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.
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.
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.
Anemia is associated with postpartum hemorrhage-- but why? For the non-clinical elements among us, we seek to break down this issue a little further. 45% of women worldwide are anemic, roughly half of them due to iron-deficiency anemia caused by inadequate iron in the diet. Pregnancy puts a high demand on iron stores, and women who have had multiple pregnancies and perhaps began in a slightly anemic state are further depleted with each pregnancy. Thus a woman facing labor in a moderately or severely anemic state may be at greater risk from excessive blood loss.
J-PAL has gotten a lot of attention for its unique approach to development interventions. They use the scientific randomized control trial (RCT) to test behavioral and community-based solutions and thus far have implemented or are in the process of implementing 280 of them. The group is known for their work on school attendance and teacher attendance. They have also covered such interventions as providing free eyeglasses to children in China and evaluating primary school performance (it helps) and providing microcredit in Morocco (it helped expand livestock but did not translate into enterprises).
Transport of women in labor is one of the 'three delays' that often cost women their lives. In more remote areas of the Philippines with mountainous terrain and rural villages maternal mortality is much higher than the national average. Simple hammocks strung from a bamboo pole are part of an approach that is making a difference in a first-of-its-kind project in Ifugao, The Philippines. The ayod is a traditional Philippine transport hammock for sick people that actually looks like about as comfortable a way to travel over mountainous terrain as one could find short of a helicopter.
Sepsis is one of the leading causes of maternal mortality and morbidity, but we don't often dig much more deeply to really understand its causes and its consequences. In a layperson's terms, sepsis is essentially an infection in the bloodstream. In maternal sepsis, usually bacteria in the genital tract causes infection which can enter the bloodstream, cause high fever and eventually organ failure, shock and death.
Maternova obstetric kits are the graduation gift for newly minted graduates trained by Midwives for Haiti. Nadene Brunk, director of Midwives for Haiti reports that the newly trained skilled birth attendants are particularly excited about the colour scale anemia detection kit--allowing them a ready way to determine that a woman is anemic. In addition, the solar powered headlamps and rotary mobile phone chargers are so appreciated by the midwives because they not only provide light and power for clinical care but because they help protect the midwives themselves. As midwives work in remote rural areas or in refugee camps, having a link to safety via mobile phone, and having a light offers physical safety.
The clinical steps around saving mothers' lives are a matter of swift-decision making and skill. A lot of attention is being given to a simple process called the 'Active Management of the Third Stage of Labor' as a way to prevent postpartum hemorrhage. While clinicians who have been trained and who do hundreds of deliveries a month will remember the steps in AMTSL, newer clinicians will need reminders. We saw an interesting rubber stamp that was created for a USAID project. It covered the steps of AMSTL and could be stamped directly into a paper medical record.
We focus on postpartum hemorrhage because it is the leading cause of maternal death in most settings. Obstetric hemorrhage kills an estimated 150,000 women each year, most of whom live in low-resource settings.