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This post is the first in a series on maternal health in the Seraikela block of Jharkhand, India. 

In 2009, Sarah Blake and I worked together at the Maternal Health Task Force, a Gates Foundation funded maternal health initiative based at EngenderHealth in New York City. Since then, Sarah went on to work as a consultant with several non-profit organizations, including UNFPA and Women Deliver.  I took off for India as a Clinton Fellow with the American India Foundation where I have been working for the past nine months on a maternal and newborn health project in Jharkhand, a state with high levels of maternal and newborn deaths.

A new mom holds her newborn in a small community called Sini, in the Seraikela block, as community members look on.

Sarah and I recently teamed up again (this time, in India) to explore our common interest in maternal health. Over the past two weeks, we have visited hospitals, health centers, government offices, rural villages, and homes in the Seraikela block, a rural area with rugged terrain and limited infrastructure outside the industrial city of Jamshedpur, in the state of Jharkhand.  We conducted a series of interviews with women, families, health workers, and government health officials. We asked questions about pregnancy, childbirth and the postpartum period. We learned about the women’s experiences with home and institutional deliveries–and the factors that influence their decision to deliver at home or in an institution. We explored the implementation of and attitudes toward Janani Suraksha Yojana, a conditional cash transfer program that aims to increase institutional deliveries across India.

A collapsed road on the way from Jamshedpur to the Seraikela Block of Jharkhand.

Conditional cash transfers are trendy. Various governments, non-governmental organizations, and private enterprises across the globe are supporting cash transfer initiatives in efforts to improve school attendance, reduce child under-nutrition, improve maternal and newborn health, and to address other development goals.

What is a conditional cash transfer program? According to the World Bank, “conditional cash transfer programs provide cash payments to poor households that meet certain behavioral requirements, generally related to children’s health care and education”.

Janani Suraksha Yojana (JSY) is a widely discussed (mostly within the global health community but to some extent in mainstream media) and frequently praised cash transfer program. JSY was launched by the Indian government as part of the National Rural Health Mission in 2005, in an effort to reduce maternal and newborn deaths by increasing institutional deliveries.

JSY provides cash incentives to women who deliver in government health institutions as well as accredited private health centers. The program also provides a cash incentive to the health worker who supports the woman throughout her pregnancy and accompanies her to the facility. (For details and FAQs on JSY, click here.)

A community health worker accompanies a pregnant woman to Mahatma Gandhi Memorial Hospital in Jamshedpur, the main referral hospital for the surrounding rural communities.

Maternal and newborn death rates have gradually been declining across India (and the world), but the problem has yet to be resolved. Both maternal and newborn deaths in India continue to make up an extremely large percentage of the overall global burden. According to a study published in the Lancet last year, 20% of global maternal deaths and 31% of global newborn deaths in 2005 occurred in India.

JSY is a big program (the biggest of its kind in the world) that aims to deal with a big problem. The lessons that are drawn from it have the potential to influence global health policy in a big way. The 2010 evaluation of JSY published in the Lancet suggested that the program is having a significant impact on perinatal and neonatal health, but the paper asserted that the verdict was still out in terms of any impact on maternal mortality.

The lesson that has emerged from JSY for newborn health is that giving women money increases institutional deliveries and reduces perinatal and neonatal mortality.  It is likely that the same message will emerge in terms of reducing maternal mortality—and there is a good chance that this approach will be picked up in national health programs in numerous other countries that also have high levels of maternal and newborn mortality.

Our concern is that JSY is far more complex than providing women with money—and reducing maternal mortality is far more complex than increasing institutional delivery.

Given the scope, cost, and potential of JSY; it is incredibly important that we ask questions about the nuances of JSY—the role of money as an incentive for women, families and health workers; the readiness of institutions;  the challenges with transportation; the human rights implications of the program; and a variety of other related factors.

Over the next week (or couple of weeks), Sarah and I will share our experiences and insights from our time with the women, families, health workers, and government health officials of the Seraikela block of Jharkhand, a focus state for JSY. We will highlight stories from the people most impacted by and involved in Janani Suraksha Yojana.

