Take collaborative strategic action to lower maternal deaths

By Azka Asif, Rotary Service and Engagement staff

In honor of Maternal and Child Health Month, Past District Governor Dr. Himansu Basu, a Rotary Foundation Cadre of Technical Advisors for Maternal and Child Health, shares about his team’s work to save the lives of mothers and babies in partnership with Rotarians, other professional volunteers, and governments.

Azka: Dr. Basu, last year you shared an update on the success of the Calmed (Collaborative Action in Lowering of Maternity Encountered Deaths) programme. Have you had any recent developments?

Dr. Basu:
Calmed, started in 2013, is funded through Rotary Foundation grants, supported by hands-on efforts of volunteer doctors and Rotarians from the United Kingdom and India. Two global grants have supported six vocational training team (VTT) visits to Sikkim, with a target population of 0.7 million, and Gujarat with a target population of 2.5 million.

Our team of 12 Obstetricians has trained 39 master trainers who continue to train professionals (currently just over 250) in emergency care of pregnant women and babies. The team has also trained approximately 100 Accredited Social Health Activists (ASHA) who raise awareness about pregnancy, child care and related issues through community women’s groups.

The programme was recognized with two international awards for excellence in 2016 — Times Sternberg award and Rotary GBI Champion of Change.

AA: Have you achieved your objectives for the programme?

HB: Maternal mortality reduction programmes take time to achieve their goal – zero preventable maternal death. We are on track for improvements in access to effective care. After three years, we see a steady fall in the number of avoidable maternal deaths in all of Sikkim, our first pilot site. We are moving towards our target of zero preventable maternal deaths.

AA: What can Rotarians do to reduce maternal and child mortality?

HB: Maternal mortality is an index of development in any community – an effective project in any of Rotary’s six areas of focus will also decrease maternal and child mortality, albeit slowly. For a more direct measurable response, a comprehensive strategy based on the Calmed template aimed at reducing the shortage of trained professionals while promoting community awareness regarding childbirth and child care issues should be implemented.

AA: What advice can you offer Rotarians planning a global grant project to reduce maternal and child mortality?

HB: Create a strategic programme with vocational training teams being a key component. It’s important to have experienced project committees supported by health professionals, and public health experts. Close collaboration with motivated Rotarians and government in the project host country is essential for impact and sustainability. The Rotary Foundation Cadre of Technical Advisors can be a valuable resource in planning, implementation and the follow-up stages. Expertise is also available from Rotarian Action Groups such as the Population and Development, Health Education and Wellness, and Preconception Care groups.

A planning visit to the project area by the international partner is very important and should focus on identifying local assets and needs, partnership opportunities with local government and professionals.

AA: What advice can you offer for organising a vocational training team aimed at reducing maternal and child mortality?

Himansu: A vocational training team for improving maternal and child health should be structured to meet the needs of the community. Here are examples of scaling a project:

Scenario 1 targets several smaller hospitals or one large hospital. Two to four experienced doctors train a group of 10 to 20 doctors and nurses on emergency care of pregnant women and new-borns.

Scenario 2 targets several larger hospitals or many smaller hospitals. 5-7 experienced doctors train 20 to 25 motivated trainers who then qualify as master trainers. These master trainers go on to train others (30-40 at a time). Two return team visits should be conducted for evaluation and further training.

Scenario 3 targets a community of one million or more. This is a most effective method, but requires close collaboration with local government. A team of 7 to 10 experienced doctors undertake:

  • training cascade as in Scenario 2 (above)
  • training 15 to 20 ASHA trainers to raise community health awareness. The ASHAs then train women’s groups in towns and villages throughout the target area
  • analysing all maternal deaths in the target area to identify preventable causes and facilitate corrective measures in partnership with local government

AA: Which scenario is most effective in your opinion?

HB: Clearly Scenario 3, but it is also the one requiring more time and resources.

AA: Thank you for sharing your knowledge and expertise! What is your vision for the future?

HB: We cannot rest on our laurels. We need to facilitate and provide support for Rotarians in many low resource countries to introduce more strategic programmes for the entire community based on the Calmed VTT template. Please contact me for further information and suggestions. Also, visit the Calmed programme website for more information.

We are in discussion to establish maternal and child health academies in partnership with governments and NGOs to provide academic support, carry out the work of vocational training teams and advocate to develop future programmes and future leaders achieve our goal of zero preventable maternal death.

