Perinatal Care in Six Eastern Caribbean Countries1 Er

Bull Pan Am Health Organ 19(l), 1985

PERINATAL CARE IN SIX EASTERN CARIBBEAN COUNTRIES1

E. R. Boersma2

A study of six Caribbean countries (Antigua, the Bahamas, Barba- dos, Dominica. Saint Lucia, and St. Vincent) was conducted in December 1981 for the purpose of evaluating perinatal health care in those countries. The following account provides an overview of the results of that study.

Introduction sociated with reduced handicaps (5). In a period of serious economic problems, Studies of children with handicaps have the governments of the Caribbean are con- shown that 30 to 50% of the handicaps are of cerned more than ever about implementation perinatal origin-that is, they arise as a result of the maternal and child health strategy as of adverse factors operating during preg- outlined by the Caribbean Community Health nancy, birth, and the first few months of life Ministers’ Conference in 1975. Among the (l-5). Many of these handicaps can be pre- recommendations accepted and endorsed at vented by greater attention, improved care, that conference, one accorded especially high and public education relating to pregnancy, priority was improving the quality of care for birth, and the newborn infant (5, 6). pregnant mothers, so as to improve the out- For example, most cases of cerebral palsy come of pregnancy, improve care of the new- (spasticity) originate during the perinatal pe- born, and reduce morbidity and mortality riod (the last 16 weeks of pregnancy and the (7a). In this regard, the health ministers pro- first 28 days of life). The unhappiness that posed that the following be included among such handicaps cause to the people affected the goals of the Commonwealth Caribbean and to their families can be prevented. In- territories for the decade of the seventies. (As deed, a reduction in the cerebral palsy rate of most of the goals could not be realized then, over 40% has been achieved over the last 20 most will probably be proposed again for the years in Sweden and the Netherlands through eighties- 7b .) improved perinatal care (6). l Reduction of neonatal mortality (mortality in More generally, an extensive perinatal pre- the first 28 days of life) by 25%. ventive health program in France has shown l Reduction of postneonatal mortality by 40%. that it is not only possible to considerably re- l Promotion of breast-feeding, early establish- duce mortality and handicaps of perinatal ori- ment of breast-feeding, and maternal-infant gin, but also that the costs of the program bonding. could be covered by the reduced expenses as- l Improvement in the quality of care for pregnant mothers. l Reduction of the number of children with de- velopmental abnormalities arising from events of ’ This article will also be published in Spanish in the the perinatal period. Boletin de la Oficina Sunitaria Panamericana. 1985. * Consultant Petinatologist. Head, Department of So that these goals might be realized, the Child Health, St. Elisabeth Hospital, Willemstad, Cu- racao, Netherlands Antilles; and Professor, State Univer- following recommendations were accepted sity of Groningen. The Netherlands. and endorsed by this conference:

45 46 PAHO BULLETIN l vol. 19, no. I, 1985

Figure 1. A map of the Caribbean showing the six study countries.

l Neonatal units should be adequately bados). Perinatal facilities, staffing, pro- equipped. grams, and feeding practices were evaluated, l A pediatrician should be assigned primary re- and proposals for two types of perinatal train- sponsibility for neonatal care. ing programs3 were presented to the appropri- l Training programs for physicians and nurses ate authorities of each country. The purpose should be modified to include adequate neonatal of this article is to provide a brief account of care. the results of this study. Information regard- l Programs of specialized training should be developed for nurses and midwives. ing various perinatal conditions was obtained l All high-risk babies should have accessto spe- from available vital statistics data gathered by cialized care facilities. local pediatricians, obstetricians, and chief l All high-risk babies should be closely followed up- * Adequate nutrition, particularly through 3 The first type of training program proposedwould breast-feeding, should be maintained. provide short, on-the-job in-service training for one or two weeks. Its curriculum would emphasize the preven- In recent years, however, training pro- tion and management of asphyxia neonatorum (re- grams in perinatology have been limited to stricted oxygen consumption by the fetus or newborn infant) and care of the at-risk pregnant woman. one or two tertiary health centers in the Carib- The second type of program would consist of a central- bean, and personnel in the majority of coun- ized half-year training program at a perinatal center in tries have had no access to any form of up-to- the Caribbean. This certified course would provide regional manpower in perinatal care, including leadership date perinatal training. This general situation for a number of categories of health workers, and would led the Dutch Government to support a 1981 help to ensure the maintenance of adequate perinatal study of perinatal conditions in six Eastern standards in the region. Arrangements should be made so that the course certificates, after approval by PAHO/ Caribbean countries (the Bahamas, Antigua, WHO, would be recognized by each individual govern- Dominica, Saint Lucia, St. Vincent, and Bar- ment involved. Boersma l PERINATAL CARE IN THE CARIBBEAN 47

An accurate scale and a phototherapy unit, such as the ones shown here, are among the items needed to provide adequate care of the newborn.