We believe that we have scratched the surface of some interesting issues related to JSY, but our time in Seraikela certainly left us with more questions than answers, and we will be sharing those questions in upcoming posts.

We will also be asking our colleagues working in maternal and newborn health to share their thoughts through guest blog posts. If you are interested in submitting a guest post, contact us at katemitch@gmail.com and sarahcblake@gmail.com.

Tata Steel Rural Development Society, my host organization for my fellowship, provided us with transportation and interpreter services. Many thanks to Shabnam Khaled for her help with translation. 

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The application process is now closed for this position. (7/22/10)

The Safe Motherhood Program at UCSF is accepting applications for an upcoming internship opportunity in the Copper-belt of Zambia. The intern(s) (2 or more interns are needed) will support the start-up of a randomized control trial of the Non-pneumatic Anti-Shock Garment (NASG) in 24 midwifery-led clinics as a low-tech and low-cost life-saving method for treating shock, resuscitating, stabilizing and preventing further bleeding in women with obstetric hemorrhage.

See below for background information on the Safe Motherhood Program and the use of the NASG–as well as details on the internship including expected deliverables, qualifications, timeline, and information on how to apply.

Background

The mission of Safe Motherhood Program at the University of California, San Francisco, is to prevent maternal deaths by promoting women’s health and human rights.   This international research program is part of the UCSF Bixby Center for Global Reproductive Health, which engages in the advancement of new reproductive health technologies and development of innovative programs to improve reproductive health.  The Safe Motherhood Program is also a member of the Women’s Health and Empowerment Center of Expertise (COE), one of three centers within the University of California Global Health Institute.  The primary goals of the Safe Motherhood Program are to:

  1. Conduct rigorous, relevant and timely research resulting in new and applicable knowledge
  2. Reduce pregnancy related death and disability
  3. Ensure maternal survival through principles of respect, dignity and equality
  4. Create direct and practical links from research to policy to implementation
  5. Train health care workers in low-resource settings
  6. Raise community awareness of maternal health
  7. Disseminate information and innovations globally

Working with distinguished colleagues in a variety of countries, the Safe Motherhood Program has the knowledge, skills, vision, technology, and energy to make a real difference in the advancement of women’s reproductive health throughout the world.

Non-pneumatic Anti-Shock Garment (NASG)

In many poor countries women deliver at home, often without skilled attendants or at clinics with limited services available.  If complications arise and a woman bleeds heavily, one, two or all of the “three delays” (Thaddeus and Maine, 1994) may impede her ability to access timely treatment.  Many women do not survive these delays.  In recognition of the direct and indirect root causes of maternal death and disability, the Safe Motherhood Program works to ensure all women have an equitable opportunity to survive childbirth.

A major research effort of the Safe Motherhood Program, the NASG is a low-technology and low cost life-saving device used to treat shock, resuscitate, stabilize and prevent further bleeding in women with obstetric hemorrhage (www.lifewraps.org).  Use of the NASG as part of standard management of shock and hemorrhage has demonstrated promising outcomes for women in low-resource settings, where appropriate health care providers and technologies are limited or non-existent.  To date, NASG use has reduced maternal mortality and morbidity by over 50%.

Internship Opportunity

To build upon the early and promising data, a randomized cluster trial is underway in Zambia and Zimbabwe.  Specifically, the trial addresses the question of whether the early application of the NASG at midwife-led maternity clinics, before transport to a Referral Hospital, will decrease maternal mortality and morbidity.

The internship will take place in the Copper-belt of Zambia and support the start-up of the randomized control trial of the NASG in 24 midwifery-led maternity clinics.  The intern(s) (2 or more interns are needed) will work with the clinics during their transition from Phase 2 study (women with obstetrical complications transported to referral facility) to Phase 3 of the research study (women with obstetrical complications transported to referral facility in the NASG).  Specific activities will include: Observing clinical procedures at the clinics and supporting clinical protocol adherence, observing data collection and supporting research protocol adherence, helping/training data collectors become familiar with data collection forms, matching data collection forms begun at the clinic with data collection forms completed at the referral facilities, supervising cleaning and completion of data collection forms, and training new providers (midwives, residents, medical officers) in the addition of the NASG to emergency response for hemorrhage.

