5

The Warmth of a Mother’s Touch: Maternal and Child Health

Sadiki lay in pain, exhausted, on the floor of her home in Malindi, a rural village in Kenya. She had been in labor for more than twenty hours. She wondered why this birth was so much more difficult than her previous one. Maybe it was because her husband had been by her side back then. But after a roadside accident made her a widow at twenty-four with a set of twins at home and a baby on the way, all of life seemed different.

After her husband’s death, Sadiki received aid from the Caris Family Foundation, an international NGO focused on helping single mothers develop health and business skills. Entrepreneurial by nature and now even more motivated, she began mastering skills and dreamed of opening a small daycare center after the baby was born.

But for now, her only desire was to end the pain.

This baby seemed way too big. So much bigger, she thought, than her twins—combined. Maybe she shouldn’t have listened to the community health worker’s suggestion to get prenatal care. Maybe the supplements they’d given her and the healthier food she was eating had made the baby too big for her small body to handle.

The community health workers had urged her to call a tuk-tuk, a three-wheeled motorized taxi, to go to the hospital as soon as the labor pains set in. But she had ignored them, and, like most of the women in her village, she summoned the traditional birth attendant when her time came and prepared to give birth at home.

Knowing the baby was soon due, the community health workers stopped by to check on Sadiki. That’s when they found her on the ground, nearly unconscious. Over the objection of the traditional birth attendant, they loaded Sadiki’s limp body into the waiting vehicle and, as they were trained, rushed her to the hospital. As soon as she arrived, she was whisked away for an emergency C-section. She delivered another set of twins, a boy and a girl. But this time only one survived.

She named her Amani—Swahili for peace, Arabic for aspiration.

Worldwide, every two minutes a woman dies of pregnancy or delivery complications; every six seconds a baby less than a year old dies.¹ In nearly every case they are living in a country like Kenya, in a village like Malindi, and in a home like Sadiki’s.

Despite the recent progress made in reducing maternal mortality, we still lose over 250,000 mothers annually due to pregnancy-related causes—an unacceptably high statistic by any measure.² A mother makes sure that her children have clothing, food, a safe place to sleep, an education, and care when they are sick.³ She is the sole provider in one-third of the world’s households, and if she dies her children are up to ten times more likely to die as well.⁴ But that’s not all. Women provide 60 to 80 percent of agricultural labor in developing countries, producing half the world’s food.⁵ At home, they prepare food, collect water, and care for the children, sick, and elderly. When women are lost, entire communities suffer.

Over the past two decades, maternal and child deaths have been reduced by 30 percent and child deaths by 40 percent.⁶ However, for these deaths to continue to fall, successful interventions need to be dramatically scaled up to reach the millions who currently don’t have access to even basic maternal and child health care. By using proven technological and business model innovations and entrepreneurial solutions we can save millions of moms and babies.

The Critical Periods to Save Mothers and Babies

To save pregnant women and their children, simple and innovative solutions can improve the access, use, quality, and cost of care during three critical periods for moms and babies: family planning, pregnancy and delivery, and early childhood.

Starting with a Plan: The Importance of Family Planning

Delaying and spacing children is not only good for couples—it can save lives. The young child of a teenage mom is 35 percent more likely to die than one whose mom is in her twenties.⁷ A child born more than two years after a sibling is twice as likely to survive her first year as one born sooner. By simply increasing the space between children to three years, nearly 2 million child deaths can be avoided because parents are better able to give those children the attention and care they require at this initial period of their lives.⁸

For these reasons and others, it is important that couples who wish to delay childbirth have access to effective means of birth control. The most effective reversible contraceptives are medical, such as implants and intrauterine devices that can be inserted by trained community health workers and last three to five years. When a woman decides to have a child, the devices can be reversed (Table 7).⁹

Even though contraceptive use has increased sixfold over the past fifty years in developing countries, more than three-quarters of women of childbearing age who wish to avoid pregnancy in Sub-Saharan Africa do not have easily available access to contraceptives, nor do the majority of women in South Asia.¹⁰

