GENERAL TITLE: QUALITY OF CARE STUDY
The general goal of perinatal care is to improve and maintain the health and well-being
of mothers, children and families. It involves assessment and continuous monitoring of the state
of women’s health and their newborn children.
Assessment of maternal and neonatal care is often considered the responsibility of local
and republican organizations. However, in 2005, the Ministry of Healthcare issued Order No.
237 regulating self-evaluation of maternities. This meant that each ward’s medical worker and
personnel should participate in the assessment to determine the success of ensuring available,
accessible, appropriate, and affordable care for mothers, children, and families.
Assessment of medical care includes, but is not limited to, the following:
- Continuous quality improvement, which involves feedback and audit activities;
- Implementation of policies and procedures based on current information, which are
reviewed on a regular basis;
- Education of all staff;
- Assessment of the outcome, to include at least a review of maternal and neonatal
mortality, major morbidity, and significant incidents;
- Use of hospital services;
- Assessment of the mother’s and child’s integration into the community, including
breastfeeding support.
However, external assessment by independent evaluators has certain advantages: the main
being impartiality, ensuring transparency of the information obtained for the medical service, the
Ministry of Healthcare, international organizations, thus achieving useful information for
maternities, “raions,” [local boundaries], regions and the national level.
This study was conducted as part of the projects “Mother and Child Health” and
“Modernizing Moldovan Perinatology System,” both supported by SDC. The decision to conduct
the study was made by representatives of the SDC Office, the UNICEF Representative Office,
the Ministry of Healthcare, and the project implementation agency – the Association of Perinatal
Medicine, to measure the impact of the Perinatology Program on mother and child health at the
end of its implementation.
To conduct this study and in order to obtain comparable results, the same methodology as
the one used in the 2001 assessment study was applied using WHO questionnaires and other
questionnaires developed by local authors.
GENERAL PART
The National Perinatology Program was implemented in the Republic in two stages: the
first phase, entitled “Improvement of Medical Perinatal Care in the Republic of Moldova” took
place from 1998 to 2002, and the second phase, “Promoting Quality Medical Perinatal Care”,
was completed between 2003 and 2008, with the support of the Government and the Ministry of
Healthcare of the Republic of Moldova, the Swiss Agency for Cooperation and Development,
represented by the Cooperation office in Moldova, the Japanese Government and WHO.
The National Program and its outcomes were assessed twice: in the final year of the first
stage one (2001) and at the end of the second stage (2008). Both assessment studies were meant
to assess the impact and efficiency of the Program on mothers’ and children’s health and on the
evolution of medical practices used in perinatal care.
The objectives of the study were as follows:
1
-
-
to know the level of implementation of mother and child care technologies
recommended by WHO;
to appreciate the level of awareness of mothers regarding postnatal care technologies,
including care for the newborn and the child within his/her first year of life, child
nutrition, as well as access to medical care;
to assess the level of knowledge of healthcare workers implementing medical perinatal
care technologies promoted by WHO;
to assess the quality of medical practices in maternity wards;
to collect information about medical perinatal care in perinatology centres of different
levels.
Methodology
Both studies were carried out at the national level, using a wider geographical
representation. The method used for both studies in the evaluated localities was descriptivecomparative. In the 2001 study, the results received from the raions at different stages of
implementation were compared and assessed as follows: advanced (Orhei, Ciadir Lunga and
Balti), average (Chisinau, maternity 2 and Lapusna) and initial (Tighina).
Given the fact that in 2008 all the localities in the Republic were involved in the program
implementation at the same time, the same localities were selected, to be able to compare the
progress and in order to ensure a larger representation of localities, adjacent localities from the
North and South of the Republic were included.
The study from 2001 included 21 raions and municipalities, while the 2008 study includes
24 raions and municipalities (Table 1).
Table 1: Localities covered by the assessment study (2001, 2008)
Team
No. 1
No. 2
No. 3
No. 4
No. 5
2001
Balti, Riscani, Glodeni, Singerei,
Falesti
Hincesti,
Cimislia,
Leova,
Basarabeasca, Carpineni
Comrat, Ciadir Lunga, Vulcanesti,
Taraclia
Orhei, Telenesti, Rezina, Soldanesti
2008
Balti, Riscani, Glodeni, Singerei,
Briceni
Hincesti,
Cimislia,
Leova,
Basarabeasca, Falesti
Comrat, Ciadir Lunga, Vulcanesti,
Cahul, Cantemir
Orhei, Telenesti, Rezina, Soldanesti,
Nisporeni
Chisinau (maternity No. 2), Causeni, Chisinau
(Perinatology
Center,
Stefan Voda
Municipal Hospital No. 1), Causeni,
Stefan Voda, Anenii Noi
Sampling
The sample size was calculated in the same way for both studies, based on the number of
deliveries registered in participating maternities. Considering that the size of the sample was
different for every maternity, the localities included in the study were divided into 3 types of
sectors:
 Type I with 600 deliveries, error 10%, expected prevalence 50, design effect 2,
confidence interval (CI) 95%, sample size 166;
 Type II with 1,000 deliveries and sample size 176;
 Type III with 2,500 deliveries and sample size 186 with the same characteristics.
2
Questionnaires
During the 2001 study, 4 questionnaires were used, as compared with 10 questionnaires
used in 2008 (Table 2). This difference is explained by the fact that in 2003, 12 questionnaires
recommended by WHO were introduced for the assessments of perinatal care, which were more
specific and allowed to obtain more information about the services provided in maternities.
WHO questionnaires were adjusted to the conditions in the Republic of Moldova by
including additional questions reflecting the specificities of the Moldova program.
To assess the quality of and access to medical care during pregnancy, the questionnaire
“Interview with the Primary Healthcare Worker”, which was developed in 2004, was used in the
recent study.
The questionnaire for the assessment of the Medical Perinatal Card (Form 113) and of the
Individual Card of the Pregnant and Postpartum Woman (Form 111) was developed and used for
the first time in the last study.
The questionnaires “Interview With the Mother (postnatal)” and “Assessment of the
Obstetrical and Neonatal Observation Card” were modified for the 2008 study to include
questions covering activities and measures carried out in recent years with the support of the
SDC office in Moldova, (information campaigns “For a Beautiful and Healthy Child” and
“Childhood without Risk”).
Table 2: Questionnaires used in the Perinatology Program Assessment Studies
(2001, 2008)
No.
1.
2.
3.
4.
2001
2008
Name
No.
Name
Questionnaire of the institution included 1.
Questionnaire of the institution
2 parts:
a) information about the institution
b) data from observation within the 2.
The results of the assessment of
maternity ward
labour management, as well as of
mother and neonate medical care
Interview with the mother (postnatal)
3.
Interview
with
the
mother
(postnatal)
Interview with the healthcare workers 4.
Interview with the obstetricianincluded:
gynecologist
The obstetrician and the midwife
The neonatologist and medical care
The family doctor and his nurse
5.
Interview with the midwife
6.
Interview with the neonatologist
7.
Interview with the nurse
8.
Interview with primary healthcare
workers (family doctor, family
nurse)
Assessment questionnaire of the 9.
Questionnaire for the assessment of
Obstetrical and neonatal observation
the Obstetrical and Neonatal
card
Observation Card
3
10.
Questionnaire for the assessment of
the Medical Perinatal Card (Form
113) and of the Individual Card of the
Pregnant and Postpartum Woman
(Form 111)
The questionnaires included in both studies are listed in Table 3.
Table 3: The number of questionnaires included in both studies
Name
Questionnaire of the institution
No. 1. Part 1
Part 2. The observation data from
the maternity
Interview with the mother
(postnatal)
Interview with the healthcare
workers:
- family doctors
- family nurses
- midwives
- obstetricians-gynecologists
- maternity nurses
- neonatologists
Questionnaire for the assessment
of the Obstetrical and Neonatal
Observation Card
No. of
No. of collected
collected
Name
questionnaires
questionnaires
Questionnaire of the 24
21
institution No. 1. Part 1
Results
of
the 136
144
assessment of labour
management, as well as
of mother and neonate
medical care
Interview with the
3,274
4,046
mother (postnatal)
1,270
290
684
99
90
76
31
3,280
Interview with the
healthcare workers
Interview with primary
healthcare workers:
- family doctors
- family nurses
-obstetricians
-consultants
Interview with the
obstetriciangynecologist
Interview with the
midwife
Interview with the
neonatologist
Interview with the
nurse
Questionnaire for the
assessment of the
Obstetrical and
Neonatal Observation
Card
Questionnaire for the
assessment of the
Medical Perinatal Card
(Form 113) and of the
Individual Card of the
Pregnant and
1,429
359
721
28
95
109
33
73
4,043
3,887
3,959
4
Postpartum Woman
(Form 111)
The fieldwork method
In both studies, field data were collected by five teams, consisting of three field operators, a
team coordinator and a driver. Each team travelled in a rented car with a driver, who was
member of the team.
Both studies were carried out within five to six weeks.
The first destination was the local maternity, where the team leader selected the sample for
the study on the basis of the registry of deliveries from the previous year.
The sampling interval was calculated by dividing the number of deliveries which took
place in the maternity in 2007 by the sample size, according to the sector type (for example, to
calculate the interval for a Type II sector, the number of deliveries is divided by 176). The
obtained interval was 5,68 rounded to 6. Thus, each sixth woman, starting with the last woman
who delivered before the team arrived to the maternity, was included in the study.
The number of women selected corresponded to the size of the sample for each sector type.
The sample size was representative for each raion (ME=10%, IÎ 95%).
All women included in the study were visited at home in the localities where they live.
Obstetrical and neonatal cards of women were taken from the archive and examined by the team
leader (an obstetrician-gynaecologist by profession) who remained in the maternity throughout
the study and, in addition to the examination of cards, supervised medical practices during
deliveries and interviewed healthcare workers of the maternity.
Members of the fieldwork team visited the women included in the study, examined their
Medical Perinatal Cards (Form 113), interviewed primary healthcare workers (family doctors,
family nurses) and examined the Card of the Pregnant and Postpartum Woman (Form 111).
Data processing and analysis
The data was introduced and processed by four operators in the Statistics and Mathematical
Analysis Department of the Cardiology Institute. The analysis of statistical data was carried out
using the SPSS program.
For each questionnaire the frequency at the raion, region and national level was calculated.
5
CHAPTER 1 - KNOWLEDGE, SKILLS AND INFORMATION OF MOTHERS ON
PERINATAL CARE
PART I. GENERAL INFORMATION
Within the 2008 study, 4’046 women were interviewed, compared to 3,274 women in 2001.
Overall, over 50 % of the total number of women included in both studies were 19 to 25 years
old, the most active reproductive age. An absolute majority (about 80 %) of interviewed women had 13 pregnancies. About 45-60 % delivered once, 30 % twice and 10-15 %  three times. In the 2008
study, 1, 6 % of all interviewed mothers stated that they had had 1-2 stillbirths, compared to 3, 5 % in
2001.
The rate of VLBW neonates in interviewed women, before the last delivery, was practically
halved, with 7% in 2001 and 4, 5 % in 2008.
For 96 % of women interviewed in 2001 and 97, 7 % of those interviewed in 2008, the last
pregnancy ended with a live birth in term. In 2008 the share of mothers who delivered a preterm baby
was 1, 5 times smaller (3, 9 %), than in 2001 (6, 2 %).
The last delivery was natural in 96 % of the cases in 2001 and in 91 % in 2008, the number of
children born through caesarean section being higher in 2008 (8, 3 % compared to 4, and 3 % in
2001). Furthermore, in 2008, the ventouse was used in 0, 3 % of deliveries, while in 2001 there was no
such case as vacuum-extractors were provided to all first level maternities in the Republic in 2007 with
the support of the first Swiss Grant.
In the majority of cases, the child was with the mother during the interview (99, 3 % in 2008,
compared to 97, 7 in 2001). 2, 3% (67) children were not with their mothers during the interview in
2001, compared to 0, 7% (30) in 2008. Of the children who were not with their mother in 2008, 11
(42%) were abandoned (being placed in orphanage), which is twice the number in 2001 (15 children
or 22,4%), 8 (30,8%) were with their grandparents, compared to 16,4% in 2001 (11 children), the
rest of them were with somebody else: 1 (4%) with relatives, 6 (23,1%) with occasional people,
compared to data from 2001 (3% (2 children) with relatives and 58,2% (39 children) with occasional
people, respectively).
Both studies included more women from the rural area (70% in 2001 and 66, 3 % in 2008) than
from the urban area (30% in 2001 and 33, 4 % in 2008).
PART II. PRENATAL CARE
Registering during pregnancy
The comparison of data shows that the rate of early registration (before 12 weeks of pregnancy) of
pregnant women with the doctor is 30% higher in 2008 (81, 90%) compared to 2001 (51, 2%).
According to official statistics (2008), 77,1 % of pregnant women were registered early, which
represents a slight decrease, compared to 2007 (78%).
Prenatal care provider
The key person providing healthcare during pregnancy and after discharge from maternity is the
family doctor (FD) together with the perinatal nurse.
In the 2008 study, when asked which specialist supervised women during pregnancy, 91,6%
mentioned the family doctor (compared to 68% in 2001, 77% in 2004), 0,6% the obstetriciangynecologist (compared to 93,9% in 2001), 6,2% the nurse (12,4% in 2001) and 0,1% other specialists
(compared to 50,2% midwife and 4,1% some other specialist). 98,5% of women who were
permanently supervised by the family doctor were seen by the gynaecologist.
The results thus show that the share of women consulting the family doctor increased in seven
years by 24%. There is a large coverage of antenatal care provided by qualified healthcare workers
in the Republic of Moldova and the survey reveal an increased trust by women in the family doctor.
6
The number of prenatal visits
An increase in the application of the standard on the number of visits to the family doctor during
pregnancy: if in 2001, 44, 3 % respondents made 6-9 visits to the doctor during pregnancy, in 2008 the
share increased up to 75, 2 %. It is worth noting that the number of women who visited the doctor 10
times and more decreased by 20%, from 39, 4% in 2001 to 1, 8% in 2008.
On the level of the visits to the obstetrician –gynaecologist, in 2008, 40,7% of the respondents
visited this practitioner three times during the last pregnancy, and 9,3% visited him/her more than 3
times, which does not correspond to national standards in case of physiological pregnancy.
Women’s preferences regarding the specialist to supervise them during pregnancy
Of all women interviewed in 2008, 60,8% mentioned that they prefer to be supervised during
pregnancy by the family doctor, 34,3% of them by the obstetrician-gynecologist, 4,8% by the midwife
and the nurse.
51% women mentioned that they want to have the specialist who supervises them during
pregnancy present during delivery.
Medical care and procedures during pregnancy
During prenatal visits, an increasing majority of women were provided with medical care and
underwent the procedures listed in the Program of investigations during pregnancy:
BP measurement - 99,5% (2008) vs. 98,6% (2001)
blood count - 98,7% women (2008) vs. 98,4% (2001)
urinalysis - 98% women in 2008 vs. 96,7% in 2001
weighing - 97,3% women in 2008 vs. 92,4% women in 2001
abdominal girth measurement - 94,5% women (2008) vs. 92,6% (2001).
The data indicate that the care and procedures provided to women during pregnancy comply with
the Program of investigations during pregnancy.
Medical advice
In 2008, 95,2 % of women were recommended to take iron supplements, 80,4% to take folic acid,
and 73% received information about appropriate nutrition during pregnancy and behaviour in case of
danger signs. Compared to 2001, the level of counselling on these procedures significantly increased,
as 7 years ago, 58% women were recommended to take iron supplements, 31% women were
recommended to take folic acid, 55,8% were advised behaviour in case of emergency.
Many fewer women received advice on the following issues during the reference years: advantages
of natural nutrition (73,5% in 2001 compared to 59% women in 2008), the place where they should
deliver (54,3% in 2001 compared to 47% in 2008), family planning/contraception (52% in 2001
compared to 43% women in 2008), child care (64,7% in 2001 compared to 49% women in 2008).
Information about signs of labour was only provided to 45,9% women in 2008.
Obviously, in 2008 fewer women were given advice on certain issues.
Doctor’s advice on pregnant woman’s diet
The healthcare worker supervising the pregnancy counsels the pregnant woman on nutrition,
during every prenatal visit.
The 2008 study reveals that primary healthcare workers gave less advice about appropriate
nutrition to pregnant women than 2001:



to eat as much as they want in 50,3% cases (2001) and 33,7% cases (2008)
to consume more protein in 61,8% (2001), compared to 41,4% cases (2008)
consume fibre in 47,8% cases (2001), compared to 33% cases (2008)
7






fruit and juice in 85,6% cases (2001) compared to 78% cases (2008)
calcium in 62,9% cases in 2001, compared to 70% in 2008
vitamin D (42,2% in 2001, compared to 47% in 2008)
to reduce fat consumption (56,3% cases in 2001, compared to 49% in 2008)
sugar consumption (58,1% in 2001, compared to 46% in 2008)
salt consumption in 65,8% in 2001, compared to 57% cases in 2008
Administration of iron supplements to pregnant women
Between 2001 and 2008, the share of women who used iron supplements increased by almost
30% (from 68% to 96,6%). Being asked about the duration of taking iron supplements, 10,1%
respondents mentioned one month, 13,6% mentioned two months, 17,2% - 3 months and 59% womenmore than three months.
Folic acid
Between 2001 and 2008, the share of pregnant women who took folic acid increased by 50%
(fig. 9), which is due to the effect of the national communication campaign “For A Healthy and
Beautiful Child” on the behaviour of pregnant women.
Women were asked about the time of folic acid administration only in the 2008 study. The
number of women who took folic acid before conception is extremely low (2,3%), however 89%
women mentioned taking folic acid within the first 12 weeks of pregnancy and only 8,2% after 12
weeks of pregnancy. 84% of interviewed women stated that the medical staff explained the importance
and effects of folic acid administration, which increases the level of informed acceptance of this
technology by pregnant women.
HIV/AIDS counselling and voluntary testing of pregnant women
Lack of treatment or inappropriate treatment of HIV-AIDS can lead to transmission to the foetus
and disturbance of the pregnancy. 99% of women interviewed in 2008 took the HIV test during
pregnancy, while only 74, 4% were offered voluntary counselling before being tested for HIV and
63,9% after being tested.
Medical perinatal card
This card is meant for the supervision and management of pregnancy and ensures the continuity
of care in primary healthcare and in the obstetric hospital.
If in the 2001 study only 6,7% of the respondents had a Medical Perinatal Card (the card was
developed and distributed in the Republic of Moldova during that year), the distribution of the card
during the period 2003-2007 was as follows: 59% (2003), 85% (2004), 87% (2005), 100% in 2006
and 2007. In the 2008 study, 96% of the respondents reported receiving the Medical Perinatal Card:
The data also revealed that the target population coverage of the card and its use by pregnant
women in maternities increased significantly every year through 2008. 97% of the respondents in 2008
mentioned that the Card was offered during the first visit and was filled out by the doctor at each
following visit. In 2001 around 95% respondents stated that the family doctor filled out the Card during
each visit. If in 2001 89,3% women had the Perinatal card with them at the maternity, in 2008 their
share increased up to 99, 8%.
Prenatal training
The training of the woman and her family starts during pregnancy, through group or individual
sessions with the pregnant woman and her family members.
The share of women who attended prenatal classes increased by 50%. There were 4 compulsory
classes in 2008 (63,3%), compared to 2001 (12, 6%), although prenatal classes were in the form of
individual discussions during visits.
Being asked about the sufficient volume of information received during prenatal classes, women
said that the information on the following subjects was sufficient:
 physical changes in pregnancy (78,9% in 2001, compared to 45,6% in 2008)
8









emotional changes in pregnancy (75,9% in 2001 and 41% in 2008); about in-uterus
development of the foetus (73,8% in 2001 and 50% in 2008)
the time in the hospital (70% in 2001 and 37% in 2008)
emotional reactions during the first weeks of pregnancy (71,1% in 2001 and 35% in 2008)
the same reactions, but after delivery (72% in 2001 and 33% in 2008)
the role of the husband / partner during pregnancy and delivery (72,4% in 2001 and 40% in
2008)
her role in pregnancy and delivery (79,7% in 2001 and 36% in 2008)
family planning/contraception (82,7% in 2001 and 42% in 2008)
partnership in labour (80% in 2001 and 46% in 2008)
the first contact with the baby - 40% in 2008
With regret, we notice that in 2008 only one third of respondents received information about
sexuality (23%), relaxation and breathing techniques during labour (32%), pain management
during labour (29%), interventions used during labour and delivery (27%), positions for delivery
(35%), being together with the baby (17%).
These results confirm once again that prenatal training is not at the appropriate level.
Women are better informed by healthcare workers regarding practical aspects of child care
(92% in 2001 and 83% in 2008), breastfeeding (90% in 2001 and 73% in 2008), possible complications
in pregnancy and a woman’s behaviour in such cases (71, 6% in 2001 and 65% in 2008).
The training of husbands/partners of pregnant women during prenatal classes is still very low:
12,4 % of cases in 2008 versus 2,5 % in 2001, although the share of women willing to have their
husband participate in the training on mother and newborn care was high in both studies (60% in 2001
and 75% in 2008).
Access to medical care
According to Law No.161-XV of 30.05.2004, pregnant women, women in labour and postpartum
women are included in the list of people ensured by the state.
In 2008, 91% of interviewed women received prenatal care as quickly and as often as they wanted
to, compared to 88, 5% of interviewed women in 2001.
Among the reasons brought up by women to explain why they could not get corresponding care
in 2008 is the lack of financial means. However, it is to be noted that this argument was less frequently
put forward in 2008. Indeed, about 10 times fewer women claimed they could not receive care because
they had no money to pay for the visit. Women only four times claimed lack of money for
transportation to the medical institution, which is an indication that financial problems are not an
obstacle to obtaining medical care.
