Position Paper on Maternal and Infant Mortality in the Democratic Republic of the Congo

By David V. Strider, RN, CCRN, MSN , BB( ASCP), ACNP

May 4, 2010

The Democratic Republic of the Congo (DRC) has one of the highest infant mortality and maternal mortality rates in the world. In 2007 the infant mortality rate was 108 per 1,000 live births, which reflected only a 15% decrease over two decades. In 2007 the DRC maternal mortality rate was 1,100 per 100,000 live births. We know that 161 DRC children will die, for every 1,000 children, before they reach the age of five. Various surveys affirm that at least 76% of the DRC population is undernourished. Only 36% of the DRC infants receive exclusive breastfeeding. (World Bank Group Data Profile for Democratic Republic of the Congo, 2010).

Compounding the maternal and infant health problems are the high
prevalence of malaria, HIV/AIDS, and the escalation in tuberculosis. 30% of DRC children under the age of 5, who have presented with a fever, were placed on anti-malarial drugs. At least 400,000 DRC individuals have HIV/ AIDs , and 37,000 of these individuals are children. There are currently more than 270,000 DRC orphans, that have lost their mother and/or father, due to HIV/AIDs. Only 27% of young DRC women and children who have HIV/AIDS are receiving antiretroviral therapy. Recent studies demonstrate that 20.1% of all DRC births involve women between the ages of 15-19 years of age. Of note, 27% of DRC women and men aged 15-24 have had sexual intercourse before the age of 15. Only 21% of DRC women use some type of contraceptive device, and only 16% of DRC males use condoms when having sexual intercourse. The incidence of tuberculosis in the DRC has more than doubled, from 165 / 100,000 in 1990 to 392 / 100,000 in 2,007. (World Bank; Millenium Development Goals, 2010) .Only 46% of the DRC population has access to safe drinking water, as compared to 43% in 1990. The overall life expectancy at birth for a child born in the DRC today is 46 years, which reflects NO change from that of 1990. The magnitude of these major health care issues in the DRC escalate as the population expands, from 50.7 million in 2000 to 64.2 million in 2007. (World Bank Group Data, Profile for Democratic Republic of the Congo, 2010; and World Bank Group, Millenium Development Goals for DRC: 2010)

The DRC has the third largest population and the second largest surface land area in sub-Saharan Africa. The DRC has abundant mineral resources, rich soils for farming, and has the second largest rain forest in the world. The DRC has undergone tremendous economic and political challenges in the last 50 years, which has led to erosion of infrastructures and instability due to ongoing fighting between the militia and remnant warlords. Many Congolese enterprises lost their assets, staff, and commercial ties. Currently , much of the DRC economy is based on subsistence agriculture, with a loss of the previous export and other value adding initiatives. The DRC GDP per capita has plummeted from $330 in 1960 to $139 (2006), such that the Congolese income per capita is one of the lowest in the world. The DRC has continued to experience large scale displacement of villages due to wars in the eastern provinces, violence and human rights abuses, rape of women as a
common place occurrence during war campaigns, and lack of adequate roads, electricity,and other basic fundamental infrastructure tenets. (World Bank Poverty Reduction Strategy Papers; 2008) .International groups have reached out to support the DRC, but the needs are so diverse and huge, that little progress can be seen on the health care and the economic fronts. The World Bank has worked closely with the DRC government and other Congolese leaders to craft the Interim Poverty Strategy Paper, the Transitional Support Strategy, and the Country Assistance Strategy, all of which reflect five fundamental tenets of long term recovery for the DRC

