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If there is one thing every mother knows, it is that babies arrive on their own schedule. And no mother knows this better than 30-year-old Tewabech Kutambo, who lives in a small village called Lahyte, 370 miles south of Ethiopia’s capital, Addis Ababa.
There is no water in Lahyte. To get water to drink, cook with, clean themselves and do washing, women leave before the sun is up and walk for two hours to the banks of the Orbole River. Filling their containers with as much water as they can carry, they make the two-hour trek back to their homes under the blazing African sun.
It’s a task that can’t be put off or postponed, no matter how tired or sick a woman feels — or how pregnant she is. Tewabech’s family depends on her, and if she doesn’t collect water, her family doesn’t eat or drink.
Tewabech gave birth to her child, a little girl, alone on the side of the road. She used some of the water she had with her to clean herself and the baby. Then, after resting for a little while, Tewabech got up and, with her baby in one hand and her water cans in the other, made her way back home.
Tewabech’s story, told by David Winder, chief executive of the nonprofit group WaterAid, isn’t uncommon. Every year 57 million women worldwide give birth without the help of a trained health worker, according to the World Health Organization. “It is often the case that they will give birth on the dirt floors in their homes,” said Dana Allison, executive director of Women’s World Health Initiative.
In these circumstances, the risk of infection to mothers and babies is extremely high. And in the developing world, where access to antibiotics is limited, infections are fatal. In this sense, Tewbech and her daughter are lucky. Although the delivery was traumatic, neither contracted an infection.
But many women and children in similar circumstances are not as fortunate. The World Health Organization estimates that half a million women per year die from infections associated with childbirth. Nearly 1 million newborns die each year from infection.
To address this issue, aid organizations have started distributing clean birth kits to women in low-resource settings around the world, such as Mozambique, Tibet and India. These aid groups, along with women’s health advocates, hope that by providing expectant mothers with a few basic hygiene items wrapped in a small portable bag, rates of infection in mothers and babies will dramatically decrease.
“When women in the United States find out they are pregnant, they are excited and think about what they will name the baby or who the baby will look like,” said Paula Dhanda, a California-based OB-GYN and founder of the nonprofit organization Worldwide Healing Hands, which works to improve maternal and infant health in developing countries.
“Women in developing countries have a lot of fear,” said Dhanda. “Will I survive the delivery? Will my baby?”
The importance of clean birth kits and hygienic practices when delivering a baby cannot be understated, said Allison. But getting attention and support for these projects is difficult.
“Because we don’t face these problems in the West, it is a difficult issue for women to connect to,” she said.
Women and babies in the West almost never die from complications related to delivery, according to Allison. “But any woman who has had a Cesarean section or had a doctor use a vacuum or forceps to facilitate delivery should understand that were it not for those interventions, they could be dead.”
Clean birth kits normally contain just six items: a bar of soap, a plastic sheet to deliver on, a razor blade to cut the umbilical cord, clean string for tying the umbilical cord, gloves and a pictorial instruction sheet that illustrates the sequence of delivery events and proper hand-washing.
Research conducted by USAID in Tanzania shows the positive impact of the kits on women’s and children’s health. In a study of 3,200 participants, including some who used the kits and some who did not, the organization found that women who used the kits were substantially less likely to develop genital tract infections, and their infants were substantially less likely to develop cord infections. USAID estimates that if clean birth kits were used in 90 percent of home births, it would save the lives of 6,300 women and 102,000 newborns each year.
While clean birth kits have incredible potential for improving the health outcomes of mothers and babies, the $2 cost of a single kit is negligible. While prices vary around the world, most Americans could pay for a kit with the change in their sofas.
Two dollars covers not only the cost of the materials in the kit, but also the cost of putting the kit together. Danielle Ehret, a neonatal and perinatal resident at Boston Children’s Hospital, works with an organization called Ayzh to distribute clean birth kits in Bangladesh. Ayzh, Ehret explained, decided to have the kits assembled locally as a way of creating work opportunities for women who may otherwise struggle to find gainful employment. In this way, her organization’s clean birth kit program is assisting women on a number of levels.
Dhanda, who started distributing clean birth kits through Worldwide Healing Hands, has found modifications need to be made to kits sent to different countries to accommodate local practices and beliefs.
“In Nepal, it is traditional to cut the baby’s umbilical cord with a coin,” Dhanda said, “but money is about the dirtiest thing out there and using it to cut a cord can lead to infection for the baby.”
Out of respect for Nepalese custom, Dhanda arranged for the razor blades to be replaced with plastic rupees.
“Everything women around the world need to have a clean birth already exists. We don’t have to invent everything,” said Dhanda. Listening to what women need and understanding their traditions and practices is essential for the project to be successful, she said.
Roadblocks to distribution
While clean birth kits represent an easy, cost-effective way of improving maternal and infant mortality rates, there hasn’t been much of a push for this project, according to Jim Patell. Patell is a Stanford professor who teaches a popular class called Design for Extreme Affordability in which students produce low cost medical devices for use in the developing world.
One of the consequences of Millennium Development Goal five, which addresses infant and maternal mortality, is that there is a push to get women to deliver in hospitals instead of at home, an orientation that limits resources for making and distributing clean birth kits.
Allison has seen this firsthand in her work with the Women’s World Health Initiative in Senegal. She tells of a well-meaning Japanese NGO that built a state-of-the-art hospital in a central village in the area she works. “It has all the latest X-ray and ultrasound machines,” said Allison, but “it stands there locked and empty because there aren’t qualified health care workers to staff it and the people have no ability to pay for care.”
Neither Patell nor Allison are opposed to hospital births. “It is empirically true that women who give birth in hospitals do better,” said Allison, but sometimes it is “infrastructurally impossible for them to access the hospital.” For example, during the rainy season in Senegal, 40 percent of villages are cut off from the urban centers where hospitals are located.
Dhanda has seen similar issues in her work in Nepal. The government there offers women small amounts of money for delivering in approved medical facilities. However, Dhanda met women who lived three days from the nearest hospital. Even if they dropped everything the moment they went into labor, many would end up giving birth en route.
Even when the hospitals are accessible, lack of awareness about the signs of labor means there is often very little time between the moment a woman realizes she is having a baby and that baby is in her arms. For example, women in developing countries often don’t even notice when their water breaks.
“They are often malnourished and dehydrated, so there just isn’t a lot of amniotic fluid,” said Allison. When you combine that with the fact that in many of these places it is hot and women are sweating profusely, it’s easy to see how signs of labor might be missed.
Allison and Patell would like to see aid organizations focus more on solutions that recognize the situation on the ground when it comes to women giving birth in the developing world.
“My dad was a golfer,” said Patell, “and he taught me that you’ve got to play the ball where it lays.”