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Working toward decreasing infant mortality in developing countries through change in the medical curriculum

Working toward decreasing infant mortality in developing countries through change in the medical... Background: High infant and maternal mortality rates are one of the biggest health issues in Pakistan. Although these rates are given high priority at the national level (Millennium Development Goals 4 and 5, respectively), there has been no significant decrease in them so far. We hypothesize that this lack of success is because the undergraduate curriculum in Pakistan does not match local needs. Currently, the Pakistani medical curriculum deals with issues in maternal and child morbidity and mortality according to Western textbooks. Moreover, these are taught disjointedly through various departments. We undertook curriculum revision to sensitize medical students to maternal and infant mortality issues important in the Pakistani context and educate them about ways to reduce the same through an integrated teaching approach. Methods: The major determinants of infant mortality in underdeveloped countries were identified through a literature review covering international research produced over the last 10 years and the Pakistan Demographic Health Survey 2006-07. An interdisciplinary maternal and child health module team was created by the Medical Education Department at Shifa College of Medicine. The curriculum was developed based on the role of identified determinants in infant and maternal mortality. It was delivered by an integrated team without any subject boundaries. Students’ knowledge, skills, and attitudes were assessed by multiple modalities and the module itself by student feedback using questionnaires and focus group discussions. Results: Assessment and feedback demonstrated that the students had developed a thorough understanding of the complexity of factors that contribute to infant mortality. Students also demonstrated knowledge and skill in counseling, antenatal care, and care of newborns and infants. Conclusions: A carefully designed integrated curriculum can help sensitize undergraduate medical students and equip them to identify and address complex issues related to maternal and infant mortality in underdeveloped countries. Keywords: Curriculum, Infant Mortality, Maternal Mortality Background Pakistan is a developing country with a population of According to current statistics, of the 8.8 million chil- approximately 160 million and is one of the major con- dren who die each year, 37% die of neonatal causes. tributors to the above statistics [2]. In 1990, Pakistan Another 38% die of easily preventable and treatable had an infant mortality rate (IMR) of 100 and a child causes such as pneumonia, diarrhea, malaria, and mortality rate (CMR) of 130 per 1000 live births. Mater- measles. Globally, more than 24,000 children die every nal mortality ratio (MMR) during that period was 550/ day and every minute one woman dies in childbirth [1]. 100,000. Currently, Pakistan has an IMR of 78 and CMR of 94 [3]. Pakistan’s Millennium Development Goals (MDG) aspire to decrease IMR and CMR to 40 and 45 * Correspondence: iffatfzaman@yahoo.com 1 (MDG4) and MMR to 140 (MDG5) by 2015 [4]. It has Department of Pediatrics, Shifa College of Medicine Sector H/8, Islamabad 44000, Pakistan not even come halfway toward that goal in the past two Full list of author information is available at the end of the article © 2011 Zaman and Rauf; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 2 of 9 http://www.apfmj.com/content/10/1/11 decades. Clearly, Pakistan will not be able to achieve its textbooks are written [7]. The emphasis as in all sub- targets if the decline in the mortality rates continues to ject-based curriculums is on learning the disciplines be this slow. rather than their application in the real life situations. Maternal and child mortality rates are an important Pakistan Medical and Dental Council is the regulatory determinant of any country’s health status. Decreasing body for undergraduate medical education in Pakistan. maternal and child mortality rates has been given high Although it now recommends integration of clinical and basic health sciences, to date there have been no reports priority at the national level [4]. Several local and inter- of the integration of the disciplines of community medi- national organizations are working to achieve this end. cine with obstetrics and gynecology and pediatrics [8]. Many interventions have been suggested and are being tried [5]. Despite these efforts Pakistan has not made The goal of this module was to sensitize medical stu- any significant improvement in this area and there is a dents to the high maternal, infant, and child mortality large gap between its goals and the current situation rates in Pakistan and equip them with knowledge and (Table 1.) [6]. skills to reduce them. This article describes our efforts We hypothesize that one of the major factors for this to modify the curriculum according to local needs, deli- lack of progress is that medical educators are not ver it in integrated fashion, and assess the students for involved in the attempt to reduce maternal and child its effectiveness in achieving its goal. mortality rates. Medical educators make little or no effort toward making young doctors and medical stu- Methods dents aware of the problem and provide no special Organization of the module training to enable them to handle the situation. Subjects Shifa College of Medicine’s Department of Medical Edu- related to maternal and child health are taught disjoint- cation formed a ten-member team consisting of three edly through different disciplines. Additionally, the text- obstetrician and gynecologists, three pediatricians, two books used in our curricula are written in the West community medicine experts, one pathologist, and one where the issues related to infant and maternal mortality pharmacologist. The team was responsible for defining are entirely different; thus our medical students and the goals and objectives of the module, identification of doctors are unaware of the local issues and are not major determinants of maternal, neonatal, and child equipped with the knowledge and skills to deal with mortality in Pakistan, development of major themes and them. subthemes, cases to represent these themes, develop- Medical education in Pakistan consists of 2 years of ment of the curriculum, and integration of various basic sciences consisting of anatomy, physiology, and departments throughout the process of curriculum biochemistry and three years of clinical training that development and delivery. The first meeting of the team includes clerkships in departments of medicine, surgery, was held 6 months prior to the delivery of the module. pediatrics, obstetrics and gynecology, and eye and ENT, Severalformaland informal meetings were held for and lectures in pathology, pharmacology, community defining goals and objectives, and for planning curricu- medicine, and forensic medicine. In our traditional med- lum and assessment. The curriculum, timetable, study ical curriculum topics related to maternal and child guide, and proposal for assessment were presented to health are taught through discrete courses and indepen- the faculty in a regular forum for critical analysis. The dent medical disciplines of community medicine in team also conducted post hoc analysis of the module fourth year and obstetrics and gynecology and pediatrics with the Medical Education Department and presented in the final (fifth) year of medical school without any it at another faculty meeting. The delivery was case- cross-referencing among these subjects vertically or hor- based and occurred mostly in small group sessions. izontally. The major portion of the curriculum deals Assessment consisted of multiple choice questions with problems of prematurity, congenital malformations, (MCQs), short answer questions (SAQs), and objective and rare syndromes because these are the common structured clinical examinations (OSCE) stations and causes of death in the Western world where these counseling sessions. We also had a mid-module and post-module focus group with randomly selected stu- dents who critically appraised the module, discussed its Table 1 Immunization & Mortality Statistics for Pakistan merits and shortcomings, and gave suggestions for its Index 1990 2006- MGD improvement. 07 target Infant mortality 100 78 40 Curriculum development Child mortality 130 94 45 Thefirst keydecision madebythe team wasthatthe Fully vaccinated children aged 12-23 50% 47% > 90% objectives of the module, the time allocated for each months objective delivery, and its weight in assessment will be Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 3 of 9 http://www.apfmj.com/content/10/1/11 directly proportional to its contribution toward maternal the situation more lifelike and elicit greater participation and child mortality in underdeveloped countries. The of students. Medical social and ethical problems were team identified the major causes of maternal, neonatal, built into the cases for identification by the students and child mortality in underdeveloped countries through (see Appendix A). a literature review and study of Pakistan Demographic Studyguideshavebecomeavaluablesupplementto and Health Survey 2006-07. Lack of prenatal care, any module’s day-to-day teaching and learning [16]. The study guide we developed consisted of a welcome mes- skilled care during child birth, postnatal care, and breast sage explaining to the students the module’s importance feeding and immunization are regarded as the most and what we expected to achieve from it, themes, sub- important causes of infant and child morbidity and mor- tality in underdeveloped countries [1]. By contrast, in themes, and cases for discussion, organization of each the developed world preterm birth is the leading cause day including time, venues, names of facilitators, refer- of infant mortality, along with congenital malformation, ences for pre-reading, and e-mail addresses of resource low birth weight, and sudden infant death syndrome [9]. persons (see Appendix B). Together, these