Using Maternova Products with Maasai Women at the last mile in Tanzania

Maternova — Fri, 27 Jan 2012 16:12:47 +0000

This is truly the 'last mile' as they call it. Here is a note from a recent trip to Northern Tanzania:

"Our (a M. D. and myself) work in Northern Tanzania was difficult but fulfilling. We were providing services in a Maasai area that people have to walk more than 10 miles to get medical services. Even in a car it takes 45 minutes because the roads are so bad. The government has set up a clinic out in this area, but besides building the building, they don’t really keep it stocked or staffed. Most people don’t even go because they can’t do anything. We had people walking over ten miles from up in the hills to come to our temporary clinic.

We saw many sick children, older adults with chronic achy joints and upper-respiratory problems, malaria, malnourished children, dehydrated children, screened the school children and de-wormed them, and screened the pregnant women and gave out clean birth kits. Unfortunately, during the 2 weeks we were there, there were no births we could assist with. We never were able to see all the people who came to the clinic to be seen. We had to triage the most severe cases to be seen first, others had to come back another day to see if they could be seen. It was very difficult to send people away, but our hosts felt it was important to try to get out of there by dark.

The attached picture shows me using the hemoglobin test strip and you can see the scale sitting on the table to my left. We screened around 50 pregnant women with the hemoglobin strips and started treatment with pre-natal vitamins with iron appropriately. We also tested a few of our children who were so sick or malnourished. It worked well for us, and it was so nice to have the capability to test for anemia in a rural setting without lab capabilities.

The other item we used quite a bit was the visor headlight. There was no electricity at all in the village where we were working, so besides using it for a spot light for medical exams or treatment, we also used it to see what we were doing as we never were able to see all the people who came to our clinic, and sometimes we worked past dark. Then we got to our hotel back in the closest town where there was accommodations, the electricity was off almost daily for periods of times. The visor headlight was very useful.

We ended up leaving the rotary cell phone charger at the village where we were working since so many of the people have cell phones, but with no electricity they have a difficult time keeping them charged. They were thrilled to have the rotary charger to use when needed.

Thank you for your help by providing resources for us to use on our first medical mission to the rural Maasai people of Northern Tanzania."

Debbie Winn

Argentinean car mechanic's inspired idea for safer birth: The Odon Device

Maternova — Thu, 19 Jan 2012 18:01:19 +0000

odon device

The following post is cross- posted with permission from the Healthy Newborn Network's Technology and Innovation for Maternal and Newborn Health. It was originally posted on (USAID's IMPACT blog)[http://blog.usaid.gov/].

It all started with friendly bet amongst friends – who could get a cork out of an empty wine bottle with only a plastic bag? The friends had seen the trick on YouTube earlier and wanted to re-enact it.

Somehow, Saving Lives at Birth finalist Jorge Odon, an Argentinian car mechanic with no medical background, drew a connection between the trick and obstructed labor, which is a major contributor to maternal mortality. The idea came to him in the dead of the night. Inspired, he woke up his wife to share his idea.

She told him to go back to bed.

Eventually, his persistence led him to patent the idea. He then worked with national and international partners to further develop a device that is now a reality and being tested. The Odon device is an example of human ingenuity and a keen ability to recognize the practical application of simple scientific concepts.

The Odon Device is made of film-like polyethylene material that can help facilitate the birth process and may provide a safer alternative than forceps and vacuum extractor for assisted deliveries. Moreover, in settings with limited surgical capacity and human resource constraints, it may be a safe alternative to some Caesarean sections since it could be used by mid-level providers or in facilities lacking the surgical capabilities for Caesarean section.

The Odon Device has potential for wide application in resource poor settings. If proven safe and effective, the Odon Device will be the first innovation in assisted vaginal delivery since the development of forceps centuries ago, and the vacuum extractor which was developed decades ago. By reducing contact between the baby’s head and the birth channel, the device could also prevent infections acquired during delivery.