Access to effective contraceptives could reduce both unwanted pregnancies and many of the 44 million abortions worldwide that result from them each year.¹¹

Table 7 Comparison of Contraceptive Methods

Staying Alive While Giving Birth

Too often, while giving birth to new life, a woman loses her own. The vast majority of these women die from preventable causes, such as severe bleeding, infections, unsafeabortions, and hypertensive crises.¹² Pregnancy and childbirth is particularly risky for younger teenage girls. A mother under fifteen is five times more likely to die during childbirth than one in her twenties.¹³

While it is best for both mothers and babies for deliveries to occur in equipped medical facilities with skilled personnel, that may not be possible for many women who live in remote regions, or who have other significant barriers to care. Fortunately, midwives and traditional birth attendants can be trained to use appropriate medications to decrease maternal bleeding, and to reduce the risk of infection for the mother and newborn during labor and delivery.¹⁴

Every Child Deserves a Fifth Birthday

We can save many of the 7 million children under age five we lose each year from preventable diseases. More than 30 percent of these children die within their first month of life. At least half of these deaths can be prevented with means that we already have available.¹⁵ Moreover, for every newborn who dies, twenty more suffer from birth-related injuries or complications that cause learning difficulties or other health conditions—many of which are permanent.¹⁶ Many of these poor outcomes for children could be prevented by providing solutions such as clean water, vaccinations, breastfeeding during infancy, and mosquito nets to sleep under.¹⁷

Clean Water. Diarrheal disease is a leading cause of death in children, taking 650,000 lives a year.¹⁸ It is both preventable and treatable. Children who drink contaminated water often get diarrhea and become very dehydrated. Their small bodies are unable to handle the rapid shift in body fluids. Oral rehydration solution (ORS), a simple homemade concoction of water, sugar, and salt, with a zinc tablet, can in most cases prevent dehydration. This simple treatment has saved 50 million children in the past twenty-five years, and could easily save many millions more if it was distributed to and used by those in need.¹⁹

However, the best solution to prevent diarrhea, and host of other diseases is by giving children clean water. There are a number of inexpensive and innovative ways to clean contaminated water. Chlorine tablets are a cheap and effective solution for cleaning dirty water, costing just pennies and taking minutes to use. Filters are an alternative to using chlorine. LifeStraw, a filter made by Vestergaard Frandsen, filters water instantly through a strawlike device and lasts up to five years. Its production is subsidized by carbon credits the company receives as its use reduces emissions that would come from burning fuel to boil water.²⁰

Tata Chemicals has developed an innovative, low-cost water filter system that uses rice husks, a common waste product in India, to filter water at very low cost.²¹ On a larger scale, GE’s Sunspring, a solar-powered water plant used in the Haiti earthquake relief effort, can process 5,000 gallons per day for up to ten years. This allows even the most remote areas in developing nations to get clean water.²²

The Coca-Cola Company has a number of projects to provide clean water in developing countries. However, to scale up these efforts in more sustainable ways, it recently teamed up with innovator and entrepreneur Dean Kamen and his DEKA Research and Development Corporation. DEKA has designed Slingshot, a water purification device that produces clean, drinkable water from contaminated water. The device boils and evaporates water from rivers, oceans, and other dirty sources and collects clean water once the vapor has condensed. Each unit is capable of producing 10 gallons of clean water an hour, enough to serve 300 people. Designed to run on less electricity than a hair dryer, the Slingshot device can be powered by a generator, solar cells, or biomass.

Though the technology has promise, it is cost prohibitive for developing countries when produced in small quantities. This is a technology feasible only at scale. To dramatically reduce costs, DEKA aims to increase volume and exploit economies of scale. DEKA’s partnership with the Coca-Cola Company plans to test the implementation of the prototypes and then rapidly scale up production. The partnership aims to deliver Slingshot devices to schools, clinics, and community centers throughout the world and provide millions of gallons of clean drinking water to rural communities.²³

Vaccines. After birth, children can be saved by vaccines and clean water. Vaccinations are one of the most cost-effective solutions in preventing childhood deaths. GAVI and other childhood immunization efforts have helped scale up immunization programs, which prevent an estimated 2.5 million child deaths a year.²⁴ Unfortunately, many children still do not receive these life-saving solutions. An additional 2 million deaths among children under age five could be prevented if currently available vaccines were more widely distributed.²⁵ Vaccines not only reduce the number of childhood deaths, they also prevent major illnesses and long-term disability.

