By Janelle Chavez, 2023-24 Global Health Media Fellow

Maternal mortality remains a pressing global concern, with nearly 95% of deaths occurring in low- and middle-income countries. Among the most vulnerable are those displaced from their home country.

Migrant women have up to double the risk of maternal mortality compared with women from host countries. Additionally, research has shown that babies born to migrant women are more likely to be born preterm or have congenital anomalies — due to a lack of primary care, the physical and mental stress of displacement, malnutrition, and trauma.

In response to this pressing disparity, a pioneering partnership between Stanford physicians and midwives serving refugee mothers at the US-Mexico border seeks to bridge the gap.

“Education — the ability to deploy knowledge in an effective way that can be sustainable and could be repeated —  that’s the mission,” said Dr. Katherine Bianco, a clinical professor of obstetrics and gynecology at Stanford University School of Medicine. “We’re helping these patients going through the difficult process of having a baby in a way that can be joyful and not deadly. Because that’s the problem that we have.” 

Training for worst-case scenarios

The presence of skilled health professionals before, during, and after childbirth can save maternal and newborn lives.

Yet, amidst a surge in the number of refugees at the border, the Mexican healthcare system has surpassed its capacity in recent years. Midwives, traditionally attending to routine births, now must acquire more advanced, life-saving skills to meet the escalating complications and demand.

To address this, a group of Stanford physicians is empowering those caring for pregnant migrants through educational simulations on postpartum hemorrhage, the leading cause of maternal mortality worldwide.

A study of 43 refugee camps across eight countries found that postpartum hemorrhage accounted for half of maternal deaths. Delays in care were identified in 97% of cases. About 80% reported lack of resources or inadequately trained staff.

Ximena Rojas, a midwife in Tijuana, Mexico, emphasizes the importance of preparedness. “We’re the experts in normal pregnancy, so that means we tend to see less high-risk situations. But sometimes it’s possible, even though patients are very healthy, even if the hemoglobin is good and everything is good, from time to time, hemorrhage can happen. So it’s good to have those skills no matter what.”

The group uses GO MOMS (Global Outreach Mobile Obstetrics Medical Simulation), a program developed at Stanford University, that has proven to be an effective method to teach life-saving procedures to medical providers in low-resource settings, such as Guatemala and Nicaragua.

The training consists of a teaching session and a virtual simulation on postpartum hemorrhage. Participants are presented a clinical scenario, including patient vital signs and delivery details, and are asked to describe their next steps. Providers of different training levels are encouraged to participate and collaborate as a team.

“It was really helpful. For me, it was the first time taking this kind of activity, like a simulation,” said Leslie Montserrat Montero Torres, a midwife in Tijuana, Mexico. “I was really surprised because even though it was not a real situation, I felt all the stress and the time running and people saying all the stuff and talking about what they were thinking was the best. I realize how important it is to be sure that people verbalize the situation and what they are doing or deciding on the patient.”

The team hopes that the midwives can use this training model for new providers joining them.

“They can learn how to do the simulation, teach others how to do the simulation, bring the knowledge, and decrease maternal morbidity and mortality at birth,” said Bianco.

Caring for migrant mothers

While bleeding is the most common cause of maternal mortality among refugee women, midwives emphasize that various factors linked to displacement and trauma pose significant risks to both mothers and their babies.

“Bleeding is kind of normal for every pregnancy, every birth. But for women under so much stress, so much trauma, so much malnutrition, a little bit of bleeding can lead to shock pretty fast,” said Rojas. “So that’s something that, como lo tomamos en cuenta; we are mindful about. So, we try not to let anyone bleed, not at all.”

Additionally, issues like high blood pressure or preeclampsia can be deadly during pregnancy. And many migrants do not have access to medication during the long journey. 

Moreover, trauma and psychological stressors often manifest physically.

“We see a lot of moms with high blood pressure and high heart rate,” said Rojas. “We sometimes even give an IV because we think a patient is dehydrated because her pulse rate is very high. We check over and over, and we hydrate the patient, and we give them ways to breathe deeply and to relax, but their pulse is still really fast.” Rojas said she believes the high pulse rates result from stress related to trauma they’ve experienced.

“We had a situation of a mom who came to clinic and her young sister passed, and she had been the one taking care of her other children in Haiti,” Rojas recalled. “She was crying, and her pulse was really high. She was healthy in all the other ways, but her trauma and her experiences were causing her to be really stressed and sad and holding grief,” she said.

“There is no space for grief, and I think we should include grief in our healthcare somehow so we can help families process their experiences, so their pulse and their blood pressure are back to normal,” said Rojas.

The midwives often serve as the sole providers that migrant women trust and count on.  

“They usually come to us in the clinic because the Mexican system is not helping them because they don’t have translators or they are not making any effort to help them,” said Montserrat Montero Torres. “They come back to the clinic and say, ‘I cannot do this paperwork there in the hospital or in the community public center because the people are not helping me.’”

The group hopes to continue to improve their skills to serve the patients who come to  their clinic.

“We are really making a huge difference in the lives of many families that are under our care,” said Rojas. “It is very important to have the skills, to have access to blood, to have access to medications. Hopefully we can grow and have more providers with the same knowledge so we all can save more lives under such difficult circumstances.”