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Accessing Maternal Health Care Services in Urban Slums: What Do We Know?
›“Addressing the needs of urban areas is critical for achievement of maternal health goals,” said John Townsend, vice president of the Reproductive Health Program at the Population Council. “Just because there is a greater density of health services does not mean that there is greater access.”
Townsend moderated a discussion on the challenges to improving access to quality maternal health care in urban slums as part of the 2011 Maternal Health Dialogue Series with speakers Anthony Kolb, urban health advisor at USAID; Catherine Kyobutungi, director of health systems and challenges at the African Population Health Research Center; and Luc de Bernis, senior advisor on maternal health at the United Nations Population Fund (UNFPA). [Video Below]
Mapping Urban Poverty
“Poverty is becoming more of an urban phenomenon every day,” said Kolb. With over 75 percent of the poor in Central Asia and almost half of the poor in Africa and Asia residing in cities and towns by 2020, “urban populations are very important to improving maternal health,” he added.
Collecting accurate data in informal settings such as slums can be very challenging, and there is often a “systematic undercounting of the urban poor,” said Kolb. Data often fails to capture wealth inequality in urban settings, and there is often a lack of attention to the significant variability of conditions between slums.
Kolb also warned about the risk of generalization: “Slums and poverty are not the same.” In practice, there is not a standardized definition of what constitutes a slum across countries, he said. “It is important to look at different countries and cities individually and understand how inequality is different between them.” Slum mapping can help to scope out challenges, allocate resources appropriately, and identify vulnerability patterns that can inform intervention design and approach, he said.
Maternal Health in Nairobi Slums
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 Kyobtungi.
Only 7.5 percent of women in Kenyan slums had their first antenatal care visit during their first trimester of pregnancy and only 54 percent had more than three antenatal care visits in all – rates significantly lower than those among urban women in non-slum settings.
“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.
The majority of maternal health services in slums are provided by the private facilities, though size and quality vary widely. “There is a very high use of skilled attendants at delivery, but the definition of skilled is questionable,” said Kyobtungi
“Without supporting the private sector,” Kyobutungi said, “we cannot address the maternal health challenges within these informal settlements.” Combined with an improved supervision and regulation system, providing private maternal health facilities with training, equipment, and infrastructure could help to improve the quality of services in urban slums, she concluded.
Reducing Health Inequalities
“While we have evidence that health services, on average, may be better in urban areas than in rural areas, this often masks wide disparity within the population,” said de Bernis. “Reducing health inequities between and within countries is a matter of social justice.”
When it comes to family planning, total fertility rates are lower in cities, but “the unmet need…is still extremely important in urban areas,” explained de Bernis. Many poor women in cities, especially those who live in marginalized slum populations, do not have access to quality reproductive health services – a critical element to reducing maternal morbidity and mortality rates.
Economic growth alone, while important to help improve the health status of the poor in urban settings, will not solve these problems, said de Bernis. To reduce health disparities within countries, de Bernis advocated for “appropriate social policies to ensure reasonable fairness in the way benefits are distributed,” including incorporating health in urban planning and development, strengthening the role of primary health care in cities, and putting health equity higher on the agenda of local and national governments.
Event Resources:Source: African Population Research Center, United Nations Population Fund.
Photo Credit: “Work Bound,” courtesy of flickr user Meanest Indian (Meena Kadri). -
Top 10 Posts for April 2011
›The launch of the “Mr. Y” national security narrative here at the Wilson Center topped the list of most popular stories last month, but IFAD’s latest rural poverty report, two interview features on population and development, and Richard Cincotta’s predictions on Tunisia also made the top 10.
