Today in Bangladesh, there are over 105,000 women who are proud to call themselves Shasthya Shebikas, the army of BRAC-trained and branded para-professionals who provide basic healthcare to their neighbors in some of the world's poorest villages and slums. A lot of that pride comes from knowing they are just the latest generation in a tradition of women living in poverty themselves who have stepped up nonetheless to become leaders for development -- a tradition that extends back to the 1970s, when BRAC first started piloting and then scaling up its community health model featuring these women from poor communities in such a central role.
As you may have read earlier this year, these women were recognized for their work by Dr. Atul Gawande, author of The Checklist Manisfesto, in an article for the The New Yorker, "Slow ideas: Some some innovations spread fast. How do you speed the ones that don't?" Dr. Gawande calls their early work "stunningly successful," as they started out by targeting child deaths due to diarrhea.
Today that tradition of stunning success, on a massive scale, continues thanks to your support.
The following post was written by ABC News Correspondent Deborah Roberts on the Million Moms Challenge blog about her recent trip to Bangladesh to see BRAC’s programs working to save the lives of mothers and children.
When I went into labor with my first child 13 years ago, I expected, like many moms- to-be, smooth sailing. It wasn’t. After 18 intense hours, my labor had not progressed much. So my skilled and trusted obstetrician ordered a cesarean section. My disappointment over having major surgery soon gave way to joy over my beautiful daughter. Three years later, I had a second C-section with my son. I healed well and didn’t think much about the medical intervention surrounding my birthing experiences, until last month.
As I prepared for a story on maternal mortality, I realized that what happened to me could have been life-threatening if I lived in another part of the world. The statistics are stunning: Every 90 seconds a woman dies during pregnancy or childbirth. That’s 1,000 girls and women a day… more than half a million women every year. And experts say more than 80% of these deaths are preventable.
And I made another shocking discovery. The United States, a country which spends nearly $3 trillion annually on healthcare has an astoundingly high maternal mortality rate. One international group ranks us 50th in the world, behind countries like Albania and South Korea. Two women in this country die each day due to pregnancy-related problems. And for black women the number is four times higher for reasons that are unclear.
My birth state of Georgia has one of the highest maternal mortality rates in the country. I visited the Atlanta Medical Center where Dr. Bradley Bootstaylor offered a stunning, and controversial theory: that we may be leaving women vulnerable to complications by turning childbirth into a medical event instead of allowing it to happen more naturally. He worries about the routine reliance on ultrasounds, epidurals and C-sections. His hospital is now taking a low tech approach to childbirth. They have eight midwives on staff who discourage painkillers and offer alternatives like massage, walking during contractions and warm tubs of water to allow women to get through the birth experience more naturally. While there are no published studies to suggest that medical intervention leads to maternal deaths, there is no arguing that maternal mortality is a problem in the U.S.
Some countries, however, are making extraordinary progress. Believe it or not, one of them is in the developing world. Bangladesh, one of the most densely populated countries on the planet – nearly 150-million people in an area the size of Iowa – is somehow creating a miracle. Over the last decade the deaths of new mothers has dropped dramatically – by 40 percent! Today Bangladesh is one of just 16 countries on the path to achieve the United Nations’ Millennium Development Goals – including cutting maternal deaths by 75% by the year 2015.
I traveled 8,000 miles to the capital city of Dhaka to see what was happening. There I met Dr. Kaosar Afsana. She’s an academic working with BRAC, an international aid group, which has had a major role in saving the lives of Bangladeshi women. In a country where close to 80 percent of women give birth at home, BRAC has discovered that the lack of skilled medical care during childbirth is at the heart of the problem.
Afsana took me by boat to a local slum called Korail. As we wound our way through narrow alleyways I met young mother after young mother. Afsana explained how women, often teens, really, die at alarming rates in Bangladesh due to hemorrhaging, obstructed labor, infections, poor nutrition and lack of knowledge about childbirth. And worse, most don’t trust the medical system to help them. So BRAC decided that the key to change is in delivering medical attention to the doorstep of expectant women.
We visited a birthing hut where eight pregnant women, wrapped in colorful saris, were being instructed on the basics of what to expect during delivery and how to recognize a possible complication before it’s too late. I asked how many of them planned to come back to the hut to deliver, and all raised their hands. The hut was clean and had a warm feeling. Then, we got word of a birth happening in a hut nearby. We raced through the litter strewn streets to another birth center to find a bright-eyed, beautiful baby boy who was just delivered by 25-year old Rina. Both mother and child, surrounded by four skilled female birth attendants, were doing fine. A nice safe birth. Six hours later, Rina was on her way home. She was escorted by two women who helped with the birth and possibly spared her life threatening complications. We could call them Rina’s guardian angels.
On the last day of my visit, I met with Richard Greene, an official with United States Agency for International Development (USAID), the U.S. government’s humanitarian aid arm. A Virginia resident now living in Dhaka, Greene is one of the architects for a new cell phone program that has enormous promise to improve health outcomes for pregnant women and new moms. Its success makes sense: more than half the population carries a cell phone
The plan is to text or call pregnant women to give them critical alerts about their pregnancies timed to their due date. They get reminders to take vitamins, see a health worker or eat healthy food (poor nutrition is a big problem in Bangladesh). Once the baby is born, they get text messages about breastfeeding and potential problems to look out for. Health workers also carry cell phones, and with a few keystrokes can upload data on specific patients to a server so doctors can monitor a pregnant woman health throughout the pregnancy.The pilot program, called MAMA, is still in its infancy. It’s an idea that’s catching on. When I returned home I learned of a similar texting program in the U.S.
