The second week of negotiations here in Copenhagen has been marked by dramatic events, as the deadline for a new global agreement to address climate change approaches.

Blocs of negotiators from developing countries have walked out, and returned. Thousands of NGO representatives who have been denied access to the proceedings are shivering in the cold. Observers inside the Bella Center have staged sit-ins. And yet slivers of hope remain for some form of a global deal that is fair, ambitious, and binding as negotiators prepare for the arrival of more than 100 heads of state on Friday.

Integrating maternal health and HIV/AIDS services “includes organizing and providing services that meet several needs simultaneously…focusing not only on the condition, but also the individual,” argued Dr. Claudes Kamenga, Senior Director of Technical Support and Research Utilization at Family Health International, during the first event of the Advancing Policy Dialogue on Maternal Health series co-convened by the Wilson Center’s Global Health Initiative, Maternal Health Task Force (MHTF), United Nations Population Fund (UNFPA), and technical support from U.S. Agency for International Development (USAID). Joined by Michele Moloney-Kitts, assistant coordinator at the Office of the U.S. Global AIDS Coordinator, and Harriet Birungi, a program associate with the Population Council in Kenya, the panelists discussed how integration of HIV/AIDS and maternal health services not only improves health outcomes, but also increases program efficiencies, strengthens health systems, and saves money.

On Friday, November 20th, 120 representatives from the maternal health community, the U.S. and around the world, gathered for an all day meeting at the Woodrow Wilson International Center for Scholars to discuss the report, Tackling the Biggest Maternal Killer: How the Prevention of Postpartum Hemorrhage Initiative Strengthened Efforts Around the World. This report describes the challenges and successes of the U.S. Agency for International Development (USAID) funded Prevention of Postpartum Hemorrhage Initiative (POPPHI).

The five-year POPPHI project was executed through the support of many partners whose main goal was to catalyze the expansion of active management of the third stage of labor (AMTSL) worldwide. The conference convened experts and advocates in the field of maternal health, to share best practices, new innovations, and future challenges for tackling maternal health’s leading killer: postpartum hemorrhage (PPH). Panelists included POPPHI field partners such as International Federation of Gynecology and Obstetrics, The International Confederation of Midwives, the World Health Organization, and international researchers.

Preventing Postpartum Hemorrhage: AMTSL

“We need to work on women postpartum–after birth we leave them,” argued Deborah Armbruster, POPPHI Project Director. Due to the fact that many women in the developing world give birth at home or in local clinics that lack the sufficient resources to prevent postpartum hemorrhaging, approximately 132,000 women die annually. Fortunately, effective and feasible interventions such as those established by POPPHI have been proven to save lives.

Active management of the third stage of labor (AMTSL) includes three factors that, when used together, can avert postpartum hemorrhage, including:

1. Administration of uterotonic drugs (including oxytocin – the most preferred drug)
2. Controlled cord contraction
3. Uterine massage after the delivery of the placenta

POPPHI’s “BOLD” Approach

In collaboration with its partners, POPPHI implemented country-level and global programs to scale up AMTSL. Driven by the “BOLD” approach, Armbruster described how the initiative provided overall frameworks and approaches for strengthening PPH interventions by Building on evidence, Obtaining consensus, Linking partners, and Demonstrating to policymakers AMTSL’s feasibility.

Additionally, POPPHI provided learning materials such as toolkits, fact sheets, posters, and guides that were used to train providers and increase their use of AMTSL. A pilot project on Uniject (a single use needle pre-prepared with oxytocin) was also executed in Mali. Uniject was shown to be acceptable and successful with birth attendants there, and the study is now being replicated in Honduras.

