Notes From the Field: Anna Knapp in Zambia

Anna Knapp

One in 10 babies die before their first birthday in Zambia, where the infant mortality rate has climbed into the top 10 worldwide in the past several years. In Zambia's Copperbelt Province, Boston University School of Public Health researchers have been working to try to save young lives through a simple but potentially far-reaching training project. Among the researchers is Anna Knapp, a senior program manager at BU's Center for International Health and Development (CIHD), who recently spent time in Zambia, where she recorded her experiences in words and photos.

The project, dubbed the Lufwanyama Neonatal Survival Project (LUNESP), is examining the effectiveness of providing a package of practical, inexpensive interventions to traditional birth attendants, as a means of reducing neonatal mortality during the first 28 days of life. Attendants receive training and supplies that enable them to intervene in four of the most prevalent, preventable contributors to neonatal mortality: asphyxia, post-partum hypothermia, sepsis, and perinatal transmission of HIV infection. The intervention attendants receive training in neonatal resuscitation, as well as in identifying sepsis and initiating antibiotics in the field.

The study, led by CIHD, is being conducted in the Lufwanyama district of the Copperbelt Province. It has been funded by the US Agency for International Development (USAID), with additional contributions from the American Academy of Pediatrics.

Knapp, MPH '07, has been involved in the study for the last two-and-a-half years.

Here are her Notes from the Field:


In October, the red earth of the Copperbelt Province is thirsty, the purple jacaranda and flame trees are in full bloom, and the heat is strong and unrelenting in the afternoons.

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The training site is in Mindolo in the Copperbelt Province of Zambia.

One year ago this week, I made my first trip to this north-central area of Zambia bordering the Democratic Republic of Congo, in order to meet and work with the Lufwanyama Neonatal Survival Project (LUNESP) field team. As the LUNESP Program Manager based in Boston, it was my first opportunity to observe the study in action and to work alongside the traditional birth attendants, rural health-center staff, data collectors and the core LUNESP team who comprise the study.

One year later, I am privileged to be here for the final training of the attendants as we wrap up our study activities that have been ongoing for the past three years.

On this trip, I am accompanied by Dr. Nicholas Guerina, a neonatologist based at Tufts Medical Center and an adjunct assistant professor in International Health at BUSPH, who is one of the project's co-investigators.  Together with the core LUNESP field staff, Nick and I will spend this week working with our group of 120 attendants who travel from 12 sub-districts in Lufwanyama under challenging circumstances to arrive at the training site. When I say challenging circumstances, I mean that these women will walk tens of kilometers, hitch rides on the backs of trucks with animals, supplies and other people, and spend the night in markets with little to no personal security in order to arrive for the first day of training. These women have very little money, many responsibilities, and families that they leave behind, and many of them will travel for several days.

We've held these trainings every three to four months for the last two-and-a-half years, and despite all obstacles, most of the women make it for each and every training session. Our training site, Mindolo Training Farms, is located down long, rough dirt roads in the bush between the towns of Kitwe and Kalulushi and near a large and active copper-mining operation. Mindolo served as an agricultural/trade school, and most of our training sessions take place in what was once a  classroom used to teach tailoring. Some days, you can feel the earth tremble slightly from explosions taking place at the nearby mine.

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The birth attendants sing to welcome each other as training begins.

I have come to know what to expect on the first day of each training, but preparation never diminishes my experience: the inaugural passage to the tailoring classroom is marked by the joyous singing and dancing of the attendants  wearing their dazzling white LUNESP T-shirts and multi-colored chitenges (the traditional cloth of Zambia) around their waists.  They sing a cappella in one of the local languages, Bemba, and their song is one of greeting after the long period since last we were together.

When I sit down for the first day of training, I usually look around the room and remind myself that I was born safely in a modern hospital with doctors and nurses attending to my mother.  If I had been born in this area of Zambia, there is a good chance that one of these women would have assisted in my birth.

Lufwanyama district is typical of many resource-constrained parts of Africa; there is poor access to basic health facilities and high rates of neonatal mortality.  A mother going into labor may have to walk upwards of seven hours to get to the nearest health facility; thus, many women end up delivering in their own homes -- homes lit by candlelight and with no running water.

In this area, there is a high utilization of traditional birth attendants -- women of their communities with limited education but some midwifery training -- who often provide first-line care for many babies during the first month of life. In fact, birth attendants in Lufwanyama attend approximately 30 to 40 percent  of all births outside of a health facility.  Sadly, many babies don't live through their first month of life and often die due to complications that could easily be averted.  This is where the LUNESP attendants provide tremendous assistance, as they practice the simple interventions intended to reduce neonatal mortality.