1. In Search of a New Security Narrative: The National Conversation at the Wilson Center
2. Rural Poverty: The Bottom One Billion
3. Watch: Roger-Mark De Souza on the Scaling Advantages of Population, Health, and Environment Integration
4. Watch: David Lopez Carr and Liza Grandia on Rural Population Growth and Development in Guatemala
5. India’s Maoists: South Asia’s “Other” Insurgency6. Managing the Mekong: Conflict or Compromise?
7. Tunisia’s Shot at Democracy: What Demographics and Recent History Tell Us
8. What “Lost” Cultures Can Contribute to Management of Our Planet
9. Dot-Mom: Innovations From Development to Delivery: Working With the Private Sector to Improve Maternal, Newborn, and Child Health
10. Tunisia Predicted: Demography and the Probability of Liberal Democracy in the Greater Middle East -
David Biello, Momentum Magazine
Coping with Change: Climate Adaptation Today
›May 2, 2011 // By Wilson Center StaffThe original version of this article, by David Biello, appeared in the University of Minnesota’s Momentum Magazine.
The view from space offers a clarity about our changing planet less visible from the ground: spring thaw coming sooner year after year, the iconic snows of Kilimanjaro and glaciers across the globe dwindling – and a great green wall of vegetation spreading across the region just south of Africa’s Sahara Desert.
This arid expanse, known as the Sahel, stretches from the Atlantic Ocean to the Red Sea. It has undergone a remarkable transformation since farmers in nations across the region began to allow trees to grow amidst their crops.
In some places it was by accident, as seeds sprouted from manure spread as fertilizer in Niger. In others it was by design, such as the “green dam” against the desert started in Algeria in 1971. But the result has been the same: improved harvests of millet, sorghum, and other staple crops in a region gripped by perennial drought.
Such “agroforestry” boosts yields by returning vital nutrients to the soil in the form of decaying leaves, shading crops from the harshest sun, and recharging underground water reserves. The trees also provide an additional source of income: wood for fires and construction. And they have another even more important benefit: They may help some of the poorest farmers in the world adapt to climate change – while potentially removing as much as 50 billion metric tons of carbon dioxide from the atmosphere, according to agronomist Dennis Garrity, head of the Nairobi-based World Agroforestry Centre.
“The transformation of agriculture into agroforestry is well underway,” Garrity says. “Agricultural systems incorporating trees increase overall productivity and incomes in the face of more frequent droughts, and agroforestry systems provide much greater carbon offset opportunities than any other climate mitigation practice in agriculture.”
Climate change is already worse than anticipated by the UN Intergovernmental Panel on Climate Change. Extreme precipitation events, such as last spring’s flooding in Nashville, Tenn., or last winter’s drought in China, have become more frequent. Sea ice extents have reached record lows in the Arctic. And 2010 marked the end of the hottest decade in recorded history.
Not only that, but the 0.7-degree-Celsius uptick in global average temperatures we’ve seen so far is only half the warming that can be expected from the concentrations of greenhouse gases already in the atmosphere, according to a 2010 report from the U.S. National Research Council. And as warming continues, according to the NRC report, the world can expect (among other things) a drop in the yield of cereal crops due to higher temperatures, an increase in heavy rainfall, and a rise in ocean levels.
In other words, whatever measures might be adopted to reduce emissions of greenhouse gases, the world will still need to adapt to a changing climate. Indeed, that process has already begun.
Continue reading on the University of Minnesota’s Momentum Magazine site.
Photo Credit: Deep in the Sahel, the dwindling Lake Chad borders Niger, Chad, and Nigeria. Courtesy of flickr user NASA Goddard Photo and Video. -
Watch ‘Dialogue’ TV on Integrating Development, Population, Health, and the Environment
›Last week on the Wilson Center’s Dialogue radio and television program, host John Milewski spoke with Geoff Dabelko, director of ECSP, Roger-Mark De Souza, vice president for research and director of the Climate Program for Population Action International, and George Strunden, vice president of Africa programs for the Jane Goodall Institute. They discussed the challenge of integrating population, health, and environmental programs (PHE) to address a broad range of livelihood, development, and stability issues. [Video Below]
“Many times that we tackle development or poverty and human well-being challenges…we do it in an individual sector – the health sector, or agriculture sector, or looking at issues of water scarcity – and it makes sense in many respects to take those individual focuses,” said Dabelko. “But of course people living in these challenges, they’re living in them together…so both in terms of understanding the challenges…and then in responding to those challenges, we have to find ways to meet those challenges together.”
