Newborn health in rural Nepal benefits from portable ultrasound donation

Sonosite’s portable ultrasound donation is providing life-saving health care to pregnant women and newborns in rural Nepal. Leading this project is Dr. Joanne Katz, Professor and Associate Chair of the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. From over 200 project proposals received, Dr. Katz was selected as one of two prize recipients for the 2014 Data for Life initiative which focused on funding interventions aimed at reducing child mortality and scientifically evaluating the impact of their work in saving lives. During a project status call with Dr. Joanne Katz, she enthusiastically shared the story of a Sonosite portable ultrasound donation for her current work in Nepal. Along with Dr. Katz, we at the CappSci Children’s Prize would like to show our gratitude for your generous donation, it supports the advancement of scientific research and maternal and child health. Thank you, Sonosite!

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Auxiliary Nurse Midwife conducting an ultrasound exam during a home visit. Sarlahi, Nepal.

 

Dr. Katz and her team are looking at the use of portable ultrasound for expecting mothers in rural Nepal where home births are very common. There are a number of risk factors that appear during the third trimester which can be detected with the help of portable ultrasound machines, allowing women to seek appropriate care and prepare for medical facility-based deliveries. Risk factors such as non-cephalic presentation (e.g. breech births) or multiple births (e.g. twins) require very skilled health workers and also the option of a cesarean section if labor does not progress properly. Trained entry-level auxiliary nurse midwives will use portable ultrasounds to uncover common risk factors during home visits. The goal of the project is to examine the sensitivity and specificity with which the auxiliary nurse midwives are able to detect conditions that may lead to delivery complications as well as compare the early neonatal mortality and stillbirth rates between those who received an ultrasound exam through the study and a separate comparable group.

Midwife administers an ultrasound.
Auxiliary Nurse Midwives (ANMs) conduct exam
and make home visits in pairs. Sarlahi, Nepal.

 

In her own words, Dr. Katz shared the following account on the Sonosite portable ultrasound donation:

Sonosite SoundCaring and Global Health Humanitarian Programs allowed the Nepal Nutrition Intervention Project Sarlahi (NNIPS) in collaboration with Tribhuvan University Institute of Medicine and Johns Hopkins Bloomberg School of Public Health and School of Medicine, to apply for a refurbished portable ultrasound system. This equipment has allowed us to bring ultrasound examinations to rural women in their third trimester of pregnancy to screen for non-cephalic presentation, multiple gestation and placenta previa. Many women in this area of Nepal deliver at home, but even for those who do go to a facility, such facilities may not be able to provide the necessary care for safe delivery for women with these conditions. With support from the CappSci Children’s Prize and a donation of a portable ultrasound system from Sonosite’s SoundCaring program, home ultrasound examinations are being provided to rural women in Sarlahi from Auxiliary Nurse Midwives trained to identify these conditions using the Nanomaxx product from Sonosite. Women with non-cephalic presentation, multiple gestation and placenta previa are told about these conditions and encouraged to seek antenatal care and to present for delivery to a special Emergency Obstetric Care Facility where the providers are best equipped to manage these more complex deliveries.

 

JHU Portable Ultrasound Data for Life
Sonosite Nanomaxx product in its carrying case.

 

Given the difficult environment in which we operate (extreme heat, dust, humidity, variable electricity and transport of equipment on the back of a motorcycle over rough roads), the equipment has failed us on several occasions. With only one system, home visits have ground to a halt while we hand carry the equipment back to the US for repair or replacement. Sonosite has been incredibly generous in repairing or replacing the equipment each time, but the need for a second piece of equipment became apparent if we wanted to continuously provide service while non-functioning equipment is being repaired. We at Johns Hopkins Schools of Public Health and Medicine wrote to Sonosite to request a donation of a second machine. They have most generously agreed to provide us a second ultrasound system, also the Nanomaxx, to allow us to provide uninterrupted home examinations. The program continues and has examined 480 women through June 24, 2015.


Driving for results: A Q&A with Dr. Anita Zaidi (part 2)

 

In this two part interview, Dr. Zaidi, the 2013 Children’s Prize Winner, shares the latest from Rehri Goth, Pakistan. The first part of the Q&A can be found here

Until you established VITAL, many women, following tradition, were having home births even if they needed medical interventions. How has the VITAL helped women who needed medical care choose facility deliveries?

