Maternal morbidity: maternal deaths are just the 'tip of the iceberg'

Maternova — Tue, 15 May 2012 15:04:34 +0000

maternal survival

Millennium Development Goal 5 sets out to “Improve Maternal Health” by 2015. To track progress on this target, researchers rely on maternal mortality ratios and rates of skilled birth attendance as indicators.

While these are important proxy measurements, maternal health is not the same as maternal survival. Indeed for every woman who dies from pregnancy-related causes, approximately 20 women develop maternal morbidities—illnesses and injuries that have a significant impact on their own health and that of their families and communities. Moreover, skilled birth attendance is not a panacea for achieving maternal health. One study in Bangladesh found that 40% of women who had facility births experienced postpartum complications, and 7% suffered a severe obstetric complication. Clinical terms like ‘morbidity’ and ‘fistula’ are another way of saying ‘a lifetime marred by suffering and stigma’ in the case of postpartum depression, psychosis or obstetric fistula.

Maternal morbidities can be acute or chronic and include mental health issues, infertility, anemia, fistula, infections, uterine rupture and scarring, and genital or uterine prolapse. Clinical terms like ‘morbidity’ and ‘fistula’ are another way of saying ‘a lifetime marred by suffering and stigma’ in the case of postpartum depression, psychosis or obstetric fistula. These conditions frequently stem from obstructed labor and they impact a woman’s ability to care for herself and her family. Often, maternal morbidities also result in financial hardship, stigma, social isolation, divorce and domestic abuse. And because women play a key role in care giving, food production and other economic activities, it is estimated that maternal morbidity costs the global economy $6.8 billion annually.

Last year, the Woodrow Wilson Center hosted an event on maternal morbidity in the developing world, and the resulting report was published in March 2012. The authors conclude that to truly improve maternal health, maternal morbidity must be recognized as a critical component of safe motherhood, and researchers must prioritize data collection that tracks morbidity outcomes. Furthermore, they argue that access to affordable and acceptable health care before, during and after pregnancy is essential for preventing and successfully treating pregnancy-related injuries and illnesses. The solutions are the same: better, faster transport, more education on the danger signs of complications, drugs and training at the community level, removal of user fees, better training of midwives, a steady supply of key commodities.

2 "Mompreneurs" unite to empower women globally

Maternova — Wed, 02 May 2012 22:01:21 +0000

culture baby

Maternova and Culture Baby have partnered in a creative way to make a newborn's entry into the world connect even more closely with the rest of the globe. Natalia Rankine Galloway is the Founder of Culture Baby After the birth of her first baby she felt very acutely the good fortune she had to give birth supported by skilled care. She also wanted to create a business that directly connected the birth of a new baby to something bigger--a lot bigger- to a global consciousness. Natalia's products are sourced from artisans all around the world--she finds beautiful hand crafted baby goods that are actually part of traditional cultures (rather than say a plastic cup with an ikat print)! Some of the gifts Natalia most treasured were those from friends she'd made from a lifetime of living overseas. Her vision was to help build a global connectedness for families from those earliest moments.

But global consciousness wasn't enough, Natalia wanted her business to give back directly to mothers who needed better care around the time of birth. That's when she and I met and immediately connected. Maternova was founded in order to make it easier to find and purchase simple technologies that save lives in low-resources settings. We've connected our two ventures through a 'Buy for Baby, Save a Baby' Campaign.' Each customer of Natalia's will have a chance to donate life-saving Maternova supplies to a deserving non-profit. We begin with our colleagues at Midwives for Haiti!

Like Natalia, I have always felt that there has to be a more direct way to connect the massive mother-baby marketplace in the U.S. with the immense needs for products in low-resource settings. When I was deeply immersed in purchasing supplies for my first baby, I could have certainly spent a lot less time asking questions of 'Stroller Queen' to determine the minute differences between three models of stroller, and would have welcomed a way to give back just a small amount to women who give birth with nothing, not even a blanket in which to wrap the baby.

Traditional Birth Attendants Save Newborns Using Bulb Syringes

Maternova — Mon, 23 Apr 2012 13:05:52 +0000

The bulb syringe is a part of many U.S. parents' armamentorium of infant supplies, but in other hands it can be truly a life saver.

