Archive for September, 2010
Kinshasa, Democratic Republic of Congo — We arrive at N’Djili International Airport late on an August night. It is a beautiful evening, the vast African sky is welcoming. We learned before our arrival of the recent rape of 200 women by rebels in Eastern Congo. Walking through a dark parking lot, I’m guarded—and thankful that our Congolese colleagues from MCHIP, the U.S. Government’s flagship program for maternal and child health led by Jhpiego, are here to welcome us.
In Congo, more than half a million children under the age of five die each year. Their killers? Diarrhea, measles, respiratory infections, malaria, pneumonia, HIV/AIDS and malnutrition. MCHIP has been working to improve health outcomes for children in Congo through supporting immunization, helping prepare new mothers to care for their newborns and advising health authorities on providing quality care. We are here to visit staff, assess the state of maternal and child health, and support our MCHIP colleagues in their life-sustaining work.
In one of my very first meetings, the impact of Congo’s turbulent times on health services is acknowledged. We climb four flights up in a concrete-block building to meet Pierre Lokadi Otete Opetha, Secretary General of Public Health. He explains that the DRC has just finished a very dark period, 25 years when almost all of the country’s health care was responding to emergencies. Now, a national plan for health care has been developed and the very first need is to develop the country’s human resources potential. Congo needs more doctors, nurses and midwives—and funding for infrastructure and information systems— to build a service delivery system for newborn and maternal health care, to prevent infections and treat diseases, he says. This new strategic plan envisions a multi-sector health system that will serve clients from the facility to the community.
Our next stop, at the U.S. Agency for International Development, is to talk about the health challenges in Congo and efforts to improve care. But first we have to get into the building. Passport checks, security gates, metal detectors, pat downs—the security is extensive. Once inside, we meet with staff who lay out the geographic realities of traveling across the country—the land mass of Congo is a quarter the size of Europe and the system of paved roads covers only about 2,000 miles. Reaching people outside of Kinshasa is a logistical challenge and often risky. Two days before our arrival, a plane carrying a team of five health workers to a remote area for an immunization project crashed.
Poor or nonexistent roads and infrastructure often impede efforts in developing countries to improve or increase health care services. Building a network of locally based community health workers, as is being done in Congo, is a practical, efficient way of meeting the basic health needs of women and families. I have seen the life-changing work of such health workers in Rwanda, Afghanistan and Nepal. Trained in basic methods of assessing clients, they are helping women and families in villages and towns confront diarrheal disease, malaria, infection and malnutrition. With a kit of basic supplies, they provide a basic level of care in the most remote locations. Their work can build support for reducing maternal deaths and, at the same time, raise awareness about the impact a lower maternal mortality rate will have on newborn lives.
At Roi Baudouin Hospital, a small but busy facility with more than 300 births a month, there is plenty to be proud of, even with the hospital’s limited resources. I notice many positive infection prevention strategies—buckets with bleach for cleaning instruments, sharps boxes and other infection prevention tools. Staff in the maternity ward show off its recent installation of air conditioning in the labor and delivery room, an achievement most appreciated on this 100-plus-degree day.
During the visit, I am introduced to Dr. Ebondo Ngoie. Now, my favorite question to ask as I travel the world and meet with physicians, nurses and midwives fighting to keep women and their families alive in these difficult places is: “Have you been trained by Jhpiego?” Dr. Ngoie proudly answers, yes—he was trained in Burkina Faso by Dr. Blami Dao, one of Jhpiego’s veteran master trainers. I ask what improvements he has made since that training. He points to a metal pole in the labor room from which he will hang a curtain to provide privacy and stop cross-contamination as women give birth on the five delivery tables that are side by side, with only a foot or two between them.
No curtains yet, but recognizing the need for them is a small step forward. He tells us that he is now talking to women during labor—trying to interact with them—to offer them information and feedback while they are giving birth. This is a new skill. He also permits women to give birth in a position they find comfortable and does not force them to deliver on their backs because they often prefer to give birth in a seated or squatting position. Many African women often refuse to deliver in a health care facility—even though that’s where they can get help if complications arise—because they are restricted in their birthing position.