Anita Zaidi: We have worked with the community to raise awareness, through employing influential local men and women to promote safe deliveries. We have also linked Rehri Goth with hospitals providing quality obstetric services, and with emergency transport services, and through a charitable trust hospital, Koohi Goth Hospital, provided ante-natal services through midwives placed in local clinic.

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In your proposal you mentioned training programs for women in the community. How will these training programs save more children’s lives in the long run and how likely will it be that they remain in Rehri Goth?

Anita Zaidi: Rehri Goth had only traditional unskilled birth attendants providing birthing services in the area. We thought that an important program legacy would be to train local women to become community midwives who could then provide safe delivery to women locally going forward, and refer when needed. To increase the chances that we will retain at least some of these women locally we have built in 3 strategies. 1) to train at least 8 women, 2) to choose women who have strong local roots, preferably with a family member who is a traditional birth attendant, and 3) to provide some support for a local business establishment.

We know that you value the hard learned lessons that come with failure. What hard learned lessons have you experienced, what did you learn and how can these be valuable to others?

Anita Zaidi: The biggest lesson is that in many very poor households, even if the pregnant woman has indicated early in pregnancy she wants to deliver in a hospital, when she actually goes into labor, she doesn’t have the wherewithal to act on this desire. She either doesn’t have access to a phone to call for emergency transport, or she can’t make the decision for herself and her husband is not around. We have developed an algorithm that identifies women who are at high risk for being in this situation, and forming local neighborhood groups that can help in time.

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What advice would you give other organizations or individuals interested in implementing interventions like yours in similarly impoverished locations?

Anita Zaidi: Building a network of partners is very important. Program should be flexible with learning and modification in response to learning built in as very rapid cycles of learn-modify-act to have quick impact. So failure is an opportunity to learn, motivate, and improve, and therefore regular checkpoints (data gathering points) have to be built into the program to allow this to happen. Measurements at the end, when you can’t change anything are too late. This is a major flaw in most development aid programs.

Anita, you are strong proponent of science-based research and are committed to data. Please indicate why you believe this is important, if not necessary, for global health. More specific to the VITAL project, what is the role and significance of data in the project’s planning and implementation? What has worked? What needs improvement?

Anita Zaidi: I am very data focused because I believe measuring impact and knowing what worked and what didn’t is the only way we can scale efforts, rather than be doomed to repeat mistakes. We need to change the culture of aid to be driving for results, and if something doesn’t work, we shouldn’t consider it a failure, but an opportunity to understand why something didn’t work, and improve the design. Currently much aid, is input and process focused, rather than impact and results focused. This bothers me.

For the VITAL project, data is key to everything we do. We have a set of dashboard indicators that we measure every week (e.g. % of deliveries that week which were in a facility), or every month (neonatal mortality rate, child mortality rate). We even look at our data geo-spatially, by team, by sub-village, to identify patterns, where we are being successful, where we aren’t.

A baseline census of RG was conducted, why was this important and how would it affect your project goals?

Anita Zaidi: We wanted to set a baseline benchmark against which we would be measured. We have a very ambitious goal of 2/3rd mortality reduction in 3 years, so we wanted an external party to document what the baseline was, and the same will be done for the endline survey.

How did you target the participation from the RG community to implement VITAL’s work? What did the numbers for program enrollment look like and what did you think about these?

Anita Zaidi: We work very closely with local community elders and councilors to design and implement this program. There are about 7000 under 5 children in this community and approximately 1100 births per year that we are targeting through this program.

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About Dr. Anita Zaidi

Dr. Anita Zaidi

In 2013, Dr. Anita Zaidi was awarded the inaugural $1 million Children’s Prize for her proposed plan to save children’s lives in the Rehri Goth fishing village, one of the most impoverished communities in Karachi, Pakistan.

Dr. Zaidi was trained in United States as a pediatrician, microbiologist, pediatric infectious disease specialist, and public health professional. She left a faculty position at Harvard to return to Pakistan where she built  a child health research program in impoverished urban and rural Pakistani communities designed to find innovative low-cost solutions to saving children's lives in resource-constrained settings. She is currently the Director of the Enteric and Diarrheal Diseases program at th
e Bill & Melinda Gates Foundation. Prior to the Gates Foundation, Dr. Zaidi was the Ruby and Karim Bahudar Ali Jessani Professor and Chair, Department of Pediatrics and Child Health, at the Aga Khan University in Karachi, Pakistan.