In order to improve birth outcomes, many organizations have designed clean birth kits containing supplies and instructions to help birth attendants prevent infection. However, many “next-generation kits” are in the works to help manage other post-delivery complications impacting mothers and newborns. One such enhanced birth kit was tested in Zambia by Dr. Christopher Gill—the first we’ve seen that has incorporated the bulb syringe for use by traditional birth attendants (TBAs).

Given the critical healthcare role played by TBAs in Zambia’s rural areas, the Lufwanyama Neonatal Survival Project (LUNESP) set out to determine whether training TBAs to manage common perinatal conditions could reduce neonatal mortality. The intervention group was trained to prevent hypothermia by drying and swaddling newborns; to prevent asphyxia by clearing the airway with a bulb syringe; and to treat sepsis using antibiotics and a health facility referral. The control group continued their existing standard of care, including the use of clean birth kits.

The results of the study were stupendous—neonatal mortality was 45% lower among TBAs that had been trained to recognize and treat perinatal conditions. This translated to one death avoided for every 56 births attended by a TBA with LUNESP training—showing great promise for enhanced birth kits and the enhanced role of TBAs.

Below, Dr. Gill responds to a few questions posed by Maternova.

Are the bulb syringes readily available in Zambia or did you need to import them?

We purchased these in bulk state side and shipped them to Zambia. They take up quite a lot of space unfortunately, so local procurement would be preferable if they can be sourced cheaply. I believe that ours went for something around 10 cents each, but the shipping costs added to that. Please note that we have just had our companion cost effectiveness article accepted to PLOS ONE, and in this we give an accounting of the costs for each of these items.

Do you have estimates of the cost of the full kit the TBAs were given/used?

This is a bit trickier to answer because some of the kits were donated by UNICEF. However, after asking the program manager (Anna Knapp), she recalls that at the time they were about $4 USD each. At least for the non-donated kits, we assembled them ourselves by buying the components in bulk and packing them into large Ziploc bags.

Has the MOH scaled up any of these interventions?

The MOH has not. Still, Zambia's official position is that all deliveries must occur at health centers. They condoned our study because it was a study and because they also recognize the reality that the policy cannot be implemented in many cases simply due to lack of resources and access in rural areas. After completion of the LUNESP study, Save the Children and Boston University’s Center for Global Health & Development assumed responsibility for sustaining the interventions through a program called LINCHPIN.

The Zambian MOH apparently is rethinking its policy on TBAs and I'm increasingly optimistic that they will move to incorporate this approach formally into their health care delivery strategy. I’m crossing my fingers.

A new take on the clean birth kit: rebranding as a wedding gift

Maternova — Wed, 18 Apr 2012 20:23:14 +0000

CBK with bow

When we came across this unique take on the clean birth kit we were really impressed--anything that puts a unique, positive spin on creating a safer birth is very welcome! This Tibetan birth kit combines 'how to' images and actual implements in a beautiful box meant to be given as a wedding gift. The RISD team rebranded the concept of birth kit as 'sanitary item' into wedding gift. To be clear, this birth kit was only taken through the prototype stage and is not available anywhere for purchase (yet).

Kathleen O'Donnell, Soomi Lee and Esther An worked on this project as part of a RISD course in 2010 for a studio class titled "Design for Social Entrepreneurship" taught by Sloan Kulper. We interviewed Kathleen O'Donnell to find out more.

We've seen a lot of birth kits, but this design is really different--what was the inspiration?

To be honest, I think we started out by trying to make a birth kit as simple and inexpensively as possible. However, after some online research, we quickly discovered that there are dozens of organizations out there who are doing exactly that: providing inexpensive, simple birth kits to developing countries. At some point we realized that the problem with these birth kits wasn't necessarily their contents, but their distribution methods. From that point on, we began to explore the possibility of re-branding the birth kits as wedding presents, rather than as a kind of necessity, or sanitary item.

What kind of research did you do for your idea?

Being based in Rhode Island, the majority of our research was conducted online, by researching relevant anthropology articles and studies. We were very fortunate to be put in touch via Skype with one woman who had grown up in a rural region of Tibet. She was tremendously helpful in explaining many of the local customs and traditions, especially with respect to weddings and the traditional daily routines for men and women.