A facility with competent providers intent on doing things to make women safer and more comfortable while giving birth—there is reason to be hopeful here. As we head for the hospital exit, we pass a cleaning crew in an examination room. The workers are sweeping needles and gauze, syringe vials and used cotton into an open gutter in the middle of the compound—a vivid reminder of the work Jhpiego and partners have yet to do here.
At St. Joseph Hospital, the maternity ward is one of the far-off buildings. I always notice that the maternity space is usually in the most distant, least tended part of any hospital. As we pass through a final gate, a sign warns, “No firearms allowed.” A woman physician, young, energetic, immaculate in her white clogs and coat, enthusiastically greets us. We enter the delivery area to the heartening sounds of a crying infant. A small but apparently healthy baby is on the scale getting its first weigh-in. The baby is flailing and howling—a wonderful sign—and the nurses and midwives are all smiles.
After the baby girl is weighed, she is dried and dressed, a little pink hat placed on her head and her umbilical cord is perfectly managed—all standards of good practice. I am warmed to see this beautiful child tended to by competent caregivers.
Jhpiego’s reputation precedes us as the doctor introduces me to several staff who have been trained by Jhpiego. She has heard such wonderful things from her colleagues; she wishes she too had been trained by us. As we chat, a pregnant woman in a wheelchair is rushed into the ward. Her ankles are swollen and her blood pressure is very elevated. For almost five days, the woman has been trying to reach a health facility. She is in grave condition, apparently suffering from severe pre-eclampsia, very likely to deteriorate into life-threatening eclampsia—the No. 2 killer of women in the developing world. We quickly exit the ward to allow everyone to attend to this dire situation.
Before the day is over, we meet another Jhpiego alumnus at St. Joseph’s who has proudly displayed his Jhpiego training certificate at every job site in the past 20 years; we hear again about the difficulty in reaching Congolese families in the far corners of this vast nation; and we meet with more than 300 Congolese health care providers whom we’ve trained and toast their efforts in fighting against great odds to care for their countrymen and women. And, I learn that I can’t leave Congo without a CD from Papa Wemba, the country’s greatest musician.
Congo, novelist Joseph Conrad’s “heart of darkness”: The contrasts in this richly resourced, violence-weary country can disarm the toughest cynic, perpetuate feelings of despair and yet engender an unlikely spirit of hope. Consider our visit to Mama Yemo Hospital. Limited resources mean infants are doubled up in incubators, women labor in beds without mattresses and illness permeates the facility. Even in these circumstances, nurses are teaching new mothers about family planning and how to care for premature infants: Tuck them in a sling nestled on mother’s chest, skin to skin, incubating in a mother’s warmth, a knitted cap placed on the baby’s head. A primal, life-affirming solution to save newborns.
By Linda Fogarty and Altina Peshkatari
Tirana, Albania—Over the years at Koco Gliozheni Maternity Hospital, nurse-midwife Laureta Ramaj would see familiar faces. Women who had given birth just a year before were back again. A veteran of the maternity ward, Ramaj quietly wondered about the frequency of their return visits and how these young mothers were coping at home. After talking to them, Ramaj realized that the mothers had little or no information on how best to plan for their families—they “just got pregnant.”
In Albania, despite its relatively favorable health indicators, Western sensibilities and proximity to modern European capitals, the use of family planning methods and contraceptives has been surprisingly low. Although 70 percent of married women do not want any more children, according to a recent national demographic and health survey, only about 11 percent of Albanian women use modern, effective contraception methods. Although exact numbers are difficult to establish, providers report that many women use abortion as a back-up to failed traditional contraception.
With funding from the U.S. Agency for International Development (USAID), Jhpiego began working in Albania in 2007 with partners to change that scenario and help Albania move toward modern contraception as part of a healthy lifestyle. The goal was to improve family planning services for women after they gave birth or had an abortion, increase the use of intrauterine devices and other modern contraceptive options, and encourage local responses to the unmet need for family planning.
