Anyone you talk to will tell you that they care about mothers and babies. But many people here in the United States don't realize that a mother dies somewhere in the world every two minutes. Every two minutes. The data is staggering.

Our hope is to make sure Christians don't let that overwhelming statistic leave them feeling overhwelmed to the point that they fail to act. Because the connection between maternal health and faith is so important.

We recently discovered this Q&A article with Courtney Fowler, a conference lay leader in the United Methodist Church, who connects the dots between maternal health, faith, and reproductive justice. It's a great resource for those who are starting to dip their toes in this issue of women's health and who passionately care about the lives of women all over the world, because you believe God cares about them too.

1,000 Days March 4 Nutrition

Last week, 1,000 Days was honored to join with Hope Through Healing Hands and Senator Bill Frist to engage community leaders in Nashville in the effort to improve maternal and child nutrition. With leaders from the faith, business, and academic communities around the table, we examined the issue of poor nutrition around the world and in Tennessee, where one in four children are food-insecure. The gathering of diverse voices—united by their passion to help mothers and children throughout the world—was a unique opportunity to bring greater attention to the issue of poor nutrition early in life and discuss ways that churches, businesses, and individuals can make an impact. 

What became clear is that the importance of good nutrition, right from the start, is universal. Whether a baby is born in Nashville, Tennessee, or Nairobi, Kenya, every child needs basic nutritional building blocks to achieve healthy growth and brain development.   

Poor nutrition—whether measured as hunger, undernourishment, or obesity—is pervasive throughout the world.  Unfortunately, it is also all too pervasive in the US as well. 

As a result, poor nutrition is arguably this generation’s largest public health issue. Globally, nearly half of all childhood deaths worldwide are caused by malnutrition and 165 million children are permanently stunted as a result of chronic undernourishment, leaving them unable to reach their full potential to grow, learn and thrive. In the US, food insecurity and the epidemic of obesity are together fueling a burgeoning health crisis. In the US, about a quarter of preschool children ages 2-5 year are overweight or obese.

Ensuring that children get the right nutrition early in life is one of the most basic yet powerful things we can do to ensure healthier and more prosperous societies. 

There is strong scientific evidence that points to one moment when the quality of a person’s nutrition can shape the foundation of lifelong health and well-being.  It all starts in the first 1,000 days. The 1,000 days between a woman’s pregnancy and her child’s second year of life is a critical window of opportunity when nutrition serves as the foundational building block for a person’s intellectual development, growth and long-term health.  Research shows that a child that is well-nourished early in life is more likely to do better in school, earn more money as an adult and have a lower risk of illnesses such as diabetes and heart disease.  The effects of good nutrition early in life have been estimated to boost economic prosperity as much as 8 percent in terms of GDP gains. 

In this way, improving nutrition for mothers and children during the critical 1,000 day window is one of the most powerful tools we have to unlock greater human and economic potential and help break the cycle of poverty.  It is the reason why the 1,000 Days Partnership was formed and includes over 80 partners working to promote greater action and investment in maternal and young child nutrition.  While the 1,000 Days partnership has helped galvanize much-needed momentum to improve maternal and child nutrition globally, much remains to be done. 

There’s a simple way to get engaged in this conversation. Throughout the month of March, 1,000 Days is hosting an online “March for Nutrition” to raise awareness about the critical role of good nutrition for women and children everywhere. I invite you to join us by sharing your stories and insights on Facebook and Twitter and by following #March4Nutrition.

 

 

Whenever I’ve heard people reflect about their international medical experiences (especially among my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate.

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from first world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

Our mission at the Faith-Based Coalition for Healthy Mothers and Children Worldwide is to create advocates for maternal health, infant and children’s health, and for the healthy timing and spacing of pregnancies for women in developing world. This includes mothers in Africa, India, Mongolia, Guatemala, and everywhere where moms and children are living in extreme poverty. Where 222 million women (mostly married) want access to contraception, but it’s simply not available where they live.

It’s hard for us in the United States to get outside of our own experience when we look at these issues. The debate about domestic healthcare rages on, and it’s difficult for us to separate this from international maternal health. But once we’re able to imagine a daily experience outside our own, the need for advocacy becomes crystal clear.