In 2008, 1/3 of the interviewees mentioned that one of the main reasons for which they could not
get corresponding care is because they were not at their place of residency at the time of the medical
consultation. This figure is 2,7 times higher than in 2001 (11,4%) and it is explained by the increasing
emigration of women of reproductive age in the last few years.
The number of women who stated that they did not know they were pregnant is 3 times less
important (2,2% compared to 6,4% in 2001), which can be a result of one of the messages of the
campaign “For a Beautiful and Healthy Child.” One argument invoked with equal frequency in both
studies was that the doctor or the midwife are not within an accessible distance. Every sixth pregnant
woman stated that she was too concerned with other problems or had other reason for not visiting the
doctor, and every fourth woman in 2008 considered that it is not necessary to ask for medical care.
Thus, the data showed that women frequently face obstacles when they need medical care, related
more to the fact that they were not at their residence place or because they did not consider it
necessary.
9
Smoking in pregnancy
Smoking is noxious both in preconception and during pregnancy. In the study from 2001 the
number of women who smoked during pregnancy was insignificantly greater (3,5%) compared 2, 5%
in 2008, but 46,4% of interviewed women in 2008 mentioned that they live with a person who smokes.
Most of smoking respondents in 2008 smoked during the first trimester of pregnancy (73%), and
the fifth part of smoking women, smoked throughout the whole pregnancy (23%).
76% of smoking women in 2008 smoked up to 5 cigarettes per day, 16,5% up to a pack per day
and 6% do not remember how many cigarettes they smoked.
Alcohol and pregnancy
Abuse of alcohol can affect the fertility of both partners. In the last study, questions related to
alcohol consumption by women referred to the entire pregnancy, whereas in 2001, the questions
concerned a 3-month period before and after pregnancy.
If in the 2001 study interviewed women confirmed some level of alcohol consumption during the
three months before pregnancy (19,6%) and in the last three months of the last pregnancy (32,7%), in
2008 the number of women who confirmed alcohol consumption decreased (12,2%) (Fig. 1).
In 2008 the number of women who had less than one drink (that is one glass of wine, one bottle
of beer or a small glass of spirits, vodka or cognac) per week is three times higher (75,5%), compared
to year 2001, three months before pregnancy (26%) and in the last three months of pregnancy (18%).
The number of women who consumed 1-3 drinks per week prevails (16, 7%), compared to the last
three months of pregnancy in 2001 (2,8%). 4-6 and 7-13 drinks per week consumed women
interviewed in 2001, three months before pregnancy (Fig. 2).
60,00%
50,00%
19,60%
40,00%
3 luni inainte
de sarcina%
30,00%
Ultimele 3 luni
de sarcina
Pe
parcursul
sarcinii
20,00%
32,70%
10,00%
12,20%
0,00%
2001
2008
Fig. 1. Distribution of interviewed women according to the number of alcoholic drinks consumed 2001
and 2008
10
Fig. 2. Distribution of interviewed women according to the quantity of alcohol consumed
100%
0,20%
90%
0%
3,80%
80%
70%
75,50%
60%
16,70%
0,40%
0,80%
3,40%
2008
50%
2001, ultimele 3 luni de sarcina
2001, 3 luni inaintea sarcinii
1,10%
40%
30%
18%
5,50%
0%
20%
10%
26,00%
0,10%
2,80%
0,20%
0
0%
Mai putin de o
bautura/sapt.
1-3
bauturi/sapt.
0,10%
4-6
bauturi/sapt.
7-13
bauturi/sapt.
> 14
baut./sapt.
nu stiu
Ultrasound examination
National standards recommend that the first compulsory ultrasound examination be performed at
18-21 weeks of pregnancy. If necessary the number of ultrasound examinations increases. According to
the results of the study, in 2008 the share of pregnant women examined by a doctor below and
including 18-21 weeks makes up 88%, compared to 60%, in 2001. At 18-21 weeks of pregnancy in
2008 were examined 45% of women 29% in 2001.
Investigations during pregnancy
Systematic blood pressure measurement of the pregnant woman is necessary and must be a
routine investigation. 95,5% of women interviewed in 2008 and 97% in 2001 said that their blood
pressure was measured during every visit to the doctor. In 19,3% of pregnant women who had their
blood pressure measured in 2008 and in 11% in 2001 were told that they had high blood pressure,
which suggests the willingness of women to be involved in their care during pregnancy is increasing,
though quite slowly.
Danger signs and asking for emergency medical care
The pregnant woman is informed about danger signs and the action plan in case such signs are
noticed, during their counselling at the first visit to the doctor and subsequently during other visits.
The absolute majority of women (96, 8%) in 2008 mentioned having talked to the doctor about
danger signs during pregnancy (55, 8% in 2001). Being asked to name the danger signs they know,
they listed the following: abundant bleeding from the vagina (92,5%), abdomen pain (93,7%), amniotic
fluid leaking (66,8%), strong headaches (63,2%), rapidly progressing oedema (61%). Fewer women
new about vision disturbances (44%), abundant discharge from vagina (39,8%), others (6,4%). In the
study from 2001, 46, 4% of respondents knew the emergency signs/necessary actions in case of such
signs.
Interviewed pregnant women answered how they would act if such signs would appear : 81,5%
will immediately ask for doctor’s help, 39,3% will call the contact person, 7% will go to the hospital /
maternity, 2,9% will lie down, 7,2% gave other answers.
11
Informing pregnant women about the awareness raising campaign “For a Beautiful and
Healthy Child”.
Because the national communication and community mobilization campaign For a Beautiful
and Healthy Child” supported by the SDC, was developed in 2006 in the Republic, the respondents
were asked this question only in the 2008study. 70,5% of respondents said they had heard about the
campaign, naming the messages promoted within the campaign and saying they will go to the doctor at
the first signs of pregnancy (70%), they will take iron supplements (70,2%) and folic acid (71,1%), they
know the signs of danger in pregnancy and will go to the doctor if such signs appear (70,1%). 11,8% of
women could not name the messages of the campaign. 90,5% of women who heard about the campaign
considered it useful to increase their level of information.
PART 3. MEDICAL CARE DURING LABOUR
Delivery without the presence of a doctor is considered a risky delivery. In 2008, 99, 3% of
deliveries took place in maternities and only 0, 67% (259) – at home, of which 159 were assisted by
healthcare workers.
Shaving, enema
WHO recommends stopping shaving and reduce enemas to the minimum.
11,4 % of women interviewed in the 2008 study said that they were shaved in the genital area, this
question not having being included in the 2001 questionnaire, but the assessment data of three
maternities in 2003 indicate a high frequency of such intervention - 56,1 % of cases.
If in 2001, 54,4% had enema during the last labour, 60,2 % of women in 2003, in 2008 their number
was two times smaller, representing 23,9%, even if such a procedure was performed against the
recommendations from the perinatology guides.
Thus, even if the frequency of shaving and enema application is considerably decreasing, these
procedures were not completely eliminated from the practice of the maternities.
Involvement of women in informed decision-making
The practice of assisting during labour previously did not include informing the delivering
woman about the evolution and procedures during labour, which were performed without women’s
consent and only on the decision of the medical staff. 76,7 of all women interviewed in 2008
affirmatively answered the question that they were involved in decision-making regarding labour
management, which is twice more frequent than in the previous study.
The presence of the healthcare worker during labour
93, 6% of women in 2008 stated that the healthcare worker was with them in the delivery room
throughout delivery. In 2003 only in 53, 1% of deliveries some of the workers of the maternity was
always next to the woman during both labour and delivery.
Psychological support (partnership) during delivery
The number of women who had a support person next to them during labour is increasing:
12,2% in 2001, compared to 47% in 2008 (Fig. 3). The rate of partnership during labour is slowly
increasing in the maternities of the Republic: 23, 3% (2003), 23, 6% (2004). This technology is being
implemented with difficulty because of insufficient counselling of the pregnant woman and, especially,
of her partner, but we have to take into account the fact that the level of implementation of such
12
practice depends on the woman’s and her family’s wish and cannot be forced by medical workers. An
important factor influencing this indicator is the prevalence of women from the rural area.
The support partner preferred by the woman
The partner can be with the pregnant woman in the partnership ward and provide support before,
during and two hours after delivery. Any person chosen by the woman can be a partner.
In both studies, being asked who supported them in labour, the interviewed women mentioned
relatives: a) husband or partner (in 51% cases in 2001 and 34,2% cases in 2008), b) mother (29% in
2001 and 12, 6% in 2008), c) sister / brother (9, 3% in 2001 and 2% in 2008). In the study conducted in
2008, 54, 3% of interviewed women were assisted in labour by a healthcare worker as a support person
(46, 7% in 2003).
In 2001 and in 2008, the main reason why women did not have psycho-emotional support during
pregnancy from someone close to them was: a) woman’s refusal (53,1% in 2001 and 44,1% in 2008),
which is, however, decreasing; the second important reason was b) absence of husband/partner from
the place of residence at the time of delivery (21,90% in 2008 and 11,9% in 2001), which is related to
high rates of migration of men abroad (in 2001 this reason was on the fourth place, while in 2008 it was
already on the second). Even if the husband / partner was at home in 2008, every fifth man did not want
(20%) to be present during labour, the number being higher than in 2001 (14,2%). The number of
women who said that they did not know about this possibility decreased 3 times (4, 6% in 2008
compared to 17, 3% in 2001).
100,00%
89,00%
90,00%
92,00%
77,00%
80,00%
66,80%
70,00%
60,00%
47,00%
50,00%
2001
2008
40,00%
30,00%
20,00%
12,20%
10,00%
0,00%
Presence of the support person
Women visited in the maternity Women who moved freely during labour
Fig. 3. Distribution of women by presence of the support person in labour, the visits they
received in maternity and the permission to move freely during labour, 2001 and 2008
Free access to the maternity
The visits of family to the mother and child are largely encouraged in Family Friendly Hospitals.
77% of women interviewed in 2008 mentioned that their husbands/relatives visited them while they
were in the maternity ward, compared to 66,8% cases in 2001 (Fig. 3), which, in our opinion, is proof
of an insignificant increase of this indicator. Slow implementation of free access to the maternity is
caused by impediments of maternity administration to such practice.
Free movement in labour
The movement of the parturient woman during labour is an alternative to the use of oxytocin for
labour stimulation. Of all the respondents in 2008, 92% stated that they moved freely during labour
(89% in 2001) (Fig. 3). Among women who did not move freely during labour, the number of women
who said they did not know they are allowed to walk, decreased three times (12,2% in 2008,
compared to 47,5% in 2001), the number of women who mentioned that they were not informed by the
medical staff, insignificantly decreased (25% in 2001, compared to 20,6% in 2008). Among other
13
reasons preventing free movement, women’s monitoring during labour and the administration of the
intravenous infusion were mentioned, these interventions being more frequent in 2008, than in 2001.
Choosing the position for delivery
Traditionally, in the country the deliveries take place in lithotomy position (on the back), which is
very comfortable for medical workers who deliver the baby. In the last years the parturient women
were encouraged to choose the position they want to deliver in. All positions are possible.
In 2008, 40,5% (compared to 25% in 2003) of all interviewed women were proposed to chose the
position for delivery, and in 93,2% cases they preferred lying down on the labour table, in 4,9% lying
down on the bed, in 0,4% cases preferred hands and knees position and in other 0,4% cases, other
positions. The explanation is, probably, the fact that healthcare workers are not ready to assist
deliveries in positions other than on the back and the fact that they do not explain to pregnant women,
what the benefits of delivery in other positions are.
The presence of the medical staff during labour
Irrespective of whether there is a support person in labour or not, permanent presence of the
healthcare worker is a decisive factor for delivery outcome.
According to both studies, women were assisted by obstetricians in an equal number of cases
(89,8% in 2008 and 89, 2% in 2001). However, an increase in the involvement of midwifes (96, 1%
in 2008 and 79% in 2001); as well as nurses (22, 4% in 2008, compared to 7, 3% in 2001) in baby
deliveries and newborn child care can be noticed.
Application of certain procedures during and after labour.
The following procedures must be excluded from routine practice of maternities, because they are
not evidence based: routine valve control of birth canals, routine bladder catheterization and use of the
ice bag to prevent post-partum haemorrhage.
18, 1% of respondents participating in the study from 2008 have had episiotomy or perineotomy
(25% in the study in 2003), in 72, 5% cases received anaesthesia for perinea suturing after
episiotomy (75% in 2003).
From the statements of women interviewed in 2008, in 74, 8% cases after delivery the vagina was
treated with antiseptic, the indicator remaining at the same level as in 2001.
The bag of ice was applied on the abdomen after delivery in the study from 2008 in 18 % cases.
The bladder was catheterized in 11% of cases (in 68, 75% cases in 2001 and 48, 3% cases in 2003),
and in 71, 5% of women the valve control was performed (74, 1% in 2003).
Handing the child to the mother.
90 % mothers interviewed in 2001 stated that the baby was brought to them in the first two
hours after delivery, compared to 94, 7 % women in 2008.
Interviewed women named a number of reasons why the child was not with them in the first
two hours after delivery: most frequently, in both studies and, especially, in the study from 2008, the
state of health of the woman was mentioned (71, 6% in 2008 and 39, 1% in 2001), then the health
state of the baby (23, 1% in 2008 and 30, 4% in 2001). It is a good sign that the frequency of cases
when the contact between the mother and child was restricted by the medical staff significantly
decreased (4, 7% in 2008, compared to 18, 1% in 2001), as well as the fact that in 2008 there was no
case when the mother did not want to have the baby with her. (10% in 2001).
Skin-to-skin contact.
Skin-to-skin contact helps the interaction between mother and child and must happen within the
first two hours after birth. “The warm chain”, including skin-to-skin contact as one of its links, ensures
prevention of neonatal hypothermia and enhances biological contact between mother and child.
The number of women who confirmed that the baby was placed on their abdomen, skin-to-skin
increased by 30% (Fig.4) (90,6% in 2008, compared to 58,1% in 2001), thus, an increase of the
14
“warm chain” application is registered, however, this technology must be applied 100% with all
healthy neonates. The technology was implemented in 75% cases in 2003 and in 94% neonates in
2004.
120%
98,60%
100%
90,60%
93,00%
87,90%
91,00%
80%
60%
58,10%
2001
2008
40%
20%
0%
Was placed in skin-to-skin contact
Early breastfeeding
Rooming-in
Fig. 4. Distribution of women according to placement of the child in skin-to-skin contact, early
breastfeeding and “rooming-in” in maternity, 2001 and 2008
Skin-to-skin contact duration.
Women were asked about the duration of skin-to-skin contact with the child only during the study
in 2008.
70% of children delivered by women participating in the study were placed on mother’s abdomen for
30 minutes, 50% of them only for 10 minutes, which means that this intervention was not properly
performed.
According to the statements of women interviewed in 2008, in 73, 1% cases the healthcare
workers interrupted skin-to-skin contact in order to perform some kind of procedure. After
performing the procedure, the healthcare workers took the following measures: in 74% cases the
child was swaddled and handed to the mother, in 18% cases, after being swaddled the baby was put on
the warming table, in 6,5% cases the baby needed special care.
First breastfeeding. The first breastfeeding, in case of a physiological delivery, occurs within 30
minutes to 1 hour after delivery. When comparing the results of the studies (Fig. 4), we noticed an
increase by 6 % of the number of babies who were breastfed early (93, 8% in 2008, compared to 87,
9% in 2001). Thus, we can see that the number of early breastfeeding is quite high in the Republic.
Rooming-in (accommodation of the child in the same room with the mother in the
maternity). According to the Order No. 327 of the Ministry of Healthcare (2005), every maternity
must promote placement of the child in the same room with the mother or “rooming-in” which
facilitates breastfeeding, thermal protection, anti-infectious resistance, and establishment of the relation
between the mother and the baby.
The implementation of rooming-in in healthy child care is increasing, thus an increase by 7 % of
the number of babies who were in the same room with the mother in the maternity was registered (98,
6% in 2008, compared to 91, 0% in 2001) (Fig. 4).
15
Exclusive breastfeeding is feeding only with breast milk during the first 6 months of life. Being
asked whether they exclusively breastfed the child while they were in the maternity, 97, 9% of
respondents in 2008 said they did, compared to 95, 3% cases in 2001.
Besides the above mentioned questions, in the study conducted in 2008 the respondents were
asked how the breast milk was given to the baby: a) in 97,9 of cases women breastfed, b) in 0,1 %
gave the baby expressed breast milk with a spoon or a cup, c) in 0,3% cases used the bottle, d) in 0,4%
cases the child was fed through a tube, e) in 1,9% cases the child was given formula, f) in 0,2% the
child was given milk expressed from another woman’s breast.
Administration of other liquids in maternity. A very important step for the promotion of
breastfeeding is that in Family Friendly Hospitals neonates are not given food or liquids other than
breast milk, except for cases when there is a medical reason to do otherwise.
The analysis of answers of interviewed women to the question what other fluids, besides breast
milk, was given to their babies in maternities shows that the number of cases when formula was used is
increasing (1,9% in 2008, compared to 1% in 2001), however the number of cases when tea was given
to the babies decreased 3 times (0,2% in 2008 compared to 0,7% in 2001), the number of cases when
they were given water decreased (0,3% in 2008 compared to 0,8% in 2001) and 1,5 times less often
glucose solution was given(0,8% in 2008 compared to 1,2% in 2001).
Mother counselling in the maternity.
Communication and training of the mother is very important to increase their knowledge level
and the quality of child care at home.
Approximately the same number of women in both studies received training on child
breastfeeding in the maternity (82, 1% in 2001 and 81, 3% in 2008).
In 2008, the share of women-related subjects such as partnership in labour (22% in 2008 compared to
51% in 2001) and family planning (28,2% in 2008 and 58% in 2001) is decreasing, on the other hand,
other subjects were brought to the attention of women, such as: breastfeeding on request (77,7% of
cases), child bathing (62,1% of cases), caring for the umbilical cord after discharge from maternity
(71,6% cases), child hygiene (65% cases), antiseptic recommended for umbilical cord treatment (60%
of cases), danger signs in the baby (63% of cases), measures to be taken when danger signs occur (50%
of cases), about the fact that the child should sleep on the back (43% of cases), avoiding smoking in the
child’s room (34% cases), about optimal t°C in the child’s room (39% cases). This may be the result of
the Campaign “Childhood Without Risk” (2008).
According to the survey results, counselling is provided more often by the neonatologist or the
nurse, because women know more about practical aspects of neonate care and nutrition.
PART 4.
POSTNATAL CARE
According to national standards, the mother and child must be visited by the primary healthcare
worker within the first days after discharge from maternity. The family doctor visits the child 3 times
in the first month of life, and the nurse one time per week (4 times).
Provider of healthcare service at home. After analyzing which specialist examined the neonate
at home, after discharge from maternity, we could see that the number of examinations decreased for
all specialists in the study from 2008 compared to 2001 (Fig. 5).
Thus, if in 2001 the child was examined by the family doctor at home in 87, 10 % cases, this was the
case in 2008 for only 72, 3 % of the respondents. A similar decrease can be noticed with the visits of
nurses (74, 4% cases in 2008, compared to 90, 3% cases in 2001) and of paediatricians (0, 7% cases
in 2008, compared to 11, 9% in 2001 a decrease by 15%, which is an indication of the fact that some
children are not examined by a healthcare worker at home.
16
100,00%
100
90,30%
87,10%
90,00%
80,00%
74,40%
90
88,4
80
72,30%
72,3
70,00%
70
62
60,00%
60
2001
2008
50,00%
50
40,4
40,00%
40
30,00%
30
20,00%
20
11,90%
10,00%
0,70%
10
0,00%
Asistenta
Medic de familie
Pediatrul
Fig. 5. Distribution of women according to the
healthcare worker who visited the child at home,
2001 and 2008
0
pina la 3 luni
pina la 6 luni
pina la 9 luni
pina la 1 an
Fig. 6. Distribution of women according to the
duration of child breastfeeding, 2008 (%)
Number of post-natal visits. The number of the healthcare worker’s visits to the child’s home
in the first month of life was the following: once: 4, 5% cases, twice: 12, 2% cases, three times in
19,3% cases, four times in 32% cases, 5 times in 12% cases, in other 20,1% cases the child was
visited 6 times and more.
Post-natal advice. During the first post-natal visit the mother received different advice from the
doctor, most frequently about breastfeeding and child care. If during the study from 2001, 95% of
women replied that they received advice about child care, in 2008 the questions asked were more
specific and women gave different examples of advice they received. Thus, advice about child bathing
was mentioned by 77% of mothers, about umbilical cord care by 73% of mothers, about avoiding
smoking in the child’s room by 39% of mothers.
According to the answers of women in both studies, they received the following advice: about
breastfeeding (96,1% in 2001, compared to 85,2% in 2008), about caring for their breasts (91,7% in
2001, compared to 58% in 2008), about child vaccination (80,7% in 2001, compared to 50,4% in
2008), about contraception/family planning (51,2% in 2001, compared to 22,7% in 2008), about
danger signs/risk for the baby (77% cases in both studies), about measures to be taken if danger signs
appear - only in 2008 - 61,2%, about mother’s diet – only in 2001 (67,3%). Only 12 (0, 3%) women
from the ones interviewed in 2001 said that they received no advice from the healthcare worker who
visited them at home.
Breastfeeding and introduction of other liquids in the nutrition of the neonate. Early
nutrition practices are very important, even vital, for the physical development of babies.
Being asked if they breastfed or still breastfeed the child at the moment of the interview, the
following results were obtained in 2008: 88,4% up to 3 months, 72,3% up to 6 months, 62% up to 9
months, 40,4% up to one year (Fig. 6).
In 2001, during the post-natal interview, 99% stated that they breastfed the child, and at the time
of the interview 80, 7% were still breastfeeding.