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Related: 

Preventing cervical cancer in Kenya

By Judy Wolf, Immediate Past President of the Rotary Club of Davis, California, USA

Kenya is a land of utter beauty, stunning exotic animals, crowded road-side markets, robust farmlands, and friendly people. Astonishingly, nearly 5000 Kenyan women are diagnosed with cervical cancer each year, and 50% will die from this disease.  A disease that is nearly 100% preventable.

Our vocational training team left for Kenya in October 2016 in hopes of making a difference in the lives of these brave women. We couldn’t help but feel a sense of pride, knowing that we were a part of a team, organized by the Rotary Club of Davis (United States) through a Rotary Foundation Global Grant, sent to Kenya to provide cervical cancer screenings, treatment, and education to women in the poor and needy region of South Nyanza. Kenya has a population of almost 13 million women aged 15 years and older who are at risk of developing cervical cancer. The bedrock of economic life in Kenya revolves around women working in their prime. And when we save women, we save their children as well.

During our first team visit, we set up medical clinics at Homabay County Referral Hospital and Kendu Bay Sub-District Hospital. The medical team, consisting of a medical director, four doctors, and a native Kenyan nurse practitioner, spent the first seven days at Homabay where 163 cervical examinations were performed. These routine examinations led to four women needing cryotherapy to freeze lesions and three women receiving the lifesaving Loop Electrosurgical Excision Procedure (LEEP). Sadly, one of the ladies was discovered to have terminal cervical cancer. Our team was in awe of her courage and strength as she sat with her husband while the Kenyan physician explained to her the stark truth of her situation.   We will never forget this beautiful woman and her husband.

Kendu Bay Sub-District Hospital was our next life-saving visit. There, the team examined 215 women and performed five cryotherapy treatments and six LEEPs. Thankfully, most of the women were found to be disease-free.

We are proud to report that our trip was successful. The team trained Kenyan physicians and nurses on how to identify cervical lesions, and now the trained doctors and nurses are equipped to carry out the work and train other Kenyan medical professionals.

We look forward to our second team trip in June 2017 to the same region to do follow-up examinations and treatment, and offer additional training. During our final trip in November 2017, we’ll hold follow-up examinations, conduct a skills assessment of the trained medical professionals, and donate medical equipment to each of the hospitals.

We are profoundly grateful to The Rotary Foundation and the clubs that supported this life-saving global grant. We share a sense of honor and deep satisfaction to have been able to serve the women of Kenya in partnership with our Rotary community.

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Stopping mothers from dying: a Rotarian’s quest for vocational service

By Past District Governor Dr. Himansu Basu, Rotary Foundation Cadre Technical Coordinator in Maternal and Child Health

Three mothers and twenty babies die every five minutes; the majority of these deaths occur in Africa and the Indian subcontinent. I was always aware of the huge global burden of maternal and new born deaths, many of which are preventable.

When my Rotary district was chosen to be a part of the Future Vision Pilot in 2010, we saw an opportunity to support a project focused on maternal and child health. I realized that to make a meaningful and sustainable impact, the programme would have to be strategic with measurable impact and evidence-based components. It became clear that such an innovative programme would need to be tested as a pilot with close monitoring and evaluation.

Collaboration

Many of my friends and supporters in global professional organisations, governments, NGOs and of course Rotary at all levels helped develop the initial programme. Through these collaborations, the Calmed (Collaborative Action in Lowering of Maternity Encountered Deaths) programme was conceived.

It became obvious that although maternal and child health was a designated area of focus for Rotary International, the problems were not very visible to many Rotarians and non- Rotarians. Many didn’t know about the high life time risk  of woman dying at childbirth: 1 in 40  in Nigeria, 1 in 250 in India and 1 in 5900 in the United Kingdom.* Even though these deaths were largely avoidable, they continued to occur in areas with limited resources.

Leveraging the Rotary Network

As part of the pilot, we also identified a need to mobilize and strengthen resources available within Rotary, including professionals (doctors, nurses, midwives, hospital workers and volunteers) who would support effective maternal and child mortality reduction programmes.

As chairman of International Fellowship of Rotarian Doctors, it was natural for me to promote the Calmed programme to a global audience through Rotary International conventions, regional and district conferences, international institutes and other meetings. I accepted the Medical Directorship role with the Rotarian Action Group for Population and Development, a RI group of technical experts who advise on Rotarian-led maternal and child health programmes.

As a Rotary Foundation Cadre Technical Coordinator in Maternal and Child Health, I remain engaged and connected with Rotarians seeking assistance with programmes and projects related to reproductive, sexual health and family planning.

