public health

Supporting my Surveillance System

| Lucy Ramos

The surgical theatre was scheduled for its first operation today! I don’t know all the details (ad will share when I get an update) but there were actually two gynecologic surgical procedures planned and they will be the first patients that will stay overnight and be admitted to Child Legacy Hospital. A really big deal for a clinic that for years has only provided outpatient care. Such an exciting time to be prepping for a trip to see it all in the flesh.

CLI operating theatre

My flight is booked, my personal expenses are saved, and now I’m asking for help to cover the remaining project costs.

Since most or all of my community volunteers only speak Chichewa, I’ll be working with a research assistant/translator to help me get around to villages throughout the catchment area and check up on the surveillance system. Everyone on the research team I’ll be working with on site is Malawian, which is another great benefit of working with CLI.

I’m also providing volunteer toolkits, to help the surveillance volunteers in the villages surrounding Child Legacy know they are part of something important and that their work matters. Gladson, my preceptor, let me know that giving them something branded would help make that connection. I’m thinking of giving all of the volunteers their toolkits (manuals, volunteer ID cards, office supplies, airtime etc) in a branded reusable bag that they can then use for other purposes and be reminded of their role.

It’s these remaining project costs that I could use some help with.

I’ve set up a fundraising page to accept donations. Every little bit counts, really!

$5 provides the airtime it takes to supply volunteer with the phone calls they need to report a death in a timely manner. If you donate $5 or more I will send you a photo and some information about the community volunteer who you are empowering to be a part of something, gain new skills and improve maternal care in their village.

If you donate $20, you’ll provide a day’s salary for my translator. If you donate this much I’ll find out what your name would be in Chichewa and report back.

My birthday is approaching and I’d love to dedicate it to this project. Please donate to my project instead of buying me a celebratory beer or a trendy greeting card. It would mean the world to me and it really makes a difference to the volunteers and communities I’ll be working in.

I’ve already received so much moral support from my family, my work family and friends. Can’t thank you all enough for all of the excitement you have shared with me and your encouragement in doing what I love.

Maternal Health in Malawi

| Lucy Ramos

Lets visit the numbers:

malawi MMR

The World Health Org has some awesome interactive visualizations of health data, showing maternal deaths per 100,000 live births.

Malawi is at 510.

In case you’re wondering, Is that a lot? Compare it to 28 in the U.S., or 6 in Switzerland.

This means that the risk of a woman in Malawi dying from a maternal-related cause during her lifetime is more than 18 times higher than the risk for a woman living in the U.S., and 85 times that for a Swiss woman.

Even compared to its neighboring countries, Malawi is still behind in maternal health care according to these parameters.

Numbers only carry as much meaning as they can be associated with real people and their stories.

On Tuesday I learned about our first deaths reported by our surveillance project. A mother who, for many reasons including lack of funds for transportation, delivered at home alone. She lost both of her twins within a week of their delivery. She was HIV positive but wasn’t taking the drugs because they made her very sick. Our HSA told her about the CLI clinic and she and her husband did come for a different therapy solution that might not cause so much nausea. We’re realizing it also has the potential to connect community members to the clinic’s resources.

The goal of my surveillance project is to document these circumstances under which mothers and their babies don’t survive. We’ll learn more about these twins’ deaths, but there are already so many obvious fixes to dramatically reduce the risk to mother and child. It is disheartening to identify these solutions after it’s too late. But getting data to illustrate these common obstacles to safe obstetric care will help plan for where new resources can make the most impact, identify training needs, and get facilities across the catchment area communicating with each other.

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For so many reasons 510 is more than just a number, and I’m feeling very privileged to be doing the tiniest something about it.

Leg Work Leading Up

| Lucy Ramos

Since the maternal ward was scheduled to open sooner than my arrival, the CLI team wanted to launch the surveillance project before I arrived–my advisor was hoping for as early as April. And it kind of did.

I’ve been working since last fall with the team to develop  (several iterations of) the death audit form, a training manual for the village volunteers, a surveillance protocol, a database, etc.