nurses. Occasionally, information was ob- Vital Perinatal Statistics tained from officers of the Ministry of Health, the government statistician, or the matron of If the recorded rates of stillbirths and the general hospital. All of the information neonatal deaths are considered separately, reported here was gathered in December the differences between these rates in the 1981. six countries studied appear remarkable (Table 1). However, when these two rates are combined into one joint rate (the perinatal Perinatal Care death rate), much of this apparent difference disappears. This suggests that problems in Despite anticipated limitations of the avail- separating stillbirths from neonatal deaths able data, it was possible to make a reason- for classification purposes could account for ably accurate assessment of relevant circum- much of the divergence. This is a well-known stances in the area of maternal and child problem, often because legal or administra- health care that related directly to the well- tive regulations make it easier to classify peri- being of the fetus and newborn infant. In only natal fatalities as stillbirths than as neonatal a few instances was it necessary to rely on per- deaths. Other circumstances that might help sonal impressions without supporting data, to account for these differences are presented and those cases are carefully indicated. In in the sections on the individual countries most countries the data were obtained from studied. the general hospital where most of the new- As Table 1 shows, most of the study coun- borns were being delivered. Hospital delivery tries appeared to have perinatal death rates is common in all the countries surveyed, ac- ranging from 29 to 38 deaths per 1,000 deliv- counting for 70 to 95% of all deliveries. eries, irrespective of economic conditions in- Therefore, the hospital figures employed ap- dicated by per capita GNP. By comparison, pear to give a reasonable representation of the perinatal death rates in Western countries perinatal data for each country. The latest generally range from 10 to 15 per 1,000 deliv- data available as of 1981 are presented eries; and data from deliveries at the Univer- (8-15). sity Hospital of the West Indies in Jamaica 48 PAHO BULLETIN l vol. 19, no. 1, 1985

Table 1. Basic data on stillbirths, neonatal deaths, and perinatal deaths in the six study countries, Jamaica, and South America, together with population and per capita GNP figures.

Neonatal Perinatal Year Per capita Stillbirths deaths deaths of Population GNP per 1,000 per 1,000 per 1,000 Countrv data (in thousands) (in USS)” births live births births

Antigua 1980 73 716 15.4 16.2 31.6 Bahamas 1980 200 2,620 13.6 18.2 31.8 Barbados 1980 247 1,940 13.7 22.3 36.0 Dominica 1980 81 440 19.5 9.9 29.4 Saint Lucia 1981 111 630 23.4 14.0 37.4 St. Vincent 1981 100 380 15k’ 22.s+ 37.5xk' Jamaicab 1981 2,200 1,110 16.0 9.1 25.1 South America’ 1981 20.5 15.9 36.1 South Americad 1981 16.2 12.2 28.2

n 1980 data (17. 18). b Data for deliveries at the University Hospital of the West Indies. c For birth products weighing 2 5OOg (16). d For birth products weighing 2 1 ,OOOg(26). c Precise figures not available.

Table 2. Average birth-weights and the incidence of low birth-weights among infants born at the principal hospital in each of the six countries studied.

Number of Average % newborns Year deliveries recorded with low of at principal birth-weight birth-weights Data Country data hospital (in grams) (~2,soog)

Antigua 1980 1,299 3,lOOkd 8.2 Bahamas 1980 5,000 3,150&d 6.7 Barbados 1980 3,815 3,OOOkd lid Dominica 1980 1,819 3,140' 5.9 Saint Lucia 1981 1,923 3,147 7.6 St. Vincent 1981 2,400 3,OOOP -c - Jamaica” 1981 2,640 3,150 10.25 8 Latin Americab 1979 - 3,069-3,286 6.2-23.0 20

p The data shown are for deliveries at the University Hospital of the West Indies. b The data shown are the highest and lowest of the national averages from six countries (Brazil, Chile, Colombia, Panama, Suriname, and Uruguay). c The average recorded birth-weight for boys was 3,286g and for girls was 2,994g. d Precise data not available. c Data not available.