causes are responsible for 47% of deaths in the neonatal period [10]. Textbooks developed in the Delivery of the curriculum West therefore focus on the abovementioned problems The delivery of the curriculum was case-based. Each [11,12]. Although 99% of all mortality in children aged < case cross-linked several subthemes and contained a 5 years occurs in underdeveloped countries [13] and complete history, physical examination, and investiga- complications related to delivery alone account for more tions. Ten facilitators were assigned for the delivery of than one third of neonatal deaths [14], doctors in Paki- this module. Facilitators were relevant team members, stan follow the same textbooks that are taught in the registrars from pediatrics and obstetrics and gynecology West and deal only superficially with major contributors departments, and instructors from basic health sciences. of infant and child mortality in underdeveloped coun- Faculty in charge of each session discussed the case tries. Complications related to pregnancy and childbirth with the facilitators 2-3 days prior to the sessions and are the most common cause of death in women of emphasized the important learning points. Additional childbearing age in Pakistan [6]. Nearly all (99%) mater- pre-reading materials were also given to the students nal mortality occurs in the underdeveloped world; com- when necessary. The class was divided into ten small mon causes include severe hemorrhage (25%), infections groups for each session and cases were discussed. A (13%), unsafe abortions (13%), and indirect causes such wrap-up session for 10-15 minutes was taken by the ses- as anemia and malnutrition (20%). By contrast, < 1% sion in-charge if s/he so desired (thought necessary) and maternal mortality occurs in the developed world [15]. itwasassuredthatobjectives forthatsession were Learning objectives and curricular contents were achieved. Subject boundaries were totally demolished in developed keeping in mind the major contributors of case development and discussions (see study guide for maternal and child mortality in underdeveloped coun- cases). Large group interactive sessions were conducted tries. Two major themes, namely, “Safe Motherhood” for some objectives. Role play was introduced to develop and “Healthy Child” were identified (see Table 2 and problem solving skills necessary for promotion of Table 3: Appendix A). Safe Motherhood had several breastfeeding. Special problems pertaining to Pakistani subthemes including problems of expectant mothers in social setup such as the influence of parental in-laws the community, antenatal care, and follow-up of normal and “bad milk” were also discussed. Other strategies pregnancy, postpartum care of the mother, epidemiology used in the delivery of the module were video demon- of maternal morbidity and mortality, and methods of strations for neonatal examination and hands-on ses- family planning. The theme Healthy Child contained sions for neonatal resuscitation in the SCIL Lab. A field subthemes including care of normal newborn, neonatal visit was arranged to a local MCH center. Special resuscitation, infant nutrition, breastfeeding and wean- emphasis was placed in case delivery on identification of ing, special children in the community, epidemiology of social, ethical, and medical problems by the students. infant morbidity and mortality, expanded program for Time allocation for learning strategies was as follows: immunization, and integrated management of childhood small group discussion, 60%; large group sessions, 15%; illnesses (see Appendix B for sample of detailed curricu- hands-on in SCIL Lab, 10%; role play, 5%; supervised lar content). The curriculum placed special emphasis on research, 5%; and research presentations, 5%. awareness of epidemiology and current guidelines for mother and child care. Several clinical scenarios were Results developed to discuss various problems. Whenever possi- Students were assessed by multiple modalities including ble, the same scenario was continued with additional written tests with 40 MCQs with five stems and one information to discuss a new subtheme so as to make best answer. These questions regarding infant and Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 4 of 9 http://www.apfmj.com/content/10/1/11 Table 2 LEARNING OBJECTIVES: SAFE MOTHERHOOD 1. Competencies Module Objectives: Assessment Student should be able to Knowledge 1. Describe care of expectant mother (antenatal care) MCQs, SAQs 2. Describe changes in maternal physiology in normal pregnancy MCQs 3. Describe pillars of Safe Motherhood 4. Describe parameters to be evaluated at each visit MCQs Describe assessment of fetal growth 5. Explain the rationale for different investigations MCQS 6. Describe methods of family planning, their respective side effects, and contraindications MCQS 7. Describe strategies to prevent maternal mortality MCQS, SAQ Skills 1. Perform maternal counseling IPE 2. Perform counseling in care of expectant mother MCQ 3. Perform counseling in family planning IPE Scholarship Perform literature search about common causes of maternal mortality Search for ways of decreasing maternal mortality in your community Community Health Advocacy 1. Screen for maternal illnesses in community MCQs 2. Provide nutritional guidance for expectant mother and child MCQs, SAQs 3. Conduct routine investigation for antenatal care Reflective Practitioner 1. Foresee complications MCQS 2. Devise ways to decrease pregnancy-related complications encountered in the community Professionalism Provide punctuality and empathy; respect patients’ rights. Communication skills 1. Provide counseling 2. Explain use of supplements and vaccinations during pregnancy IPE 3. Explain family planning methods best for different couples IPE Collaborative skills 1. Collaborate with community for safe pregnancy and delivery For preventing prenatal conditions predisposing to infant morbidity Ethical practice 1. Advocate against illegal abortions 2. Refrain from prescription of costly supplements 3. Prevent repeated ultrasound Evidence-based lifelong learning 1. Do appropriate literature search for evidence 2. perform community-based interventions to reduce maternal mortality TASKS: 1. Counsel patients regarding normal changes in pregnancy 2. Dietary counseling to patients 3. Husband counseling 4. Antenatal examination (SCIL Lab) 5. Pelvic examination (SCIL Lab) 6. Literature search about common causes of maternal mortality 7. Presentation of literature search 8. Presentation on methods applicable for decreasing maternal mortality in your community maternal mortality and its prevention and the manage- newborns and infants. (See Appendix C for sample ment of morbidity were divided into three categories questions from the exam.) All assessments and feedback such as: awareness and basic knowledge, mean score demonstrated that the students had developed thorough 69.2%; problem identification, mean score 54.6%; and understanding of the complexity of factors that contri- problem solving, mean score 71.4%. bute to maternal and infant mortality. They could iden- There were also 5 SAQs. The students’ mean score of tify the situations leading to an increase in mortality 78% demonstrated adequate absorption of course mate- and solve the problems presented to them adequately. rials. Another performance test consisted of 6 OSCE and two counseling sessions. The OSCE mean score was Focus groups, questionnaires, and feedback 86% showing that they were also knowledgeable and Focus groups and written questionnaires were used by skillful in counseling, antenatal care, and care of the Medical Education Department of Shifa College of Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 5 of 9 http://www.apfmj.com/content/10/1/11 Table 3 LEARNING OBJECTIVES: HEALTHY CHILD Competencies Module Objectives: Assessment Student should be able to Knowledge Describe routine care of a baby immediately after birth MCQs, SAQs Describe neonatal examination and common skeletal and other deformities detectable at MCQs birth (TEV, DDH, etc.) Describe APGAR scoring Describe mechanism of breastfeeding and its advantages. MCQ, IPE Define malnutrition and describe its classification IPE Discuss methods of assessing child growth and use of growth chart Describe Integrated Management of Childhood Illnesses (IMCI) program and its relevance to MCQs Pakistan Describe EPI program of Pakistan MCQ Define the terms Infant Mortality and Infant Mortality Rate MCQ Describe causes of infant mortality and discuss preventive strategies MCQ Skill Counsel about vaccination benefits and side effects IPE Counsel about rehabilitation techniques used in care of special children IPE Perform routine neonatal care IPE, in SCIL Lab MCQ Perform neonatal resuscitation SCIL Lab, on a dummy neonate Plot anthropometric measures on growth chart IPE Scholarship Perform research and present papers Draw on research for patient care Community Health Describe importance of good nutrition, proper vaccination, disease prevention, and problems MCQ Advocacy of malnutrition Describe importance of breastfeeding and appropriate weaning practices Reflective medical Be aware of extreme vulnerability of neonates and take measures to decrease their morbidity Viva station, SCIL Lab Practice and mortality Professionalism Offer punctuality and empathy; respect patient’s rights Communication skills Counsel mothers regarding infant nutrition IPE Counsel mothers regarding vaccination IPE Counsel mothers regarding danger signs; guide mother and midwife for prevention of MCQ asphyxia in subsequent babies Collaborative skills Collaborate in healthy upbringing of child (proper follow-up visits, monitor weight gain and MCQ development) Ethical practice Assist in family planning issues Empower the mother Evidence-based lifelong Perform literature search on ways to decrease infant mortality learning Incorporate the results to decrease mortality and morbidity of children in the community TASKS: Perform routine neonatal care Plot anthropometric measurements on growth chart Perform neonatal resuscitation Literature search for decreasing infant mortality Presentation of literature search Role play on breastfeeding issues Family