Midwifery in Developing Countries O.A. Ojo and Enang Bassey Briggs, A Textbook for Midwives in the Tropics, Edward Arnold, London, 1982, pp. 468 '!he appearance of a new tex ti:x:Jok on midwifery for the 1:t"qlics is a very significan t miles tone for 1he training of midwives in 1he devel",ing CX)UIltriesof Africa. '!he au thors of 1he took RUst be c:cmnendedfor to th their ingenui t¥ and effor ts in bringing ou t a took that is in tEnded anong other things to aler t 1he 5 tuden ts of midwifery and nurse educa tors to the specific heal th problEmS of the rraternal and child health popula tion in the tropics as well as drawing their at1Ention to sane intX>rtant aspects of the rnanaganent of these health problEmS. For qui te a long time we in this region have depended a lot on the tradi- tional midwifery tex 1b:loks writ 1Enby wri ters like Margaret Myles, Mary Mayes etc. In the las t tw:) decades several books on neo-na tal care and neo-na tal medicine in developing countries have been published and these books have ~at broadened the horizons of midwives' understandina of their own discipline. But of necessity such tooks, because of their" very specialised charac ter could only serve as reference rraterial ra ther than prescribed text for midwifery programres. I t is therefore refreshing to read a took tha t aims a t surveying 1he entire spec tnnn of midwifery for 5 tudents in the tropics. Iroking at the Fore\\Ord and the Introduction sections of the took one !lakes the following assunp tions aI:x:Ju t the aims of 1he book: 1. that 1he tex1b:lok is written for use by studen ts \oklo will have had instruction at 1he basic registered nursing level and are therefore professional nurses in the tropics or subtropics. i1. that 1he midwifery student is being prepared to function as an effec- tive midwife and as a member of the large health team structure. 111. 1ha t the tex 1b:lok is in tended to assis t the s tuden t midwife to see midwifery prac tice in the con text of the socio-econcmi.c, 1he geogra- phical and the cuI tural factors prevailing in the developing coun- tries, and be able to develop appropria te inte1lec tual responses to the si tuation. iv. that the textbook intends to stimllate a public-heal th oriented approach to the practice of midwifery. v. that the textbook in addi tion to providing guidelines basic to the prac tice of midwifery also exposes 1he students to recen t advances in midwifery rranagarent. On reviewing "thetook sane strengths as well as weaknesses have been iden- tified: 107 '!he lxlok is sillp1e and ooncise and thus makes g:xx1 reading. Both the language and style are clear. Diagrams are clear and appropriately located in relation to the material they are intended to anplify. H~ ever 1he diagram designed 10 illustra te "foe1al circulation" (page 83) atic. A g:xx1 bit of information on recent advances in midwifery practice managanen.t in the fonn of peri-natal maternal and foetal disorders, their early detection, diagrosis and managanent have been included. '!his should be useful in that the studen t midwife is made aware of the illpact of :irmuno1ogical advances and new nonitoring devices on midwifery managanent and subsequently child health. For us in Bots\llana it reveals the progress that has been made and is being made by prac ti tioners in lbadan and perhaps other African coun- tries in the area of early detection, diagnosis and managanent of intra- uterine foetal prob1ans. A decade ago one w:>ul.dhave expected to find such facilities in the deve1c.ped countries only. '!he managementof rormal and abnormal pregnancies and 1al:x:Jurs, the rormal newborn, the low birth weight and premature newborn etc., have been clearly handled and speCific intervention strategies are being suggested. '!he book OOesrot treat the subject of midwifery in a carprehensive health sense as such. Each section is presented and treated as a distinct and separate part of the \\b;)le and the inter-relationships among, and between the parts are rot brought out at all. '!he II'eaIlingfulness of the subject of midwifery has been sacrificed for the strict carpartmentalisa- tion of chapters. Also, the application of the aspects of prevention of carplications prarotion and restoration of health in midwifery practice is rot evident 1hrougbJut the book. '!he chapters and sections are rot quite linked up to give oontinuity to the subject matter. '!he Introduction - Section I, addresses in a very general sense, sare me- dical and social prob1ans tha t make midwifery practice in Africa different in sare way fran the practice of midwifery in 1he nore deve1c.ped coun- tries. '!his is imnediate1y followed. by the description of the bony pel- vis in Section 2. '!his section gives straightforward structural and regional ana~ information, and xretOOdsfor determining pelvic adequacy and cephalo-pe1 vie disproportion. '!here is ro prior reference to the ilrportance of the pel vie cavi ty in child bearing, ror is there any prior reference to carplica tions or prob1ans that may result fran cephalo-pe1- vic disproportion. '!his in my view 00es rot enable the student to appre- ciate the autOOrs' rationale for starting a midwifery lxlok with the lxJny pelvis. The authors give specific prescriptions for assessing the pelvis and also for determining the extent of cephalo-pelvic dispIqlOrtions tut there is ro preamble that assists the student to see this in its prq>er perspective. '!he section on the foetal skull which giyes details of the skull and the different diaxreters are discussed tut the significance of the foetal skull diaxreters to the pelvic neasurements is rot even mentioned. '!here are several illustrations of this kind of fra~tation and disoontinui- ties in the boOk, and this feature d:>es rot PIalOte integration of learnt material in the student. 