Dear Partners In Health Supporter,
Please accept our heartfelt gratitude for your partnership in preventing maternal deaths in the rural, mountainous communities where we work in Lesotho. Below, please find an update on the Maternal Mortality Reduction Project that we recently published in our quarterly newsletter. As always, please be in touch with any questions that you have about our work.
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But more than two years ago, PIH/Lesotho (PIH/L) began a program to prevent maternal deaths by making high-quality care accessible to women during pregnancy, in childbirth, and after delivery. Since then, the program has expanded to all seven clinics PIH/L serves, with dramatic results. Since the beginning of the program, more than 2,800 babies have been delivered at PIH/L-supported health clinics. From 2010 to 2012, the use of family planning has increased by more than 65 percent, and 25 percent more women and children have received care to prevent the spread of HIV from mother to child.
The comprehensive program centers on maternal health workers who make regular home visits to find pregnant women and accompany them to clinics for antenatal care and delivery. PIH/L has also established seven mothers’ waiting houses. Now, women in labor can avoid an hours-long walk to a clinic and be close to care when labor starts. PIH/L Country Director Dr. Hind Satti said the entire staff, from drivers to nurse midwives, are committed to preventing maternal deaths.
“We are not going to accept any maternal deaths,” said Dr. Satti. “We all started with that spirit—that there is no reason a woman should die during pregnancy or giving birth.”
In February, Partners In Health's Multimedia Director Bec Rollins traveled to Lesotho, where she had the opportunity to visit PIH-L sites and meet women enrolled in the Maternal Mortality Reduction Project, as well as Maternal Health Workers. I hope that you enjoy Bec's beautiful photographs of some of these women and their babies -- who have access to high-quality pre and postnatal care thanks to your support of the MMRP. Please find descriptions of each photo below.
1) (Above) February 4, 2013, Nohana, Lesotho, Nohana Clinic Site Director Meriam Sesiu Kopeli holds a healthy baby boy, delivered moments prior to the capture of this photo. The baby is the 5th child of a woman who was accompanied to the clinic on this morning by PIH Maternal Health Worker, Malineo Sethobane Lipeneng. Lipeneng lives in the same village as the mother of the baby, abouy 15 minutes from the clinic, and has attended all 5 of the woman's pregnancies.
In order below:
2) February 4, 2013, Nohana, Lesotho, Malineo Sethobane Lipeneng is a Maternal Mortality Reduction Program worker - also known as Maternal Health Worker - who brought a woman from a village about 15 minutes away to the clinic on this morning to deliver her 5th child. Lipeneng attended all 5 of the woman's pregnancies. On this day a healthy baby boy was born.
3) February 4, 2013, Bobete, Lesotho, Women and their infants wait for postnatal care visits at thh PIH funded Bobete Clinic. Women raising their hands in this photo are those who work with Maternal Health Workers and delivered their babies at the Bobete clinic.
4) February 4, 2013, Bobete, Lesotho, Tebatea Taka and her mother (left) wait for postnatal care at the PIH funded Bobete Clinic. Tebatea was born on 01.26.13. Her mother carried her to Bobete from the village of Mpokochela. Baby girl Letsaba Molokhene is held by her mother Masetsaba (RIGHT) as they also wait for their postnatal appointment. Letsaba was born on 01.11.13. The family lives in the village of Mpokochela. Letsaba's mother was accompanied to the Bobete clinic to deliver by a PIH Maternal Health Worker.
5) February 4, 2013, Nohana, Lesotho, Maternal Mortality Reduction Program workers - also known as Maternal Health Workers - gather for their weekly meeting at the PIH funded Nohana Clinic.
In September of 2012, Dr. Hind Satti and the Partners In Health Lesotho team published a paper in PLoS One (an international online journal) on the Maternal Mortality Reduction Project. Please take a minute to read a summary of this paper below, written by Christian Hague of Partners In Health:
Background: In the mountain regions of Lesotho, women must often travel hours or even days by foot to access medical care. This lack of access leads many pregnant women to deliver their babies at home, far from the life-saving care of a medical facility. As a result, there are 1,155 maternal deaths for every 100,000 live births, giving Lesotho one of the highest maternal mortality ratios in the world. One in every 31 women in Lesotho will die in childbirth at some point during her life.  Women in Lesotho have an average of 3.3 children, so each maternal death contributes to an orphan crisis with an estimated 200,000 orphans out of a population of 970,000 children under age 18.1
To more aggressively and effectively prevent maternal deaths in Lesotho, PIHL and the Ministry of Health and Social Welfare began the Maternal Mortality Reduction Program (MMRP) in 2009. The MMRP aims to expand access to facility-based prenatal care and delivery by conducting active outreach to pregnant women in the communities PIHL serves. The backbone of the MMRP is a team of community health workers who accompany women throughout their pregnancy, ensure that they attend prenatal appointments, and encourage them to deliver their babies at the health center. These community health workers are rigorously trained, supervised, and receive regular training updates and monthly performance-based pay for their work.
