Introduction:
This survey documents the reported policies and practices of normal
childbirth in maternity facilities in the West Bank (WB), including
Jerusalem. It provides information to assess the adequacy of
childbirth services in relation to the need for maternal and neonatal
care, in order to improve service planning and delivery both in the
short-term emergency situation and in the long-term perspective
of building a childbirth system. It describes the maternity hospital
infrastructure and staffing; it assesses the routine reported
practices of normal childbirth in relation to evidence-based care;
and it explores providers‘ perceptions of the effects of the
emergency situation on childbirth care and the barriers to the
implementation of best practices.
Methods:
A list of all thirty-seven WB maternity hospitals was provided by
the Palestinian Ministry of Health. For comparative purposes and
a comprehensive overview of maternity hospital utilization, data
on staffing, number of births, and workload levels were collected
from all facilities during the period of fieldwork (April 2002 to June
2003). In addition, fieldworkers visited twenty-five of these
maternity hospitals and interviewed the head obstetrician and
midwife about the policies and practices for normal childbirth. The
interviews covered all of the governmental and most of the nongovernmental
(NGO) hospitals, some of the private hospitals and
the only UNRWA hospital. Observations related to childbirth care
and to the hospital setting were also made during the field visits.
The quantitative data from the questionnaires was analyzed using
the Statistical Package for the Social Sciences (SPSS 8). The openended
questions were analyzed according to themes and served
to broaden understanding of the barriers to the use of effective
practices.
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Main Findings:
Maternity hospitals were relatively well-distributed in the three
regions of the WB (which, however, did not necessarily mean that
access was ensured during the periods of closures). However, the
north was the most underserved in maternity facilities in relation
to the number of births in the region. Three-fourths of the hospitals
belonged to the private and NGO sector. Most of the governmental
hospitals had high monthly caseloads and the private hospitals
had low caseloads. There were 84 staff obstetricians and 221
midwives working in the 37 hospitals, and only 6 (7%) of the
obstetricians were female. The mean ratio of birthing women to
midwives was 32 in the governmental hospitals, 18 in the private
and 12 in the UNRWA hospital, illustrating that the governmental
sector had the lowest proportion of midwives in relation to the
largest number of births in the WB.
Certain beneficial practices were regularly utilized, such as
midwifery care for low-risk women, freedom of movement and
choice of position in labor, non-pharmacological methods of pain
relief, prophylactic oxytocics in the third stage, and early initiation
of breastfeeding. However, some routine practices for normal
childbirth were not consistent with the best evidence. Some
interventions classified as harmful or unlikely to be beneficial that
were routinely practiced in certain hospitals were: enema and
pubic shaving, IV fluids during labor, withholding food and drink,
the lithotomy position for giving birth, the liberal use of episiotomy,
bladder catheterization and routine suction of the newborn. The
presence of a birth companion, a beneficial practice associated
with fewer interventions including Caesarean sections, was
frequently not permitted in the large hospitals, in spite of their
understaffing. The use of oxytocin for induction and augmentation
of labor and of pethidine to relieve pain are practices which may
have adverse effects on the mother and newborn, depending on
the conditions of the birthing environment. These interventions
were reported to be frequently applied in most of the maternity
facilities. Lack of knowledge, outdated habits, understaffing and
overcrowding in certain hospitals were important factors explaining
why effective care was not always provided.