Solar suitcase' saving moms, babies during childbirth
By Christie O'Reilly, CNN
October 13, 2013 -- Updated 2339 GMT (0739 HKT)
Top 10 CNN Hero: Dr. Laura Stachel
In some countries, a lack of reliable electricity is to blame for deaths during childbirth
Dr. Laura Stachel witnessed this tragic truth during a trip to Nigeria five years ago
She and her husband are now delivering a solution: solar energy in a suitcase
Berkeley, California (CNN) -- On a research trip in Nigeria, Dr. Laura Stachel watched as physicians performed an emergency cesarean section.
What happened next stunned her.
"The lights went out," Stachel recalled, "and I said, 'How are they going to finish?' "
She was even more surprised by the nonchalant response.
"You didn't even see people reacting because it was something they were so used to," she said.
Fortunately, Stachel had a flashlight with her, and the doctors were able to use it to complete the surgery. But during that two-week trip in 2008, she witnessed countless other times when the lives of mothers and babies were at risk simply because of a lack of reliable electricity. Pregnant women would arrive at the hospital with severe complications, but without adequate light to treat them, procedures had to be compromised or delayed until daylight. Some women were even turned away.
"I realized that my skills as an obstetrician-gynecologist were utterly useless (without) something as basic as light and electricity," Stachel said.
Stachel said midwives in Nigeria use all kinds of makeshift lighting when they deliver babies: kerosene lanterns, candles, even cell phones.
Inadequate lighting can be a dangerous -- and sometimes fatal -- issue during childbirth.
"That's not adequate light for maternity care," she said. "If somebody is hemorrhaging, if a baby needs resuscitation, you need to have directed light."
Nigeria is one of the 10 most dangerous countries in the world for a woman to give birth. In 2010, an estimated 40,000 Nigerian women died in childbirth -- 14% of all such deaths worldwide, according to the World Health Organization and the United Nations.
Meanwhile, the neonatal mortality rate is also one of the worst in the world. Each year, about 4% of babies in Nigeria die before reaching 28 days old; for comparison, the United States rate is only a fraction of this at 0.4%.
Stachel said that in her two weeks in Nigeria, she saw more complications than she had in her entire career in the United States.
"Once I witnessed the things that I saw," she said, "I had to let people know, and I had do something about it."
With the help of Hal Aronson, her husband and a solar energy educator, Stachel worked to find a solution. He drew up designs for a solar electric system to provide a free source of power to the state hospital in northern Nigeria where Stachel had conducted her research.
While they raised funds for the project, Stachel returned to Nigeria with a small kit to help show what the system would be able to do: It had a couple of solar panels inside, some lights and walkie-talkies to improve communication.
These solar energy kits provide much-needed light as well as power for all the necessary medical equipment.
The kit was only meant for demonstration purposes -- a miniature model of the larger system. But the surgical technicians saw it as something else.
"They said: "This is incredible. You have to leave this with us. ... This could help us save lives right now,' " Stachel said.
She did just that, and news of the kit soon spread to other clinics. So each time Stachel would return to Africa, she came with one or two new "solar suitcases" assembled by her husband.
Today, the solar suitcase includes two solar panels that are mounted on a clinic's roof and connected to high-quality LED lights. Once fully charged, it can provide light for up to 20 hours. The kit also contains headlamps, a fetal Doppler to monitor a baby's heart rate and a cell phone charging unit.
Over time, the solar suitcase has become simpler in design.
"We got to something that was really rugged, simple to use, portable and that we knew would really work in harsh environments," Stachel said.
It also spread to other countries after Stachel and Aronson started a nonprofit, We Care Solar. Since 2009, the kits have been helping health-care workers save lives not only in Nigeria but in facilities throughout Africa, Asia and Central America.
To see birth associated with death and fear is an outrage. CNN Hero Dr. Laura Stachel
The solar suitcase
For Stachel, the solar suitcase is only part of a bigger mission to improve maternal health care and lower mortality rates in developing countries.
"I really want a world where women can deliver safely and with dignity, and women don't have to fear an event that we consider a joy in this country. To see birth associated with death and fear is an outrage," Stachel said. "Before I went to Africa, I knew women were dying at high rates. I just didn't know they were run-of-the-mill things we can take care of."
In 2009, We Care Solar completed the solar electric installation that her husband originally designed for the state hospital. Over the next year, the hospital reported that the death rate for women had decreased 70%. Nurses told Stachel they could see what they were doing, they didn't have to turn women away, and they had blood for transfusions because the electricity provided power for a blood bank refrigerator.
