) developed a very cost-effective system of perinatal care, 2) developed the concept of the MOU as an accessible, affordable, and appropriate primary care facility, 4) channeled low-risk patients from hospitals to MOU care (50% of 29,000 deliveries in 1991 took place in MOUs which have approximately 15% of the beds), 5) curtailed antenatal visits of low-risk patients without maternal or perinatal jeopardy, 6) established protocols for safe delivery in MOUs for medium-risk patients, 7) continued lowering the maternal mortality rate, and 8) achieved community acceptance. Failures are 1) an increase in the number of unbooked patients and infants born before arrival, 2) a static and rising perinatal mortality rate (largely caused by untreated syphilis), and 3) a lack of community involvement. These failures are likely caused by escalating workloads from the 3 informal settlements outside of Cape Town. Overall, the PMNS provides a blueprint for cost effective delivery of perinatal health care for developing and developed countries alike.