planning counseling Medicine for assessment of each module and its feed- involved with development or delivery of the module back. Evaluation of maternal and child health module was allowed in this group. The time allocated for the focus groups was conducted by a trained facilitator from discussion was 1 hour. Focus groups concentrated on the Medical Education Department. Ten students were the usefulness of the module, evaluation of the facilita- randomly selected for this purpose. No faculty member tors by the students, and strategies to improve the Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 6 of 9 http://www.apfmj.com/content/10/1/11 module. A written questionnaire (see Additional File 1: discipline of community medicine without any horizon- Appendix D) was given to all students at the end of the tal or vertical integration with pediatrics or obstetrics. module with written examination paper. Through the This may be one reason that the rate of immunization feedback forwarded to us, we learned that students which was 50% in 1990 has now gone down to 47% found CMCH 224 a focused and organized module, the [20]. Another important project that tries to reduce facilitators of all the sessions were highly motivating, child mortality and improve maternal health is the and their enthusiasm to teach encouraged learning. Stu- Technical Assistance for Capital Building in Midwifery, Information and Logistics (TACMIL) project funded by dents also felt that application of knowledge was empha- USAID. Its main functions are influencing the policies, sized through ensuring involvement of all and community awareness was developed through sessions training journalists to address health issues, capital on immunization, breast feeding, and maternal mortal- building by 2-3-day workshops, and collecting data but ity. Students found ethical and social issues challenging none of these activities involve undergraduate curricu- and interesting. Many students were not previously lum modification or teaching and learning at an under- exposed to these issues because of their higher eco- graduate level [21]. Pakistan Initiative for Mothers and nomic and different socio-cultural background. The Newborns (PAIMAN) is a USAID-funded nongovern- high point for us in this feedback was the comment by ment organization (NGO) working to improve maternal many students that the respect shown to students and child health in Pakistan. According to its official helped develop their self-esteem and they wanted to website this NGO involves all relevant stakeholders demonstrate efficiency. including government, communities, private sector, and donors. However, it is interesting to note that there is Discussion no mention of doctors and medical students or their Improving maternal and child health is a major problem training in their agenda [22]. for a large part of the underdeveloped world. Pakistan Medical educationists have argued for reorientation of has been struggling with this problem for several dec- institutional systems, structures, and processes to meet ades now and is falling far behind the goals that it has local needs [23]. They have rightly argued that dividing assigned itself. According to MGD 4, Pakistan aims to medicine into disciplines is an artificial construct. The reduce its under 5 mortality rate to 45, IMR to 40, and real world of medical practice is trans-disciplinary in MMR to 140 per 100,000 by 2015 [4]. In Pakistan, many large part [24]. To promote preventive thinking, integra- organizations are working to realize MGD 4 and 5. The tion within departments is recommended [25]. A litera- ture search also shows that exposing medical largest task force involved in this is the system of Lady undergraduates to community-based learning early in Health Workers (LHWs). The LHW program is spon- sored by the Ministry of Health and consists of approxi- their curriculum helps sensitize them to community mately 93,000 workers. They are basically 8th graders issues and that this cannot be achieved through the tra- with a 6-month training course [17]. These health work- ditional curriculum [26]. ers work in rural areas and go from door to door for The Pakistan Medical and Dental Council (PMDC), health promotion and family planning. Family planning which is the accrediting body, also recommends integra- is an issue fraught with mistrust due to various religious tion of preventive and clinical sciences. All important and cultural reasons in Pakistan and this has generated topics that could be helpful in decreasing IMR and mistrust of lady health visitors and a potentially very MMR are included in the curriculum prescribed by good system has not been able to bring any change in PMDC but they are dealt with disjointedly through the maternal and child mortality rates. The Expanded Pro- disciplines of pediatrics, obstetrics, and community gram for Immunization (EPI) is a program funded by medicine. They are taught andexamineddisjointedly WHO, UNICEF, and many others and run by govern- without any horizontal or vertical cross linkage [7]. The ment of Pakistan [18]. It is a big project launched in importance of a maternal and child health module has 1978 and responsible for free immunization of all chil- been recognized and incorporated in learning and teach- dren. Free vaccines are supplied to all basic health units. ing in many parts of the world. Many universities in the It has made its way into the textbooks of pediatrics fol- West are also teaching maternal and child health from lowed in most medical colleges but they concentrate on the point of view of global health and underprivileged the schedule of EPI and side effects of vaccination only. communities. Internet searches led to scores of listing There is no mention of the importance of vaccination and program details for this module but it is taught not as part of undergraduate medical curriculum but rather and its impact on reducing infant mortality and morbid- in masters in public health programs. We found only ity and current burden of vaccine-preventable diseases one example where, under the guidance of WHO, a in Pakistan in local pediatrics textbooks [19]. Disease burden and mortality issues are dealt with by the maternal and child health module has been incorporated Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 7 of 9 http://www.apfmj.com/content/10/1/11 in undergraduate medical education–but nonetheless was 8 weeks previously. On missing her periods she did here again it is taught as a part of community health her home urine pregnancy test, which came out as posi- discipline [27]. tive.Now forthe past 1weekshe hasearly morning nausea and vomiting. She also feels dizzy and weak and Conclusions is unable to perform her chores normally. High infant, child, and maternal mortality rates not only Subtheme: postpartum care of mother: Sajida is are sensitive indicators of any community’s health status brought into the hospital emergency room 6 days after but also reflect the importance given by society to its her delivery with history of high-grade fever for 3 days, most vulnerable members. Maternal and child health heavy vaginal bleeding for 4 days, and burning mictura- issues have been neglected by Pakistani governments tion for 5 days. She reports that after going home she and regulatory bodies and also by the medical commu- has not been feeling well. She stopped taking all medica- nity. Medical educators have not diverted their energies tions advised to her at hospital because her mother-in- toward solving this grave problem. Medical colleges in law told her so. On examination, she is very pale, dehy- Pakistan still spend a large portion of their meager drated, and weak. Her BP is 90/40 mmHg, pulse 126/ resources in teaching medical students about problems min, temp 102°F. Her chest is clear and there is tender- described in Western textbooks. These problems are not ness in her lower abdomen. Speculum examination the major contributors of maternal or child mortality in reveals foul smelling discharge. On bimanual examina- underdeveloped countries. For the undergraduate curri- tion uterus is 18 weeks size and tender. Her left calf is culum to be meaningful in addressing these issues in swollen, hot, and painful. underdeveloped countries, it needs to be modified Subtheme: maternal mortality: Farieda is a 40-year- according to local needs and delivered in integrated old woman married to Hassan for the last 25 years. She fashion. In the development of this module for our and Hassan lived in the Northern Areas beyond the undergraduate students, the basic ideas were modifica- Hunzavalleyin anareacalledSost. Herfamily moved tion of the curriculum to serve local needs, integration to Rawalpindi 3 years ago because they were unable to of various clinical science departments with no subject sustain their living on the small piece of land that Has- boundaries, and promotion of preventive thinking. We san owned. Farida’s mother-in-law and an unmarried received positive feedback from students regarding this sister-in-law live with the couple along with her 8 module through focus groups. Assessment of the stu- children. dents done by various modalities showed a deep under- All of Farieda’s children until the seventh were born at standing of the complex problems contributing to high home by a traditional birth attendant in Sost. She maternal and child mortality in Pakistan. They also wanted to stop getting pregnant after she had her fourth demonstrated adequate skills to prevent and manage child. She was unable to visit the family planning center common problems encountered in maternal and child because the mother-in-law forbade her because she care. We hope that if medical educators start modifying wanted Hassan who was an only son to have more sons. their curricula to address local needs, it will go a long Fariedaand herfamilymoved into aslumareaof way toward solving burning health issues in their Rawalpindi. Her husband obtained work as a security communities. guard and does double duty to sustain his family by working 12-15 hours daily. She works as a maid in 6 Authors information households. Her elder daughter takes care of the home IZ is associate professor of pediatrics at Shifa