The Status Quo in Global Health: In many remote regions around the world, maternal health is provided only at local health centers, which may be several hours’ walk for many pregnant women who need care. The lack of community-based follow-up in many of these poor communities causes women to deliver their children at home, where they are more vulnerable to poor outcomes or death as a result of a complicated pregnancy or delivery.
How PIH is Innovating: A recent publication by Dr. Hind Satti and others showed that, after establishing the MMRP at Bobete health center, PIHL made great progress in getting women to the health center for prenatal care and delivery. The average number of prenatal care visits at the health center increased from
20 to 31 per month. The number of facility-based deliveries increased from 46 in the year preceding the program to 178 in the first year of the program, and 216 in the second year (Figure 1). During the first two years, PIHL transported 49 women who were experiencing complications in pregnancy or delivery to the local district hospital for care. Not one woman who was enrolled in the MMRP died during this time. These positive results show that comprehensive, integrated, community-based care can be delivered to pregnant women living in extreme poverty in difficult-to-access areas, and can help those women deliver their babies safely.
The comprehensive care that PIHL provides as part of the MMRP is unlike anything that existed before the program. By getting pregnant women into the clinic for initial prenatal visits, PIHL is able to provide routine prenatal care, HIV testing and treatment, and a wide range of other essential services, including:
How PIH is Impacting Global Health: PIH is exploring ways to use the lessons learned from the MMRP at other PIH country sites, enabling us to build on the great innovations from Lesotho. Furthermore, we have made our MMRP training materials freely available to partners and other organizations doing similar work in Lesotho and beyond. These measures will ensure this innovative program will pave the way for others to make progress in bettering the health of the destitute sick around the world.
 Satti H et al. Comprehensive approach to improving maternal health and achieving MDG 5: Report from the mountains of Lesotho. PLoS One. 2012;7(8):e42700.
 Lesotho Demographic and Health Survey, 2009.
 UNDP: http://www.undp.org.ls/millennium/Millenium%20Development%20Goal%205.pdf
Nicholas Kristof and Jordan Schermerhorn recenty visited a clinic run by Partners in Health in the highlands of Lesotho. Jordan Schermerhorn, a recent graduate of Rice University, is the 2012 “Win A Trip” winner -- a contest featured in Nicholas Kristof's 'On the Ground' column in the New York Times. She is currently traveling with Nick through parts of southern Africa. In her first post, she writes about HIV treatment in Lesotho:
For my first trip outside of the United States, I felt amply prepared for new experiences traveling across southern Africa – for witnessing both the struggles of poverty and the optimism of burgeoning economic growth.
Then I saw the plane.
Suppressing nervousness, I scrambled into the tiny six-seat propeller plane that bore us on the first leg of our journey to a health clinic. It looked hardly bigger than a toy, and each of us was weighed before stepping inside so the pilot could calculate the amount of fuel necessary. The plane was to take us to the small village of Bobete, near the center of the southern African country of Lesotho. This country is aptly named the Mountain Kingdom: immense geographical barriers limit the construction of roads and airstrips used to reach patients in remote, rural villages, and our bird’s eye view provided some insight into the complexity of delivering health care in Lesotho. Health centers in the distant reaches of the country are often swarmed with patients, many of whom are unable to trek to the clinics in snow storms. Such weather also poses immense difficulties for planes attempting to drop off supplies: for instance, the clinic we visited was out of injectable contraceptives.As we made our approach, buildings trimmed in bright red – characteristic, I later learned, of all health facilities in Lesotho – stood out sharply against grain-covered slopes. I was thrilled to spot solar panels on the periphery of the clinic. Along with a backup generator, this reliable power source allows the clinic to operate independently of regular blackouts that plague similar areas, keeping X-ray and ultrasound machines running for patients in need.
