When I give my talk “Free Delivery: the impact of a policy to improve access to maternity services in Ghana“, I generally start out by making the case that the difference between the maternal mortality rates in developed and developing countries is one of the most unjust statistics in all of global health – which I believe to be true. There are several orders of magnitude differences between the lifetime risks of deaths from a maternal death between the poorest and the richest countries in the world.

That is not to say, however, that such deaths do not occur in developed countries. Here in the United States, despite having one of the most advanced health care systems in all of the world (notice I did not say best) roughly 400 women die each year from pregnancy related conditions. That last statistic, which I have not confirmed myself, came from this deeply personal account of the death of a woman – Galit Schiller – here in the United States in 2007.

The story points to some of the challenges to lowering maternal mortality in a place like the United States – and elsewhere as well. The woman appeared to have had a normal delivery, was released on schedule from the hospital, and even celebrated the birth of her new baby with her family before dying quite suddenly from delayed bleeding. It is hard to say what should have been done differently in this case. Perhaps we will never be able to fully lower it to zero.

But the article also suggested something I did not know before – that the rate of maternal mortality has actually doubled in the United States from 1990 to 2005. I’m curious to learn more as to why this might be happening. Any suggestions?

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Greetings from my new home in New York City! After a hectic month of dealing with the logistics of selling a house and moving to the City, I am finally settled into my new apartment in the heart of the Village. There is still lots to do to get fully moved in and ready for the school term, but I am looking forward to the new adventures.

Here are some links to some things I found interesting on the net this week:

1. Ted Kennedy’s passing is a great loss to the United States and many have already begun to debate the effect of his death on the passage of a health insurance bill – as he has long been a strong champion for universal coverage. As Alanna Shaikh has argued on her Global Health Change.org blog, the Global Health community has also lost a hero. This sentiment has been echoed elsewhere by others who have also seen him to be a champion for global health issues from HIV/AIDS to the control of neglected tropical diseases.

2. A great link was posted this week on the excellent Global Health News Feed that was launched earlier this year by the Kaiser Family Foundation (sign up if you have not already) to “The Tobacco Atlas” an interactive site that allows you to get information on smoking rates and other indicators of this worst risk factor known to man.

3. Time has a great article on the power of plain old zinc tables and the tremendous impact they are having at reducing childhood deaths from diarrhea in the developing world.

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A new paper by Peter Hotez and his colleague summarizes what is known about the prevalence and distribution of the disease burden of neglected tropical diseases (NTDs) in Africa. They confirm what we have always known – that these diseases are highly prevalent and are a major contributor to the burden of disease in Africa – even though they do not kill as many people as other, more high profile, diseases.

The table above, taken from the Hotez paper, suggest that upwards of a third of the population of Sub-Saharan Africa may be infected by some of these diseases. Hookworm, for example, may infect up to 30% of the continent. Scary stuff.

Even scarier, in my mind at least, is that a lot can be done to tackle this burden. Many of these diseases can be treated with simple mass drug administration programs, which are cost-effective and relatively easy to implement. Obviously we have a ways to go.

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“Over the past decade, Zanzibar’s malaria prevalence has dropped to less than 1 percent, virtually eliminating hospital admissions and death due to malaria. 
Despite the good news, Zanzibar’s history provides a cautionary tale in the fight against malaria. This is the third time in 40 years Zanzibar has come close to eliminating this disease. In the past, the government gave up the fight too soon, and malaria came surging back. This time will be different, vow officials at every level of the government.”

That is from a recent blog post by Gabrielle Fitzgerald, Senior Program Officer at the Bill and Melinda Gates Foundation blogging from the idyllic island in the Indian Ocean. Fitzgerald is traveling with Margaret Chan, Director General of the World Health Organization, Ray Chambers, the UN Special envoy for Malaria, and Tachi Yamada, President of the Global Health Program at the Gates Foundation.

I thought this quote was particularly sobering, with all of the fanfare about the extraordinary progress currently being made in Africa against malaria – in particular on the island of Zanzibar – it is a useful reminder of how great of a challenge remains. The elimination of malaria is still an ambitious goal and one that is far from certain to be achieved.

So what is different this time around? I think it is fair to say that we have more tricks out up sleeve this time around. Spraying was key to progress against malaria in the past, and this remains as true today, but in addition we have more effective medicines and bed nets to help eliminate prevalence of the parasites. All of these help.