Voices from the Field

Representatives from Argentina, Bangladesh, Ghana, Guatemala, Peru, and Mali presented their country results with the POPPHI project–concluding that the initiative served as a catalyst for upscaling AMTSL. Dr. Abu Jamil Faisel, Project Director and Country Representative of EngenderHealth in Bangladesh, discussed how the project helped to break through misperceptions that often prevented women from wanting to use misoprostol. In Ghana, policymakers worked with program managers and drug suppliers to register misoprostol in the country’s essential medicine list and updated guidelines to reflect best practices. While each country’s experiences were unique, the importance of partnerships was common to successfully upscaling AMTSL in all locations.

Partnerships: Critical to Success

Integrating maternal health indicators directly into program design is imperative to upscaling AMTSL, argued Niamh Darcy, Director of POPPHI Monitor and Evaluation. Additionally, Darcy argued that the success of POPPHI is due to the project’s emphasis in working with all levels of partners, particularly facility providers. Working with the supportive supervisors at facilities is necessary according to Darcy because this group is ultimately responsible for executing active management and recording project outcomes.

Identifying African experts who have taken leadership and ownership of the project has been instrumental in POPPHI successfully disseminating results at the regional, national and international levels argued Doyin Oluwole, Director, Africa’s Health in 2010. Partnering with local champions as well as policymakers has enabled many of the country projects to build capacity and upscale AMTSL.

Building on Lessons Learned

“A key lesson we have learned is that, when there is political commitment, AMTSL is rapidly scalable,” stated Lily Kak, Senior Maternal and Newborn Health Advisor, USAID. Changing behaviors and practices takes significant amount of resources and time commitment, however, POPPHI demonstrates that partnerships and research can be used to upscale AMTSL and change policies more efficiently.

Photo: Women wait outside a maternity ward in Chad. Courtesy of Flickr user mknobil.

“Incorporating environment, population, and health is a timely issue. Unless we focus on integrated approaches, our Ethiopian Millennium Development Goals cannot be achieved,” says Negash Teklu, executive director of the Consortium for Integration of Population, Health, and Environment (CIPHE), in this short video.

The Center for Global Development’s latest report, Start With A Girl: A New Agenda For Global Health, sheds light on the risks of ignoring the health of adolescent girls. Like other reports in the Girls Count series, it links broad social outcomes with adolescent health. “Adolescence is a critical juncture for girls. What happens to a girl’s health during adolescence determines her future–and that of her family, community, and country,” state coauthors Miriam Temin and Ruth Levine.

Between childhood and pregnancy, adolescent girls are largely ignored by the public health sector. At the same time, programs and policies aimed at youth do not necessarily meet the specific needs of girls. Understanding the social forces that shape girls’ lives is imperative to improving their health.

Like recent books by Michelle Goldberg and Nicholas Kristof, the report argues for increased investment in girls’ education to break down the social and economic barriers that prevent adolescent girls from reaching their full potential. Improving adolescent girls’ health will require addressing gender inequality, discrimination, poverty, and gender-based violence.

“For many girls in developing countries, well-being is compromised by poor education, violence, and abuse,” say Temin and Levin. “Girls must overcome a panoply of barriers, from restrictions of their movement to taboos about discussion of sexuality to lack of autonomy.” The report points to innovative government and NGO programs that have successfully changed negative social norms, such as female genital cutting and child marriage. However, the authors urge researchers to examine the cost-effectiveness and scalability of these programs.

In the last five years, the international community has become increasingly aware of the importance of youth to social and economic development. Some new programs are focused on investing in adolescent girls, such as the World Bank’s Adolescent Girls Initiative and the White House Council on Women and Girls, but significant additional investment and support is needed.

“Big changes for girls’ health require big actions by national governments supported by bilateral and multilateral donor partners, international NGOs…civil society and committed leaders in the private sector,” maintain Temin and Levin. They offer eight recommendations:
1. Implement a comprehensive health agenda for adolescent girls in at least three countries by working with countries that demonstrate national leadership on adolescent girls.
2. Eliminate marriage for girls younger than 18.
3. Place adolescent girls at the center of international and national action and investment on maternal health.
4. Focus HIV prevention on adolescent girls.
5. Make health-systems strengthening and monitoring work for girls.
6. Make secondary school completion a priority for adolescent girls.
7. Create an innovation fund for girls’ health.
8. Increase donor support for adolescent girls’ health.

