Chadney, S

English

MSF Field Research

Burundi: childbirth in a developing country
Sue Chadney
is a midwife working
with Médecins Sans
Frontières
196  Midwives The official journal of the Royal College of Midwives Vol 9  No5  May 2006
International
Throughout the world women experience pregnancy and
childbirth. The care they receive is a product of many
factors including the culture of their country, especially
when healthcare provision is supplied by traditional
birth attendants who invariably apply age-old practices
to maternity care. This subject has been extensively
explored, for example by LeFeber and Voorhoeve (1998).
Professional practice is also dictated by factors of
culture, geography, socio-economic phenomena and
history.What follows is an account of some of the clini-
cal procedures and beliefs practised by professionally
trained healthcare workers in an area of Great Lakes
Africa, as observed and discussed while working with
Médecins Sans Frontières (MSF) for a
basic healthcare project in the province
of Kayanza in Burundi.
Burundi is classified by aid agencies
as a ‘post-conflict situation’(Médecins
Sans Frontières, 2005). It is a small
country in the Great Lakes area of
central Africa that underwent coloni-
sation briefly by the Germans, then by
Belgium, before gaining independence
in 1963. The population consists of
two main ethnic groups – the Hutus
who form 85% and the Tutsis who
form 14%.An ethnic minority group,
Twa pygmies, make up the remaining
1% of the population.
From 1965 onward, Burundi has
endured waves of ethnic-based violence, culminating in
the civil war of 1993 to 2003 during which an estimated
100000 people died in a ‘slow trickle genocide’
(Jennings, 2001). This ten-year conflict has left behind a
legacy of psychosocial and economic damage. Healthcare
facilities have been destroyed and access to medical care
significantly reduced through continuing insecurity and
poverty (Médecins Sans Frontières, 2004; World Bank,
2004). The civil war interrupted the training of health-
care professionals and caused the deaths of countless
trained personnel, which has resulted in the number of
doctors per inhabitant falling from 1:25000 in 1990 to
1:35000 in 2002 (Médecins Sans Frontières, 2004).
Most healthcare professionals prefer to either work 
in other countries or in the capital. There are fewer 
facilities, including the basics of running water and 
electricity in provincial hospitals and rural areas, and
there is a higher level of insecurity and rebel group
attacks. There is no tradition of specifically trained
midwives in Burundi – maternity care is carried out by
different categories of nurses who have received between
two and three years training and ‘aide-infirmieres’who
perform many of the institutional deliveries and have
received one year’s training.
Burundi has a total fertility rate of 6.3 per 1000 and a
maternal mortality rate of 1300 per 100000 live births
(United Nations, 2001), although the potential inaccura-
cy of the data, due to the civil disorganisation as a result
of the war and the factor of unregistered domiciliary
births, is acknowledged. The Institut de Statistiques et
d’Etudes Economiques du Burundi (2003) states that
71% of births are unsupervised by trained personnel and
take place in the home by registered or unregistered
traditional birth attendants. The
remainder take place either in poorly
staffed and equipped rural clinics, in
small hospitals supported by religious
orders or in larger, but only marginally
better equipped, regional hospitals.
The infant mortality rate is high, with
the principle causes of death being
malaria and diarrhoea.
While practices inevitably differ
between workers and institutions in a
country with unsupervised clinical
standards, certain commonly-held 
clinical beliefs were observed and are
recounted below, beginning with the
management of problems in early
pregnancy and ending with aspects 
of neonatal care.
Women with threatened abortion frequently present at
clinics, many caused by malaria. Burundi lies within an
endemic malaria zone giving rise to recurrent bouts of
the parasitic disease in patients with lowered immunity,
such as pregnant women.Another contributory factor is
the high incidence of untreated sexually transmitted
diseases among the population. In addition to prescrib-
ing medication for any suspected underlying infection –
although diagnoses remain largely unconfirmed due to
lack of laboratory facilities – the nurses who staff the
clinics routinely prescribe oral hyoscine butylbromide
(Buscopan). This treatment is based on the known
smooth muscle relaxant properties of this compound
that practitioners believe diminish uterine contractions,
hence arresting the progress of a threatened abortion.
Pharmacology formularies such as the British national
formulary (BNF) (British Medical Association and Royal
Pharmaceutical Society of Great Britain, 2004) do not
support this hypothesis and neither do clinical guidelines
Pregnancy and childbirth vary throughout the world and in many developing countries they are influenced by
traditional practices.Sue Chadney describes some such observations from the time she spent working in Burundi.
A mother with her baby in the maternity ward
at Musema Hospital, Burundi
196-198_Burundi.qxd  18/4/06  8:02 am  Page 2Vol 9  No5  May 2006 The official journal of the Royal College of Midwives Midwives  197
International
written for use in developing countries
(Pinel, 2002; Blok, 2003). The latter recom-
mends Buscopan solely to reduce the muscle
spasms caused by diarrhoeal disease and
gastrointestinal tract infestations. The same
