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Learnings from Tackling Maternal Mortality

Approx Reading Time: 5 min.

I’ve spent my quarantine developing an intervention to solve a global problem that could impact hundreds of thousands of women.

With my team of 17-year-old friends, we’ve created a distribution system for misoprostol (a postpartum hemorrhage drug) in Jigawa, Nigeria. To learn more about the project implementation, visit our website or read my last post. Our goal is to reduce the number of deaths due to postpartum hemorrhaging, the #1 cause of maternal mortality.

When we started our project, we were just young girls with a strong curiosity (and frustration) towards maternal mortality. It’s turned into so much more than just a “research project.” We’re now working on implementing it on-ground to save lives. [1]

I’ve been the project manager [2]. There have been so many times when our team was swamped with ambiguity. Our goal was pretty audacious: end maternal mortality.

I’m seriously so grateful for my awesome-sauce team (Navya Ruji, Shifra Khan and Ruhani Walia), and our friends Stephanie Porfiris and Christina Wang for contributing to this project.

This is a collection of some of the takeaways from this experience so far.

The Good

The Mentorship

I have no words to describe how thankful we are for the support we’ve gotten throughout this process.

People have been so kind sharing their time and experiences. Nothing would have been possible if not for all the thoughtful, brilliant experts who have connected with us. They’ve helped uncover our blindspots, guide us through legal barriers and shape the methodology of the project.

We’ve been able to build a network of experts to advise this project and provide feedback to strengthen it.

It’s too easy to get tunnel visioned. Having a strong support network helps create a more thoughtful plan.

We’ve been able to build a network of experts to advise this project and provide feedback to strengthen it.

Local Support

The on-ground support has been phenomenal. Our network of people has allowed us to connect and discuss implementation with key stakeholders like the Ministry of Health in Jigawa State, Nigeria.

Long-lasting systematic change comes from the ground-up. Having local support aids us in turning this “project” into a sustainable project that could last decades.

Developing Team Culture

Like I mentioned, I have an awesome-sauce team. We’ve built a culture that is results-driven, organized and feedback-centric.

We’re all breathing the mission of helping and empowering women. It’s such a passionate, dedicated team of women. My heart fills with joy every time we work together to achieve a new milestone, identify a new loop-hole or come up with a novel strategy.

I love that we’re learning and iterating together.

I’ve read a lot about how team culture is important. But now that I’ve experienced it, I understand how crucial it really is.

Starting to Get Interest Beyond Jigawa, Nigeria

In a nutshell, our project aim is to create a micro-business selling misoprostol among untrained healthcare workers in rural areas of Nigeria. We’ve really narrowed our focus to executing on a successful pilot in Jigawa, Nigeria. However, in the process of connecting with friends, mentors and experts we’ve already received interest in scaling the concept.

People want to spread it globally to the Congo, Uganda, Across Nigeria, Haiti, India, Pakistan Kenya, Zambia and more.

A large organization expressed interest in scaling our training curriculum around the globe. Other NGOs want to use a similar distribution model. Some people want to bring this into their local community/hospital/town.

This project is about global health for humankind. Right now we have the health part, but it looks like the “global” part isn’t so far away.

While we’re currently focusing on executing a pilot in Jigawa, Nigeria, I’m thrilled to see where this goes.

The Hard

Note: “hard” doesn’t mean “bad.” These are the challenges we’ve had, but we love challenges. And we expected challenges. Just because a lot of maternal mortality causes are preventable doesn’t mean it’s simple to solve: and simplicity isn’t a good reason to solve a problem. We should fall in love with the complexity of these problems and embrace the difficult aspects.

Not Being Located On-Ground

My team is from Canada. This country is very different from Nigeria. The culture is different. The economy is different. The weather is (very) different.

