The landmark Women Deliver conference, which concluded last week, reinvigorated the global health community’s commitment to improve reproductive health at both the grassroots and global levels. Providing a major boost was the Gates Foundation’s announcement that it will commit an additional $1.5 billion over the next five years to support maternal and child health, family planning, and nutrition programs in developing countries.

“We haven’t tried hard enough,” said Gates Foundation co-founder Melinda Gates. “Most maternal and newborn deaths can be prevented with existing, low-cost solutions.” Examples of these efficient and effective solutions were presented at the three-day conference’s dozens of panels on a wide range of issues, including climate change, contraceptive commodities, fistula, gender inequities, adolescent family planning, communications and technology, and much more.

Delivering Solutions for Girls and Women

“We know how to intervene; there does not need to be a magical solution,” said Søren Pind, Denmark’s minister for development cooperation, at the June 7 opening ceremony of Women Deliver 2010.

In its second year, the conference has gathered delegates from 146 countries representing hundreds of non-governmental organizations (NGOs), governments, and civil society organizations under the theme “Delivering Solutions for Girls and Women.” Delegates are working to share projects, policies, successes, and innovations in the field of maternal health and to develop strategies to meet Millennium Development Goal 5.

“Recent trends show great progress and this is very encouraging,” said Gamal Serour, president of the International Federation of Gynecology and Obstetrics (FIGO), speaking of a recent study by the Institute of Health Metrics and Evaluation (IHME). The study found that annual maternal mortality has dropped 34 percent–from 526,000 to 342,900–between 1980 and 2008. Nevertheless, Serour maintained that “we are far away from our goal for 2015.”

Overcoming Tradition and Religious Barriers

Investing in women’s health is not only the right thing to do, it is also economically advantageous. When women are healthy, they provide tremendous benefits to their families, communities, and countries. Women contribute to a majority of the small businesses and agricultural activities of developing countries and their unpaid work at home accounts for almost 33 percent of the world’s GDP. Unfortunately, over 215 million of these women do not have access to family planning services, resulting in unwanted pregnancies, childbirth, and maternal deaths.

There are many barriers to family planning in developing countries, not the least of which are cultural and social traditions that can uphold negative gender-based norms. Tailoring campaigns to address these gender inequities was the subject of discussion at the “Cultural Agents of Change Delivering for Women” session, where panelists acknowledged that collaboration and partnership with a wide-range of actors–from members of the local legislature to civil society organizations and actors in the health sector–are necessary to facilitate change.

Graciela Enciso of the Centro de Investigaciones y Estudios Superiores en Antropología Social-Sureste in Mexico, added that advocacy campaigns to increase support for family planning should be “linked with research.” In many traditional societies, strict interpretations of religion are used to control and disempower women; donors and NGOs “need to think outside the religious box at every point,” said Mary E. Hunt, co-director at the Women’s Alliance for Theology, Ethics, and Ritual.

Male Contraception, Gender Roles, and Family Planning

“I think it is important not to hide behind our cultures and religion,” said Ngozi Okonjo-Iweala, managing director of the World Bank. “We need to work with men and work together to overcome gender inequality.” “Male participation” has been a key theme echoed throughout Women Deliver and is often highlighted as a strategy for reducing maternal mortality.

At the “Men Deliver: Men’s Role in Family Planning” breakout session, experts addressed how new and existing technologies in male contraception and shifting gender roles can help to scale up family planning interventions. “Reducing unwanted pregnancies can also be carried out through male contraception,” said John Townsend, vice president of the reproductive health program at the Population Council.

Condoms are traditionally the main method of contraception for men, but usage rates quickly fall over time and to wear a condom “becomes the women’s responsibility,” said Townsend. To address issues around condom usage, development of alternative family planning technologies, such as gels and implants, is underway. As these technologies are being developed, however, it is important for program managers and donors to consider existing gender norms and the willingness of men to utilize new methods.

In researching gender roles in family planning in Zambia, Holo Hochanda, the chief technical administrator of the Planned Parenthood Association of Zambia, determined that there are many entry points for male intervention and increased family planning. “Men are clients, policymakers, and service providers. Each of these roles provides an opportunity to discuss utilization of male contraception and gender inequities in family planning,” he said. “Men can be key mobilizers and agents for change.”