College of and her younger siblings. She had her last child at Shifa Medicine, closely associated with the development of Foundation Clinic and the child is currently 10 months the integrated curriculum, and has run the MCH mod- old. She breastfed for a few months but was unable to ule three times. Her special interest within pediatrics is continue because her milk was not sufficient especially child nutrition. after working for a long day. This time she presented to AR is a coordinator in the Department of Medical Shifa Foundation Clinic again with amenorrhea for 8 Education. Her work involves assessment of different weeks and was found pregnant. She requested the obste- modules for their effectiveness and impact on students. trician for an abortion but the doctor did not oblige but was sympathetic to Farieda and counseled her and APPENDIX A offered her support to continue the pregnancy. On Sample from study guide examination she was pale and weighed 40 kg (her height SAMPLE CASES was 5 feet 2 inches). The doctor advised her to take Subtheme: care of a pregnant woman: A 26-year-old iron tablets after checking her hemoglobin, which was 6 mg/dl. She was unable to tolerate the tablets because of woman visits your clinic with complaints of nausea and GI upsets so she was not compliant with the drugs. She vomiting for the past 1 week. Her last menstrual period Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 8 of 9 http://www.apfmj.com/content/10/1/11 received tetanus injections in her antenatal visits. She (fundal height measurement, fetal heart auscultation, developed high blood pressure during one of her visits fetal growth and wellbeing, any maternal or fetal com- and was advised bed rest and antihypertensive medica- plaints (vaginal discharge, burning in urine, dyspnea, tions. During her 8th month and still with high blood fever, decreased fetal movements), mother’snutrition pressure, the doctor advised her to take bed rest but she and supplements: maternal malnutrition and obesity, gave a sarcastic laugh and said “Doctor Jee, if I go on anemia, role of folic acid, iron, and calcium, balanced bed rest who will earn for the family? How will so many diet, breastfeeding sensitization: role of breastfeeding in growth development and disease prevention in the mouths be fed? How can I take rest?” child Subtheme: infant mortality: Farieda brings her 2- month-old baby girl to hospital with 4-day history of Complications and referrals: Headaches, raised blood reluctance to feed and 3-day history of shortness of pressure, fundal height (more or less than dates) effect breath. She was giving the baby water and honey on the of maternal diseases on fetal development (diabetes, advice of her elders at home. She brought the baby to hypertension, renal disease, hyperthyroidism, hypothyr- the hospital when she realized that the baby was becom- oidism, TORCH-S, HIV, hepatitis infections) ing worse despite this treatment. Birth weight was not Antenatal examination:Height,weight,complete known because she was born at home with no skilled general physical examination (vital signs, palor, jaundice, help. Farieda says that at birth the child appeared small cyanosis, thyroid, breasts, edema) and systemic examina- but had cried right after birth. Baby on examination was tion (special emphasis on abdominal examination and weak and pale. Her weight was 2.7 kg. Her respiratory pelvic examination–speculum and bimanual), any rate was 80 breaths/minute, heart rate 162 beats per complications minute, and temperature 96°F. Her oxygen saturation SKILL: Abdominal examination, SCIL Lab; pelvic was 73%. She was worked-up for sepsis and pneumonia examination, SCIL Lab and was started on broad-spectrum antibiotics. She died Attitude: Sympathetic approach towards mothers 16 hours after admission. APPENDIX C (Sample questions from the exam) Sample questions from the module APPENDIX B A woman presents with a history of termination of (Sample from detailed curricular content) previous pregnancy because of fetal anencephaly. Karyo- CURRICULAR CONTENT typing was done and was normal. She is planning to get 1. Maternal Health in Community pregnant again. On examination she is pale looking but KNOWLEDGE: Importance of mother’s profile on the otherwise normal. Which of the following will most likely prevent similar outcome in future pregnancies? health of mother and fetus, effect of maternal age, con- sanguinity, maternal profession, radiation exposure, che- a. Ferrous sulfate 60 mg daily micals, toxins, smoking, alcohol, drugs, medications, b. Vitamin B complex nurses, doctors (hepatitis B and C vaccination) gravidity, c. Calcium 1 g daily parity, abortions age of previous child/place of birth/ d. Folic Acid 5 mg daily* mode of delivery/reason for that mode/duration of preg- e. Vitamin E 100 mg daily (Problem solving) nancy/complications of pregnancy, labor, and puerper- A baby boy was born at 37 weeks of gestation with ium/sex of baby/weight of baby prolonged rupture of membranes for > 30 hours. The SKILL: History of present complaints in chronological mother was afebrile and not treated with antibiotics. order, past obstetrical and gynecological history, family Postnatally, the woman complains of severe lower history, history of current social problems and other abdominal pain and offensive blood discharge. Most health issues not volunteered by mother (tuberculosis, probable diagnosis is: diabetes mellitus, hypertension, heart disease, renal dis- A. Urinary tract infection ease),addictions: drugs,smoking,alcohol,substance B. Pelvic inflammatory disease abuse C. Cervicitis ATTITUDE: Sensitization and development of a sym- D. Vaginitis pathetic approach towards problems common among E. Appendicitis (Problem identification) women in Pakistan The baby assessed by on call doctors was well. The TASK: Take one history from foundation clinic and most appropriate step in the management of this baby identify at least three problems. Submit the history on would be: A. Discharge the baby now and follow-up after 1 week following Monday B. Observe the baby in hospital for 48 hours THEME: Antenatal Care C. Wait for the result of vaginal swab then treat the Present state of health/immunization, appropriate maternal weight gain, fetal movements, fetal growth baby accordingly Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 9 of 9 http://www.apfmj.com/content/10/1/11 27. Searo EG: Review of preventive and social medicine, community D. Do the blood culture of the baby and start antibio- medicine and community health curriculum for undergraduate medical tics if culture is positive education social medicine. New Dehli: WHO Regional Office for South East E. Do the blood culture and treat the baby with I/V Asia; 2009. antibiotics (Problem solving) doi:10.1186/1447-056X-10-11 Cite this article as: Zaman and Rauf: Working toward decreasing infant mortality in developing countries through change in the medical Additional material curriculum. Asia Pacific Family Medicine 2011 10:11. Additional file 1: Appendix D- Feedback Questionnaire. List of Abbreviations CMR: child mortality rate; IMR: infant mortality rate; LHW: Lady Health Workers; MDG: Millennium Development Goals; MMR: maternal mortality ratio; TACMIL: Technical Assistance for Capital Building in Midwifery and Logistics; USAID: United States Agency for International Development Acknowledgements We are greatly thankful to the following for their help and support: Administration, Shifa College of Medicine for the infrastructure; Dr. K.A. Abbas, for advice regarding teaching of WHO programs and breastfeeding; Dr. Ejaz, Dr. Gulshan, and Dr. Saima for exceptional contribution in module delivery and assessment; and the module team MCH 224 for its hard work. Author details Department of Pediatrics, Shifa College of Medicine Sector H/8, Islamabad 44000, Pakistan. Department of Medical Education, Shifa College of Medicine Sector H/8, Islamabad 44000, Pakistan. Authors’ contributions IZ was the team leader for development of the module. She also conducted the major portion of the research on causes of infant and maternal mortality in underdeveloped countries. AR conducted focus group discussion and analysis of feedback questionnaire. Both authors approved the manuscript. Competing interests The authors declare that they have no competing interests. Received: 23 December 2010 Accepted: 28 August 2011 Published: 28 August 2011 References 1. Global Action for Children. [http://issuu.com/scarkonen/docs/ gac_2009_annual_report_web], (accessed August 8, 2010.). 2. Index Mundi. [http://www.indexmundi.com/map.aspx?v=Infant+mortality +rate%28deaths%2f1%2c000+live+births%29&co=as]. 3. Lalji Najma, Thaver Minhal Ali, Kamal Ameera: Maternal Neonate and Child Health (MNCH) research in Pakistan: Trend and transition . J Pak Med Assoc 2010, 60(5):401-403 [http://], (accessed August 19, 2011). 19. Khan PA, Kundi Z: Basis of Pediatrics. 7 edition. Lahore: Zahid Bashir; 2005. 20. Bhutta Z, Cross A, Raza F, Zahir Z: Measure Demographic and Health Surveys.[http://www.measuredhs.com/pubs/pdf/FR200/FR200.pdf]. 21. TACMIL Health Project. [http://www.usaid.gov/pk/sectors/health/tacmil. html], (accessed August 19, 2011. 22. Pakistan Initiative for Mothers and Newborns (PAIMAN). [http://pdf.usaid. Submit your next manuscript to BioMed Central gov/pdf_docs/PDACH527.pdf]. 23. Jones R, Pitama S, Huria T, Poople P, McKimm J, et al: Medical education and take full advantage of: to improve Maori health. NZ Med J 2010, 123:113-122. 24. Smith SR: Towards an integrated curriculum. Med Health RI 2005, • Convenient online submission 88:258-261. • Thorough peer review 25. Cheng TL, Greenberg L, Helen LH, Keller D: Teaching prevention in pediatrics. Acad Med 2000, 75(7 Suppl):566-571. • No space constraints or color figure charges 26. Buckner AV, Ndjakani YD, Banks B, Blumenthal DS: Using service-learning • Immediate publication on acceptance to teach community health: the Morehouse School of Medicine • Inclusion in PubMed, CAS, Scopus and Google Scholar Community Health Course. Acad Med 2010, 85:1645-1651. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Working toward decreasing infant mortality in developing countries through change in the medical curriculum

