Neha Limaye, MDc
Nominated From: University of Washington
Research Site: Peru
Research Area: Maternal and Child Health
Primary Mentor: Dr. Magaly Blas
Prenatal and perinatal health in the Peruvian Amazon: Understanding health determinants and training traditional birth attendants for improved outcomes
Antenatal care and deliveries with skilled birth attendants are key factors to improving maternal and child health, but in Peru’s poorest areas, these factors are often missing. Loreto is the nation’s largest region, but also one of the most neglected. In Loreto, access to care is extremely limited, and at least 80% of deliveries take place at home. The infant mortality rate is significantly higher than the rest of Peru, with 25.4 deaths per 1000 births as compared to the national average of 19.5.
Our research group is creating a new prenatal and perinatal intervention to address these disparities. To design an appropriate intervention, we need a thorough understanding of the current maternal health environment and an ability to evaluate the intervention’s impact.
Therefore, we propose a study with the following aims:
1.To explore the social and cultural determinants of prenatal and perinatal health in in Loreto.
2.To establish baseline maternal and infant mortality rates in control and intervention samples.
3.To design and evaluate a mobile device tool for traditional birth attendant training.
In rural communities along the Amazon, individual villages are separated by hours of travel along the river, limiting access to care. Amazon Hope, a non-profit organization, provides much of the care in the area, serving 60,000 people via a medical ship. But even with the organization’s efforts, infant mortality rates remain high, and the majority of women deliver at home, rather than trekking to find a health center.
Traditional birth attendant (TBA) training has long been promoted in rural areas, and has the potential to improve perinatal outcomes and increase women’s ties to existing health system. However, definitive evidence is limited by a lack of robust studies. Our group is initiating Mama River, a project to train TBAs to provide perinatal counseling, ensure prenatal visits, and track births and deaths. As we begin this project, we need baseline measures of maternal and infant mortality to be able to track progress over time. Our work will form the basis for a more robust understanding of TBA training in rural, low access settings.
One project we are proposing to add to Mama River is mobile-technology-based longitudinal training for TBAs. Our research team has noted that cell phone service reaches many Loreto communities, and studies show that integrating mobile technologies into prenatal health improves outcomes in rural settings . If mobile- technology-based education is effective in Loreto, it could serve as a model for longitudinal TBA training in other remote settings.
Nuestras Historias Video Project
Mamas del Rio, Nuestras Historias- Celia’s Story from NPGH Fogarty Fellows on Vimeo.
Mamas del Rio, Nuestras Historias- Carla’s Story from NPGH Fogarty Fellows on Vimeo.
Background on the Nuestras Historias Video Project by Neha Limaye
I have been working with Dr. Magaly Blas in the Loreto region of the Peruvian Amazon. In Loreto, most communities are riverine, and often hours away from health services, accessed via canoe. In a setting of extreme poverty, the infant and maternal mortality rates are over twice the national average, and the majority of deliveries are at home. Dr. Blas has created a program called Mamas del Rio, in which community health workers use mobile devices to connect pregnant women to health services. My goal was to create and evaluate an educational tool that these community agents could use during their pregnancy home visits- this has led to Nuestras Historias, or “Our Stories”.
Nuestras Historias was entirely developed using community-based methods. First, we held PhotoVoice workshops with community agents and local mothers. Participants took photos in their communities to identify local barriers to maternal and early child health, highlighting issues such as adolescent pregnancy, domestic abuse, home deliveries, and lack of recognition danger signs, and lack of vaccinations. We then conducted storytelling workshops, where participants shared and recorded stories related to these issues. The stories and photos were combined into a series of 7 digital stories, each a 3-5 minute audio narrative accompanied by photos that touches on a different theme.
With Nuestras Historias, we are harnessing the power of narratives to motivate behavioral change. By listening to true stories from their peers, with photos from their own communities, we hope that pregnant women and their partners will be inspired to make healthier pregnancy and delivery choices. We are currently evaluating the impact of the digital story curriculum through a pilot cluster randomized study in 12 of our Mamas del Rio communities. In the intervention communities, community agents are delivering the curriculum via solar-powered tablets. We are measuring impact through pre/post tests on knowledge, attitudes, and behavioral intentions, but thus far we have seen that both the community agents and pregnant women are extremely excited in engaging with the curriculum! We are working closely with the government’s regional health department (DIRESA), with the goal of disseminating the digital story curriculum across the Loreto region, both to more communities and to larger health centers.