The USAID-funded, ACCESS-Family Planning Initiative helped the Albania government establish national protocols and standards for family planning, developed learning materials for providers and educational brochures for clients, trained health care providers to implement new family planning services and ensured availability of family planning supplies.
In Jhpiego-led trainings, more than 340 nurses and midwives like Ramaj learned to incorporate postpartum family planning in their routine services for pregnant women. The providers learn how to promote healthy birth spacing and effective family planning methods suitable for postpartum women, including the lactational amenorrhea method, an exclusive breastfeeding method that naturally helps avoid pregnancy, and to use client materials to make modern contraception understandable and acceptable for couples. The World Health Organization recommends that women wait two to three years before having another child, a period of time that allows a mother to nurture and provide for a child without compromising the needs of siblings.
At Koco Gliozheni Maternity Hospital in Tirana, where she has been head midwife for five years, Ramaj built on her USAID-supported training and established a counseling room, where she could provide well-baby and family planning information for new mothers in a convenient, accessible and inviting setting. She set her sights on a large, cluttered storage area that was just down the hall from where women gave birth. With help from Jhpiego and hospital staff, Ramaj transformed the storage area into a warm, cheerful resource center for new mothers to meet with doctors and nurses in training.
New mothers stop in at the center to learn about and discuss family planning methods and their babies’ needs. A selection of up-to-date brochures, DVDs and other materials are available for the new mothers, and Ramaj uses them to engage women in conversation and discussions. In any given month, about 40 women on the 18-bed maternity ward will visit the resource center, Ramaj says.
Ramaj’s decision to set up a family planning resource center on the maternity ward may be unique to her hospital, but she is an example of health care providers incorporating their new knowledge into the work place and expanding on it to improve and strengthen health care services to patients. According to a review of Jhpiego-initiated family planning services for postpartum women, 92 percent have discussed family planning while in the hospital and 76 percent left the hospital using (or planning to use) the lactational amenorrhea method at the time of discharge.
“One wishes to have a first baby and a second one, but after that planning is necessary,” Marjola Kupa, a new mother, told ACCESS-FP staff. “We do not want more than two children but they may happen. We now have books and materials that will help us not to have regrets later.”
Added Irida Daci, another new mom: “It was very interesting to know that breastfeeding can be a contraceptive method.”
Another important component of the family planning project in Albania was the integration of family planning services with pediatric care. In Albania, new mothers visit their pediatrician as many as 15 times a year. “Integration of family planning services in pediatrics is essential,” said Dr. Arta Mezezi, a pediatrician in Tirana. “We should use this opportunity to advise mothers how to avoid close spaced pregnancies. I provide information and leaflets to mothers in almost every visit and meeting.”
Ramaj says the needs of her patients motivated her to act.
“You see a woman for the second time with a second child and you say, ‘What are you doing here, I mean you just had a delivery?’ and she says, ‘Well, I got pregnant.’ I ask, ‘Do you protect yourself?’ But they lack information,” says Ramaj, who has two daughters.
“Before this training happened, postpartum women would come to this department and leave without any information on health education or family planning,’’ says Ramaj, referring to the USAID-funded and Jhpiego-implemented project. “But now I provide them with information that is meaningful to them.”
In counseling mothers on postpartum family planning methods, Ramaj also discusses breastfeeding techniques and well-baby messages and reinforces them.
“Patients are very happy and they really thank me a lot.”
By Ann LoLordo
Jhpiego-supported male circumcision (MC) campaigns in three African countries have expanded access to this important HIV prevention intervention and strengthened health services for clients in a concerted effort to avert thousands of new infections.
Working in partnership with health providers from Zambia, Tanzania and Swaziland, the campaigns exceeded goals for numbers of procedures performed and set the standard for health care delivery as part of a comprehensive HIV prevention package. Clients who decided to participate in the MC campaign received HIV counseling and testing; those who tested HIV-positive or who were found to have other health problems were referred for further care and connected with related services. Jhpiego’s work in this area emphasizes a whole-system approach that develops policy and guidelines, helps supply facilities, provides counseling and surgical skills training and offers follow-up supervision.