(World Bank Projects and Programs; 2007)
1. Curbing the spread of HIV and AIDS
2. Improving access to social services and reducing vulnerability
3. Consolidating macroeconomic stability and economic growth
4. Promoting fair governance and maintaining peace
5. Improving community dynamics. This coordinated plan has been developed in conjunction with the feedback and guidance of 20 other major international donors, to include but not limited to the United Nation agencies, International Monetary Fund, the European Commission, United Kingdom, United States, Germany, France, Belgium, Japan, and Sweden. (World Bank Poverty Reduction Strategy Papers, 2010; World Bank Data and Statistics, 2008). The World Bank currently oversees 14 active projects in the DRC, representing 2.2 billion U.S. dollars in commitments. However, of these fourteen (14) large projects in the DRC, only two of them (Multisectorial HIV / AIDS project, and the Health Sector Rehabilitation Support project), representing only 12% of the total donated funds, are directly related to health care issues. Furthermore, many of these initiatives are focused on the urban areas in the DRC, with very little making it out to the rural provinces of the Congo, where there are few roads or bridges.

Ongoing resources and creative, robust , and assertive approaches with consistent funding streams and carefully planned step-wise projects will be required to address and improve the DRC maternal and infant health care. The gap in maternal and infant health care between western industrialized countries and that of the DRC is huge, but it can be narrowed by focused long term programs directed at these glaring human inequities. (World Health Organization, 2005). Rationale to improve the DRC’s maternal and infant health through the direct aid of developed countires derives from the concept of Beneficence. (Beauchamp and Childress, 2009). The principle of positive beneficence bubbles up from the following grounding concepts:

1. Protect and defend the rights of others
2. Prevent harm from occurring to others, which includes removing known harmful agents.
3. Assisting persons with physical and / or mental disabilities
4. Rescuing individuals in danger.

The concept of obligatory beneficence serves as one of the driving forces to enlist wealthier countries to provide assistance for the maternal and infant health care of poverty stricken countries such as the DRC. The infant has a “right “ to live. Such right does not imply that the infant’s living conditions will be equal to that of a baby in the wealthier country, who may be born in a hospital with Post-natal shelter including her / his own nursery room, several pairs of clothes, and toys. However, the infant born in the DRC has a “right” to life, which implies in its crudest term the avoidance of death. To assure that death does not occur, the infant needs nutrition, hydration, warmth, and medications (immunizations) to reduce the likelihood of polio, measles, mumps, and rubella. The infant also needs treatment for HIV, malaria, tuberculosis, and / or any bacterial induced diarrhea, which may require a long course of one or more medications. Low birthweight babies have a right to the additional thermoregulation, concentrated nutrition, and prophylaxis for infection, to maintain their life. The infant care for the DRC baby can certainly be different, and not as resource intensive, as the care for a similar baby in a developed country. In short, the care rendered to the DRC babies may be unequal to that rendered to the developed (richer) country’s babies. As noted by Aristotle, “equals must be treated equally, and unequals must be treated unequally.” The same obligatory beneficence supports the notion of removing harmful agents, such as a mosquito net to decrease the risk of malaria, and a shelter off the rain forest floor to minimize the infant’s death by a reptile or other wild animal. The infant is extremely vulnerable, and if not protected from the elements, may very likely die. The obligatory beneficence framework also supports the notion of saving infants who are in danger due to delivery or postnatal complications (prolapsed cord, breached placenta, severe maternal hemorrhage, erythroblastosis fetalis, and persistent patent ductus arteriosus), with such rescue being an integral part of the beneficence construct.

The notion of obligatory beneficence also carries over to the mother. The mother has a “right” to not die during or after her childbirth. Such maternal care will incorporate prenatal, deliver y, and post-natal surveillance and treatment of the mother. This care would identify any prenatal conditions such as preeclampsia, membrane rupture, severe hypertension, uncontrolled hyperglycemia related to diabetes, aortic dissection, and retained placenta. The mother has a “right” to receive these basic interventions that would maintain her life as well as enable her to retain the strength to care for her baby . Again, the care for the mother does not need to be equal to that of a woman in a developed country, as long as the care rendered keeps her from dying and helps her maintain her capacity to care for her infant. Hamric and Delgado (2010) outline the principles and rules important to professional nursing practice, and Beauchamp and Childress (2001) echo similar principled analyses with associated guiding rules. Using their definitions, the Principle of Beneficence, involving the duty to “do good and prevent or remove harm,” clearly targets the driving force to render assistance to these severely deprived, malnourished, war-stricken women and children in the depths of the Congolese rain forests . The Rule of Veracity (the duty to tell the truth and to not deceive others) applies to any attempt to provide focused resources to this unfortunate population, since there is significant potential for diversion of funds to Congolese warlords, greedy health ministers, military officers, and other government officials. (American Nurses Association ; Code of Ethics, 2001).