Compared to 2001, in 2008 positive changes can be noticed regarding the time of introducing
other fluids (water, tea etc) in child nutrition, besides breast milk, in the first 6 months of life. If in
2001 in the first six months of life 58,4% of children were given other fluids than breast milk, in
2008 the share was of only 20,8 %. At the age of 6 months and over, in 2008, 32% children started
consuming other fluids, and 47, 2% of mothers mentioned not giving their child other liquids by the
time of the interview.
Complementary food. Complementary food (semisolid and liquid) must be introduced into
child’s nutrition at the age of 6 months, when the child is breastfed.
In 2001, in 29 % of children, the mothers have introduced other liquid and semisolid food
before 6 months, which is earlier than recommended, compared to 13,1 % in 2008. This is an
indication of the fact that the practice using additional food earlier than 6 months of the child is
decreasing.
17
Knowledge of the messages of the campaign „Childhood without risk”. Being asked about the
campaign „Childhood without risk” (the active phase was carried out between December 2007- May
2008) in the study from 2008, 77 % respondents stated that they have heard about this campaign. The
women who answered affirmatively, most frequently named the following main messages of the
campaign: a) child fever over 38°C and child restlessness – 92% mothers, b) seizures - 67% mothers,
c) when the child cannot drink or suck d) diarrhoea and blood and mucus in the stool - 62%
mothers, e) vomiting / repeated regurgitation - 61% of mothers, f) vomiting after each feeding and
swallowing - 60% of mothers and others.
PART 5. PSYCHOLOGICAL STATE AND SATISFACTION WITH PROVIDED CARE
The quality of services within the perinatal system is in direct relation to the satisfaction of
consumers – pregnant women and their families. All efforts of the Program were oriented during the
implementation period, especially during the second stage (2003-2007), towards increasing the quality
of services and satisfaction of women with the provided care.
Satisfaction with the level of care during pregnancy. In 2001, 84 % respondents were very
satisfied and satisfied with antenatal care received; in 2008 this indicator increased up to 92 % (Fig.
7).
80,00%
73,20%
90,00%
70,00%
78,20%
80,00%
72,30%
60,00%
70,00%
50,00%
48,20%
60,00%
2001
40,00%
35,40%
2008
2001
2008
40,00%
30,00%
20,00%
50,00%
30,00%
18,90%
20,00%
9,70%
10,00%
3,70% 3,60%
4,30%
0,00%
Foarte mult
Mult
Indiferent
Nu prea mult
Fig. 7. Distribution of interviewed women according
to the satisfaction with prenatal care (2001, 2008)
14,40%
11,50%
10,00%
4,90%
2,10%
6,50%7,80%
1,60%0,60%
0,00%
Foarte mult
Mult
Indiferent
Nu prea mult
De fel
Fig. 8. Distribution of interviewed women
according to their satisfaction with the last
delivery experience (2001, 2008)
Satisfaction with the level of care during labour. The same number of women during both
studies stated that they were satisfied and very satisfied with the last delivery experience: 86, 7% in
2008 and 89, 7% of interviewed women in 2001 (Fig. 8).
Women’s fears related to pregnancy and delivery. Women have various fears related to
pregnancy, which makes the role of the doctor as councillor very important. The most important fear
mentioned in both studies was: a) fear of miscarriage, which increased in 2008 (37%) compared to
2001 (32, 7%), followed by b) fear of delivery which also increased (28, 80% in 2001, compared to
30% in 2008), and by c) fear of pain during labour (24, 7% in 2001, compared to 27% in 2008).
Other fears decreased in 2008, compared to 2001: fear of congenital malformations (31,6% in
2001 versus 25% in 2008), fear of baby’s death (31,1% in 2001 versus 22,5% in 2008), fear of dying
during delivery (23,7% in 2001 and 14% in 2008), fear of caesarean section (18,6% in 2001, compared
to 14% in 2008), fear of delivering before getting to the maternity (17,8% in 2001 compared to 11,4%
in 2008).
The number of respondents who named financial problems as a fear during pregnancy
decreased 7 times (18, 4% in 2001, compared to 2, 5% in 2008). The fear of hospital and doctors
remained the same during both studies.
The most important 3 fears of interviewed women during pregnancy (Fig. 9) in 2008 were
the following: a) fear of miscarriage (36%), b) fear of delivery (21%), c) fear of pain during labour
18
(18,80% ), compared to the ones mentioned in 2001: a) fear of congenital malformations (24,3%), b)
fear of death of the child (23%) and c) fear of miscarriage (21,1%).
40,00%
37
35,00%
32,70
28,80
30,00%
30
27,0
24,70
25,00%
2001
2008
20,00%
15,00%
10,00%
5,00%
0,00%
a pierde sarcina
a naste
de dureri in travaliu
Fig. 9. Distribution of interviewed women according to their fear during pregnancy,
2001 and 2008 (%)
Women’s sensations/feelings during care in labour and delivery. According to what
interviewed women said, most of them felt respected and welcomed in both studies, but in fewer cases
in 2008 (68% and 71%), compared to 2001 (compared to 2001 (78,9% and 80,9%). On the other hand,
in 2008 women experienced unpleasant sensations less frequently, such as feeling humiliated,
uncomfortable, insulted, ignored, the number of women who felt routinely, professionally, treated, but
with coldness decreased two times.
Most of the respondents stated that they were treated well during labour (84 % in 2008 and 89 % in
2001), and the medical staff from maternities showed respect for their dignity (26% in 2008 and 39, 4%
in 2001). The number of cases when women were afraid to ask for something, were ignored or refused
remained unchanged.
In an equal number of cases (96, 8 % of cases in 2001 and 96, 3 % in 2008) the staff of the
maternity was polite to women who came to deliver, and women could talk to the medical staff,
whenever they wanted to (95, 3% in 2008, compared to 94, 8% in 2001).
Women’s sensations and feelings after delivery. When comparing women’s sensations after
delivery between the two studies, the number of women who felt joy and happiness is the same, the
feeling of relief and the feeling of exhaustion were more frequent in 2001 (Fig. 10).
19
90,00%
80,00% 78,10%79,00%
70,00%
70,90%
67,00%
64,50%
60,00%
51,00%
50,00%
2001
2008
40,00%
27,40%
30,00%
20,00%
11,20%
10,00%
R
us
in
at
a
as
a
Fu
rio
at
a
Su
pa
r
no
va
ta
Vi
ta
ag
i
D
ez
am
Sp
er
ia
Ex
te
nu
at
a
U
su
ra
ta
ita
Fe
ric
Bu
cu
ro
as
a
0,00%
ta
3,50%
1,90%
3,00%
1,90% 1,30% 1,20%
0,60%1,20%0,50%0,80%0,80% 0,80%
Fig. 10. Distribution of women according to their feelings after delivery, 2001 and 2008
Being asked to name three most important feelings after delivery the respondents mentioned
similar feelings in both studies: joy (83, 2% in 2008 compared to 68, 2% in 2001), happiness (68, 5%
in 2008 and 68% in 2001) and relief (51% in 2008 and 56% in 2001).
Satisfaction with post-partum accommodation. Compared to 2001, when more than half of the
interviewed women stated that they were placed in rooms with 3 or fewer beds after delivery, in 2008,
76% of respondents were placed in rooms with 2 or 3 beds. The number of women who were placed in
rooms with 4 beds decreased, which is explained by a reduction of the number of deliveries in
maternities and the number of rooms left unoccupied.
84,4% of women interviewed in 2008 stated that they were satisfied with the room they were
placed in after delivery, compared to 86, 6% women participating in the study in 2001, which probably
indicates an increase of women’s expectations related to their maternity accommodation, as these
conditions have improved considerably within recent years (capital repairs).
Opinion about the changes in the maternities. Most interviewed women mentioned the changes
that had occurred in the maternities, compared to their last delivery experience: 47% of respondents
mentioned better accommodation conditions, 17% mentioned that medical staff were more polite,
4,6% mentioned a family like environment and 4% a more private environment.
The woman’s choice about the specialist who assists the delivery. 50% of 2008 survey
respondents mentioned the obstetrician on duty as the person to assist delivery, a quarter of
respondents (25%) – the obstetrician who was asked to assist during delivery (the woman’s choice).
16% of women chose to have the doctor (not obstetrician) who examined them during pregnancy assist
during labour, and 8,4% - chose the midwife.
Conclusions:
In the end, based on the information mentioned above, we can conclude that modern prenatal,
labour, delivery and postnatal technologies are accepted and appreciated by consumers.
The use of the majority of interventions, promoted by the Program, increased during the
period between 2001-2008.
 Early registration of pregnant women with the doctor, from 51,2% to 81,9%
20
 Permanent supervision of pregnant women during pregnancy by the family doctor, from 68%
to 91,6%
 Compliance with the national standard of 6 visits to the family doctor, from 44,3% to 75,2%
 Average coverage of 97% of pregnant women with care and procedures provided in the
Program of investigations during pregnancy
 Iron supplements administration for prevention of anaemia, from 68 to 96,6 %
 Administration of folic acid for prevention of spina bifida, from 31% to 80%; in 89 % cases
in the first 12 weeks of pregnancy
 Providing 96% of all pregnant women with Medical Perinatal Card, as a standard of behaviour
during pregnancy (6,7% in 2001), out of which 97% were given the card during the first visit
and 99,8% brought this card to the (89,3% in 2001)
 Prenatal classes attendance, from 12,6% to 63%
 Compulsory ultrasound examination at 18-21 weeks of pregnancy, from 60% to 88%
 Although the number of cases when a support person was present during labour increased by
3,5 times (47% versus 12% in 2001), this depends only on the woman’s wish, a circumstance
allowing us to consider this increase as being satisfactory. The healthcare worker is the
person preferred by women as support person (54,3%), as opposed to relatives (husband,
mother).
 Informing pregnant women about emergency signs during pregnancy, from 55, 8% to 96,
8%, although not all these signs are known to everyone.
 Free access of relatives to the maternity, from 66,8% to 77%
 Free movement of the woman during labour registers a steady increase, from 89% to 92%
 Handing the baby to the mother within the first 2 hours after delivery (94,7% versus 90%), the
number of situations when the medical staff did not allow it decreased (from 18, 1% to 4,7%
 Placing of the neonate on the mother’s abdomen in skin-to-skin contact (from 58% to 90,
6%)
 Early breastfeeding, from 87,9% to 93,8%
 Placing of the child in the same room with the mother in the maternity, from 91% to 98,6%
 Breastfeeding during the first year of life made up 88,4% up to 3 months, 72,3% up to 6
months, 62% up to 9 months, 40,4% up to one year
 Knowing the signs of danger for the baby, of which the most known was fever (92%), while all
the other danger signs for the baby were known only to 2/3 of interviewed women. Knowing the
proper position on sleeping on the back was 78%.
 The study showed high satisfaction of women with the care provided during pregnancy which
increased during 2001-2008 (from 84% to 92%) and an insignificant reduction of the level of
satisfaction with the medical care during labour (from 89,7% to 86,7%).
 The feelings of being treated with respect and goodwill during medical care in pregnancy and
labour, satisfaction with the post-partum accommodation are still high. Around 50% of
interviewed women positively appreciated the changes that occurred in the maternity.
Within the last 7 years of Program implementation, the following positive changes related to
pregnant women’s health and living conditions were noticed:
 The reduction of the number of women who confirmed that they smoked (2,5%, compared to
3,5%, 2001) and consumed alcohol during pregnancy (12,2%, compared to 19,6%, 2001)
 The reduction in the number of pregnant women who worked during both trimesters of
pregnancy
 The reduction of the number of pregnant women who worked during the first and second
trimesters of pregnancy
 The reduction of the practice of giving tea, water or glucose solution to neonates
 The reduction of fears related to pregnancy and delivery caused by financial problems (from 18,
4% to 2, 5%)
21
As well as regarding the change of nutrition practices of the child under 1 year of age:
 Reduction of the practice of giving other liquids to the child during the first year of life, from
58,4% (2001) to 32% (2008)
 The reduction of the practice of giving complementary, liquid and semisolid, food, from 29%
(2001) to 13,1% (2008)
The results of the study also show a number of drawbacks in medical perinatal care, such as:
1. The fact that, despite the standard, in case of physiological evolution of pregnancy, women
continue visiting the doctor four times or more and make more visits to the obstetriciangynaecologist in 59,3 % of cases
2. A very low level of pregnant women’s counselling, despite the fact that this component of prenatal care was permanently monitored by the Program: in 62% of cases about different issues
related to pregnancy, delivery and child nutrition/care, in 59% of cases about healthy lifestyle
and in 49% about balanced and correct nutrition in pregnancy
3. Preventive administration of iron supplements in the first 12 weeks only in 28% cases and a
sufficient period of administration of such supplements (in 59% of cases, for three months and
more)
4. Insufficient quality of prenatal education / level of women’s information during prenatal
classes, women and family counselling, despite the increase of the level of attendance of these
classes
5. Very low involvement of husbands/partners in prenatal education (12, 4%)
6. A significant number of women do not go to the doctor for prenatal care, because they are not
at the place of their residence, situation determined by high migration of women of reproductive
age
7. Insufficient coverage with advertising materials about pregnancy and child
8. Insufficient involvement (information) of women in making decisions regarding labour
management (76% )
9. Although there is a reduction in maternities of practices which are not evidence based, which
are humiliating for women, their use is still unjustified: enema (from 54,4% to 24%), shaving
(from 56% to 11,4% )
10. Presence of a healthcare worker during delivery: the obstetrician in 89,8% cases, midwife in
96,1% cases and the nurse in 22,4% cases, even though the frequency of presence of the last
two specialists increased (53% in 2003), it is still below the necessary level
11. Insufficient counselling provided by the healthcare workers in the delivery room, thus the
choice of position for delivery is not applied to the necessary extent (40,5%), and women chose
the position on the Rachmaninov table (93,2%)
12. The support measures in labour are not varied, in most cases only verbal encouragement being
used (77%)
13. Anaesthesia for perineal sutures after episiotomy is not used in all maternities (72, 5% )
14. In post-partum care, certain not evidence-based procedures are used: treatment of vagina with
antiseptic (75%), ice bag (18%) on mother’s abdomen, bladder catheterization (11%)
15. In 70% cases skin-to-skin contact lasts only for 30 min, being interrupted in 73,1% of cases by
the medical staff for procedures
16. Free visits to the woman during the post-partum period only in 77% cases related to
administrative restrictions in maternities
17. Increase of the number of cases when neonates were given formula in maternity, from 1% to
1,9%
18. Post-natal advice is under the corresponding level and is limited to child nutrition, other
aspects of post-partum counselling being neglected
19. Only 86,2% children are visited at home by the primary healthcare worker, during the first 3
days after discharge from maternity, according to the recommendations
22
20. The reduction of the number of child examinations by the family doctor, nurse and paediatrician
after discharge from maternity
23
CHAPTER 2. INTERVIEW WITH THE MEDICAL STAFF FROM MATERNITY
2.1. RESULTS OF THE ASSESSMENT OF THE KNOWLEDGE OF THE
OBSTETRICIAN-GYNECOLOGIST AND MIDWIFE ABOUT COST-EFFECTIVE
TECHNOLOGIES DURING DELIVERY
During the study conducted in 2008, 95 obstetricians-gynaecologists and 109 midwives were
interviewed. The responses will be compared with the ones given by 33 obstetricians-gynaecologists
and 35 midwives who participated in the maternities assessment study in 2003.
This part of the report present the answers to common questions for obstetricians and
midwives are.
Anesthesia. Obstetrical sleep used by certain specialists from the Republic is not based on
scientific evidence and is not practiced in hospitals around the world, other than in the former USSR
hospitals.
36,3% of interviewed doctors stated that they practice the use of obstetrical sleep, the indications
being the following: discoordination of contraction strength (29, 0%), woman’s fatigue (25, 8%),
discoordination of contraction strength + the woman’s fatigue (16, 1%), pathological preliminary
period (29, 0%).
The following medicines are used for obstetrical sleep, very often a combination being used:
analgesics (20,7%), Promedol (20,7%), Dimedrol (20,7%), Diazepam (13,8%), Atropine (6,9%),
Spasmolytics (3,4%), Papaverine (4,3%), Relanium (4,3%), Adrenaline (4,3%), Sedatives (4,3%).
Often a combination of 4, 5 drugs with analgesic and sleeping drugs.
Vaginal examination. 77,9% of doctors stated that in the maternity were they worked prenatal
vaginal examination is performed. 83,1% of obstetricians stated that no vaginal examination is
performed if there is an abundant bleeding before delivery.
The gravidogram. In 2008 obstetricians-gynaecologists used the gravidogram in 98,9% cases,
compared to 2003, when they used it in 85,6% and filled it out in the following cases: for all
deliveries - 82,4% (48,9% - 2003)*; for high risk deliveries – 2,2% (1,1% - 2003); for physiological
deliveries – 12,1% (46,7% - 2003); they did not know - 3,3% (3,3% - 2003).
Midwives, on the other hand, stated that the gravidogram is being used in their: for all deliveries
– 96, 3% *; for high risk deliveries - 0, 9%; for physiological deliveries – 2, 8%.
Despite the fact that most obstetricians and midwives attended re-training programs and other
forms of training, not all of them know that the gravidogram has to be filled out for all deliveries.
As a result of the interviews of obstetricians about collection of supervision/information data, to
be included in the gravidogram, 98, 9% obstetricians-gynaecologists and 80% Midwives stated that
they are collecting data. As a result of interviews with midwives, the data from supervision/information
to be included in the gravidogram are collected by the obstetrician-gynaecologist in 87, 2% and by the
midwife in 9, 2% cases, which is a proof that midwives are actually not involved in this activity.
The doctors confirmed in 97, 9% cases that they were responsible for introducing data/results
in the gravidogram and in 56, 8% that the midwife was responsible for that. 81, 7% of interviewed
midwives confirmed that the obstetrician was responsible for introducing data/results in the
gravidogram and only in 18, 3% the midwife.
Long labour / with slow evolution
The criteria of diagnostication of long labour/with slow evolution during the active stage of the first
labour period remained the same among obstetricians: cervix opening pattern of less than 0,5 cm/h
(59,1% in 2008 compared to 57,5% ) and increased among midwives (73,8% in 2008 and 57,1% in
24
2003), and the lack of changes in cervix opening during 4 hours increased in both specialists: 76,3%
(2008) / 60,6% (2003) among obstetricians and 84,1% (2008) and 68,5% (2003) among midwives.
Providing psychological support in labour. 97, 9% doctors and 94, 5% midwives think that the
support of the mother during labour by her husband or by a family member is appropriate. 98,9%
doctor and 98,1% midwives manage to provide such psychological support.
Psychological support during labour and during delivery was provided by healthcare workers from
the maternity in 55,5% cases by doctors and in 57,9% by midwives, compared to 2003 when these
number were 27,7% for obstetricians and 25,6% for midwives. The comparison of data obtained from
healthcare workers shows an increase of indicators by 25%.
Monitoring foetal heart rate
98,9% of doctors and 98% midwives perform periodical auscultation of the foetal heart rate BCF
in the second stage of labour, while the dopplerography with a portable device – by 53,3% and,
correspondingly, 63,5% of them.
Although only 18 (75% ) of the 24 assessed maternities have a cardiotocograph, only 50,9% of doctors
and 48,8% of midwives perform cardiotocography of the foetus during labour and/or delivery.
The mothers were involved in the decision making process in 98% cases according to the doctor and
in 90,7% according to the midwife, these data being different from those obtained (76,7%) during the
interviews with the mothers.
Delivery through caesarean section. In 2008, obstetricians stated in the evidence-based indications
for caesarean section is:
- long labour (distocy) = 74,7% of the respondents (2008), compared to 81,8% (2003)
- foetal distress syndrome= 71,6% of the respondents (2008), compared to 69,6% (2003)
These answers show that the correct indications are not known to all specialists, fact which does not
allow choosing a correct tactic for labour management.
Hypertension / eclampsia
The results of the assessment allow us to conclude that within the last 5 years, the knowledge of
obstetricians on the treatment of eclampsia and preeclampsia did not change. If in 2003, 87, 8% of the
interviewed obstetricians named magnesium sulfate as a remedy for these conditions, in 2008 the
same answer was given by 78,7%. Hypotensive drugs were mentioned by 84,8% obstetricians in 2003
and 86,2% in 2008. Thus, 15-20% cases of prereclampsia /eclampsia are not treated according to the
provisions of the national protocol on preeclampsia.
Hemorrhage / hematosalpinx. 16,1% (2008) respondents, compared to 33,3% (2003), stated that
they do not have an optimal blood transfusion service. 4,8% (2008) face difficulties in the surgery
room and 6,5% (2008) – difficulties in referring the patients to specialized care providers; 12,4% of
them stated that there is no anaesthesiologist - reanimatologist in the institution where they work,
neither are blood substituent available (8,1%).
Referring patients for specialized care. 100% of obstetricians-gynaecologists (78, 8% - 2003) stated
that they refer pregnant women from the institution they work in to higher level institutions. According
to the answers of obstetricians, the indications for referral/transportation are the following:
 Severe preeclampsia / hypertension (diastolic BP  110 mmHg) – 65,0% (48,4% - 2003);
 Imminent eclampsia / preeclampsia (*) – 75,0% (2008) and 54,5% (2003);
 Premature delivery (<34 weeks)/ rupture of membranes (*) – 45,0% (51,5% - 2003);
 Suspected placenta praevia (*) – 18,8% (27,2% - 2003);
 Suspected placenta abruption (*) – 17,5% (27,2% - 2003);
 Suspected septicaemia leading to shock (*) – 11,3% (27,2% - 2003);
25
 Other: extra genital pathology – 11,3% (21,2% - 2003); multiple pregnancy – 6,3%; scarred
uterus – 5,0%; cardiovascular pathology – 2,5%; narrow pelvis – 2,5%; premature rupture
of membranes – 1,3%; Intrauterine growth restriction – 2,6%; diabetes – 1,3%; foetal
development abnormalities – 1,3%; post-term pregnancy – 1,3%.
Only half of specialists know the correct indications and criteria of referral/transportation.