The GAVI Alliance is a public-private partnership launched in 2000 to increase access to lifesaving vaccines in low-income countries. The partnership was formed by donor countries, developing countries, international aid organizations, and the vaccine industry, and includes the World Bank, WHO, UNICEF, the Bill and Melinda Gates Foundation, and many others. GAVI requires host countries to initiate participation and contribute financial resources, ensuring that vaccination efforts are incorporated within the nation’s larger health care strategy.

The partnership has created innovative finance structures that give the pharmaceutical industry incentives to invest in research and development on diseases primarily impacting low-income countries. In addition, host countries are supported by GAVI’s guidance on program design, mobilization, and monitoring. The partnership has been extremely successful in increasing access to vaccines. Coverage of basic immunization has reached nearly 80 percent in GAVI-supported countries.²⁶ Through GAVI-supported vaccination programs, an estimated 5.5 million deaths from hepatitis B, measles, influenza, and other diseases have been averted.²⁷

Developments in technology are making vaccines easier to deliver and distribute. Delivery systems are transitioning from needle-based delivery to easier methods, such as skin patches, oral drops, and aerosol sprays. In addition, heat-stable vaccines can reduce the cost of distribution by removing the need for refrigerated transportation.²⁸ As some of these technologies become more available and effectively distributed, even more lives can be saved.

Saving Mothers and Babies: The Basics

Saving the lives of mothers and their babies is not complicated in most cases. Prenatal care can help ensure that problems are prevented or anticipated, and that when they occur providers are available and equipped to help. Most of what is needed is basic education, supplies, and care for common issues and access to more advanced clinical care when complications arise (Table 8).²⁹

• Basic Knowledge. Basic knowledge involves learning how to avoid unplanned pregnancies, the benefits of prenatal care, and the importance of delivery within an equipped facility with a skilled attendant. It also involves learning why it is important for children to be breast-fed, vaccinated, and sleep under mosquito nets. Mothers must learn how to make sure that they and their families use only clean water.

• Basic Supplies. The supplies needed are also basic, such as contraceptives, chlorine or other methods to purify water, routine antibiotics, oral rehydration solution to prevent deaths from dehydration during diarrhea, and insecticide-treated mosquito nets.

• Basic Care. Most of care, diagnosis, and treatment of uncomplicated cases of pneumonia, diarrhea, and malaria can be provided in community settings, small clinics, or people’s homes. About 15 percent of all births have complications that could be fatal if not diagnosed and treated promptly.³⁰ Optimally, women should deliver in equipped facilities under the supervision of skilled birth attendants. However, when such a facility is not available, health workers can be trained to deliver in the home or other community setting. The most common cause of maternal death is post-partum hemorrhage, and community-based health workers, including traditional birth attendants, can be trained to safely administer medications to reduce risk of post-partum hemorrhage when women are unable to deliver in equipped facilities.³¹

Table 8 Solutions to Prevent Most Maternal and Infant Deaths

There are many examples in both the public and private sectors of excellent care being provided for mothers and children right in the community by trained and supervised community health workers and volunteers who are linked to more experienced providers and equipped facilities.

Public Options That Work

Ethiopia: Bringing Effective Contraceptives to the Women Who Need Them

Ethiopia is the second-largest country in Africa, with a population of 84 million. In 2000, it was one of the world’s most underdeveloped countries, ranking number 171 out of 174 countries in the Human Development Index, a measurement of health, education, and income.³² As in most Sub-Saharan African countries at the time, only 8 percent of Ethiopia’s married women were using contraception.³³ The low rates of contraceptive use were related to the fact that 82 percent of Ethiopians lived in rural regions; nearly 60 percent lived more than six miles from the nearest health facility, and most did not have easy access to transportation.³⁴