Asia Pacific Family Medicine , Volume 10 (1) – Aug 28, 2011

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Copyright © 2011 by Zaman and Rauf; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/1447-056X-10-11
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Abstract

Background: High infant and maternal mortality rates are one of the biggest health issues in Pakistan. Although these rates are given high priority at the national level (Millennium Development Goals 4 and 5, respectively), there has been no significant decrease in them so far. We hypothesize that this lack of success is because the undergraduate curriculum in Pakistan does not match local needs. Currently, the Pakistani medical curriculum deals with issues in maternal and child morbidity and mortality according to Western textbooks. Moreover, these are taught disjointedly through various departments. We undertook curriculum revision to sensitize medical students to maternal and infant mortality issues important in the Pakistani context and educate them about ways to reduce the same through an integrated teaching approach. Methods: The major determinants of infant mortality in underdeveloped countries were identified through a literature review covering international research produced over the last 10 years and the Pakistan Demographic Health Survey 2006-07. An interdisciplinary maternal and child health module team was created by the Medical Education Department at Shifa College of Medicine. The curriculum was developed based on the role of identified determinants in infant and maternal mortality. It was delivered by an integrated team without any subject boundaries. Students’ knowledge, skills, and attitudes were assessed by multiple modalities and the module itself by student feedback using questionnaires and focus group discussions. Results: Assessment and feedback demonstrated that the students had developed a thorough understanding of the complexity of factors that contribute to infant mortality. Students also demonstrated knowledge and skill in counseling, antenatal care, and care of newborns and infants. Conclusions: A carefully designed integrated curriculum can help sensitize undergraduate medical students and equip them to identify and address complex issues related to maternal and infant mortality in underdeveloped countries. Keywords: Curriculum, Infant Mortality, Maternal Mortality Background Pakistan is a developing country with a population of According to current statistics, of the 8.8 million chil- approximately 160 million and is one of the major con- dren who die each year, 37% die of neonatal causes. tributors to the above statistics [2]. In 1990, Pakistan Another 38% die of easily preventable and treatable had an infant mortality rate (IMR) of 100 and a child causes such as pneumonia, diarrhea, malaria, and mortality rate (CMR) of 130 per 1000 live births. Mater- measles. Globally, more than 24,000 children die every nal mortality ratio (MMR) during that period was 550/ day and every minute one woman dies in childbirth [1]. 100,000. Currently, Pakistan has an IMR of 78 and CMR of 94 [3]. Pakistan’s Millennium Development Goals (MDG) aspire to decrease IMR and CMR to 40 and 45 * Correspondence: iffatfzaman@yahoo.com 1 (MDG4) and MMR to 140 (MDG5) by 2015 [4]. It has Department of Pediatrics, Shifa College of Medicine Sector H/8, Islamabad 44000, Pakistan not even come halfway toward that goal in the past two Full list of author information is available at the end of the article © 2011 Zaman and Rauf; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 2 of 9 http://www.apfmj.com/content/10/1/11 decades. Clearly, Pakistan will not be able to achieve its textbooks are written [7]. The emphasis as in all sub- targets if the decline in the mortality rates continues to ject-based curriculums is on learning the disciplines be this slow. rather than their application in the real life situations. Maternal and child mortality rates are an important Pakistan Medical and Dental Council is the regulatory determinant of any country’s health status. Decreasing body for undergraduate medical education in Pakistan. maternal and child mortality rates has been given high Although it now recommends integration of clinical and basic health sciences, to date there have been no reports priority at the national level [4]. Several local and inter- of the integration of the disciplines of community medi- national organizations are working to achieve this end. cine with obstetrics and gynecology and pediatrics [8]. Many interventions have been suggested and are being tried [5]. Despite these efforts Pakistan has not made The goal of this module was to sensitize medical stu- any significant improvement in this area and there is a dents to the high maternal, infant, and child mortality large gap between its goals and the current situation rates in Pakistan and equip them with knowledge and (Table 1.) [6]. skills to reduce them. This article describes our efforts We hypothesize that one of the major factors for this to modify the curriculum according to local needs, deli- lack of progress is that medical educators are not ver it in integrated fashion, and assess the students for involved in the attempt to reduce maternal and child its effectiveness in achieving its goal. mortality rates. Medical educators make little or no effort toward making young doctors and medical stu- Methods dents aware of the problem and provide no special Organization of the module training to enable them to handle the situation. Subjects Shifa College of Medicine’s Department of Medical Edu- related to maternal and child health are taught disjoint- cation formed a ten-member team consisting of three edly through different disciplines. Additionally, the text- obstetrician and gynecologists, three pediatricians, two books used in our curricula are written in the West community medicine experts, one pathologist, and one where the issues related to infant and maternal mortality pharmacologist. The team was responsible for defining are entirely different; thus our medical students and the goals and objectives of the module, identification of doctors are unaware of the local issues and are not major determinants of maternal, neonatal, and child equipped with the knowledge and skills to deal with mortality in Pakistan, development of major themes and them. subthemes, cases to represent these themes, develop- Medical education in Pakistan consists of 2 years of ment of the curriculum, and integration of various basic sciences consisting of anatomy, physiology, and departments throughout the process of curriculum biochemistry and three years of clinical training that development and delivery. The first meeting of the team includes clerkships in departments of medicine, surgery, was held 6 months prior to the delivery of the module. pediatrics, obstetrics and gynecology, and eye and ENT, Severalformaland informal meetings were held for and lectures in pathology, pharmacology, community defining goals and objectives, and for planning curricu- medicine, and forensic medicine. In our traditional med- lum and assessment. The curriculum, timetable, study ical curriculum topics related to maternal and child guide, and proposal for assessment were presented to health are taught through discrete courses and indepen- the faculty in a regular forum for critical analysis. The dent medical disciplines of community medicine in team also conducted post hoc analysis of the module fourth year and obstetrics and gynecology and pediatrics with the Medical Education Department and presented in the final (fifth) year of medical school without any it at another faculty meeting. The delivery was case- cross-referencing among these subjects vertically or hor- based and occurred mostly in small group sessions. izontally. The major portion of the curriculum deals Assessment consisted of multiple choice questions with problems of prematurity, congenital malformations, (MCQs), short answer questions (SAQs), and objective and rare syndromes because these are the common structured clinical examinations (OSCE) stations and causes of death in the Western world where these counseling sessions. We also had a mid-module and post-module focus group with randomly selected stu- dents who critically appraised the module, discussed its Table 1 Immunization & Mortality Statistics for Pakistan merits and shortcomings, and gave suggestions for its Index 1990 2006- MGD improvement. 07 target Infant mortality 100 78 40 Curriculum development Child mortality 130 94 45 Thefirst keydecision madebythe team wasthatthe Fully vaccinated children aged 12-23 50% 47% > 90% objectives of the module, the time allocated for each months objective delivery, and its weight in assessment will be Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 3 of 9 http://www.apfmj.com/content/10/1/11 directly proportional to its contribution toward maternal the situation more lifelike and elicit greater participation and child mortality in underdeveloped countries. The of students. Medical social and ethical problems were team identified the major causes of maternal, neonatal, built into the cases for identification by the students and child mortality in underdeveloped countries through (see Appendix A). a literature review and study of Pakistan Demographic Studyguideshavebecomeavaluablesupplementto and Health Survey 2006-07. Lack of prenatal care, any module’s day-to-day teaching and learning [16]. The study guide we developed consisted of a welcome mes- skilled care during child birth, postnatal care, and breast sage explaining to the students the module’s importance feeding and immunization are regarded as the most and what we expected to achieve from it, themes, sub- important causes of infant and child morbidity and mor- tality in underdeveloped countries [1]. By contrast, in themes, and cases for discussion, organization of each the developed world preterm birth is the leading cause day including time, venues, names of facilitators, refer- of infant mortality, along with congenital malformation, ences for pre-reading, and e-mail addresses of resource low birth weight, and sudden infant death syndrome [9]. persons (see Appendix