30, 4% of obstetricians (2008) mentioned difficulties for transportation caused by lack of
transportation means (82, 0% - 2003). Even if the perinatology service had an ambulance for the
transportation of pregnant women and neonates to higher level institutions, there are several other
difficulties mentioned by obstetricians: the decision on transportation by car to the III level
institution is not followed (13,0%), problems with the staff accompanying the pregnant woman
(13,0%), the ambulance refuses to transport premature babies (4,3%), the higher level institution
refuses to receive the pregnant woman (4,3%), no transportation means (4,3%; in 2003 - 9,0%).
Infections/septicaemia. The answers of obstetricians regarding early signs of postnatal
infection/septicaemia is an indication of a sufficient level of knowledge about this subject, but not for
all listed signs: temperature  38,5°C starting from the second day after delivery (*) - 98,9% (87,8%
in 2003), pain in the pelvis (*) 88,3% (75,7% in 2003), abnormal vaginal discharge (*) - 83%
(81,8% in 2003) and secretions with unusual/bad smell (*) – 91,5% (91% in 2003).
Tactics of management of the mother. Being asked about the use of certain interventions during and
after delivery, the obstetricians answered:
- Recommend routine enema before delivery– 1,1% cases (2008) and 13,7% (2003);
- Recommend genital area shaving before delivery – 1,1% cases (2008) and 3,5% (2003);
- Use vagina treatment with antiseptic during delivery – 4,2% cases (2008) and 15,5%
(2003);
- Allow mothers to move freely and chose their position during delivery (98, 9%);
- Allow mothers to independently chose their position, other than to lie on the back during
delivery 95,7% cases (2008) and 70,6% (2003);
- Actively encourage mothers to push during delivery - 28, 3% (2008) compared to 62, 0%
(2003). The answers of doctors regarding active encouraging of the woman to push during
delivery were the following: foetal distress syndrome – 42% (2008) and 20,6% (2003);
long second stage of labour – 40% (2008) and 22,4% (2003); other – 8% cases (the head is
in the cavity - 4%, does not push hard enough – 2% cases, during contractions – 2% cases)
versus 12% (2005).
- Practice pushing on the uterus fundus to speed up delivery 4, 3% cases (2008) and 6, 9%
(2003).
- Practice episiotomy 22, 7% cases (2008) and 32, 0% (2003), the causes of episiotomy:
foetal distress syndrome – 80% (2008) and 18, 9% (2005); long second stage of labour–
19% (2008) and 8, 6% (2003) and others - 1% (2008) and 10, 3% (2003).
- Uses anaesthesia during episiotomy in 62,5% cases (2008) and 91,3% (2003)
- Physiologically manage the third stage of birth in 16,5% cases and actively in 83,5%
cases.
- Mentioned that they perform the following actions during active delivery management:
abdomen palpation to exclude the probability of twins delivery– 32,9%; intravenous
injection of 10 units of oxitocine – 96,1%; controlled stretching of the umbilical cord–
72,4%; examination of the uterus funduss after placenta expulsion (massage, if it is
necessary) – 43,4%; others – 1,3%.
26
Provision of assistance to the mother in the postnatal period. The obstetricians mentioned
suturing insignificant ruptures (even if there is no bleeding) in 8, 0% deliveries. According to the
answers, in 93,4% deliveries the suture of ruptures/perineum after episiotomy is performed with
anesthesia, compared to 96,5% cases (2003).
According to doctors’ answers, the vagina is treated with antiseptic in 23, 1% (2008) cases,
compared to 58, 3% cases (2003), which is a positive change. The perineum after delivery is treated
with antiseptic in 30,2% cases (2008) as opposed to 70,6% (2003).
1, 1% (2008) obstetricians mentioned applying and ice bag on the woman’s abdomen after
delivery, as opposed to 25, 8% (2003).
They also stated that they perform bladder catheterization after delivery in 26,4% cases (2008)
compared to 77,0% (2003). According to the answers provide by obstetricians, the exploration of the
cervix with the use of instruments after delivery is performed in 51,8% cases (2008) compared to
27,5% (2005)
Umbilical cord clamping. Caring for the umbilical cord is an important part of the clean chain.
59,3% obstetricians (73% in 2003) and 72,5% (68,5% in 2003) midwives answered correctly to the
question on the right time for umbilical cord clamping (after the pulsations in the umbilical cord
cease, which means approximately 1 minute after delivery ). Midwives gave more frequently the
correct answers.
Anaemia. 88,9% of obstetricians-gynaecologists proved to know correct criteria of diagnosing
anaemia, compared 98,2% in 2003.
Prescribing iron supplements by obstetrician-gynaecologist for prevention purposes increased
by 82 % (from 14, 8% in 2001 to 57, 5% in 2003 and 96, 5% in 2008), according to obstetricians.
According to the answers of obstetricians-gynaecologists, prescribing of folic acid for
prevention purposes increased up to 100% (12,4% in 2001, 66,6% in 2003 and 100% in 2008)),
which means an increase by  87%.
Conclusions:
An increase of the positive attitude of obstetricians and midwives towards cost effective
technologies in labour promoted by the Program:
1. Using the gravidogram for labour management (98,9% of obstetricians 2008, compared to
85,6% in 2003) and 100% midwives in both studies.
2. Filing out of the partogram for all deliveries (82,4% of obstetricians and 96,3% midwives in
2008, compared to 48,9% obstetricians in 2003).
3. Using the gravidogram for decision making (100% of obstetricians during both studies).
4. Supporting of the mother during labour by a relative or family member (97,9% of doctors and
94,5% of midwives in 2008, compared to 79% obstetricians and 100% midwives in 2003).
5. Providing psychological support o the woman during labour and delivery (100% doctors and
Midwives 2008, compared to 100% midwives and 63, 5% obstetricians in 2003).
6. Periodical foetal heart rate auscultation during the second stage of labour (98, 9% doctors and
98% midwives in 2008, compared to 93, 8% obstetricians and 92, 7% midwives in 2003).
7. According to the opinions of obstetricians, the rate of active management of delivery is
increased up to 83, 5% cases (2008), compared to 55, 3% (2003).
8. In 82 % cases the obstetricians have prescribed the correct dose of iron supplements for
prevention purposes to pregnant women in the first trimester of pregnancy (an increase from
14,8% in 2001 to 96,5% in 2008), which is a correct tactic.
9. In 100% cases folic acid was prescribed to pregnant women for prevention purposes (12,4 % in
2001 up to 100% in 2008).
27
10. The frequency of cases when doctors propose women to chose another position than lying on
the back during delivery increased (95, 7% cases in 2008 compared to 70, 6% cases in 2003).
However, the answers received from these specialists indicate the lack of certain knowledge
which is necessary for ensuring quality services in labour, delivery and post-partum:
1. There is a very small increase of the knowledge of midwives about the right time for
umbilical cord clamping, which is after the pulsations in the cord cease (69, 7% in 2008
compared to 8, 5% in 2003) or one minute after delivery (72, 5% in 2008 and 74, 2% in 2003)
and a decrease of the obstetricians’ level of knowledge (59% in 2008 compared to 73% in 2003
for both answers).
2. Only 50% obstetricians in 2008 had the necessary knowledge and used it in order to make
decisions about labour inducing based on the following criteria: cervix opening slower than 0,5
cm/h (57,5% in 2003) lack of cervix opening during 4 hours (60,6% in 2003).
3. Obstetricians-gynaecologists did not improve their knowledge about anaemia diagnostication
criteria (after Hb level) in pregnancy (88,9% in 2008, compared to 98,2% in 2003).
4. Despite the fact that most specialists were trained during retraining courses and other forms of
training, not all of them know that the partogram must be filled out for all deliveries.
5. Correct indications for caesarean section are not known to all obstetricians, which does not
allow them to chose a correct labour management tactic, confirmed by the fact than certain C
sections are performed in level one maternities and are not referred to a higher level
institution for care.
6. The knowledge of doctors about the remedies used for hypertension/preeclampsia treatment
remained: hypotensive drugs (86, 2% in 2008 and 84, 8% in 2003), the number of doctors who
mentioned magnesium sulfate decreased (78, 7% in 2008 and 87, 8% in 2003).
7. Only 83,1% of obstetricians know the contraindications to vaginal examination.
8. Only 50,9% doctors and 48,8% midwives working in maternities which have a cardiotocograph
available, perform the cardiotocography of the foetus during labour and/or delivery.
9. Although an ambulance was provided for transportation of pregnant women to higher level
institutions, according to obstetricians-gynaecologists there are a number of difficulties: in 13%
cases the decision regarding the transportation by car to a level III institution is not executed, as
well as problems with the staff accompanying the patient, in 4, 3% cases – the ambulance
refuses to transfer premature babies, to receive the pregnant woman, or there was no
transportation means available.
According to the answers of interviewed specialists, they continue practicing certain technologies
which are not evidence based:
1. 36,3% obstetricians continue practicing obstetrical sleep.
2. 28,3% (2008) compared to 62% (2003) obstetricians actively encourage mothers to push
during delivery.
3. 4,3% obstetricians (2008), compared to 6,9% (2003) still practice pressing on uterus funduss to
speed up delivery.
4. 22,7% of obstetricians interviewed in 2008 stated that they routinely apply episiotomy (32% in
2003).
28
THE RESULTS OF THE KNOWLEDGE TEST OF THE NEONATOLOGIST AND
NURSE ABOUT NEONATE EVIDENCE BASED CARE
During the 2008 study, 33 neonatologists and 73 specialized nurses were interviewed. The
answers of specialists were compared to similar data from the study conducted in 2001 (31
neonatologists and 76 nurses interviewed) and 2003 (17 neonatologists and 28 nurses
interviewed).
We will further present the comparative answers given by neonatologists and nurses
to similar questions from both questionnaires.
Essential neonate resuscitation
100% neonatologists in both studies, as well as 89,5% (2003) and 98,6% (2008) of nurses
answered that the resuscitation equipment from the delivery room is functional.
The answers regarding the main equipment /methods used in the delivery room for initial
resuscitation of the neonate are included in Table 1.
Table 1
Equipment/methods used in the delivery room for initial resuscitation of the neonate, %
Resuscitation equipment /
methods
Aspirator*
Respiration bag and mask*
Oxygen
Endotracheal intubation
External cardiac massage
Adrenaline
Neonatologists
2003
2008
85
100
95
100
89,5
93,8
36,2
87,5
48,1
87,5
40,3
87,5
Nurses
2003
100
95
95,0
49,0
52,0
44,3
2008
98,6
100
94,2
96,4
100
100
Although for essential resuscitation of the newborn the aspirator and he mask with the bag
are recommended and the level of knowledge about this subject seems to have increased among
neonatologists and nurses, most of them named other methods as well, including oxygen, as
being absolutely necessary for neonate resuscitation. The situation is similar with nurses. Thus,
the level of knowledge of essential neonatal resuscitation steps/methods cannot be considered
sufficient.
All (100%) neonatologists in both studies mentioned that the evaluation of the baby’s state
is carried out immediately (limited to 30 sec) after delivery, as well as when the baby is placed
on mother’s abdomen. 97,5% of specialists in 2003 and all 100% in 2008, mentioned that the
child according to the Apgar score in the first minute and in the fifth minute after delivery.
Prevention of hypothermia
48, 5% neonatologists and 60% specialized nurses mentioned an optimal air temperature in
the delivery room in winter (25-26°C), which means that only in half of assessed maternities,
according to the opinion of the medical staff, the adequate temperature is ensured.
1/3 of neonatologists and 2/3 of nurses never assisted a neonate with hypothermia, which
allows us to conclude that hypothermia was less frequent in 2008 than in 2003. Within the last
half year 28% of neonatologists and 14% of nurses have diagnosed cases of neonatal
hypothermia.
To the questions related to the technology of daily measuring the temperature of the
healthy neonate 22, 5% (2003) / 36, 4% (2008) of neonatologists and only 3, 2% (2003) / 11%
(2008) of interviewed nurses answered correctly.
Measuring the temperature of the premature baby, according to WHO recommendations,
4 times was mentioned by 56,2% (2003) / 48,5% (2008) neonatologists and 28,7% (2003) /
60,3% (2008) interviewed nurses.
29
During the study conducted in 2003 measuring t°C of the sick neonate every hour was
mentioned by 10,8% nurses, and as a monitoring method 27,7% neonatologists and 19,8%
nurses. During the study from 2008, 25% neonatologists and 15% nurses mentioned 9 times, the
others indicated a lower frequency of temperature measuring.
Breastfeeding
There are cases when the healthcare workers make an incorrect decision whether the baby
can be breastfed or not and it happens because of insufficient knowledge about the conditions
when breastfeeding is truly forbidden. 80,6% of neonatologists and 55,6% specialized nurses
answered during the study conducted in 2008 that there are cases when breastfeeding is
forbidden, in the maternity were they work. Comparing the frequency of conditions named by
neonatologists as contraindications in 2001 and 2008, we can see a clear decrease of the number
of cases when neonatologists mention such contraindication as mother’s (from 59, 4% to 12,
1%), asphyxia (from 37, 5% to 12, 1%), infection (from 25% to 9, 1%), which can be seen as a
good change in the context of ensuring successful breastfeeding in maternity.
Thus, the frequency of contraindications to breastfeeding of the neonate in the maternity is
decreasing, according to the opinions of neonatologists and, on the contrary, increasing
according to the opinions of specialized nurses.
Nutrition of the baby with low birth weight
All 100% neonatologists in both studies, 83,6% (2003) and 95,6% (2008) of nurses
mentioned that in the maternity they worked in the routine practice of applying the child with a
low birth weight to the breast immediately after birth.
In case when the underweight neonate cannot suck, the nutrition of the neonate is ensured
by means of:
- cup/spoon with expressed breast milk: 82,5% (2003) / 87,9% (2008) neonatologists and
84,5% (2003) / 76,7% (2008) nurses;
- Probe with expressed breast milk: 90% (2003) / 91% (2008) neonatologists and 100%
(2003) / 74% (2008) nurses;
- Other (pipette, syringe): 7,9% and 10,7% corresponding only in the study conducted in
2003.
Initial treatment of the neonate
62,5% (2003) and 85% (2008) of neonatologists stated that in the maternity where they
work, the neonate is given additional vitamin K for prevention of haemorrhage. Being asked
about the manner of administering this vitamin, 16,7% (2003) and 36,4% (2008) of
neonatologists answered that they administer vit. K in from of drops (*), and 63,6% in form of
intramuscular injections (*) only in the study from 2008. 43,2% (2003) and 6,1% (2008) of
neonatologists stated that they use vicasol for this purpose.
When asked about the time when vitamin K is given, neonatologists answered:
immediately after birth (3%, 2008 / 10%, 2003), 10 minutes after birth (5% only in 2003), 30
minutes after birth (6%, 2008 / 15%, 2003), an hour after birth (90,9%, 2008 / 70%, 2003), the
last answer being the correct one.
Management of neonates with asphyxia, according to the neonatologists’ opinion. The
frequency of correct answers given by neonatologists to questions about management of the
neonate with asphyxia at birth is higher in 2008, compared to 2003: a) ensuring a good heating
in the room (*) 87,9% compared to 82,3%; b) ensuring early and frequent breastfeeding
(feeding the child breast milk from a cup, if the child cannot suck) (*): 93,8% compared to 75%
c) monitoring the frequency of heart contractions (*): 100% compared to 88,2% d) monitoring
respiration frequency (*): 100% compared to 94,1% e) if possible, monitoring kidney function,
the level of glucose and calcium in the blood (*): 96,9% compared to 52,9% f) other (O2 therapy,
30
infusion therapy, dopamine) (*): 97% compared to 29,4%.
Management of neonates with cephalohematoma
58,8% neonatologists in 2003 and 30,3% in 2008 considered necessary to treat
cephalohematoma, despite WHO recommendations.
The frequency of answers related to aggressive and harmful interventions, like
cephalohematoma drainage (9, 1%, 2008 and 40, 0% in 2003) and application of cold
compresses to the baby’s head (6, 1% in 2008, compared to 10, 0% in 2003) is decreasing.
Referral / transfer of the neonate
Practically all (97%) neonatologists interviewed in 2008 and 82% in 2003 mentioned
having an experience of neonate referral to a higher level institution.
34, 8% neonatologists in 2003 and 15,2% in 2008 stated that they have faced difficulties
during baby transfer. In the 2003 study neonatologists mentioned difficulties caused by lack of
transportation means (50%), insufficient communication means (telephone etc.) (25%),
difficulties in coordinating the transfer of patients with the consultant of the receiving institution
(25%). In 2008 the last cause was named only by 1 doctor (3%), and 12% respondents
mentioned that sanitary aviation refused to transfer the baby with congenital malformations
during the night, this being a difficult time for transportation (15%) and the ambulance left
considering that transferring the baby to level III is unnecessary (18%).
Umbilical cord care
In 2008, 46 (63%) of specialized nurses and 13 (39, 4%) neonatologists answered that they
daily apply the umbilical cord ligature until the umbilical cord detachment.
According to received answers, most frequently for the care of the cord and the wound
brilliant green solution (62, 3% on average according to neonatologists and 76, 4% according to
nurses in 2008 compared to 21, 1% neonatologists and 65% specialized nurses in 2003) and
kalium permanganate (68% on average according to neonatologists and 57% according to nurses
in 2008 compared to 53% neonatologists and 60% specialized nurses in 2003). Over time we can
see that certain specialists do not use any remedy for umbilical cord care.
Conclusions:
According to the answers of neonatologists and specialized nurses, we can notice the
following positive trends registered in the maternities from Moldova within the period 2001
(2003)-2008:
1. The conditions for the resuscitation of children born with asphyxia are better from the
point of view of resuscitation equipment availability and O2.
2. The frequency of conditions mentioned by neonatologists as contraindications for
breastfeeding decreased (eclampsia, asphyxia, infection), which helps ensuring successful
breastfeeding in the maternity.
3. Routine practice of applying underweight children to the mother‘s breast after birth is
more frequent, and when the neonates cannot suck the cup/spoon is used instead of a
feeding bottle.
4. The doctors more frequently supplementary administer vitamin K for prevention of
haemorrhage in neonates, especially drops; the use of vicasol instead of vitamin K
decreased in about 90% of cases. The vitamin K in about 90% of cases is given at the
right time- one hour after birth.
5. The proper management of the neonate with asphyxia at birth is better known to
neonatologists (the average level of knowledge about management of the child with
asphyxia was of about 92, 5%, 2008, compared to 71, 2% in 2003).
31
6. The frequency of aggressive and harmful interventions in cephalohematoma
management, such as drainage and application of cold compresses to the baby’s head, is
decreasing.
7. The number of neonatologists who stated that they had no experience of transfer
decreased by 5 times, which is an indication of a better referral and transfer of neonates.
The frequency of statements related to problems during neonates transfer decreased.
However, some answers received from these specialists indicate lack of necessary
knowledge to ensure quality services:
1. Not all neonatologists and nurses named correctly essential resuscitation methods and
equipment.
2. The proper frequency of measurement of neonates body temperature is not well known by
the neonatologists (63, 6% for a healthy baby, 51,5% for a premature baby), neither by
midwives (89% for the healthy baby, 71,3% for the premature baby). The frequency of
measuring the temperature of the sick baby for monitoring purposes was not known to
any specialist. Thus, performs measures of the temperature more often than
recommended by WHO.
3. 48, 5% neonatologists and 60% nurses mentioned an optimal air temperature in the
delivery room during winter (25-26°C), which means that, according to the opinion of the
medical staff, only in half of assessed maternities an adequate temperature is ensured.
4. 80,6% neonatologists and 55,6% nurses named certain contraindications to
breastfeeding, which are not absolute contraindications and limit breastfeeding of
neonates in the maternity.
5. One third of neonatologists still think that treatment of cephalohematoma is necessary,
against WHO recommendations.
6. According to the opinion of neonatologists, there still are a number of problems related to
the transportation of sick neonates: transportation of children with congenital
malformations, it is difficult to carry out transportation during nighttime (15% ) and there
are cases when the ambulance leaves without considering if necessary to transfer the
child to a level II institution (18%).
7. Against WHO recommendations, kalium permanganate is still used for treatment of the
umbilical cord and the wound, although WHO recommends different antiseptics, among
which tincture of iodine, chlorhexidine, gentian violet.
2.3. COMPARATIVE RESULTS OF THE TESTING OF MATERNITY STAFF
KNOWLEDGE ABOUT CERTAIN COMMON ASPECTS OF PERINATAL CARE
The opinion of Specialists about the need of their participation in delivery
According to 96.8% of obstetricians, all deliveries in their institution are assisted by an
obstetrician, 92.4 of them consider their presence compulsory.
36.8% of obstetricians stated that a neonatologist assisted all deliveries in their institution,
91.4 % of them consider the presence of a neonatologist compulsory.
100 % (2003) and 97 % (2008) of neonatologists stated that an obstetrician assisted in all
deliveries in their perinatal care institution; at the same time 75 % (2003) and 81.3 % (2008) of
those who gave a positive answer mentioned that they considered the presence of an obstetrician
compulsory.
95 % (2003) and 45, 5 % (2008) of neonatologists participating in the study confirmed that
they assisted all deliveries in their institution; 75 % (2003) and 86.7 % (2008) of them consider
their presence absolutely necessary.
32
According to all obstetricians in both studies, 5 % (2003) and all neonatologists
participating in 2008 study, anesthesiologists usually are not present during deliveries and their
presence is not considered mandatory.
Skin-to-skin contact
93.2 % (2003) and 100 % (2008) of obstetricians; 98.1 % (2003) and 99.1 % (2008) of
midwives, 95.0 % (2003) and 100 % (2008) of neonatologists, as well as 96 % (2003) and 100
% (2008) of nurses mentioned that skin-to-skin contact was ensured to (almost) all newborns
in maternity.
In the 2008 study almost all neonatologists (97 % and obstetricians (91 %), as well as the
great majority of nurses (86.3 %) stated that they ensured skin-to-skin contact for 1-2 hours after
delivery.
