Editorial note: Maternal health care is often used as a primary measurement of the overall health of a community. In this article and throughout Solve’s work, we aim to respect self-identified language, with the understanding that patient-centered and affirming care are important elements for achieving health equity. As such, the term mother, birthing person, or a variation of these terms, are all used to capture the real and expansive experiences around pregnancy, labor and delivery, and postpartum care that our Solver teams engage in.
Although mothers and birthing people are essential to a thriving society, they often do not receive the care they require or deserve. One way of visualizing this inability to receive adequate care is through the Three Delays Model. The Three Delays Model holds that there are three steps in maternal health care where care is delayed:
A delay in seeking care
A delay in reaching care
A delay in receiving care
These delays can result in both maternal and infant deaths, as well as health complications. Three of our 2022 Solver teams are deploying solutions to the three delays as they solve maternal health problems around the globe.
The First Delay: Delay in Decision to Seek Care
Many people wait too long to seek prenatal care. This can be caused by many things including; financial implications, a lack of education on when they need to seek professional care, and societal issues like acceptance of maternal death or stigmas against maternity care.
Jacquelyn Ingram, Program Director of Healthy Mothers Healthy Babies and team lead of the initiative Mana Mama/Anax Angil, is diminishing this delay by providing education and resources on everything from Covid-19 vaccines to contraception options for women and birthing people in Hawaii.
“We have high premature birth rates, especially in non-white populations, so there is clearly a health disparity,” Ingram said. “You have to start peeling back the layers and asking; is this because of race, or is there inequitable access to food, education, and other resources?”
Mana Mama began operating during the pandemic, when Hawaii was one of the most restrictive places to live. “People were very isolated and especially, if it was a first time mom, they risked birthing alone. If they're [part of military families], maybe the spouses were deployed, and so it was just about getting information out there, and then kind of evolving again to what people needed. We started with food deliveries, then launching the mobile care van, and then going to the telehealth line.”
Maternal mental health services have become a large piece of Mana Mama’s operations, with perinatal mental health screenings integrated into the services they provide.
“We know other [places] are still lacking specialists, especially with maternal child health, which can include maternal mental health. The need for mental health access increased during the pandemic, and it has stayed like that, but a silver lining of the pandemic would be that telehealth is here to stay.”
“We created an initiative to use the midwives model of care, which is a very holistic way of looking at maternal health. It also encompasses the baby and not just pregnancy, but preconception, even into menopause and longer.”
Ingram and her team are also infusing cultural sensitivity into their work. There is a lack of access to Indigenous care teams, which can be problematic because often, a non-Indigenous provider will recommend practices, diets, or other things that are incongruent with that birthing person’s culture.
In order to create this innovative model of Indigenous-first birthing teams and resources, Mana Mama sought the expertise of local people within the communities they are working in.
“I think that will also reduce traumas related to birth. With the Indigenous too, I think we have to keep ceremony and culture into birth,” Ingram said.
Ingram says the most impactful part of the Mana Mama solution is the wealth of knowledge and support it can provide to a mother reaching out for just one service.
The Second Delay: Delay in Reaching Care
The second delay in maternal health care deals with the physical challenge of transporting a mother to a care facility to receive medical attention. This is made very difficult, especially in rural and low-income areas, by long distances to health centers, high costs of transportation, tough terrain, and poor transportation infrastructure.
“We've seen that there are not very many organizations working on the second delay, and that if the first delay is being improved, and the third delay is being improved, if the second delay is not taken care of, then they still are split apart from each other,” said Emily Young, Co-Founder and CEO of Moving Health, a medical transport solution currently operating in Ghana.
Solving the second delay seems straightforward—it’s all about transportation, but there is the added difficulty developing a mode of transportation with the tools to navigate tough terrain and travel long distances.
"In our initial market research to understand the most common problems for rural communities, this connection to the health facilities was often the root of a majority of issues,” Young said.
Like Ingram, Young is using community-centered design to perfect her solution while empowering the communities that eventually use and own the ambulances.
“What was really important for us was making sure that our design was something that communities trusted, that they actually wanted to see, and that they also felt ownership in the design and really wanted to be using it. We interviewed about 250 stakeholders; community health workers, traditional birth attendants, women that had been pregnant, community leaders, and we heard a lot of stories about how bad this problem is. There's no ambulance system that's reliable in these rural areas. It is common that women end up walking many kilometers to get to a hospital that can provide them the services they need. Though it is dangerous and painful, there is no other option.”