For more coverage on Women Deliver 2010 click here and to learn more about the Wilson Center’s Maternal Health Dialogue Series visit the Global Health Initiative’s website here.

“Referral has been called an orphan cause,” said Patricia Bailey, public health specialist for Family Health International and Columbia University, because it is “everybody’s responsibility and therefore nobody’s responsibility.”

As part of the Maternal Health Dialogue Series the Woodrow Wilson International Center for Scholars’ Global Health Initiative convened a small technical meeting on May 19, 2010, with 25 experts from five countries to discuss their experiences and share lessons, challenges, and recommendations for improving transportation and referral for maternal health. Following the technical meeting, a public dialogue was held on May 20, 2010, to share the knowledge gaps and recommendations identified. The formal report from the technical meeting will be available in the near future.

“Displaced people are like every other human being, they want, they need the advantage of family planning. They are asking only for services to be available for them, affordable for them, and acceptable for them,” said Dr. Grace Kodindo in a recent interview with ECSP about the challenges of family planning in conflict regions. The OB/GYN from Chad calls for family planning services to be included in the provisions made for displaced and refugee communities.

Kodindo identified five key barriers to family planning for displaced people, including a lack of coherent policies for displaced people in host countries and a lack of awareness and attention by donors to family planning. Other barriers include the lack of access in remote areas, and a lack of knowledge and therefore demand.

However, in many cases family planning services are very much in demand. One refugee mother compared herself to a “hen being followed by many chicks,” said Kodindo, who “ask[s] the government and the donors to give and to make policy that can really facilitate the provision of services and to provide funding so that services can be available to all these people.”

Kodindo, who recently spoke at a Wilson Center panel on “Family Planning in Fragile States,” is also speaking in DC on Thursday, June 3 at a showing of the documentary about her work in the Democratic Republic of the Congo, Grace Under Fire.

Maternal mortality rates in many low income countries, such as India, are declining, according to a recent study by researchers at the Institute of Health Metrics and Evaluation (IHME) at the University of Washington. According to the report, maternal deaths have fallen from 526,000 a year in 1980 to 342,900 in 2008. This news, while welcoming, has caused dissent among some global health activists who fear donors and policymakers will dismiss the issue and call into question the higher maternal mortality rates last reported by the United Nations. While concerns over monitoring and evaluation raise important methodology questions, this news must also serve as catalyst for world leaders and donors to take action and recognize that investing in women pays.

The data reported by IHME only concludes what maternal health advocates already know. “We know how to save women’s lives, we don’t need a cure…this is a political problem and political will is essential,” said Theresa Shaver, director of White Ribbon Alliance, at a Wilson Center event in December 2008. Greater funding for family planning and access to emergency obstetric care and HIV/AIDS services should all be included in a scaling up resources for improved maternal health programs. “Without HIV, annual maternal deaths would have been 281,500 in 2008,” said Richard Horton, editor of The Lancet, in last week’s Lancet comments.

Investing in contraception and family planning services through vertical funding mechanisms can reduce maternal mortality rates by addressing all of a woman’s health needs at the time of service. To widen the platform of comprehensive services for women and their families, efforts to link public health services and offer more at one location should be expanded. “Many women have expressed a need for contraception and family planning services…when you offer family planning services on-site with HIV services, you have a huge uptake in family planning use,” shared Michelle Moloney-Kitts, assistant coordinator at the Office of the U.S. Global AIDS Coordinator at a the Wilson Center in December 2009.

Yet political will remains in short supply. “Despite strong advocacy efforts, political leaders have either ignored the call or failed to make the health of women in pregnancy a priority,” stated Horton. Six countries–Afghanistan, Democratic Republic of Congo, Ethiopia, India, Nigeria, and Pakistan–account for over half of all maternal deaths worldwide, and increased investment in these countries will improve maternal health targets, such as Millennium Development Goal (MDG) 5 seeking to reduce maternal deaths by 75 percent.