The number of obstetricians and neonatologists who know the best 2 hour duration of skinto-skin contact increased, so has the number of nurses who, like the doctors, stated that they
followed the requirement of 2 hour skin-to-skin contact.
Maintaining the body temperature of the newborn
The knowledge of the "warm chain”
An important question included in the questionnaire was about the measures taken in
maternities to prevent the newborn hypothermia. These are directly associated with the practices
used in the maternity for the prevention of newborn hypothermia.
The obtained data show that the average knowledge of these measures by obstetricians
insignificantly decreased in time (89.6 % – 85.9 % while the midwives’ knowledge remained
almost at the same level (89.6 % 89 % and the knowledge of neonatologists (79.7 % – 87.3 %
and nurses (92.5 % – 97.6 % increased. It can be noticed that the "warm chain” links,
especially the most distant from birth are known insufficiently by obstetricians and midwives
as they consider it the obligation of the neonatologist.
However, fewer neonatologists mentioned such necessary measures like preparing a clean and
warm surface (92.5 %, 2003 – 78.8 %, 2008) and the importance of child transportation
without temperature loss (65 %, 2003 – 56.3 %, 2008).
Certain links of the "warm chain” were insufficiently known by almost all Specialists and
the level of knowledge about these links decreased: drying the baby immediately after birth,
covering the newborn together with the mother with the same blanket/bed sheet, ensuring safe
transportation of the baby, without heat loss. However, such measures as skin-to-skin contact
and breastfeeding were better known by the respondents.
Thus, the interview showed, in general, that the level of warm chain knowledge by the
interviewed specialists could be considered acceptable, but insufficient.
The analysis of overall knowledge of all interviewed specialists (obstetricians, midwives,
neonatologists, nurses) reveals that the best known practices are those related to skin-to-skin
contact (97.8 %), to the need to cover the baby's head (96.1 %), ensuring the right temperature
in the delivery room (95.2 %). They were equally informed about the need to dry the baby
(92.3 %), to cover both the baby and the mother with the same blanket (92% ), to provide a
warm and clean surface (91.4 %). The lowest knowledge level is recorded regarding the need to
transport the baby without heat loss (70 %).
Measuring the body temperature of the neonate
33
It is known that taking the axillary temperature is the best measuring method. Almost the
same number of neonatologists chose this answer in both studies: 86.1 % (2003) and 81.8 %
(2008), 93.6 % (2003) and 76.4 % (2008) of nurses, and 86.5 % (2003) and 71.4 % (2008) of
midwives participating in the study.
Unfortunately, the knowledge of axillary temperature measuring by maternity health care
staff decreased within the period 2003 – 2008, more significantly in case of nurses and
midwives.
The minimal body temperature in newborns (36.5°C) was named correctly by 85.7 % (2003)
and 72.7 % (2008) of neonatologists, by 66.5 % (2003) and 64.2 % (2008) of midwives, as well
as by 55 % (2003) and 49.3 % (2008) of nurses (tab. 6).
The knowledge of the maximal temperature (37.5°C) increased significantly among
neonatologists – 90.9 % (2003) and 92.4 % (2008), in case of nurses 78.1 % (2003) and 87.7 %
(2008) and remained almost at the same level in case of midwives (78.9 % – 2003 and 77.1 % 2008).
Thus, we can conclude that, unfortunately, the healthcare staff responsible for body
temperature monitoring does not know well enough the normal temperature values of
newborns. The knowledge of the minimal temperature decreased in time for all respondents,
while the knowledge of maximal temperature changed insignificantly only among midwives.
Placing of the baby and the mother in the same room
96.5 % of obstetricians in both studies, 62.8 % (2003) and 93.6 % (2008) of midwives, 85 %
(2003) and 78.8 % (2008) of neonatologists, as well as 89.5 % (2003) and 80.8 % (2008) of
nurses interviewed in both studies answered that the newborns, who did not require special
car, were placed in the same room with their mothers.
The comparison of the answers given by interviewed medical staff, shows that the
obstetricians and the midwives presented different maternal and neonatal conditions as reasons
for not allowing the baby to stay together with the mother, more frequently, compared to
neonatologists and nurses.
It must be mentioned that all categories of maternity specialists named maternal conditions
as causes for not rooming-in, rather than neonatal conditions. All interviewed medical staff
mentioned the following causes hindering the rooming-in in decreasing order: asphyxia (40.05
%), obstetric trauma (36 %), child prematurity (34.05 %), infection (1%8.4 %), Caesarian
section (17 %) and extra-genital pathology of the mother (16.2 %).
Breastfeeding
Asked about the share of women in maternity facing breastfeeding difficulties or problems
related to mammary glands condition, 10 % (2003) and 23.3 % (2008) of nurses and 2.98 %
(2003) and 31.4 % (2008) of interviewed midwives confirmed the occurrence of these
difficulties. This answer indicates the increase, according to healthcare staff, of problems related
to mammary glands in women breastfeeding their babies in the maternity.
A higher number of specialists in all categories interviewed during the 2008 study opted
for exclusive breastfeeding of the baby up to the age of 6 months: 91.5 % of obstetricians,
93.5% of midwives, 95.7 % of neonatologists and nurses.
Breastfeeding, along with complementary food, up to the age of 12 and 24 months was the
answer given by 90.9 % (2003) / 94.7% (2008) of obstetricians, 94.2% (2003) and 100% (2008)
of neonatologists, 100% (2003) and 93.6 % (2008) of midwives; 100 % (2003) and 91.8 %
(2008) of nurses. The evolution of correct answers is more significant among neonatologists and
is decreasing in case of the interviewed midwives and nurses.
34
Neonatal eye complications prevention
Approx. 80% of neonatologists and 90% of midwives in both studies gave a correct answer
about the time when eye complications prevention measures should be taken (one hour after
delivery).
All neonatologists in 2003 study and 93.9 % in 2008, the majority (95 % - 2003 and 95.9
% in 2008) of nurses, as well as the majority of midwives - 96.3 % (2008) answered that eye
complications prevention of the newborn is performed by applying tetracycline cream, while
6.1 % of neonatologists (2008), 5 % (2003) and 3.7 % (2008) of nurses and midwives
respectively – with erythromycin cream, both creams being recommended by the WHO.
The status of Rhesus system
All neonatologists and obstetricians interviewed in 2003 and 2008 mentioned that the Rh
system status of the mother and anti-D antibodies titration at the baby were usually known before
the delivery.
93.9 % (2003) and 72.3 % (2008) of obstetricians and 76.4 % (2003) and 93.9 % (2008)
of neonatologists stated that the routine control of the Rh system status and of antibodies
titration in case the mother is Rh negative (*), was performed in the 28th week of pregnancy.
If the mother is Rh-negative and does not have anti-D antibodies, 93.9 % (2003) / 88.7 %
(2008) of obstetricians and 73 % (2003) and 80.3 % (2008) of neonatologists would verify the
Rh system status of the baby after his/her birth (*).
In case the newborn has Rh (-), 75.7% (2003) / 83% (2008) of obstetricians, as well as
52.9% (2003) and 94% (2008) of neonatologists said it was necessary to inject anti-D-immune
globulin to the mother 72 hours after delivery at the latest.
76.4% (2003) / 100% (2008) of neonatologists in both studies answered that they would
also assess the bilirubin level in Rh positive babies of Rh negative mothers.
Thus, the level of neonatologists’ and obstetricians’ knowledge about the measures to be
taken in case of a condition related to the RH system increased since 2003.
Specialists’ level of knowledge about perinatal mortality audit
An average of 94.5% of interviewed obstetricians, 71% of midwives, 100% neonatologists,
68.7% of nurses mentioned they heard about perinatal audit, 83.3 %, 57.8%, 96.3% and 65.6%
of these specialists said this technology was implemented in their institution.
Thus, the level of knowledge about perinatal mortality audit is higher among obstetricians
and neonatologists, than among midwives and nurses. According to received answers, the
implementation of audit is lower than the level of information about this technology. Specialists'
answers to these questions depend on their degree of involvement in the implementation of the
audit process.
The interviewed healthcare staff more frequently expressed the opinion that perinatal audit was
an intervention for a) reduction of perinatal mortality (80.3 %), b) increase of the quality of
services (79.2 %), c) identification of problems (76.9 %) and d) for increase of the knowledge
level (73.6 %). More seldom the healthcare staff mentioned that the audit was meant to improve
practical skills (51.4 %) and team work (64.6 %).
Conclusions:
According to the opinions of interviewed specialists, the following cost-effective
technologies had a positive evolution in the maternity, compared to previous studies (2001,
2003):
35
1. Ensuring skin-to-skin contact in the maternity for all/almost all newborns immediately
after delivery, mentioned by representatives of all four categories of specialists: 100 %
obstetricians, neonatologists and nurses, as well as 99.1 % of midwives.
2. The level of neonatologists’ (79.7 %, 2003 and 87.3 %, 2008) and nurses’ (92.5 %, 2003
and 97.6 %, 2008) knowledge of the “warm chain” links increased, while the midwives’
knowledge of this subject remains the same (89 %). Some links of the chain are known
better by specialists directly responsible for these measures. Skin-to-skin contact and
breastfeeding are better known by specialists, than other links of the chain.
3. The knowledge of the best period for exclusive breastfeeding (up to and including 6
months) by all specialists interviewed in 2008 increased, compared to 2003:
obstetricians (81.8%-91.5%), midwives (68.7%-93.5 %), neonatologists (88.2 %).
4. The level of obstetricians’ (90.9%, 2003 – 94.7%, 2008) and neonatologists’ (94.2%,
2003 – 100 %, 2008) knowledge of breastfeeding practices combined with
complementary food up to the age of 12 and 24 months of the baby increased.
5. The healthcare staff showed a better understanding of the right position of mother’s and
baby’s body and of the signs of correct application of baby to breast during breastfeeding.
6. The majority of neonatologists (80 %), midwives and nurses (90 %) answered correctly
to the question regarding the time when eye complications prevention should be
performed (one hour after delivery) and named the remedies (tetracycline and
erythromycin creams) recommended by WHO for eye complications prevention
(neonatologists 100 % - 93.6 %; nurses 95 %-95.9 %; midwives 96 % in both cases).
7. Approximately 96.5 % of obstetricians, 93.6 % of midwives and 78.8 % of
neonatologists, as well as 80.8 % of nurses mentioned the rooming-in practice of
newborns, who do not require special care.
8. The level of the obstetricians’ and neonatologists’ knowledge of the measures to be taken
in case of a situation related to Rh incompatibility increased and is satisfactory.
9. 90 % of obstetricians and approx. 80 % of midwives are informed about the instructions
issued by MH regulating their activity in the maternity.
10. The level of knowledge by obstetricians (95 %) and neonatologists (100 %) about the
perinatal mortality audit was high.
11. The healthcare staff expressed more often the opinion that perinatal audit was an
intervention for reduction of perinatal mortality (80.3 %), for increase of the quality of
services (79.2 %), for identification of problems (76.9 %) and for increase of knowledge
level (73.6 %).
However, the following knowledge gaps remain among maternity staff:
1. Some, though few, maternity specialists continue to state that skin-to-skin contact
duration is of only 30 minutes (3% of neonatologists, 9% of obstetricians, 13.7% of
nurses).
2. The obstetricians’ knowledge of the "warm chain” links decreased (89.6% - 85.9%).
3. A decrease in the number of correct answers given by nurses (97% - 76.4%) and
midwives (86.5%-71.4%) about axillary temperature measuring of the newborn, as a
more efficient measure compared to rectal or oral temperature taking is noticed.
The healthcare workers measuring the body temperature have insufficient knowledge of the
normal temperature limits of the newborn. The knowledge of the minimal temperature
decreased in time in all respondents (midwives: 64.2%-66.5%; neonatologists: 72.7%-85.7%;
nurses: 49.3%-55%), while the knowledge of maximal temperature decreased insignificantly
only in midwives (77.1%-78.9%).
36
4. Only 80 % of neonatologists and nurses mentioned placing babies who do not require
special care in the same room with the mother.
5. The health conditions of the baby as impediments for rooming-in were mentioned more
frequently than mother’s health conditions. Among them asphyxia, obstetric trauma,
prematurity and infection.
6. According to the opinion of midwives (31.4 %, 2008 – 2.98 %, 2003) and nurses (23.3%,
2008 – 10%, 2003) the share of women in maternity facing breastfeeding difficulties or
problems related to mammary glands condition increased.
7. The number of correct answers regarding combined breastfeeding and complementary
feeding of the baby up to the age of 12-24 months decreased among obstetricians (100 %,
2003-95.8% in 2008).
8. Only 2/3 of neonatologists and about 50% of specialized nurses have sufficient
knowledge of the standard documents issued by the Ministry of Healthcare regulating
their daily activity. The worst known document is the Decision No. 462/214A “on the
approval of methodological norms of application of the Compulsory Health Insurance
Program in 2008.”
9. Approximately 2/3 of interviewed midwives and nurses mentioned that they know about
perinatal audit. According to the healthcare staff, the level of audit implementation is
lower than the level of knowledge about it.
10. Only 50% of the healthcare staff mentioned that perinatal mortality audit helped
improving practical skills and team work.
Recommendations to ensure the increase of the level of healthcare staff knowledge, the
change of practices, increase of the level of information, family education and community
mobilization:
I. Objectives of disseminating the results of the study
1. To organize several joint seminars for maternity staff and the staff of family doctor’s centres,
in order to inform them about the results of the study
2. To discuss the results of the assessment with all the staff drawing their attention to
insufficiently known subjects. To present a comparison of the results of neighboring
maternities.
3. To organize a joint session of Primary Health Care Workers, Family Doctors, Obstetricians
and Midwives associations to discuss the results of the assessment and develop a specific
plan of situation improvement.
II. Improvement of medical staff continuous training
1. To cooperate with the lecturers from postgraduate departments of the University of
Medicine: Obstetrics, General Therapy and Pediatrics – Neonatology departments, as well as
with the Medical School for Continuous Training of Nurses for the purpose of
completing/reviewing the study curricula and including insufficiently known subjects.
2. To improve the skills and knowledge of doctors from the departments of the State Medical
and Pharmaceutical University "Nicolae Testemitanu" of midwives from the School for
Continuous Training of Nurses, emphasizing insufficiently known subjects.
3. To organize a limited number of regional seminars for healthcare staff in maternities
(obstetricians, neonatologists, midwives and nurses) and the staff of Primary Health Care
Associations, selecting the subjects which are insufficiently known by healthcare staff in that
region.
37
4. To carry out on-the-job training of maternity/PMA staff in the theoretical and practical
aspects of qualitative implementation of cost-effective and scientific based interventions,
including the use of Information and Communication technologies (Telemedicine).
5. To test the knowledge of healthcare staff about advanced technologies and the knowledge of
specialized clinical protocols at the work place.
6. To continue organizing perinatal audit sessions in the maternities throughout the Republic.
III. Improving monitoring/assessment measures
1. The child and mother health coordinators, at raion and municipality level, will encourage
counselling of pregnant women and mothers with children less than 1 year of age, by means
of periodical monitoring of the activity of prenatal family training centres existing within
PMA and maternities.
2. To implement the benchmarking system in order to promote the positive experience of some
maternities and to create a spirit of positive competition between the maternities of the
Republic.
3. To perform periodical monitoring of the quality of implementation of maternity perinatal
care by teams of independent specialists or by the administration of maternity/hospital for the
purpose of knowing the real situation in the area.
IV. Implementation of standards / protocols
1. To review the medical standard related to the number of visits to the newborn after discharge
from maternity
2. To place the names of standard documents developed and approved by the Ministry of
Healthcare, regulating the activity of the perinatal service in visible places in the maternity.
3. To review developed protocols once in 2-3 years.
4. To develop new protocols related to subjects of interest in the field of perinatal care.
V. Intensifying the family information and training, as well as community mobilization
activities
1. To publish promotional materials on some priority subjects related to mother and child,
which the interviewed mothers mentioned they would need (The guide of the mother-to-be)
2. To have developed, by maternity staff at local level, information materials on the subjects
insufficiently known by them and to place them in delivery rooms (normal values of
newborn body temperature, “the warm chain,” the signs of correct breastfeeding position
etc.)
3. To monitor through self-evaluation the mothers’ knowledge level.
4. To improve the knowledge and skills of the primary healthcare staff and maternity staff in
different subjects related to prenatal and postnatal care.
5. To develop and carry out communication, family education and community mobilization
projects, at national and local levels, on priority problems of the perinatology system.
6. To improve the family education centres, by providing information materials on the
following subjects: nutrition of a pregnant woman, signs of danger in pregnancy, family
planning, neonate care and nutrition, signs of danger for a newborn etc.
38
CHAPTER III. THE QUALITY OF DATA RECORDING ON SERVICES
PROVIDED DURING PREGNANCY IN MEDICAL DOCUMENTS (PERINATAL
CARD) COMPARED TO THE KNOWLEDGE OF PRIMARY HEALTH CARE
WORKERS, DURING DELIVERY (OBSTETRIC SUPERVISION CARD) AND THE
PRACTICES SUPERVISED DURING DELIVERY MANAGEMENT
a. The quality of data recording on services provided during pregnancy (perinatal card)
and the level of knowledge of medical staff in primary healthcare centres (family
doctor, nurse).
GENERAL DATA
This chapter summarizes the results of the interview carried out for the purpose of
assessing the knowledge of primary healthcare specialists in prenatal care facilities and the
results of analysis of recordings in the medical perinatal card.
Within the study carried out in 2008, 1110 primary healthcare specialists were
interviewed, including: 358 family doctors (32.3 %), 721 nurses (65.1 %) and 28 obstetriciansconsultants (2.5 %); 3887 perinatal cards were analyzed and the practices of pregnancy
monitoring and newborn care in 136 deliveries were supervised.
PART 1. PRENATAL CARE
Filling in and providing medical perinatal card (MPC) in primary healthcare. The
perinatal card is a primary healthcare supervision form for pregnant women, comprising a
number of compulsory examinations: 6 visits to the family doctor, of which 3 visits to the
obstetrician at the same time, compulsory examinations, additional examinations depending on
existing problems and advice for the woman and family members. The perinatal care card is
held by the woman and is the document she brings to each prenatal visit, for delivery and in
postnatal period to the family doctor. The perinatal card is issued for 2 pregnancies.
Knowledge. The primary healthcare staff mentioned that the perinatal card is provided
to pregnant women in 99,9 % of cases (2008) compared to 93% (2005). In most cases the card
was provided to women during the first visit: 74.5 % (2008) and 99.9 % (2005); so we can
conclude that 24.5 % of healthcare workers do not provide PC to pregnant women, as they
already have them from previous pregnancies; 98.7 % (2008) and 96.4 % of respondents
(2005) consider the PC useful, and only 1.3 % respondents said they did not understand its
usefulness, considering it just another document used in primary healthcare.
Recordings. In 2001 only 30 % of pregnant women had medical perinatal cards, while in
2008 this share amounted to 96.9 % of interviewed women. The medical documentation
presented for analysis was filled out in 99.4 % of cases, filled out at a satisfactory level in 53.9
%, and it was not filled out in 0.6 % of cases; in Chisinau a satisfactory data recording in PC
was attested in only ≈ 45 % of cases, partial filling out was recorded in 53 % of cases.
Number of prenatal visits
Knowledge. We can notice a positive change in the observance of the national standards
39
of visits to family doctor during pregnancy: while in 2005 26.8% of respondents said they
recommended pregnant women 6 visits to the family doctor, in 2008 their share increased to
91.2%. The number of prenatal visits of 7 and more times decreased from 42.4 % in 2001 to 5% of
cases, or by 30% in 2008.
Most interviewed primary healthcare workers answered correctly to the questions
regarding the terms when a pregnant woman must make compulsory visits to the family doctor,
according to the National standard: 96.2 % (2008) and 94.1% (2005)
Asked to list the pregnancy terms when the woman must visit the family physician, the
interviewed healthcare workers answered correctly as follows: before 12 weeks of pregnancy
(95.5 %, 2008), 16-18 weeks of pregnancy (96.0 %, 2008); 22-24 weeks of pregnancy
(96.7%, 2008); 28-30 weeks of pregnancy (96.7 %, 2008); 35-36 weeks of pregnancy
(96.7%, 2008) and 38-40 weeks of pregnancy (93.6%, 2008). About 60.8% of respondents in
2008 mentioned that they recommended 2 visits to the obstetrician during pregnancy, while
21.8% recommended three visits stipulated in the National standard; 18.1% recommended 4
or more visits during pregnancy, probably because the third compulsory visit to the obstetrician
was introduced in 2007. Asked about the pregnancy terms when the woman should visit the
obstetrician, the primary healthcare workers listed correctly the standard pregnancy terms in
72.4% of cases on average, while 15.6% named other terms.
Recordings. According to the analysis of primary healthcare documentation, 92% of
pregnant women made over 4 prenatal visits to the doctor during pregnancy, 4% made
between 2 or 3 visits and only 4% made only one visit or did not visit the doctor at all.
Registration for prenatal care
Knowledge. 95.5% (2008) of healthcare workers interviewed during the study
recommended pregnant women to make the first visit to the doctor before 12 weeks of
pregnancy.
Recordings. According to the analyzed documentation, women made their first visit to
the doctor at an early pregnancy term in 82% (2008) of cases, compared to 51.2% (2001),
however 12% of women in 2008 study made their first visit to the doctor at 16-18 weeks of
pregnancy, compared to 17.8% (2005) and 5% of women at 22 – 24 weeks of pregnancy,
compared to 9.6% in this study.