Our clinical field supervisor and head Zambian trainer, Charity, begins the opening lecture, and I watch the women intently.  Their faces are all familiar to me now: I know the comedians from those more reserved, the young mothers from the elders.  I know that each and every one of them will try her best to grasp the concepts that are demonstrated today and during the week.  These women are hungry for the simple skills and knowledge that may help them to save lives.


~

Surprises and Resilience
I spend a lot of time in my job making plans that inevitably change and then responding to those changes with as much flexibility and patience as possible.

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Workers carry bundles through the fields.

Some typical field "surprises" include personal luggage that is lost and does not arrive until days later, study funds held up at the bank, ATMs that systematically break down all over town, the training facility being double-booked, personal accommodations being mis-booked.  Sometimes, the surprises are more imperative - a traumatic road injury where our help is critical, city-wide fuel shortages, a colleague whose health is in jeopardy, even the tragic death of the President of the country.  In all cases, we try our best to find reasonable and timely ways to respond or to make due while continuing the work at hand.  Oftentimes, there is nothing to do but to wait out the situation.

Early in the training, we arrive to find two of our field staff in somber conference outside of the tailoring classroom. One of the elder attendants had just learned of the unexpected death of her 36-year old daughter. This woman lived a good 48 km beyond the nearest town in a rural village, and her daughter's body needed to be buried immediately, as there was no refrigeration or other method of preserving the body in the October heat. The priority was to get this woman home as soon as possible. Our colleagues had taken her to mourn privately in a separate room and were discussing what could be done. There were no vehicles present, except for the one in which we had just arrived. We swiftly determined that I would drive her to the nearest town where she could catch a ride on to her home village.

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One of the birth attendants participating in the training.

With the dear woman in the passenger seat and one of the data collectors as my navigator, we set out on the dirt road for town, each bump making the sorrow in the car feel heavier. This woman had only just arrived, eager to be with her colleagues and friends. Too soon and for heartbreaking reasons, she would be traveling the long road home again. It took a good part of the morning, but we were able to see the woman off safely with a relative.

No matter how much advanced planning or intense preparation goes into a training session, we bear in mind that normal events and passages of life may intervene.  During this particular week, several attendants suffered deaths in their families and had to excuse themselves early from the training in order to travel home. In the past, the women have had to leave a training session for both joyful and tragic reasons. They have given birth to their own children, fallen sick with malaria or other illnesses, sustained injuries from their long travels, or have attended marriages of their children or their own. But for each woman who has left the session unexpectedly, there is another who has overcome personal hardship and left her family behind to stick out the training.

Life bears down on these women, but their resilience endures.


~

From Practice to Mastery
I am sitting on a wooden chair under a shady mango tree about 75 yards from the tailoring classroom with one of the Zambian data collectors, Michael, and one of the elder birth attendants. Michael and I have been sitting under this tree for the past four hours, informally interviewing the women one-by-one about their experiences with one of the interventions. We are trying to learn more about the barriers that they encounter when trying to administer a rapid HIV test to a mother who is about to deliver.

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Anna and Michael talk about the training experience.

Michael discusses the questions with each woman in Bemba, then translates for me.  In this way, if I have follow-up questions or clarifications, we can talk to the attendant right away before she departs. The woman we are currently interviewing has an in-depth response to one of the questions.  While she is talking, I observe her strong hands resting in her lap. She is holding her pediatric pocket mask -- a resuscitation device that each LUNESP woman has been given and trained to use -- and a suction bulb, which the women use to clear the newborns' breathing passageways. I imagine the history in her hands, the number of babies she has delivered in her time, the stories that she could tell.

Across the dry grassy field, I see a long line of birth attendants sitting against the outside wall of the classroom.  It is hot, and they are pressed as closely to the wall as possible in order to capture the most of the skinny shade cast by the corrugated tin roof.  We are mid-way through the week, and these women are patiently awaiting their turn to complete their certification skills testing with Nick and Charity.

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The birth attendants wait in line to demonstrate their mastery of the LUNESP interventions.

Inside the classroom, each birth attendant will demonstrate her comprehension and mastery of one of the LUNESP intervention cornerstones - a modified version of the American Academy of Pediatrics/American Heart Association Neonatal Resuscitation Program (NRP).  Using a special infant manikin called a "resusci-baby," each woman will display her ability to follow the NRP steps and to properly use her pediatric pocket mask in the event that a newborn requires resuscitation.  The birth attendants have been practicing intently for this day and for their chance to show that they have successfully understood and can expertly implement their training.

For the women and for us, it is a long day. There are 51 women who need to complete the NRP certification, and after emerging proudly from the classroom, each of them comes to sit with me under the mango tree for the brief interview.  At times, it feels too hot to think.  Most of the waiting women sit languidly in wooden chairs placed in the long, attenuated shadows cast by the trees.

