›Afghanistan has one of the highest rates of maternal mortality in the world: 327 out of every 100,000 women who give birth die during childbirth. Despite some recent improvements, political, social, cultural, and economic factors present enormous challenges. Last month, the Center for Population and Development Activities hosted an online viewing and dialogue discussion of the PBS Independent Lens film Motherland Afghanistan, which follows Afghan-American filmmaker Sedika Mojadidi and her father, Dr. Qudrat Mojadid, as they return to their home country and visit the Laura Bush Maternity Ward in Kabul. The conditions they find are devastating and underscore not only the need for greater commitment to reproductive health services, but also the advancement of women’s and girl’s access to education, security, and political participation.
Like most health facilities in Afghanistan, Dr. Mojadid found that the ward lacks sufficient human resources and adequate health supplies. Health care workers were limited, most with out-of-date skills, and no functional training. “Most of these doctors don’t have the basic knowledge to take care of their patients. They’re so thirsty for just one word of wisdom, but there’s nobody to give them that,” he says.
According to the United Nations Population Fund (UNFPA) only 14 percent of births in Afghanistan are attended by a skilled healthcare worker. Qualified birth attendants ensure a continuum of care through pregnancy and birth, leading to healthier mothers and children. One strategy to address the human resource shortages in places like Afghanistan is to expand and acknowledge the skills and responsibilities of non-physician health workers through task-shifting (redistribution of tasks to persons with a baseline set of skills). Task-shifting can help lighten the load, but trained midwives are essential, as panelist Jeffrey Smith, regional technical director for Asia Jhpiego pointed out during the Wilson Center’s Advancing Dialogue to Improve Maternal Health series.
“The most important decision made early in the reconstruction [of] Afghanistan was that midwives would be the backbone of the reproductive health workforce and they would be empowered with the skills to perform the tasks necessary for provision of basic emergency obstetric care,” said Smith.
Due to population growth and existing shortfalls, the UNFPA estimates that Afghanistan needs an additional 4,000 midwives in order to attain a 95 percent skilled birth attendance by 2015. Although it is a long road to progress, the government of Afghanistan has worked with UNPFA and other international donors such as USAID to create the first National Policy and Strategy for Nursing and Midwifery Services, which provides nurses and midwives with a comprehensive education and skillset to address preventable causes of maternal deaths.
While improving the overall health system is imperative to decreasing maternal mortality rates in Afghanistan, I found it impossible to ignore the cultural and political backdrop of Motherland Aghanistan’s setting. Forced marriages, lack of education and political participation, violence, insecurity, and patriarchal cultural norms clearly play a large role.
Women for Afghan Women – a women’s rights organization based in Kabul and New York – joined the video discussion and had a strong message about the prospects for women in ongoing negotiations with insurgents. “Afghan women have been left out of any formal talks,” said Executive Director Manizha Naderi:
We are trying to get our voices heard by doing media interviews and speaking anywhere we can. We are against any form of negotiation with the Taliban because they can’t be trusted. Our position against negotiating with the Taliban does not mean we are giving in to a permanent war or that we want war. It means we look for strategies that are not destined to failure before the ink is dry on the settlement pages.Just this April, Afghan Minister of Health Suraya Dail said at the Wilson Center that “the gains we have made [in reducing maternal mortality rates] are remarkable; however, gains are fragile and donor resources are declining. Substantial investments must be maintained to safeguard these hard-wins.” The film reiterates her point.
The most important point is that the subjugation of women is not a sidebar, something that can be avoided through negotiations, it is the linchpin of Taliban strategy, having nothing to do with religion. The subjugation of half a country is the straightest path to subjugating the whole. Just forbid women from going to work or school or leaving the house without a mahram (male escort), beat them with whips or guns on the street because a square inch of ankle shows below the burkha, drag a few into the Kabul stadium, force them to their knees and shoot them in the head, and a terrorized country will submit.