“We estimate that a complete set of interventions, including health services and community and school-based efforts, would cost about $1 per day,” say the authors of Start With a Girl. There is no doubt in my mind that this small investment would indeed have a high return for the entire global community.

In a meeting with business leaders in Lahore in late October, Secretary of State Hillary Rodham Clinton pointedly warned of the potential economic impacts of Pakistan’s rapidly growing population: “There has to be…in any plan for your own economic future, a hard look at where you’re going to get the resources to meet these needs. You do have somewhere between 170 and 180 million people. Your population is projected to be about 300 million as the current birth rates, which are among the highest in the world, continue,” she said.

Pakistan is ranked 141 (out of 182 countries) in the Human Development Index. High rates of unemployment are compounded by low levels of education and human capital. Clinton noted that Pakistani women are more vulnerable to poverty; only 40 percent are literate, compared to 68 percent of men.

The Secretary’s emphasis on the need to provide adequate education, jobs, and resources to motivate economic growth and improve well-being is welcome. But demography also has important political consequences. U.S. policymakers and the Pakistani government should consider the impact of population dynamics on the country’s intensifying instability.

As Pakistan’s population grows rapidly, it is maintaining a very young age structure: in 2005, two-thirds of its population was younger than age 30. Research by Population Action International has shown that countries with very young age structures are three times as likely to experience outbreaks of civil conflict than those with a more balanced age distribution.

The members of a “youth bulge” are not inherently dangerous, but when governments are unable to foster employment opportunities or the prospects of stability, a young age structure can serve to exacerbate the risks of conflict, as recently noted by John O. Brennan, assistant to the president for Homeland Security and Counterterrorism, in a speech on “A New Approach to Safeguarding Americans.”

As Secretary Clinton and her colleagues consider the complex barriers to achieving peace and stability for Pakistan’s people, their humanitarian and development strategies should include demographic issues. When couples are able to choose the number and timing of their children, very young age structures like Pakistan’s, can change.

Family planning and reproductive health services are fundamental human rights, but remain out of reach for many in Pakistan, where one-quarter of all married women (and 31 percent of the poorest) have an unmet need for family planning.

Greater access to family planning would lower fertility rates and increase the share of working-age adults in the population. In this transition, countries can harness the “demographic dividend”—a change that could turn Pakistan’s age structure into an economic opportunity.

However, funding from the United States—the world’s largest single donor for international family planning—has declined by one-third over the past 15 years. The foreign assistance funding priorities of the Obama administration should reflect this recognition of the linkages between population, development, and stability.

By addressing the high unmet need for family planning and reproductive health services of women in countries like Pakistan, the United States could help to create a more balanced age structure in future generations—and promote stability at the same time.

Elizabeth Leahy Madsen is a research associate at Population Action International (PAI). She is the primary author of the 2007 PAI report The Shape of Things to Come: Why Age Structure Matters to a Safer, More Equitable World..

“Family planning is one of the biggest success stories of development cooperation,” said Bert Koenders, Dutch Minister for Development Cooperation, via video at a Wilson Center roundtable discussion on the future of family planning funding. Koenders was followed by representatives of three of the field’s largest donors, Musimbi Kanyoro, director of the David and Lucile Packard Foundation’s Population and Reproductive Health Program; José “Oying” Rimon, senior program officer for Global Health Policy and Advocacy at the Bill and Melinda Gates Foundation; and Scott Radloff, director of USAID’s Office of Population and Reproductive Health.

“We have a new administration that places a priority on family planning and reproductive health,” Scott Radloff, director of the Office of Population and Reproductive Health at the U.S. Agency for International Development (USAID), tells ECSP Director Geoff Dabelko after a discussion on the future of family planning at the Woodrow Wilson Center.