Reproductive health

Making medical interns as maternal care service providers at the remote or the rural locations to overcome the global health care workforce crisis. As a public health specialist, I firmly believe that one of the cause of the high rates of the maternal mortality and morbidity is the lack of the health care providers, inadequate maternal health policies and lack of access to quality maternal care.

Pregnancy is not a disease and pregnancy related mortality is almost always preventable. Yet more
than half a million women die annually worldwide, due to pregnancy related complications. About
90-95% of these come from developing countries. Maternal Mortality Ratio (MMR) in developing countries ranges from 300 to 1000 in contrast with 2.9 in the industrialised world. This is the only Public Health Statistic with such a huge difference. In Pakistan alone, an estimated 30,000 maternal deaths occur each year, due to pregnancy related complications
.

This figure is indicative of the need of quick attention about the maternal health intervention especially in the developing nations. Maternal Health is directly related to the maternal and neonatal mortality and morbidity. The conceptual framework for maternal and neonatal mortality and morbidity presented by UNICEF explains that there are various determinant of the maternal health responsible for the maternal and neonatal morbidity and morbidity.

There are direct factors such as obstetric risks including complications of abortion, disease and infections, inadequate dietary intake. The framework also explains about the underlying causes at the household/ community and district levels such as Insufficient access to the maternity services- including emergency obstetric and newborn care, inadequate maternal and new born health practices and care seeking. As a health planner, the basic causes at the societal level concerns me the most that is the quality and the quantity of the actual resources for the maternal health- human, economic and organizational- and the way they are controlled.

The global health workforce crisis is one of the challenge which makes the delivery of the desired quality of the maternal health care to the remote locations where it is required the most. The problem is worse in the developing countries due to migration of skilled health workforce to the developing countries.

The solution is to use the available resource in a sustainable and feasible framework. This idea proposes utilising the community medicines departments of the medical colleges in the various countries for the delivery of the maternal health care for the pregnant females. Every medical college has a team of medical staff and medical interns appointed to work in the community medicines. This staff can be utilised to impart the maternal check-up and assist the lady health workers.I propose to shift the duties of these interns from the hospital to the village based centres or kiosk to reach maximum people especially females in the developing countries who are dependant on the male members for travelling to the hospitals also.
I don't think it should involve much of the change in the curricullum but yes strong policy by the public health department to make such intern-ship at the rural centre mandatory.Also, it will increase the exposure of the interns which is the main idea of the intern-ship.

A network can be developed engaging the skills of the medical interns, the Lady Health Workers (LHW)and the traditional birth attendants (TBAs). The capacity building and mentoring of the of the LHW & TBA can be done by the interns for the basic Ante Natal Check-ups of the pregnant females, the deliveries and post natal check ups . The services such as delivery by the TBAs can be charged from the beneficiaries whereas the interns can screen the complication of the females and refer the pregnancies to the hospitals for the management of the complications at the right time.

The following can be the advantages of the proposed idea:

1)Increased maternal health care workforce- The team of medical interns can replace the need of locating the gynaecologist at the peripheral locations. The valued human resource can be located at a central location where they can be accessed by larger population.
2)Low cost and sustainable set-up – The cost of locating an intern to a rural or remote locations is much lower than the gynaecologist. The Lady Health Workers (LHW) and the attached TBAs can work on the basis of user fee. This will also ensure higher motivation levels of the among the LHW and TBAs
3) Higher accountable maternal health care force- If the postings of the medical interns are part of their curriculum they will be more responsible towards the duties assigned to them.
Lastly, if the interns can not be utilised in delivering the care as a professional then at-least they can be the first point of contact for the pregnant females or other patients in screening the complications and establishing timely referrals.

Maternal health problems especially Vesico Vaginal Fistula (VVF) and Recto Vaginal Fistula (RVF)which are mostly as a result of prolonged obstructed labour has been observed and reported by the United Nations Population Fund (UNFPA). Aproximately, one million women are with the condition, with 50,000 to 100,000 new cases documented each year. Most of these patients are from poor rural areas where access to health facility is low. They are often malnurished, low economic status, illiterates and lack formal education. Associated co-mobidities of these conditions include: the continous uncontrolled leakage of urine or feces as the case may be, results to footdrup, chronic skin irritation, and offensive odor. The sequelae of these are stigmatization, isolation and loss of social support. It sometimes leads to divorce or separation, worsened malnutrition, suffering and premature death. Existing international support could be harnessed to help the predicaments of these patients. It was formally associated to the Northern Nigeria. But of late, more cases are been recorded in southern part of the country where patients have leaved with the condition for almost 46 years.
Now, my organization has been carying out intervention programs with intermediate results on access to quality fistula care, Prevention through access to Family Planning and Community mobilization and sensitization, training and capacity building of doctors and nurses on fistula care, reintegration of clients to their communities, and the use data for decision making.
The International Labour Organization (ILO) had documented that 428 million women work in the agricultural sector around the world, compared to 608 million men. In Sub- Saharan Africa where Nigeria is a part, and in South Asia, 68% and 61% of women are employed in Agriculture. The fact that women contributed 65% success in the Agricultural sector is known (ILO, 2008).