Veracity helps maintain the spotlight on actually delivery of and utilization of the goods and services by the impoverished target population. The Rule of Fidelity is also paramount in this situation , in that any commitments that are made by donors and / or care providers will be completed, to the fullest extent that is possible, within the confines of donated resources, available trained health care professionals, and achievement of access to such goods and services by these underprivileged mothers and children. The American Nurses’ Association’s code of Ethics supports the need to address the inequities in the DRC regarding the very high infant and maternal mortality.
Wendy Austin (2007) notes that “Making globalization an inclusive and positive force may be the central challenge of this millennium. The United Nations Millennium Declaration (2000) outlined eight goals that the world inhabitants need to attain if the lives or our citizens are to be improved. Goals 4 and 5 involve the reduction of child mortality and maternal mortality, respectively, and Goal 6 addresses the treatment and reduction in the incidence of HIV/AIDS, malaria, tuberculosis, and other serious infectious diseases in underdeveloped countries. By addressing Goal 6, one will enhance the likelihood of making progress in pediatric and maternal health (Goals 4 and 5). Austin argues that we, as care providers in a developed country, have an obligation to assist individuals who are far less well off than their peers in developed countries. The impetus to assist these individuals stems from their rights to health, regardless of gender, race, religion, ethnicity, and social status, and the right to a standard of living that includes adequate food, clothing, housing, and medical care. Austin provides a number of examples of communities in underdeveloped countries where there are very few health care resources and few stopgaps to prevent childhood death from acute respiratory infection, malaria,tuberculosis, and HIV/AIDs. Despite her failure to directly impose an ethical construct for dealing with the profound health inequities in many of the African, Far East, and central American countries, she paints a rich picture of what the children and women do not have. The principle of beneficence appears to fit nicely with such glaring health care needs of the children and mothers, and certainly those individual in the DRC would fall into this category.

Allocation of resources to provide basic infant and maternal care to the infant / mother dyad may also be validated by the principles of distributive justice. (Beauchamp & Childress, 2009); with the distribution of basic infant and maternal health care, based on need. Most Congolese childbearing women have a need for an experienced health care provider to offer prenatal counseling and surveillance, to preside during the actual delivery of the baby, and to provide direct care for the mother and baby during and immediately after the delivery. The health care provider also must evaluate the mother and baby at regular intervals for at least 24 hours after the delivery, and then at weekly intervals for the next month to make sure the mother is recovering and the baby is obtaining adequate hydration and nutrition. This need may not be equal among Congolese women, in that the 15 year old primapara diabetic woman may need more medical assistance than the multipara woman who had no pre-existing medical comorbidities. The Egalitarian theory, as espoused by John Rawls, supports the premise that all childbearing women should receive the basic resources necessary to avoid death or serious illness prior to, during, and after the delivery of their child (children). Furthermore, infants (who are one of the most vulnerable in the human lifespan, due to their inability to protect themselves and communicate) also should be afforded a distribution of goods and services within the health care domain to maintain the life of that infant. (Beauchamp and Childress, 2009) The scope and magnitude of perinatal resources allocated to each infant may vary,based on the specific basic physiologic needs of that infant.