texts warn against the use of Buscopan in late
pregnancy. In Burundi it is widely used in the
third trimester for lumbar and ligamental
pain, instead of giving simple analgesia or
physiologically-based lifestyle advice. It
remains, however, a cheap and easily available
drug and will no doubt continue to be
prescribed for these pregnancy problems in
Burundi, despite the lack of a pharmaceutical
evidence base.
With no availability of intensive neonatal
care in Burundi, nor of medication to
promote lung maturity, healthcare staff are
acutely aware of a poor prognosis for any
preterm baby, hence the need to arrest
preterm uterine contractions.Western medi-
cine provides a selection of tocolytics with
continuous clinical studies to realise the most
effective pharmacology. In countries with few
resources, the beta 2-agonist Salbutamol is
readily available and so is the tocolytic of
choice by default. This is prescribed in the
rural clinics as an oral medication for use at
home for five to seven days, despite the
recommendation of intravenous administra-
tion for 48 hours as an effective treatment
(British Medical Association and Royal
Pharmaceutical Society of Great Britain,
2004; Pinel, 2003). For the few women who
are transferred to hospital and can pay for
treatment, intravenous Salbutamol is invari-
ably followed by five days oral supply.
Prolonged therapy is advised against in the
BNF (2004) as it increases the risk of side-
effects to the mother and does not have
proven clinical effectiveness. There is little
recording of outcomes from hospitals or
clinics, so neither the clinical effectiveness of
this drug strategy nor cases of side-effects can
be assessed.
Tetanus, caused by the toxin of
Clostridium tetani, is responsible for 50% of
infant deaths in Africa (Blok, 2003).
Neonatal tetanus is entirely preventable by
vaccination of the woman during pregnancy.
The administration of the anti-tetanus
vaccine is a priority during antenatal consul-
tations in Burundi with the aim of adminis-
tering at least two doses, with an interval of
at least four weeks. This results in a neonatal
protection rate for three years of over 85%.
Various factors conspire against the achieve-
ment of this goal by healthcare workers in
Burundi.As 25% of women only present for
one antenatal consultation and that, from
personal observation, is at approximately 36-
weeks’gestation, the likelihood of them
receiving the two necessary doses is low.
Additionally, in a resource-poor country
such as Burundi, the cold chain frequently
breaks down, perhaps due to lack of petrol
for the fridge or insecurity preventing a trip
to the vaccine store to replenish supplies –
thus often vaccines are unavailable even
when women attend correctly and in time.
Although many rural Burundian women
are unaware of the date of their last
menstrual period, or perhaps have not
menstruated since their previous delivery,
there are occasional clinical indications to
induce labour. These may include a known
post-maturity and intrauterine death where
labour does not spontaneously begin.With
no prostaglandin preparations available,
cervical ‘ripening’is effectuated in primi-
parae by the insertion of a large-size Foleys
catheter into the vagina with the tip, that is,
the balloon, inside the cervix. The balloon 
is filled initially with the amount of water
recommended by the manufacturer, then
additional millilitres are added over 24
hours.When the catheter falls out, it is 
either due to the balloon bursting or to
initial cervical effacement and dilatation. I
have observed this method being unexpect-
edly effective!
Where pharmacological induction of
labour is deemed necessary and in the
absence of oxytocics, medical practitioners
in this area of Africa are reported to use
intravenous quinine. Oral and parenteral
quinine is used routinely for the treatment of
malaria caused by the parasite Plasmodium
fulciparum, however, I have found no clini-
cal or pharmaceutical text to reveal any
reference to its use as a uterine stimulant
(British Medical Association and Royal
Pharmaceutical Society of Great Britain,
2004; Pinel, 2002). However, the
International Union for the Scientific Study
of Population (1998) and the Marxists
Internet Archive (2004) have documented
the 19th century use of quinine as an 
abortificant. The administration of high
doses produced toxicity causing cardiac
arrhythmias and convulsions, which in turn
provoked an abortion. I presume this to be
the clinical basis for its use to stimulate
labour, albeit at an unknown cost to mother
and baby.
Once a woman presents in spontaneous
labour at a clinic or hospital, little monitoring
of mother or fetus takes place. There is an
official ‘partogramme de Burundi’that is
seldom available or used. Pinards stetho-
scopes are widely used, often having been
donated by a charity, church or aid agency,
with the fetal heart noted as simply positive
or negative – the relevance of rate and rhythm
are not taught as being significant.When
there is no progress to a normal delivery
following full dilatation with the presenting
part in low cavity with expulsive contractions
and maternal effort, practitioners employ
fundal pressure to achieve a vaginal delivery,
mainly when there is no option of operative
delivery or transfer. In the Great Lakes area,
among French-speaking professionals, this is
called the ‘manoeuvre de chrystalline’– I was
An education session for traditional birth attendants
Testing a pregnant woman for malaria
Mothers and babies outside the maternity ward