Unicef photo childPhoto (c) Unicef

In the country of Niger, for example, 75 percent of girls become child brides. Of course, this is the country that has the highest prevalence of child marriage, but the truth is that young girls—often around eleven years old—are regularly given in marriage across Africa and southeast Asia. When these girls marry, they’re often forced to leave school, stunting their intellectual development and their social growth. They've also frequently not been educated about reproduction, and their young bodies simply are not ready to become mothers, evidenced by the fact that a girl is 10-14 times more likely to die in childbirth if she has her children before the age of 18.

Or consider Beatrice Namulondo. She was 13 when first became a mother, and she had dreams of raising a small family of children. But at age 36 she’s now mother to 17, because she had no access to any kind of contraception. This is compounded by the fact that the women in her village told her timing and spacing her pregnancies to suit the life she dreamed of and to match what she was economically and emotionally prepared to care for would make her weak and unable to work her garden, when the exact opposite is the truth.

But good work is being done to turn the tide, and in countries like Ethiopia the maternal mortality rate is dropping, the country’s GDP is rising, and political leaders believe these things are intimately connected. With Ethiopia’s Health Extension Worker (HEW) program, women and children receive visits from the 38,000 HEWs like Miheret, who travel to hard-to-reach places (like Ethiopia’s border with South Sudan) to administer vaccines, test for diseases like diarrhea or pneumonia, and monitor the hygiene in the home. Women are given access to contraception and maternal care when they do choose to have children. The results are staggering—child mortality has been slashed in half, poverty rates are down, and twice as many children are in school.

If you want to learn what you can do to help more women get access to this kind of life-saving assistance, visit our Faith-Based Coalition for Health Mothers and Children Worldwide page and see what advocacy activities we’re involved in at the moment. Follow us on Twitter @HTHHglobal and on Facebook. We need you!

Prior to my arrival in Guyana, I had the opportunity to spend a considerable amount of time with one of the Guyanese EM residents when they visited Vanderbilt. In one of our discussions, he brought up a fact that surprised me: the majority of Guyanese in the world do not reside in Guyana. Instead, they are scattered throughout North America, namely New York and Toronto. Only 10-20 percent of his family, for instance, remained in the nation, with the rest living in one of New York’s five boroughs. When I asked him if he would eventual join them in the US, he said no. His colleagues, however, had a much different approach.

After being here, I can understand why that sentiment exists. Guyana is a nation in flux. On one hand, it is quite modern; many people have cell phones, the Internet is widely available (I had WiFi in the middle of a rainforest), and the dissemination of information can occur rapidly and quickly (via Facebook, or other methods). Many of the excesses of our time are at the fingertips of a large portion of the population, especially in Georgetown. Unfortunately, it seems luxury has outpaced necessity, with the end-result being a palpable level of frustration.

This is quite evident in the sphere of healthcare. The physicians here harbor much of the same knowledge and skills that we possess and they know what interventions are needed to treat the most complicated of medical or trauma patients. However, they have very limited resources in terms of pharmaceuticals, imaging, and surgical support to adequately treat the conditions they see. I’ve only been here a few days and I have often felt handcuffed. I can’t imagine how hard it is on the local staff to feel constrained to that degree all the time. When faced with the options of either staying home and going through the growing pains (which may take decades and is by no means guaranteed), or moving to a place (the US or Canada) that has already arrived and that boasts a seemingly thriving ‘local’ Guyanese community, the decision to stay can seem illogical. This is probably why many young, educated folks, especially doctors, leave, which in turn only serves to delay progression further. It’s a detrimental dynamic.

The doctor who visited me at Vanderbilt says he’ll stay in Guyana. Being a part of the construction of not just the specialty of Emergency Medicine but of his nation is something he cannot leave. It’s a brave stance to take, and I genuinely think the new residency program in Emergency Medicine will help him avoid succumbing to the temptation to leave. For me, I am honored to be able to help support this institution, even though it’s in a very minor way.

In the end, while it’s a baby step, it’s still a step, and they will eventually add up. 

Andrew Pfeffer headshot

The next two weeks I found myself much better able to engage in the hospital system. Now I had learned the names of Benson, Mugo, Humphries all clinical officer or medical officer interns. It became my pleasure on night and weekend call to lead them through surgical triage or procedures. On subsequent calls I was able to help one of the medical officer interns through two chest tube placements. These patients had spontaneous pneumothoraces, but were not in extremis, thus I could take my time and coach the intern through the procedure. By the second placement, Mugo was able to anesthetize the patient appropriately, make the incision, and perform this life saving procedure. He remained a bit tentative, but I had seen vast improvement by this second time. These guys and gals are the front line of the Kenyan medical system, and are seeing patients in isolated places with no surgeons, or even residency trained physicians available. Teaching Mugo to place a chest tube well could benefit multiple Kenyan patients in the future.

