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Borderline Health

Borderline Health

Borderline Health (continued)

By Cathy Shufro

The survey team has already completed baseline and midpoint surveys. Because eastern Burma generally has no postal system and surveys must be returned by hand, the final surveys will "trickle back," says Teela. They will be delivered by medics from other health programs who are passing through MOM villages en route to Mae Sot, which is home base for many cross-border projects.

The fact that she and Mullany can't directly supervise the surveyors complicates the task of controlling the quality of data. For instance, Teela and Mullany noticed that mortality rates for one area were triple the rates elsewhere. When Teela got a chance to talk to the surveyor, months later, she found that the surveyor had misread the question. Instead of asking how many people had died in a household in the past year, she had asked if anyone had ever died. Those numbers could not be used.

"We do our best to have these amazing trainings, but when it's done, we just have to hope the surveyors got what we'd hoped out of it and that they go back and do the best job they can," says Teela.

She and her colleagues monitor security conditions every two weeks, mostly by word of mouth. When villages are invaded, supplies that are lost or destroyed must be replaced. Sometimes data sheets are lost, too. "If a site has security problems for three months, it may explain why we have so many fewer pregnancy record forms than usual," says Teela. Despite all these logistical challenges, the project managed to get a 98 percent return on the midpoint survey.

Mullany and Teela are reluctant to judge the effectiveness of the MOM Project before the final surveys are evaluated. In any case, the surveys don't try to gauge changes in maternal mortality rates; the numbers are too small, says Mullany, because even where rates are high as in eastern Burma, from a statistical standpoint maternal death is rare. But he says that access to care can serve as a proxy for changes in survival rates. And access has dramatically increased: At the start of the study, 60 percent of women giving birth had no attendant at all, and only 5 percent had a skilled birth attendant comparable to a senior maternal health worker. Eighteen months into the project, more than half the women surveyed had given birth with help from a midlevel or senior maternal health worker.

MOM's director of training, Palae Paw, notes that this is the first program to systematically provide emergency care to pregnant women in eastern Burma. "They feel like their lives and their newborns' lives are more valued," she says. Mullany feels confident that the approach merits adoption elsewhere. "Expanding the level of skill of people working directly in the community is a model worth pursuing," he says.

The pilot project will be complete once the final surveys are evaluated, but the MOM project will continue. The Mae Sot-based Burma Medical Association will manage the program, and expand it, with funds from nonprofit groups in Thailand and beyond.

This kind of collaboration will continue even after the fall of the military regime in Burma, says Eh Kalu Shwe, the secretary of the Karen Department of Health and Welfare. When that day comes, he says, "We will invite GHAP people and Johns Hopkins University people to consult for public health and primary care for the people of the new Burma."

BY THE TIME Naw Tha Mu and the others reached the woman's side that late afternoon in April, she had suffered two more seizures. Naw Tha Mu gave her a magnesium injection to stop the seizures and nifedipine to bring down her blood pressure. Naw Tha Mu knew that the best treatment for eclampsia is to get the baby out, but she wanted to take her patient to the clinic, where she had more supplies than she'd been able to carry. The woman's husband and brother placed her in a cloth sling tied to a bamboo pole. They hoisted the pole to their shoulders, with the woman suspended between them, and the group set off for Thaw D- village. They arrived two hours later, just before dark.

The soldiers came again. Naw Tha Mu's aunt and cousin fled in the wrong direction. They met the soldiers face to face.

Naw Tha Mu laid the woman on a straw mat, strapped on a headlamp so she could see, inserted an IV and gave her oxytocin to speed her labor. Two and a half hours later, she gave birth to a baby boy. His skin was blue-black, and his heart rate, at 80, was dangerously low. Naw Tha Mu moved fast: she injected the baby with adrenaline and began to breathe into his mouth. After five minutes, he began to breathe on his own. His heart rate quickened.

Meanwhile, the mother was bleeding. She had not delivered the placenta. While the husband stroked his wife's hand, the assistant health worker gave her misoprostol, which caused contractions that expelled the placenta. The bleeding stopped. The woman drifted in and out of consciousness all night, talking gibberish. But by morning she was conscious and nursing her baby. In a week, she had the strength to walk home with her son.

They have visited Naw Tha Mu twice since then. "I feel very happy to see them," she says. "If I had not been there, the mother and baby would have died."

Still, she has her fears and sorrows. When she was returning from Thailand from follow-up MOM training in October 2007, she saw Burmese soldiers on the road, and she ran, dropping the backpack with the drugs, contraceptives and medical forms that she'd need for the coming 10 months. She spent that night hiding alone in a cave before returning home.

Burmese soldiers invade her village often. "I can't count how many times," she says. Everyone runs. Recently, the soldiers came again. Her 43-year-old aunt and 13-year-old cousin fled in the wrong direction and met the soldiers face to face. "We don't know if they're alive or not. ... I can't think about what the soldiers will do to them," she says, and she turns her face away.

In July, after following a forest path to visit a patient in a nearby village, she heard that she'd missed stepping on a landmine by inches.

"I am working for my people," she says. "If I die, it's OK."

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