Norman Daniels suggests that for such a Rawlsian concept of justice, health care needs are unique and that fair opportunity is a key component of this type of justice. As long as each patient receives the minimal goods, services, and resources to maintain life and avoid undue suffering, there can be considerable variation in the degree and amount of additional health care resources allocated to these same patients. This Rawlsian construct validates the construct of “equal access for each mother and infant in the DRC to a minimal, life-sustaining mode of health care.” Such delivery system would include the focused , timely treatment of life threatening diseases such as HIV/AIDs , malaria, typhoid, and tuberculosis. Daniels, Kennedy, and Kawachi (2002) suggest that the relationship between socioeconomic status and health is not fixed and that the health achievement and accomplishments by countries is mediated by factors other than wealth. Therefore, allocation of additional dollars or money to such underdeveloped countries may not have as much impact on the societal recognition and des

Dispensing of medications will have a more pronounced and enduring effect on the health of such patients. Rawls’ acknowledges socioeconomic in equalities, and describes his “difference principle” where health inequalities between societies are permitted long as the “Worst off groups are provided with the opportunity to be as well off as possible. “ Like Aristotle, Rawls appears to acknowledge that the administration of justice and subsequent allocation of goods / service / for different , unequal global communities may result in unequal allocation of such resources over time.

Danis and Patrick (2002) describe the notion of “vulnerable populations,” which include individuals who are “at risk at any particular point in time for unequal opportunity to achieve maximum possible health and quality of life, because of differences in intrinsic and extrinsic resources that are associated with good health. “ The term , vulnerable populations, includes but is not limited to mothers and infants, persons with chronic illness, disabilities, HIV/ AIDS, living in substandard housing, immigrants, and refugees. Of note, most of the above descriptors can be applied to the Congolese rural inhabitants

Rawls (1999) and Daniels (1985) describe the social contractarian approach to justice, where the distribution of goods and services to those individuals with distinct, measured needs depends on three factors:
- Placement of oneself in the original position of the patient
- Justice principles that note certain particular considerations as morally relevant
- Priority rules for these principles of distributive justice
Rawls stipulates the importance of apportioning out goods and services in a way that is (1) reasonably expected and to everyone’s advantage, and that (2) is attached to provisions and offices open to all. In his commentary , Danis notes that any donation of resources must improve the
well –being and outcomes of the least advantaged members of society. In other words, a distributive justice construct for maternal / infant health care aid to the Congo permits the allocation of medication, food, treated water, and direct health care services to the most wealthiest war lords and diamond mine owners, as long as the poorest refugees, orphans, and maimed war victims in the rural Congolese rain forest also receive similar services.

Hamric and Delgado (2009) note that issues of access and distribution of resources create powerful dilemmas for Advanced Practice Nurses (APNs), many of whom care for underserved populations. It is likely that moral distress will arise and escalate amongst those nurses who are providing direct care for the many Congolese infants ( many of whom are orphans) and unhealthy pregnant teenagers and young adults, where there is not only poor access to care, but gross inadequacy of health care resources at the traditional health care clinics in the DRC.

A counter argument to this position , that would not suppor t the timely, carefully planned provision of basic infant and maternal health care to each of the DRC child-bearing women, is the Utilitarian approach. Utilitarianism, or consequentialism, suggests that the most appropriate intervention for any health care circumstance is one that yields the best overall result, based on the value of well-being for the patient(s). Such well-being may be measured in terms of pleasure, happiness, preference satisfaction, or general welfare. Utilitarianism espouses the salient principle of utility, where we should aim to do the greatest good for the greatest number of individuals. The foundations of the utilitarianism approach emanate from the work of Jeremy Bentham and John Stuart Mill. There is often disagreement as to which values should be maximized in the utilitarian approach. In terms of the utilitarian approach for infant and maternal basic health care in the DRC, the notion of such consequentialist paradigm can be appreciated by the following excerpt from a letter I received, when asking specifically for donations to a non-profit program aimed at maternal / infant health care in the Congo:

“ My friend, I admire your cause to help these poor people. But I feel as if giving money for this is like throwing it down a black hole. I do not know where it will end up. Until the African men get a handle on the birth control and the government does something on family planning, I do not want to commit my money to this cause. I would rather donate to causes in the States where I am fairly certain of the outcome. I am sorry I cannot help you at this time, and I commend you for your interest and commitment to this cause. ” (Personal Communication from citizen in Virginia, Anonymous, 2009).

