Showing posts from category maternal health.
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Women Deliver: Real Solutions for Reproductive Health and Maternal Mortality
›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.
Empowering Young Girls to Access Family Planning
“When we speak about adolescents we typically think of prevention. However, we must also think about providing access to safe abortions and supporting young women who want to be mothers and empower young women to make choices,” said Katie Chau, a consultant at International Planned Parenthood Federation.
In Nigeria, “there is not much attention on adolescent sexual and reproductive health, even though a majority of rapes occur before the age of 13, and the rate of teenage pregnancy and abortions is high,” said Bene Madunagu, chair of the Girls’ Power Initiative (GPI) in Nigeria. GPI teaches girls about their rights to make decisions, including those regarding sex and reproductive health, as well as improving their critical thinking skills, self-esteem, and body image. “Girls develop critical consciousness and question discriminatory practices, while also learning about the legal instruments to take up their concerns,” he said.
Sadaf Nasim of Rahnuma Family Planning said child marriages are common in his country, Pakistan. “Marriage is an easy solution for poor families. Once a girl is married she is no longer the responsibility of the family,” he explained.
While laws in Pakistan and other parts of the developing world condemn child marriage, the prevalence of child marriage remains high: 49 percent of girls are married by age 18 in South Asia, and 44 percent in West and Central Africa. Nasim said birth registration at the local and national levels should be improved to prevent parents from manipulating their daughter’s age.
In Kyrgyzstan, “community-based efforts worked to galvanize media attention and disseminate information to demonstrate the need for improved adolescent family planning,” said Tatiana Popovitskaya, a project coordinator with Reproductive Health Alliance of Kyrgyzstan. Such community-based approaches use grassroots education to mobilize community leaders, which is a critical step in overcoming child marriage and other harmful traditions.
Cell Phones and Maternal Health
“There is a lot of information being collected, but it is not necessarily going where it needs to because of fragmentation,” said Alison Bloch, program director at mHealth Alliance. In developing countries, the people most in need are often the most isolated, but mobile technology is emerging as a way to bridge the gaps.
According to a recent report by mHealth Alliance, 64 percent of mobile phone users live in developing countries and more than half of people living in remote areas will have mobile phones by 2012. The potential for improving global health with cell phones and PDAs is significant, and can address a wide range of health issues, such as human resource shortages and information sharing problems between clinics and hospitals.
“Mobile technology provides benefits to individuals, institutions, caregivers, and the community. It reduces travel time and costs for the individual, improves efficiency of health service delivery, and streamlines information to health workers to reduce maternal mortality,” said Elaine Weidman, vice president of sustainability and corporate responsibility at Ericsson.
“Mobile technology is the most rapidly adopted technology in history and represents an existing opportunity to reach the un-reached,” said Fabiano Teixeira da Cruz, a program manager for the Inter-American Development Bank, speaking of the benefits of using mobile technology to train field-based healthcare workers in Latin America.
While mobile phones are indeed reaching parts of the world not currently equipped with quality healthcare, the lack of systematic coordination and infrastructure at the district and regional levels must also be addressed, as highlighted during a recent Wilson Center event, Improving Transportation and Referral for Maternal Health.
Read about our first impressions of Women Deliver 2010 here.
Calyn Ostrowski is program associate with the Wilson Center’s Global Health Initiative
Photo credit: Woman and child in South African AIDS clinic, courtesy Flickr user tcd123usa. -
Women Deliver 2010: First Impressions
›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. -
Improving Transportation and Referral for Maternal Health
›“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.
Mobilizing District Communities in Rural GhanaTo improve maternal health care in Ghana, “we needed to shift [services] to the community level, where 70 percent of our population lives,” said Dr. John Koku Awoonor-Williams, the east regional director of Ghana Health Service. The “Community-based Health Planning and Services” (CHPS) program was created to galvanize local leadership and empower communities to engage in health outreach activities.
Through this approach, “community health officers and nurses are trained and delegated to distant village locations called CH[I]P zones, in which they are responsible for health education, treatment of minor illnesses, maternal and antenatal care, and referral to district hospitals for emergency care,” said Awoonor-Williams. Community health officers use two-way Motorola walkie-talkies to communicate with traditional birth attendants and referral centers. Pregnant women are given the phone numbers so they can call in the event of complications.
1-0-8 Emergency Number for Improving Maternal Health in IndiaMany parts of the developing world do not have a 911-style emergency response service. To address this gap, the GVK Emergency Management & Research Institute in India developed the toll-free 1-0-8 telephone number for all medical, police, and fire emergencies.