108 '!he psychological and socio-cul tural factors that are likely to af£ect the midwifery patient have rot been given the mphasis they deserve. Very little mention or oone is trade of the inportance of the patients' family life style, the cultural beliefs and values of the family and row infonnat.j,On al:out these factors is inportant in assessing the patient as a total person. Several factors that are likely to militate against the regular attendance of the ante-natal care clinics by the patients such as distance, fati9Ue, danestic chores, young children to be looked after, healthw:>rkers' attitudes, and family beliefs sOOuldbe highlighted so that the student midwife learns to recognise the need to plan for a systsn that would ease the patients' problans and encourage the patients to seek med- ical assistance. Having mentioned in the introductory chapter that malaria, hookw::>nn in- festation, nutritional anaemia and sickle-cell anaemia were rife in the tropics one would expect that history-taking, and health assessment \\O.lld E!lphasize ways of identifying the presence of the aJ::oveconditions. '!his E!lphasis does rot quite cane out in the book. History taking, health assessment, physical examination and recording, d::l rot quite get the aIphasis they deserve throughout the book. It srould be b:>me in mind that a cpod number of pregnant IrOthers in the developing countries never get to see a d::lctor during pregnancy, delivery and puerperium. So the nurse midwife nust develop a high level of catpetence in the ab:>veskills. Also, the nurse should be able to interpret certain laJ::oratory test find- ings so that appropriate referral can be made. A textbook written for the practice of midwifery in the tropics sln.1ld pay particular attention to such issues. '!he book is conpletely dewid of any form of suggested readings or reference materials for students to consult. '!he book itself is written for the average student. '!he aJ::oveaverage student lib:> is capable of ask- ing questions and critically analysing the content of the book certainly will rot find this textbook intellectually challenging. '!he book airrs at preparing a midwife that will function in the tropics; and in the introduction sane reference is made to the peculiarities of mid- wifery in developing Africa. '!here are however ro real situations cited in the line of research reports, case studies or observation studies con- ducted in Africa or in Nigeria. In this respect I found the book very limiting lx>th for the teacher and the student. '!his is indeed a weakness throughout the book. sane statistics that would dsronstrate the frequency with \J1ich sane of the obstetric and medical problans referred to occur ...ould d::l a lot to help the student and the teamer to recognise or appreciate the 'unique- ness' of the book and its relevance to the clinical setting in Africa. In fact without statistical evidence of occurrence of obstretic problems in Africa, there is 00 basis for writing the book. '!he book certainly roes rot enrich the students' unOeJ:"standingof the speoial emergencypro- cedures that the midwife can carry out -yt..en the situation Qenands emer- gency action. The iItpression one gets fIan reading the book is that the writers have in mind a setting ...nere the midwife will always be within easy reach of a d::lctor and sophisticated euq,1pment. Unfortunately such situations are rare in IrOst of the developing countries within the tropics, especially in Africa. 109 The section on Fertility regulation is written clearly and is very infonrative. '!he aspect of client counselling and education in fertili- ty regulation is a very inportant one. Yet one oooerves that the wri- ters have catpletely anitted this major cPITpOnentof fertility regula- tion. At the present tilre ~en health \IOrkers claim that clients are being fully inmlved in the decisions concerning their healthcare, one cannot help rot rotice the failure of the aut:n)rs to put across to their students, the concept of counselling and education in fertility regula- tion. '!he broader principles and process of health education in midwif- ery have not been addressed fully in this texttook. Here and there one finds a catalogue of the health talks that the students should give and lx:lw these should be given. Professional nursing students srould be encouraged or assisted to grasp the broad principles of the purpose and process of health education rather than merely being given a list of things to do. '!hese students are going to find thanselves in various midwifery si tuations ~ere they will be required to carry out patient teaching, family and coommity education. Thus a good grasp of the principles underlying health education srould help midwifery students to deal with any eventualities in health education situaticns. '!he section on Public Health which deals with inmmisation, enviromnental sanitation, basic health services, vital statistics and fertility regu- lation srould be useful for student midwives; rot these chapters are tucked in at the end of the took as additional chapters and the link between than and the rest of the material in the rook is rot effectively brought out and sustained throughout the took. '!his gives the took a kind of patch\lOrk d1aracter. '!he concept of the team in heal thcare has rot been handled well. For a J:ook that has just been reprinted one \<\Ould have expected serre treatIrent of the concept of Primary Health Care approad1 as applied to midwifery practice. It may be argued that a textl:ook is rot an end in itself rot a means to an end. It is also a fact that a textl:ook does rot necessarily replace the teacher and therefore cannot be everything to the student. '!hese and similar allowances rotwithstanding, it is still rot unfair to state that these authors have raised the expectations of midwifery teachers and students in Africa and elsewhere, and it is accordingly rot too nuch to expect that tj-,eir textOOok srould at least do for African and other '!hird World countries ~t Margaret Myles' well-koown Textbcok for Midwives did so splendidly for Britain rot still could rot quite aca:JlPl1sh for the. developing countries. 1. Myles, Margaret, TextOOokfor Midwives: with rcodern Con~ Obstetrics and Neo-natal Care, Churd'lil1 living, Edinro , 9 1; Rosenary E. Bailey, MayesMidwifm: ]I, textbook for MidWives: Loncbn, '!he English Book Society and. Bai are Tindald Eighth EditibJiT976 V. NDIKI NGCONGCO National Health Institute Gaborone. 110