196-198_Burundi.qxd  18/4/06  8:02 am  Page 3198  Midwives  The official journal of the Royal College of Midwives Vol 9  No5  May 2006
unable to establish the origin of this term.
MSF acknowledges this practice as one ‘to be
used with caution, and only in rural and
isolated situations’(Pinel, 2003 – transla-
tion). The technique employed is directed in
this manual:‘Using two hands flat on the
fundus, push downwards with moderate
pressure at the same time as the woman
pushes with a uterine contraction’(transla-
tion). However, I once entered a delivery
room in Burundi to find a nurse astride the
woman on the delivery bed, facing the
perineum and exerting fundal pressure with
all her weight and might. Sadly, on this occa-
sion, the baby was stillborn.
The materials and skills appropriate for
neonatal resuscitation are not easily available
to healthcare workers, and the most common
practice observed was to stimulate and drain
secretions by holding the neonate by the feet
and slapping the buttocks.When a neonate
does not respond to this action, two further
actions normally take place. Firstly, the baby
is lain down on a table and oro-nasal suction
is performed using a ‘poire d’aspiration’– a
rubber device the shape and size of a pear –
that is inserted superficially into the mouth
and nostrils and compressed manually to
exert suction. The ‘poire’is washed out with
chlorhexidine solution between uses, but not
sterilised, so the risk of cross infection,
notably the transmission of HIV, is evident.
The second intervention is for the health-
care worker to put some pure alcohol in her
palms and rub this on the neonate’s abdomen
and back.When asked to explain the reason
for this action, the universal reply was that it
stimulated respiration. There is an obvious
clinical logic to the tactile stimulation,
perhaps also to the application of cold alcohol
shocking the baby into breathing, but I also
discussed this common practice with a
European doctor who had worked for many
years in Africa. He related that in developing
countries without sophisticated health care
and lacking most medications, patients with
pulmonary oedema and asthma may be
treated with inhalations of alcohol that engen-
der a bronchodilating effect. This practice has
become internalised and applied routinely to
other respiratory problems, including lack of
respiratory effort in neonates, in the belief
that the alcohol will be absorbed through the
skin and aid respiration.
Immediate neonatal care in health struc-
tures follows certain procedures. The 
umbilical cord is tied with two pieces of
umbilical twine and a clean piece of gauze is
applied, followed by a cotton bandage
wrapped around the abdomen and tucked
into itself at the back. No lotions are applied
to the cord stump and the mother is told to
leave on this dressing for a week.As there is
no culture of postnatal care in Burundi, I
was unable to observe either compliance
with or effectiveness of this treatment.
The second routine treatment given to
neonates is a single application of
Tetracycline eye ointment. This protocol is
followed to prevent neonatal conjunctivitis
and ensuing corneal lesions caused by infec-
tion with Neisseria gonorrhoea or Chlamydia
trachomatis during delivery. The incidence of
these infections is thought to be high in Great
Lakes Africa, and, in the absence of antenatal
screening, diagnosis and treatment, preven-
tion forms part of normal health care.
Working as a midwife in developing 
countries provides a fascinating opportunity
to observe and discuss differing clinical 
practices. Some of the above practices are
appropriate responses to the clinical needs 
of the continent, such as vaccinating against
tetanus and preventing neonatal conjunc-
tivitis. Others appear to be rooted in clinical
beliefs that are either misplaced or applied 
in inappropriate contexts, such as the use 
of alcohol to aid neonatal respiratory effort.
I remember the practice of holding the baby
up by the feet at birth being standard 
practice at the start of my midwifery career
in Scotland! Of most concern are those 
practices that potentially or actually harm
the mother and/or baby, specifically incor-
rect prescribing and manoeuvres such as
fundal pressure.
However, can professionals in the devel-
oped world, practising within an organisa-
tional framework that provides emergency
transfers by ambulance along tarmac roads,
and essential obstetric interventions not
limited by the ability to pay, rightfully criti-
cise the clinical practice of their colleagues in
the developing world who often do not have
access to such options?
Finally, to replace inappropriate or unsafe
practices by evidence-based ones requires
standardisation of professional care within
an organised healthcare system. Given the
social and political chaos existing in
Burundi, a country emerging tentatively but
hopefully from a decade of conflict, this will
take time and effort to achieve.
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International
A young mother with her baby attends a family planning
consultation in a rural clinic
196-198_Burundi.qxd  18/4/06  8:03 am  Page 4

Across the red river: Rwanda, Burundi and the heart of darkness.

Association, Royal Pharmaceutical Society of Great Britain.

for the Scientific Study of Population.

Guide clinique et thérapeutique (cinquième edition révisée). Médecins Sans Frontières:

Obstétrique en situation d’isolement (deuxième edition). Médecins Sans Frontières:

Statistiques et d’Etudes Economiques du Burundi.

Burundi: childbirth in a developing country.

Burundi: childbirth in a developing country.

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