January 15, 2013
Greetings from Lucknow, Uttar Pradesh, India! This is my first time in Lucknow and first time in India. I have been inundated with sites, sounds, and smells(!) since I touched down and it has been exciting at times, a bit frightening (mostly just the traffic) and invigorating. For the next three weeks I’ll be working in Uttar Pradesh (UP) with BetterBirth on an implementation and evaluation project of the WHO Safe Childbirth Checklist (more info here and here). PSI-India and Harvard School of Public Health, with a generous grant from the Gates Foundation, are implementing a cluster randomized control trial in 120 facilities across UP to show the effect of the checklist on maternal mortality and morbidity, newborn mortality, and health worker practices.
This checklist could not be more relevant. UP is the most populous state in the country with poor maternal and newborn outcomes. For example, the maternal mortality ratio is 359/100,00 live births (India overall is 212/100,000) [Government of India Family Welfare Statistics 2011]. India is ranked number one in numbers of maternal deaths and UP, a state of nearly 200 million people with a high maternal mortality ratio, contributes significantly to that [Save the Children’s State of the World’s Mothers report 2012]. The infant mortality rate is 63 per 1,000 live births (India: 50/1,000) [Government of India Family Welfare Statistics 2011]. The checklist program targets major causes of death for mothers and babies worldwide. For mothers the killers are bleeding, infection, elevated blood pressure, and prolonged or obstructed labor and for babies they are asphyxia, infection, and complications of prematurely. I am incredibly excited to begin work with the BetterBirth Team as we work towards the goals of implementing and evaluating this checklist program and improving maternal and newborn lives.
So far my experience in Lucknow has shown me the importance of this checklist as I observe the economic growth, infrastructure growth and the poverty that exists alongside these advancements and imagine what a reduction in maternal and newborn deaths could do in this context. I am including along with this post a photo (below) taken just outside my hotel window: “Aspire for quality lifestyle in New Lucknow” is splashed across a billboard with crisp high-rises and a happy couple smiling juxtaposed with the huts of a few families—you can see their laundry, their cooking fire, and the women going back and forth to the well collecting water. Their whole lives are here at this hut and even more so since they work on the construction site you can see in the background. One woman will watch the children while the others carry bricks on their heads – sometimes 8 to 10 bricks at a time – the men lay the bricks and pour the concrete creating the building represented in the photo of New Lucknow. Perhaps this juxtaposition is depressing because in all likeliness this family will not be future residents of this building but perhaps it is the hope I have started to see here in UP. All this construction provides jobs and income for these families who may decide to use this money to buy extra protein for their family or medicines for a sick child or save for a better education. Of course this type of living is not without its problems – lack of sanitation, smoke inhalation from the fires, close quarters increasing likelihood of disease spreading, outdoor living increasing exposure to mosquitoes, the list goes on – but if I have learned anything in my first few months is that India is a country of hope.
In this project we are seeing hope: hope in the faces of the trainers of the checklist, the healthcare workers tasked with using the checklist, and those brand new healthy babies and happy mothers exiting the healthcare facilities. As Robyn Churchill, Research Associate from Harvard School of Public Health, says, “If we learn love from Italy, organization from Germany, and time management from Switzerland, then we learn hope from India.”
January 19, 2013
What an incredibly warm welcome from the BetterBirth staff in Lucknow! When I walked into the office I was greeted by the lively people who make this whole project possible. Their faces were beaming and eyes shining against bright saris and salwar kameezes. Hugs, handshakes, and smiles welcome me: how incredible to be here and meet these people whose voices I had only heard from thousands of miles away. I’ve enclosed a picture of me with the implementation team.
Soon after my arrival Jonathan Spector, one of the P.I.’s of the project from HSPH, arrived and three days of intense meetings ensued. The team has been preparing for a meeting of the scientific advisory group that weighs in on the project giving scientific feedback and brainstorming solutions to issues or obstacles. So these prep meetings leading up to the scientific advisory meeting included running through the presentations regarding the research and implementation of the program and listing the questions we wanted to bring to the scientific advisers. I can’t go into too much detail of these presentations but I was thoroughly impressed with how much had been accomplished so far in the pilot and the thoughtfulness of the questions that the team had prepared for the advisers.
About mid-week Atul Gawande arrived, he is one of the P.I.’s and the mind behind the Safe Childbirth Checklist, and we visited some health facilities to get an even better understanding of the context for the trial and use of the checklist. The ride to the facilities was beautiful with rich green fields and swaths of yellow mustard flowers flanking the way. We passed through villages with many stores and homes along the road, myriad cows and buffaloes, and still, in the rural area, many, many people. We arrived at the first facility: a cement building painted yellow with an entry way full of signs warning of dengue and anemia. The medical officer in charge spoke with us about the checklist in his facility, about the benefits and challenges and we took a tour of the facility. We saw where the checklist would be used at different points and the supplies used for delivery. It was especially exciting to see the Safe Childbirth Checklist posters on the wall! It was relatively quiet and no women were delivering or in the ward. The second facility was much smaller than the last and painted pink: despite being smaller this facility was a bit busier with men, women, and babies waiting to see the nurse or pharmacist. It was not hard to notice how cold it was in the facilities and especially the lack of electricity at the smaller one. I can imagine giving birth to a baby in such a cold place would be hard, both on the mother and baby, though one of the doctors on the BetterBirth team assured me that the summers are no better when there is intense heat. She also told me the staff are incredibly motivated and excited for this program and truly see the value of the checklist–more evidence of the hope in Uttar Pradesh!