are intermediate, indicating a perinatal death 500 grams or more and 28.2 per 1,000 deliv- rate on the order of 25 deaths per 1,000 deliveries among newborns with birth-weights of eries. In this vein, it is also interesting to note 1,000 grams or more (16). that a study of perinatal mortality in South It should be mentioned that perinatal mor- American maternity wards (based on data tality data from the university hospital in Ja- from 35 maternity wards in 11 countries that maica are not representative of data from the delivered approximately 300,000 newborns country as a whole. For example, data from weighing 500 grams or more) found overall the Victoria Jubilee Hospital in Kingston, perinatal death rates of 36.1 per 1,000 deliv- where approximately 14,000 children are eries among newborns with birth-weights of born annually, indicate perinatal mortality on Boersma l PERINATAL CARE IN THE CARIBBEAN 49 the order of 40 deaths per 1,000 deliveries. to 400 grams above averages in Far Eastern There are good reasons for thinking that countries such as India and Indonesia. the relatively low neonatal death rates re- The percentages of children found to have corded in Dominica and Saint Lucia reflect low birth-weights (2,SOOg or less) varied con- fairly high standards of neonatal care. These siderably (from 5.9 to 11%) in the six coun- reasons, which are felt to override the poor tries studied. The low birth-weight rates re- economic conditions indicated by low per cap- ported for the Bahamas, Dominica, and Saint ita GNP and shortages of sufficiently trained Lucia (ranging from 5.9 to 7.6%) were within personnel, include the following: the range (3.6 to 7.7%) reported for developed countries (20). However, the average l an awarenessof perinatal health problems on the part of pediatricians, obstetricians, other birth-weights found in these three Eastern health workers, and political authorities that has Caribbean countries were lower than the aver- produced effective action; age birth-weights found in the developed l implementation of a strategy that includes countries. It thus appears that birth-weights early breast-feeding, mother-infant bonding, and tend to be distributed in a narrower range in keeping the mother and her baby together after these Caribbean countries, with infants tend- birth and for the following days while in the ing to have birth-weights closer to the na- hospital; tional average. l early discharge of low birth-weight babies (those weighing 2,500 grams or less); and l promotion of good communications between central and peripheral health workers through in- Causes of Perinatal Death troduction and use of a “child health passport” (19). In the absence of a postmortem examina- tion, precise causes of death are often hard to However, recorded rates of stillbirths on Dominica and Saint Lucia are relatively high. This suggests (especially on Saint Lucia) that Table 3. Leading causes of perinatal death in the classification problems may exist. It also un- six countries studied and Jamaica. derlines the need to make a combined effort Leading causesof against prenatal, delivery, and neonatal prob- Country perinatal death Sources lems. Obviously, close cooperation between Antigua Perinatal asphyxia: II the health workers involved in the care of the complications of pregnant mother and her newborn child is es- prematurity sential, a point that should be emphasized in Bahamas Perinatal asphyxia; 12. 14 complications of the curricula of training programs. prematurity Barbados Respiratory distress IO syndrome; perinatal asphyxia; infections; congenital abnormalities Some Other Indices of Perinatal Health Dominica Complications of abnormal I5 growth and maturity; For the six study countries combined, the perinatal asphyxia Saint Lucia Perinatal asphyxia 9 average birth-weight of newborns was found St. Vincent Perinatal asphyxia; -h to be around 3,lOOg (see Table 2). This fig- infections ure, which is within the range of average Jamaica” Perinatal asphyxia; 8. 13 intracranial bleeding; birth-weights found by a WHO study of birth- infections; congenital weights in six South American countries, is abnormalities some 400 to 500 grams below the averages p Causes based on information reported for the Univer- typically found in developed countries, about sity Hospital of the West Indies 18. IS). 100 grams above African standards, and 200 b Precise data not available. These pictures show (a) basic pieces of equipment required for resuscitation of newborns; (b) oxygen hoods of different sizes; (c) oxygen supplied by a hood placed over the head of a newborn suffering from meconium aspiration. Boersma l PERINATAL CARE IN THE CARIBBEAN 51 determine. Despite this fact, however, it ap- cate what is going on in the Eastern Carib- pears that, in general, complications follow- bean with regard to initiation of supplemen- ing perinatal anoxia or hypoxia (perinatal as- tary feeding after birth, the duration of phyxia), complications of prematurity, and breast-feeding, the principal reasons given for infections of newborns are the main causes of commencement of bottle-feeding, and access perinatal death (Table 3). As several studies to formula feeds. Most of the information in- inside and outside the Caribbean area have volved (see Tables 4-6) was gathered in 1979 shown, these causes of death are also the com- or 1980. In Barbados and Jamaica, however, mon causes of handicaps when the affected the data were collected considerably earlier children are able to survive (2, 4-6). and should not be regarded as necessarily re- flecting current feeding practices. As Table 4 shows, bottle-feeding appears to Feeding Practices be a common practice in the countries studied, and most mothers start bottle-feeding Compared to infant formulas (including so- their infants within a few weeks of delivery. In called “humanized” milks), breast-milk is the Bahamas, while no precise figures are nutritionally superior, imposes little or no available, it appears that exclusive or supple- economic burden on the parents, and con- mentary bottle-feeding begins almost imme- tains maternal antibodies that play a major diately after birth. role in disease prevention. Breast-feeding also These data, when combined with those in appears to have contraceptive, emotional, Table 5, indicate that most mothers habitu- and psychological effects that are beneficial. ally give their infants a combination of breast Therefore, especially in circumstances where and bottle feedings from around the age of hygiene is inadequate, piped water is absent, one month until somewhere between four and incomes are low, and education is poor, seven months of age. The only exception indi- breast-feeding without supplementation cated by the data would be the Bahamas, should be encouraged for an infant’s first four where exclusive bottle-feeding is commonly to six months of life. practiced from the age of one month onwards. Unfortunately, available data on common Regarding the reasons given for initiating feeding practices in the six countries studied bottle-feeding, those most commonly stated are limited (21-29), and lack of uniform data- indicate that the mothers involved believe gathering in the different countries makes their breast-milk does not satisfy their comparative analysis difficult. Nevertheless, babies-as demonstrated, for example, when the available information is sufficient to indi- the baby cries after a feed. Unfortunately,

Table 4. Average times at which bottle-feeding begins, as reported by a variety of sources, in the six countries and Jamaica.