"When we saw the impact, that gave me the impetus to provide this fundamental thing for people to do the job they knew how to do," Stachel said.
We Care Solar provides its solar suitcase, along with training and installation, to hospitals and clinics for free. Each solar suitcase costs $1,500, which the nonprofit funds through grants and support from partner organizations and sponsors.
Stachel also works with its partners in various countries to identify clinics in need and help engage the community.
The top 10 CNN Heroes of 2013
"We often ask them to be involved participating in research studies, giving us feedback and making a commitment to maintain these and to replace parts as they're needed," Stachel said.
So far, We Care Solar has provided nearly 400 solar suitcases to facilities in 27 countries. They're being used in main hospitals as backup systems and in rural clinics as a primary source of electricity.
"It's just shifted the morale of the health-care worker," Stachel said. "They're now excited to come to work. ... Mothers are now eager to come to the clinics."
Fanny Chathyoka, a midwife at a rural clinic in landlocked Malawi in southern Africa, used to use light from her cell phone when treating patients at night. She said the solar electric kit she received from Stachel last month "keeps me going."
"This light ... is going to bring good changes," she said. "We should not lose any women. I will be able to give good deliveries. Suturing will not be a problem for me. Resuscitation of a baby during the night will not be a problem, because of the light. I feel very happy."
Ultimately, Stachel hopes her efforts will be part of a movement that makes a dent in a very big problem.
"We didn't set out to transform maternal health care around the world, but it feels like this has grown to something so much bigger than I had ever imagined," she said.
"Communities are celebrating the fact that they have light. And that they now have one more component to help with safe motherhood. It's amazing."
Want to get involved? Check out the We Care Solar website atwecaresolar.org and see how to help.
The Kirkos clinic, which performs abortions in Addis Ababa, Ethiopia. Photograph: Marie Stopes International
Just 1km away from the African Union conference centre, and the international evangelical church in Addis Ababa, the Kirkos health clinic feels far from the politicking and religious opposition that continue to stalk abortion – one of the most contentious global health issues.
Outside, a blue and white sign displays the range of services on offer. Safe abortion tops the list, stenciled in big bold letters, followed by HIV testing, family planning and infertility treatment. Inside, the clinic's orderly waiting room is already full. It's 8.30am. Most visitors are young, between 18 and 25 years old, and nurses talk candidly about sex.
While abortion remains a radioactive issue in the US, a number of developing countries have liberalised their abortion laws in recent years, often citing alarming public health statistics. Globally, the World Health Organisation estimates that 47,000 women die from unsafe, "back-alley" abortions each year, and millions more are left temporarily or permanently disabled.
In 2005, Ethiopia legalised abortion in cases of rape or incest, for all young women under the age of 18, and in a number of other situations. Guidelines from the ministry of health in 2006 went further, expanding the range of health facilities allowed to provide abortion services and instructing health workers that women seeking abortions do not have to provide proof of rape or incest, or of how old they are.
The Kirkos clinic, run by the NGO Marie Stopes International (MSI), saw up to 13,000 patients last year, more than 8,500 of whom seek abortions. Being able to offer and advertise a range of services is critically important, says Shewaye Alemu, area manager for MSI in Addis, the Ethiopian capital. It means women can walk into the clinic without disclosing to the world whether they are seeking an abortion, she says.
But despite having one of the most liberal abortion laws in Africa, progress on expanding access to services has been slow, particularly in rural areas. If the Kirkos clinic shows what is possible under Ethiopia's new law, it is still the exception rather than the norm.
Some 200km from Addis, in the West Arsi zone of Ethiopia's Oromia region, the Buta health post stands in a small valley.
Inside, the walls of the small, two-room building are covered with hand-drawn tables charting community progress on vaccinations, malaria treatment, use of contraception, and other targets. Staffed by a small team of community health workers, the Buta post serves more than 4,000 people in nearby villages and is one of thousands of such facilities built by the government to extend services into rural areas.
But while women visiting the health post can get their children vaccinated, have contraceptive implants fitted and deliver babies a woman seeking an abortion would have to travel dozens of kilometres to find someone to carry out the procedure.
Staff at the health centre, 8km away, the next rung up in Ethiopia's multi-tiered healthcare system, say the person trained to provide abortions left a year ago and has not yet been replaced. Women who arrive looking for abortion information and services are referred to the public hospital or NGO clinic in the towns of Awassa (19km away) or Shashamane (26km).