It’s called Text4Baby, and it’s a free messaging service. All a mother has to do is text 511411 and put in the word BABY or BEBE (for Spanish service), along with her due date or her child’s birthday, and she’ll receive three personalized, health-related text messages a week through her entire pregnancy and the first year of her baby’s life.
There’s an old African proverb: to be pregnant is to have one foot in the grave. The hope among those engaged in the fight against maternal mortality is that those ancient words will soon be forgotten.
The BRAC birthing kit is a small packet wrapped in plastic, about the size of a Pop-Tart, and it’s saving lives. This packet is an excellent example of jugaad, one of the buzzwords making the rounds in the business world.
Jugaad is a colloquial term in Hindi for an innovative fix or improvised solution – a frugal innovation..
In the developing world, life often runs on jugaad solutions. According to the authors of Jugaad Innovation: Think Frugal, Be Flexible, Generate Breakthrough Growth, western businesses could learn a lot from the jugaad approach of innovation and radical affordability.
Development organizations, too, must create inexpensive and adaptable solutions to alleviate poverty. The BRAC birthing kit is one such example.
Founded in Bangladesh in 1972, BRAC has grappled with the problem of high maternal and infant mortality in a country where the vast majority of women still give birth at home without a skilled attendant. Your response might be to build more or bigger hospitals; BRAC instead brought suitable alternatives to the women themselves, in the form of “birthing huts” in the slums of Dhaka and other Bangladeshi cities, as well as the BRAC birthing kits.
A BRAC birthing kit contains the necessary tools for a safe and sterile delivery: gauze, carbolic soap, a sterile plastic sheet to go over the mattress, a thread to tie the umbilical chord and a surgical blade to cut it. That’s it.It might not be the most elegant solution, but it transforms any home into a safe and sterile place to have a baby. The cost to the consumer? A mere 40 cents.
By slimming the product down to the bare necessities, the birthing kit is simple to manufacture and distribute. At the Sanitary Napkin and Delivery Kits unit, a BRAC social enterprise, the kit costs 28 cents to make. It is then sold to BRAC’s Health Program for 32 cents, the same price at which it is sold to BRAC community health promoters, or shasthya shebikas in Bengali. These women are trained by BRAC and, as part of a range of products and services they provide, sell the kits for 40 cents to their community.
Of course, it’s not enough to only have a birthing kit. A skilled attendant is still necessary to manage complications. You might think it’s time to send in the doctors, but BRAC learned that with a bit of training – and access to a network of qualified help should complications arise – women from the community can be trained to be skilled birth attendants.
BRAC has made headway in frugal innovation by providing products and services that are affordable, accessible, and – crucially – relevant to those being served. BRAC has already seen measurable results; meanwhile Bangladesh is well on its way to reducing maternal and child mortality by the 2015 deadline of the UN Millennium Development Goals.
When people can afford the tangible and intangible costs of basic services, they are better positioned to mobilize themselves economically and socially. Poverty is not unique to the developing world, but what is the west providing in terms of low-cost solutions? Perhaps the developed world can take a lesson or two from frugal innovation.
BRAC's Manoshi project uses innovative and sustainable methods to provide maternal healthcare services, linking urban slum residents with skilled birth attendants who bring the services to the local level, working in clean and private birthing huts that dot the landscape of sprawling urban slums. This is a unique and important feature of this initiative as slum dwellers usually live in small shacks with large numbers of family members. Even more importantly, the centers provide rapid diagnosis and referrals in case of birth-related emergencies, and patients are provided quick transportation to health care facilities better equipped for complicated deliveries. Each delivery center has two birth attendants who serve about 2,000 households (about 10,000 people). Community midwives are also readily available to provide skilled service during delivery. Currently, the project is providing the maternal and child health services to around 6.1 million inhabitants of seven city corporations in Bangladesh.
Manoshi also works to enhance the knowledge of BRAC's community health workers and birth attendants, working to ensure quality health services for pregnant and lactating women, infants and children in all age groups; timely referral to quality health facilities; and strengthening and sustaining a linkage with the community, national and local government and NGOs. Over the last five years, Manoshi has developed a wide range of health cadres - slum health volunteers, health workers who visit households, urban birth attendants, community midwives, and referral advocates (program organizers) located in hospitals. The initiative has rapidly increased the access to clean delivery at birthing centers and emergency obstetric care at hospitals/clinics (from 16% at baseline to 81% after few years of intervention) and significantly contributed to reducing maternal and neonatal deaths in urban slums in Dhaka.
BRAC's Manoshi project continues to be a driving force in the organization's mission to ensure access to quality health care all the way through the "last mile".
While it's decreasing in prevelance through education and social interventions, child marriage still occurs in Bangladesh. With girls getting married as young as 12 years old, many girls become mothers before they are even adults. These girls are at increased risk for complications during pregnancy.17 year old Shiuly Begum from Goudium village in Mymensingh got married at a very young age. She became pregnant soon after her marriage and didn't know what to do. A health worker from BRAC visited Shiuly and taught her about care during pregnancy as well as complications and warning signs. BRAC's neonatal health worker visited Shiuly seven times to provide antenatal check-ups during her pregnancy. She also taught Shiuly essential newborn care. When her labor began, the health worker noticed some complications, and Shiuly was taken to a BRAC health center, where she gave birth through a caesarian section. BRAC helped bear the cost of the surgery by paying TK 3,000 (about $36). “The health worker from BRAC still visits me for checkup and gives me advice about taking care of the baby," says Shiuly. "I am very grateful to BRAC for all their support.”
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