We also had opportunity to entertain these learners in our home. We got to learn of some of the struggles they had to overcome. One resident commutes nearly an hour each morning and evening for the benefit of her family. Other interns come from extremely poor or difficult circumstances. The Kenyan health care system relies on these young men and women.

Jason Axt with staff

Another sad and challenging case that I encountered was that of D. He is 45 year old man who had been diagnosed with appendicitis over a month prior to my meeting him. He had been taken to theater for an appendectomy at an outlying hospital. When I met him he was post op day 2 and 3 from a second laparotomy for peritonitis and periappendiceal abscess. He had succus pouring from the lateral portion of a “hocky stick” incision. It seems he had been diagnosed with a post appendectomy abscess, and the medical officer (almost certainly not a surgeon) had encountered dense adhesions as he or she had attempted to drain this abscess. The operation had resulted in multiple enterotomies and now enterocutaneous (EC) fistulas. He likely had generalized peritonitis after his first operation or maybe at the time of his first operation. EC fistulas are difficult problems in the United States; here an EC fistula is devastating and likely fatal. We took him to theatre and did a diverting ostomy while closing or resecting the 5 enterotomies or anastomoses that had been left. We placed him on TPN – a rare and expensive resource here. We were unable to close his abdominal fascia, and settled for closing the skin.

He remains alive now 1 ½ weeks later. He remains on TPN after an episode of central line related sepsis and partial opening of his abdominal wound for infection. D. is an example of advanced surgical care done amidst quite austere and resource limited setting. He also is an example of a patient who would have fared much better with initial treatment by a well-trained surgeon. Simple ultrasound guided abscess drainage could have avoided this morbid procedure in this patient, but is available here in a limited fashion. D. remains very grateful for his care and is asking the hospital clergy and medical staff to pray with him and for him. Surgery in Kenya is far different from that at home. Learning to work and teach amidst the resource constraints here has been a stretching and eye opening experience. 

FGHL Jason Axt: Extreme Medical Issues in the Field

Warning: This post contains graphic medical images.

Feb 28 2014

Warning: This post contains graphic medical images.

This week started with an orientation to the hospital. I learned where the theatres were, where the clinic patients were and the location of the wards. Patients were housed in common sleeping rooms with 4 – 20 patients per ward, with men and women housed separately.  I was introduced to Dr. Irungu, the Kenyan consultant whose service I would join. 

I quickly realized here that the practice of general surgery is far broader than what I am used to. One of the first cases I scrubbed into was a transcystic suprapubic prostatectomy. This is a case that is seldom performed in the US but is frequently done here. This man had disabling enlargement of his prostate that had resulted in urinary retention and renal failure with a creatinine of nearly 4. His renal failure resolved after the placement of a foley catheter and monitoring for several weeks. After confirming by biopsy that the prostate was not enlarged due to cancer we removed his prostate by this transabdominal procedure. He was extremely thankful when we discharged him four days later sans catheter and urinating on his own. This basic surgery had transformed his life and reversed the process that had resulted in his renal failure.

I encountered a disturbing patient early in my second week. During clinic we see about 80 to 100 patients between two consultants and two residents. I met and admitted a young man from a large refugee camp. He had initially had a “leg blister” two weeks prior. When I met him he had at least 15% body surface area total skin loss to his left leg. It was a lesson in muscular anatomy, as all the muscles were completely in view. The joint capsule was open, seeping a mixture of pus and synovial fluid. He had had a debridement procedure elsewhere, but it had been wholly inadequate. Although not in critical condition or septic shock, he would need extensive debridement and at least an above knee amputation if not a disarticulation of the entire leg. Regardless, he would require weeks to months of rehab even given an expeditious amputation with skin closure. We took him to the theater the next day, and our fears were confirmed. There was extensive soft tissue loss with residual deep infection. He would require leg disarticulation. 