In the above anonymous monologue, the potential donor stipulates that he wants his donation of goods and resources to do the most good for the most individuals. The United States maternal / infant program to which he has donated in the past has measurable and timely progress makers, which he can attribute as due partly to his generous donations. There is no certainty where the DRC donated money is going, due to the governmental inefficiencies and the existing disconnects between the National Health Ministries in the Congolese districts and the childbearing women living on subsistence farms in the rain forests. The anonymousdonor has less assurance that his donation will actually

make it to the intended recipients. Even if his donation does make it to the village, and a paid nurse midwife sets up a facility for prenatal care and emergent deliveries, what about the simultaneous issues of nonpotable water, the deficient sanitation systems, the concerns with HIV in her father, and lack of enough anti malarial medication for the mother, who currently has malaria? The returns for any maternal / infant health care donation will clearly be more consistent and predictable in a developed country that already has adequate disease control interventions, maternal / infant delivery structures in place, and well defined post-partum surveillance.
Munson (2000) notes that utilitarianism approaches produce the most benefit for the least cost. The action that is taken may produce some unhappiness, but it balances happiness over unhappiness, such that actions are correct or acceptable to the extent that they enhance the notion of happiness or Improved well being, even if it requires the creation of “unhappiness” in some members of the community. As a consequentialist theory, the utilitarianism approach weighs in heavily on the outcomes or consequences of actions, in terms of assessing the moral “rightness” of an action. In other words, the means are not important, as long as the desired end result is acceptable.
With this utilitarianism approach, one could do the following approach:
- Set up a clinic in one or two large cities, and provide extensive prenatal care
- Only those women who seek to come to the clinic will get the prenatal care.
- Exclude any women under the age of 18 or over the age of 40, or any
known diabetic women, since these are high risk mothers who may have
delivery problems
- Require all women to attend family planning class. Those who do not attend will be
released from the clinic roster.
- Eliminate all women who have HIV/ AIDS, active malaria, or tuberculosis
As you can see, this approach will maximize success in the maternal population , by carefully selecting those women who have easier geographic access, who have some means of transportation to get to the clinic, and who are not in higher risk categories based on age or pre-existing infectious diseases, and who are committed to family planning (smaller families, more attention by mother to each child) and are likely to be compliant with prenatal care.
The utilitarian approach, at best, will ignore the allocation of goods and services to the pregnant teenagers and those with active infectious diseases or other systemic conditions. The maternal morbidity / mortality rate and the infant mortality rate will most likely be decreased significantly by such a utilitarian program,with a minimal investment due to pre-existing infrastructures (hospital in the city) and personnel (health care workers already employed in the city) , so this will yield a high benefit for a low cost. Of course, such a utilitarian approach does little for the many women and infants (many of whom are orphans) in the rain forest, and for those women in the city who have HIV, malaria, and /or TB. The Utilitarianist would say that these women will most likely die soon anyway, as will their infant due to disease transmission and severe malnutrion, so why invest an abundance of resources in such clients when the long term return is an early death? Furthermore, many of these women in the depths of the rain forests and river valley unreachable by roads, are almost forgotten by the government, and their deaths, as well as the deaths of their infants, will most likely go unnoticed since the government statistics bureau does little to capture such outreach citizens. In a utilitarian approach, the truth can be “bent” a bit and former commitments can be altered, as needed, to achieve a positive end result. The utilitarianists feel strongly that the ends, as long as they incur positive outcomes, will justify the means of attaining such outcomes. Thus, deliberate exclusion of certain subpopulations of women and infants and tailored commitments to those women who have good health behavior patterns and low risk profiles, as a means, are justified if the end result of lower maternity and infant mortality in the targeted population is achieved.