A couple of weeks ago some 30 community surveillance volunteers came to the McGuire Wellness Center to get familiar with their roles in the project and learn about maternal and neonatal mortality. Involving the community is vital for these kind of projects: these volunteers don’t need to know all of the medical stuff, but they are our eyes and ears in the villages.

When any of the volunteers across the 60+ villages hears of a death of a baby or a woman (we give them a wide age range), they report it to CLI. From there, one of our Health Surveillance Assistants asks a few more questions to determine whether this death fits our case definition of a maternal or neonatal death. If it seems to, they head out into the field to get the details from the health care provider and family of the deceased. They complete the audit and take a narrative version of the interviewees’ testimonies.

One tricky part was figuring out how to incorporate an existing audit: the Ministry of Health’s maternal death report. It does exist, but is not shared among facilities, and is not as comprehensive as many of our CLI physicians would have liked to see. I added to the maternal version and included a neonatal section. I also added some questions and did some rewording to apply to deaths that might occur in the community. Our hope is that for the facility deaths, the MOH audit form will already be complete when our HSA arrives, and that the form can be used to cross reference answers we get from the interviewees.

Doing this kind of auditing requires some tact: No one likes to get interviewed on all the things they do wrong. It’s our job to assure the facilities and providers that we’re simply collecting information and are not placing blame or taking any kind of retributory action.

Getting everyone together for a meeting was an exciting first start, and the partners who conducted the training said it was an energetic group. Volunteers have agreed to go ahead and contact their assigned HSA when they hear of a death, but CLI is still translating of the forms I developed. I’ll also be sending over funds for airtime cards for the community volunteers. We’ll continue attracting more volunteers so each village can (more or less) have its own surveillance volunteer. The (kind of) good news is, the maternal ward has not yet opened.

My advisor is traveling to Malawi next month, and she’ll deliver my “volunteer toolkits” that provide each participant an ID badge as a CLI surveillance volunteer, the airtime cards and some other things that will help them feel Official. I hope these tokens and trainings empower and motivate them to take an active role in the project.

Moms in Malawi deserve safe deliveries too! I’m excited to be a part of it and look forward to spreading the good feelings.

 

I’m knee-deep in the project so am surely missing pieces and parts when talking about it. Would love to receive your questions in the comments below!

Next Stop: Malawi

| Lucy Ramos

Every Master of Public Health student  has to complete a practicum project. For mine, I knew I wanted to go abroad again, and the project requires me to work more hands-on in the health work than my Peru visit allowed.

mwafrica

In April of last year (yes, before my trip to Peru) the Child Legacy International team made a visit to Ohio State to talk about their wellness center and other services provided to rural Malawians. They shared their plans to open a new maternal ward and illustrated the need–Malawi has high maternal and infant mortality rates, even compared to their neighboring Sub-Saharan countries.

I got in touch with their Ohio State partner and asked how I could contribute to their work for my practicum. The stars aligned then, and their biggest need (that I could help with) happened to be related to maternal health. They needed a maternal death audit system to assesses their services and the care provided to mothers and their newborns throughout their catchment area of 20,000 people across 68 villages.

So it’s been a year working on and off (though more ‘on’ recently) to develop a surveillance system that can help us learn more about what happens when a mother dies from childbirth or when her neonate doesn’t survive. This data is collected routinely in western health facilities and used frequently to improve care practices and identify risks. Collecting and analyzing this information for the MWC catchment area will allow the quality of care to improve for their community as well.

I’m looking forward to sharing more with you as the project approaches and then will post stories from the field. I leave in early July for my 4-week trip.

An Intro to Shilla, Peru

| Lucy Ramos

I said I’d share about my Peru trip all along the way, and several months later I’m sitting down to do my first post. Sorry! Internet and free time were not plentiful. I have no excuse for once I got back to the states but better late then never?

There are so many memories and moments to share. First I wanted to talk about the site we worked in: Shilla, Peru.

Shilla was a 15 minute ride from our hotel in Carhuaz. It was way up in the mountains and every morning we got a stunning view of snow-capped Mt Huazcaran. Every single day we oooooh’ed and aaaahhh’ed over it on the drive there and several times throughout the work day.