Jason Axt Patient Leg

The man refused to consider amputation, stating that he was young, needed to work, and could not do without his leg. He and his friends demanded discharge so that they could go to look for another surgeon who would be able to save his leg. Reluctantly we released them, telling them we were more than willing to help them if they wanted to return. The needs are large, the presentation was late, and the die was cast. I hoped that this was not the last that we would see from him, because I am sure he would progress to generalized sepsis and death without amputation.  

The Ethiopian Orthodox Church (EOC) comprises 43.5% of the population, or almost half.  After that, Muslim communities make up 33.9% of the population. In the minority, Protestant denominations comprise 18.6%. And finally, there are a few other traditional religions at 2.6%, and Catholics at less than 1%. The EOC has a long, rich cultural history in Ethiopia. It was a part of the Coptic Orthodox Church until 1959 when it was granted its own patriarch. It is a hierarchical religion with archbishops and bishops worldwide.

rock church_ethiopia

In the Tigray region, there exist a host of monolithic churches, or churches hewn out of one single rock. There is a community of churches in Lalibela that are famous rock churches, but there are a few in Mekele as well. We visited one on the outskirts of town while there.

Perhaps most famously, in the town of Axum, The Chapel of the Tablet at the Church of Our Lady Mary of Zion claims to house the original Ark of the Covenant with the Ten Commandments as held by Moses.

In Mekele, we were able to visit with both an Eastern Orthodox Priest, Keshi Gebre Tsadkan, as well as staff from the St. Frumentius Abba Selama Kessate, Berhan Theological College Mekelle including Mr. Tesfaye Hadera, Dean; Mr. Mekonnen Tesfay, Vice Dean; and Mr. Assefa Reda’e, Bible for Development Coordinator.

priest_ethiopia

Knowing that there are over 500,000 Ethiopian Orthodox Priests throughout the nation of Ethiopia, there is an embedded potential arm of the culture to support and educate citizens about access to health care. Before he died in 2012, the former Patriarch Abune Paulos urged Ethiopians to seek not only “holy water” to heal HIV/AIDS, but he also encouraged his followers to adhere to their regimen of anti-retroviral medications. This was a crucial message for people living with HIV/AIDS to seek proper care and treatment.

In the same way, priests serving as “godfathers” to families throughout the country have the opportunity to educate families about the importance of women’s health, antenatal care, and family planning. This being said, the situation is made complex by the current stigma that still surround issues of sexuality.  The statistics show little participation in pre-marital sex in Ethiopia, probably due to the average age of 16 for marriage for girls. Yet, girls typically marry older men who want children immediately. The gatekeepers of the community including ethnic leaders, mothers-in-law, and religious leaders tend to support the husband in the wish for families. Thus, the highest unmet need for contraception in the country is for young married girls between the ages of 15-19 at 30% as of 2011.

However, some priests are aiding in the destigmatization of family planning in their communities, such as Gebretsadkan. He shared that he goes with his wife to the Health Post to demonstrate his support for her choice of contraception. As a “godfather,” he advises many husbands and families on how to better time and space pregnancies, encouraging contraception, as a life saving mechanism in some cases.

When I asked about his theological position supporting family planning, he asked, is it not a sin to not be able to provide food, clean water, and clothing for your own children? To allow your children to suffer from hunger, malnutrition, and potential disease because you cannot support them? Isn’t it better to take advantage of the knowledge that family planning allows for healthier deliveries, births, newborns and children properly timed and spaced as well as a more stable family economically?

Similarly, in speaking with the Dean and Professors of the Seminary, they too argued that in fact Ethiopia had accomplished the request to “Be fruitful and multiply the earth,” as noted in Genesis. Now, it was time to rethink the health of mothers, children, and families with access to family planning.

The St. Frumentius Abba Selama Kessate, Berhan Theological College Mekelle partnered with UNFPA and Population Council to create a “Developmental Bible.” This book, printed in Amharic, held 365 different devotions with Scripture related to development and health issues. The Scripture correlated with issues such as HIV/AIDS, maternal and child health, infectious disease, hunger, malnutrition, and family planning.

These books are the basis of a “Developmental Bible” course at the Seminary for formal training of priests as well as an informal training for current priests through workshops. At the end of the training, they receive the books to use in their communities in devotion and worship. These Developmental Bibles have been disseminated throughout the nation.

