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Socorro em Desastres , Altruísmo , Humanos , Cooperação Internacional , Ucrânia , Nações UnidasRESUMO
PROBLEM: The shortage of doctors in Liberia limits the provision of comprehensive emergency obstetric and neonatal care. APPROACH: In a pilot project, two midwives were trained in advanced obstetric procedures and in the team approach to the in-hospital provision of advanced maternity care. The training took two years and was led by a Liberian consultant obstetrician with support from international experts. LOCAL SETTING: The training took place in CB Dunbar Maternity Hospital. This rural hospital deals with approximately 2000 deliveries annually, many of which present complications. In February 2015 there were just 117 doctors available in Liberia. RELEVANT CHANGES: In the first 18 months of training, the trainees were involved with 236 caesarean sections, 35 manual evacuations of products of conception, 25 manual removals of placentas, 21 vaginal breech deliveries, 14 vacuum deliveries, four repairs of ruptured uteri, the management of four cases of shoulder dystocia, three hysterectomies, two laparotomies for ruptured ectopic pregnancies and numerous obstetric ultrasound examinations. The trainees also managed 41 cases of eclampsia or severe pre-eclampsia, 25 of major postpartum haemorrhage and 21 of shock. Although, initially they only assisted senior doctors, the trainees subsequently progressed from direct to indirect supervision and then to independent management. LESSONS LEARNT: To compensate for a shortage of doctors able to undertake comprehensive emergency obstetric and neonatal care, experienced midwives can be taught to undertake advanced obstetric care and procedures. Their team work with doctors can be particularly valuable in rural hospitals in resource-poor countries.
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Tocologia/educação , Obstetrícia , Feminino , Humanos , Libéria , Médicos/provisão & distribuiçãoRESUMO
BACKGROUND: The modes of communication which patients use are seen as important within the sphere of palliative care and have been the focus of much research. AIM: This literature review aims to identify and analyse one particular mode of patient expression, namely that of the figure of speech (trope) 'metaphor', and ask questions regarding metaphor's therapeutic usefulness when engaging with the life-limited patient. DATA SOURCES: The investigation revolves around a literature review of academic papers which focus on the metaphorical ways in which patients speak of their condition. RESULTS: This paper provides the theoretical foundations for the patient's metaphoric utterances. It also delineates the variety and diversity of metaphors used by patients and categorises them into broad groupings which encompass metaphors of war, journeying, personhood, the natural world and existential concepts. CONCLUSIONS: The papers reviewed suggest that metaphoric communication allows sensitive subjects to be dealt with and provides benefits for patients. The results suggest that engaging with patients at the metaphoric level enables them to create new ways of viewing their situation and opens up the possibilities of new coping strategies. Finally, some developmental trajectories emanating from the reviewed papers are suggested, which will allow the efficacy of metaphor to be explored further within a palliative care setting.
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Adaptação Psicológica , Comunicação , Metáfora , Cuidados Paliativos/psicologia , Feminino , Humanos , Masculino , Narração , Assistência Terminal/psicologiaRESUMO
For a multitude of eminently modifiable reasons, death rates for pregnant women and girls and their newborn infants in poorly resourced countries remain unacceptably high. The concomitant high morbidity rates compound the situation. The rights of these vulnerable individuals are incompletely protected by existing United Nations human rights conventions, which many countries have failed to implement. The authors propose a novel approach grounded on both human rights and robust evidence-based clinical guidelines to create a 'human rights convention specifically for pregnant women and girls and their newborn infants'. The approach targets the 'right to health' of these large, vulnerable and neglected populations. The proposed convention is designed so that it can be monitored, audited and evaluated objectively. It should also foster a sense of national ownership and accountability as it is designed to be relevant to local situations and to be incorporated into local clinical governance systems. It may be of particular value to those countries that are not yet on target to meet the Millennium Development Goals (MDGs), especially MDGs 4 and 5, which target child and maternal mortality, respectively. To foster a sense of international responsibility, two additional initiatives are integral to its philosophy: the promotion of twinning between well and poorly resourced regions and a raising of awareness of how some well-resourced countries can damage the health of mothers and babies, for example, through the recruitment of health workers trained by national governments and taken from the public health system.