Post was written by: Karen Clune, USAID and Mario Merialdi, World Health Organization

120 year old Method of Fetal Monitoring where there is no Electricity

Maternova — Tue, 17 Jan 2012 16:59:07 +0000

pinard horn

Fetal heart rate is an important indicator of fetal health. For this reason, significant resources have been employed adapting ultrasound machines for use in low-resource settings. However, for over a century doctors and midwives have successfully monitored fetal heart rate using a more basic method—a type of stethoscope known as the pinard horn.

This simple device can be made from wood, plastic or aluminum, and is inexpensive, portable and durable in comparison to ultrasound machines. On one end is a cone-shaped opening, which is placed on the pregnant abdomen. On the other is a flat surface, which is held to the ear. Sound is conducted from one end to the other through a hollow tube, which amplifies the sound of the heartbeat.

Use of this instrument requires practice to locate and correctly assess fetal heart rate, which can sometimes be obscured by ambient sounds or the position of the fetus. The sound is best heard over the fetus’ back beginning at 18-20 weeks of pregnancy, and has been described as subtle—like a muffled watch ticking, or like a vibration in the ear. According to the sound quality of the heartbeat, an experienced birth attendant is also able to determine the orientation of the fetus, which can help detect breech births. Though we know anecdotally that the Pinard Horn or ‘fetoscope’ is used in many low resource settings, overviews and studies of effectiveness are non-existent.

We have seen field reports including this report from Malawi and this from Uganda and in this basics of maternal and newborn care guide by JHPIEGO.

The device was invented in 1895 by French obstetrician Adolphe Pinard—a champion for modern perinatal care. Pinard was an advocate for providing adequate housing and nutrition for impoverished pregnant and post-partum women. He was also a proponent of breastfeeding, hygiene for preventing infection, and non-separation of mother and baby at birth. Today, these practices are part of routine perinatal care procedures.

In form and function, the pinard horn resembles the very first stethoscope developed in 1816 by René Laennec. Laennec’s stethoscope in turn was modeled on the ear trumpet, an early form of hearing aid that utilized a bell shape to collect and amplify sounds, and a long tube to direct sounds into the ear.
A more recent incarnation is the fetoscope, which combines the technology of the pinard horn and the conventional stethoscope. It relies on a flat bar that is held against the forehead of the listener. This helps direct the sound of the fetal heartbeat through the earpieces of the stethoscope.

We are very interested in any reports or studies comparing the Pinard Horn to electronic fetal monitoring.

The image in this post is from Flickr and is: "KITGUM, Uganda, Oct 20, 2009 -- Stella, the head midwife of the Pajimo Clinic in rural Kitgum, Uganda, uses a Pinnard Horn - a wooden listening device to listen to a baby's heartbeat. The expectant mother was rushed into the clinic where Stella and a two Army Reserve Soldiers with the 7225th Medical Support Unit helped her deliver a 5.5 lb. baby boy about 90 minutes later."

A simple recipe to save 40% of newborns and 50% of mothers

Maternova — Wed, 11 Jan 2012 14:54:07 +0000

Let’s sum it up simply—to save mothers we need to manage postpartum hemorrhage, eclampsia and sepsis. To save newborns it’s: breastfeeding, antenatal care and close management of hypothermia and pneumonia. During October’s MH Buzz Meeting, Dr. Zulfiqar A. Bhutta of Pakistan’s Aga Khan University drove home the value of simple, evidence-based interventions for maternal and newborn health and the work out of Aga Khan.

Based on the 2006-07 Pakistan Demographic and Health Survey (the first to examine cause-specific maternal and child mortality), he reported that the leading cause of maternal mortality is postpartum hemorrhage, followed by sepsis and eclampsia. The survey also found that the major causes of death among children under five are birth asphyxia, sepsis, pneumonia, diarrhea, and prematurity.