Some argue that the religious leaders pose a barrier to family planning. Others contend that the support of religious leaders has been helpful from HIV/AIDS awareness and education to family planning. We conclude that due to the pastoral, rural nature of the country, that likely there is much work to be done to educate and encourage priests to urge their followers to seek information and services to improve maternal and child health, including family planning.

In every village, there is a priest or an imam or a pastor. If these religious leaders were incentivized to promote awareness and education of health care opportunities, like family planning, the religious communities could also be a powerful arm mobilizing the nation to achieve MDG5, improving maternal health.

Haiti Nursing Graduate Faculty

Two years ago, the Clinton-Bush Haiti Fund granted $462,800 to Regis College to advance Haiti's future nursing leaders through a master's degree of nursing program in the country. The goal was to unite Haiti's government and higher education institutions to support nursing programs in their country. 

The grant enabled the country to elevate their nursing program to a higher level, which has resulted in sustaining nursing jobs, promoting healthcare standards, and transforming the health sector.

On February 18, 2014, the first twelve faculty graduates of the master's degree in nursing program from the University of Haiti. Twenty-four more faculty members will complete the program, who will in turn pass their education on to more than 4,000 students each year.

Read more at Regis College's website.

by Jenny Dyer, PhD

Over the last ten years, Ethiopia has implemented their Health Extension Worker (HEW) program building Health Posts with HEWs throughout the country. To date, there are some 38,000 HEWs; two at every post. This has amazing reach to communities whose individuals might otherwise have to walk for miles and miles just to have basic services for a sick child, contraception, or antenatal care. This being said, the Health Post does have limitations. The HEW cannot provide a high level of skilled care. For instance, women in Tigray are highly encouraged to take a “mobile ambulance” (i.e. stretcher) to the Health Center where they can have access to skilled health workers that are better prepared to manage complications during birth.

Agulae health center_ethiopia

We visited Agulae Health Center in Tigray which won the award for the best Health Center in the country a couple of years ago. The sign outside reads “Healthy Mom, Happy Child.” The Center focuses on maternal and child health , ART treatment, TB treatment, family planning, and youth friendly services, providing a holistic approach for development of identity for teens in the area. Ethiopia is serious about improving maternal health, or conversely, reducing maternal mortality. And, one step to do this is by encouraging moms to have their babies in the health center, not at home.

Healthy Mom happy child_ethiopia

Inside, patients waited for services including anti-retroviral treatment, immunizations, contraception, antenatal care, and pediatric care. The Health Center Director, Tirete Zeleke, shared with us the progress particularly in delivery services over the last five years. See the chart below. Note that Ethiopia’s calendar is eight years behind ours, so it is 2006 currently. In 2001 (Ethiopian calendar – so 2009), they record that only eight percent of mothers were coming to Agulae to have their newborns. But by 2005 (2013), they note 95 percent were choosing to come to the Center to take advantage of the services and resources for a safer delivery. This is an unbelievable change.

D/S_ethiopia

There has been much resistance from Ethiopian women to give birth outside her home. First, the “stretcher” that some communities in Tigray have developed to  carry the pregnant women from their community to the Center, or at least to a paved road to get transportation, has been stigmatized. It was said if you left on the stretcher, you never would return. To destigmatize the stretcher, they now call it a “traditional ambulance.” Secondly, there are rituals to be performed immediately after birth to drive away the evil spirits that might take your life or the life of your newborn. This involves a coffee ceremony and the partaking of porridge. Family and friends in the community join in these rituals, partaking together. The Center has recognized this void for the community, and it has created a space for performing the coffee ritual.

coffee ritual_ethiopia

Also, it has required all farmers in the region to donate 1 kilo of teff (an ancient grain) from their harvest to the Center to make the porridge. This attention to community beliefs and ritual has helped break down the cultural barriers that were impeding the women to leave her home during labor.

Lastly, as a final incentive, they have started to create beautiful, laminated birth certificates after one year of postnatal care and infant care. These special documents serve as birth registries and include a photo of the child and all the necessary health care information. Birth registration is so important for establishing name, nationality, and providing the dignity of identity for citizens.

brith certificates

Finally, they have pursued religious leaders to join them in encouraging couples to seek out both family planning options as well as to encourage women to deliver in the Health Centers. The synergy of religious, social, cultural, and governmental forces working together in Tigray has made Agulae Health Center a model for progress in Ethiopia, particularly for maternal health.

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