1. Maternal health interventions among IDPs in eastern Burma: Blood Transfusion 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 The MOM Project: “Mobile Obstetric Medic”

2. Eastern Burma Context Minimal access— CBOs only Minimal access— CBOs only HRVs and conflict: 600k- 1,000k IDPs HRVs and conflict: 600k- 1,000k IDPs Limited mobility, long transit times Limited mobility, long transit times IMR 91, U5MR 221, MMR 1000- 1200 * IMR 91, U5MR 221, MMR 1000- 1200 * *Lee T, Mullany L, et.al. TMIH 2006

3. MOM Project Rationale Ethnic minority CBOs Ethnic minority CBOs –No bricks and mortar –Mobile clinics and “backpack” teams –Health workers Adapt RH interventions to existing service delivery models Adapt RH interventions to existing service delivery models –Emphasis on mobility of providers to bring services to communities –Community-based providers with variable skill sets—training based on intervention

4. MOM Selected Interventions BEOC BEOC –Kiwi, MVA, Magnesium, Misoprostol, Antibiotics, Manual removal placenta Focused ANC Focused ANC –Deworm, ITN, Malaria Screening, Fe/FA Clean Deliveries, PNC, Family Planning Clean Deliveries, PNC, Family Planning Transfusion Transfusion

5. 3-tiered provider network Maternal health workers (MHW) Maternal health workers (MHW) –8 months training in RH department –Complex services (such as transfusion) Health workers (HW) Health workers (HW) –Some BEOC, ANC/PNC Traditional Birth Attendants (TBA) Traditional Birth Attendants (TBA) –Link between community and MHWs/HWs –Some basic services

6. Transfusion Needs High Trauma: landmine-specific mortality rate = 1/1000 persons/yr Trauma: landmine-specific mortality rate = 1/1000 persons/yr Falciparum malaria prevalence >10% Falciparum malaria prevalence >10% Malaria cause of death >40% Malaria cause of death >40% Maternal anemia >60% (Hg 60% (Hg<11) PPH leading cause of maternal death PPH leading cause of maternal death

7. Transfusion Program Key Components Rapid diagnostic tests for low resource settings Rapid diagnostic tests for low resource settings “Walking Blood Bank” concept “Walking Blood Bank” concept –Blood taken from donors at time of need Community Education Community Education –Program acceptance, Donor Recruitment

8. Transfusion Technical Issues Rapid Diagnostic Tests Rapid Diagnostic Tests –Heat stability –Capillary blood vs plasma (centrifuge) –Adequate sensitivity No cross-matching (Type-specific) No cross-matching (Type-specific) Blood typing Blood typing

9. “Walking Blood Bank” Donor list and map with blood types Donor list and map with blood types Donor recruitment during ANC: standby during time of delivery Donor recruitment during ANC: standby during time of delivery Not anonymous Not anonymous Counseling/treatment for screened diseases Counseling/treatment for screened diseases

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

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

13. Kiwi problems Technically challenging for health workers Technically challenging for health workers Inadequate training time Inadequate training time Kiwi mechanical problems 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)

14. Future Avenues One-sample donor screening test One-sample donor screening test “Black-box” donor screening test “Black-box” donor screening test –safe or unsafe Heat stability studies Heat stability studies

15. Thank you Partners Burma Medical Association Burma Medical Association Karen Department of Health and Welfare Karen Department of Health and Welfare Shan Health Committee Shan Health Committee Karenni National Health Organization Karenni National Health Organization Mon Health Department Mon Health Department Mae Tao Clinic Mae Tao ClinicColleagues Palae Paw Palae Paw Lin Yone Lin Yone Eh Poh Eh Poh Eh Kalu Shwe Oo Eh Kalu Shwe Oo Cynthia Maung Cynthia Maung MOM Administrative staff MOM Administrative staff Technical Advice/Oversight Luke Mullany Luke Mullany Catherine Lee Catherine Lee Kate Teela Kate Teela Nicole Franck-Masenior Nicole Franck-Masenior Chris Beyrer Chris BeyrerFunders Bill and Melinda Gates Institute for Population and Reproductive Health Bill and Melinda Gates Institute for Population and Reproductive Health Hussman Foundation Hussman Foundation Foundation for the People of Burma Foundation for the People of Burma Global Health Access Program Global Health Access Program Burma Border Projects Burma Border Projects