A global pandemic + underaged young girls make travelling to a rural part of Nigeria very difficult. This leads to a loss of perspective and lots of wrong assumptions. We tried to make up for that by connecting with as many people from Nigeria as possible. We now have an advisory network of Nigerian global health professionals, doctors and lawyers to provide their input on the protocol development.

For example, when thinking about drug storage it didn’t even cross our mind that hospitals might not have electricity to have air conditioning. And because it gets really hot, a non-air-conditioned hospital will be too hot for some drug storage. We overcame this by identifying ways to store the drugs without electricity during the hot weather.

We don’t know what’s best for Nigeria. But we can ask questions, and validate our assumptions with people who do know what’s best. We don’t learn anything new from talking, but we do from listening.

I’m so beyond grateful for all the kind support on-ground.

But, if I could wave a magic wand, I’d want to talk to as many people on-ground as possible. I’d immerse myself in the environment. I’d try to really really really understand the status quo of maternal health. It’s easier to talk to people on-ground when you’re on-ground (plus, there’s less network and connectivity breaks 😅).

This isn’t about us Canadian girls going in to change the system. It’s about us understanding the system and helping the community strengthen it. That’s the only way to get sustainability: if we become easily replaceable. If an on-ground community can continue operating the project without relying on grants/external support, it’s more likley to last decades vs just the period of the pilot.

Bringing oneself as close to your “customers” as possible is the most important aspect of a successful intervention. We want it to help the people, not harm them.

If the opportunity ever works itself out, going to our on-site location before our pilot in 2021 would help us identify holes in the plan before it even happens. This will help us learn from mistakes we could have avoided.

Environmental Constraints

Maternal mortality, overall, is a very complicated issue. Women are dying from a multitude of issues. It’s not a problem exclusive to the developing world. The US is an example of a developing country where maternal mortality rates are increasing.

But it becomes much more difficult to tackle in an environment with many constraints. Specifically educational and economic constraints. [4]

Educational Constraints:

Many stakeholders in our implementation plan are illiterate.

This makes it difficult to design training programs or build technology to facilitate the intervention. We’ve had to think really outside of the box to consider usability and feasibility while achieving the targets of the intervention.

For example, many people who play important roles in the implementation of our proposal are illiterate. We had to redesign pictorial explanations and training that were both culturally appropriate and effective in their communication.

Another example is designing a digital data collection system in a low-tech environment. We’ve had to consider challenges around devices available, what to do with a network failure, etc.

Simple, almost always, is better. Why? Because it is easier to execute. Execution produces results. Ideas don’t produce results.

Note: it’s not easy to make things like “prescriptions” or “inventory tracking” or “medical knowledge” simple. The hardest part about this project hasn’t been deriving the actual intervention / method. It’s been simplifying it.

Economic constraints:

Not surprisingly, the poorest places in the world are generally the ones with the highest maternal mortality ratios.

In order to save a lot of lives from maternal mortality, we’re probably working with women living in or very close to extreme poverty.

At first, our intervention cost about $2 USD (per birth). From local feedback, we were told it needs to get below $0.5, ideally below $0.15 to be potentially feasible.

The low economic incentive makes creating a profitable (and sustainable) initiative much more tricky. And again, we have to get really scrappy and creative. But that’s what needs to be done to save lives.

Staying Within Project Scope

Maternal mortality is a big, interconnected issue. Every solution seems to lead to another problem.

For example, women might have trouble finding transport to get to a hospital. If we solve the transport problem, the hospital itself might not have enough staff to handle emergencies, which leads to another issue. It feels like a never-ending cycle of gaps in the system.

Choosing what to focus our project on, and continually refining the scope has been tough. There’s too much optionality. Too many possible ideas. Not enough execution.

At some point, we need to accept that the pilot can’t do everything. Yes, women will still have problems getting ultrasounds during their pregnancy after our pilot. And it will still be hard to reach the general hospital 100 km away. And babies will still die because there is no training on avoiding infections after delivery.