“We assure every citizen that wherever you are, [if] you call us we will be there,” said Subodh Satyawadi, chief operating officer of GVK. In order to reach the 433 million people covered by GVK, they have:
“Although we address all kinds of emergencies, we heavily focus on maternal health…31 percent of emergencies are pregnancy-related,” said Satyawadi, who said that GVK’s emergency response system has helped save more than 200,000 mothers. Institutional deliveries have increased in the state of Gujarat by 92 percent. “We have been able to reduce maternal mortality by 20-25 percent in different geographies,” he said.- 19,623 EMTs and 10,000 doctors and other healthcare professionals
- 2,710 ambulances
- 16,300 call-center employees
Pre-Hospital Barriers: Reducing Maternal Morbidity in BoliviaWomen in Bolivia receive free maternal care. In cities like La Paz, emergency obstetric care is often available within a short distance. However, “37 percent of our maternal deaths [occur] at our hospitals,” said Víctor Conde Altamirano, OB/GYN of CARE Bolivia.
To better understand this mortality rate, Altamirano evaluated whether pre-hospital barriers and routine antenatal care are associated with near-miss morbidity. He found that women who are older, have lower levels of education, lack antenatal care, are pregnant for the first time, or live in rural areas are at a greatest risk of illness or death
“We are trying to organize our communities and service facilities, and promote improved health management by the municipalities. If our authorities can be sensitive and invest in health; invest in fuel, drugs, and human resources; we can improve near-miss morbidity rates,” said Altamirano.
Strategies and Recommendations for Improving Transportation & ReferralThe workshop participants agreed on six key topic areas for improving transportation and referral:
1. Multi-sectoral collaboration
The group called for improved multi-sectoral engagement and continuous dialogue among key ministries: Health, Finance, Communication, Social Welfare, Security and Defense, Transportation, and Public Works.
2. Mobile phone technology
3. Public-private partnerships
4. Referral for newborns
5. Indicators for referral
6. Sharing evidence
Private-public partnerships, such as those demonstrated by GVK in India and the CH[I]P program in Ghana, create opportunities for collaboration. “Cell-phone technology can reduce delays in transport and treatment by identifying which facilities might be the most appropriate for referral,” said Bailey.
The final recommendation by the group calls for increased pooling and use of existing evidence to move the transportation and referral agenda forward. Updated synthesis papers on existing evidence are needed, said Bailey. “We have a lot of data that is perhaps less than perfect, but this should not be a barrier for further action,” she said. -
Urbanization, Climate Change, and Indigenous Populations: Finding USAID’s Comparative Advantage
›May 26, 2010 // By Kayly Ober
“Part of the outflow of migrants from rural areas of many Latin American countries has settled in remote rural areas, pushing the agricultural frontier further into the forest,” writes David López-Carr in a recent article in Population & Environment, “The population, agriculture, and environment nexus in Latin America.” In a May 4 presentation at the LAC Economic Growth and Environment Strategic Planning Workshop in Panama City, Panama, he discussed how to integrate family planning and environmental services in rural Latin America.
Latin America is one of the most highly urbanized continents in the world, with an average of 75 percent of the population living in cities. However, “there are two Latin Americas,” said López-Carr at the workshop, which was sponsored by the Woodrow Wilson Center’s Environmental Change and Security Program and Brazil Institute, as well as the U.S. Agency for International Development. Largely developed countries like Chile, Argentina, and Uruguay are close to 90 percent urbanized, while Guatemala, Ecuador, and Bolivia are about 50 percent. In less urbanized countries, rural-rural migrants in search of agricultural land remain a major driving force behind forest conversion, he said.
Between 1961 and 2001, Central America’s rural population increased by 59 percent, said Lopez-Carr. The increasing density of the rural population had a negative impact on forest reserves: a 15 percent increase in deforestation totaling some 13 million hectares.
“Rural areas of Latin America still have high fertility rates but (unlike much of rural Africa, for example) also have a high unmet demand for contraception, meaning that improved contraceptive availability would likely result in a rapid and cost-effective means to reduce population pressures in priority conservation areas,” he said. Additionally, remote rural areas with high population growth rates tend to be associated with indigenous populations located in close proximity to protected forests.