In an effort to prevent these conditions and to curb maternal and child mortality worldwide, in 2005 Dr. Bhutta conducted a comprehensive review of the evidence for community-based neonatal health interventions. Among the most cost-effective measures were antenatal care, breastfeeding, and close management of low-birth weight newborns for hypothermia and pneumonia. Indeed, "saving newborn lives does not require pulse oximeters, incubators and fancy equipment,” he stressed at the MH Buzz Meeting.

On December 15, 2011, these findings were affirmed with the release of a three-year study aiming to establish a “global consensus” on evidence-based interventions that have the potential to save up to 40% of newborns, and to half the maternal mortality rate. The study, conducted by the WHO, Aga Khan University and the Partnership for Maternal, Newborn & Child Health, was led by Dr. Bhutta.

Some of the 56 key interventions identified in the report include: managing maternal anemia with iron; preventing and managing postpartum hemorrhage; immediate thermal care for newborns; extra support for feeding small and preterm babies, and antibiotics for the treatment of pneumonia in children. Researchers emphasize that these interventions are most likely to save lives when implemented in packages that are relevant to local settings.

Ummul-gargaar: “Help for a new mother who has just given birth”

Maternova — Sun, 18 Dec 2011 13:45:40 +0000

Misoprostol is part of the WHO’s List of Essential Medicines for the prevention of post-partum hemorrhage (PPH). In addition, multiple studies have proven that misoprostol is a safe, effective alternative for oxytocin. But to date, very few countries have established nationwide misoprostol programs.

Population Services International (PSI), however, has utilized its expertise in social marketing to tackle the barriers preventing the widespread deployment of misoprostol. PSI operates programs in Nigeria, Somaliland, Tanzania, Uganda and Zambia, which promote, distribute and train providers in the safe use of misoprostol for the prevention of PPH.

The program in Somaliland presented a unique set of obstacles. With a maternal mortality rate estimated at 1013 per 100,000 live births—one of the highest in the world—misoprostol is desperately needed to protect the lives of mothers. However, cultural and religious beliefs mean that large family sizes are encouraged, while any discussion of sexual and reproductive health is taboo. As a result, women possess low levels of health literacy.

Therefore, PSI partnered with Venture Strategies Innovations(VSI) to develop a country-specific, culturally appropriate brand and communications strategy. The result was Ummul-gargaar, which translates to “help for a new mother who has just given birth”. In this way, PSI and VSI were able to ease the introduction of the drug in spite of sensitivities around issues of sexual and reproductive health.

PSI also faced tremendous resistance in getting the Ministry of Health to approve the use of misoprostol for PPH, due to the drug’s alternative use for inducing medical abortion, which is illegal in Somaliland. Intensive advocacy efforts by PSI and its partners succeeded in 2009, when the Ministry of Health announced its support for misoprostol for PPH

Moreover, PSI decided upon a low-profile launch, which began with a 2010 pilot intervention in maternity hospitals in a single region. PSI thus aimed to “build the reputation of Ummul-gargaar through targeted communications and demonstrated effectiveness of the drug”. Thereafter, PSI slowly expanded the project to include all six regions in Somaliland.

Due to continued concerns however, PSI had to alter its distribution plan to exclude traditional birth attendants. Instead, misoprostol is available only from trained professionals during facility-based deliveries. To compensate, PSI is conducting a communications campaign to encourage safe motherhood practices, such as spacing births and obtaining antenatal care.

Despite the limitations of PSI/Somaliland’s program, their culturally-sensitive, country-specific approach will be integral in launching misoprostol programs around the world. According to PSI, their experience in Somaliland taught them several lessons. First, targeted interventions will be more successful in the context of a comprehensive maternal health program. It is also critical, they say, to develop a positive relationship with the Ministry of Health, and with local health professionals, who must serve as partners in promoting misoprostol for PPH.