What is the Calmed programme?

 The Calmed programme utilizes the train the trainer model to build medical expertise in emergency obstetric and new born care. The programme also raises awareness of pregnancy and child birth related issues in rural villages with limited access to larger health care facilities.

The third component of the programme analyses all maternal deaths to identify avoidable causes and makes recommendations for corrective action (Maternal Death Surveillance Response- MDSR). As the state of the art programme evolves, we continue to add new elements and technologies such as Kangaroo Mother Care (KMC), anti-shock garments (NASG), Golden Hour concept, etc. to address identified needs.

Calmed Vocational Training Teams:

There are three Rotary Global Grant funded Calmed programmes that are currently taking place in:

  • Sikkim, India l Target population 0.7 million – introduced in 2013, with repeat visits in 2014 and 2016.
  • Bhuj, Gujarat, India l Target population 2.5 million  – introduced in 2014 with a second visit in 2016.
  • Madhya Pradesh, India l Target population 3.5 millionpreparatory work is in place and the visit is planned for October, 2016.

So far, these teams have trained 39 approved Master Trainers (goal is 100). These Master Trainers have trained 264 doctors and nurses (goal is 500) in emergency obstetric and new born care, as well as 95 ASHA trainers.

Impact of Calmed Vocational Training Teams:

The primary aim of the programme is to enhance trained workforce in the emergency care of pregnant women and babies and to improve participation of village women groups in raising awareness for health care issues during pregnancy and childbirth. Doctors and nurses in target areas have reported increased confidence in tackling emergencies since the inception of Calmed. A three year follow up from Sikkim shows progressive reduction of maternal deaths to a quarter of yearly deaths in the population since Calmed was introduced 3 years ago.

What can you do?

  • Invest in women and children’s health as it is vital for sustainable economic and social development.*
  • Unleash the power of vocational expertise of Rotarians and professionals, the Calmed VTT programme is a template for action.
  • Share Calmed’s success stories and consider introducing the programme in areas with high rates of maternal and child mortality.

Please act now! Visit the programme website and contact me with any questions or comments. Together, let’s stop mothers from needlessly dying!

The Rotary Calmed programme is an award winning programme having received two coveted national awards – The Times Sternberg Award in 2015 and Rotary GBI Champions of Change Award of 2015-16.

*[World Bank 2014], *[PMNCH, 2013]

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Improving maternal and child health in Uganda

By Past District Governor Ronald Smith, member of the Blue Bell Rotary Club, District 7430 (USA)

I began planning a vocational training team with my son Ryan in 2006, who at the time was a medical student at Drexel University in Pennsylvania, USA, with an interest in doing a rotation in Africa. This idea, combined with my friendship and previous matching grants experience with a governor classmate, Francis Tusibira “Tusu”, who I met at the San Diego Zoo at International Assembly, led to forming a vocational training team.

Later, as we met at various Rotary International conventions, we collaborated on several medical center Matching Grants. When Tusu and I were District Rotary Foundation Chairs in District 9200 (east Africa) and District 7430 (USA) respectively, we began exploring the idea of exchanging medical professionals.  As a District Rotary Foundation Chair, I was interested in learning how vocational training teams would be developed and managed under the new global grants structure.  Combining my personal interests with the support of my district and the Rotary Club of Blue Bell, a detailed plan evolved.

During a personal visit to Uganda in January 2013, I met with the Rotary Club of Kampala North and faculty at Makerere University in Kampala. The need for improved maternal and child healthcare education in suburban and rural areas of Uganda emerged through meetings and discussions between faculty and Rotarians. Visits were made to more than eight health centers and interviews held with health officials and the ministry of health uncovered a need for midwife education in emergency obstetric care and childbirth interventions.

The plan that emerged aimed to:

  • Exchange healthcare professionals to develop sustainable results.
  • Develop a sustainable computer network for educating healthcare professionals.
  • Improve community health center infrastructure with equipment and supplies.

Team members were selected from both Drexel University faculty in the United States and from Makerere University in Uganda. In Uganda, the team provided healthcare to patients along with obstetricians and pediatric training for health center staff. Drexel faculty was trained in Helping Babies Breathe, an infant resuscitation technique used in resource-limited settings, and Helping Mothers Survive, an innovative training initiative designed to equip health workers with the knowledge and skills they need to prevent mothers from dying during birth. The team helped set up health camps, trained midwives, and provided a computer network that will not only assist with continued self-training,  but will also be the back-bone for distance education learning. During the vocational training team from Uganda’s visit to Drexel, they were trained in developing distance education courses focused in healthcare.