De Souza noted that the drive for integrated development stems from the communities being served, not necessarily from outside aid groups. “We’ve seen that there’s a greater impact because there’s longer sustainability for those efforts that have an integrated approach,” he said. “There’s a greater understanding and a greater appreciation of the value that [PHE] projects bring.”
Strunden said that the Goodall Institute has found similar success in tying health efforts with the environment in places where previously conservation work alone had been unsuccessful.
The panelists also discussed the role of population in broader global challenges, including energy, water, and food scarcities, and women’s rights.
Dialogue is a co-production of the Woodrow Wilson International Center for Scholars and MHz Networks. The show is also available throughout the United States on MHz Networks, via broadcast and cable affiliates, as well as via DirecTV and WorldTV (G19) satellite.
Find out where to watch Dialogue where you live via MHz Networks. You can send questions or comments on the program to dialogue@wilsoncenter.org. -
Watch: Jennifer Dabbs Sciubba on Population and National Security
›April 28, 2011 // By Schuyler Null“Long-term trends really are what shape the environment in the future,” said Jennifer Dabbs Sciubba in this interview with ECSP. “As we’ve seen recently with…revolution in North Africa, it’s the long-term trends that act together for these things to happen – I like to say demography is not usually the spark for a conflict but it’s the fodder.”
Sciubba is the Mellon Environmental Fellow in the Department of International Studies at Rhodes College. In her new book, The Future Faces of War: Population and National Security, she discusses the importance of demographic trends in relation to security and stability, including age structure, migration, youth bulges, population growth, and urbanization.
One of the most important things to emerge from the book, said Sciubba, is that countries that are growing at very high rates that are overwhelming the capacities of the state (like many in sub-Saharan Africa) really will benefit from family planning efforts that target unmet need.
Afghanistan, for example, “has an extremely young age structure,” Sciubba pointed out. “So if you’re trying to move into a post-conflict reconstruction atmosphere…you absolutely have to take into account population and the fact that it will continue to grow.”
“Even if there are major moves now in terms of reducing fertility, they have decades ahead of this challenge of youth entering the job market,” Sciubba said. “Thousands and thousands more jobs will need to be created every year, so if you have a dollar to spend, that’s a really good place to do it.”
For more on Jennifer Dabbs Sciubba and The Future Faces of War, see her book launch at the Wilson Center with Deputy Under Secretary Kathleen Hicks of the Department of Defense (video) and some of her previous posts on The New Security Beat. -
The U.S. Government’s Response to Disasters: Myth, Mistakes, and Recovery
›“Major crises and disasters have massively changed over the last generation,” said Dr. Frederick Burkle, senior public policy scholar at the Woodrow Wilson Center and senior fellow and scientist at the Harvard Humanitarian Initiative. “We have to start a new narrative of what we need to do to address [them].”
To discuss the emerging and persistent challenges of disaster prevention, preparedness, response, and recovery, Burkle was joined by Paul Born, co-founder and director of the Tamarack Institute for Community Engagement; Leonard Doyle, Haiti country spokesperson at the International Organization for Migration; Arif Hasan, adviser at the Orangi Pilot Project and founder and chairman at the Urban Resource Centre; and Dr. Eliane Ubalijoro, adjunct professor at McGill University and member of the Presidential Advisory Council for Rwandan President Paul Kagame.
“Retrieving the Wisdom of Those in Need”
Unfortunately, disaster responses often fail to “listen and gain a corner on the obvious,” said Born, discussing the need for community engagement and healing in times of disaster and conflict.
After Hurricane Katrina, for example, the formal disaster response failed to use hundreds of available buses to evacuate people, leaving thousands of people stranded in the floods. “If people were engaged, had a role to play, knew what to do, were part of a team, would this have made a difference? Would those buses have been deployed to help people?” asked Born.