New Diagnostics for Infant HIV Diagnosis

Maternova — Tue, 29 Nov 2011 16:19:29 +0000

The critical first step in accessing lifesaving antiretroviral therapy (ART) is knowledge of one’s HIV status. Although voluntary counseling and testing (VCT) has been scaled up significantly in recent years, population surveys conducted in 2007-2009 by the WHO indicate that on average, less than 40% of individuals living with HIV in sub-Saharan Africa are aware of their status.

This lack of awareness has dramatic implications for preventing mother-to-child transmission of HIV (PMTCT). Early detection and treatment also play a key role in enhancing prevention efforts more broadly, and in reducing the problem of drug resistance. This has led to a call for cheaper, point-of-care diagnostic tools. In response, UNITAID—an innovative global-health financing mechanism that funds the purchase of lifesaving drugs through airline taxes—released a technical report entitled, HIV/AIDS Diagnostic Landscape.

Authored by Maurine Murtagh, a former long-time leader at the Clinton Health Access Initiative, this report examines both diagnostic technologies already in use and those in development, on the basis of sensitivity, specificity, affordability and ease of use. The aim of the report is to guide the investments of UNITAID and other organizations toward technologies that “could be transformational in effecting improved and lower cost access to diagnostics for HIV/AIDS in resource-limited settings.”

For diagnosis among people older than 18 months of age, the rapid HIV antibody test is commonly deployed— it is inexpensive, accurate and does not require laboratory infrastructure. These tests are widely available from a variety of manufacturers. However, antibody tests are useless for children under 18 months, due to the persistence of maternal antibodies in the child’s system. Early Infant Diagnosis (EID) instead relies on virological testing (DNA PCR) to detect the genetic material of HIV itself. These “qualitative” tests do not measure viral load, but instead indicate the presence of HIV.

Current WHO guidelines stipulate that all HIV-exposed infants should receive virological testing at 4-6 weeks of age. However, DNA PCR tests are produced by only a few manufacturers, and require expensive laboratory equipment, trained technicians and transportation networks that allows for the movement of specimens. Blood is collected at clinics or PMTCT centers, transported to labs, and then results are returned to the clinic. The advent of Dried Blood Spot (DBS) technology— a method of collecting blood on filter paper— has improved the efficiency of DNA PCR testing, but the process remains slow, expensive, and often patients do not return for follow-up. To improve access to EID in resource-limited settings, the cost of these tests must be reduced, and they must be brought closer to the point of care (POC) without sacrificing quality.

In fact, at least two POC tests are being developed for EID. The Northwestern Global Health Foundation has created a rapid, ultrasensitive p24 antigen assay, which will be available in early 2012. The processor is battery-powered, and returns results in about 20 minutes. Field tests have yielded promising results. In addition, Micronics is developing the PanNAT™ Diagnostic Platform, a small, portable device that diagnoses multiple infectious diseases, including a qualitative assay for EID. Battery operated, the PanNAT™ device captures waste for safe disposal, stores 350 test results and returns results in 30-40 minutes.

These point-of-care diagnostic tools have the potential to bring quick, affordable infant HIV testing to low-resource settings, and to revolutionize the prevention of mother-to-child transmission.

The right to survive pregnancy is a fundamental right for women

Maternova — Thu, 17 Nov 2011 13:24:18 +0000

Maternova often highlights innovations in technology and health care protocols—but saving mothers’ lives requires an even broader set of tools. In recent years, human rights law has emerged as a critical tool for protecting women while giving life.

Organizations such as the International Initiative on Maternal Mortality and Human Rights) (IIMMHR) promote a human rights approach to maternal health, because it allows advocates to demand government accountability and action. More simply, a human rights framework makes plain that maternal death and injury violate the basic rights of women and girls—the rights to life and to the highest attainable standard of health.

Paul Hunt, UN Special Rapporteur on the Right to Health, reminds us that:

“Human rights are not just about prisoners of conscience, they are also about prisoners of poverty. Human rights are not just about torture, they are also about avoidable deaths from preventable health conditions.”