The Tibetan birth kit is a beautiful design-- how did the design evolve?

Two key ideas drove the design of this birth kit - ease of use and acceptability as a wedding present. For the interior of the kit, we designed each of the pages to unfold out of the box in the order that they are needed. Each page contains a large illustration of the action to be performed, and any tools required for that action (such as cord ties, razor blades, or soap) are contained in a sealed plastic bag on that page. The exterior of the box was designed to reflect some of the cultural traditions about marriage. Judith (our Skype contact) mentioned that wedding presents are always presented wrapped in a white silk scarf, or katag, which symbolizes good luck. Likewise, the red color of the box was also chosen for its lucky connotations.

Do you think this is something that could be produced locally?

It was always our intent that the final design be something that could be produced locally (or at least quasi-locally, in one of the larger cities in Western China). The prototype we made was entirely assembled by hand, so I think it's just a question of sourcing the individual components for the kit, and whether or not it would be cost-effective to do so locally.

What do you wish had happened when you finished the design?

Although we tried our best to make the design as clear and appropriate as possible, a lot of our design decisions were based on incomplete information and our best instincts. I would have loved to see this idea go through a few rounds of user testing to see if it has the potential to become a reality and hopefully make a difference for women in this part of the world.

Please give us your feedback on this fascinating rebranding idea.

The B-Lynch Suture invented by a reknowned UK obstetrician born in Sierra Leone

emilyellisonfallon — Tue, 03 Apr 2012 16:44:56 +0000

Sometimes, the answer to severe hemorrhage turns out to be not a device or gadget, but an innovative surgical technique--in this case the B-Lynch suture.

Over 100,000 women die of postpartum hemorrhage (PPH) each year, accounting for 35% of all maternal deaths. An estimated 90% of these cases are caused when the uterus is unable to adequately contract after childbirth (uterine atony).

When “conservative management” using massage, pressure packing and drugs such as oxytocin or misoprostol fail to stop severe bleeding, healthcare providers must often resort to radical surgical intervention, including hysterectomy (the removal of the uterus). In addition to loss of fertility, these interventions can cause a range of complications and even death.

In attempt to avoid hysterectomy, Christopher Balogun-Lynch developed an innovative surgical technique to treat atonic PPH. Using this method, a continuous suture is used to envelop and mechanically compress the uterus. The Global Library of Women’s Medicine provides a poster explaining the procedure in more detail. Since its invention in 1997, the B-Lynch technique has been used successfully in approximately 1,300 cases worldwide.

For example, in a review of PPH cases in Pakistan, authors favored the B-Lynch technique for its safety, simplicity, lifesaving potential and ability to preserve fertility. The suture was successful for cases of PPH after both vaginal and caesarian deliveries. As a result, the authors believe the B-Lynch suture “should be considered as a first line surgical treatment before…hysterectomy”.

In Singapore, one study indicated that out of 5,470 deliveries, 100 women experienced PPH. Only seven of these women were treated with the B-Lynch suture, successfully avoiding hysterectomy in five cases. The authors thus conclude that the B-Lynch technique is an effective procedure for managing PPH before any radical surgery is considered. “It has the advantage of being applied easily and rapidly, and should be taught to all trainees and registrars in obstetrics,” they argue.

Since 1997, several modifications of the B-Lynch method have been developed, for which there is a growing body of supportive evidence. We're curious to know how standard the teaching of the B-lynch suture is in the training of obstetrician/gynecologists and others in Africa, Asia and Latin America.

We hope it goes without saying that this is a procedure meant for surgeons! Don't try this at home!

Responding to Reproductive Health Needs In Humanitarian Crises

emilyellisonfallon — Thu, 29 Mar 2012 15:24:49 +0000

During humanitarian crises (such as armed conflicts, famine, epidemics and natural disasters), danger and uncertainty mean that access to quality reproductive health services is often severely limited. As a result, reproductive health issues become more pronounced and more urgent—including an increase in preventable maternal and child deaths due to lack of emergency obstetric care; sexual violence and trauma; unwanted pregnancies and unsafe abortions; and the spread of sexually transmitted diseases, including HIV.