Although we believe women must be at all negotiations and decision making tables, we also believe these negotiations are doomed to failure. They have not worked in the past, they will not work in the future. Let’s invest our considerable energies and experience in other solutions to the Afghan situation. Security, infrastructure, economic, and civic development are essential for Afghanistan as well as advancement of women’s and girls’ economic, educational, health, civic participation, and political rights. Funding from NATO countries is necessary to secure these goals.
Indeed, exposés like Motherland and the work of photographer Lynsey Addario, who presented at the Wilson Center last year, show the precariousness of women’s rights and development in ways that statistics and politicking sometimes mask.
Sources: MEASURE DHS, PBS, UNFPA, World Health Organization.
Video Credit: Independent Lens Motherland Afghanistan, courtesy of PBS. Feature image: “Side streets of Kabul,” courtesy of flickr user Abdurahman Warsame.
›“The gains we have made [in reducing maternal mortality rates] are remarkable; however, gains are fragile and donor resources are declining. Substantial investments must be maintained to safeguard these hard-wins,” said Afghan Minister of Health Suraya Dail at the Wilson Center on April 23. [Video Below]
As part of the Wilson Center’s Global Health Initiative, the Advancing Dialogue to Improve Maternal Health series partnered with the U.S. Agency for International Development to co-host Minister Dail, along with Honorable Dr. Mam Bunheng, Minister of Health, Cambodia; Honorable Dr. Bautista Rojas Gómez, Minister of Health, Dominican Republic; and Dr. Fidele Ngabo, Director of Maternal and Child Health, Ministry of Health, Rwanda.
These ministers spoke about the lessons learned in countries where there has been tremendous progress under challenging circumstances.
In the Dominican Republic, Bautista Rojas Gomez said the first challenge was to address the “Dominican paradox,” where maternal mortality rates were high despite the fact that 97 percent of women received prenatal care and delivered in hospitals. The government created a zero tolerance policy that included a comprehensive surveillance system, mandatory maternal death audits, and community oversight of services, which assured better quality services.
Similar political commitment improved indicators in Cambodia, where maternal mortality rates dropped from 472 to 206 per year from 2005 to 2010. “It takes a village…and the prime minister has inspired the country to act,” said Mam Bunheng. Through increased access to contraception the number of children per woman went from seven to three and commitment to family planning, education, technology, infrastructure, and community have been the key drivers of success.
“In Rwanda, the big challenge we are having is education,” said Fidele Ngabo. “Many of the maternal health indicators depend on education.” When women and girls are educated they are twice as likely to utilize modern contraception. The efforts of Rwanda’s government have been instrumental in facilitating positive change, he said, particularly the efforts of First Lady Jeannette Kagame, who he called a “champion” for women and girl’s health.
As witnessed throughout the Advancing Dialogue to Improve Maternal Health series – and reiterated by the ministers of health – the interventions to improve maternal mortality rates exist, what’s left is to generate the needed political willpower.
›“Faith-inspired organizations have many different opportunities [than non-faith-based NGOs]. The point that is often reiterated is that religions are sustainable. They will be there before the NGOs get there and will be there long after,” said Katherine Marshall, executive director of the World Faiths Development Dialogue at the Wilson Center on November 16. Marshall noted in her opening remarks that maternal health should be an easy issue for all groups, regardless of religious tradition, to stand behind. Yet, in reality, maternal health is a topic that “very swiftly takes you into complex issues, like reproductive health, abortion, and family planning,” she said.
As part of the Advancing Dialogue on Maternal Health series, the Woodrow Wilson International Center for Scholars’ Global Health Initiative collaborated with the World Faiths Development Dialogue and Christian Connections for International Health to convene a small technical meeting on November 15 with 30 maternal health and religious experts to discuss case studies involving faith-based organizations in Bangladesh, Nigeria, Pakistan, and Yemen. The country case studies served as a springboard for group discussion and offered a number of recommendations for increasing the capacity of faith-based organizations (FBOs) working on maternal health issues.