4. Medical Care and Procedures Applied to Pregnant Women
Compulsory examinations in pregnancy
Knowledge. The interviewed healthcare workers were asked to list the tests pregnant
women undergo in their institution. These data were compared to the data obtained in 2005:
- WR: 92.1 % (2008) and 92.8 % (2005);
- HIV/AIDS: 91.7 % (2008) and 92.8 % (2005);
- Vaginal swab: 93.0 % (2008) and 93.3 % (2005);
- Blood count: 96.6 % (2008) and 92.9 % (2005);
40
- Urine test: 94.4 % (2008) and 93.0 % (2005);
Recordings. The evaluation of the presence and quality of recording in analyzed medical
forms under ”Compulsory tests” during the first medical examination revealed an average of
65.8 % of cases. Body weight was recorded during each visit in 90 % of cases, a lower age is
recorded for the 6th visit, probably because not all pregnant women visit the doctor at this
pregnancy term, as some of them already deliver by then.
The study shows that the waist of the pregnant woman was measured during the first
visit in 86.1 % of cases. The inspection and visualization of the thyroid gland was performed in
38.1 % of cases; while the examination of mammary gland in 68.7 % of cases. Pelvimetrics
was performed in 83.1 % of cases, slightly decreasing compared to 2001 when this indicator was
of 92.1 %. The study shows that vaginal examination was performed in 67.7 % of cases; vaginal
swabbing with KOH 10% sol. test - in 73.6 % of cases. Blood pressure (BP) during each visit
is recorded in 95.3 % of cases on average, varying from 92.3 % (I visit) and 94.9 % of cases by
the 6th visit, allowing us to talk about a high age of health care workers performing this
procedure. Blood count was performed in 91.2 % of cases. According to our study HbsAg test
was recorded in medical documentation in 71.2 % of cases. Wasserman reaction was mentioned
in 89.5 % of cases. 86% of pregnant women covered by our study underwent HIV/AIDS test.
Additional Examinations
Knowledge. The primary healthcare workers mentioned the following additional
examinations based on certain health conditions of pregnant women:
- Blood group and Rh factor: 89.8 % (2008) and 89.7 % (2005);
- Antibodies screening in Rh-negative women: 79.2 % (2008) and 66.6 % (2005);
- HbsAg: 83.1 % (2008) and 93, 3 % (2005);
- Serum glucose 43.5 % (2008).
Recordings. The blood group and the Rh factor were established in 81% of cases
covered by our study. The antibodies screening of RH negative women was performed in 8.6 %
of cases, while anti D-gamma-globulin was administrated orally only to 10.4 % of Rh-negative
pregnant women.
Ultrasound in pregnancy
Knowledge. According to healthcare workers, ultrasound examinations of pregnant
women were recommended as follows:
- 1 ultrasound examination: 33.1 % (2008) and 32.3 % (2005);
- 2 ultrasound examination*: 62.9 % (2008) and 44.2 % (2005);
- 3 ultrasound examination: 4.0 % (2008) and 33.3 % (2005).
41
The respondents stated the pregnancy ages when USG examinations should be made
as follows:
- Before 12 weeks of pregnancy: 17.3 % (2008) and 13.5 % (2005);
- 13-17 weeks of pregnancy 15.6 % (2008) and 19.3 % (2005);
- 18-21 weeks of pregnancy* 81.6 % (2008) and 46.0 % (2005) (compulsory
examination according to the National standard);
- 28 weeks and later 42.8 % (2008) and 10.9 % (2005);
- Other: 9.0 % (2005).
Recordings. According to analyzed documentation the ultrasound examination at 18-21
pregnancy terms was performed in 77.4 % of cases, increasing by ≈10 % compared to 60.7 % in
SEPP (2005).
Supplements during pregnancy (Folic acid and iron)
Knowledge. The healthcare workers recommend folic acid to pregnant women in 97.6%
of cases (2008) compared to 24.3% (2005), this indicator increased by 60%. 98.3% (2008) and
(34.8%, 2005) of healthcare workers respectively recommend folic acid to pregnant women until
12 weeks of pregnancy.
Only 42.5% of interviewed healthcare workers know the standard dose of folic acid
recommended in pregnancy for prevention of congenital malformations, especially of spina
bifida.
99.6% (2008) and (54.3% in 2005) of healthcare workers recommended iron tablets
to pregnant women. 10.4% (2008) (17.4%, 2005) of healthcare workers recommended iron
tablets for prevention purposes during the first three months of pregnancy. 86.4% (2008) of
healthcare workers (39.8%, 2005) recommended iron administration during the entire pregnancy.
The dose of iron recommended to pregnant women ranges as follows:
- 1 tablet per day – 75.3% (2008) and 23.9% (2005) cases;
- 1 tablet twice daily – 11.3% and 15.2% of cases;
- Other doses – 4.2% and 60.9% of cases;
The respondents said they diagnosed anaemia when the Hb level was:
- 120 g/l: 9.1% (2008) and 18.2% of cases (2005);
- 110 g/l*: 77.9% (2008) and 62.3% 2005);
- 100 g/l: 12.1% (2008) and 9.4% 2005);
- Other: 0.9% and 10.1% of cases respectively.
9.1% mentioned 120 g/l as anaemia threshold, while 12.1% ≤ 100 g/l.
Healthcare workers diagnosed severe anaemia when the Hb level was:
- 90 g/l: 22.6% (2008) and 25.1% of cases (2005);
- 80 g/l: 23.1% (2008) and 15% (2005);
- 70 g/l**: 53.0% (2008) and 53.3% (2005);
- Other: 1.3% (2008) and 6.6% (2005).
42
Note: * - anaemia diagnosis standard*, severe anaemia**
In 45.7% of cases the respondents mentioned the Hb level > 80 g/l as severe anaemia
indicator.
Though the share of respondents answering correctly to the questions regarding
anaemia diagnosis based on Hb level is of 77.9%; for severe anaemia this number is only of
53%.
According to healthcare workers, the following measures are taken in case severe
anaemia is diagnosed in a pregnant woman:
• The woman is referred to the obstetrician: 45.8% (2008) and 49% (2005);
• The woman is referred to the hospital: 53.6% (2008) and 31.6% (2005);
• Additional iron administration: 23.9% (2008) and 39.4% (2005);
• Other: 9.4% (2008) and 11.2% (2005).
Recordings. Promotion of healthy nutrition in pregnancy aims at preventing
micronutrients deficiency (iron and folic acid supplements). According to statistical data, about
40% of pregnant women in Moldova annually suffer from anaemia and, according to the
assessment carried out in 2008, based on the information recorded in PC, only 66.4% women
took iron supplements and 57.7% folic acid during pregnancy. The analysis of medical
documentation (PC) showed that data on iron and folic acid administration was not always
recorded. Therefore, there is a discrepancy with the data reported by mothers regarding the
administration of these substances, which, according to them, amounts to 96.6% and 83%
respectively.
Gravidogram
The gravidogram (a compulsory component of the PC) is a graphical estimation of
foetus development by means of measuring the uterine funduss at a certain pregnancy term. The
indicators (BP dynamics, funduss uteri height and weight during pregnancy) characterize the
intrauterine foetus development. Insufficient monitoring of these indicators does not allow
detecting the foetus development disorders, such as intrauterine growth retardation or
macrosomia. Appropriate monitoring allows more qualitative pregnancy supervision in order to
prevent many antenatal or neonatal deaths.
Knowledge. The interview of primary healthcare workers reveals that the gravidogram is
filled out:
-during all visits*: 96.1% (2008) and 47.6% (2005);
- Irregularly: 2.1% (2008);
- Not filled out: 1.4% (2008) and 39.5% (2005);
- Other: 0.4% (2008) and 13.0% (2005).
The use of gravidogram by healthcare workers increased since 2005 by ~ 50%.
97.3% (2008) and 47.6% (2005) of interviewed healthcare workers stated that the
Gravidogram helped them to make decisions regarding intrauterine foetus development.
Asked about the components of a gravidogram, the healthcare specialists
mentioned:
- BP and fetal heart beat dynamics – 96.5% (2008) and 61.1% (2005);
43
-
Pregnancy evolution according to funduss uteri height 97.9% (2008) and
61.1% (2005);
Dynamics of the weight of pregnant woman – 95.3% (2008) and 64.1% (2005).
Asked about which of these components helped them in assessing foetal
intrauterine development, the health care workers mentioned (2008):
- BP and foetal heart beats dynamics – 55.6%;
- Pregnancy evolution according to funduss uteri height – 94.2%;
- Evolution of the body weight of the pregnant woman – 63.2%.
Asked about what measures they would take in case the weight growth curve
exceeds or is lower than normal, the healthcare workers said:
- They would continue supervising the woman without taking any extraordinary
measures – 6.6% (2008) and 11.6% (2005);
- They would refer the woman to the obstetrician – 86.7% (2008) and 41.7%
(2005);
- Would refer the woman to the hospital– 2.9% (2008) and 11.6% (2005);
- Other – 0.4% (2008) and 46.7% (2005).
In case the funduss uteri curve exceeds or is lower than normal, the healthcare
workers would:
Continue supervising the woman without taking any extraordinary measure –
0.4% (2008);
Refer the woman to the obstetrician – 90.3%;
Refer the woman to the hospital – 3.5%;
Other – 5.8%.
Recordings.
The analysis of perinatal care cards showed that, on average (2008), the Gravidogram was
filled out in 92.3% of cases, compared to 34% (2003) and 47.6% (2005), but it was filled out
adequately, during all visits, only in 54.4% of cases; in 38.8% of cases it was filled out
partially and in 6.8% of cases it was not filled out at all. "BP and FHB Dynamics” section
was filled out in 59.6% (2008) and 41% of cases (2005); in 33.5% (2008) and 20% of cases
(2005) only during some visits to the doctor and in 6.9% (2008) and 38.8% (2005) cases it
was not filled out at all.
Also, the "Funduss uteri height" section was filled out during each visit in 56.2% of
cases, in 33.5% only during some visits and in 10.3% of cases it was not filled out at all.
44
Fig. 1. The level of gravidogram filling out
In 55.3% of cases the section "Body weight dynamics in pregnancy" was filled out
during each visit; in 32.8% of cases only during some visits and in 11.8% of cases it was not
filled out at all.
The study also analyzed the correlation between filling out section II of the gravidogram
in medical documentation and detection of foetal intrauterine growth retardation, revealing the
following: intrauterine growth retardation was detected, on average, in 2.9% on the basis
of the gravidogram. Analyzing the measures taken by primary healthcare workers in case of
intrauterine growth retardation suspicion, on the basis of the gravidogram, we can conclude that
in 65.5% of cases, on average, the woman was referred to the obstetrician, the ultrasound
examination was performed (35.2%), or the pregnant woman was referred to the hospital
(13%).
Risk level in pregnancy
Recordings. On the basis of medical documentation analysis, the study revealed that in
29.7% of cases the level or pregnancy risk was assessed; 84% of them were assigned minimal
risk, moderate risk in 14.4% of cases and high risk in 1.5% of cases compared to 12.5% (2005)
and respectively minimal risk – 90% of cases, moderate risk – 9% of cases and in 1% a high
risk.
Family planning
Recordings. The analysis of medical documentation revealed that post-partum
counselling in family planning was provided to women in only 12.9% of cases (2008): the most
frequently recommended contraception method was: IUD (43.2%); LAM (34.4%), barrier
method (15.4%), oral contraception (3.5%), emergency contraception (3.1%), mini-pill (1.9%),
spermicides (1.5%) and Depo-Provera (0.75%) compared to 9.3% (2005).
Referral/transportation
Recordings. The analysis of data regarding the place where the delivery is planned
to take place revealed that 75.9% of deliveries were planned to take place in level I
maternities, 23.7% of cases in level II maternities and about 0.4% in level III facilities.
45
Among the cases covered by our study the level of neonatal risk was assessed in 23.4% of cases,
with the following conclusions: minimal risk in 87.7% of cases, moderate risk – in 10.6% of
cases and high risk – in 1.65% of cases. In case of neonatal risk it was recommended that the
delivery should take place in level 1 maternity in 75.7% of cases; in level II maternities in
23.7% of cases and in 0.5% of cases – in level III. These data were compared to the data on
where the delivery actually took place and no significant differences were found.
3. Training in emergency situations
Knowledge. The interviewed specialists listed the following medications used in
emergency assistance in case of bleeding: physiological solution: 79.2% (2008) and 87.4%
(2005); oxytocin: 72.5% (2008) and 64.1% (2005) and other: 4.7% (2008).
The interviewed healthcare workers mentioned the following medications for emergency
assistance in case of preeclampsia/eclampsia: magnesium sulfate: 97.9% (2008) and 91.1%
(2005); diazepam: 78.7% (2008) and 94.1% (2005) and other: 29.4% (2008) and 18% (2005).
The following medications used in case of hypertension in preeclampsia/eclampsia in
emergency situations were mentioned by healthcare specialists: methyldopa: 11.9% (2008) and
11.6% (2005); atenolol: 21% (2008) and 47.4% (2005); niphedipin: 82.8% (2008) and 83.7%
(2005) and other: 4.7% (2008) and 33.8% (2005).
Emergency assistance medications in case of shock prescribed by primary healthcare
workers were: adrenalin: 86.5% (2008) and 87% (2005); glucocorticoids: 87.6% (2008) and
93.3% (2005); antihistamines: 79.9% (2008) and 83.3% (2005); and other: 4.7% (2008) and
5.8% (2005). The answers show that some family doctors prescribe glucocorticoids and
antihistaminic drugs in a very large dose along with adrenalin in case of shock.
The data analysis revealed the following: there is no significant difference between the
answers regarding the danger signs given by family doctors and nurses with an average of:
77.8% and 77.6%; only the obstetricians-gynaecologists gave more correct answers (94.5%).
Medical recommendations
Knowledge. The perinatal care staff listed the following signs when the pregnant woman must
consult the doctor:
- Skin itchiness: 63.9% (2008) and 57% (2005);
- Fever: 92.4% (2008) and 87% (2005);
- Vomiting and nausea: 85.2% (2008) and 70.3% (2005);
- Hands and legs edema, varices: 87.8% (2008) and 70.3% (2005);
- Unjustified fatigue, discomfort, weakness, dizziness: 72.5% (2008) and 67% (2005);
- Urination problems: 66.9% (2008) and 68.6% (2005);
- Diarrhea: 71.5% (2008) and 64.1% (2005);
- Severe headache: 75.1% (2008) and 67.4% (2005).
The analysis of the answers given by primary healthcare workers reveals that 76.9% of
them know the danger signs (2008), compared to 68.9% (2005), at the same time this
indicator increased by ~10.3% compared to 2005. The fewer correct answers were provided by
respondents regarding the following signs: skin itchiness, unjustified fatigue, discomfort,
46
weakness, dizziness, urination problems and diarrhea; the obstetricians and family doctors
answered better to these questions.
The healthcare staff named the following danger signs in pregnancy:
- Vaginal bleedings: 98.4% (2008) and 85% (2005);
- Amniotic fluid leakage: 78.1% (2008) and 86.6% (2005);
- Abdominal pain: 91.4% (2008) and 87% (2005);
- Quickly progressing edema: 83.5% (2008) and 67.4% (2005);
- Severe headaches: 75.7% (2008) and 67.4% (2005);
- Vision disorders: 78.2% (2008) and 60% (2005);
- Severe vaginal discharge: 62.9% and 58.2%.
The interviewed healthcare workers gave more correct answers in the 2008 study
compared to 2003 by approximately 20 per cent.
Table 1
Share of correct answers regarding danger signs in pregnancy given by different categories
of healthcare workers
SYMPTOMS
FP
N
OG
99.5
97.6
100
Vaginal bleeding
80.1
76.5
100
Amniotic fluid leakage
93.6
89.9
100
Abdominal pain
81.5
83.6
100
Quickly progressing edema
Severe headaches
Vision disorders
Strong vaginal discharge
Other
Average
77.6
78.6
65.3
90.8
83.4
74.4
74.3
61.3
94.4
81.5
96.4
92.9
85.6
100
96.9
Thus, the respondents interviewed in 2008 (81.5%) gave more correct answers to this
question compared to 2005 (70.8%).
Table 2
Share of correct answers regarding danger signs for the parturient woman given by
different categories of healthcare workers
SYMPTOMS
FP
N
OG
85.7
80.3
92.9
Strong vaginal bleeding
89.9
87.7
100
Bad smelling vaginal discharge
74.8
68.8
85.7
Hypothermia
74.5
75.9
92.9
Shivering
Mammary glands pain or pain in the lower part of the
76.5
73.9
100
abdomen
95.0
93.7
100
Other
47
Average
82.7
80.1
95.3
Table 3
Share of correct answers regarding the danger signs for a neonate during the first year of
life given by different categories of healthcare workers
SYMPROMS
Refuses breast or other nutrition
Is sleeping for several hours or is lethargic
Vomiting after each feeding
Convulsions
Hyperthermia/hypothermia
Cyanosis/paleness
Breathing problems (dyspnoea. apnoea)
Other
Average
FP
95.8
92.4
92.7
93.3
86.0
70.2
68.0
91.9
86.3
N
94.8
85.6
90.2
86.8
87.7
65.4
62.6
92.7
83.2
OG
79.2
79.2
87.5
87.5
75.0
62.5
75.0
95.8
80.2
The results show that the healthcare workers gave by 20 more correct answers regarding
the danger signs for an neonate in 2008 study; fewer answers were given regarding:
cyanosis/paleness (67.1%) and breathing problems (dyspnoea, apnoea) (64.2%).
In case of any of these signs the interviewed specialists recommend the pregnant woman
the following:
- To look for immediate specialized assistance: 92.2% (2008) and 93.3% (2005);
- To call the contact person: 6.1% (2008) and 20.9% (2005);
- To go to the maternity (hospital): 1.6% (2008) and 6.2% (2005);
- To stay in bed: 0.1% (2008) and 5.8% (2005).
Asked about the measures taken in case of emergency situations the healthcare workers
mentioned:
- Calling emergency (89.3%) (2008);
- Refer the patient to a higher level healthcare professional (22.3%);
- Fill in the perinatal card (16.7%);
- Quickly asses the condition of the pregnant woman (40.4%);
- Provide emergency assistance (76.6%);
- Recommend the pregnant woman to stay in bed (36.9%).
Table 4
Answers given by different categories of healthcare workers regarding the measures taken
in case of emergency situations
SECTIONS
Calling emergency;
FP
N
OG
90.4
88.8
92.9
48
Refer the patient to the hospital
Fill in the perinatal card;
Quickly asses the condition of the pregnant woman
Provide emergency assistance
Recommend the pregnant woman to stay in bed
30.3
19.0
53.5
81.9
36.5
17.6
14.3
33.1
73.7
35.7
50.0
53.6
67.9
78.6
57.1
Asked about who they call in case of emergency situation with a pregnant woman the
healthcare workers answered as follows:
- The manager of the primary care institution: 48.3% (2008) and 30.9% (2005);
- The raion mother and child health coordinator: 32.2% (2008) and 60.1% (2005);
- The deputy manager for treatment activity: 1.6% (2008) and 35.2% (2005);
- The mayor: 23.5% (2008).
91.2% of healthcare specialists (2008) compared to 64.2% in 2005 stated that psychosocial training classes for pregnant women and their families were organized in their
institutions (2005).
Prenatal counselling of pregnant women
Knowledge. The training is organized in form of: individual sessions - 78.3% (2008);
group sessions – 67.2%; theoretical lessons – 17.5% and practical lessons – 6.3%.
According to the respondents, the following categories of people participate in psychoemotional training sessions (2008): pregnant women (96.3%); husbands/partners (55.7%);
grandparents (13.9%); siblings (9.1%) and other (2%). There are a lot of differences
between the data obtained from healthcare workers interview and mothers’ interview
regarding the involvement of husbands/partners in antenatal counselling.
Knowledge. The results of the study reveal that the interviewed specialists recommend
exclusive breastfeeding of the child up to: less than 6 months: 1.1% (2008) and 11.8% (2005); 6
months*: 82.5% (2008) and 81.9% (2005) and over 6 months: 16.5% (2008) and 12.5%
(2005).
The recommended age for the introduction of complementary food is:
- Less than 6 months: 1.2 % (2008) and 20% (2005);
- After 6 months*: 98.8% (2008) and 90% (2005).
Knowledge. The healthcare staff provided different recommendations regarding nutritional
habits during pregnancy:
- To increase fiber consumption *– 54.7% (2008) and 38.5% (2005);
- To reduce sugar consumption * – 50.8% cases and 46.2%;
- To reduce salt consumption* - 47% and 59.9%;
- To increase fruit/juice consumption*- 79.5% and 64.7%;
- To increase calcium intake * - 83% and 63.9%;
49
- To increase vitamin D intake*– 68.7% and 34.7%;
*Note: measure recommended by the national standard.
Knowledge. The analyses of these data reveals that about 61.4% of healthcare workers
supervise up to 10 pregnant women in their area, 24.4% –up to 20 pregnant women and only
14.2% of healthcare workers take care of more than 20 pregnant women.
50
CONCLUSIONS:
The application of a number of interventions promoted by the National Perinatology
Program increased within the period 2001 – 2008:
1. According to the analyzed documentation, 82% of pregnant women were early
registered for perinatal care, compared to 51.2% in 2001.
2. 95.5% (2008) of interviewed healthcare practitioners recommended the pregnant
women to make the first visit to the doctor before 12 weeks of pregnancy.
3. According to primary healthcare workers the perinatal care card is provided to
99.9% of women (2008), compared to 93% (2005).
4. In 99.4% of cases the medical documentation presented for analysis was filled out;
53.9% of them were filled out to a satisfactory extent.
5. 26.8% of primary care workers recommended the pregnant women to make 6 visits to
doctor during their pregnancy in 2005; in 2008 this number increased to 91.2%.
6. There is an obvious decrease of the number of 7 or more visits during pregnancy from
42.4% in 2001 to 5% in 2008, or by 30% less according to the answers provided by
primary healthcare workers.
7. According to the analysis of primary care documentation – 92% of women made
more than 4 antenatal visits during pregnancy.
8. The respondents named the pregnancy terms recommended for ultrasound
screening during pregnancy as follows: 18-21 weeks – 81.6% (2008) and 46%
(2005), this examination is compulsory according to the national standard.
