Why Do Malawians Birth at Home?

Nearly 200 babies have been born in Child Legacy’s health center! Getting to check in on the CLI Facebook page brings me lots of pleasant surprises. There’s so much going on there, it’s amazing to see the speed of their growth in healthcare, agriculture and clean water access. The HSAs bring basic medical services out to the communities, and I spy a couple of my community volunteers in this photo!

Child Legacy mobile clinics. See more photos like this on their Facebook: https://www.facebook.com/childlegacyinternational/
A Child Legacy mobile clinic. See more photos on their Facebook page

Meanwhile, the research team has been dedicating a lot of time to the maternal and neonatal death audit over the last couple of weeks. It always feels good to see those 4 a.m. messages in my inbox.

Recently the team has followed up on four more neonatal deaths, held a community volunteers meeting, and gathered as a M&NDA committee, which has been in the works for many months but difficult to pull off with the turnover and other project work on their plates.

One of the most insightful pieces I’ve heard from the group is feedback on why women so often deliver at home. A significant proportion of the neonatal deaths we recorded occurred after a delivery outside of a hospital or other health facility. The research team asked the community for their insights, (which I LOVE–what better way to engage our volunteers than giving them a platform to provide their expertise and have a stake in the solution?). Here are the notes from that meeting:

We had to look at reasons why people don’t come to the hospital on time sometimes not even coming to the hospital when labor starts (these are the reasons which people can not confess themselves)

Then we observed that:

1. In a lot of women, it is just in their mind that to deliver at the hospital is no better than delivering at the TBA, nothing else.

2. Some women met cruel nurses in the hospitals and they don’t have a willing to go again to the hospital when they are in labor, TBA’s takes good care of them. (They gave some scenarios)

3. Unnecessary confidence. They are confident that they are much experienced with how labor goes and see going to the hospital as waste of time.

4. Other old women mislead young women, because they had 8 children all delivered at home or TBA without any problem, they discourage their children to go the facility for delivery and they want to conduct deliveries at home.

5. Laziness, other women are just lazy to act fast/on time, as a result others are even delivering in the bathroom outside the homes alone.

SO INTERESTING. So many opportunities for new research and continued work. I could unpack these notes alone for days.

I had to smile at the comment about ‘laziness’ — let’s be real. If I had to pay three day’s worth of my own pay, to ride over giant potholes on an ox cart for hours in active layer with no meds, I’d probably choose the person who birthed me and would come to me in my home.

It’s funny to consider how natural home birthing is kind of bourgeois in the West, where medicine is advanced enough to have skilled midwives who can handle a low-risk delivery pretty much anywhere. But Traditional Birth Attendants like those in Malawi are a different story. Finding a way to respect cultural practices and integrate safe medical practices (like standards around sterility) is vital in addressing this issue. And it needs addressed–in one neonatal death case, a TBA directed a mother to withhold from feeding her newborn because the baby was premature. Quite the opposite from what the child needed.

Birthing without a skilled labor attendant is one clear obstacle that we can definitely address in the Msundwe community. The question is how. I’m really looking forward to visiting with my team again in August to take the next step in improving care for these families. !

Yes, Women are Marginalized.

I was happy to hear about the Undergraduate Student Government’s resolution to encourage Ohio State’s administration to open a women’s center. I saw the vote was Aye: 37 Nay: 1 Abstain: 9 and was proud to see the way our undergraduate population was becoming more aware of male privilege and the gendered experiences we live every day. Feminism is a now mainstream concept on social media and in everyday life, but this wasn’t the case when I was an undergrad, so it was good to see progress.

But then I learned more. I learned that the debate over this proposal took two and half hours. The worst part I learned was that a USG representative said, on record, that women aren’t marginalized.

USG women not marginalized_annotated

It deeply saddens me to have to do this, but let me point out three very current and well-known events that illustrate women’s marginalization:

  1. Kesha’s legal bounds to her alleged abuser
  2. A Peer-Reviewed, NSF-funded study showing Males Under-Estimate Academic Performance of Their Female Peers in Undergraduate Biology Classrooms
  3. And, have you heard about the war on women’s healthcare? New Ohio legislation will severely limit access to healthcare for women in need.”This legislation will have devastating consequences for women across Ohio,” Planned Parenthood President Cecile Richards said.

    Sounds like marginalization to me.