There are also many strong organizations out there trying to push this through and certainly more money. Organizations like the Gates Foundation, the Global Fund to fight AIDS, Tuberculosis, and Malaria, and the US government’s President’s Malaria Initiative have put money on the table to make things happen. But this is not the first time malaria elimination has been pushed by the international health apparatus – it was a big focus of the WHO many decades ago.

Zanzibar is a special case – it is small island – which makes fighting the disease a little bit easier. If it can happen here – and it looks like it might – than it might be doable elsewhere as well. If we have any hope of eliminating Malaria we will need to see evidence from trailblazing places like Zanzibar.

So will it be enough? For the 250 million people who fall ill to malaria each year and the nearly million of people who succumb to the disease every year (mostly children) let’s hope it is. The last inch will likely be the hardest, and it is certainly the most important.

Photo Credits to Eric Lafforgue, who has tons of beautiful photos of Africa on his website.

P.S. For those who are wondering, yes, Zanzibar is that beautiful. If you have not been, you should definitely planning a trip. It is by far my favorite place in the whole entire world.

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In 1985, the late Allan Rosenfield published an articled entitled “Maternal Mortality – A Neglected Tragedy: Where is the M in MCH?“. It has a paper that has resonated well with me and sadly – over 20 years after its publication – it remains as true today.

Rosenfield argued that maternal and child health programs, despite the name, focus too little on the health of the mother (the M) but instead focus almost entirely on the delivery of a healthy baby (the C). While clearly this latter outcome is desired by all, it is important to realize that the health of the mother is itself a desirable outcome and it can also down the road influence the health of the child. I have frequently remarked that how we collect data on maternal and child health seems to be based on the idea that the pregnant woman are simply vessels to deliver a baby – and once the baby has arrived, it seems we care little if the vessel sinks.

Globally, almost a third of all maternal deaths are believed to be caused by post-partum hemorrhage (PPH) – a phenomenon that happens immediately after birth or what is known as the “third stage of labor”. My one paragraph understanding of the physiology is that the uterus is extremely well supplied with blood vessels. When a woman is pregnant her uterus needs to open up to accommodate the placenta. Contact with the placenta prevents bleeding (although imperfectly, this is a cause of bleeding during pregnancy). After delivery, the uterus contracts to expel the placenta. To prevent bleeding, it needs to fold back onto itself making contact with another part of the uterus. If something prevents proper contraction, the uterus may not fold back together properly leading to bleeding. Lots of it. So much that the mother may die if she does not receive immediate attention.

Once bleeding begins, the stuff she needs at that point is not the kind of stuff the midwives, traditional birth attendants, or community health extension workers cannot provide – she may need a blood transfusion to save her life – so having access to emergency obstetric care is key to prevent maternal mortality. This is one of the excuses as why it is so hard to reduce maternal mortality – it would involve such large expansions in highly specialized health workers and infrastructure.

However, while these health workers cannot do much once something goes wrong, they can do a lot to prevent PPH – hence supervision with a skilled attendant is key. Most of this can be done at relatively low cost. There is a standard set of practices following birth that together are known as the “active management of the third stage of labor (AMTSL)”. AMTSL includes controlled cord traction, uterine massage after delivery, and prompt clamping of the umbilical cord. Increasingly, the package also includes the use of a uterotonic drug (e.g. oxytocin). New research suggests that this last component can be extremely effective at reducing PPH and saving lives, but the rollout has been relatively slow.

A recent study of the use of oxytocin to prevent PPH in Vietnam, a country with moderate levels of maternal mortality, has demonstrated that the drug is effective and really cheap and cost-effective. The authors conclude:

“The low net incremental cost of AMTSL [with oxytocin] suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women’s health without adding much to national health care costs. In countries with scarce health care resources, where levels of PPH are generally much higher, AMTSL by either ampoule or Uniject device would likely be cost neutral, if not cost saving.”

Um, so we can save lives and maybe even save money? So why the heck aren’t we? Why are we not buying Starbucks Coffee and donating 5 cents to save the lives of women in Africa – because that is about as much as it would cost? Why is this not a bigger priority with donors? Why are countries themselves not paying for this technology? Why are women themselves not paying for it?

Part of it is that the intervention is a little tricky. The drug needs to be injected, so the midwives would need to be equipped and trained to inject the drug, and would need to ensure adequate supply of drugs and equipment, which could be a problem. There is a growing interest in using another drug, called misoprostol, which can be administered orally or vaginally reducing the need for additional equipment or supplies, but the drug is not as effective and might even be associated with some severe side effects. But I generally think the “its too complicated” argument is a bit lame. If we can get vaccines into the arms of nearly every child born in the world and can think about drawing blood for VCT testing in most parts of Africa, I think we can overcome this one as well. In the grand scheme of things, that seems solvable.