The communitarian theory to justice (Beauchamp & Childress; 2009)also challenges the unilateral allocation of goods and services to those rural outposts in the rain forests of the Congo. Have the communities or village leaders asked for more maternal and / or infant health care? Although there may be no nurse midwives in the village, there is a neighbor who has experience with prenatal care and often childbirths. The maternal mortality of 1100 / 100,000 may be an accepted part of their culture, along with the 10.8% infant mortality . Women have more children, knowing that one of them may die during their infancy. Powerful superstitions also surround the process of Congolese childbirth in the rain forests, such as eclampsia related seizures being a sign of evil spirits, and the ingestion of eggs by a pregnant mother (en excellent and readily available source of protein) as causing baldness in the infant. The communitarian theory permits the allocation of some resources, that would be normally sent directly to the care providers for the maternal / child basic needs, to the village council or other clearing body, and they in essence determine how such resources are used. The communitarians emphasize the responsibility of the community to the person ,and the accountability and responsibility of the person to her / his surrounding community. The solidarity engendered by such communitarian models may serve as a local “clearinghouse” for any distributed goods / services offered by outside benefactors.
The guiding theme for my ethical position on the allocation of scarce health care resources to the Democratic Republic of the Congo is centered around the preservation of life and the minimization of suffering for mothers and infants prior to , during, and after the childbirth experience. As human beings, I believe that each infant as well as her / his mother has right to live. With this premise, basic interventions should be deployed to afford the mother a protective prenatal,delivery, and post-natal experience. Such interventions should include life-saving measures such as emergent cesarean section, dealing with prolapsed cord, magnesium for eclampsia, and rapid fluid replacement for extensive blood loss. The same parallel interventions should be present and readily available to all for safe delivery of the infant and possible infant resuscitation during the early post natal phase, and later adequate nutition and hydration, even if this requires a temporary nasoenteral tube, for the infant. Concomitant administration of antiretroviral agents and antimicrobials for HIV/AIDS, malaria, tuberculosis, and other possible parasites is also a critical part of this fundamental care for the maternal / infant experience. Denial of these services runs the risk of death in the mother and /or the infant, which in our Rawlsian construct of egalitarian justice, is an unacceptable outcome.
There are numerous policy implications related to this preferred position. It will be paramount to recognize existing structures for such specific health care missions, and to work with these entities as much as possible. The initial conversations would most likely occur between the potential donor(s), the overseeing health care entity, and the local health ministers in the Congo. A careful assessment would need to be made of the existing health care delivery system and available resources for maternal and infant care. There would have to be agreement with the health ministers and the community leaders as to the importance of reducing both the maternal and infant mortality. Buy in from the national DRC ministers , local (provincial) community leaders, and the designated caregivers is essential. The DRC national ministers should be provided with a measurable plan for specific interventions, with endpoints being a reduction in infant and maternal mortality. The type of prenatal guidance and counseling should be written out and should be easy to follow by a trained provider. It would be reasonable for the initial interventions to be focused on certain geographic localities, such as a “pilot region.” The field minister (public health medical director for the province and the local public health nursing directors need to be apprised of this planned maternal / infant program. Again, each specific intervention, such as duration and number of prenatal visits, venue for delivery (done in a clinic, hospital area, village school, or in a person’s home) , and designation of the care provider who attends each delivery) needs to be written out clearly before the start of the program.
The next critical juncture is the determination of personnel for the direct care providers for prenatal / perinatal / postnatal experience for the DRC women. Will these care providers be experienced, trained residents of the Congo, or will they be “foreigners” who will be brought in for this mission work. The key service delivered to the DRC women and their respective newborn infant will be prenatal and perinatal care, which involves specialized training. A sustained maternal / infant health care program will be more likely to thrive if the primary caregivers , advanced nurse midwives, are natives to the land itself. If this is the case, these Congolese nurses will most likely need additional training. There are several very good clinical / didactic programs in South Africa, such as the one