The intern(s) will receive mentorship and supervision from the Safe Motherhood team members both in Zambia and in the US during the field experience.

Deliverables

Weekly reports on progress, participation in weekly calls/Skype with Project Coordinator are expected.

Qualifications

  • Professional degree, graduate student or junior faculty in the health or social sciences (such as medicine, nursing, public health, anthropology, sociology, etc.)
  • Previous experience in health or social science research
  • Knowledge of global sexual and reproductive health, maternal health preferred
  • Ability to work well with partners
  • Flexibility and willingness to travel
  • Highest preference for those with some midwifery/obstetric experience or those who have worked on field-based research projects

Timeline

The internship requires a minimum eight-week commitment (Fall 2010 – Winter 2011) to live and work in Zambia.  Preference will be given to applicants who can remain in Zambia longer than 8-weeks.

Expression of Interest

To apply for the internship, please send a current resume and cover letter to Ms. Elizabeth Butrick (ebutrick@globalhealth.ucsf.edu) with copy to Ms. Jennifer Clark (JClark@globalhealth.ucsf.edu) by August 15, 2010.

For more information on the use of the NASG (specifically the LifeWrap), check out a recent guest post from the Director of the Safe Motherhood Project, Suellen Miller, on the Maternal Health Task Force‘s new MedScape blog, GlobalMama. (You will need to register with MedScape. Registration is free.)

Also, take a look at www.lifewrap.org for additional information about LifeWraps.

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Ray Suarez of PBS, travels to Peru to investigate how health officials, obstetricians, nurses and activists are making better use of existing resources and linking pregnant women to those resources—all in hopes of seeing a reduction in maternal deaths. In this article and video, Suarez reports on a system of maternity homes, homes where pregnant women from remote areas can stay in the final stages of their pregnancies in order to be closer to emergency obstetric care, in the event of an emergency.

PBS NEWSHOUR/The Rundown

“…The NewsHour team headed out to the remote rural town of Vilcashuaman, high in the Andes mountains, to see the new approach at work. We visited a Casa Materna, a mother’s house, where three women from communities far away waited to deliver. In a nurse’s office was a felt bullseye map, with the name and due date of all the women in the region known to be pregnant, along with the approximate distances and travel times to their homes…

…Once ready to deliver, a woman can choose a conventional Western delivery table with an elevated bed and leg stirrups, and as part of the new approach traditional birthing chairs are also available. Women who use the chairs do not have to completely undress, very important in a culture in which modesty is prized…”

Read the full story, In Peru: Life for the Life-Givers—and watch the video.

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The government of Sierra Leone has announced an end to health center user fees for pregnant women, lactating mothers, and children under five. Questions remain regarding the multiple factors that contribute to maternal death in Sierra Leone.

IRIN Humanitarian News and Analysis

In this story, IRIN Humanitarian News and Analysis takes a closer look at the issue of maternal mortality and raises concerns regarding the various factors leading to extremely high levels of maternal mortality in Sierra Leone, factors that will likely not be addressed by a quick-fix abolition of user fees.

“…C.T.H. Bell, a gynaecologist with the privately owned New Life hospital in Sierra Leone’s capital, Freetown, says that more critical than free treatment is speed of decision-making in the home, an efficient transport infrastructure, and prompt treatment on arrival at a health centre…

…Monir Islam, head of WHO’s Making Pregnancies Safer Programme, told IRIN poor roads and a lack of ambulances made it hard for people from rural areas to get to a city for emergency care. ‘Free care means little on its own. If women cannot make it to a centre, what good is free care?’…”

Read the full story, Free Care for Expectant Mothers: Is it Enough?

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A NOW team from PBS recently went to Haiti to investigate high levels of maternal mortality in the country. They happened to be in the Haiti when the earthquake hit. In collaboration with the Bureau for International Reporting (BIR), a non-profit video news production company, PBS produced Saving Haiti’s Mothers, a show that examines the state of maternal health in Haiti before the earthquake and immediately following it.