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Direitos Humanos , Cooperação Internacional , Gestantes , Defesa da Criança e do Adolescente , Países em Desenvolvimento , Medicina Baseada em Evidências/métodos , Feminino , Humanos , Recém-Nascido , Guias de Prática Clínica como Assunto , Gravidez , Direitos da MulherAssuntos
Cuidadores/ética , Instituições de Caridade/ética , Maus-Tratos Infantis/prevenção & controle , Cura pela Fé/ética , Altruísmo , Cuidadores/organização & administração , Instituições de Caridade/organização & administração , Criança , Maus-Tratos Infantis/estatística & dados numéricos , Pré-Escolar , Feminino , Humanos , Masculino , Avaliação das Necessidades , Organizações sem Fins Lucrativos/ética , Organizações sem Fins Lucrativos/organização & administração , Reino UnidoRESUMO
Without security, adequate healthcare is not possible. Armed conflicts continue to be waged with pregnant women and girls, babies and children affected most. Most countries in conflict are poorly resourced and their mortality and morbidity statistics so much higher than rich countries that nothing short of a global revolution to create equity is going to solve the problem. When the arms trade is added in and analysed the maternal and child mortality rates for those countries exporting most of these killing machines is so much lower than the countries in which they are used that we have an ethical issue that must be addressed by health professionals. Armed conflict is probably the most serious global public health challenge and two solutions are proposed. Health professionals have a major voice and must support the currently progressing Arms Trade Treaty and call for more effective protection for healthcare in areas of conflict.
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Atenção à Saúde/ética , Pessoal de Saúde/ética , Guerra , Armas , Criança , Mortalidade da Criança , Feminino , Geografia , Prioridades em Saúde/ética , Prioridades em Saúde/legislação & jurisprudência , Humanos , Lactente , Mortalidade Materna , Pobreza , Gravidez , Saúde Pública/ética , Estupro , Seguridade Social/éticaRESUMO
INTRODUCTION: Majority of studies on evaluation of emergency management courses have focused on outcomes such as knowledge and skills demonstrated in non-clinical or traditional testing manner. Such surrogate outcomes may not necessarily reflect vital changes in practice. The aim of this study was to determine if and to what extent, specific training in the management of life threatening emergencies resulted in an increased in compliance with established care guidelines of doctors working in the emergency departments of public sector hospitals in Pakistan. METHODS: A cluster randomised controlled trial was conducted in three districts hospitals in three cities (Khairpur, Vehari and Peshawar) of Pakistan. Thirty-six doctors, 18 in intervention (trained in ESS-EMNCH training) and 18 in control (untrained), were enrolled and 248 life threatening emergency events, 124 in each group, were observed for the correct use of the Airway, Breathing, Circulation (ABC) structured approach. The outcome measure was structured approach defined a priori. Data was analysed by using STATA software. RESULTS: At individual level, 79 (63.7%) life threatening episodes were managed according to the structured approach in the intervention group and 46 (37.1%) were managed according to the structured approach in controls (OR 2.98, 95%CI 1.78-4.99, p-value=0.0001). At cluster level, the mean percentage (95% CI) of the structured approach used by doctors in the intervention group [62.9% (50.4-75.3%)], was significantly higher than those in the control group, [36.3% (26.3-46.4)] (p-value=0.001). CONCLUSIONS: 5-day training of ESS-EMNCH significantly increased the compliance with established care guidelines of doctors during their management of life threatening emergency episodes in the public sector hospitals in Pakistan.