Engaging Religious Leaders in Pakistan
“When working with religious leaders to improve maternal health there are some do’s and don’ts,” said Nabeela Ali, chief of party with the Pakistan Initiative for Mothers and Newborns (PAIMAN). Ali described a PAIMAN project that worked with 800 ulamas (religious leaders) to increase awareness about pregnancy and promote positive behavior change among men.
One of the “do’s” highlighted by Ali was the need to build arguments for maternal health based on the Quran and to tailor terminology according to the ulamas preferences. The ulamas who worked with PAIMAN did not want to utilize the word “training,” so instead they called their education programming “consultative meetings.” More than 200,000 men and women were reached during the sermons and the strategy was been picked up by the government as one of the best practices written into in the Karachi Declaration, signed by the secretaries of health and population in 2009.
Despite the successes of the program, Ali warned against having unrealistic expectations for religious leaders interfacing with maternal health. She stressed the importance for having a long-term “program” approach to the issue, as opposed to a short-term “project” framework.
Behavior Change in Yemen
“Religion is a main factor in decisions Yemeni people make about most issues in their lives and religious leaders can play a major role in behavior change,” said Jamila AlSharie a community mobilizer for Pathfinder International.
Eighty-two percent of Yemeni women say the husband decides if they should receive family planning and 22 percent say they do not take contraception because they belief it is against their religion and fertility is the will of God, said AlSharie. Therefore, the adoption of healthy behavior change requires the involvement of key opinion leaders and the alignment of messages set in religious values. Trainings with religious leaders included family planning from an Islamic perspective, risks associated with early pregnancy, nutrition, education, and healthcare as a human right.
Male Participation a Key Strategy
“As a faith-based organization we believe it is a God-given right to safe health care and delivery so we mobilize communities to support pregnant women to address their needs, educate families about referrals and existing services in the community,” said Elidon Bardhi, country director for the Bangladesh arm of the Adventist Development and Relief Agency (ADRA).
Through female-run community organizations, ADRA educates men and women about the danger signs of labor and when to seek care. For example, many men in Bangladesh hold the belief that women should eat less during pregnancy to ensure a smaller baby is born, thereby making delivery easier, said Bardhi. ADRA addressed such misconceptions through a human rights-based approach and emphasized male participation as a key strategy, ensuring there were seven male participants for every one female.
A Culturally Nuanced Approach in Nigeria
The Nigerian Urban Reproductive Health Initiative (NURHI) is a public-private partnership that identifies and creates strategies for integrating family planning with maternal health. According to Kabir Abduallahi, team leader of NURHI, “family planning” is not as acceptable a term as “safe birth spacing” in Nigeria, so the project highlighted how family planning can help space births and save lives.
Religion and culture play an important role in the behavior of any community. The introduction of a controversial healthcare intervention (such as family planning) in a religiously conservative community requires careful assessment of the environment and careful planning for its introduction, said Abduallahi. Baseline surveys and formative research data helped NURHI understand the social context and refine intervention strategies.
Ten Ways to Increase the Capacity of FBOs
Faith-based organizations’ close links to communities provide them with an opportunity to promote behavior change and address other cultural factors contributing to maternal mortality rates such as early marriage and family planning.
Working in collaboration with FBOs and other stakeholders is critical to promoting demand for maternal and reproductive health services; however, there is limited knowledge about faith-based maternal healthcare and FBOs are often left off the global health agenda. In conclusion, Marshall noted 10 areas the group identified as areas to focus on:
- Move projects to programs: Projects are often donor driven and limited in scope and duration. Donors and policymakers should move from project-oriented activities to local, regional, and national-level advocacy programs to build sustainable change.
- Coordinate, coordinate, coordinate: Significant resources are wasted due to a lack of coordination between FBOs and development agencies. A country-level coordinating mechanism should be developed to streamline efforts not only between agencies but also across faiths.
- Context, context, context: A thorough understanding of the local culture and social norms is imperative to successful program implementation.
- Terminology is important: In Pakistan, religious leaders redefined sensitization meetings around family planning and maternal and child health as “consultative meetings” not “trainings.” In Nigeria, the culture prefers “child birth spacing” over “family planning.” In Yemen, it’s “safe age of marriage” instead of “early childhood marriage.”