Year of Time when Country data bottle-feeding begins sources

Antigua 1980 Within 3-4 weeks of delivery 26 Bahamas - At birth” - Barbados 1969 Within 3-4 weeks of delivery 27 Dominica 1979 Within 2 weeks of delivery 28 Saint Lucia 1979 Within 2 weeks of delivery 24 St. Vincent 1980 Within 1 week of delivery 22 Jamaica 1976 Within 2-3 weeks of delivery 25

B No precise figures available. 52 PAHO BULLETIN l vol. 19, no. 1, 1985

Table 5. The reported duration of breast-feeding, Bahamas, Saint Lucia, and St. Vincent) sam- whether or not supplemented by bottle-feeding, ples were commonly given away free. in the six countries and Jamaica.

Year of Duration of Conditions and Needs in Specific Countries Country data breast-feeding Sources

Antigua 1980 6 months 26 The Bahamas Bahamas - 1 month - Barbados 1969 4 months 27 Dominica 1979 4 months 28 The main island of New Providence- Saint Lucia 1979 4 months 24 which includes the capital, Nassau-has rates St. Vincent 1980 7 months 22 of perinatal mortality (31.8 deaths per thou- Jamaica 1976 4 months 25 sand births), neonatal mortality (18.2 deaths per thousand live births), and thus an inci- this also appears to be a belief that most dence of handicaps that are higher than mothers already have at the time of delivery, might be expected in view of the island’s rela- before they have had any actual experience tively good socioeconomic infrastructure (12, with their own babies (221. It also appears, 14). This is especially true of neonatal mortal- contrary to common belief, that work is not ity (see Table 1). Little is presently known usually cited as an important reason for initi- about perinatal conditions on the out-islands ating bottle-feeding. All this suggests that in of the Bahamas, which number approxi- planning future breast-feeding campaigns, mately 700. steps should be taken to provide mothers with Facilities for managing newborns are rela- more information about problems associated tively good at the well-equipped and well- with breast-feeding, so that they will be better staffed main hospital. However, resuscitation prepared to deal with those problems. facilities are poor. Breast-feeding is extremely Other circumstances encouraging bottle- unpopular, and over 90% of all mothers em- feeding were that infant formula or food was ploy bottle-feeding exclusively from birth commonly advertised, infant formula was without attempting to breast-feed their very accessible, and in some countries (the babies.

Table 6. Principal reasons given by mothers in the six study countries and Jamaica for initiating bottle-feeding,

Year of Main reason(s) given for Country data starting bottle-feeding Sources

Antigua 1980 Breast-milk is not enough 26 Bahamas - Unknown - Barbados 1969 Unknown - Dominica 1979 Baby is not satisfied 28 Breast-feeding is not sufficient Saint Lucia 1979 Breast-feeding is not sufficient 24 Baby is not satisfied by the breast St. Vincent 1980 Insufficient supply of breast-milk 22 Baby is not satisfied by the breast Jamaica 1973 Insufficient milk supply 25 Free distribution of formula samples and advice by the medical profession to commence bottle-feeding instead of breast-feeding Boersma l PERINATAL CARE IN THE CARIBBEAN 53

In general, the nurses, pediatricians, obste- Antigua and is promoted at the prenatal clin- tricians, and Chief Medical Officer on New ics as providing the only infant food needed Providence showed great awareness of perina- during the first four months of life. Most tal problems, and all expressed great interest mothers continue breast-feeding until their in upgrading perinatology training for health babies are six months old. However, supple- workers at all levels. An initial on-the-job in- mental bottle-feeding is generally introduced service training course, sponsored by PAHO/ before the child is four weeks old. WHO, was conducted in 1983. Food supplementation for lactating moth- Priority perinatal health needs in the Baha- ers has been provided by an extensive supple- mas include the following: mentary feeding program sponsored by the World Food Program. However, a compari- l promotion and implementation of training in perinatal care, via both short- and long-term son of mothers receiving the supplement and courses, with emphasis on adequate monitoring of ones not receiving it failed to demonstrate the “at risk” mother during the last stage of preg- that the program was having any positive ef- nancy and the resuscitation and management of fect on breast-feeding practices (26). Health the asphyxiated newborn; service authorities, including the Chief Medi- l improvement of resuscitation facilities; cal Officer and the Permanent Secretary of l promotion of breast-feeding and early bond- the Ministry of Health, were highly conscious ing; of the need to improve perinatal care by pro- l improvement of the communication between moting training for health workers. central and peripheral health workers through introduction of a “child health passport,” preferably Priority perinatal health needs on Antigua one with a home-based growth chart (19); include the following:

