Pairing Up Saves Mothers in Central America
By Harvey Black, photo Carlos Gaggero
Antonia Chapeta Querma of Xeujupup, Guatemala, delivered a healthy baby, but in doing so, she almost lost her life. The 32-year-old mother of six bled severely after giving birth. Dr. Juan Gonzalez controlled the bleeding, and saved her life. Only a few months earlier, none of the physicians at the Sololá health center would have been likely to recognize, much less treat, the hemorrhaging.
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In the rural Nicaraguan province of Matagalpa, a pregnant woman with severe preeclampsia, high blood pressure, and headaches walked into the La Dalia Health Center. Just two weeks earlier, the center's nurse had been trained to recognize and treat this problem and had pasted treatment protocols on the walls. The patient was stabilized, the nurse flagged down a bus, and the woman arrived at the provincial hospital where she delivered a healthy baby. Untreated, she and the baby might well have died.
These are but two of the lives spared because of basic training provided through a relatively new initiative, the Save the Mothers Fund. Pregnancy and giving birth are, of course, natural, but something can go wrong. "If you just leave it to nature, about 10 to 15 percent of women will develop a complication that can be life-threatening if not treated in a timely way," says Dr. Anne Foster-Rosales, an assistant professor of obstetrics, gynecology, and reproductive science at the University of California, San Francisco. Major complications and potential causes of death are infection, hemorrhage, obstructed labor (the baby cannot pass through the birth canal), unsafe abortion, and preeclampsia (a condition specific to pregnancy and characterized by high blood pressure).
Save the Mothers Fund
The Save the Mothers Fund is attempting to cut the toll of maternal deaths, primarily by training health care workers to recognize the danger signs. Dr. Foster-Rosales and her colleagues trained a core group of physicians on how to recognize and treat these five conditions. The core group then trained the doctors and nurses in four Central American provinces. The medical providers in the provinces are generalists and many therefore lack the specialized knowledge to diagnose and treat these conditions. "Over the past 18 months, we trained more than 1,000 rural health providers in emergency obstetric care to respond to those five obstetric emergencies," she explained. "High death rates reflect the tremendous social and health disadvantages women face worldwide, but focused training in emergency obstetric care can make an immediate difference by preventing maternal deaths," she added.
The fund pairs the obstetrics and gynecology society of a developed country with that of a developing country. The American College of Obstetricians and Gynecologists (ACOG) is paired with societies in four Central American countries, and works with projects in provinces selected because they seemed to have a higher than expected number of deaths of women of childbearing age: Sololá in Guatemala, Sonsonate in El Salvador, Santa Rosa de Copán in Honduras, and Matagalpa in Nicaragua. The fund works in a similar manner in other parts of the world: Italy is paired with Mozambique, Canada with Uganda, Sweden with Ethiopia, and the United Kingdom with Pakistan.
Golden Opportunity
"This project is a golden opportunity to carry out interventions and do something immediately," says Dr. Ben Curet, director of maternal and fetal medicine at the University of New Mexico, and coordinator of the fund in Central America. "Perhaps as important, it can bring the needs to the attention of ACOG and other people who are in positions to provide funds and know-how." A native of Puerto Rico, Dr. Curet adds that working on this project is especially meaningful because of his background. "You don't know how good it feels," he says.
The Save the Mothers Fund is the brainchild of Dr. Mahmoud Fathalla, professor of obstetrics and gynecology, Assuit University, Egypt, and a past president of FIGO, the International Federation of Gynecology and Obstetrics. FIGO began the fund in 1997. To get a grasp on the extent of the problem of maternal deaths, the fund, assisted by the national societies of obstetrics and gynecology of the involved countries and representatives of the ministries of health, conducted a survey of maternal deaths in the four Central American provinces.
The study found that maternal deaths are underestimated because they are misclassified, according to Dr. Giuseppe Benagiano, director general of the National Institute of Health of Italy and chair of the Save the Mothers Fund. "For example, a woman might be severely anemic and bleed to death during childbirth...however, the death would be attributed to anemia."
In Latin America and the Caribbean, at least 23,000 women die from pregnancy-related causes each year. Even more women suffer from long-term complications of pregnancy. The chance of dying during pregnancy and childbirth in Latin America and the Caribbean is one in 130 during a woman's reproductive lifetime. In the United States, it is one in 3,500.