In addition to including the community in the design of the solution, Moving Health has designed a maintenance plan with a local fabrication team.
“We really wanted to not only have Moving Health be about health care and improving health outcomes, but also about community and economic development as well. We wanted to show that you can make vehicles like this with the local manufacturing that's available in the country. Not only does this create job opportunities, and economic growth, but it also creates a really strong maintenance network for the ambulances. This means we don't have to deal with the very common situation of an imported product going out of commission because nobody knows how to fix it.”
Though the Moving Health ambulances are used for all kinds of medical emergencies, Young and her team focused specifically on designing it for birthing mothers.
“One of the biggest reasons that we've always wanted it to be very maternal health focused is because so many complications, and so many deaths related to pregnancy are preventable. 90% of deaths related to pregnancy are preventable if you can get to the right health care. In so many parts of the world, the right health care does exist, it just might be far away from you, so there's this huge gap in transportation.”
To date, 50% of the rides that Moving Health has provided were pregnancy-related. "We are happy to see that Moving Health Ambulances have led to more successful births, which has increased the amount of trust that the communities have in our ambulances,” Young said.
The Third Delay: Delay in Receiving Adequate Health Care
Once birthing people reach medical facilities, there can still be a critical delay in receiving the care they need due to poor facilities, lack of medical supplies in facilities, inadequately trained staff, and inadequate referrals to other types of care.
At a teaching hospital in Nigeria, Executive Director and Founder of We Care Solar, Laura Stachel MD, DrPH experienced the third delay firsthand while conducting research there as a graduate student.
“The state hospital was really limited in what they could offer. They didn't have a lot of technical machinery. They didn't have things like mattresses on the beds in the triage area. They didn't have an electronic fetal heart rate monitor for the babies. They didn't have incubators that worked, but the thing that also really impressed me was that they didn't have electricity for 12 hours each day.”
“Without electricity they were really limited in who they could admit and what they could do. Sometimes at night, when there was no power, even if someone came to the hospital door bleeding, they would send them away because they didn't have a way to take care of the problem. If someone needed something like a cesarean section, without having electricity, you couldn't call for someone to help, you had to look around and physically try and track down a doctor. You didn't have lights to turn on the operating theater, you didn't have power for the machinery in the operating room. So there were tremendous delays in getting procedures done and sometimes they wouldn't be done at all until the next morning if there was no power.”
The We Care Solar’s initiative to solve this electricity issue is called Light Every Birth. Solar suitcases equipped with light sources and other life-saving devices are deployed in rural and underserved communities in Africa.
The first time Stachel brought a prototype solar suitcase to a hospital, feedback from the staff was overwhelmingly positive.
Stachel recalls that the locals asked her to leave the solar suitcase, although she had plans to bring back a bigger system, they pleaded with her for the prototype. “They said to me, ‘You don't understand, this can help us save lives right now.’” Stachel said.
Stachel’s solution evolved over a span of about two years as the team collected feedback from the communities and health workers implementing the solar kits.
“We saw people needed really good lights. They needed lights for surgeries and they needed lights for deliveries,” Stachel said. We Care Solar also added cell phone chargers, headlamps, fetal dopplers, and infrared thermometers to the suitcases.
After using the original solar kits for several years, the team revamped the model with newer battery technology and stronger lights designed by the team to last about 70,000 hours.
“Our programs now not only bring technology, but they actually train people to do installations. We send in all the hardware needed for installation as well as a set of tools including retractable ladders, cordless drills, and sturdy tool bags filled with equipment, because it's so hard to obtain high quality tools in some of the countries we work. It's part of really understanding the context of the people we serve.”
In addition to empowering the community and creating jobs, the Light Every Birth solution has also had an impact on the morale of health workers within the communities they work with.
“One of the things that hadn't necessarily occurred to me when I started is how demoralizing it is for health workers to be in a health facility at night when they don't have light. It's scary. They feel like they can't do the thing that they were trained to do. It is so fulfilling to see the kind of joy and the pride that [health workers] have once they have reliable electricity. We find that many of them tell us that many more patients can come for care than before. It seems to uplift care, even though it's a very limited amount of power. When we bring light and power into a health facility that hasn't had that, it is absolutely transformative,” Stachel said.
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