The Safe Motherhood IBD team included Puneet Agarwal MBA 2014, Molly Bode MBA/MPH 2014, Kate Morris MBA 2014, and Francis Wong MD MBA/MPH 2014. The team spent three weeks working in Lusaka, Zambia to implement the non-pneumatic anti-shock garment (NASG), also known as the Lifewrap (http://www.lifewraps.org). The NASG is a first-aid device that has the potential to reduce maternal mortality by 50% for women with post-partum hemorrhage (bleeding after childbirth) and was recently recommended by the World Health Organization as a standard of care. The NASG is a low-technology compression device that, when placed around the lower body of a woman with obstetric hemorrhage, will decrease bleeding, reverse shock, and buy the woman time until she can reach definitive care. The team developed an end-to-end analysis for implementing the NASG in Zambia from manufacturing and distribution through to sustaining local use. The team conducted over 25 interviews with various organizations ranging from funders such as the U.S. Agency for International Development, implementers like Clinton Health Access Initiative, and key stakeholders at the Ministry of Community Development and Mother and Child Health. After three weeks, the team delivered a comprehensive implementation report for Zambia as well as a universal roadmap for implementing the NASG in other low-resource settings. We are confident that the NASG is a simple life-saving technology, and sincerely hope it is scaled up in Zambia and many other countries.
Below is just one day in the life of the Safe Motherhood team that involved work and play!
Sunday June 2, 2013
Leaves rustled and we heard the cracking of branches breaking outside our windows. At 5:06am we were surrounded by darkness, but through the thin white mosquito net that adorned our beds, we could see dark masses moving just outside the barred window frames. Pulling back the mosquito net curtains, we realized we were being greeted by two large elephants – what an amazing wake-up call!
Our same elephant friends had visited the camp the day before, which was a perk of staying directly next to South Luangwa Park. As soon as the elephants were content with their morning meal and cleared the path, we made our way to the Flatdogs Lodge kitchen for breakfast ourselves.
By 6:00am we were aboard our safari jeep with an amazingly knowledgeable guide, Geoffrey. It wouldn’t be long before we started travelling by foot for our walking safari in South Luangwa Park. Geoffrey was an expert after training specifically to be a safari guide for years and dreaming of being a guide since he was a little boy in the nearby village. Despite leading hundreds of tourists over the years, Geoffrey always answered our questions with enthusiasm and would marvel over the animals with our same child-like wonder.
Over the course of four hours we identified tracks from hippos, zebras, puku, and buffalo. We tracked prints and droppings to find a herd of 200+ buffalo migrating toward a watering hole. Occasionally the buffalo would stop and look inquisitively in our direction – trying to decide whether we were a threat. Luckily we were accompanied by Mike, a trained scout and shooter, who helped us keep a safe distance and made sure we weren’t prey!
After watching the herd of buffalo flow slowly across the plains, we ventured on and discovered a tree with a perfectly cut hole in the trunk. Geoffrey conjectured that the tribal people who had lived in the park carved the hole 50-100 years ago. When Luangwa became a national park the people were asked to vacate. However, they left remnants of their livelihoods such as the petrified honey we found in the hole, where they had created a space for bees to form hives.
When walking back to the safari jeep we also tracked a honey eater, a small flighty bird. Not only would tribes collect honey by creating holes which attracted bees, but also they tracked bees by following the honey eater bird. Geoffrey explained how people would follow the bird, which hopped from tree to tree until it found honey. We were skeptical and pondering just how long people would follow around a little bird and how often it would lead to no avail, but he led us straight to a honey bee hive! Unfortunately for the honey eater, we were not brave enough to try to attain the honey by smoking out the hive as tribes people used to do and leave larvae for him to eat. Poor bird! We were thankful for the trek and glimpse into past every-day life in the park.
After returning from the walking safari, we headed into the village to visit the Kakumbi rural health clinic and meet with the staff. We had already spent time at the busy University Teaching Hospital, the largest hospital in Zambia and one of the largest hospitals in Africa, where there can be 100+ deliveries in one day. The care at the hospital is vastly different than care in rural areas. There are staff shortages due to high demand, and many rural clinics do not have any trained staff. Luckily, the clinic in South Luangwa had multiple trained staff members, a rare luxury.
At the clinic we met with Musepa, a clinical officer who explained the clinic hours, services, and operations. Despite being closed on the weekend for appointments, he was gracious enough to meet with us. The clinic received monthly shipments of medical supplies to meet the demand, and sometimes received donated supplies as well. The clinic occasionally had stock-outs, but had a good supply of essential immunizations. Immunizations were available to patients once a month and antenatal visits occurred weekly. The clinic was well-staffed compared to other comparable clinics, with two midwives and clinical officer. They delivered approximately 24 babies per month. Musepa explained that most of the time the clinic staff could handle the cases, but occasionally they referred cases up to the next level health center, especially in cases of post-partum hemorrhage.
While we met with Musepa, Grace, the lead midwife at the clinic, stayed busy with two pregnant women, one of whom was giving birth and had a high fever she was monitoring. She made time to talk with us as well, and assured us the other staff were taking care of the patients. Grace informed us about the types of delivery cases at the clinic and shared the log books to show us how she recorded the deliveries and any complications.
In one column she noted complications and in another column noted whether the patient was referred. Post-partum cases were typically marked in red. When we asked about cases of post-partum hemorrhage, the condition in which she would use the NASG, she relayed that there was only once case in the year since January that they had to refer, and that they could normally manage cases (i.e., repair minor tears that occurred in childbirth and resulted in bleeding). More complicated cases were referred to the regional hospital.
While the number of post-partum hemorrhage cases was low, Grace was adamant that the NASG would be useful at the clinic level. She said it would help them provide care more confidently and that they would be able to control bleeding more easily. When we asked about the type of training and skills update they received at rural clinics, she mentioned that they were planning to take an Emergency Obstetric Care (EmOC) course soon. One recommendation we made to the Ministry of Community Development Maternal and Child Health was to integrate the NASG into the EmOC training in the future, so it was great to hear that rural clinic workers received this training directly. Another training option we proposed is to conduct training-of-trainers (TOT) at the district level and cascade training to rural healthcare workers.
Grace and Musepa were both enthusiastic about the NASG and thought it should be introduced at the rural level, where women give birth. While many women deliver at clinics, much due to the work of Safe Motherhood Action Groups (volunteer mothers who encourage births in facilities), 47% of women still deliver in their home. Many of those women present after birth with bleeding at clinics like Kakumbi, so having the NASG in the facility would be useful. Many of the clinics are hours away from the referral hospitals, so the NASG would be invaluable in buying time to transport women with post-partum hemorrhage who might bleed out before reaching definitive care.
While Grace and Musepa had not previously seen the device in person, they had seen the Zambia’s First Lady Dr. Christine Kaseba, a gynecologist who worked with the NASG, speak about it on national television. We were pleasantly surprised that the news had reached so far, and gained insight on an appropriate media outlet for sensitization and awareness of the NASG.
After thanking Grace and Musepa for spending time with us on a Sunday afternoon, we headed to the airport and boarded a small prop plane to return to Lusaka to finish our final deliverables. We had a lot of work ahead of us, but it was well worth the trip to see wildlife and to visit a rural clinic where we gained critical insights into maternal health care in remote settings. What a Zam-azing experience!