Old World Sexism

Last year I wrote about a bylaw requiring women and TBAs to pay a fine of a goat to the chief of their village each time they have a home birth. The other day I found out that when a young girl “falls pregnant*” her family also owes a fine to the chief as a penalty. I couldn’t help but ask “what about the boy or man’s family?” even though I knew the answer was that there is no accountability on the male’s part.

*So often the language alone says so much.

It’s bad enough when you know a culture facilitates victim blaming and double standards, but when the policies enforce them so blatantly, it gets to me. Don’t get me wrong—I’m aware of reproductive rights issues we have around the world including at home, but at least our policymakers have to try working a little more discreetly to write sexist legislation.

I also learned that medical students are taught just two categories for induced abortions: “inevitable” or “criminal.” The physicians had a dynamic conversation* about the appropriateness of putting that kind of language on a medical record. Their job is to treat people, not to get involved in legal disputes and criminal cases. The truth is abortions are still illegal here (pretty comprehensively), so technically calling it criminal is accurate. But the fact that stigmatizing language can even be found on your hospital chart demonstrates how pervasive the oppression of women really is.

*I was proud of the clinic leadership for even having the conversation—it was not easy or comfortable, as the Christian faith is a big part of this hospital. Ultimately, they were clear about wanting to do right by their patients.

Working on a research team connected to a clinic means it’s easy to see how these systemic issues touch individual lives.

The founder of CLI, Jeff, told me about a 12 year-old who was raped and impregnated by a local boy and ran away from her parents (no surprise given the environment I just described). She sought refuge with her uncle but was turned away, so was on her own until she came to deliver at CLI hospital. She is one of many cases to inspire the clinic’s new teen motherhood program. They’re working to offer nutritional and parenting support for the mother including a stipend for someone in her family to take time off of work so she can return to school.

It’s a needed service but it’s hard not to think ‘upstream’ about how we can prevent the pregnancies in the first place. Motivating cultural change is so complicated, resource- and time-intensive, so I’m happy to hear that the clinic staff is interested in using the community volunteers organized through my surveillance project as advocates for other initiatives driven by the clinic. These volunteers seem to really believe there is opportunity to improve their villages, and they are one thousand percent critical to driving sensitization efforts. You can’t be a mzungu running around insulting someone’s culture, but a respected champion who shares your vision (maybe an army of them) actually has a chance to incite change.

So, this is where the ‘less data, more doing’ pressure comes from. But evidence has shown time and time again that empowering girls and women promotes growth in all areas (econ/edu/health), arguably with more efficience than any other type of intervention. I hope CLI can learn from those cases and leverage data from Malawi and around the world to move the needle for girls and women right here.

New and Old, Same and Different

I usually pride myself on my adaptability, especially when traveling, but maybe now that I’m working on this project over so long it seems like it takes a little more energy to go with the flow. Of course reminding myself that it’s been an entire 13 months since my last visit makes things more comfortable. My life back in the states sure doesn’t look the same since last time I made this trip.

To organize what would otherwise be a random smattering of updates, here’s what’s inevitably changed, and what’s stayed the same:

CHANGES

Malawian Kwacha

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The currency here has taken a dive since my trip. I thought that meant good news—that what’s left of the money i left in USD would be worth even more now than it was before! But it turns out the funds were all exchanged at once. Ouch. So even though the money has been well managed I’ll be needing to leave some extra behind to complete the 18 months of surveillance we originally planned for.

Clinician Buy-In
One of my two main supporters in the clinic no longer works at MWC. Another doctor has jump started a new, awesome initiative providing support for the teenage mothers they see in the maternity ward (another change that i’m super excited to share in more detail later!).

I’m going to be testing the waters in the next weeks to see what kind of room there is left to take action in response to the data we see from the surveillance (cases include a couple of teenage mothers but not many).

Office Location
The old research office is the new and improved laboratory for the clinic. We’re jus around the corner in a  space that feels about the same—it might even be a bit bigger.

SAMESES

Attention on Home / TBA Births

One of the research assistants delivered an impressive proposal for an initiative to work with Traditional Birth Attendants in the area and retrain them as advocates for safe deliveries at a facility with skilled assistance. I was considering this as a potential intervention to explore, so I’m glad to see someone else was thinking in the same direction.