- Most religious leaders are open and with adequate information can produce behavior and value changes. Utilizing the Quran, Hadith, and Bible can support arguments and emphasize the issue of health and gender equity.
- Relationship building: Winning the trust of religious leaders can be difficult and time-consuming but is necessary for opening doors to patriarchal societies.
- Rights-based approach: A human rights-based approach can be a very powerful agent of change for addressing negative social structures such as violence against women, but it can also create controversy. In Bangladesh, ADRA utilized the approach to educate men about nutrition, dowry and child marriage, and education of women.
- Networks: There is a significant need to create forums that bring together the various FBO and global development communities in order to share knowledge and enhance advocacy messages. Networks are needed to streamline resources and inventory existing research, projects, and faith-based models that work.
- Monitoring and evaluation systems: There is a striking lack of data about the impact and outcomes of FBOs. Increasing the monitoring and evaluation skills of FBO workers can improve evaluation systems and meet the demand for new data.
- There needs to be greater political will for engaging the faith-inspired community.
›Addressing the maternal health needs of the nearly 60 percent of urban residents who live in slums or slum-like conditions will be a critical step to improving maternal health indicators of a rapidly urbanizing Kenya, said Catherine Kyobutungi, director of health systems and challenges at the African Population Health Research Center in Nairobi.
“In some respects, [the urban poor] are doing better than rural communities, but in other ways they are behind,” said Kyobtungi. But, she said, there are many unique opportunities to improve maternal health in slums: “With these very high densities, you do have advantages; with very small investments, you can reach many more people.”
Output-based voucher schemes – in which women pay a small fee for a voucher that entitles them to free, high-quality antenatal care, delivery services, and family planning – have been implemented to help poor, urban women access otherwise expensive services. But poor attitudes towards health care workers, transportation barriers, and high rates of crime still prevent some women from taking advantage of these vouchers, said Kyobtungi.
Celebrating Ordinary Women Doing Extraordinary Things to Improve Gender Equality and Maternal Health Worldwide›few forums dedicated solely to maternal and reproductive health in Washington, D.C., I am particularly excited about this year’s 100th anniversary of International Women’s Day. This day commemorates ordinary women doing extraordinary things and acknowledges both the progress made and barriers still faced by women worldwide.
“When it comes to the boardroom meetings, government sessions, peace negotiations, and other assemblies where crucial decisions are made in the world, women are too often absent,” said Secretary of State Hillary Clinton during her remarks for International Women’s Day. “It is clear that more work needs to be done to consolidate our gains and to keep momentum moving forward.” [Video Below]
For mothers worldwide, some momentum has indeed been gained: Maternal mortality rates dropped from 526,000 a year in 1980 to 342,900 in 2008, according to a report by the Institute of Health Metrics and Evaluation at the University of Washington. In September of last year, a group of international leaders – including the UN and other multilateral institutions, donors, the business community, and NGOs – launched the “Global Strategy for Women and Children’s Health” and committed $40 billion to save the lives of 16 million women and children in developing countries.
At the sixth meeting of the Wilson Center’s Advancing Policy Dialogue on Maternal Health Series, Mayra Buvinic, sector director of the World Bank’s gender and development group, said: “Investing in women and girls is the right thing to do. It is not only fair for gender equality, but it is smart economics.” She said the World Bank has found that empowering women allows families to better endure economic crises and leads to better futures for their children as well.“When women have better education and health, mothers have greater household decision-making power and prioritize the well-being of their children,” said Buvinic. “In return, children have better educational attainment and are productive adults, building long-term economic growth.”
However, increased investment will only pay off when money is translated into action and stakeholders are held accountable for empowering women.
Since the inauguration of International Women’s Day 100 years ago, the low status of women in many parts of the world has remained relatively unchanged. Many women are still subject to male-dominated values that preclude them from making basic decisions about “who to marry, when to marry, when to have children, and how many children to have,” said Nafis Sadik, special envoy of the UN Secretary-General for HIV/AIDS, in an interview with the Population Reference Bureau. To change this, international development strategies need to prioritize improving gender equality, women’s status, and women’s voice in the political process.