Older woman holding protest sign reading "I cannot believe i still have to protest this shit"
(image via twitter @alsboy)

There are plenty of campus-based manifestations of women’s marginalization, too. 1 in 4 female undergrads on Ohio State’s campus report having been sexual assaulted, and 1 in 10 report having been raped. And while it might be the case that women are leading the USG, the glass ceiling is alive and well in the administration they send their resolutions to. We have strong allies in this group of leaders, but the lack of representation is its own source of marginalization of women at Ohio State.

We can’t get 77% of the way there, tune out to remaining disparities and say “good enough.” I have higher expectations for Ohio State’s undergraduates, and I encourage all students to hold their representatives accountable for how they speak and make decisions on the behalf of others. It is especially important that a representative for the Off-Campus Living Area is in tune with the issues that impact students living off campus, since so many of these incidents take place off of university property.

I know it’s cliché to say this around election time, but I am sincerely pleading the undergraduate student body to know their representatives and hold them accountable year-round. Part of adulthood in a democracy is knowing what people are saying when they speak on your behalf.

Now Delivering Deliveries!

 

The maternity ward is open! And I can’t stop obsessing over their photos of the adorable new babes and moms. I stole these from the CLI Facebook, give them a follow for more cute pictures (farm babies too!), updates on their other cool projects and news about the seasonal challenges in the day of a typical Malawian.

Based on the rate of cases we’re seeing, and the confidence we have in our community volunteers, it seems as though maternal and neonatal deaths were about the same as the national rates in Malawi, which would predict ~4 maternal deaths in our area annually and ~ 35.2 infant deaths in our area annually. It will be very interesting to see if the offering of obstetric services at CLI will impact these mortality rates. They’ve slowed since December, but the research team tells me that the women in the catchment area typically deliver in April – October. So, fewer deliveries would mean fewer birth-related deaths. My assumption is that this is due to the cyclical nature of life in the area: Wet (malaria) season followed by hunger season (which is going to be big this year, BTW) and then the harvest.

This had me wondering if the US has seasonal ‘birthing’ patterns like this, and a precursory Google doesn’t bring up anything definitive. Supposedly there are spikes depending on where you live, which vary by state in the US, but I wonder if they are as dramatic as those in low resource areas.

And there you have it–15 minutes in the life of my brain. Sorry you’ll never get those back, but comment if you know the answer and stay tuned for updates probably unrelated to American conception patterns!

Surveillance Findings So Far

MNM surveillance report Nov 2015_CoverWe’re about six months into surveillance, and have audited 16 deaths, 15 of which were neonatal. When these deaths occur, a community volunteer calls our research team and we wait at least 2 weeks for grieving. Then, our audit forms are completed through 1:1 interviews with family of the deceased and anyone who provided care during the delivery. Those audits are compiled in a database, where we can get a snapshot of dozens of factors that could influence maternal and neonatal mortality.

Patterns we’re seeing so far include:

  • Delivery occurring outside of a clinic
    • 10 cases
  • No skilled assistance
    • 14 cases
  • Lack of funding for transport or care reported in 3 interviews but possibly a more prominent issue
    • Average distance between home and nearest facility: 15 KM

An opportunity we identified was that mothers in all cases reported receiving antenatal care.

This interaction could serve as an opportunity to educate patients on the importance of delivery with skilled assistance, early warning signs of active labor, and how to get to a nearby facility.

And new questions arose:

  • Why do women deliver outside of the facility?
    • Culture?
    • Costs?
    • Delays in decision making?
  • What are our avenues for collecting this information?
    • Add a question to the audit
    • Ask mothers at CLI who have delivered at home
    • Ask the mother during her prenatal visit how she plans to choose the location of her delivery

It seems inevitable that new questions will evolve and present themselves as we redefine our bigger initial questions: Why is maternal mortality so high in this area? What can be done about it? How would these improvements be made? But we’re narrowing in on the problem in order to identify a solution. A solution that would be generated with the culture and resource context necessary for lasting change.

See the Full MNM surveillance report

Maintaining Community Engagement

When we hosted our first community volunteer meeting back in July one of the strongest pieces of feedback I received was “don’t disappear!” In communities that become subjects of multiple research projects and interventions like CLI’s, it’s important to work with intention to follow through, and illustrate the value these projects bring back–and not just to the PIs.

