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LESOTHO

Saving mothers

Concord native works to cut maternal mortality in Africa

The pregnant women who till the soil and plant the seeds will not be there to gather the harvest. The small garden will feed other women like themselves later, women who stay at the house in Nohana, Lesotho, for two or three weeks, waiting to give birth.

By donkey, by horse, or more often, by foot, they have trekked for hours from their homes in the isolated mountains of the southern African country to spend the last few weeks of their pregnancies in closer proximity to medical care.

They are not just tending a garden but helping turn around a deadly statistic in their country.

Halfway around the world, in an office in Boston, a Concord High School graduate works to support the waiting-in house for expectant mothers, and other missions to improve health services in Lesotho.

When Jennie Riley graduated from Concord High in 1995, she had no idea she would end up in a job that sends her to a tiny African country four times a year. She only knew she liked biology class.

Years later, after stints at a laboratory in Seattle and an immigration law firm in Boston, she received a master's degree in law and diplomacy from The Fletcher School at Tufts University, with a focus on global health and development economics.

The impact of maternal mortality can be hard to measure but impossible to ignore, she said.

"There's something you cannot quantify about the loss of a mother, on her children, her family and her community," she said. "The emotional toll that takes at its most basic level, that is hard to quantify, but it has an effect on everyone."

Between 1990 and 2008, the global maternal death rate dropped by more than 30 percent. That's good news for pregnant women in countries such as Mozambique and Rwanda, where the rate fell for the first time since it's been studied, according to the World Health Organization.

But for mothers-to-be in Lesotho, the news is more grim.

A nation of about 2 million people, Lesotho was one of the handful of countries where the death rate increased during that span.

In 2009, 1,155 women in Lesotho died during or shortly after childbirth per 100,000 live births.

Six years ago, Boston-based nonprofit Partners in Health joined the Lesotho government to rehabilitate and support clinics in the country's rough, isolating mountain terrain. It started with one clinic, and expanded gradually to seven.

In 2009, the group launched a pilot project, reaching out to pregnant women through traditional midwives, hoping to test and treat them for HIV and tuberculosis and give them access to vital prenatal care.

 'A moral reason'

 

Riley joined Partners in Health in January 2010.

"There's a moral reason we should invest in women's sexual and reproductive health, because no woman in Lesotho should die of something that here, I would get high-quality medical treatment for. . . . But there is also an economic piece," she said.

"Children who lose their mothers are less likely to go to school and less likely to finish if they do go. They are more likely to be malnourished, to face more challenges and more likely to have poor outcomes."

Even if a woman doesn't die in childbirth, a difficult birth or any traumatic medical event can be devastating for a family living on less than $2 a day, she said.

"It causes ripple effects from one family to entire communities to a country," she said.

Riley works in Boston at the Partners in Health headquarters, arranging the budget, writing grants, securing supplies and arranging complicated deliveries. All of the program's services are free of charge to the women in Lesotho.

Once a year, Dr. Hind Sati, the program leader from Lesotho, visits Boston for a series of meetings updating the staff on work that's being done and planning for the next year.

Sati, who was in Boston for those meetings last week, has been with the program since the beginning. Born in Sudan, Sati's mother died of kidney failure when she was 7, likely tied to excessive bleeding after giving birth to one of Sati's younger siblings.

After becoming a doctor, Sati spent a year providing dialysis treatment in other parts of Africa. Then she moved to Lesotho and was confronted with a more devastating epidemic.

 Deadly cycle

 

Lesotho has the third-highest HIV infection rate in the world. Almost 25 percent of the country is infected, and more than 75 percent of them don't know it.

HIV, when paired with inadequate prenatal care, creates a deadly cycle, Sati said.

"If mothers are not accessing health services, they will not even know they are HIV positive, and they will go on and transmit it to their baby," she said. "Or, the mother will lose her child and try to compensate for that by having another pregnancy, and her risk for dying increases, and the cycle will continue."

Most women in the country choose to give birth at home, sometimes with a midwife present. They live hours from the nearest hospital, so if something goes wrong, there is often no help.

Even if they start the journey at the beginning of their labor, Lesotho's terrain makes the journey not just long, but treacherous.

The lowest point in the entire country is 4,500 feet above sea level, higher than all but the highest peaks in the White Mountains, and many villages are tucked on the sides of mountains much higher.

"Imagine you lived in a small village in the Presidential Range, and that in order to access health care, you had to walk three to five miles in that kind of terrain," Riley said. "It's very beautiful in geography and terrain, but it forms really big challenges."

Partners in Health has created a training program for midwives and now employs many as ambassadors for the clinics. They receive a monthly paycheck for finding pregnant women in their communities and arranging for them to go to the clinic for a prenatal examination. The exam includes testing for HIV and tuberculosis.

If the mother is infected with either disease, the clinic is equipped to treat her and ensure she doesn't pass it to her baby. Women from the farthest villages are encouraged to spend the last few weeks of their pregnancies at the waiting-in houses near the clinics, so they don't have to make the journey during labor.

"The women build some relations with each other, coming from different villages and working to care for the house together," Sati said.

The gardens like the one in Nohana are a picture of their cooperative work, she said.

"They know in two weeks they cannot grow anything for themselves, but they do it for the clinic community."

 Gradual change

 

Those mothers are also more likely to bring their babies and other children to the clinic for vaccinations and testing for malnutrition and anemia. Some of them will talk with women there for their first prenatal visit, encouraging them to come back for their deliveries, she said.

"In the beginning, people were doubtful if was going to work," Sati said, but the first step was talking with chiefs in the rural mountain villages about what challenges their people faced.

"The question actually brought a lot of examples of the chiefs tell us how many women died in childbirth. Then we could make the link that if you provide them with services and skilled midwives, this is all preventable deaths, and it will not happen any more," she said.

Since then, "what we've seen is a gradual transformation of engaging with the health center staff, the village chiefs and the communities to have conversation about the fact that women were dying and we all wanted together to make this stop," Riley said.

The whole project - seven clinics, one hospital, the waiting-in houses, HIV and TB testing, and gift baskets of baby clothes, pins and a bathtub for women who get tested for HIV, attended at least three prenatal visits and deliver their baby at the clinic - costs about $1 million a year, and that funding also provides some general primary health services at the clinic.

It was first funded by a grant from the Elton John AIDS Foundation UK, and expanded with support from the Positive Action for Children Fund, UNICEF, private donations and family foundations.

The government of Lesotho provides funding for some of the nursing and professional staff, medicines and supplies that include drugs for treating HIV and TB, and family planning services.

Within five years, the first clinic where Partners in Health worked went from delivering two or three babies each month to almost 40 last August. That's all of the babies that can be expected in a month in the area that clinic serves, Riley said.

"We think we are reaching every woman who should be served by that clinic, and that's incredible, but that's one clinic," she said. "Now that we are showing that this can be done, we want to hit the same target in all the health centers."

But that is still only seven clinics, only serving some of the population, and the women leading this effort said they won't rest there.

"I think the longer-term issue is working with the government to expand the program much more widely within Lesotho, working with organizations and governments in other countries to implement similar programs. . . . I don't know if there is ever a moment when we are going to rest and say we've succeeded," Riley said.

"When it comes to women's health and their health and survival during childbirth, we're not going to sit back and say we've done our part."

(Sarah Palermo can be reached at 369-3322 or spalermo@cmonitor.com.)

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