I am grateful to be working in collaboration with extraordinary institutions such as the Maternal Health Task Force (MHTF) and United Nations Population Fund (UNFPA) who take real steps every day to help improve the lives of women and girls. In collaboration with these institutions, the Wilson Center’s Global Health Initiative is please to announce that it will partner with the African Population Health Research Center in Kenya to co-host a three-part dialogue series with local, regional, and national decision-makers on effective maternal health policies and programs. These in-country dialogue meetings will create a platform for field workers, policymakers, program managers, media, and donors to share research, disseminate lessons learned, and address concerns related to policy, institutional, and organizational capacity building for improved maternal health outcomes.
It is our goal that programs like these will continue to highlight neglected maternal health and issues and galvanize the community everyday – and not just on International Women’s Day.
Sources: Population Reference Bureau, UN, UN Population Fund, U.S. State Department.
Photo Credit: Afghan girl, courtesy of flickr user U.S Embassy Kabul Afghanistan, and Secretary Clinton’s video address courtesy of the U.S. State Department.
›Global Maternal Health Conference. “Just look at ICPD, Beijing, and CEDAW. Obviously, there must be something wrong with accountability,” she said, since 15 years later women continue to die every minute giving birth.
Wrapping up the conference with a discussion of accountability makes sense – we need to learn from the past and close the gap between commitments made and real action on the ground. So what does today’s buzzword, “accountability,” mean, and how do we enforce the realization of commitments made…or lack thereof?
“Accountability is power, and includes transparency, answerability, and enforceability,” said Lynn Freedman of Columbia University. Through international law, budget transparency, and grassroots mobilization it is possible to ensure that policies make a difference to improve women’s lives.
A review of the Ministry of Finance’s allocation for health can tell us a lot about the government’s real commitment to eradicating maternal mortality. As the overarching instrument of policy the “budget is inextricably linked to development and exists for those who have less,” said Helena Hofbauer of the International Budget Project. “If there were greater transparency of government spending, we could have done more to push for change five years ago,” said Hofbauer. This is indeed true; however, it is also true that if governments simply followed through on the international agreements they are signatories to, women would be better protected.
Accountability through the legal system is possible and Nancy Northrup of the Center for Reproductive Rights demonstrated how international law has overhauled programs and sparked governments into action. For example, in India, the high court recently ruled that the government must execute audits and report back on the steps taken to align programs with policies that ensure a woman’s right to skilled birth attendance.
In order to bring about such judicial interventions a social movement must first be in place to build awareness and demand accountability. Building such a movement starts at the grassroots level and Aparajita Gogoi of CEDPA presented strategies for empowering local communities with a global voice. By providing a safe space for dialogue, communities are given the opportunity to share concerns and demand action from local health facilitators and government officials.
Increasing opportunities for dialogue allows for bottom up solutions and ensures that contextual variables are taken into consideration. “We need arenas for brokering diverse groups to compare notes and streamline synergies, ” said Mogedal. I am energized by the lessons learned today and eager to apply these key messages next week in Washington, DC during the seventh meeting of the Advancing Policy Dialogue for Maternal Health at the Woodrow Wilson International Center for Scholars that will further address “Monitoring, Transparency, and Accountability for Maternal Health.”
Originally posted on the Medscape blog Global Mamma, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.
Photo Credit: “Mothers and children waiting at the Bolemba healt centre” courtesy of flickr user hdptcar.
›a young woman died giving birth in a bustling marketplace in New Delhi. Just steps away from Parliament, this woman was left to die and no emergency care was sent to her – no midwives, nurses, or doctors; just people walking around her accepting the situation as normal and an uncontrollable way of life. But this is Delhi…not a remote tribal village where the nearest health clinic is hours away (on foot).
This juxtaposition lingers on in me as I sit in the plenary session of day two at the Global Maternal Health Conference and listen to Syeda Hameed, member of the Indian Parliament Planning Commission, discuss her recent visit to a remote village where every house has 10 children living in filth, flies, and emptiness.