So, even though the next volunteer meeting occurred sooner than I had planned, I was still happy to hear that Monday’s gathering was well attended, and that our IDs are still being made and new volunteers recruited. The people in our catchment area move frequently, so we anticipated roll over in volunteers who moved out of the catchment area or into a village that was already represented by an existing surveillance volunteer.

Speaking of rollover… our star Health Surveillance Assistant, Lamulani, went off to university! He’s studying medicine and how can we not be excited for that? Luckily, the rest of the HSAs are stepping up and taking care of business. Frank, pictured, is working with fellow HSA Chrispine to continue cultivating this wonderful community dedicated to improving our knowledge about maternal and neonatal care in the MWC catchment area.

3 Ways to End Wimpy Writing

It might be hard to tell from my recent posts, but my day job is in Marketing Communications. I write a lot, and I edit a lot of copy written by others. Over the years I’ve noticed some patterns that no one shared with me while learning to write, and for what it’s worth, I thought I would share:

I see (or commit) these specific wimpy writing techniques almost daily. When you have these moments: stop, think, and write boldly.

1. When you say something “helps”

A wise yogi once said, “You don’t have to prove anything to anyone; just become it.” It reminds me of sheepish writing. If we know Open Educational Resources save money, why would we say OER helps save money? Just say the subject DOES the verb. Consider: If you aren’t sure it’s true, why are you writing it that way? Know your material and say it like you mean it.

2. When you use the word “and” twice (or more) in once sentence

I run into this often, when the writer seems to lack focus. It’s like they haven’t quite figured out what they want to say. They want to talk about how great this thing is, that it does everything for everyone! If it really does all of those things, are you sure you want to cram them all into one sentence? I’m as big a fan of tight copy as the next lady, but there are times when more sentences are needed to tell the story. Ask yourself: if it’s not worth elaborating on, is it worth including at all?

There are two types of these sentences:

The double list syndrome: The application saves money, time, and energy for students, parents, teachers and staff.

The ‘and we can’t forget…’ sentence: “The tools and resources we’ve developed will help drive research and scholarship at Ohio State and around the world.”

Just decide what you’re talking about and make it a stronger statement. Consider: Can’t we just say tools OR resources? Is this thing we’re doing actually involved in research or is it really about publishing scholarly work? Be decisive. Be direct.

3. When you use an exclamation point

Exclamation points are to copy writing as “thirst” is to dating. What you have to share is valuable, right? If it isn’t, you’d just not write it, right? Exclamation points say “hey I couldn’t figure out a way to make this relevant for you, but I’m desperate so here’s THIS!

Find other ways to connect readers to your content. It takes more brainpower than tacking on an exclamation point (or, G-d forbid, points), but punctuation isn’t going to convince someone to be excited about what you have to say.

 

How do you write boldly? When do you catch yourself writing wimpy?

Wrapping Up

Turns out I had no problem staying busy for my time on site without the research team.
I got consultation from one of CLI’s resident obstetricians, who offered great feedback including the ever-looming “does the District Health Office know about this?” question. This, along with advice from my advisor, and 2014 conversations where I inquired about the need to involve the govt public health orgs, led to a field trip yesterday. After several stops at various DHO buildings and lots of help from a CLI surgeon/administrator, we had a parking lot meeting with Malawi’s Coordinator for Safe Motherhood. It actually left me feeling much more accomplished than the term ‘parking lot meeting’ implies.
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I also found out that the CLI Maternal and Neonatal Mortality Committee I was proposing to be established already existed. !
And, that the Ministry of Health has, in fact, updated their maternal death audits recently. Which means changes for ours—but good ones, since the additions they made align with a portion of the information we included in ours.
Finally, I put together a ‘sustainability report’ that outlines what project management and resource alignment needs to happen to ensure that this whole thing doesn’t lose steam when I leave. This involved calculating what the project costs and how long my fundraising could sustain it.
Good news: The money I fundraised (plus some that I saved), is enough to support the maternal and neonatal mortality surveillance for 18 more months!
This is a significant amount of time. Long enough to plan for 12 and 18 month evaluations to see if the information collected is valuable enough to absorb the future costs into the regular expenses of the research program and continue with the surveillance. Since I’ll need to do a ‘final project’ to complete my MPH in a year, this could create a perfect opportunity for me to get some experience in public health program evaluation, which I’ve always had an interest in.
I spent my last day in the research office sending many emails of terrifying lengths, like a mom leaving for an extended vacation and needing to make sure you know how to set the alarm right and what to do in case you set it off anyway and also that the key to the shed for watering the garden (the half that needs watering, NOT the other half that gets all the rainwater from the gutters) is behind that lawn chair with the… you get the picture.
I’ve agreed to remain a resource for the team to be sure that the foundation for the system is strong. The CLI staff will take over all routine aspects of the system such as volunteer recruitment, training and kit distribution, case auditing and reporting.IMG_2816
It was a crazy last half of my visit, (especially with a safari weekend squeezed in the middle!) but I’m very proud of what I’m leaving the team with as I head back to the states. Thanks, again, to all of the moral and financial support from friends and family.
Zikomo kwambiri, and see you soon Ohio!