By 2005, use of contraceptives had increased to 15 percent, still very low given that nearly half of married Ethiopians wished to delay or stop childbearing.³⁵ Of the women fortunate enough to obtain contraceptives, two-thirds received injectables, requiring them to return to the health clinic every three months for additional injections. Due to poor distribution channels, these injectable contraceptives were frequently out of stock when women arrived.³⁶

Task Shifting

To combat this problem Ethiopia began task-shifting contraceptive implants from the hospital and clinics to health extension workers (HEWs) who are based in communities throughout the country and are linked to health facilities. The Ethiopian Health Extension Program was designed to increase primary health care access in the community. Since 2004, the Ministry of Health has trained 35,000 workers and coordinates and monitors the program. Health extension workers are based primarily in rural regions and deliver a standard package of seventeen health care messages, including education about disease prevention and control (for example, HIV/AIDS, STIs, and TB), first aid, family planning, basic maternal and child health care, immunization, nutrition, hygiene, and environmental health. They also distribute immunizations and injectable contraceptives and can treat dysentery, intestinal parasites, and other ailments. They refer complicated cases to the nearest health center when necessary. By 2010, maternal deaths in Ethiopia had dropped by 50 percent and child deaths by 26 percent over a ten-year period (Table 9).³⁷

Rwanda: The Little Country That Could

One of the more impressive success stories in health improvement in a low-income country is Rwanda. This small landlocked country of 11.37 million was devastated by genocide in 1994 that left 800,000 people dead, affecting everyone in the country.³⁸ The tragedy occurred over a month, leaving hundreds of thousands of orphans, broken families, raped women infected with HIV, and maimed and injured people. All of this happened in a country already struggling with high rates of disease, illiteracy, and other social problems.

However, as we noted in the introduction, when our backs are against the wall, we become innovative and entrepreneurial. Rwanda did just that. In 2000, Rwanda had a maternal mortality rate of 1,071 per 100,000 live births—almost 20 percent higher than in Africa as a whole. And Africa had the worst maternal mortality rate in the world—more than double the world average. Child mortality was no better. In 2000, on the worst continent for health, Rwanda was near the bottom.³⁹

But what a difference a decade makes! By 2010, maternal mortality had been cut by 60 percent, and child deaths had dropped by the same percentage.⁴⁰

So what did Rwanda do?

To combat its high rates of maternal and child deaths, Rwanda in 2000 began improving its health facilities and began task-shifting basic services to the community through an exciting all-volunteer CHW program, Animateurs de Santé (Table 9). In the program, each community selects three CHWs, including one who focuses on pregnant women and children under a year old. Because the CHWs are selected by the community, they are also responsible to the community.

Task Shifting

Community Health Workers monitor child milestone attainment and distribute family planning supplies, including condoms, contraceptive pills, and injectable contraceptives. They are able to give antibiotics for some illnesses, but for the most part they refer patients to nearby clinics for care. For pregnant women, the CHWs ensure that women attend prenatal visits, sleep under insecticide-treated bed nets to prevent malaria, deliver their babies in a health facility, and receive and understand information on proper nutrition, contraception, pregnancy, HIV, and malaria.⁴¹

Rwanda had a clear target to achieve. However, by 2006, despite the potential of the CHW program, death rates were not dropping fast enough for the government to achieve its target.⁴² In response, it implemented both demand (directed toward mothers and valued at $10) and supply-side (directed toward the CHWs) non-cash incentives for pregnancy, delivery, and postnatal care. Within the first nine months of this program, 86 percent more women accessed prenatal services, and 16 percent more women delivered in the hospital!⁴³

Accountability

Complementing the CHW program to stimulate demand and supply is Rwanda’s health insurance program, which started around the same time. Consumers can select their plan, ranging from a very basic plan to one that covers all services and drugs provided by the health center as well as ambulance transport to a district hospital. Premiums and copayments do vary based on income. The average premium is $1.80 per family member; the very poor, approximately 20 percent of the population, pay nothing.⁴⁴

Creating Demand

The health insurance scheme has also created incentives for the private sector to increase the supply of health services. Child and Family Wellness (CFW), a maternal and child health franchise that originated in Kenya, began operating in Rwanda partly in response to the incentives that the negotiated health insurance brings.