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Competência Clínica , Medicina de Emergência/educação , Cirurgia Geral/educação , Bem-Estar Materno , Pediatria/educação , Padrões de Prática Médica/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Hospitais Públicos , Humanos , Lactente , Recém-Nascido , Masculino , Paquistão , GravidezRESUMO
A system to improve the management of emergencies during pregnancy, childbirth, infancy and childhood in a region of The Gambia (Brikama) with a population of approximately 250,000 has been developed.This was accomplished through formal partnership between the Gambian Ministry of Health, the World Health Organisation, Maternal Childhealth Advocacy International and the Advanced Life Support Group.Since October 2006, the hospital in Brikama has been renovated and equipped and more efficiently provided with emergency medicines. An emergency ambulance service now links the community with the hospital through a mobile telephone system. Health professionals from community to hospital have been trained in obstetric, neonatal and paediatric emergency management using skills' based education. The programme was evaluated in log books detailing individual resuscitations and by external assessment.The hospital now has constant water and electricity, a functioning operating theatre and emergency room; the maternity unit and children's wards have better emergency equipment and there is a more reliable supply of oxygen and emergency drugs, including misoprostol (for treating post partum haemorrhage) and magnesium sulphate (for severe pre-eclampsia). There is also a blood transfusion service.Countrywide, 217 doctors, nurses, and midwives have undergone accredited training in the provision of emergency maternal, newborn and child care, including for major trauma. 33 have received additional education through Generic Instructor Courses and 15 have reached full instructor status. 83 Traditional Birth Attendants and 48 Village Health Workers have been trained in the recognition and initial management of emergencies, including resuscitation of the newborn. Eleven and ten nurses underwent training in peri-operative nursing and anaesthetics respectively, to address the acute shortage required for emergency Caesarean section.Between May 2007 and March 2010, 109 patients, mostly pregnant mothers, were stabilised and transported to hospital by the new emergency ambulance service.293 resuscitation attempts were documented in personal logbooks.A sustainable system for better managing emergencies has been established and is helping to negate the main obstacle impeding progress: the country's lack of available trained medical and nursing staff. However, insufficient attention was paid to improving staff morale and accommodation representing significant failings of the programme.
RESUMO
OBJECTIVES: To assess the birth preparedness and utilisation of services in an urban union council where only the private sector provided any healthcare. METHODS: Descriptive study design was adopted which had two components: 1) a cross-sectional community survey on birth preparedness and utilisation of services and 2) a provider survey with census of all eligible healthcare facilities. Door to door survey was conducted by visiting every tenth household. All allopathic healthcare facilities in the selected union council were visited for collecting information about the available services and amenities. RESULTS: Knowledge regarding danger signs during pregnancy and delivery was low. Sixty four percent women received some antenatal care while 45% deliveries were conducted at home. Among those having to seek emergency care during pregnancy, delivery or postpartum, 39% approached a health facility. Lack of preparation in terms of transport was reported in 83% cases. Two of the health facilities had a skilled birth attendant while four provided antenatal care services. Health education was provided by four; deliveries were conducted at one; while family planning services were provided by five facilities. CONCLUSION: Women and their families are not sensitised to prepare for safe deliveries. There is a need to improve the essential maternal and newborn health care services at the health facilities. The role of private health sector towards improving MNH; especially birth preparedness in the country needs to be explored at a larger level.
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Conhecimentos, Atitudes e Prática em Saúde , Serviços de Saúde Materna/organização & administração , Setor Privado , Adulto , Serviços de Saúde Comunitária/organização & administração , Estudos Transversais , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Recém-Nascido , Paquistão , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Inquéritos e Questionários , Adulto JovemRESUMO
Our three years' experience of Essential Surgical Skills-Emergency Maternal and Child Health (ESS-EMCH) Programme in Pakistan suggests that despite a compromised healthcare delivery system, a tangible improvement in the management of emergencies in pregnancy, the neonate and children can be achieved by adopting a novel but robust mechanism of effective advocacy along with provision of innovative, evidence based and high quality training for healthcare staff.