Adaptability Training

Got a big surprise on Friday:
Most of the research team including my preceptor Gladson will be in Lilongwe (the capital) for the rest of my time on site. They were able to schedule the training that was pushed back originally, so my relief of having lots of research team availability was a bit premature.

Continue reading

A Day in the Life

When I’m not running around like a crazy person preparing for a meeting like yesterday’s, here’s what a typical day at the office looks like:

Morning

Breakfast with my roommates, Araseli the CLI hospitality manager and sometimes other people on site.IMG_2722

Eggs with beautiful yokes and indulgent toast is the norm.

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For those who were wondering, my coffee solution is perfect and is a hit with others on site.

Breakfast is sometimes rushed so we can hop across the site and get to our morning meeting at the clinic.

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Clinic and research staff attend to give updates, ask for feedback on upcoming projects, and raise any issues. There’s usually also a presentation. We saw two last week about malaria diagnosis and treatment. I like how the doctors and ‘superior’ staff take time to share what they learn about new standards and best practices with the broader group. For example, they shared doses for children taking first-line malaria treatment with everyone, even though only a few of those present had authority to prescribe.

Last Friday we used this time to get feedback on the volunteer guide, and the project as a whole, from the clinic and research teams.

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After the morning meeting we go to the office. It’s simple, I’ll call it an ‘open workspace’ concept with lots of sun. Everyone works diligently, as a group or quietly on their own, until lunch.

Afternoon

Mzungus eat separate from the rest of the staff, which is kind of a bummer. We do benefit from more variety of the kinds of foods we eat, but “doing as the Malawians do” was more of what I expected. I can’t complain though; they just want us to be happy, and the food is great.

IMG_2737Sometimes we are served Malawian food; the main staple being nsima, a white cornmeal kind of dough that you mold in your hand and dip in whatever it’s served with. That is usually “relish” which reminds me of southern cooked greens at home; and then sometimes another version with some kind of peanut flour or paste in it. They call it “peanut butter” flavored.

Everyone in Malawi gets a 90 minute lunch break: it’s actually the law. So depending on the day I check in on things back at the home front (hi ODEE!), take care of things in my room (like cleaning the shoes I filled with dirt on the walk to the market last weekend) or practice some yoga. It’s super sunny, every day this time of year.

Our afternoon at work is our chance to communicate with people in the states so sometimes we do some of that. The other day it took 30 minutes, two computers, and several phones to connect for a conference call which was still off-and-on connectivity that often required transcription on the typing section of skype while my advisor Alison spoke on her end. It’s an exercise in patience.

IMG_2721Otherwise, we just do more of whatever we did in the morning. In the afternoon there are fewer people around, as some staff get assigned to work outside the clinic.

Evening

IMG_2760We’ve often come back to the room to find Midnight on one of our beds, which is just like home for me. I recently found out that this was ‘against the rules’ though, oops.

Sometimes we work out before dinner. I’m sharing the room with an agriculture volunteer (Mackenzie) and a student researcher (Julika) and the three of us have done circuit training and running. Malawians, of course, think it’s funny that we exercise. I’m glad we can provide them some entertainment while we get some of that extra energy out from all the eating we do.

Sometimes after dinner we play games like bananagrams or puzzles. Usually we make calls home, do some reading and go to bed early. Like, lights out by 9.

That’s a (week)day in the life for me. It’s a nice routine with some wonderful people and a lot shorter to-do list than at home. I’m learning how to multitask effectively–loading a web page can take dozens of minutes and downloading a device driver has proven to take an hour or two. But with all the progress we’ve made already, I’m feeling confident about having a comprehensive system in place by the time I head home.

Zikomo kwambiri (thanks much)!

Lucy