At the end of a Jhpiego-supported MC campaign, health providers have what they need to carry out subsequent campaigns and provide high-quality services at local facilities.
The three campaigns have demonstrated that the public sector has a critical role to play in the rapid scale up of safe MC services as part of a comprehensive HIV prevention package. Previous MC campaigns have relied heavily on providers from non-governmental organizations, but during these three campaigns Jhpiego-trained nurses, clinical officers and doctors from Ministry of Health facilities played a key role.
In Tanzania and Zambia, they provided the vast majority of the circumcisions, and in Swaziland, public sector nurses were trained and mobilized to work with volunteer expatriate doctors.
These skilled providers will continue providing services during both campaign and post-campaign service delivery. Their new MC counseling and surgical skills will eventually be transferable to other health services, providing a lasting benefit to their countries once adult MC services have been fully scaled up. In addition, this work has encouraged providers at professional associations to discuss task shifting and sharing, which play an essential roles in addressing staff shortages.
Male circumcision, one of the world’s oldest medical procedures, is the removal of the foreskin of the penis. Scientific studies have shown that men who are circumcised are about 60 percent less likely to be infected with HIV during heterosexual sex than men who are uncircumcised.
The World Health Organization has recommended MC as part of a comprehensive package of HIV prevention services, which includes condom promotion, screening and treatment for sexually transmitted infections and HIV testing and counseling. Mathematical modeling suggests that scaling up male circumcision to 80% of men in East and Southern Africa would avert more than four million new HIV infections and save more than US $20 billion in HIV treatment costs.
The Zambia campaign was supported by the U.S. Centers for Disease Control and Prevention. The efforts in Tanzania and Swaziland were supported by the U.S. Government’s flagship Maternal and Child Health Integrated Program (MCHIP), which Jhpiego leads. Here are summaries of the successful implementation of these projects:
- In Zambia, 5,148 circumcisions were conducted at Jhpiego-supported sites, exceeding the team’s original target of 4,000 procedures. The majority of the circumcisions occurred at 10 sites that had been identified for intensive support. Preliminary testing data show a significant improvement in the numbers of men agreeing to be tested—about 80 percent, up from about 40 percent at these sites. The extent of the coverage is important because experts estimate that for every seven male circumcisions in Zambia, one new HIV infection will be averted by 2025. This means that the campaign in August will avert an estimated 735 new HIV infections in Zambia. The intensive campaign began in August with a community outreach effort to publicize the circumcision sites and the free cost of the service. Megaphone trucks circulated through towns and villages, encouraging young men to undergo circumcision and participate in counseling and testing. Condoms were also distributed to clients. Partners included Population Services International.
- In six weeks, an HIV prevention campaign in Tanzania performed 10,352 circumcisions in Iringa, a region with the highest HIV prevalence rate in the country (about 16 percent of adults are living with HIV) and lowest circumcision rate. The total number of circumcisions far exceeded original targets and could potentially avert more than 2,000 new HIV infections. In this region, it takes 4.5 circumcisions to avert one new infection. Ninety-nine percent of clients were counseled and tested for HIV and provided with key information about HIV prevention; clients were also screened for sexually transmitted infections and given condoms. Working in cooperation with regional health authorities and several other partners, Jhpiego trained 100 doctors, nurses and HIV counselors for the project, developed client education and counseling materials, and set up five, high-volume male circumcision sites in public health facilities.
- Capitalizing on a three-week school holiday in Swaziland, the government-led MC campaign launched in August resulted in 7,165 procedures at 13 sites. Six of the sites exceeded their weekly targets of MCs consistently over the three weeks. The back-to-school campaign is the start of a year-long effort to circumcise 80 percent of men and adolescent males, ages 15–49, in the African kingdom. In Swaziland, it takes four circumcisions to avert one new infection. The goal of the HIV prevention intervention is to reach more than 150,000 clients and avert more than 35,000 new HIV infections in Swaziland by 2025. Jhpiego supported the provision of skilled nurses and doctors for the Ministry of Health’s back-to-school campaign with partners Futures Group, Population Services International, Marie Stopes International and Family Life Association of Swaziland.