Progress is possible and “policymakers are more likely to act on issues that they think they can do something about,” said Jeremy Shiffman, associate professor of public administration at Syracuse University, at the Wilson Center in March 2009. The maternal health community must rally around these positive findings and galvanize support for greater financial contributions. “Two decades of concerted campaigning by those dedicated to maternal health is working,” said Horton.” “[G]reater investment in that work is likely to deliver even greater benefits.”

Calyn Ostrowski is the program associate for the Wilson Center’s Global Health Initiative.

Photo Credits: A woman in India safely delivers her baby in the hospital through the Madhya Pradesh Health Sector Reform program. Courtesy Flickr user Department for International Development

“Conflict-affected countries have some of the worst reproductive health indicators,” said Saundra Krause of the Women’s Refugee Commission at a recent Wilson Center event. “Pregnant women may deliver on the roadside or in makeshift shelters, no longer able to access whatever delivery plans they had. People fleeing their homes may have forgotten or left behind condoms and birth control methods.”

Media reports on the neglected discussion of maternal and child health often focus on the problems and projects in sub-Saharan Africa or South Asia, which is understandable, as a disproportionate 90 percent of global maternal deaths occur in these two regions. Last month, however, PBS correspondent Ray Suarez reminded us that maternal and child mortality affects countries all over the world, including Peru, where “maternal death rates has historically been unusually high,” he noted in a report for NewsHour. 

“Few people in the highlands of central Peru own automobiles and it’s hard to know exactly when the next bus is going to rumble by,” said Suarez. “Villagers are a long way from the nearest health clinic, even further from a fully equipped clinic.” Unfortunately, this scene could describe most developing countries struggling to reach the Millennium Development Goal (MDG) 5 target of reducing maternal deaths by 75 percent by 2015. Maternal health advocates argue that MDG 5 does not require a cure, but rather increased political willpower.

“Health officials, obstetricians, nurses, and community activists looked for ways to make better use of existing resources and connect expecting mothers with them,” said Suarez, reporting from the remote town of Vilcashuaman. At the Casa Materna, or “mother’s house,” nurses plot on a felt, bulls-eye map the names, due dates, geographical proximity, and travel times of pregnant women in nearby villages. Utilizing two-way radio communication, Casa Materna stays in contact with these remote villages and can signal the regional hospital, hours away in Ayacucho, for ambulance assistance for women needing emergency obstetric care.

Delivery teams at the Ayacucho hospital are familiar with indigenous languages and cultures, and welcome traditional practices, such as displaying herbs and giving figurines to new mothers. “The medical professionals in the area know bringing delivering mothers to the hospital can mean the difference between life and death and are prepared to be as accommodating as possible to lure women from home delivery,” reports Suarez. In the Ayacucho district, maternal mortality rates have decreased by 50 percent in five years.

While Suarez said “cultural competence, a welcoming atmosphere, and low-cost, high-result treatment strategies” may seem “pretty smart and straightforward,” it is important to evaluate the regional health system at a larger level, and consider additional factors, such as access to family planning, that may have contributed to Ayacucho’s success in reducing maternal mortality.

Another part of the solution is improving transportation and referral strategies, but increased research is needed to evaluate best practices and scalability of programs such as the one in Ayacucho. On May 19-20, as part of the Maternal Health Dialogue Series, the Wilson Center’s Global Health Initiative will host a two-day conference on “Improving Transportation and Referral for Maternal Health.” Speakers working on transportation and referral strategies in Bolivia, Ghana, and India will share their experiences and best practices.

Calyn Ostrowski is the program associate for the Wilson Center’s Global Health Initiative.

Photo Credits: Mothers in Peru learn to identify risk factors during pregnancy. Courtesy of Flickr user International Women’s Health Coalition

Among the many initiatives that have recently been launched to strengthen health systems in the developing world, there is little consensus on execution. Traditional strategies for improving the health system, such as the vertical approach, which prioritizes communicable diseases, or the horizontal approach, which prioritizes non-communicable diseases, are limited in scope and fail to include a comprehensive gender lens.

To overcome the shortcomings of these two health financing approaches, the “diagonal” strategy combines them by “clearly defining priorities and utilizing these priorities to drive general improvements of the health system,” said Julio Frenk, dean of the Harvard University School of Public Health, at the Global Health Initiative’s third event in the “Advancing Policy Dialogue on Maternal Health” series.