改善非洲馬拉威北部公共衛生的相關研究：傳統接生婆受訓後的表現與愛滋病人接受治療的存活分析

Abstract

馬拉威位於非洲東南內陸，總人口約1,300萬人，為全世界低度開發國家之ㄧ。馬拉威人的平均餘命只有50.9歲，新生嬰兒死亡率為每千位活產數83.5個死亡，五歲以下幼童死亡率為千分之100。每名婦女平均生育5.5名小孩，但衛生環境不理想，加上醫療資源缺乏，產婦死亡率高達1,100/100,000。馬國人民主要死因為傳染性疾病，如愛滋病、肺結核、瘧疾、肺炎和腹瀉等。在成人(15~49歲)中愛滋病的盛行率約11.9%，2007年估計全國感染愛滋病人數達93萬多人。 為了幫補馬拉威醫療資源的缺乏，台灣於2000年在馬國北部Mzuzu市興建完成Mzuzu中央醫院，並派駐醫療團協助。屏東基督教醫院自2002年7月接手管理此醫療團。面對馬拉威過高的產婦和嬰幼兒死亡率，醫療團在台灣衛生署支持下在2004-2006年間，共訓練81位傳統接生婆，至2008年八月共接生了1905位嬰孩。結果新生嬰兒死亡率為每千位活產數13.6人，不到馬國全國統計值的一半，接生婆所服務的產婦也沒有人死亡。另外，醫療團為了協助馬國對抗愛滋病，從2004年7月1日起開辦馬國北部第一個愛滋病免費治療門診「彩虹門診」，並研發出「指紋辨識資訊系統」，以登錄病人臨床過程和用藥情形。 聯合國2000年訂定千禧年八大發展目標，其中的四到六項為衛生健康議題，包括第四項：降低孩童死亡率；第五項：促進母親健康；第六項：對抗愛滋病、瘧疾和其他疾病，這三項議題可歸納為婦幼衛生和愛滋病，正是全球衛生的核心課題，也是本論文的主軸。本論文包含兩大部份：(一)婦幼衛生，分析產婦到醫療院所的可近性和傳統接生婆受訓後的表現與再教育對他們的重要性；(二)愛滋病，分析彩虹門診病人接受藥物治療的存活率，分為成人(15歲以上)和小孩(15歲以下)。以下為四篇論文的重點摘要： 第一篇論文：發現距離是產婦選擇生產地點的最重要因素。使用GPS結合Google Earth能客觀測量產婦到達醫療院所需要的距離和時間，有助於醫療可近性的評估。結合此兩種工具，幫助我們了解醫療資源的分布，可作為公共衛生決策上的參考。 第二篇論文：發現經過訓練和再教育的傳統接生婆能夠有良好的表現，她們所接生的嬰孩，死亡率不到全國平均值的一半。接生婆可以是醫療人才不足國家的重要人力資源，但他們需要良好的訓練與再教育，再教育每年應至少舉辦一次。 第三篇論文：發現在接受愛滋病治療的成人中，男性的存活率顯著比女性差，這可能和男性較晚被診斷、接受治療時的臨床嚴重度較高和較差的遵醫囑性有關。這點提醒我們在推廣愛滋病藥物治療時，應注意性別差異可能帶來的影響。 第四篇論文：發現嚴重營養不良，如BMI小於15kg/m2，是愛滋病兒童早期死亡最重要的預測因子。營養不良對於死亡的影響在開始治療的前三個月內特別顯著，所以早期的營養評估和介入應該整合在愛滋病童的治療計畫中。 從2000年開始到現在2010年，已經過了千禧年發展目標預定時間(2015年)的一半，但世界衛生組織評估發現許多國家千禧年發展目標進展緩慢，最大的瓶頸就是專業醫護人員缺乏。本論文從傳統接生婆的訓練和他們受訓後的表現，發現他們可以是潛在的人力資源，前提是要給他們好的訓練和再教育，有良好的監督管理與後勤支援，並把他們納入醫療體系。如果我們能挑選合適的人，將他們訓練成社區衛生工作者，進行接生、轉介危險妊娠到醫療院所、衛生教育、愛滋病母子垂直感染的預防、給營養不良的孩童補充營養等基本衛生照護，將可減少對專業醫療人力的依賴和改善落後地區的婦幼衛生與愛滋病防治。如此，千禧年衛生發展目標才有機會在2015年前圓滿達成。