in Durban (University of McCord), which will render an advanced nurse midwifery certification in only 18 months of intense training. Such caregivers will be the backbone of the Congolese maternal / infant mortality reduction initiative, and will require this caliber of training to operate in a fairly autonomous, efficient, safe, and highly productive manner in clinics and village in the rural provinces of the DRC .A concern with such additional training for Congolese nurses is the potential for such health care providers to leave the Congo, once they have received their advanced practice training in nurse midwifery, and take a job in a developed country with a much higher salary. Aiken (2004) and Chaguturu (2005) both describe the outflowing of trained health care providers, particularly nurses, from developing countries to more affluent, developed countries, where working conditions are generally better and the salaries and other employer benefits are substantially better. Retention incentives, as well as educational tuition grants tied into a 2 to 4 year non-moving clause, will be needed to minimize the potential migration of highly trained nurse midwives out of the Congo. Dwyer (2007) notes that health care providers who leave poor countries to work in more prosperous countries are “exercising an important human right and helping rich countries fulfill their obligations of social justice. These same health care providers also create problems of social justice in the countries they leave. Solving these problems requires balancing social needs against individual rights (autonomy) and studying the relationship of social justice to international justice.”
Key to the support of this maternal / infant Congolese initiative, once the above names parties are mobilized, is a consistent source of funding for the program. Such funds may emanate from the World Bank as a grant,from United Nations, from private but well know philanthropies such as the Gates fund, the White Ribbon Alliance, and the WeAreOne fund. Securing of funding source for this initiative is critical.
Once funds have been secured for this initiative, implementation timelines and checkpoints for accomplishment along each aspect of the initiative need to be set. There could be a non-profit entity established in the United States or other non-African country, if there is a concern that donated funds could be diverted by the DRC government officials. This non-profit “Board of Directors” would report directly to the donating entity AND to the Congolese national health ministries, on the progress with the initiative. Holding the donated funds from Grant allocations in a United States bank and sending specific funding to the Congolese maternal / infant centers directly will decrease the likelihood of cash diversion by Congolese intermediaries. Quarterly reports on the progress with each maternal /infant clinic in the rural Congolese provinces would be written and sent to the national health ministers and to the supporting Grantor, and would be available on the website for public scrutiny.
Hamric and Delgado (2010) describe the four phases of core competency in ethical decision making for advanced practice nurses (APN). The first three phases: Knowledge Developmnent, Application of the knowledge (moral action), and Creation of an Ethical Environment, lay the foundations for the fourth phase, “Promoting Social Justice within the Health Care System.” This fourth phase requires the APN to understand existing health policies affecting a specialty population and to be proficient in the skills of community advocacy, multimodal communication , and consistent leadership.
Hamric and Delgado validate the importance of this fourth APN phase in ethical decision making, and challenge us to push up to this level through ongoing collaboration with our health care teams, sensitivity to driving political forces in the community, and patience to sort out and cultivate the attention and trust of informal and formal leaders within the local community, state, and federal level who have the motivation and power to catalyze changes in how precious health care goods and services are allocated to those patients and families in need.
Such coordination of an initiative to significantly improve the maternal / infant health care in a very impoverished, war ridden country with lacking infrastructure is a rather daunting task. The statistics demonstrating extremely high maternal and infant death rates ( one of the highest in the world) and the associated disease conditions, dearth of family planning, and malnutrition make this a ve y complex challenge but one that is well worth the climb. The constructs of obligatory beneficence and the Egalitarian perspective of distributive justice support the need to bring basic health care services to the Congolese provinces so that prenatal, perinatal / delivery, and postnatal care can be improved and so more mother s and infants can live. No mother deserves to die giving birth to a child, and every infant needs to have the opportunity to celebrate her / his first birthday.

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