Although I have been working on such development issues for the last five years I do not work in the field, nor do I visit the developing world on a regular basis. Hearing these stories, coupled with my firsthand experience of witnessing poverty here in Delhi reminds me of the daily reality of those 342,900 women who die every year. This is their way of life and I think it’s poignant that today’s sessions emphasize community based care, family planning, accountability, behavior change, and culture.
“Context, context, context,” said Wendy Graham of IMMPACT at yesterday’s plenary session. I agree, the context of social and cultural norms is an underlying factor that must be taken into consideration when implementing maternal and child health (MNCH) programs. With a background in psychology, I appreciated when Dr. Zulfiqar Bhutta, of Aga Khan University, recognized the toll of poverty on the imagination and the mentality of fatalism.
That is why it is so essential to “ask the people how they feel and bring their voices into the forums where policy decisions are made,” said Hameed. It is also important to hold key players accountable and include men in MNCH activities.
During the side session Male Involvement in Reproductive and Maternal and Newborn Health six field experts (in which half the panelists and audience members were men!) discussed effective methods for increasing male participation in family planning, vasectomies, gender equality, and hospital care.
The key findings from this discussion include:
- Targeted interventions that educate men about danger signs and pregnancy complications correlates with behavior change and increased facility births.
- Many young married men feel pressured to prove their fertility. A sample of men was evaluated and those who had increased education and income were more likely to delay first pregnancy.
- Vasectomy is not something men want to talk about with family planning fieldworkers; however, official recognition of the vasectomy benefits by the government did increase referrals.
- Puppet and theater shows that demonstrate gender equity behaviors provide an opportunity for dialogue. Women in this study reported increased gender equity in family planning decision-making.
Originally posted at Maternal Health Task Force, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.
Photo Credit: “Parliament Street” courtesy of flickr user ~FreeBirD®~.
›Global Maternal Health Conference in New Delhi. Co-hosted by the Maternal Health Task Force and the Public Health Institute of India, this three-day technical meeting builds upon the momentum of Women Deliver and the G8 summit by bringing together 700 researchers, program managers, advocates, media, and young people to exchange ideas, share data, develop strategies, and identify solutions for reducing maternal mortality.
In order to reduce India’s maternal mortality rates, Azad called for the repositioning of family planning programs to include maternal and child health and not limit the scope of services to population control as historically executed. Improving family planning and maternal health services must also address the reproductive health needs of adolescent girls, and India is currently developing a new ministry that will target gender inequality, poverty, early child marriages, as well as other critical health issues important to young girls such as the dissemination of sanitary napkins.
“Although the legal age of marriage is 18, there are districts in India where 35 percent of the population is married between the ages of 15-18,” said Azad. During the side event “Adolescent Girls: Change Agents for Healthy Mother and Child,” technical experts such as Anil Paranjap of the Indian Institute of Health Management presented evidence that girls who marry between 15-18 are five times more likely to die during childbirth than women in their early 20’s.
“We still have deep-rooted subordination that makes it very difficult for young women to realize their sexual and reproductive health rights,” said Sanam Anwar with the Oman Medical College. Interventions such as the UDAAN project – a private-public partnership between the Center for Development and Population Activities (CEDPA) and the Government of India – demonstrate promising solutions for empowering young people through the use of existing infrastructure. In collaboration with teachers, parents, principals, and students, this project successfully increased leadership skills and improved youth knowledge on menstruation, health, friendship, peer pressure, early marriage, and reproductive health, said Sudipta Mukhopadhyay of CEDPA.
Empowering “young people” to improve maternal health also requires that the community support committed new thinkers and future leaders. The Young Champions of Maternal Health Program is a unique and refreshing group of young professionals from 13 countries dedicated to improving maternal health, and I look forward to learning how this new energy will further the maternal health agenda.
Originally posted at Maternal Health Task Force, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.
Photo Credit: “Indian Girl” courtesy of flickr user Jarek Jarosz.
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