Jhpiego Advisory Board Members Dr. Howie Mandel and Ellen Hoberman co-hosted a fabulous “friendraiser” for Jhpiego in Los Angeles recently. Guests, many from the entertainment industry, were invited to The Geffen Playhouse to see a production of the Pulitzer Prize-winning play, “Ruined,” a searing portrait of the lives of women in the violence-scarred Democratic Republic of Congo. At a pre-theater supper, Jhpiego President and CEO, Leslie Mancuso, talked about the organization’s work to prevent the needless deaths of women and families with such luminaries as actor Jason Alexander of “Seinfeld” fame, actress Melina Kanakaredes, who starred in “CSI,” and Jamie McCourt, owner of the LA Dodgers.
This is the last of three stories on Jhpiego’s participation in a successful project, sponsored by the United States Agency for International Development, which served two million people and 126 health care facilities in Pakistan.
By Deedar Nawaz
Neelam Benazir is the new face of maternal and child health care in Pakistan’s northern frontier.
The 18-year-old is the first girl in her family to leave home to get an education. She is studying to be a midwife. Neelam’s family lives in Hangrai, a mountainous farming village of 1,600 with few opportunities for schooling for girls beyond fifth grade.
“I have seen and heard of so many mothers and babies dying because there are no skilled birth attendants,” says Neelam, who is staying with her uncle so she can attend the Mansehra Community Midwifery School. “I know we can save so many babies and mothers easily with simple interventions like adopting infection prevention practices, keeping the newborn warm and promoting immediate breastfeeding.”
What she enjoys most about the program at Mansehra is the hands-on approach to learning essential midwifery skills. “When we go to the labor room and nursery, we do have a chance to apply those skills confidently.”
In the past two years, more than 50 midwives-in-training have been “learning by doing” as part of the PRIDE Project, which is funded by the United States Agency for International Development. The students are learning how to resuscitate newborn babies, assist in a breach birth and identify a pregnant mother suffering from a potentially life-threatening high blood pressure disorder.
Classes take place in refurbished midwifery schools in the earthquake-damaged districts of Mansehra and Bagh in northern Pakistan. The schools, renovated by the Pakistan Department of Health with support from the United Nations Population Fund, provide an environment conducive to learning when compared to poorly equipped and rundown facilities.
This year’s graduates from the Mansehra Midwifery School all passed their exams and three of them finished first, third and ninth among all students in the province who took the test.
One focus of the PRIDE Project, a partnership of Jhpiego, the International Rescue Committee and Management Sciences for Health, was midwifery education—building the skills of students to provide skilled birth care, encourage women to have their babies in health facilities and provide follow-up care to a mother and new baby.
The interventions introduced to reduce maternal and newborn deaths are part of a larger effort to improve health care services in two areas hit hard by the 2005 earthquake—communities that are still recovering.
Mumtaz Rasheed, principal and teacher at the Mansehra Community Midwifery School, says “hands-on-training” in a skills lab improves the quality of care midwifery students provide to pregnant women.
The students are being trained by experienced midwives who use life-like models in a professional, clinical setting that simulates real-life situations.
“When we started teaching at school, we were like trying to repair the car without tools,” says Sarwat Shahnaz, a teacher and midwifery tutor at the Mansehra school. “We have to pay money from our own pocket to buy flip charts, markers [and other supplies]. Establishment of the skills lab has changed [our] world. We think we are so lucky to have the latest models, audiovisual aids and CDs and books with the latest updates.”
Improvements in the skills lab—developed with technical support from Jhpiego—so impressed the Pakistan Nursing Council that the Mansehra school was the first to be recognized by the council in the province.
As part of the PRIDE project, five public health officers provided clinical updates for midwifery tutors on prenatal care, labor and delivery, use of a partograph and active management of the third stage of labor
“We are lucky to have a very good faculty and all of them are very supportive and mentor and guide us,” said Neelam. “When we are going back to our communities with almost no backup, we must be competent to conduct safe delivery and know how to take proper care of newborns.”
PRIDE staff Dr. Shabana Zaeem and Bushra Nisar contributed to this story.