These teams of doctors, nurses, midwives and information technology faculty have now exchanged twice.  Both teams immersed in one another’s environments and cultures. Through the personal and professional relationships that have been made between the two medical schools, these universities have now signed major collaboration agreements that will sustain this effort well beyond the vocational training teams. Additionally, the Ugandan health centers will become Centers of Excellence in Midwife Training and demonstrates how Rotary clubs and universities both in Uganda and the rest of Africa can work together to develop sustainable technology-based healthcare education systems.

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Why do mothers die? A Rotarian’s mission to reduce maternal mortality

By PDG Dr. Himansu Basu, MD, PhD, RI Technical Coordinator on Maternal and Child Health 2013-16

My world stopped when I was 15 – my mother died after her seventh childbirth (I was the eldest). The pain and misery in the years that followed were unimaginable. Since then, I have been asking myself the question –“Why do mothers die?”

I entered medical school, specialised in Obstetrics and Gynaecology and did full time research on pregnancy haemorrhages. My interest in childbirth-related mortalities did not wane, but I did not get real answers to my question.

Then I became a Rotarian. I wanted to utilise my hands-on vocational efforts for service, but the opportunities at that time were limited.

In the 1990s, global organisations like the U.N. challenged the world to address this question in the form of Millennium Development Goals. Global organisations and governments put a lot of funding towards improving hospital facilities and started promoting institutional childbirth deliveries but progress remained slow.

Two events in 2010 helped me find an answer to my question. First, my district, 1120 (England), became part of the Future Vision pilot. This opened the door for service through hands-on vocational efforts and advocacy through a global grant-sponsored Vocational Training Team. Second, I had the good fortune to chair an international collaborators meeting on maternal mortality in Delhi focused on why mothers die in low resource settings. The combined results were fantastic.

Second CALMED1The concept of Calmed (Collaborative action in lowering maternity encountered deaths) developed during the next three years with the help of important collaborators including FIGO (The International Federation of Gynecology and Obstetrics), GLOWM (Global Library of Women’s Medicine) and MAF (Medical Aid Films), Laerdal, Department of Health and Family Welfare, National Health Mission and of course our own Rotarian Doctors Fellowship and Rotarian Action Group on Population Development.

India remained our challenge. In spite of massive efforts by the Indian government, maternal mortality reduction in India was slow. Still today, the lifetime risk of a woman dying at child birth is 40 times higher in India than in the UK. India has the highest annual number of maternal deaths (about 55,000). Ironically, most are preventable.

TRF-sponsored Vocational Training Teams played leading roles in implementing the Calmed model. Using hands-on approaches, modern technology and a “train the trainer” model in two states in India, the team led skills trainings in managing emergencies at childbirth and raising awareness of childbirth related issues in the villages and urban communities. Monitoring and evaluation is an important component of the Calmed programme.

1st Calmed programme

First CALMEDIn Sikkim, India, where the programme was first introduced in 2013, our vocational training team of six doctors from the UK trained 13 local Ob Gyn staff members who became master trainers after stringent pre- and post-test assessments. The local master trainers have since trained over 200 doctors, midwives and health activists in the practical management of emergencies at child birth. Following the introduction of Calmed, the maternal mortality ratio was halved in just over 12 months.

2nd Calmed programme

Second CALMEDInvitations from the government and local Rotary clubs led to a second vocational training team to visit Gujarat in 2014 and train 26 master trainers. More than 40 doctors and midwives were then trained and the training cascade continues with outstanding results.

As we move forward, we are planning to take a team this year to Madhya Pradesh, India, for the third Calmed programme.
We are also working with India’s government to establish skills trainings and development centres where selected local master trainers (rather than vocational training team members from England) will be responsible for training future master trainers. This will offer a sustainable, realistic local solution to eliminate preventable maternal and new born deaths.

CALMED teamWe would not have been able to move forward without the constant support, encouragement and stewardship of Rotarians at all levels, from the clubs t to districts , RIBI and RI, including past Rotary International Presidents, Directors, Trustees, and many officers (past and present). Our collaborators remain fully supportive.

It has taken more than 50 years of searching, but I am glad I have found the answer to why mothers die and more importantly, how we can save mothers and babies from dying or experiencing complications from childbirth. We have found a solution that works.

Read more about the Calmed programme and contact me if you would like to support this vocational service effort.

Pledge your support now and join the Calmed revolution!