9. According to analyzed data, in 77.4% of cases the ultrasound screening was
performed at the pregnancy term of 18-21 weeks, compared to 60.7% in 2005,
increasing by ≈10%.
10. The healthcare workers recommend the administration of folic acid by pregnant
women in 97.6% of cases (2008), compared to 24.3% (2005), this level having
increased by 60%; 98.3% (2008) of medical staff compared to 34.8% (2005)
recommend folic acid administration by pregnant women up to 12 weeks of
pregnancy.
11. The interviewing of primary healthcare workers reveals that the Gravidogram is
filled out during all visits in 96.1% of cases (2008) compared to 47, 6% (2005). The
use of gravidogram by healthcare staff increased in 2005 by ~ 50 %.
12. 97.3% (2008) and 47.6% (2005) of interviewed healthcare workers answered that
the Gravidogram helped them to make decisions regarding foetal intrauterine
development.
13. On the basis of medical documentation analysis, the study revealed that in 29.7% of
cases the level or pregnancy risk was assessed; 84% of them were assigned minimal
risk, moderate risk in 14.4% of cases and high risk in 1.5% of cases compared to
12.5% (2005) and respectively minimal risk – 90% of cases, moderate risk – 9% of
cases and in 1% a high risk.
14. Among the cases covered by our study the level of neonatal risk was assessed in
23.4% of cases, with the following conclusions: minimal risk in 87.7% of cases,
moderate risk – in 10.6% of cases and high risk – in 1.65% of cases. In case of a
neonatal risk it was recommended that the delivery should take place in level I
51
maternity in 75.7% of cases; in level II maternities in 23.7% of cases and in 0.5% of
cases –in a level III facility. These data were compared to the data about the facility
where the delivery actually took place and no significant differences were found.
15. The data analysis did not reveal any serious discrepancy between the knowledge of
danger signs by family doctors and nurses, with an average of 77.8% and 77.6%
respectively; only the obstetricians-gynaecologists gave a higher number of correct
answers (94.5%).
16. The analysis of the answers given by primary healthcare workers reveals that 76.9%
(2008) of them know the danger signs, compared to 68.9% (2005), at the same time
this indicator increased by ~10.3% , compared to 2005.
17. The results show that the healthcare workers gave by approximately 20% more
correct answers regarding the danger signs for an neonate in the study conducted in
2008; a smaller number of answers were given regarding: cyanosis/paleness
(67.1%) and breathing problems (dyspnoea, apnoea) (64.2% )
However, the study revealed several gaps and low levels of implementation of some
perinatal care practices, such as:
1. 1.3% of respondents stated that they did not see the meaning of the Medical
Perinatal Card, considering it just another document among many others used in
primary healthcare.
2. An insufficient filling-in of perinatal cards in Chisinau was detected in ≈ 45% of
cases.
3. The healthcare practitioners said they recommended 2 ultrasound screenings
during pregnancy - 62,9 (2008) and 44,2 (2005);
4. Only 42.5% of interviewed healthcare workers know the standard dose of folic
acid recommended in pregnancy for prevention of congenital malformations,
especially of spina bifida.
5. Though the share of respondents answering correctly to the questions regarding
anaemia diagnosis based on Hb level is of 77.9%; this number for severe anaemia
is of only 53%.
6. According to the data recorded in the PC, only 66.4% women took iron
supplements and 57.7% folic acid during pregnancy. The analysis of medical
documentation (PC) showed that the data on iron and folic acid administration
was not always recorded.
7. The analysis of the medical perinatal cards showed that, on average, (2008), the
Gravidogram was filled out in 92.3% of cases, compared to 34% (2003) and
47.6% (2005), but it was filled out adequately, during all visits, only in 54.4% of
cases; in 38.8% of cases it was partially filled out and in 6.8% of cases it was not
filled out at all.
8. The answers show that some family doctors prescribe a large dose of
glucocorticoids and antihistaminic drugs together with adrenalin in case of shock.
52
Recommendations:
1. To present the results of the assessment during the joint meeting of Family Doctors
Association and the Association of Obstetricians.
2. To carry out a theoretical-practical training on gravidogram for family doctors and nurses.
3. To review the post-graduate curricula for family doctors according to the results of the
study, emphasizing insufficiently known subjects and practices.
4. The knowledge and the implementation of evidence based technologies must be used as a
criterion in awarding qualification degrees.
3.2. THE QUALITY OF DELIVERY MANAGEMENT PRACTICES AND
RECORDS FROM OBSTETRICAL AND NEONATAL OBSERVATION CARD
PART I. GENERAL DATA
This subchapter synthesizes the results of observing practices as opposed to data
presented in medical documents. The study included the observation of 136 deliveries and the
examination of 4043 observation cards.
Records. The analysis of observation cards reveals that, like in 2001, most women who
delivered in 2008 were aged 19 – 25, but the age of women under 18 decreased from 8.1% to
6% and the share of those aged 26 – 35 increased (36.8% and 30.9% respectively), which will
have a positive impact on neonates’ health. The vast majority (over 80%) of pregnant women in
both studies had 1-3 pregnancies and no miscarriage – 73%. The 4043 women, whose cards were
examined, delivered 7241 children, i.e. 1.81 neonates per woman, 1.68 neonates per woman
in urban areas and 1.89 neonates per woman in rural areas. Women who delivered one or
two live-born neonates made up a higher age while the number of those who delivered 1-2 dead
children was smaller in 2008 as compared to 2001. 48 women had antecedents of stillbirths in
anamnesis (1.3%), by 0.8% less than in 2001. Out of 48 women who had stillbirths, 96% or 46
women had one dead neonate and 4% or 2 women – 2 dead neonates each. On average, there
were 1.3 dead neonates per 100 women, the highest number being for the age category 3645 – 2.6 followed by women aged 25-35 – 1.7, without differentiation on the basis of the
environment of residence. It is worth noting that the number of stillbirths per 100 women
was twice as high among unmarried (1.4%) than among married women (0.7%). The
examined cards reveal that the delivery resulted in a live-born neonate delivered at term in 96%
of cases of women who delivered 2001 and in 97.5% - 3879 women in 2008, a premature liveborn neonate – in 2.2% (in 2001 – 3.6%), stillbirths –13 – 0.3% (0.4% in 2001).
According to the analysis of observation cards, the vast majority of deliveries –
95.4% (89.8% in 2001) were vaginal. The frequency of caesarean sections almost doubled –
from 4.4% (2001) to 8.3% (2008), while the age of planned and emergency caesarean sections
was the same in both studies – 23% and 76% respectively. The number of forceps deliveries
reduced from 0.3% in 2001 to 0.1% in 2008, while vacuum extractions grew from 0% in
2001 to 1.8% in 2008. According to official statistical data, the share of caesarean sections
increased from 6.8% in 2001 to 13.6% in 2008.
PracticesObservation. Most of the observed deliveries were physiological vaginal
53
deliveries (88.3%), natural deliveries after caesarean section in anamnesis (0.7%), with
vacuum extraction of the foetus (3.7%), through caesarean section (7.3%).
The pregnancy age of neonates in the observed deliveries varied between 27 – 42 weeks:
27- 28 weeks – 1.5%; 35 - 36 weeks – 1.5%; 37 weeks – 3.7%; 38 weeks – 12.5%; 39 - 40 weeks
– 67.6%; 41 weeks – 12.5% and 42 weeks – 0.7%.
The mortinatality in the last study was twice as small as in 2001, 0.3% (2008) and 0.6%
(2001) respectively. The prophylaxis of fetal respiratory distress syndrome was carried out in 4
(40%) cases of 10 of premature deliveries with the term of pregnancy less than 34 weeks of
pregnancy, which is below the desired level.
Conditions for assisting deliveries
Practices. In 93.2% of cases the delivery rooms meet the requirements set for a delivery
room, 94.8% of the assessed maternities have one-bed wards for parturient and postpartum
women beside wards with 2-3 beds.
According to the results of observing the personnel that assisted deliveries, the delivery
was managed by the obstetrical-gynaecologic specialist in 88.6% (2008) of cases as compared
to 96.5% (2001), the midwife in 99.2% (2001 – 98.6%), the presence of the nurse in 86.8%
(2001 – 2.8%) cases and of the neonatologist in 41.1% of cases.
The study shows that 96.2% of the assessed maternities had a centralized water supply
system. 96.1% of healthcare workers washed their hands before assisting the delivery (2008) as
compared to 93.7% (2003). The average air temperature in delivery rooms was 23°C, varying
from 17°C to 29°C, in comparison with the 2003 study, the average temperature in delivery
rooms was 21°C, varying between 18 and 24°C.
In most of the cases, the woman was respected, treated politely and in a personified
manner in the delivery rooms. Unfortunately, healthcare workers of several maternities were
indifferent; they humiliated and embarrassed the parturient (fig.1).
95.50%
76.30%
43.50%
3.10%
Respected
Treated
Politely
Personified
Approach
Treated
Indifferently
3.10%
Embarrassed
3%
Other
0.80%
Humiliated
Fig. 1. Distribution of deliveries subject to
healthcare workers’ attitude towards the woman, 2008
Psychological support at the delivery
Practices. The partnership at delivery is a new technology intended to encourage, praise
and promote the parturient’s calmness and to contribute to labour progress. Most healthcare
workers assisted labour and deliveries (99.2%), 76.9% of deliveries were assisted only by the
healthcare worker (2001 – 67.4%). 23.1% of deliveries (2001 – 32.6%) were assisted only by
the supporting person, the husband was present in 62% of cases (58.4% - 2001), the mother in
54
22% (18.8% - 2001), the sister in 4%, the godmother in 2% and another person in 10% (4.2% 2001). There is a decrease in the number of deliveries assisted by a supporting person, which
suggests poor counselling of the woman/family on this subject, the non-enforcement of the
principle of psycho-emotional support for the pregnant woman at the delivery and the
unwillingness of healthcare workers to allow other people to assist at the delivery.
The first stage of delivery
The gravidogram is a tool used for monitoring the evolution of labour and delivery,
which records the fetal heartbeats and the cervical dilatation. The gravidogram must be
completed for every delivery, being a key tool in the early detection of complications at birth.
Records.
The assessment of delivery cards showed that the gravidogram was annexed for the
first stage of delivery in 90.1% (2008) of cards as compared to 37.3% (2001). The gravidogram
was completed in real time in 85.3% of cases, which shows that it does not always serve as a
tool to help decision making on delivery management. The study revealed that the gravidogram
was interpreted in 100% of cases by doctors in 2008 (100% - 2003), by the midwife in 50.8%
(2003 – 36.7%), which shows the growing role of the midwife in interpreting data, while the
nurse interpreted the gravidogram in 0.8% of cases.
The percentage of deliveries in which the gravidogram line was to the left or in an alert
position decreased from 83.9% of cases in 2001 to 77.6% (2008) due to the reduction of the
percentage of deliveries in which the alert level and the action level were exceeded in 18.8%
(14% in 2001) and in 3.6% of cases in 2008 (2% in 2001) respectively. According to data from
the cards, the conducted activities have a tendency to reduce these (stimulation from 39.3%
(2001 to 21.1% in 2008), in 1.7% of cases the obstetrical sleep was recommended as compared
to 7.5% (2001) a reduction by over 50% of the obstetrical sleep, except caesarean section,
which is increasing (Fig.2).
70
60
50
40
2001
30
2008
20
10
0
Stimulationobs. sleep
ARAM
cesarean
operation
Fig. 2. Actions undertaken when the action level is exceeded
When the action level is exceeded, similar measures recommended by national protocols
are taken, but in different percentage: while labour stimulation was used in fewer cases in 2008
(57.8%) than in 2001 (60.9%), the artificial rupture of amniotic membranes (ARAM) and the
caesarean section were used more frequently than in 2001.
In 2008, the percentage of deliveries that ended with caesarean section almost doubled –
55
from 4.3% in 2001 to 7.5%. The vast majority of deliveries – 87.9% (90.2% in 2001) were
vaginal without anaesthesia, vaginal deliveries with anaesthesia in 2.1% of cases, including
0.5% with epidural anaesthesia. 0.5% of vaginal deliveries (0.3% in 2001) and 1% (0.2% in
2001) of caesarean section deliveries were done with epidural anaesthesia, this indicator being
higher than at the first evaluation. The frequency of applying vacuum extraction grew from 0.1%
in 2001 to 1.3% in 2008.
Practices
According to the observation of deliveries, the gravidogram was used in 98.4% of
cases, as compared to 65.7% of deliveries (2001) and only in 88.5% of real-time deliveries
(91.4%, 2001). The gravidogram was completed retrospectively in 11.5% of cases.
The gravidogram was interpreted in 100% of cases by the doctor and by the midwife in
50.8% of cases (2003 – 36.7%), which shows the increase of the midwife’s role in data
interpretation. The gravidogram was used, on average, in 90.6% of cases to make decisions on
the tactics of delivery. As compared to 2003 assessment, there is an improvement of data
fixation in terms of: opening of the cervix, advancement of the head, uterine contractions, AT,
mother’s high temperature. The doctor is required to collect data/results of the
observation/information to include them in the gravidogram in 100% of cases (96.7% in 2003),
the midwife in 84.8% of cases (60% in 2003), and the nurse in 0.8% of cases. Data/results of the
observation/information are recorded in the gravidogram by the doctor in 100% of cases
(93.3% in 2003) and the midwife in 75% of cases (53%, 2003). The following measures were
taken in the last study after the decision was made on the basis of the gravidogram: conservatory
management – 47.9%; vaginal spontaneous delivery – 21.9%; other – 11.0%, emergency
cesarean section – 6.8%.
Oxytocin
The oxytocin was used for delivery stimulation in 11.7% of cases. It was administered
correctly in all cases.
Procedures at the delivery (hair shaving, enema, vaginal treatment with antiseptic)
Practices. According to data received from delivery observation, there is a significant
reduction of reconsidered/non-recommended practices in the last five years such as: enema,
shaving the hair on the mons veneris before and after delivery and cleansing the vagina with
antiseptic during the delivery, which we cannot state in terms of the vaginal touch, which raised
by 47.6%. It is noteworthy that 97.7% of women (2003 – 87.5%) were allowed to move freely
during labour, mothers were allowed to choose their position for delivery in 86.9% of cases
(2003 – 25%) (Fig.3).
99.10%
68.75%
56.10%
56.25%
51.50%
2003
2008
3.10%
Enema before delivery
3.10%
Shaving hair on mons
veneris before delivery
6.30%
Vagina cleansing with Vaginal touch
antiseptic during delivery
during labour
56
Fig. 3. The frequency of using certain procedures in the maternity before and after
delivery, 2003 and 2008
Management of the second stage of delivery
Monitoring the foetal heart rhythm
Records. This indicator was introduced in 2008 as a supplement to the gravidogram
for the second stage of delivery as a result of the perinatal audit. The gravidogram for the
second stage of delivery was completed in 34.4% of the observed cards, of which 86.8% were
completed in real time and 13.2% retrospectively. The gravidogram for the second stage was
included as a technology of assistance at delivery in 2008. Foetal heartbeats were recorded in
91% of cases, tachycardia with frequency above 180 beatsmin was detected in 1.8% of cases
and brachycardia under 120 beatsmin in 4.8% of cases. The record of head opening on the
gravidogram in the second stage of delivery was carried out in 96.5% of cases.
Practices. According to delivery observation, the periodic auscultation of foetal
heartbeats in the second stage of delivery was conducted in 99.3% of observed deliveries
(2008) in comparison with 87.5% (2003). The Dopplerography with a portable device was
conducted in 49.3% of deliveries. Foetal cardiotocography was performed in only 27.2% of
cases (43.75% in 2003) during labour/delivery, which demonstrates that doctors either are not
familiar with, or do not want to apply it in practice. Foetal cardiotocography was performed in
the following cases: suspicion of foetal suffering (12.8%); as a result of indications (3.8%);
foetal hypoxia (3.1%); routine practice (3.2%); other (2.2%). Mothers were informed about the
advantages and disadvantages of cardiotocography being involved in decision making in 22.1%
of cases as opposed to 6.5% (2003).
Selection of the position for delivery.
Mothers were given the possibility to choose their position for delivery in 83.1% (2008)
of cases in comparison with 25% (2003). According to the observations, the mother was actively
encouraged to make expulsive contractions during delivery in 16.5% of cases as opposed to
56.2% (2003), which shows positive dynamics in phasing out of this procedure. This
encouragement was practiced in the following cases: foetal respiratory distress syndrome – 80%
(18.7% in 2003), the second stage of delivery that exceeded two hours – 45.5%, other – 36.4%
(25% in 2003). Pressing the uterus bottom to enhance delivery was practiced in only 4.9% of
cases (12.5% in 2003).
Episiotomy
Records. The number of episiotomies reduced from 15.2% in 2001 to 11.6 in 2008.
Practices. Episiotomy was performed in 16.0% of cases (2008) as compared to 25%
(2003) of observed deliveries, which is higher than the rate recommended by the WHO. The
following reasons for episiotomy were claimed: foetal respiratory distress syndrome in the
second prolonged stage of delivery – 0.8%; imminence of perineal tear – 1.6% (2003 – 12.5%);
upon indications – 1.6%; premature delivery – 1.6%; no reason – 2.4%; in pelvic presentation –
0.8%. Anesthesia was applied in only 26% of cases of episiotomy in 2008, as compared to 2003
(75%). The parturient was informed about the need to carry out the episiotomy in only 66.7% of
57
cases, which shows that women were not always involved in decision making.
3. Management of the third stage of delivery
Records. Were physiological in 20% of cases and active in 80% of cases. The last
record included: intramuscular administration of 10 AU oxytocin in 89.9% of cases, use of
pincers on the umbilical cord in 60.1%, waiting for uterus contraction – 55.4%, controlled
pulling of the cord – 41.6% of cases. This technology was not implemented in the Republic of
Moldova in 2001.
The examination of observation cards shows that the frequency of post-partum
haemorrhage (500 ml and above) dropped almost twice, from 2.9% (2001) to 1.6% (2008),
which can be explained by the fact that a new technology was implemented in the country
in this period – the active conduct of the third stage of delivery, which, as already
mentioned, aims at preventing post-partum haemorrhage. Most of haemorrhage (80%), as in
the 2001 study (86.7%), made up 550 ml to 1000 ml, 15% (13.3% in 2001) of haemorrhage
represented 1050 and 1500 ml and 4.5% of it was massive – over 1500 ml. There was no
massive haemorrhage in 2001.
Practices. According to observations, 59.3% of women (2008), as compared to 31.2%
(2003), were informed about risk factors and advantages of physiological management as
opposed to the active tactics of delivery management in the third stage. In 62.1% (2008) of
cases, the parturient were involved in decision making on the tactics of delivery management in
the third stage, in comparison with 18.65% (2003).
At the moment of observing the third stage of delivery, the method had a
physiological character in 12.8% of cases as compared to 75% (2003) and active in 87.2%
of cases, as compared to 25% (2003).
The study reveals the growth of correct procedures carried out by healthcare workers and
included in the active management of the third stage of delivery; although one of the correct
procedures included in the active management of the third stage of delivery is the intramuscular
injection of 10 IU of oxytocin, some maternities also use the intravenous injection of
ergometrine 0.2 mg for haemorrhage prophylaxis in the third stage of delivery (fig.4).
100%
91.80%
86%
89.60%
2003
43.75%
2008
25%
12.50%
Abdominal palpation
to exclude
the likelihood
of twins
6.25%
Intramuscular
injection of 10
IU of oxytocin
Controlled stretching
of the umbilical cord
Examination of uterus
bottom after expulsion
of placenta
Fig. 4. Distribution of deliveries based on correct procedures included in the active
management of the third stage by healthcare workers, 2003 and 2008
4. Provision of healthcare to the mother in the postnatal period
58
Practices. Figure 5 shows positive dynamics towards the reduction of the use of such
interventions with no scientific evidence such as: sutures of insignificant perineal tears,
catheterization of the urinary bladder as a routine procedure, application of the ice bag on
woman’s abdomen. There is a three-fold reduction of vaginal treatment with antiseptic, a twofold reduction of the perineum cleansing with disinfectant and a reduction by 1.5 times of
instrumental exploration of the cervix after delivery. The frequency of perineal sutures after
episiotomy under anaesthesia grew by 10%. According to card analysis, the number of
postpartum women who had over 380C for more than one day decreased by 50% – from 0.9% to
0.5%.
91.50%
81.25%
87.50%
75.00%
62.50%
50.00%
47.50%
29.30%
26.60%
12.60%
sutures of
vagina
perineum
cleansing
after
with
antiseptic
episiotomy
under anesthesia
cleansing
of perineum
with
disinfectant
2003
2008
6.25%
0.80%
sutures of
insignificant
perineal tears
62.50%
55.40%
37.50%
4.10%
application catheterization instrumental
of ice bag of urinary
exploration
on
bladder of the cervix
woman’s
as a routine after
abdomen
procedure delivery
instrumental
exploration
of the cervix
as a
routine procedure
Fig. 5. Distribution of women according to procedures
performed after delivery, 2003 and 2008
Maternal morbidity/Complications during pregnancy
Severe preeclampsia / eclampsia
Records. According to the analysis of observation cards, 41 cases (1.0%) of severe
preeclampsia / eclampsia were recorded. The Mg sulfate was used in 26.8% of these cases and
the diazepam in 9.8% of cases. Hypotensive drugs are used in 39% of cases
(atenolol/metaprolol, in 31.7% - nifedipine and dopegyt in 7.3%).
Antihypertensive drugs like papaverine, dibazol, trental and clofelin are still used,
although very rarely, because of the lack of evidence.
The revealed data suggests insufficient use of national protocols on the management of
preeclampsia/eclampsia.
The dose of Magnesium sulfate saturation was used in 83.3%, and of diazepam in 50%
of cases of severe preeclampsia / eclampsia and the supporting dose in 16.7% and 50%,
respectively.