I think the bigger problem is that maternal big M issues are low on the radar of both national policy makers and international donors. Maternal health has not been successfully framed to us in such a way to make us want to invest. There have not been organizations that have successfully convinced us to do more and make this a real priority. So while we might be able to do a lot about this issue, we are not compelled to do so. The issue is not pressing enough.

There has been little progress towards achieving a reduction in maternal mortality in Africa – one of the MDGs. Good actionable interventions should continue to be evaluated and more effort should be made to ensure that the good ones get the attention they deserve. This might very well be one of them.

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Last year I posted a blog about a post-doctoral program in global health. It consistently ranks among the most viewed posts on my blog because apparently there is significant demand out there for programs like it – in particular people from developing countries. Almost every day someone searches for something like “global health scholarship” or “global health fellowship” or “doctoral studies in global health” and ends up on my blog.

I therefore wanted to help publicize that I think is a really exciting opportunity for health researchers from developing countries. The Tropical Disease Research (TDR) programme, a special research unit sponsored by the World Health Organization (WHO) and other organizations, has launched a “leadership development fellowship” post-doctoral programme for researchers from developing countries who already hold a PhD but are looking to learn new skills and widen their international exposure. The programme includes an internship at the WHO in Geneva, an internship abroad, a network of similar fellows, and financial support.

It looks like a great program from a great organization. Click here to learn more.

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Two great videos from Africa, addressing totally different issues, caught me eye today and thought I would pass them along:

1. Nigerians now drink more Guinness than the Irish, making it the second largest market for the product after the UK. A few years ago, I scuba dived in Tanzania with a girl who was responsible for the supply chain for Guinness bottles in Cameroon and I learned so much about the hold that this brand has over the region. Christian Purefoy documents the keys to Guinness success in Nigeria – despite all the reasons why most foreign companies shy away from investments in this country.


2. Via the Africa Works blog, a new video available on YouTube documents a traditional circumcision ceremony in Uganda. The reporter, Juliet Torome, makes the connection between the practice and the growing interest in circumcision from the public health community as a means to reduce HIV-AIDS transmission. But I was struck by how important this procedure in so many cultures, how culture-specific the practice is (the reporter was Kenyan and found the procedure very foreign), and just how challenging it will be to apply the bio-medical model to this practice. How on earth does one scale up ceremonies like this to the national level???

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Thoughts on a global health textbook?

On August 12, 2009, in education, global health, NYU, by Karen Grepin

I am busy pulling together the syllabus for my new course “Introduction to Global Health Policy”, which will mostly be offered to NYU-Wagner Master’s students and likely some students in the University-wide Global Public Health Master’s Program at NYU as well. The course is designed to be introductory and multidisciplinary in nature and aims to introduce the basic language and frameworks used Global Health discourse and will investigate a number of current debates.

While it has been a lot of fun – reliving my favorite courses in global health during my Master’s at the Harvard School of Public Health and courses I took during my doctoral studies at Harvard as well as going through my list of favorite readings – it has also been a lot of work as well.

One of my biggest struggling points is whether I should require a textbook, and if so, which one. When I took most of these courses no such textbook existed, but since then a number of books have come on the market and I am considering which might be best for this course.

I’ll probably end up including a lot of readings from the Disease Control Priorities Book – they are well researched, comprehensive, informative – and freely downloadable off the internet – but I am starting to feel as though some of them are a bit outdated (what does it say when a 2006 publication seems old?). I am also considering including Millions Saved as I plan to investigate many of the cases in this excellent publication.

I’ve TAed a course that used “International Public Health: Diseases, Programs, Systems and Policies” by Merson, Black, and Mills. Despite the star power among the authors in this book, but I am not sure how appropriate it is for Master’s level students.

Has anyone had any experience with either of these books?

1. Essentials of Global Health by Richard Skolnik?

2. Introduction to Global Health by Kathryn Jacobson?

Have you been a student who has used any of these books? Have you been an instructor that has used or considered using these books? Are you the author and want to tell me all about why your books is the best? If so, do email me at karengrepin.blog at gmail.com. Any and all feedback or suggestions would be most appreciated – including other books or an argument for no books.

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