B). Together, these causes are responsible for 47% of deaths in the neonatal period [10]. Textbooks developed in the Delivery of the curriculum West therefore focus on the abovementioned problems The delivery of the curriculum was case-based. Each [11,12]. Although 99% of all mortality in children aged < case cross-linked several subthemes and contained a 5 years occurs in underdeveloped countries [13] and complete history, physical examination, and investiga- complications related to delivery alone account for more tions. Ten facilitators were assigned for the delivery of than one third of neonatal deaths [14], doctors in Paki- this module. Facilitators were relevant team members, stan follow the same textbooks that are taught in the registrars from pediatrics and obstetrics and gynecology West and deal only superficially with major contributors departments, and instructors from basic health sciences. of infant and child mortality in underdeveloped coun- Faculty in charge of each session discussed the case tries. Complications related to pregnancy and childbirth with the facilitators 2-3 days prior to the sessions and are the most common cause of death in women of emphasized the important learning points. Additional childbearing age in Pakistan [6]. Nearly all (99%) mater- pre-reading materials were also given to the students nal mortality occurs in the underdeveloped world; com- when necessary. The class was divided into ten small mon causes include severe hemorrhage (25%), infections groups for each session and cases were discussed. A (13%), unsafe abortions (13%), and indirect causes such wrap-up session for 10-15 minutes was taken by the ses- as anemia and malnutrition (20%). By contrast, < 1% sion in-charge if s/he so desired (thought necessary) and maternal mortality occurs in the developed world [15]. itwasassuredthatobjectives forthatsession were Learning objectives and curricular contents were achieved. Subject boundaries were totally demolished in developed keeping in mind the major contributors of case development and discussions (see study guide for maternal and child mortality in underdeveloped coun- cases). Large group interactive sessions were conducted tries. Two major themes, namely, “Safe Motherhood” for some objectives. Role play was introduced to develop and “Healthy Child” were identified (see Table 2 and problem solving skills necessary for promotion of Table 3: Appendix A). Safe Motherhood had several breastfeeding. Special problems pertaining to Pakistani subthemes including problems of expectant mothers in social setup such as the influence of parental in-laws the community, antenatal care, and follow-up of normal and “bad milk” were also discussed. Other strategies pregnancy, postpartum care of the mother, epidemiology used in the delivery of the module were video demon- of maternal morbidity and mortality, and methods of strations for neonatal examination and hands-on ses- family planning. The theme Healthy Child contained sions for neonatal resuscitation in the SCIL Lab. A field subthemes including care of normal newborn, neonatal visit was arranged to a local MCH center. Special resuscitation, infant nutrition, breastfeeding and wean- emphasis was placed in case delivery on identification of ing, special children in the community, epidemiology of social, ethical, and medical problems by the students. infant morbidity and mortality, expanded program for Time allocation for learning strategies was as follows: immunization, and integrated management of childhood small group discussion, 60%; large group sessions, 15%; illnesses (see Appendix B for sample of detailed curricu- hands-on in SCIL Lab, 10%; role play, 5%; supervised lar content). The curriculum placed special emphasis on research, 5%; and research presentations, 5%. awareness of epidemiology and current guidelines for mother and child care. Several clinical scenarios were Results developed to discuss various problems. Whenever possi- Students were assessed by multiple modalities including ble, the same scenario was continued with additional written tests with 40 MCQs with five stems and one information to discuss a new subtheme so as to make best answer. These questions regarding infant and Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 4 of 9 http://www.apfmj.com/content/10/1/11 Table 2 LEARNING OBJECTIVES: SAFE MOTHERHOOD 1. Competencies Module Objectives: Assessment Student should be able to Knowledge 1. Describe care of expectant mother (antenatal care) MCQs, SAQs 2. Describe changes in maternal physiology in normal pregnancy MCQs 3. Describe pillars of Safe Motherhood 4. Describe parameters to be evaluated at each visit MCQs Describe assessment of fetal growth 5. Explain the rationale for different investigations MCQS 6. Describe methods of family planning, their respective side effects, and contraindications MCQS 7. Describe strategies to prevent maternal mortality MCQS, SAQ Skills 1. Perform maternal counseling IPE 2. Perform counseling in care of expectant mother MCQ 3. Perform counseling in family planning IPE Scholarship Perform literature search about common causes of maternal mortality Search for ways of decreasing maternal mortality in your community Community Health Advocacy 1. Screen for maternal illnesses in community MCQs 2. Provide nutritional guidance for expectant mother and child MCQs, SAQs 3. Conduct routine investigation for antenatal care Reflective Practitioner 1. Foresee complications MCQS 2. Devise ways to decrease pregnancy-related complications encountered in the community Professionalism Provide punctuality and empathy; respect patients’ rights. Communication skills 1. Provide counseling 2. Explain use of supplements and vaccinations during pregnancy IPE 3. Explain family planning methods best for different couples IPE Collaborative skills 1. Collaborate with community for safe pregnancy and delivery For preventing prenatal conditions predisposing to infant morbidity Ethical practice 1. Advocate against illegal abortions 2. Refrain from prescription of costly supplements 3. Prevent repeated ultrasound Evidence-based lifelong learning 1. Do appropriate literature search for evidence 2. perform community-based interventions to reduce maternal mortality TASKS: 1. Counsel patients regarding normal changes in pregnancy 2. Dietary counseling to patients 3. Husband counseling 4. Antenatal examination (SCIL Lab) 5. Pelvic examination (SCIL Lab) 6. Literature search about common causes of maternal mortality 7. Presentation of literature search 8. Presentation on methods applicable for decreasing maternal mortality in your community maternal mortality and its prevention and the manage- newborns and infants. (See Appendix C for sample ment of morbidity were divided into three categories questions from the exam.) All assessments and feedback such as: awareness and basic knowledge, mean score demonstrated that the students had developed thorough 69.2%; problem identification, mean score 54.6%; and understanding of the complexity of factors that contri- problem solving, mean score 71.4%. bute to maternal and infant mortality. They could iden- There were also 5 SAQs. The students’ mean score of tify the situations leading to an increase in mortality 78% demonstrated adequate absorption of course mate- and solve the problems presented to them adequately. rials. Another performance test consisted of 6 OSCE and two counseling sessions. The OSCE mean score was Focus groups, questionnaires, and feedback 86% showing that they were also knowledgeable and Focus groups and written questionnaires were used by skillful in counseling, antenatal care, and care of the Medical Education Department of Shifa College of Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 5 of 9 http://www.apfmj.com/content/10/1/11 Table 3 LEARNING OBJECTIVES: HEALTHY CHILD Competencies Module Objectives: Assessment Student should be able to Knowledge Describe routine care of a baby immediately after birth MCQs, SAQs Describe neonatal examination and common skeletal and other deformities detectable at MCQs birth (TEV, DDH, etc.) Describe APGAR scoring Describe mechanism of breastfeeding and its advantages. MCQ, IPE Define malnutrition and describe its classification IPE Discuss methods of assessing child growth and use of growth chart Describe Integrated Management of Childhood Illnesses (IMCI) program and its relevance to MCQs Pakistan Describe EPI program of Pakistan MCQ Define the terms Infant Mortality and Infant Mortality Rate MCQ Describe causes of infant mortality and discuss preventive strategies MCQ Skill Counsel about vaccination benefits and side effects IPE Counsel about rehabilitation techniques used in care of special children IPE Perform routine neonatal care IPE, in SCIL Lab MCQ Perform neonatal resuscitation SCIL Lab, on a dummy neonate Plot anthropometric measures on growth chart IPE Scholarship Perform research and present papers Draw on research for patient care Community Health Describe importance of good nutrition, proper vaccination, disease prevention, and problems MCQ Advocacy of malnutrition Describe importance of breastfeeding and appropriate weaning practices Reflective medical Be aware of extreme vulnerability of neonates and take measures to decrease their morbidity Viva station, SCIL Lab Practice and mortality Professionalism Offer punctuality and empathy; respect patient’s rights Communication skills Counsel mothers regarding infant nutrition IPE Counsel mothers regarding vaccination IPE Counsel mothers regarding danger signs; guide mother and midwife for prevention of MCQ asphyxia in subsequent babies Collaborative skills Collaborate in healthy upbringing of child (proper follow-up visits, monitor weight gain and MCQ development) Ethical practice Assist in family planning issues Empower the mother Evidence-based lifelong Perform literature search on ways to decrease infant mortality learning Incorporate the results to decrease mortality and morbidity of children in the community TASKS: Perform routine neonatal care Plot anthropometric measurements on growth chart Perform neonatal resuscitation Literature search for decreasing infant mortality Presentation of literature search Role play on