Indeed, organizations and communities around the world have begun to invoke human rights doctrines old and new in order prevent maternal mortality:

December 18, 1979: UN adopts the Convention on the Elimination of Discrimination Against Women (CEDAW)
June 17, 2009: UN Human Rights Council adopts landmark resolution on Preventable maternal mortality and morbidity and human rights

This resolution marks the first time UNHRC has recognized maternal mortality as a human rights issue. Led by Columbia and New Zealand, over 70 countries co-sponsored the resolution, thereby committing to allocate more resources toward maternal health.

August 10, 2009: Sylvia Nalubowa dies in Mityana hospital from the complications of obstructed labor in Uganda
December 10, 2010: Jennifer Anguko dies from a ruptured uterus in Arua regional referral hospital in Uganda
December 28, 2010: Protests take place against maternal mortality in India
Over 1000 people gather to protest the high levels of maternal mortality in Barwani district, which persist despite the presence of a comprehensive emergency obstetric care unit.

*January 10, 2011: Vapari Bai dies due to eclampsia outside Barwani district hospital in India

*The death of Vapari Bai highlights the lack of access to emergency obstetric care, despite its availability.

August 16, 2011: UN Committee holds Brazil accountable for the death of Alyne da Silva Pimentel from postpartum hemorrhage
A UN Committee concludes that Brazil failed to fulfill its obligations under CEDAW in the case of Alyne da Silva Pimentel, who died after her local health center delayed essential emergency care.
September 5, 2011: Case Brought Before Constitutional Court of Uganda
The families of Sylvia Nalubowa and Jennifer Anguko initiate legal action against the government of Uganda for violating women’s rights to life and health. As a result of inadequate care and facilities, 16 women die each day giving birth in Uganda.

Finally, mothers, women as individuals with names and families are in the headlines.

“The right to survive pregnancy is a fundamental human right,” says Soyata Maiga, UN Special Rapporteur on the Rights of Women in Africa. However, if this right is to be realized, advocates and communities worldwide must follow the lead of groups in India, Brazil and Uganda. They must take their governments to task for failing to provide promised resources for maternal health.

Rapid Nationwide Deployment of the DoseRight™ Syringe Clip

Maternova — Tue, 15 Nov 2011 13:20:10 +0000

About 1 in 4 people in Swaziland are infected with HIV, so preventing mother-to-child transmission (PMTCT) is an essential strategy in reducing the country’s burden of HIV/AIDS. To achieve this however, pediatricians working in Swaziland and other low0income settings underscored the need for a simple tool to enhance the dosing accuracy of liquid antiretroviral (ARV) regimens.

In response, undergraduates at Rice 360º, the prolific Institute for Global Health Technologies at Rice University, developed the DoseRight™ Syringe Clip. These color-coded, low-cost clips are inserted into an oral dosing syringe, limiting the amount of liquid that is dispensed and dramatically increasing the likelihood of accurate dosing. Using DoseRight™, mothers can effectively administer ARVs to themselves and their children.

We’ve featured some of Rice 360º’s global health technologies in our Innovation Index, including the salad spinner centrifuge and the OB/GYN Lab-in-a-Backpack. However, what distinguishes the DoseRight™ clip is the way this technology was so rapidly deployed at the national level. In August, Swaziland’s Ministry of Health began distributing more than 200,000 dosing clips as part of its PMTCT Program.

This is the largest rollout yet of a global health technology developed by Rice 360º’s undergraduate students, who were also instrumental in securing DoseRight™’s nationwide dissemination. Rice students worked for two years to build an alliance among the Swazi Ministry of Health, the Clinton Health Access Initiative, and 3rd Stone Design, which has facilitated the distribution, funding and manufacturing of the dosing clips.

