By David Brown
Washington Post Staff Writer
Tuesday, July 6, 2010; HE01
Given that she was simulating childbirth on a couch in a carpeted hallway off a hotel lobby right after breakfast, Paulina Quinones Gonzalez decided to keep it simple. No umbilical cord wrapped around the baby's neck, no obstructed labor, no shrieking and flailing.
Nevertheless, she didn't want to make it too easy for the woman attending her and the dozen others watching, all nurse-midwives at their annual convention in Washington last month.
"Oh, dear, there's a part of it missing," said Barbara Reale, 50, of the University of Pennsylvania, as she inspected the afterbirth she'd gently delivered after the baby. A stream of fake blood rattled into a basin on the plastic sheet in front of her.
The midwife reached her gloved hand into the uterus. After a momentary search she extracted a Velcro-backed "placental fragment" as Gonzalez moaned in pretend pain. More blood poured into the basin. She massaged the abdomen, which slowly shrunk as the uterus contracted into a hard ball. The bleeding turned to a trickle, then a drip, and then stopped.
"It feels pretty realistic, guys," Reale said as she stripped off her gloves and everyone gave a sigh of relief.
It could have been a lot worse. Gonzalez could have let loose with the full quart of fake blood, gone into shock and died. After all, fatal postpartum hemorrhage happens to perhaps 115,000 women around the world each year, almost all of them in developing countries, and half in sub-Saharan Africa.
The simulated pregnancy that Gonzalez demonstrated to the midwives (and that she helped design) may be a tool in helping bring that number down. At least that's what its maker, a Norwegian medical device and simulator company, and a group of experts in maternal mortality hope.
"In terms of the global health agenda, this year the big focus is on mothers and care at birth," said Joy Lawn, a pediatrician with Save the Children who is helping lead that organization's effort to lower newborn and maternal mortality.'A whole scenario'
Deaths in childbirth are notoriously hard to quantify in poor countries, where most of them occur, in part because many women deliver at home and the collection of vital statistics is weak. (In the three dozen countries with the highest maternal mortality, about half of all deliveries have no skilled attendant present.) A report published in May by the Institute for Health Metrics and Evaluation estimated that in 2008, about 343,000 women died during pregnancy, childbirth or the six weeks after delivery. Millions more are disabled in some way.
Among basic health statistics, the maternal mortality ratio -- the number of maternal deaths per 100,000 live births -- shows the widest variation among nations. The global average is 251, ranging from lows of 4 (Italy) and 5 (Sweden) to 1,575 (Afghanistan) and 1,570 (Central African Republic). More than half of maternal deaths occur in six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic Republic of Congo.
Reducing maternal mortality is one of the eight Millennium Development Goals agreed to by 189 world leaders in 2000. Although largely unknown to Americans, the MDGs are a major focus of foreign aid decisions worldwide. They specify targets for reducing poverty, ending educational disparities between the sexes, decreasing childhood mortality and cutting HIV incidence (among other things), to be reached by 2015. Millennium Development Goal 5 seeks to cut the 1990 maternal mortality ratio of 320 deaths per 100,000 births by 75 percent.
The world is not on pace to meet that goal, according to a recent report by a collaboration of organizations called "Countdown to 2015." In the 68 countries where nearly all of the world's deaths in childbirth occur, the rate has been falling about 1.8 percent a year. It would need to drop an average of 5.5 percent a year for that whole period to reach the target -- which is to say there will have to be dramatic reductions in the next five years to reach it.
Laerdal Medical, a Norwegian manufacturer of medical simulators, hopes its low-tech $100 "frontpack" will play a part in the pursuit of MDG 5 by giving birth attendants a chance to practice. And unlike most birth simulators on the market -- which cost $3,500 to $30,000 -- this one forces the student to interact face-to-face with a person.
The abdomen is made out of washable neoprene wet-suit material; the teacher straps it on, more or less like an apron. It comes with a term-size baby, which can be packed in the normal head-down position or feet first (breech).
Using both hands, the teacher wearing the device can move the baby through the birth canal, which is formed from a flexible plastic frame. Simulated blood flows out of the vagina, controlled by a thumb-operated roller valve. To simulate the contraction of the uterus after delivery, the teacher squeezes air from a large bladder into a smaller one while pulling the latter lower in the pelvis. She can tap on a piece of hard plastic inside the mannequin to create a heartbeat, varying the rate and loudness to simulate fetal distress. In all cases, the sense of reality is heightened because the equipment is connected to and manipulated by a human being.
"This is attached to a person, so you can have a whole scenario," said Catherine A. Carr of the University of Washington, one of the midwives critiquing the device at the American College of Nurse-Midwives convention. Among the problems that can be simulated are not only disordered physiology and anatomy, but cramped environments and unusual social situations, such as delivering a baby whose mother doesn't speak the midwife's language.
"You can do it with an interpreter, which is hard for students to get used to. You could do it with an anxious relative. There are so many different scenarios," Carr said.In a flash
The simulator, with baby, will be sold at cost to health ministries in developing countries and to organizations working with them, said Tore Laerdal, the 58-year-old president of Laerdal Medical, whose father started the company in 1940. It is called "MamaNatalie," a name that plays on "natalis," which means "pertaining to birth" in Latin. The version shown at the Women Deliver conference in early June was a prototype; it won't be manufactured in quantity until later this year.
"Normally it's not good practice to show a product six months before it's available, but we brought it here because so many people are focusing on this problem," Laerdal said. (The company makes a newborn mannequin, "NeoNatalie," which it also sells at cost in developing countries. It is used to teach birth attendants how to resuscitate infants who aren't breathing. About 10,000 of those devices have been made in the past two years; the Ethiopian government just ordered 1,000.)
The idea of making a strap-on abdomen came in a flash to Gonzalez, a 29-year-old industrial designer from Guatemala who was spending time at Laerdal Medical last summer as part of a program called Design Without Borders. She and a summer intern were assigned by Tore Laerdal to come up with a way to reduce postpartum hemorrhage. For six weeks they read up on the subject, talked to experts, sketched and free-associated.
Gonzalez recounted recently that one day after ruminating on the fact that abdominal massage is the best technique for making a uterus contract and stop bleeding, she drew a picture of two people embracing. Basically a doodle. She looked at it again, and it appeared to be something tied to the front of a woman.
Then they were off and running.
Three weeks ago, Gonzalez was hired full time by the company.