breastfeeding issues Family planning counseling Medicine for assessment of each module and its feed- involved with development or delivery of the module back. Evaluation of maternal and child health module was allowed in this group. The time allocated for the focus groups was conducted by a trained facilitator from discussion was 1 hour. Focus groups concentrated on the Medical Education Department. Ten students were the usefulness of the module, evaluation of the facilita- randomly selected for this purpose. No faculty member tors by the students, and strategies to improve the Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 6 of 9 http://www.apfmj.com/content/10/1/11 module. A written questionnaire (see Additional File 1: discipline of community medicine without any horizon- Appendix D) was given to all students at the end of the tal or vertical integration with pediatrics or obstetrics. module with written examination paper. Through the This may be one reason that the rate of immunization feedback forwarded to us, we learned that students which was 50% in 1990 has now gone down to 47% found CMCH 224 a focused and organized module, the [20]. Another important project that tries to reduce facilitators of all the sessions were highly motivating, child mortality and improve maternal health is the and their enthusiasm to teach encouraged learning. Stu- Technical Assistance for Capital Building in Midwifery, Information and Logistics (TACMIL) project funded by dents also felt that application of knowledge was empha- USAID. Its main functions are influencing the policies, sized through ensuring involvement of all and community awareness was developed through sessions training journalists to address health issues, capital on immunization, breast feeding, and maternal mortal- building by 2-3-day workshops, and collecting data but ity. Students found ethical and social issues challenging none of these activities involve undergraduate curricu- and interesting. Many students were not previously lum modification or teaching and learning at an under- exposed to these issues because of their higher eco- graduate level [21]. Pakistan Initiative for Mothers and nomic and different socio-cultural background. The Newborns (PAIMAN) is a USAID-funded nongovern- high point for us in this feedback was the comment by ment organization (NGO) working to improve maternal many students that the respect shown to students and child health in Pakistan. According to its official helped develop their self-esteem and they wanted to website this NGO involves all relevant stakeholders demonstrate efficiency. including government, communities, private sector, and donors. However, it is interesting to note that there is Discussion no mention of doctors and medical students or their Improving maternal and child health is a major problem training in their agenda [22]. for a large part of the underdeveloped world. Pakistan Medical educationists have argued for reorientation of has been struggling with this problem for several dec- institutional systems, structures, and processes to meet ades now and is falling far behind the goals that it has local needs [23]. They have rightly argued that dividing assigned itself. According to MGD 4, Pakistan aims to medicine into disciplines is an artificial construct. The reduce its under 5 mortality rate to 45, IMR to 40, and real world of medical practice is trans-disciplinary in MMR to 140 per 100,000 by 2015 [4]. In Pakistan, many large part [24]. To promote preventive thinking, integra- organizations are working to realize MGD 4 and 5. The tion within departments is recommended [25]. A litera- ture search also shows that exposing medical largest task force involved in this is the system of Lady undergraduates to community-based learning early in Health Workers (LHWs). The LHW program is spon- sored by the Ministry of Health and consists of approxi- their curriculum helps sensitize them to community mately 93,000 workers. They are basically 8th graders issues and that this cannot be achieved through the tra- with a 6-month training course [17]. These health work- ditional curriculum [26]. ers work in rural areas and go from door to door for The Pakistan Medical and Dental Council (PMDC), health promotion and family planning. Family planning which is the accrediting body, also recommends integra- is an issue fraught with mistrust due to various religious tion of preventive and clinical sciences. All important and cultural reasons in Pakistan and this has generated topics that could be helpful in decreasing IMR and mistrust of lady health visitors and a potentially very MMR are included in the curriculum prescribed by good system has not been able to bring any change in PMDC but they are dealt with disjointedly through the maternal and child mortality rates. The Expanded Pro- disciplines of pediatrics, obstetrics, and community gram for Immunization (EPI) is a program funded by medicine. They are taught andexamineddisjointedly WHO, UNICEF, and many others and run by govern- without any horizontal or vertical cross linkage [7]. The ment of Pakistan [18]. It is a big project launched in importance of a maternal and child health module has 1978 and responsible for free immunization of all chil- been recognized and incorporated in learning and teach- dren. Free vaccines are supplied to all basic health units. ing in many parts of the world. Many universities in the It has made its way into the textbooks of pediatrics fol- West are also teaching maternal and child health from lowed in most medical colleges but they concentrate on the point of view of global health and underprivileged the schedule of EPI and side effects of vaccination only. communities. Internet searches led to scores of listing There is no mention of the importance of vaccination and program details for this module but it is taught not as part of undergraduate medical curriculum but rather and its impact on reducing infant mortality and morbid- in masters in public health programs. We found only ity and current burden of vaccine-preventable diseases one example where, under the guidance of WHO, a in Pakistan in local pediatrics textbooks [19]. Disease burden and mortality issues are dealt with by the maternal and child health module has been incorporated Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 7 of 9 http://www.apfmj.com/content/10/1/11 in undergraduate medical education–but nonetheless was 8 weeks previously. On missing her periods she did here again it is taught as a part of community health her home urine pregnancy test, which came out as posi- discipline [27]. tive.Now forthe past 1weekshe hasearly morning nausea and vomiting. She also feels dizzy and weak and Conclusions is unable to perform her chores normally. High infant, child, and maternal mortality rates not only Subtheme: postpartum care of mother: Sajida is are sensitive indicators of any community’s health status brought into the hospital emergency room 6 days after but also reflect the importance given by society to its her delivery with history of high-grade fever for 3 days, most vulnerable members. Maternal and child health heavy vaginal bleeding for 4 days, and burning mictura- issues have been neglected by Pakistani governments tion for 5 days. She reports that after going home she and regulatory bodies and also by the medical commu- has not been feeling well. She stopped taking all medica- nity. Medical educators have not diverted their energies tions advised to her at hospital because her mother-in- toward solving this grave problem. Medical colleges in law told her so. On examination, she is very pale, dehy- Pakistan still spend a large portion of their meager drated, and weak. Her BP is 90/40 mmHg, pulse 126/ resources in teaching medical students about problems min, temp 102°F. Her chest is clear and there is tender- described in Western textbooks. These problems are not ness in her lower abdomen. Speculum examination the major contributors of maternal or child mortality in reveals foul smelling discharge. On bimanual examina- underdeveloped countries. For the undergraduate curri- tion uterus is 18 weeks size and tender. Her left calf is culum to be meaningful in addressing these issues in swollen, hot, and painful. underdeveloped countries, it needs to be modified Subtheme: maternal mortality: Farieda is a 40-year- according to local needs and delivered in integrated old woman married to Hassan for the last 25 years. She fashion. In the development of this module for our and Hassan lived in the Northern Areas beyond the undergraduate students, the basic ideas were modifica- Hunzavalleyin anareacalledSost. Herfamily moved tion of the curriculum to serve local needs, integration to Rawalpindi 3 years ago because they were unable to of various clinical science departments with no subject sustain their living on the small piece of land that Has- boundaries, and promotion of preventive thinking. We san owned. Farida’s mother-in-law and an unmarried received positive feedback from students regarding this sister-in-law live with the couple along with her 8 module through focus groups. Assessment of the stu- children. dents done by various modalities showed a deep under- All of Farieda’s children until the seventh were born at standing of the complex problems contributing to high home by a traditional birth attendant in Sost. She maternal and child mortality in Pakistan. They also wanted to stop getting pregnant after she had her fourth demonstrated adequate skills to prevent and manage child. She was unable to visit the family planning center common problems encountered in maternal and child because the mother-in-law forbade her because she care. We hope that if medical educators start modifying wanted Hassan who was an only son to have more sons. their curricula to address local needs, it will go a long Fariedaand herfamilymoved into aslumareaof way toward solving burning health issues in their Rawalpindi. Her husband obtained work as a security communities. guard and does double duty to sustain his family by working 12-15 hours daily. She works as a maid in 6 Authors information households. Her elder daughter takes care of the home IZ is associate professor