Maternal health interventions among IDPs in eastern Burma: Blood Transfusion

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Maternal health interventions among IDPs in
eastern Burma Blood Transfusion
The MOM ProjectMobile Obstetric Medic

• Thomas Lee, MD MHS
• Director, Global Health Access Program (GHAP)
• Adj. Associate Professor of Medicine, UCLA School
  of Medicine
• Luke Mullany, PhD
• Director, GHAP Monitoring and Evaluation
• Assistant Professor, International Health /
  Center for Public Health and Human Rights
• Kate Teela, MHS
• MOM Project Coordinator
• Funding Bill and Melinda Gates Institute for Pop
  and RH

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Eastern Burma Context

• Minimal accessCBOs only
• HRVs and conflict 600k-1,000k IDPs
• Limited mobility, long transit times
• IMR 91, U5MR 221, MMR 1000-1200

Lee T, Mullany L, et.al. TMIH 2006
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MOM Project Rationale

• Ethnic minority CBOs
• No bricks and mortar
• Mobile clinics and backpack teams
• Health workers
• Adapt RH interventions to existing service
  delivery models
• Emphasis on mobility of providers to bring
  services to communities
• Community-based providers with variable skill
  setstraining based on intervention

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MOM Selected Interventions

• BEOC
• Kiwi, MVA, Magnesium, Misoprostol, Antibiotics,
  Manual removal placenta
• Focused ANC
• Deworm, ITN, Malaria Screening, Fe/FA
• Clean Deliveries, PNC, Family Planning
• Transfusion

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3-tiered provider network

• Maternal health workers (MHW)
• 8 months training in RH department
• Complex services (such as transfusion)
• Health workers (HW)
• Some BEOC, ANC/PNC
• Traditional Birth Attendants (TBA)
• Link between community and MHWs/HWs
• Some basic services

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Transfusion Needs High

• Trauma landmine-specific mortality rate 1/1000
  persons/yr
• Falciparum malaria prevalence gt10
• Malaria cause of death gt40
• Maternal anemia gt60 (Hglt11)
• PPH leading cause of maternal death

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Transfusion ProgramKey Components

• Rapid diagnostic tests for low resource settings
• Walking Blood Bank concept
• Blood taken from donors at time of need
• Community Education
• Program acceptance, Donor Recruitment

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TransfusionTechnical Issues

• Rapid Diagnostic Tests
• Heat stability
• Capillary blood vs plasma (centrifuge)
• Adequate sensitivity
• No cross-matching (Type-specific)
• Blood typing

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Walking Blood Bank

• Donor list and map with blood types
• Donor recruitment during ANC standby during time
  of delivery
• Not anonymous
• Counseling/treatment for screened diseases

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Donor screening

• Sequential testing
• avoid testing for less treatable or more
  stigmatizing diseases
• resource conservation
• Simultaneous testing for emergencies
• Goal of screening is blood safety, not
  necessarily diagnosis

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Conclusions

• Rethink appropriateness of limiting transfusion
  to referral centers (Basic vs. Comprehensive
  dichotomy)
• Transfusion may be easier than some elements of
  Basic EmOC
• Mobility of service provision to the population
  rather than centralized services accessed by the
  population
• Flexibility in toolkit for different types of
  providers

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Kiwi problems

• Technically challenging for health workers
• Inadequate training time
• Kiwi mechanical problems
• Connection between pump and cup breaks too easily
• Suction decreases with reuse
• Belt loses consistency (too elastic) after
  decontamination
• Too many pieces (multi-use model)

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Future Avenues

• One-sample donor screening test
• Black-box donor screening test
• safe or unsafe
• Heat stability studies

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Thank you

• Partners
• Burma Medical Association
• Karen Department of Health and Welfare
• Shan Health Committee
• Karenni National Health Organization
• Mon Health Department
• Mae Tao Clinic
• Colleagues
• Palae Paw
• Lin Yone
• Eh Poh
• Eh Kalu Shwe Oo
• Cynthia Maung
• MOM Administrative staff
• Technical Advice/Oversight
• Luke Mullany
• Catherine Lee

• Funders
• Bill and Melinda Gates Institute for Population
  and Reproductive Health
• Hussman Foundation
• Foundation for the People of Burma
• Global Health Access Program
• Burma Border Projects