Labors of Love

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Every five-to-seven minutes in India, a woman dies in labor. Almost every one of these deaths-roughly 500,000 a year worldwide-is preventable. Suellen Miller and Stacie Geller are working to save these mothers' lives.

Globally, the largest cause of maternal death is obstetric hemorrhage, or excessive bleeding, which often occurs after labor. Most of the women dying are poor and live far from emergency medical care. The key to preventing hemorrhage is recognizing and treating it early. And central to that effort is a project developed by Suellen Miller and Stacie Geller, called the Continuum of Care to Prevent Postpartum Hemorrhage. Faced with what has been an intractable global tragedy, Miller and Geller have focused on low-tech solutions that show great promise in saving the lives of the developing world's most vulnerable women.Their work involves simple solutions, like the blood-collection drape that Geller helped invent, and the simple anti-shock garment that Miller is currently studying in the field in Zambia and Zimbabwe. The drape, tied at a woman's waist and hips after delivery, easily measures blood loss, while the anti-shock garment, made of two-way stretch neoprene, is fastened with eight Velcro closures around the woman's legs and torso to counter the effects of shock, which can result from postpartum hemorrhage. GOOD recently spoke to Miller and Geller by telephone about their work.GOOD: How did you, Stacie, come up with the idea of the blood-collection drape?SG: It was a team effort-it wasn't me coming up with it alone. We had a big [National Institutes of Health]-funded study as part of a global health network in India, way back in 2000-2001. We were testing the efficacy and safety of using misoprostol [an anti-inflammatory drug] to prevent postpartum hemorrhage for women delivering at home or in rudimentary health facilities. We had to be able to show the measurement of actual blood loss … So we took a plastic drape, which had been used elsewhere in the U.S., and we modified it. We changed the shape and we put calibrated lines on it. The [Auxiliary Nurse Midwives] liked it, not only because it was clean, but they called it a security blanket. It gave them a sense of how much the woman was bleeding, so they would have a faster sense of when to call for help and when to transfer the woman.G: How much does the drape cost?SG: Between $1 and $1.50.G: And Suellen, can you describe how the anti-shock garment works? SM: In shock, the body starts to overcompensate for the blood loss. The heart starts beating really rapidly, things get very cold in the extremities-the heart is working to keep blood in the heart, brain, and lungs. But at some point, one of the systems that fails is this anti-gravity system, and that's when blood starts pooling in the extremities-the feet, the legs, and the lower abdomen. The anti-shock garment overcomes that. You place it on, starting at the ankles, and push the blood that's been pooling down there up into and past the uterus and to the heart, brain and lungs.G: How quickly can it work?SM: Within minutes of being wrapped in a garment, a woman who has been unconscious will regain consciousness.G: What makes these devices unique?SM: Well, with the anti-shock garment, it's all there is. It's very unique; there's nothing else like it. And it's necessary. There's no first aid for shock, right now. So having something that's extremely easy to use, [people] can be trained in a very short period of time, it doesn't require any … medical education at all, it's pretty revolutionary.SG: I think the thing around the drape or any other tool, is it addresses one of the delays, which is recognition. So that's very important. And recognition when you are far from treatment is a critical piece. And with the shock garment, what it does is, it really buys time. And time is something that is critical to women who are getting transported and waiting for treatment.GOOD: What challenges do you see in using these devices throughout the developing world?SM: For the anti-shock garment one of the big hurdles is getting approval of it as an essential medical device by the World Health Organization and the other U.N. agencies…. And this is what we are doing in the study in Zambia and Zimbabwe. Another hurdle right now is that there is only one manufacturer and that manufacturer is charging us $170 per garment. That's a price that, most likely, even with donations, would be difficult to maintain at the kind of level at which it's needed-one in every village or one at every primary health care center.G: But the garment can be reused, right?SM: The cost per use is about $4, even at the $170 price, because it can be reused 40 times and in some places 50 times, depending on the length of time it has to be decontaminated.G: In India garbage-especially plastic garbage-is a huge issue. Is that something that you see as a challenge with the drape?SG: I don't agree that this is the way to cut back. This is a device that is relatively inexpensive and could be, in fact, used to help recognize early blood loss … decreasing morbidity and mortality. There are lots of other plastics that are used in India that may be the way to focus one's efforts.SM: And I think Stacie, as she's said, is very open to whatever is the most appropriate way of being able to alert women and families to early recognition. So if it's not plastic drape because the government won't allow plastic, we might be able to come up with another methodology.G: Both the drape and the anti-shock garment are really simple. How they can so effectively combat such a large global health and humanitarian problem?SG: I think the issue here is that they are part of a continuum. I'm not saying that the drape should be used and nothing else. I'm saying its part of a multi-faceted strategy to prevent, recognize and treat excessive blood loss.SM: I have the same exact sentiments about the garment. In and of itself, the garment will not save a woman's life; it has to be part of a system. That is why, one of the reasons, we joined forces and want to work together to make sure this continuum of care uses whatever methods possible.All photos by the author.--Suellen Miller is an associate professor and director of the Safe Motherhood Programs, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California San Francisco. Stacie Geller is the G. William Arends Professor of Obstetrics and Gynecology at the University of Illinois at Chicago, and the director of the Center for Research on Women and Gender and the National Center of Excellence in Women's Health. Pathfinder International, a U.S.-based non-profit, is now implementing the Continuum of Care they developed in India and Nigeria.