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Emergências , Serviços Médicos de Emergência/organização & administração , Educação em Saúde/organização & administração , Centros de Saúde Materno-Infantil/organização & administração , Criança , Medicina Baseada em Evidências , Feminino , Programas Governamentais/organização & administração , Educação em Saúde/métodos , Implementação de Plano de Saúde , Humanos , Recém-Nascido , Corpo Clínico/educação , Objetivos Organizacionais , Paquistão , Defesa do Paciente , Gravidez , Avaliação de Programas e Projetos de SaúdeRESUMO
OBJECTIVE: To evaluate the use of a structured training programme in emergency care in Pakistan through the completion of logbooks documenting actual resuscitation attempts. DESIGN: Cross-sectional survey. SETTING: All tiers of health care settings across all regions of Pakistan. PARTICIPANTS: 120 health workers, trained in the skills for managing maternal, neonatal and childhood emergencies as part of a system development programme called "Essential Surgical Skills-Emergency Maternal and Child Healthcare (ESS-EMCH). METHODS: Following a series of 6 five-day training courses developed as part of the ESS-EMCH programme between January and December 2006, participants were provided with logbooks to document the actual use of their newly acquired skills during the resuscitation of mothers, infants and children. RESULTS: 1123 resuscitation attempts were documented and received from 63 of the 120 participants (response rate 53%; number of forms 4-22 per participant). Seventy-six percent (858/1123) of documented cases were received from doctors and 24% (265) from nurses. The patients receiving resuscitation were neonates 31% (n=349), infants and children 38% (n=426), pregnant mothers 21% (n=233) and other adults 10% (n=111). The commonest emergencies treated in neonates were resuscitation at birth, sepsis, shock and difficulty in breathing. Haemorrhage was the commonest obstetric emergency (52%, n=52/101), followed by eclampsia and shoulder dystocia. Skills used to secure the airway; breathing (use of oxygen and bag valve mask ventilation) and circulation were used in 58%, 82% and 73% of resuscitated patients. Oxygen was used in 87% of neonates and in 62% of pregnant mothers. The overall survival rate in the cases reported was 89%. CONCLUSIONS: Resuscitation logbooks can be used to assess which skills are used in emergency care. This analysis provides some evidence that the skills taught during the ESS-EMCH programme are used by the trained health workers. Individually held and completed logbooks should continue to act as a feedback and audit mechanism to measure outcomes, in conjunction with other methods of evaluating the impact of the training component of this programme.
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Serviços de Saúde da Criança , Países em Desenvolvimento , Educação Médica Continuada , Serviços de Saúde Materna , Ressuscitação/educação , Ressuscitação/estatística & dados numéricos , Adulto , Atitude do Pessoal de Saúde , Criança , Pré-Escolar , Competência Clínica , Estudos Transversais , Currículo , Feminino , Humanos , Lactente , Recém-Nascido , Paquistão , Gravidez , RegistrosRESUMO
OBJECTIVES: To compare the rates of under-5 mortality, malnutrition, maternal mortality and other factors which influence health in countries with and without recent conflict. To compare central government expenditure on defence, education and health in countries with and without recent conflict. To summarize the amount spent on SALW and the main legal suppliers to countries in Sub-Saharan African countries (SSA), and to summarize licensed production of Small Arms and Light Weapons (SALW) in these countries. DESIGN: We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in SSA which have and have not experienced recent armed conflict (post-1990). We also compared the percentage of children who are underweight in both sets of countries, and expenditure on defence, health and education. SETTING: Demographic data and central government expenditure details (1994-2004) were taken from UNICEF's The State of the World's Children 2006 report. MAIN OUTCOME MEASURES: Under-5 mortality, adjusted maternal mortality, and government expenditure. RESULTS: 21 countries have and 21 countries have not experienced recent conflict in this dataset of 42 countries in SSA. Median under-5 mortality in countries with recent conflict is 197/1000 live births, versus 137/1000 live births in countries without recent conflict. In countries which have experienced recent conflict, a median of 27% of under-5s were moderately underweight, versus 22% in countries without recent conflict. The median adjusted maternal mortality in countries with recent conflict was 1000/100,000 births versus 690/100,000 births in countries without recent conflict. Median reported maternal mortality ratio is also significantly higher in countries with recent conflict. Expenditure on health and education is significantly lower and expenditure on defence significantly higher if there has been recent conflict. CONCLUSIONS: There appears to be an association between recent conflict and higher rates of under-5 mortality, malnutrition and maternal mortality. Governments spend more on defence and less on health and education if there has been a recent conflict. SALW are the main weapon used and France and the UK appear to be the two main suppliers of SALW to SSA.