Again, though, I am wary of moving forward with a comprehensive reaction to the surveillance before we’ve really completed the data collection, looked at the results as a whole and evaluated our efforts. I guess I can’t be surprised that everyone is moving at twice my pace, since they’re here working all day every day. Sometimes being strategic just takes a bit more time, and it can be difficult to wait if you already see where you can have a very positive impact.

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meeting prep is better when you’re prepared enough to know they don’t have a color printer, so you’ve bought markers to make it work.

Life at the Guest House
I’m back to sleeping in the same room, enjoying the same food cooked by Freddie, playing with Afshan’s kitty and sitting by a fire almost nightly. It’s still cold like last time and I’m unprepared for it like last time.

Navigating Needs
There are so many good things to put time and money into. Good people trying to go to school, interventions designed to fill obvious needs in the community, existing efforts and interest expressed by the CLI or MWC leadership… I’m putting on my collaboration cap and trying to see how I can align my existing work with the initiatives MWC is already committed to, but I hope we aren’t doing too much shoe-horning just to make that work. Every project brings a dozen new needs to the surface and it’s hard when you know you can’t do it all.

Tomorrow I meet with clinic leadership to see just how that alignment might work. Wish me luck!

Zikomo.

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!

Meeting the Volunteers

Today was our big volunteer meeting! 63 of the surveillance volunteers from the villages around CLI came to the clinic. We didn’t have a big enough space for everyone inside so we set up in a courtyard outside the research office.

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In the last week I’ve developed a community volunteer guide, which helped explain a little about the project and its purpose, the role of the village volunteers, and important information like contact info on who to report the deaths to. It also defines neonatal and maternal deaths to help them identify what a ‘case’ would be.

Check out the English Version | Chichewa Version

The volunteers got these guides, their t shirts, and volunteer IDs. They also got a round of training from my preceptor and the CLI research lead Gladson. The clinic’s head physician addressed the group as well, expressing his appreciation for the project and their involvement.

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As with any well attended meeting, refreshments were served.

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I had some really great interactions with our participants, even across the language barrier. It was fun getting to meet them in person after seeing their faces from the ID photos.

Planning the logistics of it all was pretty stressful. For our 1 p.m. meeting, attendees arrived anywhere from 11 a.m. to 2:30 p.m. But overall it was a great opportunity to get everyone together. The volunteers asked thoughtful questions and worked together to figure out solutions that fit their communities.

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The HSAs (CLI staff who act as liaisons in the villages) got some great face time with virtually all of the community volunteers for their areas at once, which was valuable too. Despite a long gathering, everyone was in high spirits at the end.

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In addition to returning volunteers we also had new participants, so now all of the villages in the catchment area should be covered. I’ll verify when the dust settles and the registration forms are compared tomorrow.

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My next step is to take a very close look at what happens after the community volunteer level reporting: how the HSA collects information for the audit, how it’s entered into the database, and how it’s analyzed for applications in clinic decision making.

These are just a few of the photos I was able to snap while helping carry on the meeting. I had a fellow volunteer come take more, so stay tuned.

Tionana (see you later!)

Lucy

What I’m Lacking, What I’m Packing

I leave Sunday! The countdown is now less than a week and I’m pulling things together. This is my third international trip and I’m not forgetting all the lessons learned the hard way from my first two:

IMG_2661Coffee. Peru and Uganda both being known for their coffee exports, I thought I’d be drinking some fancy brews, but was woefully mistaken.

In an effort to avoid 4 weeks of instant Nescafe, I’m bringing a disposable pour-over for each day. I think the materials inside the packet are compostable. I found these on Amazon for a fraction of what I pay for coffee here at home. Traveling internationally is always an exercise in flexibility, but I’m giving myself a pass on this one. I think allowing myself a few creature comforts can help me direct my energy on all the other ways I’ll be out of my element.

