Postpartum tubal ligation by nurse--midwives in Thailand: a field trial.

PIP: 25 nurse midwives with at least 12 years of schooling, 3 1/2 years of training in nursing and midwifery, and a minimum of 1 year of operating room experience were selected from 18 provincial hospitals in Thailand for training in tubal ligations. During the 12 week course in a maternal and child health center in northeastern Thailand, the nurses received preliminary training and assisted surgeons with 3-5 operations; if their performance was approved, they performed 20 operations under a doctor's supervision. All completed the training and returned to be primarily responsible for postpartum sterilizations at their hospitals under the supervision of a gynecologist. Informed volunteer subjects, apparently healthy women having vaginal deliveries who had requested sterilization before delivery, were screened before the operations. The nurse midwives successfully performed 3549 postpartum tubal ligations in the 1st 12 months. The mean age of the sterilization acceptors was 28.2 years and the mean number of living children was 3.6. Assistance was needed from supervising doctors in 18 cases. After 12 months the average operation time was 14.8 plus or minus .3 minutes. The postoperative complications were similar to those in a pilot study, except that mild pyrexia was more common, occurring in 9.1% of cases. 97.4% expressed complete satisfaction on discharge from the hospital. At 6 weeks postpartum 28 of the 1746 cases returning for checkups had minor local complaints. Attitudes of the doctors at the participating hospitals were generally favorable.^ieng

Postpartum sterilization by operating-room nurses in Thailand.

A training project to assess the performance of experienced operating room nurses as operators in postpartum sterilization was conducted in 1977-1978. The results for over 1000 nurse-operated clients and a comparison group of approximately 300 physician-sterilized clients show that nurses achieved comparable success with physicians in postpartum sterilization, as judged by clinical and attitudinal follow-up. No serious complications were recorded in either group. Minor infections in both groups were treated routinely. A stitch abscess for one nurse-operated client resulted in hospitalization; the client was released after 3 days. The clients in both groups returned to routine chores at home rapidly, and client satisfaction with the procedure was virtually unanimous in each group. This study lends support to the use of nurses in performing contraceptive surgery. The need for increased service coverage in this area is of high priority, and nurses provide a readily available and easily trained cadre of support staff.

Post-partum tubal ligation by nurse-midwives and doctors in Thailand.

A shortage of doctors limits the provision of post-partum sterilisation services in rural areas of Thailand. To overcome this problem nurse-midwives with theatre experience were trained to perform post-partum tubal ligation by a mini-laparotomy incision under local anaesthesia. The performance of the nurse-midwives was compared with that of doctors in a controlled, randomised clinical trial. Some operative difficulty was encountered by the nurses in 4.9% of cases and by the doctors in 2.0% of cases. This difference is not statistically significant and arose largely because the nurse-midwife cases were more obese. Nurse-midwives required a significantly longer operating-time (18.5 min) than doctors (11.9 min). However, postoperative morbidity was similar in the two groups (7.0% and 6.0%, respectively). These results suggest that trained nurse-midwives with theatre experience can safely provide post-partum sterilisation services. A further field trial is underway.

PIP: A randomized controlled clinical study of the competence of operating-room nurses in performing tubal ligation as compared with that of doctors was conducted. 5 nurse-midwives with more than 1 year's experience as operating room assistants were selected from the Khon Kaen Maternal and Child Health (MCH) center, and were taught pelvic and abdominal anatomy and the principles of local anesthesia and postpartum tubal ligation. Each of the 5 nurse-midwives was required to perform 30 sterilizations and 3 doctors were required to perform 150 operations. All subjects were healthy volunteers with no history of abdominal surgery; they were randomly allocated to either a trained nurse-midwife or a doctor for the operation. No statistically significant difference in the number of difficult cases were encountered by the 2 operator groups. Average operating time required by nurse-midwives (18.5 minutes) was significantly longer than that needed by doctors (11 minutes) (t=12.7, p 0.001). Thickness of abdominal fat correlated significantly with time required by nurse-midwives (r=0.34, p 0.001). Postoperative complaints and complications were similar for both groups (7.0% and 6.0%, respectively). The findings suggest that postpartum sterilization services can be safely proided by trained nurse-midwives with operating-room experience. Further study should be done to evaluate safety of the nurse-midwife providing sterilization services under usual program conditions in MCH centers and provincial hospitals with operating facilities, as well as cost-effectiveness of such services.

Attitudes toward abortion in Thailand: a survey of senior medical students.

A majority of senior Thai medical students favored induced abortion in many circumstances not now considered legal. While 20 percent would not perform abortions for any reason, many of these would refer cases to colleagues. Independent variables consistently and significantly influencing attitudes conservatively were: female sex, certain medical schools attended, larger ideal family size, intention not to teach in a medical school as a career, having a father in unskilled or semiskilled or work, never having witnessed an illegal abortion, and never having been asked to find an abortion practitioner for a friend. A random reordering of the questions did not affect reports of attitudes toward or willingness to perform induced abortion.

Nurse-midwife insertion of the copper T in Thailand: performance, acceptance, and programmatic effects.

While oral contraceptives have been widely available in rural Thailand since their distribution by lower level paramedical health workers was authorized in 1970, the IUD has been restricted to large, urban clinics staffed by physicians. A study was conducted in 1972-73 to evaluate the performance of nurse-midwives in IUD (Copper T) insertion and to assess the reaction of acceptors and the likely effects on the National Family Planning Program. It was found that nurse-midwives were competent to insert Copper Ts and handle early complications. Acceptor continuation rates were very high and nurse-midwife acceptors clearly preferred IUD insertion by a female health worker. Programmatic evidence suggests that using nurse-midwives more extensively for Copper T insertion would increase IUD acceptance at no cost to the existing loop program.

The postpartum approach to family planning. Experiences in Thailand, from 1966 to 1971.

PIP: Since 1966, 4 large Bangkok hospitals and since 1969, 11 rural Thailand hospitals have operated a postpartum program with a total of 99,434 women accepting family planning services within 3 months of delivery or abortion, the majority accepting the IUD or female sterilization before hospital discharge. There were more than 48,000 immediate postpartum acceptors of the IUD which may be the largest series of cases yet reported. Acceptors had a mean age of 28 years, median 3.2 living children and most accepted to limit family size. "First method" continuation rates were high: 79% at 12 months, 65% at 24 months, and 47% at 48 months. Success was due to emphasis on motivation during antenatal and postpartum period. It was recommended that family planning become a routine part of postpartum care. This program should be modified to reach women delivering at home in the rural areas.^ieng