l evaluation and promotion of perinatal care on l improvement of resuscitation facilities for the out-islands; newborns-including provision of a source of heat l measuresto prevent neonatal cross-infections; and light as well as infant bag-and-mask ventila- l enlargement of the neonatal interior care unit. tors (Rendell Baker sizes 00, 01, and 02 for different face sizes); l upgrading of facilities for providing proper Antigua care of mothers and newborn infants; l promotion of training for nurses, midwives, The island of Antigua is rather flat and has and other health workers in the field of a population of about 73,000 people. Facili- perinatology; l recruitment of two pediatricians and two ob- ties for care of the pregnant mother and new- stetricians to serve the entire island. born child are poor. Two-thirds of all deliveries in Antigua take place in the main medical facility, Holberton Hospital. Only Dominica one obstetrician and one pediatrician were available at the time of this study, and the ob- The departure of the only pediatrician on stetrician was planning to leave soon. Plans the island a few months before my visit had for building a new and larger pediatric ward had a large impact, but the energy and spirit had not been implemented. exhibited by people at the Health Ministry Basic resuscitation facilities for newborns and by the main hospital’s lone obstetrician were very poor. There was no heat supply and were impressive. no light; only an adult resuscitation bag and Despite very difficult circumstances cre- an oversized mask were available. Observa- ated by the 1979 hurricane and poor re- tion of at risk pregnant mothers and at risk sources, the existing team of health workers newborns was inadequate. and staff members was able to provide a rela- Breast-feeding is a common practice on tively high standard of perinatal care. 54 PAHO BULLETIN l vol. 19, no. 1, 1985

It appears that a few modifications4 in the hospital, introduction of the “child health prevailing principles of perinatal care could passport,” encouragement of breast-feeding, contribute to an improved result for mothers early mother and child bonding in the hospi- and their babies. Nevertheless, the relatively tal, development of research on local growth high standards of care that now exist, to- patterns, establishment of good basic statisti- gether with accurate and well-documented cal records, and education of the general pub- statistics, appropriate operational research, lic via the mass media. In general, health and strong general interest in public health team members (including the Health Minis- work could make this country, like Saint Lu- ter) at the time of the visit felt that the next cia, an example for the entire Caribbean burst of energy should be directed at identify- region. ing and eliminating the causes of early child- Breast-feeding is popular, and although hood morbidity and mortality, many of which many mothers begin some bottle-feeding of have their origins in the perinatal period. their babies within two weeks of delivery, On the negative side, it should also be breast-feeding is continued by most mothers noted that despite the breast-feeding cam- for over four months. paign, some 80% of all mothers begin bottle- Priority perinatal health needs on feeding their babies within six weeks of birth. Dominica include the following: Also, resuscitation facilities for newborns are poor, and the relatively high stillbirth rate l the recruitment of a total of two pediatricians and another obstetrician; (see Table 1) suggests special attention should l upgrading the training of nurses, midwives, be focused on better management and care of and other health workers in prenatal and perinatal the pregnant woman, especially in the last tri- care through provision of both short-term and mester of pregnancy and during delivery. long-term courses; In general, under the conditions prevailing l establishment of a better liaison with other in Saint Lucia, it could be expected that up- teaching units in the Caribbean dealing with peri- grading the knowledge of various levels of natal care (on Barbados, Curacao, Jamaica, and health workers in the area of perinatal care Trinidad); and modifications in perinatal care proce- l reduction of pregnancies among teenagers dures would have a beneficial effect on the under 17. outcome of pregnancy. Priority perinatal health needs on Saint Lu- cia include the following: Saint Lucia l better resuscitation facilities; With guidance and support from the l upgrading of training in perinatal care; Health Ministry and a coordinating pediatri- l upgrading of neonatal care facilities; cian, an effective team of health workers has l upgrading the monitoring of “at risk” moth- brought about an enormous improvement in ers during the last stage of pregnancy; l encouragement of ongoing research. maternal and child