Figures from 2008, the most recent statistics, suggest just 27% of abortions were safe procedures carried out in health facilities. Many women remain unaware of their rights, and where they can access services. Stigma around abortion also persists, particularly for young and unmarried women, and the quality of care available varies dramatically across the country. In 2008, only two-thirds of health facilities were sufficiently equipped to provide basic abortion care, treatment for post-abortion complications, and antibiotics; just 41% of the primary care facilities on which most rural women rely offer basic abortion services.
According to some human rights lawyers and public health NGOs, Ethiopia is a prime example of how controversy about abortion in the US continues to limit women's access to safe services, even in countries where it is legal. While reproductive health issues and efforts to end maternal deaths have risen up the agenda of aid donors, very few are willing to fund abortion. The largest global health donor, the US Agency for International Development (USAid) attaches anti-abortion restrictions to all of its foreign assistance.
"There is increasing recognition by the international community of the impact of unsafe abortions on maternal mortality. But funding does not reflect this," said Manuelle Hurwitz, senior advisor on abortion at International Planned Parenthood Federation.
US funding flaws
The Buta health post is part of a massive USAid programme, which aims to reach more than half the country's population and help reduce maternal and child mortality by supporting integrated family healthcare. The programme does not fund safe abortion – though it does support some services for women suffering health complications following unsafe abortions.
Pathfinder, the US NGO that implements the USAid programme in Ethiopia, says this is a "missed opportunity" and that it is actively looking for other sources of funding so that abortion services can be offered too.
"Any primary health clinic that doesn't provide abortions is a missed opportunity," said Demet Güral, a physician and vice-president of programmes at the NGO. Even if women have access to contraception, there are always failure rates, says Güral, and it is essential they can access safe abortion if needed. "Especially for youth; most are not married, they have a future. How can you talk about family planning for youth and not talk about abortion? It's nonsense."
While US president Barack Obama repealed the 'global gag rule', which prohibited foreign NGOs from receiving US funding if they performed or promoted abortion, anti-abortion restrictions remain attached to US foreign assistance through a relatively obscure and often misunderstood amendment, attached to the US foreign assistance act.
The Helms amendment, first enacted in 1973, says no US aid can go towards abortion "as a method of family planning" or to "motivate or coerce any person to practice abortions". What this means is open to interpretation, however. In practice, USAid has implemented the Helms amendment as an absolute ban on abortion.
Liz Maguire, CEO of IPAS, a US-based NGO, says Ethiopia is "one of the best examples" of how these restrictions can impact on women's lives. "Abortion is the most neglected area in women's health," said Maguire, who worked for USAid for decades and was head of its population assistance programme during the Clinton administration. "Here, what's sad is that women are being discriminated against because they live in areas with USAid funding."
Güral said it is a sad fact that most of the world's deaths due to unsafe abortions happen in developing countries, where US foreign aid is a critical resource. Many NGOs shy away from working on abortion because they fear the 'global gag rule' could return, or are confused about which specific services are allowed under the Helms amendment, she added. "On the ground ... we have a 'let's not go there' feeling. That's the chilling effect," said Güral. "Of course this is affecting the lives of women."
• Claire Provost travelled to Ethiopia with Pathfinder
According to some estimates, malaria accounts for between 13 to 50 % of preventable medical causes of absenteeism. Photograph: George Osodi/AP
In Ethiopia, over two thirds of the population are at risk of malaria. Unlike other sub-Saharan African countries, in Ethiopia, the transmission of the disease can vary significantly from one year to the next. Whilst several years may pass with relatively low levels of malaria, the country is prone to frequent and often large-scale epidemics.
The impact of epidemics is not only clear in hospitals and clinics but in schools too. According to some estimates, malaria accounts for between 13 to 50 % of preventable medical causes of absenteeism.
"Malaria is affecting the teaching and learning process in the school. The area is malaria endemic. Students get sick and are absent. Teachers also get sick and are absent from school. More is said about HIV in local media here but the impact of malaria is not less than HIV," explains the head teacher of Shinshicho primary school in Kembata Tembaro Zone, a malaria hotspot in the south of the country.
With support from Malaria Consortium and the Ethiopian federal ministry of health, Shinshicho primary school is one of 50 project schools in malaria hotspot zones across the southern regional state of the country that has established an anti-malaria club, with the aim of tackling low levels of awareness of the disease. The project, supported by the Global Fund to Fight Aids, Tuberculosis and Malaria, completed in 2012, but using the training and materials provided, teachers at the school have been running the club since.