For example, in Guatemala, communities surrounding Sierra de Lacandon National Park have, since 1990, grown by 10 percent each year, with birthrates averaging eight children per woman. Larger communities and larger households have led to agricultural expansion, which infringes on the park and accelerates deforestation in one of the most biologically diverse biospheres in the world, said López-Carr.
Based on these demographic and environmental trends, López-Carr suggested USAID’s work in the region should focus on rural maternal and child health, and education – especially for girls. Not only does USAID already invest in such programs, but they only cost pennies per capita and could reduce the number of rural poor living in Latin American cities by tens of millions.
Given the strong links between population density and deforestation in Latin America, expanding access to family planning would also be a smart investment in forest conservation and climate mitigation, López-Carr concluded.
Source: Population Reference Bureau.
Photo Credit: Dave Hawxhurst, Woodrow Wilson Center. -
Coffee and Contraception: Combining Agribusiness and Community Health Projects in Rwanda
›“Population pressures and diminishing land holdings – due to high fertility rates, war and genocide, and subsequent migration – have caused a rapid decrease in the forested and protected areas and increased soil infertility and food insecurity” in Rwanda, USAID’s Irene Kitzantides told a Wilson Center audience.
Kitzantides, a population, health, and environment advisor and global health fellow, said “the population is projected to reach over 14 million by 2025” – nearly one-third more than today, due to the country’s high fertility rate of nearly 5.5 children per women–which could continue to negatively impact forests and food supplies.
In response to these challenges, USAID supported the Sustaining Partnerships to Enhance Rural Enterprise and Agribusiness Development (SPREAD) Project. SPREAD uses an integrated population-health-environment (PHE) approach to develop the coffee agribusiness and bring family planning, HIV/AIDS, and reproductive health services to coffee workers.
Combining income generation with health services was thought an effective way to “fulfill the overall SPREAD goal of improving lives and livelihoods,” said Kitzantides.
A SPREADing Mandate: Integrating Health and Agribusiness
SPREAD follows USAID’s PEARL I and II Projects, which focused exclusively on agricultural development. Coffee is still at the center of SPREAD’s activities, with $5 million of the project’s $6 million USAID budget earmarked for agricultural development.
However, a broader mandate to include health services emerged after recognition that greater income alone does not ensure greater quality of life. The additional health funding leverages SPREAD’s already established relationships with farming cooperatives to bring health services to traditionally underserved rural communities.
“We really tried to build on the existing assets of the cooperative,” said Kitzantides. “We also really tried to complement local and national public health policy and partners.”
The integration of health with agricultural goals, and the use of already established in-country health programs, has made SPREAD extremely cost-effective, with HIV/AIDS prevention education costing less than $2 per person.
Examples of SPREAD’s integrated work include:Combined health and agricultural lessons: Kitzantides and her colleagues trained nearly 400 animateurs de café, cooperative employees running the agricultural education programs, to incorporate public health objectives into their activities. Combining health and agricultural education into one session takes advantage of workers already trained during previous USAID programs. The combination also attracts more male participants, who traditionally shunned HIV/AIDS, family planning, and reproductive health campaigns and services.
Radio programming: SPREAD worked with the agricultural radio program Imbere Heza (“Bright Future”) to incorporate health messaging at the end of each program.
Mobile clinics: SPREAD works with cooperatives and local health centers to bring convenient services to farmers when they gather at sales or processing stations during harvests.Community theater: SPREAD hires local theater groups to perform skits on health. The farming communities “really love community theater and always ask for it,” said Kitzantides.
In its relatively short existence, SPREAD’s health activities have reached over 120,000 people with HIV/AIDS prevention messages; nearly 90,000 with messages discussing family planning/reproductive health; and almost 40,000 about maternal and child health. The project counts 347 women as new users of family planning services.
Lessons learned – which will be examined in more detail in an upcoming issue of Focus – include the importance of using community-based approaches to overcome perceived social barriers; the advantages of integrating cross-cutting activities at the outset of a program; and the need for strong monitoring and evaluation systems to measure the effort’s outcomes.
Jason Bremner of the Population Research Bureau said PHE projects such as SPREAD go “beyond what the health sector itself can do and find new ways of reaching underserved remote populations.” He presented a soon-to-be-released PRB map plotting the location of more than 40 PHE projects in Africa.
The success of SPREAD and similar projects demonstrates the potential for PHE approaches to bring reproductive health and family planning services to rural areas, Bremner noted, but there is still much work to be done to scale up this integrated approach – and to document its successes.