For this reason, the Minimum Initial Service Package (MISP) for Reproductive Health is an international standard designed to address the priority reproductive health needs of populations during the onset of emergency situations.

A distance-learning module is provided to instruct emergency response teams in implementing a minimum set of reproductive health services, such as the distribution of clean birth kits and condoms, prevention of sexual violence and provision of care and support for survivors. The online version of the learning module is interactive, containing quizzes and links to additional resources. The module is available in English, Spanish and French.

The MISP module is based primarily on Reproductive Health in Refugee Situations: An Inter-agency Field Manual, first developed by the WHO, UNHCR and UNFPA in 1995 and revised in 1999. Recent evaluations by UNHCR in Yemen, Republic of Congo and Uganda indicate that while humanitarian response teams are incorporating the MISP more than ever before, implementation must be significantly improved to ensure public health and safety during emergency situations.

A Free Clinical Textbook on Post Partum Hemorrhage

emilyellisonfallon — Mon, 26 Mar 2012 15:47:43 +0000

A Free Clinical Textbook on Postpartum Hemorrhage

Imagine lifesaving clinical guidelines on maternal health could be made widely available at no cost to health workers across the world. The Global Library of Women’s Medicine (GLOWM) is a nonprofit initiative doing just this. Published by David and Paula Bloomer, GLOWM aims to advance women’s health by providing free access to a “vast and constantly updated, peer-reviewed resource of clinical information and guidance.”

Among GLOWM’s many resources is A Textbook of Postpartum Hemorrhage: A comprehensive guide to evaluation, management and surgical intervention, first published in 2006. Hard copies were distributed to physicians across the developing world, while an electronic version is accessible online at all times, free of charge. There is in fact the full version in Turkish available online.

It contains 500 pages, 53 chapters and contributions from 104 experts, who donated their time and expertise to improve the management of postpartum hemorrhage (PPH). Based on this comprehensive textbook, GLOWM also provides simple instructional resources to assist health workers in managing PPH. These include a leaflet and wall chart designed for midwives and birth assistants (available in five languages), and a series of films and video clips demonstrating techniques, tools and action steps.

The editors of the text include Christopher B-Lynch FRCS, FRCOG, D.Univ, (inventor of the B-Lynch technique for suturing the uterus in massive postpartum hemorrhage), Louis Keith MD, PhD, Andre Lalonde MD, FRCSC, FRCOG and Mahantesh Karoshi MBBS, MD.

A new edition of the textbook is in the works, with over 80 chapters and links to videos and other media. GLOWM is also developing free learning modules in the form of smartphone apps, which will provide practical support to healthcare workers worldwide

White Ribbon Alliance’s “Respectful Maternity Care” Charter- 1st of its kind

emilyellisonfallon — Thu, 15 Mar 2012 22:39:17 +0000

It is widely known that improved access to skilled health professionals and health technologies dramatically improves the chances that mothers and newborns will survive an obstetric emergency. Skilled care utilization is a key indicator for Millennium Development Goal 5.

However, fewer are aware of the disrespect and abuse that women worldwide frequently face when they choose to seek maternity care in hospitals and clinics. Disrespectful and abusive maternity care includes verbal and physical abuse; discrimination; non-consented care; abandonment; detention for inability to provide payment; and lack of confidentiality. We have heard story after story of a woman actually making it to a health center and then being subjected to verbal insults and slaps, an incredible affront to the idea of a dignified birth.

In addition to the direct physical and emotional effects of this ill treatment, the way a woman is treated by health professionals significantly influences whether she will seek out facility-based care again in the future. When women come to associate health facilities with indignities and abuse, maternal and newborn health outcomes suffer as a consequence.

In response to these issues, the White Ribbon Alliance (WRA) is working to build a global community of concern to promote respectful maternity care. In addition to collecting stories and articles related to respectful maternity care, WRA is creating tools allowing advocates to apply a human rights framework to the issue of maternal health.

With support from USAID’s Health Policy Project, WRA recently convened a multi-sectoral group to develop the Respectful Maternity Care Charter: The Universal Rights of Childbearing Women. According to WRA, “It is our hope that this charter, and the accompanying brochure and poster will be used to break the veil of silence around the issue of disrespectful and abusive maternity care and to empower women and communities to recognize respectful maternity care as a basic human right”.