health care in recent years. At the time the island was visited, gastroenteritis no longer appeared to be a great problem. Important advances made recently St. Vincent included provision of relatively good prenatal care, early discharge of the newborn from the Environmental health services on St. Vin- cent are poor, and most houses are without 4 Including better prevention and/or early detection of any “official” supply of piped water. The neonatal infections, improved resuscitation procedures, quality of the water is poor, especially after the training of nut-Sing staff members to detect any neonatal pathology at an early stage, and the promotion of the rains. breast-feeding for infants admitted to the neonatal unit. The attendance rate at the clinics of the Boersma l PERINATAL CARE IN THE CARIBBEAN 55 maternal and child health services is low, and tion, prenatal and postnatal care-and recruit- immunization coverage is too low (on the or- ment of more manpower to provide these services; der of 17%) to be of any general preventive l encouragement of breast-feeding: value. l provision of better facilities for management of the “at risk” pregnant woman and newborn Gastroenteritis and malnutrition are major infant-especially improved resuscitation facilities problems in the first year of life, contributing for the newborn child; to the highest infant mortality figure (49.9 l adaptation of existing practices to provide for deaths per thousand live births) among the establishment of early bonding without any separa- Eastern Caribbean countries (17). Perinatal tion of the mother and newborn, early discharge of services are poor, as is suggested by high peri- low birth-weight infants (<2,5OOg), and better natal mortality. screening and management of “at risk” pregnant At the Kingstown General Hospital, new- women; borns are separated from their mothers and l encouragement of basic training in perinatal nursed in a different room. Late discharge is a care for all health workers; common practice, making the normal estab- l introduction on a broad scale of the “child lishment of breast-feeding extremely difficult. health passport” in order to improve communication between the hospital maternity ward, pediat- Resuscitation facilities are very poor, hygienic ric health workers, and parents after the newborn standards are low, and an adult resuscitation is discharged (19). bag and oversized face mask are used during the resuscitation procedure. There is no Barbados source of heat or light, and adequate facilities for clearing the newborn’s airways during the Partly because of stimulation provided by resuscitation procedure are lacking. the pediatric faculty and personnel at the More than half of the mothers start supple- Queen Elizabeth Hospital and the University mental bottle-feeding of their newborns of the West Indies campus on Barbados, the within seven days of delivery, and within a way has been paved for better management of month 89% of the children are receiving sup- the newborn infant. Research directed at plementary feeding. Provision of free formula identifying and eliminating perinatal care feed samples to mothers is still a common problems is underway; perinatal care facili- practice. These poor feeding habits, com- ties are good; and high standards of hygiene, bined with poor water supply and sanitary fa- careful observation, and adequate manage- cilities, could help to explain the high inci- ment have reduced the number of infections dence of gastroenteritis and malnutrition. among admitted newborns. Although facilities at the main hospital Nevertheless, perinatal mortality (princi- have been improved by the establishment of a pally the neonatal mortality component) is new pediatric ward, the standards of facilities still relatively high-higher than in many for newborns are low. The two energetic pedi- other countries of this region. It thus seems atricians of the recently established Offshore likely that neonatal mortality can be reduced Medical School are working under extremely sharply by means of some simple and inex- difficult conditions. The instruction of nurses pensive measures-measures that could also and midwives in basic principles of perinatal be expected to produce a noteworthy decline care, which began quite recently, may have a in the incidence of mental and neurologic beneficial effect on the care provided for preg- handicaps among young Barbadian children. nant women and perinatal health. Discussions with medical personnel and Priority perinatal health needs on St. Vin- administrators at the Ministry of Health indi- cent include the following: cated that an existing need to upgrade the . strengthening of baseline public health ser- perinatal training of health workers at various vices such as sanitation, piped water, immuniza- levels was widely recognized. 56 PAHO BULLETIN l vol. 19, no. 1, 1985