But our pilot will reduce the amount of postpartum hemorrhaging in the area by 85-90%, which is the #1 cause of maternal mortality. We will train health workers on post-birth protocols and basic newborn health. We will help local women make a small profit from distributing this life-saving drug.

Dispersed activities today bring dispersed results tomorrow. Focused activities today bring focused results tomorrow.

Do less to achieve more.

Understanding our Long-Term Vision

Most projects I’ve worked on have had a pre-defined timeline or deliverable. They all (generally) had a termination date. When we started this, we didn’t know what direction it would go in, how long it would last and so on.

There has been ambiguity with where we see this all going and with what we want this to become beyond our pilot in 2021.

Many people have encouraged us to think about the vision, mission and values of our project. It’s been novel and confusing to try and take an ultra-long-term approach - to try and envision what we can do beyond just distributing misoprostol in Nigeria.


This project is a step towards creating healthcare powered by local communities and accessible to everyone.

Footnotes

[1] Implementation will consist of implementing our postpartum hemorrhage training curriculum across a local government area in the state to train health workers, and supplying local hospitals with misoprostol at a subsidized rate.

[2] I’ve learnt so much about working with others and empowering teams throughout this experience (and I have still sooooo much to learn). I might write about that soon if I get enough email suggestions.

[3] There are constraints in every environment, but these tend to be particularly extreme/unfamiliar. One constraint I did not mention is culture because I’m not sure if it should be called a “constraint.” I don’t think it’s fair to impose a way of life (e.g. Western) and to call a society’s way of life a “constraint.” Culture can live in coexistence with health and prosperity.


Special Thank Yous ❤️

Maternal mortality is a societal, systematically rooted and complex situation. No one person or team will solve this epidemic of dying mothers. Progress wouldn’t and won’t be possible if it wasn’t for everyone who has helped so much this far. Thank you especially to all of these rockstars:

Dr. Ahmed Sarki, Dr.Babatunde Fakunle, Maryam Ahmad, Isah Muso Ayo, Dr. Victoria Adepoju, Navid Nathoo, Saleema Khimji, NkasiObim Nebo, Nsikakabasi George, Sodiq Ade Balogun, Tolulope Oyekanmi, Ruth Ayi Ofuka, Umar Mantu, Usman Inuwa, Dirjke Jenson, Neelie Kroes, Danielle Salisbury, Mehreen Shahid, Sayantan Chowdhury, Dr.Aminu Baffah Muhammad, Dr.Hasan Ul Bari, Lisa Gullbransson, Dr.Ameen Ali, Samantha Lobis, Dr. Seun Aladesanmi, Jennifer Brown, Christiane Boeck, Jimmy Rollins, Funke Fasawe, Badiya Magaji, Mohammed Ibrahim, Sani Abubakar, Zainab Mohammed, Bukar Zarami, Oluwaseun Aladesanmi, Hauwa Abbas, Blessing Chiroma, Babasola Oluwafolakemi, Ayokunle Ogundipe, Barbara Shitnaan Maigari, Valkamiya Ahmadu-Haruna, Taiye Fadayini, Gozie Ezeobi, Queen-Amina Biobaku, Rachael Peters, Jessica Barnes, Jennifer Kirkey-Chan, Karen Hobday, Muhammad Sani Suleiman, Zulaikhah Agoro, Cindy Filiatrault, Nene Akintan, Justina Joshua-Eke, Amoura Zynga, Alobo Gabriel, Alice Namuli Blazevic, Demba Ahmad, Aishat Adeniji, Madhav Malhotra, Farah El Siss, David Ye, Leah Sepiashvili, Odile Bartlett, Tim Mutto, Laura Lima, Frances Low and all my friends for supporting us 💖.

Thanks to Madhav Malhorta, Eesha Ulhaq, Makayla Atkins, Adam Majumdar, Shifra Khan, Navya Riju, Ruhani Walia and Kiran Mak for reading drafts of this.