Its known that most women with Vesico Vaginal Fistula (VVF) and Recto Vaginal Fistula (RVF) are from poor agrian family setting. Before now, the reintegration of women who undergo fistula repair involves rehabilitating them by way of teaching them a trade or a skill that could enhance their source of income without necesarily knowing their socioeconomic background such that when they leave the facility after they might have been repaired, they seldomly use the skills they acquired at the rehabilitation center. More to it, there are inadequate established systems for tracking this patients to see whether they have been using the skill profitably.
I want to establish a strong tracking system that is community base and can be reached anytime and can give account of the socioeconomic well being of the clients who have been repaired or whose fistula is irrepairable through traditional leaders and religious leaders which can be coordinated by Community Based Organizations (CBOs). Thus, fistula repaired or irrepaired patients who were farmers before now may be taught improved way of farming along side the kniting and tailoring skill they acquire at the rehabilitation center. Those who may have been divorced because their conditions are irrepairable, through gender equity advocacy to the traditional rulers we can procure lands for them. Those who are repaired and reintegrated into their families do not loss out in their contribution towards achieving food security for the family, or else we end up creating a gap while trying to bridge one.

Adolescent girls are future for healthy and strong motherhood. But their status is very poor and tragic condition in the intervention area. About 70-80% of the girls are anemic. Their energy and rights are plucked by the long walking on forest one path road and crossing wild animals and forest river to sale of firewood. They oppressed by the social curt owes and norms. Our idea is to strengthen reproductive health and rights of adolescent girls with supporting of meaningful intervention in aspects of health, psychological, social, economically and spiritually. The above interventions promote reproductive health and rights of the adolescent girls for future motherhood.

My idea is to have villagers in Etoko village and Nchemba II in Southwest Cameroon sew hospital scrubs made of West African fabric to be sold to health care workers in the United States. The funds from the sale of the scrubs in the U.S. would go back to the sewing cooperatives to help defray the costs of clinic delivery fees, prenatal vitamins, and medical supplies that must be purchased for labor.

After visiting Cameroon in January 2007, I thought the vibrant West African fabrics I saw in Cameroon would make great hospital scrubs. The funds from the sale of the scrubs in the U.S. would go back to the NGO I worked with in Cameroon, United Action for Children. The project was called Scrubs for Slugs as the proceeds would continue to fund the pilot snail farming project we began in the summer of 2007. The village clans and schools that cultivated the snails were to use the profits from the sale of the snails at local markets to pay for health care at the local village clinic. Health care in Cameroon is particularly scarce in the rural areas and paid for out of pocket by all recipients. After witnessing various medical procedures, including a Cesarean section performed with gauze scissors and a razor blade, I knew that women's health in Southwest Cameroon was particulary precarious.

I purchased several yards of fabric in the summer of 2007 when I returned to Cameroon, and arranged for friends to purchase more fabric on a return trip in January 2008. I wanted to learn how to sew the scrubs myself since I could not be in Cameroon to organize the project with local seamstresses. I got a sewing machine and had recruited some friends to help teach me how to sew. The task proved more challenging than anticipated and was moving slowly. Then, on June 7, 2008 a flash flood hit my home town and destroyed most of our home and belongings, including most of my fabric and all of my sewing supplies. I salvaged what fabric I could, but having lost my sewing machine and devoting my free time to rebuild my family's house, I decided to send the fabric with a friend to Mexico to have it sewn there by local seamstresses. It took several months for the finished scrubs to return from Mexico as I was dependent upon friends to bring the scrubs back in their luggage to avoid exorbitant shipping costs. In total, the fabric I saved from the flood was enough to make about fifteen scrubs tops. I had a hard time finding interested buyers in Indiana, and have only sold around five to friends and colleagues. I have been trying to sell the remaining tops through student organizations at George Washington University, but my contacts have never replied to my communications. I am now left with a small stock of beautiful handmade scrubs of fabric made in Nigeria, purchased in Cameroon, and sewn in Mexico. These scrubs have made their way around the world and touched several economies.