Malawi, located in southeastern Africa with an estimated population of 13 million, is among the world's least developed countries. The life expectancy of Malawian people is only 50.9 years. The high rates of infant and under-five mortality are 83.5 deaths per 1,000 live births and 100 deaths per 1,000 live births, respectively. Although the total fertility rate averages 5.5 children per womon, the maternal mortality rate is as high as 1,100 deaths per 100,000 live births due to poor environmental health and a shortage of medical resources. The leading causes of death in Malawi are infectious diseases such as acquired immunodeficiency syndrome (AIDS), tuberculosis, malaria, pneumonia and diarrhea. The prevalence of AIDS in adults aged 15-49 years is 11.9% and more than 930,000 people were living with AIDS in this country in 2007. In 2000, the Taiwan government built the Mzuzu Central Hospital in the northern region of Malawi in order to compensate the severe shortage of medical resources and dispatched a medical team to assist in managing the Mzuzu Central Hospital. Since July 2002, Pingtung Christian Hospital has taken over the medical team. To face the challenge of high maternal and infant mortality rates, the medical team trained 81 traditional birth attendants (TBAs) during 2004-2006 with support from the Department of Health, Taiwan and totally 1905 babies were delivered until August 2008. The neonatal mortality rate was 13.6 per 1,000 live births, lower than half of the national statistics and the maternal mortality rate was zero. Moreover, the Rainbow Clinic, the first free antiretroviral therapy (ART) clinic has been opened in northern Malawi since 1st July 2004 in order to fight against AIDS, and furthermore a fingerprint identification information system was developed to record patients’ clinical courses and medication history. The United Nations set up eight Millennium Development Goals (MDGs) in 2000. Three of them are related to health issues: MDG4, to reduce child mortality; MDG5, to improve maternal heath; MDG6, to combat HIV/AIDS, malaria and other diseases. These three MDGs, i.e. Maternal and Child Health and AIDS, are the core issues of current international health. This doctoral dissertation also includes these two issues: (1) Maternal and Child Health, evaluating the accessibility of health facilities for pregnant woman and the importance of continuing education for TBAs and their performance; (2) AIDS, analyzing survival rates of AIDS patients on antiretroviral therapy for adults (aged more than 15 years) and children (aged less than 15 years). Summaries of the four dissertations are listed below. The first paper: The distance is the most important concern of women’s choice of delivery places. GPS and Google Earth were used to measure the distance and time needed for pregnant women to reach health facilities. The combination of these two tools helps us to know the resource distribution and the accessibility of delivery services, which may be helpful for public health planning and policy making. The second paper: Through initial training and continuing education, TBAs are able to have a good performance in decreasing the neonatal mortality rate to less than half of the national statistics. Well trained TBAs under regular supervision and continuous support can be a potential human resource for countries lacking medical professionals. We recommended that continuing education should be regularly provided, at least annually. The third paper: The mortality rate was significantly higher in adult males than in adult females with AIDS on ART. This may be associated with the delayed diagnosis, seeking for medical care in a more advanced clinical stage and poorer compliance to therapy in male patients. The gender difference needs to be addressed in scaling up ART programs in Africa. The fourth paper: Severe malnutrition, indicated by BMI <15 kg/m2, may be the most significant prognostic indicator for premature mortality in children on ART. The first three months after starting ART is the golden period of nutrition assessment and intervention, especially for malnourished children. Early and proper nutrition support should be integrated with ART management. From 2000 to 2010, half the MDGs time frame (2015) has passed, but WHO found that the progress of MDGs in some under-developed countries is very slow, mostly due to the shortage of medical professionals. This doctoral dissertation found that TBAs can be a potential human resource, if they can have a proper training and continuing education, under regular supervision and logistic support, and are also well integrated into the current medical system. For example, if we can select good candidates and train them to become TBAs or community health workers, they can do some primary cares such as delivery service, referring high risk pregnancy to health facilities, health education, prevention of maternal-to-child HIV transmission (PMTCT), and nutrition support for malnourished children. They are able to reduce great burden of medical professionals and improve the maternal and child health as well as AIDS control in remote rural areas. Then, there will be an opportunity for us to accomplish MDGs by the end of 2015.