Shilla is pretty remote and up in the mountains. Our work site, specifically, was too high up for the truck with our equipment. So we took it up on our shoulders from our host family’s home.

Our host family was made up of parents Celestino and Señora Norma plus their four sons.

Shilla is full of very hard-working “campesinos,” rural people who tend to their fields all day by hand–no tractors, power tools are to be found. A neighbor was using pre-made bricks and looked almost out of place with the modern materials.

Women wore traditional outfits with lots of layers–it reminded me of Colorado in that the high temperatures and low humidity made it cold at night and hot in the sun during the day. Only in Shilla the layers weren’t shed throughout the day. These women often were the ones in the campos (crop fields). Growing papas (potatoes), maize, cilantro, and quinoa. They worked until sundown and then had little light to travel by–making it difficult for the women to gather for the women’s organization at Sonja’s house.

Katie, Señora Norma y Luis

In  Shilla everyone says hello. You make sure to say the time-appropriate greeting as you pass people on the road. The site had never hosted gringo volunteers before so I’m sure seeing us hauling bamboo bundles up the mountain with pathetic ‘omg this hurts, what is this incline?’ look on our faces was a pretty humorous sight for the locals.

Our host family brought us into their home with open hearts and showed us true humility, work ethic and compassion. As brief a time we spent with them, they made a lasting impression on all of us.

GHI Peru blog

| Lucy Ramos

The GHI team of undergrads I traveled to Peru with was so special–each surprising me with their amazing attitudes, maturity and collaborative energy that I totally didn’t expect from a cohort of people 5-6 years younger.

peru team

One of the many ways they out-did me in responsibility was maintaining a blog about the project. Three cheers to Nina and Tori who led the way.

Read up on our project at the GHI Peru page.

Q&A for Bike Commuters

| Lucy Ramos

rules of the road, bikers

It’s good to know your rights as a cyclist. Mostly to win arguments in casual encounters with friends or not-so-friendly neighbors on the road. And that might be the most rewarding kind of knowledge exercise anyway.

In all seriousness, knowing how bike laws are structured for your safety helps you feel confident in sharing the road. Following the rules keeps everyone safer and sets the right example for potential new bikers on the road.

Do I have to ride in the road?

A thousand times, yes. Bicycle riders, except small children, are prohibited from riding on sidewalks in Columbus. It might seem like a safer place to bike, but with the mix of pedestrians, pets and other commuters by wheels, traffic is nowhere near as predictable on the sidewalk as it is on the road.

Am I fast enough for riding in the road? Won’t I be impeding traffic?

You ride at your own speed. The law for reasonable speed is applied for an appropriate pace for your vehicle. Just like other vehicles (horse drawn, for example) have different ‘reasonable’ speeds, you’re only expected to go as fast as a biker should, not with the flow of car traffic. When you’re on a bike in the road, you are traffic, and thus not impeding traffic for going slower than a motor vehicle’s speed.

Where in the road should I be positioned?

The law states that bikers shall ride as near to the right side of the roadway as practicable. Practicable, not possible.

– i.e. you do NOT have to hug the line.

  • Maybe there’s debris, or a pothole, or you just want to be more visible. Giving yourself a few feet of room is A-okay.
  • The new 3 foot law requires drivers to allow space between you when passing. Commercial drivers need to allow 5 feet of passing space.

What equipment do I need to stay legal?

The law states that every bicycle when in use shall be equipped with the following:

(1)  A front white light

(2)  A red reflector on the rear

(3)  A red rear light in addition to the red reflector

  • If the red lamp performs as a reflector in that it is visible as specified in division (A)(2) of this section, the red lamp may serve as the reflector and a separate reflector is not required.
  • Additional lamps and reflectors may be used in addition to those required, except that red lamps and red reflectors shall not be used on the front of the bicycle and white lamps and white reflectors shall not be used on the rear of the bicycle.

(4)  Every bicycle shall be equipped with an adequate brake when used on a street or highway.

Other laws you should know:

Riding side-by-side is legal (law says no more than two abreast), of course it’s a good idea to be courteous and ride single file when in traffic.