NOW on PBS

“Haiti’s catastrophic earthquake, in addition to leaving lives and institutions in ruin, also exacerbated a longtime lethal risk in Haiti: Dying during childbirth. Challenges in transportation, education, and quality health care contribute to Haiti having the highest maternal mortality rate in the Western Hemisphere, a national crisis even before the earthquake struck. While great strides are being made with global health issues like HIV/AIDS, maternal mortality figures worldwide have seen virtually no improvement in 20 years. Worldwide, over 500,000 women die each year during pregnancy. This week, a NOW team that had been working in Haiti during the earthquake reports on this deadly but correctable trend. They meet members of the Haitian Health Foundation (HHF), which operates a network of health agents in more than 100 villages, engaging in pre-natal visits, education, and emergency ambulance runs for pregnant women…”

Read the full story and watch the special here.

Learn more about Haitian Health Foundation, UNFPA, and Family Care International—all organizations featured in the show.

Visit the Bureau for International Reporting (BIR) site here.

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For over two years, Amnesty International has been researching maternal health and investigating maternal death in Burkina Faso.

Amnesty International

In five days, the organization will release a report on the state of maternal health in Burkina Faso and launch a caravan campaign that will travel throughout the country raising awareness around the issue of maternal mortality.

“Amnesty International went to Burkina Faso four times to conduct research in several cities including the capital, Ouagadougou, as well as Bobo-Dioulasso, Ouahigouya and Kaya. Amnesty International also visited a dozen rural areas throughout the country. Researchers investigated over 50 cases of women who died during pregnancy and childbirth…”

Read the full story here.


Take a look at this video showing highlights of the 2009 Amnesty International maternal mortality caravan campaign in Sierra Leone:

As part of the countdown to the launch of the campaign, Amnesty International is sharing the stories of women who have died of pregnancy complications in Burkina Faso. See below for an excerpt from one of the stories:

“…Safiatou’s husband told Amnesty International: ‘The day of her delivery, she was in good health and worked all afternoon as usual without any problem. She prepared tô [a local dish made from maize flour] for her children and went to get the hay for the animals. In the evening, when her labour began, she left for her mother’s home. Her mother came to warn me that she was not well, that we had to take her to the clinic. I do not have a motorcycle, so I had to go and get one. That made us lose time.’ The husband added that he ‘did not know that she should have delivered at the clinic. When I came to fetch her at her mother’s house, she had lost consciousness.’ The husband borrowed a small motorcycle from his neighbour…”

Learn more about Safiatou here.

A man holding a picture of his wife who died in childbirth, Burkina Faso. Copyright Anna Kari

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Veil of Tears is a collection of transcribed interviews with children, women, and men in Afghanistan about loss in childbirth. These interviews are part of IRIN’s  Kabul-based radio project, which closed at the end of 2009 after six years of humanitarian radio production and journalistic capacity building in Afghanistan.

IRIN Humanitarian News and Analysis

“In Veil of Tears, a 60-page colour booklet launched today, IRIN brings you a unique collection of personal stories of loss and courage in childbirth, as told by women, men and children from different parts of Afghanistan.

The stories were originally recorded in local languages, Dari and Pashto, for IRIN Radio broadcasts. Transcribed into English in Veil of Tears, they convey the immediacy and intimacy of the interviews conducted by IRIN reporters, who travelled in some cases for several days to reach the remotest villages in Afghanistan.

The interviewees in the booklet talk about the struggle to get enough nutritious food to sustain a woman through pregnancy, and to feed their families on any given day; they describe the awesome distances and terrain that separate people living in the villages from the nearest health facility; they describe the lack of proper roads and transport that may leave a donkey cart as the only option to attempt a life-or-death journey with a pregnant wife or mother to a hospital; they explain the cultural and social rules that might mean decisions by men are made too late to save a woman and her baby…”

Read the full story here.

Click here for a PDF of the Veil of Tears.

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