If I were to be able to take the project to scale, I would like to construct a community center in the village that inspired the project and that has the only local clinic, Etoko village. With a community center those interested in participating in the project could receive training in how to sew on sewing machines. The local seamstresses use antique Singer sewing machines powered by large foot pedals. Such machines could be purchased and stored in the community center to keep them safe and well maintained. The machines are energy efficient as they do not use electricity, although the village has electricity in the pilot phase of the project avoiding the costs of electricity for the machines may prove a wise choice. As the project grows the costs of electric sewing machines may prove profitable. Local seamstresses could be contracted to train the villagers on how to sew the particular items that will be sold, and in this way increase business for local seamstresses paid to conduct trainings. By selling the scrubs in the U.S., any conflict of interest is removed as there would not be local competition for the products.

In Etoko and the neighboring village, Nchemba II, there are established women's groups that produce palm oil, and they could provide fruitful partnerships for income generation projects. The project should not exclude men from participating as their involvement in the project helps ensure sustainability, and they also tend to have more free time than the women. Any village member wishing to participate should be allowed to contribute.

The transport of the scrubs from Cameroon to the U.S. would be logistically complicated and financially difficult. The funds needed to move the items abroad would be significant and require donor funding to subsidize those costs in order to make the products affordable to U.S. consumers. The products could theoretically be sold in Europe as well, but my idea was based on the culture and connections with which I am familiar in the U.S.

Funds from the sale of the scrubs could be filtered through the NGO United Action for Children as they have a longstanding presence in the communities of Etoko and Nchemba II and have knowledge of project implementation in those two communities. Scrubs could potentially be transported with their vehicles on their trips from the villages to the areas of Buea and Mamfe where goods could be shipped to the U.S.

Lastly, while the project was originally titled Scrubs for Slugs and intended to continue the snail farming project which subsidized health care, the concept could be easily modified for specific MCH purposes. The clinic has electricity and running water and is generally staffed by one nurse, but the facility is not equipped with basic medicines or instruments. I saw the "pharmacy" which was a box of band aids and a bag of unsold prenatal vitamins. The clinic has one solar powered microscope, and no rubber gloves or appropriate bio-hazard disposal capabilities. Any birthing difficulties can prove life threatening very quickly. With increased funding for MCH, hopefully the clinic could afford to carry the drugs that women would need in a labor emergency and for a healthy pregnancy.

Additionally, the very high rates of HIV make safe delivery almost impossible. When I was in Cameroon in January of 2007, local doctors estimated the HIV prevalence to be over 50% in the area and we were told it was a topic too taboo to discuss. When I returned to the village in the summer of 2007, we interviewed local health professionals all over the Southwest Province to find out about the availability of HIV testing, CD4 count testing, and ARVs. These services and medications are not available to these people in any remotely accessible fashion neither economically or geographically as the nearest town is 20 km away and the machines required for testing are frequently broken. Nevirapine is a drug that could potentially save the lives of many children in the village if the mothers had access to better medical care. The first step in making any of these medical advances accessible to the families of these villages is to increase the funds available for these women to seek medical care and pay for treatment.

Educational empowerment on reproductive health (working name) is an idea being born. The idea is to create a collaboration of people to improve reproductive health and maternal health in Cameroon. The collaboration is comprised of health professionals, volunteers to educate and employees to keep the program sustainable. Volunteers will be young people who can empower their peers by educating them on gender equality, reproductive health and contraception. Health officials will be responsible for disseminating information on reproductive health, contraceptives and abortions to other health professionals. Employees will manage the program and see to the information is recycled with new research discoveries and new information from international agencies. Employees will also recruit new health professionals and volunteers to keep the program going, recruitment will be in different locations every four months or so. The collaboration is based on creating a knowledge network that will eventually disseminate into the community. By creating knowledge, raising awareness and motivation the future will be that reproductive health will be integrated into the health care system fully and young people will be aware of reproductive health and how to steer clear from unwanted pregnancies.
It is my hope that a program of this size that start small and builds momentum will in the future reduce maternal mortality rate and improve maternal health.

most of the rural women do not know how to use the computer. this computers will be installed in some pilot villages and these women will learn how to use the computer. this computers will also be connected to the internet were this rural women could sell their farm and other products through the internet.

eHealth Nigeria transforms maternal health information management in Nigeria. It provides the timely, accurate information needed to manage facility planning (ie drug ordering), influence funding and policy decisions, as well as providing clinicians with patient histories they can use to improve decision making before, during and after labor/delivery.