Sustaining SPREAD
Kitzantides said it took several years to integrate health activities with the already established agricultural programs. Since USAID funding for the program is scheduled to end in 2011, she is uncertain that the time remaining will be enough for SPREAD’s health partners to develop the logistical and financial capacities to become self-sustaining. But SPREAD has changed attitudes and beliefs, two key objectives that do not require sustained funding.
“We used to talk about growing coffee, making money, buying material things like bikes – not about problems like malaria, HIV/AIDS, etc.,” said one SPREAD agricultural business manager during the program’s evaluation. “Someone could have 5 million Rwandan francs in the house but could suffer from malaria where medicine costs 500 Rwandan francs, due to ignorance. You have to teach people about production, you have to also think of their health to improve their lives.”
Photo Credits: Irene Kitzantides, courtesy David Hawxhurst; condom demonstration, courtesy Nick Fraser; community theater group, courtesy SPREAD Health Program; Jason Bremner, courtesy David Hawxhurst. -
New Maternal Mortality Statistics: A Catalyst for Increased Investment
›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 -
Family Planning in Fragile States
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“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.”
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Thinking Outside the (Lunch) Box: Meat and Family Planning
›May 3, 2010 // By Dan AsinJoel Cohen, a renowned population expert and professor at Columbia and Rockefeller universities, recently gave a lecture simply titled “Meat.” As it was co-sponsored by the International Food Policy Research Institute and the Population Reference Bureau, I was hoping for an insightful discussion of meat eating and its implications for feeding a world of nine billion. While I think Cohen avoided the question of whether meat eating is ultimately sustainable, I was pleased that he included two key insights: the potential for family planning services to contribute to food security, and the importance of using multidisciplinary approaches to solve today’s global problems.
Family Planning for Food Security
In working to improve food security, Cohen said policymakers and practitioners need to focus on those who are most vulnerable. To this end, he identified five groups and suggested targeted policies for each:While the healthy eating policies will not surprise food security experts, his recommendations on family planning might. He highlighted what should be–but is not always–apparent: that tackling food security without thought for family planning is like attempting to fill an empty bucket without first plugging the holes.
Feeding the one billion hungry people in the world today is an enormous challenge that cannot be met by any single policy. Instead, it will take an array of partial solutions, and offering family planning services to women and young people is an important part of the package. Such projects can help reduce the number of children being born into hunger by allowing women and couples to assess their economic and food situations and plan according to their needs and wishes. Voluntary family planning services and materials will not solve the food security challenge on their own, but they can make it more manageable, especially in the long run.
Family planning’s potential contribution to food security is just one part of Cohen’s larger take-home message: population, economics, environment, and culture all interact. To meet today’s multidisciplinary challenges, single-sector approaches are not up to task.
The Many Faces of Meat
Cohen offered two competing perspectives on meat eating. On the one hand, average global meat production generates a fraction of the calories and protein, per unit of land, that could be derived from plant sources. It is likely the “largest sectoral source of water pollution,” said Cohen, and is at least partly responsible for the spread of over a dozen zoonotic diseases. It contributes to only 1.4 percent of world GDP while comprising 8 percent of world water consumption.
These hidden “virtual water” costs made headlines in Britain the other week, when a study on global water security published by the Royal Academy of Engineering popularized the Water Footprint Network’s earlier findings that that an average kilogram of beef requires 15,500 liters of water–over eight times the volume needed to produce the equivalent weight in soybeans and greater than 10 times that needed for the equivalent amount of wheat.
On the other hand, Cohen pointed out that meat production provides livelihoods for an estimated 987 million of the world’s rural poor, and has important cultural significance in many societies. And it can provide many essential nutrients, even in small doses.
In one study he cited, children living in Kenya who were provided 1 ounce of meat a day received 50 percent of their daily protein requirements and showed greater increases in physical activity and development, verbal and arithmetic test scores, and initiative and leadership behaviors as opposed to students who received the calorie-equivalent in milk or fat.
The Four Factors: Population, Economics, Environment, and Culture
Clearly, Cohen’s four factors all come in to play when evaluating meat’s role in food security. An analysis of any global health issue that looks at only one factor would miss indispensable parts of the problem.
“Population interacts with economics, environment, and culture,” Cohen concluded. “If you use that checklist when somebody gives you a simple-minded solution to a problem, you can save yourself a lot of simple-minded thinking.”
Photo: Pigs on a farm, courtesy Flickr user visionshare.