So many technologies stop at the student design stage despite extensive research and good links with a facility or Ministry in a low-income country. This is a terrific example of a full rollout that occurred quickly. Watch an instructional video or a video showcasing the clips on Rice 360º’s website!
In April, former President Bill Clinton honored Rice students for their innovation in developing the clips and their dedication in achieving its swift uptake at the national level.

Building In-Country Capacity for the Maintenance and Repair of Medical Equipment

emilyellisonfallon — Mon, 31 Oct 2011 17:25:16 +0000

The stories of in-kind donations of high-tech equipment laying dormant in developing countries are many. The computers donated to a Haitian school that had no electricity. The computers, full of heavy metals, were buried in the yard of the school, leaching into the water supply. Incubators with directions only in French donated to a non-French speaking country: fragile equipment that requires trained technicians for constant maintenance and repairs sitting unused just months after being delivered.

At Duke’s Pratt School of Engineering, Robert Malkin’s Developing World Healthcare Technology Laboratory took these anecdotes and completed a thorough analysis of unused or underutilized medical equipment in developing countries. With this data in hand, they went further: they designed and have been implementing a comprehensive curriculum for biomedical technicians in Ghana, Rwanda, Honduras, and Cambodia.

Working with Engineering World Health, Duke formed the Biomedical Equipment Technician (BMET) program, funded by the GE Foundation. Over the three years of the program, BMET combines intensive didactic classroom instruction with periods of experiential learning. Approximately every six months, the students attend a two-month intensive classroom session, with interim support being provided online. The BMET training program takes into account the relative experience level of the technicians- Ghana and Honduras- based technicians already possess some training, while Rwandan technicians need introductory and remedial training. The ultimate goal is to build in-country capacity for the maintenance and repair of medical equipment.

The most recent iteration of the BMET program is taking place in Cambodia. The first two month intensive, held in June and July 2011, focused on sterilization, suction and blood pressure machines. Subsequent intensives will focus on oxygen and respiratory systems, ventilators, anesthesia machines, cardiac and monitoring systems, x-ray equipment and peripherals, clinical laboratory equipment, generators, electro surgery units, and other miscellaneous equipment.

More information at Engineering World Health’s website.

Maternal Hypothermia? An Unexpected Finding Affecting Kangaroo Mother Care

Maternova — Wed, 26 Oct 2011 14:15:53 +0000

It is widely known that hypothermia is a leading cause of morbidity among newborns and that an effective low-cost solution is maternal warming of the infant through skin to skin contact. But what role does maternal body temperature play? A 2008 study examining community management techniques for neonatal care in Shivgarh, India showed unexpectedly that a significant number of mothers also suffer from hypothermia. Using the ThermoSpot temperature indicator, researchers discovered that in almost half (42%) of the cases of newborn hypothermia, mothers were even colder than their infants! This limits mothers' ability to warm their babies using skin-to-skin contact, or (STSC)[http://maternova.net/health-innovations/kangaroo-mother-care-saves-low-birthweight-babies]—an effective, WHO-recognized method for warming low birth weight newborns.

While there are many studies examining neonatal hypothermia, this is the first study we've heard about that measured maternal hypothermia in tandem with the infant's hypothermia. The main objective of the Shivgarh study was to discover the best community-based care package for newborns. They found that newborn mortality could be cut in half through simple interventions like warming and breastfeeding. While the Shivgarh study suggests that innovative tools such as ThermoSpot(TM) could be used to monitor both newborn and maternal temperatures, additional research is needed to understand the causes of hypothermia among mothers, as well as the impact of low maternal body temperature on neonatal health and survival. It struck us as a good example of how mother and infant morbidity and mortality are so obviously linked, and an argument for measuring both in large scale studies. Otherwise important data and connections are missed. This is a good example of a serendipitous finding that should result in follow-up studies!

Photo: Nurse Fatoumata Kamissoko helps a mother wrap her baby in the Kangaroo Mother Care position. (Photo Credit: Joshua Roberts / Save the Children)