To promote high-quality care, the government of Rwanda implemented a pay-for-performance scheme as a financial incentive for government-sponsored health care facilities. The scheme pays bonuses to primary health care centers based on fourteen maternal and child health indicators, including the reason for patient visits and the type of services delivered. These performance indicators are then paired with facility quality factors to determine the payment bonus rewarded.⁴⁵

A World Bank study showed that the incentive program was associated with an increase in the quality and number of maternal and child health services provided. In fact, providers began encouraging women to deliver in facilities because of the associated financial rewards. Some even had health workers conduct community outreach to find pregnant women to deliver at the health facilities.⁴⁶

Many other government-sponsored community health programs have been similarly successful (see the summary in Table 9). Many of these programs provide a salary to the workers (for example, Ethiopia, Malawi, Brazil, and Pakistan), while others provide nonfinancial incentives, such as recognizing the CHW as a community leader. Ongoing training and supervision of these CHWs, as well as linking them to backup support for more advanced needs, is critical for task shifting to work well in these programs.

Private Options That Work

Public options for community-based care for mothers and children can work well when the government is stable; there is a well-functioning health infrastructure; community providers are trained, supervised, and linked to the health system; and effective quality control mechanisms are in place. Unfortunately, many countries fall short in some or many of these areas. Even where the public health system is strong, government cannot meet the challenges alone. Therefore, it is essential that there be private options as well, since they can play a critical role in supporting public options to ensure that women and children get the care that they need.

Private Option Varieties: Basic Care

There are a number of private options to improve health care for women and children in developing countries. In many cases these options have developed out of necessity: women and children were dying. Even stable governments in developing countries face herculean challenges providing just basic and essential services—sanitation, education, electricity, food, water, security—so health care often takes a back seat. In places that are unstable or plagued with corruption, services may be crumbling.

If you go to any developing country, you are likely to find a host of chemists, pharmacists, and health practitioners operating out of their homes and small shops. They are often micro-entrepreneur practitioners, and they are generally unregulated, unlicensed, and do not have much formal training. The most commonly used options used by women and children include traditional birth attendants, and franchised or networked private health enterprises.

Traditional Birth Attendants. Traditional birth attendants (TBAs) provide the majority of maternal and early childhood care in many low-income countries and some middle-income countries as well, particularly for the poor. They are often seasoned or older women who have had children themselves and serve to help the other women in the community. Though they may have assisted at the birth of many children, they often have little formal training—some may apprentice with other TBAs, but generally their skills are built over time through experience.⁴⁷

Table 9 Task-Shifting Government Health Services for Women and Children

Even when there are options for modern care, women like Sadiki, whose story appeared earlier in this chapter, prefer to use TBAs. As part of the community fabric, TBAs are generally known, respected, relied upon and trusted. Some TBAs may be linked to the formal health care sector, but for the most part they generally operate outside it. In some countries TBAs have been banned because of the perceived risk they pose to mothers and newborns due to their limited formal training and for performing deliveries outside of equipped facilities.⁴⁸

However, for many women, particularly those in remote and rural regions, a TBA may be their only option for maternal and infant care and support. Recognizing that skills to perform specific tasks can be learned by providers, regardless of professional title, some programs are beginning to train TBAs to provide safe deliveries, while evaluating the effectiveness of their newly honed skills.⁴⁹

A number of studies have shown that TBAs can provide good maternal and child outcomes, if they are:

• Trained and supervised

• Collaborate with other health workers

• Linked to the health infrastructure⁵⁰

TBAs can be valuable resources to improving health care for women and children in low-resource settings with the appropriate support. Fortunately, advances in technology, such as mobile phones, may be able to play a role in facilitating their inclusion. Partnerships between TBAs, governments, and others in the private sector may help include and use TBAs as part of the solution, rather than the problem.