This charter is the first of its kind, and was nominated by Women Deliver as one of the top 50 inspiring ideas and solutions that deliver for women and girls.

Click here to watch WRA’s respectful maternity care video.

Saving Newborns by Screening Mothers for Strep B

emilyellisonfallon — Fri, 09 Mar 2012 13:55:54 +0000

Infection with group B streptococcus (GBS) is one of the leading causes of newborn morbidity and mortality worldwide—causing septicemia, pneumonia, meningitis, hearing loss, developmental disability and death. Unrelated to group A streptococcus (which causes strep throat), GBS is present in approximately 1 in 4 women and typically causes no symptoms in the mother. However, the bacteria can be transmitted to the infant during delivery unless women receive intravenous antibiotics during labor.

During the 1990s, the increased use of antibiotic prophylaxis in the United States led to an 80% reduction in the incidence of GBS-related disease in newborns within the first week of life (WHO). Today, the Centers for Disease Control and Prevention (CDC) recommends women get screened for GBS when they are 35-37 weeks pregnant, and even provides "Health eCards" to educate and encourage women to obtain a screening.

However, outside of the Americas, Europe and Australia, the burden of GBS on neonatal health is unknown due to a lack of comprehensive research. A recent meta-analysis led by Dr. Katherine M. Edmund indicates that the highest rates of GBS-related complications in newborns occur in Africa (1.21 cases per 1000 live births), with a case fatality rate of 22%. To put these numbers in perspective, incidence in Europe is 0.57 per 1000 live births, with a fatality rate of 7%. Edmund and colleagues emphasize that further research is necessary to fully understand the global burden of GBS infection.

These findings suggest that GBS interventions commonly utilized in high-income countries could have a dramatic impact on newborn health in the developing world. One organization called Group B Strep International is working to accomplish this goal by raising awareness and increasing prevention efforts worldwide.

India's Giant Maternal Health Experiment: Paying Women for Facility Births

emilyellisonfallon — Wed, 22 Feb 2012 15:36:59 +0000

Mother holding baby

In 2005, India launched the largest conditional cash transfer program in the world with its Janani Suraksha Yojana (JSY) initiative. JSY, which roughly translates to “Safe Motherhood Scheme”, provides cash payments to pregnant women who deliver in public medical facilities, as well as the women health workers or ASHAs who accompany them. JSY was established in response to India’s persistently high rates of maternal and neonatal mortality, which account for approximately 20% and 31% of the worldwide totals. Interestingly, the cash transfer scheme targets the most vulnerable, defined as those living below the poverty line and those of specific scheduled castes or tribes.

Results have been mixed. PLOS has a great blog on the subject here. A study published in The Lancet in 2010 reported marked improvements in perinatal health outcomes, as well as an increase in the total number of institutional births. However, maternal mortality has been unaffected, and there have been no significant improvements in the quality of care received in government health facilities. Several assessments have concluded that because JSY so successfully stimulates demand for facility-based births, there must be parallel efforts to enhance the capacity of the public healthcare system to handle the new influx of patients. A rapid anthropological assessment in Maharashta found that the administrators of the program were not active enough and infrastructure inadequate tot the task. Comments on the JSY blog point to the fact that increased institutional deliveries does not, in an of itself, offer a logic for reducing deaths, say due to hemorrhage, if comprehensive emergency obstetric care is not available.

Furthermore, a UNFPA study found that the poorest women are the least likely to access JSY benefits and to deliver in health facilities. Other observers note that accessing JSY is difficult for homeless women, who cannot provide the documentation certifying that they live below the poverty line—a requirement for participation in some states.

Despite some of JSY’s successes so far, more rigorous monitoring and evaluation are vital in order to understand the full scope of the program’s impact on maternal and neonatal health. There is currently no data concerning how mothers spend their cash benefits, or whether women possess the autonomy to spend the benefits on health care. Recent evidence even suggests that some households have been plunged further into poverty due to medical costs that were not reimbursed by JSY.

Health outcomes and quality of care are more telling metrics than the mere quantity of institutional births. An excellent summary of cash transfer, financing schemes and involving the private sector was done by Dfid. Given the sheer size of this social experiment it is in fact surprising that more has not been written on the subject.