You should signal for turns and stops, even sudden slowing just as a car would, if you can. It is not always required. For example, when you need both hands for braking or otherwise controlling the bike, signaling is not mandatory.

And for the lady bikers out there, a silly/ingenious cycle hack video, Penny in Yo Pants:

Penny In Yo Pants from Johanna Holtan on Vimeo.

 

All of this I learned at the annual Women’s Bike Summit from a local bike attorney. He blogs on current cases and translates legalese with his own notes on how the laws are applied in practice, at ohiobikelawyer.com.

Yes, You Can Help

| Lucy Ramos

plush uterus

I’m leaving for Peru in less than a week! If you’re still looking for ways to help, consider these:

Education materials on sexual and reproductive health
( in Spanish would be the most helpful )

  • educational boards of reproductive systems,
  • menstrual cycle visual aids,
  • pregnancy process materials,
  • demo kit of birth control methods, etc.judy blume book

Judy Blume’s “Are You There God? It’s Me Margaret” (in English and/or Spanish)

  • This book will  be used as an educational/discussion tool around menstruation for pre-teen and teen girls at Shilla primary and secondary school, and in the context of English classes. It allows for  participatory discussion about menstrual popular culture with an intercultural approach and in a fun context.

Kale seeds

  • for community organic garden and school garden

English Language Learning materials

  • to donate to the primary and secondary schools in Shilla

If you live in Columbus and want to donate something, let me know! I’ll pick them up from you this weekend.

and Cash, of course

Some of these are pretty specific so another option, for dwellers of Columbus or any city, is to donate money. Project needs will undoubtably arise once we are on site. Also, some things make sense to buy there, due to travel limitations, and also because learning materials obtained locally will have better cultural relevance to the learners than something we might bring over. Any donations collected will go straight to the community, not the volunteers’ expenses. So pitch in and help us boost our effectiveness.

Solpayki (thank you)!

Connecting the Dots

| Lucy Ramos

So I’ve shared a lot about national public health policy in Peru. You might be wondering what this could possibly have to do with my work on the ground, in an indigenous community, up in the mountains.

Policy decisions have remained regressive and are causing harm to the traditional practice of the Quechua. A few examples how:

  • A fine against home delivery
    • both the family and the midwife are subjected to such fines
    • this policy is causing the practice of midwifery to fade, as young people passionate about maternal health are studying obstetrics over midwifery because of the government’s ‘harassment’ of midwives.
    • meanwhile, practicing midwives are taking their operations ‘underground’
  • Refusal of birth certificates unless the fine for home birth is paid
    • There are serious implications associated with not having proper documentation. It restrict’s the child’s eligibility for necessary social services.
    • The internationally recognized right to personhood is violated with this practice.
  • An abortion ban, even in cases of rape or incest
    • though less severe punishments are prescribed for these situations
    • no reference to term, so the traditional beliefs of early term abortion as ‘menstrual cycle regulation’ are disregarded
  • Lacking adequate accommodations for Andean communities
    • Women hours from a facility are required to deliver in one, but they cannot come early to ensure that their transportation is covered
    • Attending in Quechua is not a routinely practiced standard of care, causing obvious communication barriers and further dividing the biomedical world from the indigenous community
    • Some facilities allow for vertical delivery, a method that’s shown to ease the birthing process and is seen as critical in the ritual of giving birth as recognized by the Quechua.
Natural birth in a vertical position is promoted, because the baby should be received close to Pachamama or Mother Earth. Other rituals take place, such as burying or burning the placenta. This event takes place in a horizontal relation between the midwife and the birthing woman.
    • Many facilities do not allow for vertical delivery, as it is a more difficult position for the doctor. It seems as though traditional handling of the placenta is even less accommodated.

 

The volunteer group had dinner at my house a couple of weekends ago and I shared the following Haikudeck. I covered repro history as my last entry recounts. Then I shared cultural barriers to biomedical health settings, and suggested solutions to making care more culturally appropriate. Explore my notes if you’d like, or leave a comment below if you have any questions.