The eHealth Nigeria EMR is built using the robust OpenMRS (medical records system) and customized specifically to the needs of maternal and child health stakeholders in Nigeria. The eHealth Nigeria EMR is built on low-cost, low-power computing equipment that can run for eight hours without grid or generator power, is recharged by low-cost solar panels, and can be synchronized between implementations and a central server on- or offline. Community health workers can access the patient/client records with mobile phones and add postnatal or other health follow-ups in real time from rural villages.

The eHealth Nigeria EMR project is an important part of improving the health infrastructure needed to address the desperate lack of accessible and timely information needed to save the lives of women and children during labor.

INTRODUCTION
In this world, every minute one woman dies of pregnancy or birth related complications. WHO defines maternal death as: death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy from cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Perinatal death means death of a fetus from 28 weeks of gestation to seven complete days of life including stillbirths. The perinatal mortality; is a sensitive indicator of health status of women, the health of the newborn and quality of health care provided during perinatal period especially delivery and immediate postnatal period. According to TDHS 2004/5,there is high antenatal care coverage- 94% at least one visit; 62% makes four or more visits yet the maternal mortality ratio is still high- 578/100,000 live births and under 5 mortality rate = 112/1000 live births.
Tanzania is amongst countries with very high number of maternal deaths in the world, the high maternal and newborn mortality constitute a silent emergency in Africa, (WHO, 2004) .Two decades after safe motherhood initiative (SMI); the maternal and perinatal mortality levels have sadly continued to rise instead of declining. Health indicators are not improving which may be attributed by poor quality of health services provided (reproductive and child health survey, 1999; TDHS, 2004/5).Poverty, social exclusion, low levels of education and women violence/abuse are amongst the contributing factors.
ANGELS OF CHANGE
Angels of Change is an entry point to prevent maternal deaths using the Positive Deviant/Hearth Approach. Angels of Change is an Idea of intensive behavior change Intervention targeting Mothers of Childbearing age and Pregnant mothers who at risk of maternal complications. It is derived from the fact that despite of all of the above factors contributing to the high Maternal mortality in Tanzania, one thing is evident, that there are a number of women who has never experienced Pre, intra and post delivery complications within our communities under the same resources, these mothers has been able to explore the environment and make use of the available resources while others are not able to do that, these are the one I call the Positive Deviants or The Angels of Change. Through identifying these Positive Deviant Mothers and Using the Community Based Hearth Session Approach, women of Childbearing age and Pregnant women can be brought together to share the Positive Deviant behaviors practiced by Positive Deviant Mothers. Different issues involving locally-discovered positive deviant practices as well as promote other practices essential to healthy living. Hearth sessions incorporate a number of approaches for behavior change including identification of Angels of change in a community, peer to peer support, Mother Dialogues, counseling, negotiation, Adult learning principles, skills building, motivation through visible practices and Women mobilization. Family planning, prevention of unwanted and high risk pregnancies, ensure skilled care during childbirth; ensure access to quality emergency care when a complication arises are among the topics during Hearth sessions.
It involves learning what these Role Models (Angels of Change) has been doing to promote their socially and communally acceptable behaviors and practices promoting good maternal health, HIV/AIDS Prevention and Health care utilization and promoting these practices to be adopted by other mothers. The Hearth part of Angels of Change idea using a PD approach is an intensive behavior change Intervention targeting mothers at risk of maternal Complications.
Sites of implementation including selection of places where majority of Youths are found/lives/work in relatively close proximity, where there are a significant number of risk behaviors.
Angels of Change will be identified though Initial dialogue with respective mother’s groups in a particular community/Institution through peer voting systems especially during antenatal visits. The respective group, guided by Community health workers will anonymously select an Angels of Change with positive deviant behaviors and practices communally acceptable which promotes good maternal health using a special tool. Our Health Volunteer(s) together with the selected Angels of Change will facilitate a mothers Conversation process to discover behaviors and Practices depicted by a selected Role Model and the Group will set up Action Plan. The selected Role Model will trained on facilitation skills and be responsible to conduct Hearth Sessions with Material support provided. She will also be Our contact person in a Particular group observing how peers are adopting her/his practice and behaviors and recommending the way forward. The project will facilitate group meeting at least twice a month and Group learning visits to other successful group with the same socio-economical circumstances. Each group will have a chairperson, Secretary, one Angel of Change and one guardian, teachers/ a community member identified by the group will serve as Guardians. Our Health volunteers will be conducting regular supportive visits to respective group(s) and Provide Monthly report.
.