Franchised and Networked Health Enterprises

Bangladesh, with 150 million people, is the most densely populated large country in the world, and 40 percent of the population has no access to basic health care.⁵¹ And with three-quarters of all births being performed without skilled assistance, it’s not surprising that the country has high rates of maternal mortality (2.4 per 1,000 births) and infant mortality (38 per 1,000 births). These rates are made worse by the fact that 45 percent of women use no form of birth control, resulting in many pregnancies and births.⁵²

Despite the fact that Bangladesh remains one of the world’s poorest countries, about 65 percent of health care expenditures are out of pocket. Public sector community clinics provide basic care and family planning, as well as health assistants who visit homes. The public health system provides primary care, but it is mainly used for emergency and hospital-based care.⁵³

The private sector comprises NGOs and microentrepreneurs, which include traditional healers, community health workers, retail pharmacists, and others providing a large proportion of outpatient treatment. For most, the pharmacy and drug sellers are generally the point of entry for people receiving any sort of health care at all.⁵⁴

A Private Partnership Designed for Scale: The Smiling Sun Franchise Program

The Smiling Sun Franchise Program, a USAID-supported initiative, is the largest clinical social franchise program for health care in the world. By standardizing and supporting care for a group of 27 existing NGO health clinic networks—many already receiving USAID support—in 64 districts, and with 9,100 satellite sites and 6,000 community service providers, Smiling Sun is able to provide care to 15 percent of Bangladesh’s population.

As a part of the network, each clinic has a similar look and feel—very clean and with the franchise’s logo, a smiling sun, prominently displayed. Smiling Sun provides family planning and maternal and child care services, including contraceptives, prenatal care, labor and delivery, emergency obstetric care, postnatal care, early childhood vaccinations, pediatric evaluations, diarrheal disease treatment, malaria treatment, tuberculosis case management, pneumonia testing and treatment, STI treatment, and cervical cancer screening. Some clinics, equipped with laboratory facilities and pharmacies, are able to provide a more robust suite of services. In a span of four years, the network has given over 5 million prenatal care consultations, and its skilled birth attendants assisted almost 24,000 deliveries each year between 2009 and 2011.⁵⁵

Scaling

The Smiling Sun brand maintains quality through a variety of quality control standards and processes. Quality monitoring and supervision visits track a variety of indicators and also include provider knowledge quizzes and process observations. All clinic staff members are responsible for ensuring and maintaining the quality of their services.⁵⁶

Maximizing Efficiency & Effectiveness

Most people will walk into one of the 9,100 satellite clinics providing basic health services. These mobile outreach clinics are located primarily in rural regions and often set up in different places each day. Services at satellite clinics cost patients the equivalent of less than $0.50. If the workers in the satellite clinic find an advanced case, they refer the patient to a higher level of care within the system, the first stage of which would be one of the 276 “Vital” clinics.

These Vital clinics have the facilities to offer basic outpatient services and limited laboratory services. The “Ultra” clinics—of which there are forty-six—offer basic outpatient services, emergency obstetric care, and comprehensive laboratories. A single “Maxi” clinic has the most advanced facilities, laboratories, and care. The Vital, Ultra, and Maxi clinics are all run by a clinic manager and an administrative assistant, while the services are provided by physicians and paramedics, who are assisted by clinic aides and counselors. Smiling Sun also has 6,200 “salaried volunteers” who receive a $17 per month honorarium to educate their communities and refer people to the satellite clinics. They also sell water treatments, soap, safe delivery kits, pregnancy tests, zinc tablets, condoms, and other basic health products.⁵⁷

Seeking Stability and Financial Sustainability

To stay operational, any business has to remain financially sustainable. To this end, Smiling Sun has several approaches to ensure there are both sufficient revenues and high demand for its services. Commodities are provided to the clinic for free by the government of Bangladesh, which also provides vouchers to stimulate demand. With the vouchers, which still provide only 1 percent of payments, prenatal visits are priced at about $0.40, basic pneumonia treatment at about $0.30, injectable and implantable contraceptives at about $0.50, and deliveries at about $12. Further, emergency obstetric care generates revenue, and Smiling Sun has a number of partnerships with businesses to increase revenue further.⁵⁸