of pediatrics at Shifa College of and her younger siblings. She had her last child at Shifa Medicine, closely associated with the development of Foundation Clinic and the child is currently 10 months the integrated curriculum, and has run the MCH mod- old. She breastfed for a few months but was unable to ule three times. Her special interest within pediatrics is continue because her milk was not sufficient especially child nutrition. after working for a long day. This time she presented to AR is a coordinator in the Department of Medical Shifa Foundation Clinic again with amenorrhea for 8 Education. Her work involves assessment of different weeks and was found pregnant. She requested the obste- modules for their effectiveness and impact on students. trician for an abortion but the doctor did not oblige but was sympathetic to Farieda and counseled her and APPENDIX A offered her support to continue the pregnancy. On Sample from study guide examination she was pale and weighed 40 kg (her height SAMPLE CASES was 5 feet 2 inches). The doctor advised her to take Subtheme: care of a pregnant woman: A 26-year-old iron tablets after checking her hemoglobin, which was 6 mg/dl. She was unable to tolerate the tablets because of woman visits your clinic with complaints of nausea and GI upsets so she was not compliant with the drugs. She vomiting for the past 1 week. Her last menstrual period Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 8 of 9 http://www.apfmj.com/content/10/1/11 received tetanus injections in her antenatal visits. She (fundal height measurement, fetal heart auscultation, developed high blood pressure during one of her visits fetal growth and wellbeing, any maternal or fetal com- and was advised bed rest and antihypertensive medica- plaints (vaginal discharge, burning in urine, dyspnea, tions. During her 8th month and still with high blood fever, decreased fetal movements), mother’snutrition pressure, the doctor advised her to take bed rest but she and supplements: maternal malnutrition and obesity, gave a sarcastic laugh and said “Doctor Jee, if I go on anemia, role of folic acid, iron, and calcium, balanced bed rest who will earn for the family? How will so many diet, breastfeeding sensitization: role of breastfeeding in growth development and disease prevention in the mouths be fed? How can I take rest?” child Subtheme: infant mortality: Farieda brings her 2- month-old baby girl to hospital with 4-day history of Complications and referrals: Headaches, raised blood reluctance to feed and 3-day history of shortness of pressure, fundal height (more or less than dates) effect breath. She was giving the baby water and honey on the of maternal diseases on fetal development (diabetes, advice of her elders at home. She brought the baby to hypertension, renal disease, hyperthyroidism, hypothyr- the hospital when she realized that the baby was becom- oidism, TORCH-S, HIV, hepatitis infections) ing worse despite this treatment. Birth weight was not Antenatal examination:Height,weight,complete known because she was born at home with no skilled general physical examination (vital signs, palor, jaundice, help. Farieda says that at birth the child appeared small cyanosis, thyroid, breasts, edema) and systemic examina- but had cried right after birth. Baby on examination was tion (special emphasis on abdominal examination and weak and pale. Her weight was 2.7 kg. Her respiratory pelvic examination–speculum and bimanual), any rate was 80 breaths/minute, heart rate 162 beats per complications minute, and temperature 96°F. Her oxygen saturation SKILL: Abdominal examination, SCIL Lab; pelvic was 73%. She was worked-up for sepsis and pneumonia examination, SCIL Lab and was started on broad-spectrum antibiotics. She died Attitude: Sympathetic approach towards mothers 16 hours after admission. APPENDIX C (Sample questions from the exam) Sample questions from the module APPENDIX B A woman presents with a history of termination of (Sample from detailed curricular content) previous pregnancy because of fetal anencephaly. Karyo- CURRICULAR CONTENT typing was done and was normal. She is planning to get 1. Maternal Health in Community pregnant again. On examination she is pale looking but KNOWLEDGE: Importance of mother’s profile on the otherwise normal. Which of the following will most likely prevent similar outcome in future pregnancies? health of mother and fetus, effect of maternal age, con- sanguinity, maternal profession, radiation exposure, che- a. Ferrous sulfate 60 mg daily micals, toxins, smoking, alcohol, drugs, medications, b. Vitamin B complex nurses, doctors (hepatitis B and C vaccination) gravidity, c. Calcium 1 g daily parity, abortions age of previous child/place of birth/ d. Folic Acid 5 mg daily* mode of delivery/reason for that mode/duration of preg- e. Vitamin E 100 mg daily (Problem solving) nancy/complications of pregnancy, labor, and puerper- A baby boy was born at 37 weeks of gestation with ium/sex of baby/weight of baby prolonged rupture of membranes for > 30 hours. The SKILL: History of present complaints in chronological mother was afebrile and not treated with antibiotics. order, past obstetrical and gynecological history, family Postnatally, the woman complains of severe lower history, history of current social problems and other abdominal pain and offensive blood discharge. Most health issues not volunteered by mother (tuberculosis, probable diagnosis is: diabetes mellitus, hypertension, heart disease, renal dis- A. Urinary tract infection ease),addictions: drugs,smoking,alcohol,substance B. Pelvic inflammatory disease abuse C. Cervicitis ATTITUDE: Sensitization and development of a sym- D. Vaginitis pathetic approach towards problems common among E. Appendicitis (Problem identification) women in Pakistan The baby assessed by on call doctors was well. The TASK: Take one history from foundation clinic and most appropriate step in the management of this baby identify at least three problems. Submit the history on would be: A. Discharge the baby now and follow-up after 1 week following Monday B. Observe the baby in hospital for 48 hours THEME: Antenatal Care C. Wait for the result of vaginal swab then treat the Present state of health/immunization, appropriate maternal weight gain, fetal movements, fetal growth baby accordingly Zaman and Rauf Asia Pacific Family Medicine 2011, 10:11 Page 9 of 9 http://www.apfmj.com/content/10/1/11 27. Searo EG: Review of preventive and social medicine, community D. Do the blood culture of the baby and start antibio- medicine and community health curriculum for undergraduate medical tics if culture is positive education social medicine. New Dehli: WHO Regional Office for South East E. Do the blood culture and treat the baby with I/V Asia; 2009. antibiotics (Problem solving) doi:10.1186/1447-056X-10-11 Cite this article as: Zaman and Rauf: Working toward decreasing infant mortality in developing countries through change in the medical Additional material curriculum. Asia Pacific Family Medicine 2011 10:11. Additional file 1: Appendix D- Feedback Questionnaire. List of Abbreviations CMR: child mortality rate; IMR: infant mortality rate; LHW: Lady Health Workers; MDG: Millennium Development Goals; MMR: maternal mortality ratio; TACMIL: Technical Assistance for Capital Building in Midwifery and Logistics; USAID: United States Agency for International Development Acknowledgements We are greatly thankful to the following for their help and support: Administration, Shifa College of Medicine for the infrastructure; Dr. K.A. Abbas, for advice regarding teaching of WHO programs and breastfeeding; Dr. Ejaz, Dr. Gulshan, and Dr. Saima for exceptional contribution in module delivery and assessment; and the module team MCH 224 for its hard work. Author details Department of Pediatrics, Shifa College of Medicine Sector H/8, Islamabad 44000, Pakistan. Department of Medical Education, Shifa College of Medicine Sector H/8, Islamabad 44000, Pakistan. Authors’ contributions IZ was the team leader for development of the module. She also conducted the major portion of the research on causes of infant and maternal mortality in underdeveloped countries. AR conducted focus group discussion and analysis of feedback questionnaire. Both authors approved the manuscript. Competing interests The authors declare that they have no competing interests. Received: 23 December 2010 Accepted: 28 August 2011 Published: 28 August 2011 References 1. Global Action for Children. [http://issuu.com/scarkonen/docs/ gac_2009_annual_report_web], (accessed August 8, 2010.). 2. Index Mundi. [http://www.indexmundi.com/map.aspx?v=Infant+mortality +rate%28deaths%2f1%2c000+live+births%29&co=as]. 3. Lalji Najma, Thaver Minhal Ali, Kamal Ameera: Maternal Neonate and Child Health (MNCH) research in Pakistan: Trend and transition . J Pak Med Assoc 2010, 60(5):401-403 [http://], (accessed August 19, 2011). 19. Khan PA, Kundi Z: Basis of Pediatrics. 7 edition. Lahore: Zahid Bashir; 2005. 20. Bhutta Z, Cross A, Raza F, Zahir Z: Measure Demographic and Health Surveys.[http://www.measuredhs.com/pubs/pdf/FR200/FR200.pdf]. 21. TACMIL Health Project. [http://www.usaid.gov/pk/sectors/health/tacmil. html], (accessed August 19, 2011. 22. Pakistan Initiative for Mothers and Newborns (PAIMAN). [http://pdf.usaid. Submit your next manuscript to BioMed Central gov/pdf_docs/PDACH527.pdf]. 23. Jones R, Pitama S, Huria T, Poople P, McKimm J, et al: Medical education and take full advantage of: to improve Maori health. NZ Med J 2010, 123:113-122. 24. Smith SR: Towards an integrated curriculum. Med Health RI 2005, • Convenient online submission 88:258-261. • Thorough peer review 25. Cheng TL, Greenberg L, Helen LH, Keller D: Teaching prevention in pediatrics. Acad Med 2000, 75(7 Suppl):566-571. • No space constraints or color figure charges 26. Buckner AV, Ndjakani YD, Banks B, Blumenthal DS: Using service-learning • Immediate publication on acceptance to teach community health: the Morehouse School of Medicine • Inclusion in PubMed, CAS, Scopus and Google Scholar Community Health Course. Acad Med 2010, 85:1645-1651. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Aug 28, 2011

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