I’m lucky to have very little to worry about as far as regular medications–just a daily Malaria pill and the typical travelers’ kit of SPF, DEET and ahem, digestive precautions. IMG_2662

I’m going during Malawi’s cool, dry season. Which means fewer mosquitos, so lower malaria risk. It’s also a lot easier for me to stay comfortable and dress conservatively. When you think about going to Africa in July you don’t think about breaking out the sweaters, but that’s what I’m doing as nights will be pretty chilly and days will be in the 70s. In my first trip to Africa I completely underestimated what’s appropriate for dress and was way too casual–this round I’m wearing long skirts and outfits I wear to work now to make a good impression.

volunteer shirtsI’m taking over a bunch of items for the project, too. Including my volunteer t-shirts! I was so excited to get these in the mail last week. It was a much-needed tangible reminder of all the people who are involved in this surveillance system and the impact we can have on maternal health in their community.

These shirts cost 2-3 times what I originally expected to pay for the volunteer incentives, but I’m so happy I was able to get them. They’re really going to help volunteers identify with the project, which is the whole point. I’ve met my extended goal on my fundraising page and that provided me some additional funds for this expense.

*The shirts are also taking 2-3 times the space that my original idea–the volunteer totes–would have taken. Which means I’m looking to borrow a large suitcase. Anyone in Columbus have one they don’t need until August? A BIG one you have to check.

As many projects go, unexpected expenses happen. I wanted to pick up a scanner, for example, so the team members on site can have access to digitizing the audit forms as they’re completed. I’m currently receiving photos of the completed forms taken with a point-and-shoot, and doing data entry from those. This system works in the short term, but should really be improved. So, if you meant to donate to my project and have procrastinated, it’s not too late! At this point, the more I can raise the longer I can support the expenses of my project before they become CLI’s burden.

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I can’t say thanks enough to everyone who has supported me and this project. I’m incredibly lucky to be surrounded by so many great people who have taken an interest and offered to help in so many ways. It’s another motivation on a long list of reasons why I’m committed to perfecting this system while I’m on site. More on that next!

Thank You! + CLI Photos

Guys. You, ahem, made it rain on my birthday. Knowing I’m surrounded by people who believe in me and what I do is the BEST gift I could ask for and I can’t thank you all enough.

Immediate costs of the project are covered, but the longer we can pay our own way in staff salaries and supplies, the better for CLI. They will pick up the expenses when my contributions run out, but that does take away from other funds they would otherwise use to care for the community and execute other important research projects in the catchment area.

So in case you haven’t made it over to my fundraising page yet, I’m keeping it open through this month.

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My advisor took a good hard look at our materials and started asking the what-ifs and other awesome questions that will make my tools more powerful. Grateful for the close look but I have a lot of the more tedious work that’s not so fun to blog about. Instead of boring you to death about my spreadsheets and protocols, I want to tell you more about the site I’m working at, Child Legacy International.

Just from looking at photos you get the impression that there’s a lot going on in this compound in rural Malawi.

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First, it runs off of wind and solar power. When you run a clinic and research lab, having consistent power supply is not an option, so they’re building a pretty robust system. When I met one of the founders a couple of months ago,  he made a good point about providing creature comforts as incentives to retain the Malawian staff they train and educate to work at the center. I get it, too–those little things count and you want to have the best people.

Though my project is really focused on work for the McGuire Wellness Center, CLI is way more than just a clinic.

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Their compound has farms,

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including tilapia ponds that feed staff and patients, then extra go to market for profit to the center

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clean water access projects,

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below is a photo of the cofounder I haven’t met yet–from what i can see in the photos she walks the walk when it comes to collaborative efforts and i love it.

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There’s also a school for young kids, and opportunities for vocational training too.

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plus a lab for bio testing, a pharmacy, a research arm, so much!

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It’s impressive to peruse their photos and see how much they have going on, and to see their plans in the future.

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The more I learn about this organization the happier I am to get this opportunity to work with them. I was also glad to see that they’ve earned the highest possible rating by Charity Navigator. It’s another reason why I want to support my surveillance system for as long as possible. The money that’s being put to work by this organization is used where it’s needed and it’s used efficiently.

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Thanks for all of the support you’ve all shown me already, and for any new supporters reading this now!

Supporting my Surveillance System

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

Lets visit the numbers:

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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.

Next Stop: Malawi

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.

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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.