Records. Among the extra-genital pathology associated with pregnancy, anemia
dominated, with a light growth from 31.2% of cases in 2001 to 32.8% of cases in 2008
(according to the Demographic and Health Study of 2005, 38% of the interviewed women
had anaemia during their pregnancy), renal maladies growing from 5.3% to 5.8% (10.1% in
2005 DHS), cardiovascular maladies accompanied the pregnancy in 1.2% in both studies (4.6%
in 2005 DHS), hepatic maladies in pregnant women reduced from 0.8% to 0.5% (2.1% in 2005
DHS) and the colpitis diminished dramatically from 12.3 to 1,3%, 1.4% of pregnant women
in 2008 presented obesity and 0.4% had fibromyoma and Acute Viral Respiratory Infections.
59
Problems related to the labour process
Records. According to the assessed cards, there were no problems related to labour
progress between the two assessments in 81.8% (2008) of cases, as opposed to 79.3% (2001),
the frequency of pathologies of contraction forces diminished by 0.5%, of the prolonged period
without fluid by over 50% and of the prolonged labour by more than three times, which can be
explained by increased use of the Gravidogram in 2008.
The 2008 study assessed the pathologies of the umbilical cord in 38.8% of cases and
their impact on delivery evolution and management, as well as on perinatal results. Among the
pathologies of the umbilical cord, the cord circular dominated with 26.2%, followed by true
nodules in 1.5%, prolapsed cord– 0.3% and other (short, long anatomic cord) – overall 10.8%
of cases.
In cases of cord pathologies, the delivery ended in 89.1% of vaginal cases spontaneously,
through urgent caesarean section in 7.8% of cases and other – 3.1%; according to the
confidential questionnaire of the perinatal death, the pathology of the umbilical cord that led to
foetal perinatal death made up 21.3%: in the antenatal death – 31.5% and Early Neonatal
Mortality %.
The 2008 study identified a few deliveries that were complicated by uterus ruptures
(0.1% in 2001 and 0.2% in 2008).
Cesarean section and vaginal surgical interventions
Records. The observation of obstetrical cards shows an increase in the number of
caesarean sections from 4.4% in 2001 to 8.3% in 2008, through vacuum extraction – 1.8% in
2008. The absolute indications for caesarean sections were the obstructive delivery – in 75%
of cases and 24.9% placenta pathology. Relative indications were: prolonged delivery –
6.6%, foetal distress – 17.7%, pelvic presentation of the foetus in 23.9%,
preeclampsia/eclampsia – in 2.9%, scarred uterus – 22.2% and severe extra-genital
pathology in 3.3%. The caesarean section was performed in the first 30 minutes after the
decision in just 38.9% of cases.
Practices. 10 (7.8%) out of the 136 observed deliveries ended with caesarean section, 5
deliveries (3.9%) with vacuum extraction.
Prophylaxis of the respiratory distress syndrome
Records. The prophylaxis of the respiratory distress syndrome with dexamethazone in
premature pregnancy under 34 weeks of pregnancy was carried out in 40% of cases of premature
deliveries as opposed to 31% of cases (2005).
NEONATAL SECTION
60
Initial resuscitation of the neonate
Records. According to the analyzed cards, 96 of 129 children with asphyxia were
resuscitated in 2008, which represents 74.4%. In addition, free-flow oxygen was administered to
33.1% of children, the tactile stimulation was used in 95.8%, the bag mask was used in 60%, the
intubation and VAP was used in 8.4%, the heart massage was used in 8.4% and medicines were
administered to 10.6% of the reanimated children during resuscitation. The following medicines
were used for resuscitation: adrenaline in 61.9%, Na bicarbonate in 9.5% and volume expansion
in 9.5% of cases.
Practices. The results obtained from observing deliveries reveal that 4.4% of neonates
needed resuscitation. In 16.2% of cases, the need for resuscitation was anticipated. The
neonatologist was present at the delivery in only 64% of cases, which suggests that not all of the
1st-level maternities have neonatologists in the night shift. The resuscitation kit exists in the
delivery room in 97.1% of maternities (50% - 2003), the equipment for primary pulmonary
ventilation (Ambu bag) existed in 42.7% of cases in the delivery room and was brought by the
neonatologist when required in the other cases. The initial reanimation was carried out using:
cure of respiratory passages (100%); the bag and the mask (100%); oxygen (97.6%);
endotracheal intubation – 100%; external heart massage – 100%; adrenaline – 97.6%.
Assessment of neonate’s condition
Records. The results of the 2008 study after examination of delivery cards on neonate’s
condition according to the Apgar score in the first minute after delivery show a better delivery
management than the previous assessment.
The percentage of children appreciated with 0-3 points in the first minute after delivery
reduced by three times in the 2008 study as compared to the 2001 study – from 1.2% to 0.8%,
3.7% of children received 4-6 points (4.4% in 2001) and 95.6% of children with more than 7
points, i.e. by 1% more than in 2001.
1.4% of neonates were given less than six points in the 2008 study and 1.8% in 2001 and
98.6% and 98.2% of children obtained more than seven points in the fifth minute after delivery.
Practices. The analysis of the observed deliveries denotes that the general condition of the
neonate was assessed immediately after delivery in 94.7% of cases, while the primary
assessment of the child, after he/she was placed on mother’s abdomen was carried out in 87.3%
of deliveries. 77.6% of those born in the period of delivery observation had 8-10 points
according to the Apgar score in the first minute, 20.8% had 6-7 points and 1.5% - 4 points. In the
5th
minute after delivery, the assessment of these children using the Apgar score showed the
following result: 94.8% - 8-10 points, 3.7% - 6-7 points and 1.5% - 5 points.
Neonate care
Practices.
The neonate was placed on mother’s abdomen immediately after delivery in 92.5% of
61
cases, with different duration of contact: ranging from 10 minutes (10.2%), 10 to 30
minutes (18.7%), 30 minutes to 1 hour (29.7%) and from 1 to 2 hours (41.3%).
In 85% of cases, neonates were breastfed prematurely on mother’s abdomen, with a lower
frequency in the central region of the country (76.3%). 98.4% of healthcare workers participated
in ensuring the first breast-feeding. In 28.7% of cases, the skin-to-skin contact was interrupted
for care procedures. After the care procedures, 3.7% of children (2003 – 3.3%) were swaddled
and placed on the table with radiant light, 26.5% of children (2003 – 6.7%) were swaddled and
handed to their mother. 34.6% of children (2003 – 43.3%) were placed again on their mother’s
abdomen to continue skin-to-skin contact and 2.9% of children were transferred for special care.
Umbilical cord care
Practices. Navel care is part of the clean chain. The primary toilet of the navel is done at
the end of the first hour after delivery to avoid the interruption of skin-to-skin contact between
mother and neonate and to support breast-feeding without forcing the neonate. In 96.9% of the
observed deliveries, the umbilical cord was pulled 1 minute after delivery (after cessation of
pulsation). The cord was tied with a rubber band (64.4%), dressing, such as thread (19.3%) and
other (16.2%). Cleansing of the umbilical cord navel with hydrated disinfectant (Iodinate
solution 1%) was carried out in 61% of cases. The umbilical cord of all neonates in most of the
maternities was treated with disinfectant.
Initial neonate care
Practices. The vitamin K was administered in the first 30 min after delivery to 54.4%
neonates, per os - in 13% of cases, intravenously – in 0.2% of cases, and intramuscularly –
in 43.6% of cases. Although all maternities were provided with vitamin K, a series of
maternities used Vicasol – 9.9%. The prophylactic treatment of neonates’ eyes was carried out in
99.2% of cases.
Thermal chain
Practices. Immediately after delivery, cleanliness and warmth were ensured in the delivery
room, the lack of draught was recorded in 97.7% of cases. Clean and warmed up surface was
prepared for all the observed deliveries. There is positive dynamics of growth of interventions
that ensure the continuity of neonate hypothermia prevention measures.
Observation of the first breast-feeding practices. During the assessment, observers
stayed in mother’s ward and observed the correct application to the breast and the effective
breast suction. We observe a reduction by 3 times of tight swaddling in 2008, as compared to
2001 (from 67% to 20.2%), which provides comfort to the child (comfortable position during
sleep, free breath). The correct application to mother’s breast in the first 30 minutes succeeded
for 94 neonates (75.2%), in the first 60 min – for 25 neonates (24%) and for only one neonate
(0.8%) in the first 2 hours. In 88% of maternities there are one-person wards for the conjoint
stay of mother and baby, in 97.4% of maternities – there are wards for two persons, and in
78.7% - for three and more persons. Relatives were able to change their clothes and shoes in a
special room in only 83.2% of deliveries. The free access, at any hour, of the mother to her child
62
if the latter was in neonates’ ward was ensured in 90.5% of cases, in comparison with 2003,
when this indicator constituted 71%. Relatives were granted free access in the postnatal period to
the mother and neonate in 90.5% of cases (68.75% in 2003): almost free access (49.6%); free
access only for women after caesarean section (5.8%); in the lobby (2.5%); the woman went
downstairs (0.8%); at certain hours (28.1%); for people trained in antenatal courses (1.7%); in
visitors’ room (0.8%); in line with the rules (6.6%) and other (6.6%). Early discharge from the
hospital (three days after physiological delivery at most) was practiced in 59.3% of cases.
Status of the Rhesus system
Records. In case of neonatal hyperbilirubinemia diagnosis, the neonates were investigated
for: blood group (100%); Rh factor (81.5%); red blood (52.3%); direct bilirubin (84.6%);
indirect bilirubin (66.2%); transaminases (7.7%) and the Coombs test (1.5%).
Practices. Mother’s Rh system status and titer of anti-D serum antibodies was known
before delivery in 97% of cases, of them 11.4% parturient had Rh (-) at the moment of delivery.
The status of neonate’s Rh system was checked after delivery in 77.3% of cases of these
parturient. After the verification of the Rh status, there were indications for the preventive
administration of anti-D-immunoglobulin in 57.1% of cases (mother with Rh (-) in the absence
of anti-D serum antibodies and neonate with Rh (+)).
Neonatal morbidity
Records. According to the cards analyzed in the last study in 2008, the first place in
morbidity structure was taken by neonatal infection with 4.6%, followed by asphyxia – 3.2%,
traumatism – 2.1%, respiratory distress syndrome – 1.7% and congenital malformations,
which made up 0.8%. In 2001, neonatal morbidity was predominant: respiratory distress
syndrome with a rate of 6.8%, followed by asphyxia/hypoxia in 6.4% of children, neonatal
infections found in 2.7% of children and congenital malformations in 0.7% of neonates. The
reduction in the incidence of RDS in 2008 can be explained by the fact that premature children
(especially those weighing less than 1500 g) are mainly born at level III where there are higher
possibilities to establish this diagnosis on solid grounds. While it was rather based on clinical
criteria in 2001, it is clinical-para clinical and instrumental (+X ray) in 2008.
As it can be seen in the 2008 study, morbidity via infections increased significantly
while morbidity via asphyxia and respiratory distress syndrome decreased; congenital
malformations are approximately at the same level. The high difference between the rates of
certain conditions resulted from the study and those supplied by the official statistics shows that
different definitions are used to establish the diagnosis. For a justified diagnosis of
asphyxia/hypoxic-ischemic encephalopathy (HIE) the following was used adequately: criteria
of the American Academy of Pediatrics (AAP) (16%); SARNAT for neonates delivered at term
(13.6%), lactate (0.5%) and the USG (5.6%).
The following was used to establish the diagnosis in case of neonates who had RDS:
Silverman/Downes score (10%), X-ray of the thoracic cage for establishing the surfactant
deficiency (1.5%), blood gas and BAB (3%) and SaO2 (6%).
The diagnosis of infection in neonates was established after: changes of the hemogram
(65.6%), PCR (11.6%) and X-ray for pneumonia confirmation (17.5%).
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Four vital indicators were monitored in the absolute majority of neonates of both studies:
body temperature, weight growth, pulse and respiration frequency; pulse monitoring grew by 20%
and respiration frequency grew by 18% in 2008. Meanwhile, diuresis monitoring diminished by
0.9%. The growing quality of monitoring children’s general state is based on the provision of
monitors, pulse oximeters, etc. to hospitals of the country.
During their stay in the maternity, neonates were subject to laboratory and para-clinical
tests, which are important for establishing the diagnosis and for monitoring results of the
treatment applied to sick neonates. As compared to the 2001 assessment, the share of children
examined through general blood analysis increased insignificantly in 2008 – from 33% in 2001
to 35% in 2008; red blood was examined in 2008 almost twice as frequently as in 2001 – 8.8%
and 4.6% respectively. In addition, more children were examined to determine the level of
bilirubin in blood in 2008 (35.8% in 2008 and 26% in 2001), almost twice as many children
were examined for their blood group/Rh – from 20.6% to 39.6%. The percentage of neonates
tested for C-reactive protein increased from 0.8% to 7.1%, of those tested for the level of
glycemia grew from 2.4% to 8.2% and the percentage of children subject to radiological
examination for pneumonia diagnosis and of those subject to bacteriological examination to
confirm the septic state increased from 0.3% to 0.9%. The increase in the number of children
tested for the level of glycemia is explained by the provision of glucometers to 1st-level
maternities.
Referral/transportation
Records. 55 children were referred to higher levels of care in 2008, which means 1.4%,
by 0.5% less than in 2001. The vast majority of children – 74.5% (2008) and 45% (2001) – were
referred from the district maternity to the Scientific Research Institute of Mother and Child
Health Care / Municipal Hospital no.1, 12.7% (2008) from the 1st level to the 2nd level (31.7% in
2001) and four children from the 2nd level to the Scientific Research Institute of Mother and
Child Health Care / Municipal Hospital no.1 (23.3% in 2001).
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CONCLUSIONS:
The analysis of this chapter shows that a series of technologies/practices have
positive implementation:
1.
The analysis of observation cards reveals that the vast majority of deliveries – 95.4%
(89.8% in 2001) were vaginal.
2.
The mortinatality was twice as low in the recent study than in 2001, 0.3% (2008) and
0.6% (2001) respectively.
3.
In 93.2% of cases delivery rooms meet the requirements set for a delivery room, 94.8%
of the assessed maternities have one-bed wards for parturient and postpartum women
beside wards with two to three beds.
4.
In most of the cases, the woman was respected, treated politely and in a personified
manner in the delivery rooms.
5.
The assessment of delivery cards showed that the gravidogram was annexed for the first
stage of the delivery in 90.1% (2008) of cards as compared to 37.3% (2001).
6.
The percentage of children who were attributed 0-3 points in the first minute after
delivery reduced by one third in the 2008 study as opposed to 2001 – from 1.2% to 0.8%.
7.
The neonate was placed on mother’s abdomen immediately after delivery in 92.5% of the
observed deliveries.
8.
In 96.9% of the observed deliveries, the umbilical cord was pulled one minute after
delivery (after cessation of pulsation).
9.
The prophylactic treatment of neonates’ eyes was carried out in 99.2% of cases.
10.
We observe a three-fold reduction of tight swaddling in 2008, as compared to 2001 (from
67% to 20.2%).
11.
The free access, at any hour, of the mother to her child, if the latter was in neonates’ ward
was ensured in 90.5% of cases, in comparison with 2003, when this indicator constituted
71%.
12.
Relatives were granted free access in the postnatal stage to the mother and neonate in
90.5% of cases (68.75% in 2003).
13.
Mother’s Rh system status and titer of anti-D serum antibodies was known before
delivery in 97% of cases, of them 11.4% parturient had Rh(-) at the moment of delivery.
14.
Four vital indicators were monitored in the absolute majority of neonates of both studies:
body temperature, weight growth, pulse and respiration frequency; pulse monitoring
grew by 20% and respiration frequency grew by 18% in 2008.
15.
The growing quality of children’s general state monitoring is based on the provision of
monitors, Pulse Oximeters, etc. to hospitals of the country.
16.
More children were examined to determine the level of bilirubin in blood in 2008 (35.8%
in 2008 and 26% in 2001).
Gaps/negative aspects
1. The frequency of caesarean sections almost doubled – from 4.4% (2001) to 8.3%
(2008).
2. The prophylaxis of foetal respiratory distress syndrome was carried out in 4 (40%)
cases of 10 of premature deliveries with the term of pregnancy fewer than 34 weeks
of pregnancy, which is below the desired level.
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3. Unfortunately, the healthcare workers of several maternities were indifferent; they
humiliated and embarrassed women.
4. There is a decrease in the number of deliveries assisted by a supporting person, which
suggests poor counselling of the woman/family on this subject, the non-enforcement
of the principle of psycho-emotional support of the pregnant woman during the
delivery and the unwillingness of healthcare workers to allow other people to assist at
the delivery.
5. The gravidogram was completed in real time in 85.3% of cases, which shows that it
does not always serve as a tool to help decision making on delivery management.
6. Antihypertensive drugs like papaverine, dibazol, trental and clofelin are still used,
although very rarely, because of the lack of evidence.
7. The cesarean section was performed in the first 30 minutes after the decision in just
38.9% of cases.
8. The prophylaxis of the respiratory distress syndrome with dexamethazone in
premature pregnancy under 34 weeks of pregnancy was carried out in 40% of cases of
premature deliveries as opposed to 31% of cases (2005).
9. In 28.7% of cases, the skin-to-skin contact was interrupted for care procedures.
10. Although all maternities were provided with vitamin K, a series of maternities used
Vicasol – 9.9%.
11. Early discharge from the hospital (3 days after physiological delivery at most) was
practiced in 59.3% of cases.
12. As it can be seen in the 2008 study, morbidity via infections increased significantly
while pathology via asphyxia and respiratory distress syndrome decreased; congenital
malformations are approximately at the same level.
Recommendations:
1. Between the two studies, some of the healthcare workers who had been trained in new
technologies were replaced with workers who came from education institutions, which
influenced the rate of use of these technologies. Meanwhile, new technologies were
implemented and, therefore, it is good to continue holding zonal seminars in order to
update workers’ knowledge and improve their skills.
2. The post-graduate training programs for obstetricians, neonatologists and family doctors
must be consolidated in line with the results of the study, with focus on gaps in knowledge
and practices.
3. The implementation of technologies based on scientific evidence must be one of the
criteria for assigning categories of qualification.
4. Data received from the assessment must be analyzed at a meeting of primary healthcare
workers, at seminars held at the chair with neonatologists and at the annual national
reporting.
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Recommendations at the national level:
Management capacity development
1. To discuss the results of the evaluation study carried out in district/municipal hospitals
with the participation of specialists from maternities and primary care institutions.
2. To develop an analytical summary of the study results and to translate it into English in
order to submit it to international organizations (WHO, UNICEF) and the project donor
(SDC).
3. To develop and afterwards to implement an action plan aimed at improving the situation
at the level of institution based on the discovered major problems in perinatal care at the
institutions in the region (seminars, round tables, development of local protocols,
information materials for medical staff and promotion materials for the population,
evaluation of evidence-based practices, etc.).
4. To develop and implement projects in maternities in order to increase the quality of
services provided to women/newborns, based on the total quality management, taking
into account the existent problems in order to develop management capacities and
clinical practices at the level of institution.
5. To increase the access to primary care, mainly in rural areas; to improve the monitoring
of home visits by family doctors.
6. To improve the process of data registration in statistical medical forms used by specialists
at primary care institutions and maternities.
Institutional capacity development
1. To continue improvement of technical and material resources of healthcare institutions,
complying, in case of maternities, with provisions of the Order No.327 of the Ministry of
Health dated October 25, 2005, on mother and child stay in LDR (labour – delivery –
recovery) and LDRP (labour – delivery – recovery – post-partum) rooms.
2. To create (medical and social) integrated services for the most vulnerable families with
children.
Human capacity development at maternities and PMA
1. To continue trainings for perinatal service providers in the priority fields, such as
evidence-based medicine, essential care in obstetrics and neonatology, prevention of HIV
transmission from mother to baby, total quality management.
2. To review continuous training plans for the medical staff of maternities and primary care
institutions at departments of continuous training for family doctors, obstetriciangynecologists, neonatologists, and pediatricians of the State Medical and Pharmaceutical
University "Nicolae Testemitanu" and Medical Colleges and to include there, subjects
less familiar or not familiar to specialists, according to the evaluation results.
3. To extend the implementation of Telemedicine to consult serious clinical cases within all
II-level perinatology centers, as well as to organize video conferences dedicated to
topical subjects in obstetrics and neonatology.
4. To organize visits and meetings at maternities with a high level of implementation of
evidence-based practices in obstetrics and neonatal care for representatives of maternities
with a low level of their implementation.
Community/family mobilization in the priority subjects of perinatal care
1. To develop annual woman/family education plans at each district/municipal FDC and to
include there subjects less familiar to women/families: nutrition during pregnancy, family
planning/contraception, child care and nutrition in their first year of life.
2. To improve the work of pregnant woman/family education rooms at maternities and
FDC.
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3. To increase the knowledge of families and communities about signs of danger for mother
and child life and health, as well as correct child development, care, and nutrition.
4. To develop and implement projects to mobilize communities and educate families in the
priority subjects of perinatal care at the national and local levels.
5. To develop and distribute promotion materials for the population, where, according to the
interviews held with women, there is an important deficit, as well as of other materials on
the subjects less familiar to women/families.
Improvement of evaluation/monitoring measures
1. To continue improvement of the system of perinatal care definitions and indicators and
perinatal care evaluation tools, and to ensure continuous training of the staff involved in
data collection and processing.
2. To recommend to curator obstetricians of the Public Medical Sanitary Institution
Scientific Research Institute of Mother and Child Health Care to include certain
issues/components of the questionnaires used to evaluate maternities and obstetric care in
the raions of the Republic.
3. To evaluate the application of national protocols/standards by the medical staff of
maternities/PMA institutions while evaluating these institutions or during visits by
curators.
4. To strictly comply with the provisions of Order No.327 on self-evaluation of maternities
and afterwards to discuss the obtained results during reporting back medical staff
meetings.
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