Partner Coordination

The pricing structure also helps Smiling Sun keep a balance between sustaining services and providing care to those who cannot afford it. There are maximum and minimum price ranges that correspond to local market conditions, such as location and the existence of nearby competition. More than half of the payments for services are out of pocket, a third of services are free, about 15 percent is paid by third-parties (insurance), and, as noted, above 1 percent comes from government-provided vouchers. Program revenue covers 43 percent of program costs, with international donors supporting the remainder. Greater revenue is generated by clinics that are larger, provide a broader range of services, and are located in places with larger populations.⁵⁹

Of course, Smiling Sun is not the only clinic social franchise. There is also Marie Stopes International’s BlueStar network, which provides reproductive health services to women in Ethiopia, Ghana, Madagascar, Malawi, and Vietnam. Similarly, Health Store Foundation’s CFW clinics provide maternal and child health products and services through a franchise model. These franchised networks provide access to critical health care products and services while ensuring quality though the checks made by the central organization. Each of the clinical social franchising organizations listed in Table 10 fills a different niche in the health sector, has its own business model, and generate its own level of financial sustainability.

Table 10 Select Social Franchising and Networked Programs for Maternal and Child Health

Mobile Technology

Mobile applications for pregnancy and delivery help facilitate distribution by communicating information to people and thereby increasing demand for health care. Mobile technologies are increasingly important for delivering health information to remote areas in developing countries and allow programs to easily scale and replicate across regions and cultures. Mobile phones and other telemedicine technologies can support all of the above distribution models in providing quality care, making them even more effective and efficient.

Innovation & Entrepreneurship

Mobile Alliance for Maternal Action (MAMA) is a public-private partnership to facilitate distribution through health and nutrition text messages for expectant and new mothers. It was created in 2011 by the White House Office of Science and Technology Policy, the U.S. Department of State, the U.S. Agency for International Development (USAID), Johnson & Johnson, the United Nations Foundation, and BabyCenter, and is hosted by the mHealth Alliance. MAMA is currently being tested in Bangladesh, India, and South Africa.⁶⁰

Expectant mothers participating in MAMA receive regular health messages on their phones regarding topics ranging from proper nutrition and safe delivery practices to breastfeeding and vaccinations. By providing health information, MAMA creates demand for health services, which in turn facilitates distribution of goods and services. The program is easy to scale and integrate into existing health care models, and can potentially have a considerable impact on maternal and infant health.⁶¹

Mobile technology facilitators are not strictly phone-based applications. Portable technologies now allow health workers to conduct tests in remote regions. GE’s battery-powered vScan is a pocket-sized ultrasound device that takes screening and diagnostics to the poor. This device removes the travel cost that deters many people in rural areas from seeking high-level medical care that often is available only in large urban clinics.⁶² Telemedicine applications are also being developed to link rural clinicians to physicians for support, guidance, and training.

Keeping Them Safe: Saving for Keeps

We now have successful systems, programs, partnerships, and organizations that have demonstrated how we can save mothers and children with basic, community-based care. Like the pharmacy on a bicycle, if patients can’t go to a provider, the provider must go to them. From community health worker programs to a variety of franchise programs, we have programs that can save lives at a low cost in low-resource settings. By shifting tasks to community health workers and traditional birth attendants, and training and supporting them well, we can save millions of moms, babies, and children, even in the most remote places.

Over the past two decades, business model and technology innovations, coupled with entrepreneurial approaches from governments, NGOs, businesses, and donors, have helped increase the access, use, and quality of maternal and child health care and cut deaths of moms and babies by half. However, despite the progress, it is not yet time to celebrate. Like Sadiki’s pregnancy with twins, our goal cannot be to save just one baby. Such a bittersweet outcome should only serve to strengthen our resolve to be even more innovative and more entrepreneurial to achieve all that is possible.

And that is just what Sadiki did. Following Amani’s birth, she began a crusade to organize help and save others, just as she had been helped and saved. On her own initiative, she founded two women’s self-help collectives where women pool their resources and start small businesses to realize their dreams.

And by the time Amani was three, Sadiki had realized a dream of her own: she opened the village’s first daycare center.