public health | Lucy Ramos

Now Delivering Deliveries!

January 18, 2016February 18, 2016 | Lucy Ramos

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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

December 1, 2015February 18, 2016 | Lucy Ramos

We’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

November 18, 2015February 18, 2016 | Lucy Ramos

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.

Wrapping Up

July 30, 2015 | Lucy Ramos

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.

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.

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

July 20, 2015 | Lucy Ramos

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

July 15, 2015July 15, 2015 | Lucy Ramos

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.

Eggs with beautiful yokes and indulgent toast is the norm.

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.

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.

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.

Sometimes 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.

Otherwise, 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

We’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

Meeting the Volunteers

July 14, 2015July 15, 2015 | Lucy Ramos

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.

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.

As with any well attended meeting, refreshments were served.

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.

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.

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.

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

and the work begins

July 7, 2015July 7, 2015 | Lucy Ramos

I made it! With almost all of my stuff and almost no plane sleep.

Which meant 11 hours of deep, deep sleep and waking up to the cleaning staff knocking at the door this morning. My roommate and I arrived at the same time and both slept in and missed the daily 7:30 meeting at the clinic. Oops. We’ll have to do the formal intros at tomorrow’s and hopefully everyone will understand that jet lag is real.

Accommodations are very hotel-like; the bathroom is much nicer than my own at home. The staff is amazing, food is great, and the site is gorgeous. I will take a walk around the premises this weekend to better illustrate in photos.

And, there is a cat. A black cat named midnight who follows people around and commands attention like all great cats should. Malawi is known as ‘the warm heart of Africa’ and the people are living up to the name entirely. I am spoiled here.

In spite of my tardiness, I was pleasantly surprised by how productive my first day was. I got to sit down with the Health Surveillance Assistant who is our main connection to all of the community surveillance volunteers. We reconciled some long lists of participants and their villages that had a bunch of disparities. We have almost 50 volunteers trained, photographed and with IDs made!

I also made a guide for the community volunteers that’s more visual and less text-heavy. We’re going to meet with as many as possible this Tuesday so I’ll be preparing for that in the coming days. Another big project that was supposed to be taking off this month was significantly delayed, so I’m very happy to know that getting my work complete is actually feasible and that the people I need to work with have the availability.

Since I’m meeting with volunteers, I need to learn some Chichewa. Greetings aren’t bad:

Muli Bwanji – how are you?

Ndili bwino, kaya inu? – I am well, and you?

Ndili bwino – I am well

Zikomo – thank you

Ndapita – Goodbye

But things get scary pretty quickly:

Ndithandizeni – Help

Sindikumvetsetsa – I don’t understand

So, fingers crossed I understand everything and never need help.

Photos coming soon, I promise. Ndapita!

What I’m Lacking, What I’m Packing

June 30, 2015 | Lucy Ramos

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:

Coffee. 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.

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.

I’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.

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

June 7, 2015June 7, 2015 | Lucy Ramos

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.

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,

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.

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

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

CLI map

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

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.

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