Through the clubs, teachers and students learn about malaria, the signs and symptoms of the disease and how to prevent it. They discuss critical issues, such as how to use mosquito nets effectively and what to do if they, or a family member, show symptoms of the disease. Students get involved in spreading messages about malaria control, organising dramas for assembly time and parents days, and writing stories and poems.
"After having training and conducting the club, the awareness on malaria has increased and improved. We were able to know how to prevent malaria, how to use ITN and how to get treated early. So not only amongst the students, but even amongst the teachers there's been behaviour change."
With global efforts towards universal primary education, school-based initiatives are increasingly recognised as an effective means of reaching communities with information and advice about health.
"When we are teaching the students, we tell them to reflect, to pass this knowledge to the community. From our observation,in the community, awareness on malaria has improved. Our students are one of the contributors to this change."
This content is produced and controlled by Malaria Consortium
Elephantiasis can be caused by regular contact with volcanic red clay soil that irritates the skin. Photograph: Wellcome Trust
There are two principal causes of elephantiasis, or lymphoedema, in the tropics. The most common cause, and already known to be a significant public health problem, is lymphatic filariasis (LF). The other main cause is podoconiosis: a form of elephantiasis arising in barefoot subsistence farmers who are in long-term contact with irritant red clay soil of volcanic origins.
The disability associated with elephantiasis creates considerable stigma, and reduces productivity in patients. According to a study in Ethiopia, published by Tropical Medicine and International Health, the total direct costs of podoconiosis amounted to the equivalent of $143 (£88) per patient per year and a productivity loss of 45% of total working days per year.
Ethiopia recently launched its national master plan (2013-2015) for neglected tropical diseases, and podoconiosis and LF are two of the eight NTDs prioritised within it. In order to achieve the goals of this plan, health and development organisations will need a clear understanding of the geographical distribution and burden of the diseases. With that knowledge, they will be able to target priority areas and determine geographical overlaps among the disases to enable integrated control.
Elephantiasis is one of the NTDs with a clear potential for elimination. LF infection can be prevented and treated with a combination of medicines, while podoconiosis is easily preventable if shoes are consistently worn, and early stages can be successfully treated. For those who developed advanced disease of either cause there are proven ways to manage symptoms and prevent disabilities. Nonetheless control and elimination efforts can be hampered by a lack of information on the geographical distribution of the diseases.
One of the best ways to overcome this problem is by using integrated mapping. Mapping can help to identify populations at risk of diseases, indicate priority areas, target resources and help to monitor control progress.
A total of 136 health providers have come together into 34 teams to survey the districts throughout the country. Each team includes a health officer, two nurses and a laboratory technician. The teams all receive training on data collection and diagnostic tools from experts from Ehnri and BSMS. Each of the 34 teams select two communities per district [with district health offices] based on reported cases of elephantiasis from health facilities.
About 100 individuals from each community are then randomly selected and included in the study. LF is diagnosed based on immunochromatography tests, while podoconiosis is diagnosed by excluding other causes of lymphoedema, supplemented by antifilarial antibody tests. The data is recorded using mobile phones collection to overcome the costs and challenges posed by paper-based surveys. For example, copying, transporting abnd storing forms can be expensive, and manual data entry often brings around errors.
For integrated LF and podoconiosis mapping, text messages are used to report number of cases of diseases under surveillance, and to help encourage patients to take medications. A big advantage of using smart phones is that they have built-in global positioning systems (GPS) to instantly capture geographic co-ordinates, which otherwise would have been collected using external handheld GPS devices. Results can be electronically entered at the point of data collection, transferred to a central database and analysed immediately after collection by researchers in Ethiopia.
The integrated mapping data collection has not been without its challenges. First, there is no rapid diagnostic test for podoconiosis. The diagnosis is established by excluding other causes of lymphoedema, and at times this is cumbersome for health providers. Second, althoughaccess to mobile phones is rapidly growing in Ethiopia, not all districts have network coverage, which can result in a backlog of data from the field.
However, the multi-organistion partnership has brought together national and global experiences in mapping and use of technologies. The collaboration with Ethiopian health ministry through Ehnri is expected to enhance uptake and country ownership of health data and maps more broadly.
The maps will be available for decision makers at national, regional and district level through publication and online databases. This will allow the Ethiopian health ministry and partners working on LF and podoconiosis to plan properly and better target their interventions to eliminate the disease.
You can find pictures showing the different stages of the integrated mapping process in this gallery.