Regarding breast-feeding, the last infant grading health workers’ training in perinatal feeding survey was performed in 1969, too care at all levels could make a major contribu- long ago to necessarily reflect current prac- tion to reducing both perinatal mortality and tices, and so knowledge of this subject is the incidence of handicaps arising during the lacking. perinatal period. Priority perinatal health needs in Barbados Another point that should probably be include the following: mentioned is that in the Caribbean as a whole over 80% of all deliveries are attended by l a “Quantum jump” forward in virtually all ar- eas of perinatal health; midwives. Therefore, within this larger con- l upgrading the training of one of the pediatri- text, the upgrading of midwife training and cians in perinatology, preferably at a Caribbean performance is essential. center; or, alternatively, employment of an outside Overall, with regard to the six study coun- consultant perinatologist familiar with “tropical tries, it is possible to identify a number of ap- perinatology” to provide adequate training for var- proaches and specific measures that appear ious categories of health workers: feasible and that could play an important part l upgrading of the training in perinatal care in improving perinatal care. These include provided for nurses and midwives; the following: l encouragement of ongoing perinatal research; l establishment of better liaison with other peri- 1) Public health education should be provided natal centers in the Caribbean. through leaflets, posters, booklets, and radio or television messagesand spot announcements. Pre- natal and postnatal clinics could assist in distribut- Discussion and Conclusions ing mimeographed or printed materials through- out the country. Such health education should If the Table 1 data presented on the six cover important matters previously noted that are study countries are truly comparable, they relevant for the general public and should also deal would appear to indicate that neonatal mor- with all aspectsof family planning and contracep- tality in these countries is not directly related tion, especially those of importance for adolescents to differences in their reported gross national and women over 35 years of age. products; and this suggests, in turn, that fac- 2) Training should be provided for all staff tors such as adequate staffing of health facili- membersworking in the perinatal care field-both at the community (primary care) level and in the ties and available knowledge are apt to be maternity wards providing secondary or tertiary more critical than prevailing differences in so- care. This training should include the following: cioeconomic conditions. (a) provision of various types of courses in perina- Since most deliveries take place in hospital care for registered nurse/midwives and medical tals, and since most neonatal deaths occur personnel that will help to ensure adequate stan- within the first 48 hours after birth, it seems dards of care in all maternity units: (b) develop- appropriate that particular attention should ment of regional manpower in perinatal care, so as be paid to providing adequate care for the at to provide leadership in various health worker cat- risk pregnant woman and newborn infant egories and ensure the maintenance of adequate within the hospital. Partly for this reason, standards in the region: (c) dissemination of up-to- strict separation of health care into “pri- date knowledge in perinatology to various catego- ” “secondary,” and “tertiary” categories of health workers (including the issuance of mary, manuals describing minimum standards of perina- ries does not seem appropriate for perinatal tal care, serving as guides to resuscitation equip- care in the six study countries. To the extent ment, listing basic drugs appropriate for all mid- that such a separation exists, however, it ap- wives and hospitals, and guiding the organization pears that all levels need to be improved. Spe- of workshop seminars and on-the-job training cifically, the health personnel interviewed courses); and (d) training of public health workers. during the course of this study felt that up- 3) The equipment in all maternity units should Boemna l PERINATAL CARE IN THE CARIBBEAN 57 be upgraded and properly maintained, for which nity units with the necessary equipment and facili- purpose personnel should be trained to maintain ties as economically, simply, and efficiently as pos- it. The basic equipment required for the resuscita- sible while ensuring proper maintenance of this tion of newborns (see pictures) is as follows: equipment. l mucous extractors, Regarding the educational side of these rec- l bag-and-mask ventilators with different mask sizes for infants with different face sizes (Rendell ommendations, any funding agency wishing Baker sizes 00, 01, and 02), to promote implementation of the maternal l means of keeping the baby warm (e.g., a por- and child health strategy endorsed some time table standing lamp with a 60 to 100 watt bulb), ago by the Caribbean Health Ministers (7) l a laryngoscope with a straight blade, replace- could make a worthwhile contribution by sup- ment lamps, and batteries, porting “on-the-job”’ training courses de- l oral/nasal endotracheal tubes (sizes 2.5, 3.0, signed to improve care for at risk mothers and and 3..5), infants, and to overcome the limitations in ex- l McGill forceps, pertise and facilities in each country involved. l an oxygen supply. It also appears that certain centers of learn- Other equipment essential for care of the new- ing, including the University of the West In- born includes: dies campuses in Barbados, Jamaica, Trini- l an accurate scale (see picture), dad, and the Bahamas, and the advanced l a bilirubino-meter (measuring total serum bil- irubin from capillary blood), Medical School of the Netherlands Antilles at l a phototherapy unit (a blue lamp with. an Curacao could serve as centers for dissemina- emission spectrum centered at 440-460 nano- tion of knowledge in this field within a rela- meters-see picture), tively short period of time. l a perspex hood to supply oxygen over the head of the infant (different size hoods for different Epilogue head sizes). 4) Steps should be taken to promote the early As in many other fields of medicine, “tropi- detection and management of jaundice in the cal” perinatology differs from “Western” community. perinatology in many ways. Differences are 5) Free distribution of anti-D-globulin should found in the physiology of the pregnant be ensured for Rh-negative mothers who give birth woman, the pattern of complications com- to Rh-positive children (whether live or stillborn). monly found during pregnancy and labor, the 6) Linkages between delivery of babies in the hospital and their subsequent care in the commu- pattern of complications experienced by new- nity should be improved (e.g., by use of a “child born infants, the physiology of the newborn, health passport“ or its equivalent (19). the composition of the mother’s breast-milk, 7) The system for early detection and manage- feeding practices during the first year of life, ment of high-risk pregnancies and high-risk chil- the infant’s growth pattern, the motor and dren should be improved. Obstetric activities that neurologic development of the infant, and so can reasonably be improved include the manage- forth. ment of hypertension, breech presentation, and Hardly any information about these differ- prolonged rupture of the membranes, as well as ences can be found in commonly used text- management of distressed mothers and their- un- books; and whatever information is given is born children, mothers with cephalopelvic dispro- often placed in a negative context. portion, and mothers who are under 17 years old or In some ways, however, the pregnant over 35. 8) Measures should be taken to encourage and woman and newborn living in the tropics are provide funding for research in “tropical” “better off” than their industrialized-country perinatology. counterparts. Respiratory problems of the 9) Development of appropriate technology preterm infant due to the Respiratory Distress should be endorsed with an eye to providing mater- Syndrome are rare compared to Western 58 - PAHO BULLETIN l vol. 19, no. 1, 1985