Just at the longest, hottest point in the afternoon, a bus full of young women who are also staying at Mindolo comes driving through the training site.  The young women are singing gaily, and through the open bus windows, their song comes spilling out into the hot afternoon, giving us the last boost of energy that we need to push through to the end of the day.

~

Celebrating Lives Saved
It is time to bring the week of training to a close. Even more monumental for us is that it also is time to bring the LUNESP study to a close after three years.


During the height of Zambia's copper boom, the town of Kitwe boasted all sorts of sporting attractions for wealthy miners and their families.  After the copper crisis of the 1970s and 1980s, the town of Kitwe declined drastically. The Kitwe Badminton Club, for example, is no longer in the best shape, but it still serves admirably as a space for our closing ceremony.
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The birth attendants work on mastering their skills together.

The tall, arched ceiling over the main badminton court has buckled particleboard tiles and a resident white owl living in the rafters.  Lean horizontal fluorescent lights line the perimeter of the court's ceiling and cast a cheerless glow all the way down the painted sky-blue walls to the concrete court floor.  Despite the rather gloomy lighting, there is excitement in the air.

When we arrive, a host of LUNESP participants are seated along both sides of the expansive court -- birth attendants, data collectors, staff members, volunteers, children.  The singing and dancing commences almost immediately. Everyone is excited that we have come so far, and they are ready to celebrate their hard work and the achievements of the study.

Groups of birth attendants have prepared poems about LUNESP that describe how much the study means to them and their communities, and they share them bravely, in English, standing in the middle of the badminton court. We enjoy traditional dances from young boys and girls. We hold silly competitions. We share a common meal. At some point very late in the evening, I notice several women quietly excusing themselves. When they come back into the room, they are dressed in their finest -- bright, bold colors with sequins and sparkles.

I know that the certificate ceremony is at hand.

A woman named Mary is the first to receive her certificate, and she bounds out of her seat and breaks into song. Mary dances her way slowly and proudly all the way across the badminton court to the head table, where Nick and I are standing in the long receiving line. Piles and piles of certificates that we transported from Boston rest behind us on the long table. Each birth attendant receives two certificates - one certifying them in NRP and the other for their participation in LUNESP.

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At the certificate ceremony.

As the names are called, I quickly realize that this is not going to be one of the somber graduation ceremonies to which I am accustomed.  These women ululate and dance as they approach the receiving line, and as each returns to her seat with her certificates, the nearby women clasp her in strong embraces and physically demonstrate their pride and excitement in one another.

If nothing else, this is the moment when I truly feel what this training means to these women and how hard they have worked for the last three years.  They have delivered more than 3,000 babies in this time -- many of whom likely would have died without trained intervention. The 16 young Zambian men and women who served tirelessly as the LUNESP data collectors are also bursting with pride.  Many of them speak into my ear as they pass by to shake my hand: "This opportunity has changed my life, thank you."

One of my senior colleagues in Boston once told me that a person is fortunate to work on a study like LUNESP at least once in his or her career.  Being present for this closing event makes me reflect appreciatively on all that I have learned and experienced over the years.

This is both an exciting and exhausting time. While I know that we still have a great deal of work ahead in order to analyze our data and disseminate our findings, there are many things still left uncertain concerning the continued employment of our core study staff and the programmatic continuation of LUNESP. This uncertainty is one of the most difficult personal aspects for me about seeing LUNESP close.

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One of the women brings her own child with her to training.

Our core Zambian study staff -- Grace, Joshua, Charity, Emeldah and Gladys -- have dedicated the last three years of their lives to this work, and we could not have completed the study without them. We share a common hope that the time and resources that we have invested in the training of the birth attendants will have natural extensions beyond the end of the study; that the outcomes of the study will be favorable and will influence local, regional and national policies and programs; and that we will continue to see a reduction in neonatal mortality in Zambia.

After the ceremony, the women see us off just as they had welcomed us - with song. I had told them earlier in the evening that when I sit at my desk in Boston on a dreary or slow day, I often think of them singing to improve my spirits.

I know we now must return to the business of data-cleaning, analysis and writing manuscripts.  There are many long days ahead of us. The women also will return to their homes to continue their work and lives; now they have more training, more confidence, and a greater ability to save the lives of the newborns in their communities.





For more information on LUNESP, please contact Anna Knapp at This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

The Boston-based LUNESP study team includes Christopher Gill, MD, David Hamer, MD, Nicholas Guerina, MD, PhD, Mark Mirochnick, MD, Bill MacLeod, DSc, and Lora Sabin, PhD.