Photo credits: Farheen Khan


Making a real difference: A Q&A with Dr. Anita Zaidi (part 1)

 

The Children's Prize team interviews the 2013 inaugural competition winner, Dr. Anita Zaidi, about implementing her million dollar life-saving project in Pakistan. It focuses on five key areas including antenatal care, skilled delivery, community care, nutrition and immunization. Read below to see how her results are leading to improved maternal and child health.

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Give us a little background on the village where you set up the VITAL Pakistan Trust. Why did you select this area?

Anita Zaidi: I have been working in the impoverished coastal communities of Karachi since 2002. Rehri Goth is a village I got to know well, where lack of access to health services for pregnant women and children, and malnutrition are responsible for large numbers of child deaths. In 2012-2013, one out of every 10 children died before reaching their 5th birthday, over half of them in the first month of life. I thought that if I win the Children’s Prize, we could make a real difference in maternal health and child survival in Rehri Goth.

What are some of the most significant changes you have seen in the community since you started your work?

Anita Zaidi: Some of the earliest changes we have started seeing are in the numbers of women seeking facility-based delivery for their births, which has resulted in a noticeable decrease in newborn death rates of about 20%.

What are some of the challenges you have encountered, and may encounter in the future, as you continue to implement your program?

Anita Zaidi: Changing behavior practiced for centuries is very hard, especially within short time spans, and we have realized that the most marginalized families need specifically tailored approaches. For example, women whose husbands are fishermen and away at sea for many weeks, and yet their wives are not empowered to make decisions regarding facility birth, or hospitalization for their infants if they become sick and need hospitalized care. We are developing and trying behavior change strategies for these situations.

Another challenge is that we under-estimated the very poor health status of pregnant women in Rehri Goth, where about 20% do not just suffer from a high degree malnutrition due to insufficient food, but also have severe anemia which puts their life in danger at the time of birth with no reserve for blood loss. We are finding women with hemoglobin levels as low as 3 mg/100 ml (normal is 12-14 for women).

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Health systems strengthening is essential towards improving public health and global health, how will your program aid in the efforts to strengthen the health systems of your community?

Anita Zaidi: We feel that improving access to skilled care at the time of birth is the most important health system change that we need to make for the women and children of Rehri Goth. This is why we have a strong focus on training local women to be midwives, and linking the community with transport and emergency obstetric services. 

Changing the legal framework of states, cities, or countries can aid in the progress toward better health for all. In Pakistan, or more specifically in Rehri Goth, what policies are enacted that compliment your work? What are some of the legal barriers that you have faced in implementing your project?

Anita Zaidi: We have not faced any legal or policy barriers in our work. What we have recognized is the serious shortage of emergency obstetric services in the city of Karachi (20 million population) that can cater to women with life-threatening emergencies at night. There are very few hospitals that offer 24/7 emergency services to poor women, and they are overwhelmed. We feel that there is not a private sector solution to this problem, because of disincentives for operative deliveries, and unless we address this issue with a public sector approach we are unlikely to see much improvement in maternal and newborn mortality rates. Pakistan has the worst maternal and newborn mortality rates in the South Asian region.

What are some the most rewarding partnerships forged through your project?

Anita Zaidi: We have been astounded by the generosity and willingness to partner with us by many organizations. I’d specifically mention Koohi Goth Hospital, for offering free delivery services, The Aman Foundation, for providing emergency ambulance services, and the Aga Khan University for offering subsidized services for newborns in need of intensive care support.

 

Woman & Child

 

 

About Dr. Anita Zaidi

Dr. Anita Zaidi

In 2013, Dr. Anita Zaidi was awarded the inaugural $1 million Children’s Prize for her proposed plan to save children’s lives in the Rehri Goth fishing village, one of the most impoverished communities in Karachi, Pakistan.

Dr. Zaidi was trained in United States as a pediatrician, microbiologist, pediatric infectious disease specialist, and public health professional. She left a faculty position at Harvard to return to Pakistan where she built  a child health research program in impoverished urban and rural Pakistani communities designed to find innovative low-cost solutions to saving children's lives in resource-constrained settings. She is currently the Director of the Enteric and Diarrheal Diseases program at the Bill & Melinda Gates Foundation. Prior to the Gates Foundation, Dr. Zaidi was the Ruby and Karim Bahudar Ali Jessani Professor and Chair, Department of Pediatrics and Child Health, at the Aga Khan University in Karachi, Pakistan.

 

Photo credits: Farheen Khan