standards (30). Although born with a lower All in all, it appears that tropical perina- average birth-weight, the “tropical” child’s tology and the particular countries involved growth tends to be faster just before and dur- have sufficiently distinctive characteristics ing the first month after birth compared to and conditions so that it is not appropriate to Western standards (31, 32). And the breast- simply apply “Western” knowledge and care milk of mothers in poor tropical countries in a “tropical” setting. Rather, the knowledge tends to contain a fat component that is better disseminated and applied should be predi- absorbed by the young infant than is the fat cated upon each country’s local conditions, component of Western breast-milk samples facilities, and experiences. Put simply, a ho- (33, 34). listic approach is required.

ACKNOWLEDGMENTS

Special thanks are due those health personnel who provided the information cited in this article. In particular, I wish to thank Dr. M. Steven- son, Dr. P. D. Roberts, Dr. P. McNeil, and Dr. B. Nottage in the Baha- mas; Miss Gardner, Matron of the Holberton Hospital in Antigua; Dr. E. Cooper, Dr. M. 0. D. Chase, and Dr. H. Marius in Saint Lucia; Dr. Sorhaindo in Dominica; and Dr. R. Weiss and Dr. T. F. Doran in St. Vincent for their valuable information and assistance in establishing links with the Ministries of Health and with other medical personnel in the field of perinatology. I also owe a great debt to Dr. M. Thorburn, Dr. N. Hosang, and Dr. P. Roberts for their valuable suggestions and critical review of the manu- script. In addition, I wish to thank the Government of the Netherlands for giving me the opportunity to conduct the study upon which this article is based.

SUMMARY

In view of Caribbean Government concern about deal of the divergence disappeared, suggestingthat perinatal problems, combined with very limited much of it could have been accounted for by the resources for conducting perinatology training problems involved in accurately classifying still- programs, the Government of the Netherlands births versus neonatal deaths on official registers. sponsored a study of perinatal conditions in six In general, perinatal mortality in the six countries Caribbean countries-Antigua, the Bahamas, appeared to range from about 29 deaths per thou- Barbados, Dominica, Saint Lucia, and St. Vin- sand births in Dominica to about 38 deaths per cent. The study, conducted in December 1981, in- thousand in St. Vincent. Complications following volved a series of visits to the six countries, assess- perinatal asphyxia (anoxia or hypoxia), complica- ment of the data available there, and discussion of tions of prematurity, and infections of the newborn the situation with local health authorities. were the main causesof perinatal death. The aver- Hospital data from the six countries indicated age birth-weight of newborns was found to range wide divergencesin the rates of stillbirths and neo- between 3,000 and 3,150 grams in the six coun- natal deaths. However, when the two rates were tries, while the incidence of low birth-weights combined into one (perinatal mortality) a good (I 2,500 grams) appeared to range from 6 to 11%. Boersma l PERINATAL CARE IN THE CARIBBEAN 59

With regard to infant feeding, breast-feeding health education for the general public; provision was said to last anywhere from one month on the and effective maintenance of adequate resuscita- average in the Bahamas to seven months on the av- tion and other equipment; better early detection erage in St. Vincent. Bottle-feeding typically began and management of jaundice; ensured free distri- anywhere from immediately after birth (in the Ba- bution of anti-D-globulin for Rh-negative mothers hamas) to three or four weeks after delivery (in delivering Rh-positive birth products; introduction Antigua and Barbados). of a “child health passport” and other measures In general, health personnel interviewed in the designed to improve coordination between health course of the study felt that upgrading health workers delivering babies and others providing pe- workers’ training in perinatal care at all levels diatric care; improvement of the system for detect- could make a major contribution to reducing both ing and managing high-risk mothers and new- perinatal mortality and the incidence of handicaps borns; encouragement of research on “tropical” arising during the perinatal period. Other basic perinatology; and development of technology suit- recommendations for improving perinatal health able for perinatology services in the Caribbean. in most of the study countries include improved

REFERENCES

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FIRST INTERNATIONAL SEMINAR ON DENGUE HEMORRHAGIC FEVER IN THE AMERICAS

A seminar sponsored by the Puerto Rico Department of Health, the Pan Ameri- can Health Organization, and the United States Centers for Disease Control will be held in San Juan, Puerto Rico, on 14-16 June 1985. The purpose of the seminar is to better inform medical communities and health officials in the Americas about the potential threat of epidemic dengue hemorrhagic fever, to acquaint them with current methods of diagnosis and treatment, and to emphasize the need for prevention and control measures. Seminar presentations, to be made by invitation only, will deal with clinical diagnosis and treatment, pathophysiology, pathogenesis, vaccines, laboratory diagnosis, surveillance, and control. Inquiries regarding the seminar should be addressed to Duane J. Gubler, Chief, Dengue Branch, and Director, San Juan Laboratories, Centers for Disease Con- trol, CID, G.P.O. Box 4532, San Juan, PR 00936, U.S.A.

Source: World Health Organization, Week/y Epidenriological Record 60(14): 105, 1985.