The Bobete clinic, an outpost tucked away in the mountains, is run by Partners in Health, the organization founded by Dr. Paul Farmer and best known for its work in Haiti. The clinic is used primarily to treat HIV patients in a catchment area of 30,000 people. In Lesotho, 23% of the adult population is HIV positive – most of them women of childbearing age – and treatment is undergoing a transformation. With a HIV diagnosis no longer considered an immediate death sentence, the stigma surrounding the disease here is vastly reduced.
One HIV-positive woman we spoke to said she was not scared when her test results first came back: she knew what HIV was, and that it was manageable with medication. After a few weeks of antiretrovirals, she felt well enough to head to the capital city of Maseru in search of a job – only to catch tuberculosis four months later. Though she was forced to retreat to the clinic that had first saved her life, she soon expects to be back in her healthiest state. Unfortunately, this cycle of concurrent infectious and chronic disease is not uncommon: HIV patients may catch tuberculosis time and time again.
It helps immensely that antiretroviral drugs are available for free here, but the question remains as to whether or not that will be sustainable as people with HIV live longer. Prevention is becoming increasingly important, and one of the most essential paths to eradication of the epidemic is the prevention of mother-to-child transmission. Pregnant women arriving at the Bobete clinic are HIV tested as a matter of course, and those who test positive are provided with a substantial support system to ensure their children are borne free of the virus.
We met another HIV-positive woman with a toddler whose squirming could not be suppressed even when strapped tightly to her back under a blanket. She had followed careful protocol while pregnant, diligently boiling water and cleaning bottles when opting to exclusively formula-feed her son. Though her mother had eight children, she says this one is quite enough for her; though she halted her education after two years of secondary school, she dreams of sending her son to university. This is the progress Lesotho can hope for in the next generation of the fight against HIV and AIDS: with effective prevention techniques, an educated population, and an expanding health system, all toddlers should be so lucky.
And, yes, the visit to the clinic was worth a bumpy flight in a tiny airplane. I even got to ride in the co-pilot’s seat on the way back for a free flying lesson.
An Update from the Field - Patient Story
Below is the story of Malebohang Setona, a patient at the Nohana health center in Lesotho who is benefiting from the Maternal Mortality Reduction Project.
Written by Susan Sayers, Hannah Hughes, and Charles Howes
March 21, 2012 Malebohang Setona is 21 years old, nine months pregnant, from the village of Ha-Kori, which is about a 3 hour walk from the Nohana health center. She is pregnant with her second child. Her first child, a girl, is 3 years old. She is married, and her husband, 26 years of age, is at home, unemployed. They have some fields which they plow, and they have a few livestock. Just Malebohang, her husband, and her first child live in their household, and her mother-in-law lives nearby. Malebohang delivered her first child at home, attended by mothers in the village and her mother-in-law, without complications. At that time that her first child was born, the Nohana health center had been rebuilt by Partners In Health (this was done in 2006) but we had not yet launched the Maternal Mortality Reduction Project (MMRP) here, and the women’s shelter at Nohana did not exist.A very soft-spoken woman, Malebohang described how she came to learn about the MMRP. She attended a community gathering where a Maternal Mortality Reduction Project Assistant (MMRPA, a traditional birth attendant who PIH has trained to be a maternal health worker) informed the community about the program, the importance of women attending antenatal visits and delivering at facility, the ability to stay at the clinic while awaiting delivery. Malebohang was not yet pregnant then, but when she became pregnant, she approached the MMRPA, and they came together to the Nohana health center for her first antenatal visit.In total, Malebohang received three antenatal visits, including an ultrasound early in her pregnancy to determine the gestational age of the baby. When we asked her what her expected delivery date was, she smiled, and replied in Bosutho “March 27 ”. She checked in to the women’s shelter on March 2. At the shelter, she receives three meals a day; she is required to bring her own linens and toiletries. Importantly, her mother-in-law is supportive of her being at the shelter; she came to visit Malebohang last week. Her husband is at home taking care of the other child.When asked about the benefits of the program, Malebohang, through a translator, said that “in case of emergencies, I will get the appropriate care here, unlike at home.” She added that she and the other mothers are “very thankful for the support, for their own good and for their babies.”
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