In 11 Latin American countries and the Caribbean, more than 100 mothers die for every 100,000 births: Bolivia, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, Paraguay, and Peru. The Pan American Health Organization (PAHO) is working to reduce this high toll of pregnancy-related deaths by supporting essential obstetric care through an inter-agency initiative, the Regional Plan for the Reduction of Maternal Mortality.
PAHO's role in the partnership is to promote the policies necessary to address and sustain quality maternal health services and community access to these services in 11 countries. The activities of Save the Mothers fund complement the activities of the regional plan, says Dr. Ernest Pate, coordinator of the Family Health and Population Program at PAHO's Division of Health Promotion and Protection.
Benefits Beyond Reducing the Death Toll
In addition to the human benefits, reducing the toll of maternal deaths means that societies can be more productive and can reduce poverty. That is one major reason the World Bank has given the Save the Mothers Fund US$75,000. Dr. Jerker Liljestrand, an obstetrician who is the bank's lead health specialist dealing with maternal health issues, makes the economic case quite simply: "If a woman dies at 20 from causes that could be easily prevented, society could lose 50 productive years or so, apart from the fact that children may die because the mother is gone, so this is something worth investing in. It is one of the best buys in health care."
Dr. France Donay, a senior program officer of the United Nations Population Fund, which contributed US$750,000 to help support the fund's initial three-year effort, points to an additional health issue: "As serious as is the death of a mother in childbirth, the damage to the health of a woman who survives in a weakened condition is also a major concern." More women survive childbirth in a weakened state–for example, with chronic anemia–than die in childbirth. Throughout the developing world, for every woman who dies in childbirth, 30 survive with impaired health. That impairment affects the women and their children, and society bears the economic cost.
Noting that it was he who proposed that FIGO include Central America in the fund's activities, Dr. Edgar Kestler, a Guatemalan obstetrician and gynecologist, describes the fund's Central American efforts as "his son." He foresees the project expanding beyond the demonstration projects in the four provinces, raising awareness of the importance of cutting the maternal death toll. "We are working very closely with the ministers of health in the four countries to raise awareness and bring attention to this public health issue," says Dr. Kestler, who serves as the fund's Central American coordinator. Awareness may require that finance ministries view health funding from a new perspective, and Dr. Liljestrand notes a promising trend: "Today the general thrust of international development is seen as investing in health as a means to reduce poverty."
A Positive Response
El Salvador already has responded positively. Its health minister, Dr. José Francisco López Beltrán, wrote to Dr. Curet in September that he would like to see the model in Sonsonate transferred to other provinces in the country. Dr. Liljestrand talks of involving nongovernment organizations in such work and helping to set the civic agenda.
Pharmacia, a major U.S. pharmaceutical company with headquarters in New Jersey, is another major contributor to the fund. "Pharmacia's US$750,000 contribution represents the company's commitment to women's health care," says Ms. Kristin Elliott, company spokesperson for women's health matters. "We were the first to commit when FIGO approached us three years ago." Dr. Benagiano noted that Pharmacia "donated this money for a lost cause, commercially. There is nothing they can sell these people or in this area."
The next phase of the project, says Dr. Foster-Rosales, is one of "social marketing," that is, educating the community–specifically, getting women to come to clinics earlier. "Women have to know that if you start bleeding at home, you shouldn't wait six hours to get care. You should get going right away, " she says. "If a woman starts to have trouble in labor, the community has to make certain that she gets to a clinic quickly."
Looking ahead, Dr. Kestler wants to choose one or two health centers in each province of the four countries to provide emergency and basic obstetric care. Looking further ahead, the fund wants to make sustainable interventions. One long-term outcome Dr. Foster-Rosales hopes for is a change in the way Central American doctors and nurses are trained: "They will all serve in a rural area at some point, so good training in family planning and emergency obstetric care is a must because it is a basic human health need."
As to the outlook for the Save the Mothers Fund, Dr. Benagiano is hopeful. He plans to continue asking for donations because he believes that people are eager to give money to projects that save lives.
Harvey Black, is a freelance writer, based in Madison, Wisconsin, who specializes in science and medicine.