Wednesday, December 19, 2018 06:20:03 AM
Sophie Bader :
On a humid afternoon in Kunipara slum, one of Bangladesh's largest informal settlements, a group of young women sit in a circle on the floor of a health care center run by BRAC, the world's largest development organization.
The women, who live in tin sheds above a canal, are all between seven and nine months pregnant. They are at the center to learn about safe birth preparedness.
In the middle of the circle is a health care worker who explains to the women what danger signs to look out for; what to do in an emergency such as excessive bleeding; and where to go for delivery - here at BRAC's delivery center, or another facility.
The women listen attentively and watch the health care worker as she cleans the doll and wraps it in a blanket. The women are aware that the knowledge they receive here could save not only their own life, but their baby's.
Every day, over 800 women die from pregnancy or childbirth-related complications. Almost all deaths happen in developing countries, and most could be prevented.
The leading cause of maternal deaths in developing countries is postpartum hemorrhage, or PPH, defined as the loss of 500 milliliters of blood or more within 24 hours after birth.
Most of these deaths from excessive bleeding could be prevented if the interventions needed to treat PPH were available, including timely emergency referrals, obstetric care, blood transfusion, and surgery.
The risk of PPH can be reduced by what is known as the active management of the third stage of labor, or AMTSL - as recommended by the World Health Organization. This consists of three components: Administering uterotonic drugs such as oxytocin and misoprostol; assisting with the delivery of the placenta; and massaging the uterus after the placenta has been delivered.
AMTSL relies on women giving birth at facilities with adequately trained staff. But in Bangladesh, home births, assisted by traditional birth attendants or family members, are far more common. In fact, 62 percent of deliveries take place at home and more than 56 percent of those are assisted by traditional birth attendants - TBAs - or relatives. Such births are often performed in unsafe and unhygienic conditions, resulting in increased risk of complications and death for both mother and child.
In community settings, misoprostol - a drug that can prevent PPH and decreases postpartum bleeding - has been widely recommended when other methods are not available. But it can be fraught with challenges: Although its recommended for home births, it is not universally used across Bangladesh because of supply and cultural issues, such as a fear of the medication because it is also used in abortions, experts say.
Between 2010 and 2016, Bangladesh's maternal mortality rate declined significantly, but it has stalled since. In 2016 it was 196 deaths per 100,000 live births - a slight increase over 2010's rate of 194 deaths per 100,000 live births.
Enter the Q-Mat
Recognizing that the key to preventing deaths from PPH was to recognize and treat it early, Abdul Quaiyum, a reproductive health scientist at the International Center for Diarrhoeal Disease Research, Bangladesh, or icddr,b, a public health research organization based in Dhaka, knew he had to do something.
He designed a biodegradable, absorbent birthing mat, called Q-Mat. The mat is placed under a woman immediately after she gives birth. If the mat becomes fully soaked with blood, it means that the woman has lost around 450 ml of blood and needs to be immediately transferred to a health facility.
Most deaths from PPH, he says, "are because family members or TBAs couldn't recognize the woman has excessive bleeding. There's no objective measurement tool. By the time they realize, it's too late."
The Q-Mat, which Quaiyum began designing a decade ago, aims to bridge that knowledge gap and help birth attendants to easily recognize when a woman is bleeding too much. It also recognizes excessive hemorrhage at the outset, rather than relying on treatment once potentially life-threatening symptoms occur.
Designing the mat wasn't without its challenges. For one, Quaiyum needed blood to test how much fluid the mat would soak up. He decided to mix red dye and water but then an opportunity came through that he couldn't turn down: A chance to test the mat with cow's blood.
"I poured cow's blood on the mat so I could get the size of the mat correct. When it's soaked with cow's blood, it can soak up to 458 ml," he said.
Secondly, the first mat he designed was made of foam and wasn't biodegradable. He wanted something that was not only environmentally friendly but something that was safe, to ensure blood-borne diseases such as HIV couldn't spread. The mat is now made of biodegradable polythene and tissue.
To test the mat's effectiveness, back in 2013, the icddr,b collaborated with the Rangpur Dinajpur Rural Service, a charity that distributes birthing kits to women. They added the mat to 77,000 kits, which already included items such as a thread to tie off the umbilical cord and a sterile razor blade to cut it. Almost 90 percent said they would use the mat again and that they would purchase it.
The mat costs $0.80 and is included in safe delivery kits distributed by several NGOs in Bangladesh including PATH and BRAC. Quaiyum said he is also planning to scale up distribution in three subdistricts as one part of an intervention package funded by Japan and administered by Bangladesh's government aimed at reducing maternal and infant death. He hopes the mat will eventually become part of the government's maternal health program.
Quaiyum was granted $100,000 by the Bill & Melinda Gates Foundation for the work in 2011, and is currently trying for funding for redesign and implementation research in Myanmar.
Health system challenges
Quaiyum designed the Q-Mat in the hope it would be rolled out not just across Bangladesh but in other developing countries. But Shams El Arifeen, senior director of maternal and child health at the icddr,b, says a major challenge is that the mat relies on transport being available and health care facilities being equipped to deal with PPH. In many parts of Bangladesh, a lack of transport and poor roads, coupled with health care system challenges including a severe health care workforce shortage means that often women don't get the treatment they need.
"There's no point having a referral system that doesn't work," he says.
"We need to test the whole system, not just the mat. Most facilities don't have the tools to deal with PPH - the surgical help is not there."
Quaiyum said he's been in discussion with other Asian and sub-Saharan African countries about rolling out Q-Mat. But he's faced another hurdle: Many other developing countries are rapidly moving to having deliveries at rudimentary facilities. The Q-Mat is designed to be used on a flat surface but in facilities, women deliver on tables where the surface isn't even. That means the Q-Mat in its current form needs an additional person to hold it in place. In response, the team is planning on redesigning the mat so it can be used in basic facilities.
"This has to be able to be used in other countries, where the context is different," El Arifeen explained.
If the mat is redesigned to be able to be used on delivery tables, it will still have the same purpose, though in a different context: to let midwives or other health care workers know that a woman is bleeding at an alarming rate.
"Primary health facilities don't have a lot of skill when dealing with severely hemorrhaging women," El Arifeen added.
"The mat would signal that she needs to be transferred if surgical help is not there. It would ensure she's moved on time."
Looking ahead, while the future of the Q-Mat is uncertain, Quaiyum hopes that one day there will be no need for the Q-Mat for home births.
"If we could just make midwives available on people's doorsteps then the situation would improve," he said.
(Sophie Bader is a journalist covering global health based in South Asia. She recently completed a master's of public health and writes frequently for The Lancet and The Guardian).
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