Effective disaster response must utilize “the assets, the skills, and the knowledge that are present,” concluded Born. For example, when the systems in place by the Philippine government in the village of Talba failed to give proper warning to evacuate from a volcanic eruption, “it was a parallel warning system, developed by the community, that warned people, on time, to vacate the area and avoid any loss of life,” said Born. Community preparedness and engagement led to better utilization of available humanitarian assets and mitigated what could have been a much more severe disaster.
The Changing Nature of Humanitarian Emergencies
Increasingly, humanitarian crises are the result of unconventional warfare, causing major challenges for the humanitarian community, said Burkle. Rather than refugees, “what we are beginning to see today is an unprecedented number of internally displaced people.”
Many of the displaced migrate to urban settings, contributing to rapid urbanization which is straining water, sanitation, and public health infrastructure. In these settings, he said, there is sometimes only one latrine for every 200 people, new and infectious diseases are rampant, and high rates of violence and rape are common, putting women particularly at risk.
“It is a lot more than population size – it’s really density of population,” said Burkle. In Mumbai, for example, there is an average of 30,000 people per square kilometer, but there are major areas of the city with over one million people per square kilometer.
“People moving to the cities are still remaining in extreme poverty,” said Burkle. While the majority of the poor once lived in low-income fragile states, recent population data indicates that 72 percent of the world’s poor now live in middle income countries like India, Indonesia, and China. “It’s a total reversal – we’ve spent almost 20 years crafting our foreign aid budgets and policy around this…we have to start a new narrative about what we are going to do.”
“The other issue that I don’t think we hear about, but certainly the young people in the audience will be dealing with on a daily basis, are the biodiversity crises,” said Burkle. “Of the 34 biodiverse areas, 23 have experienced prolonged conflict,” which has had major impacts on the availability of water, food, and energy in these regions, said Burkle.
Moving forward, “we have to change the humanitarian community; we have to have more accountability and more accreditation, leading to a blueprint for professionalizing the humanitarian field,” concluded Burkle.
Community and Communication in Haiti
A little over one year after the devastating earthquake in Haiti, 680,000 people remain internally displaced, said Doyle. “About half the population has moved out of the camps, and there is some congratulations to be given to the humanitarian community for organizing that,” he said. “But, when you look at the statistics…only a tiny fraction of these people have reached what you would call durable solutions such as sustainable housing.”
“There is clearly a problem… why has more progress not taken place given the number of international organizations there and the generosity of the funding?” asked Doyle.
“People have a right to communicate and there is a benefit in that communication,” said Doyle. To help make this possible in the Haitian displacement camps, he and his colleagues at the International Organization of Migration (IOM) set up 140 suggestion boxes. The response was amazing, he said, and with the help of a local Haitian organization, IOM has begun broadcasting some of the over 5,000 letters received on a daily radio show.
“We need to help create respectful conversations in countries where we do so much hard work but see so much of it go nowhere,” said Doyle. Information from the letters has been compiled into reports detailing the major challenges faced by people including a lack of jobs, education, and housing. These letters are being used as a monitoring and accountability mechanism through which Haitians can tell NGOs and donors the successes and failures of projects being implemented in their communities. “Through this communication you can see what the community needs, rather than what the experts tell you the community needs,” he said.
Engaging Local Communities
“Regions are sometimes so badly devastated [after a disaster], that to rehabilitate their agriculture, transport, water supply systems, is a very daunting task,” said Hasan. His home country of Pakistan faced all of these challenges after heavy rains and subsequent flooding wiped out 3,000 villages and affected over 20 million people last year.
“Without a governance system, you cannot provide rehabilitation or relief,” Hasan said, citing an added challenge for disaster response in many developing countries. Often the needs of the people are not translated in to policy actions, he said, and “there is a big difference between what people want and what politicians want.”
Hasan offered some insights on how the development community can work with local communities to improve disaster response, pointing out that “pre-disaster situations determine the effectiveness of relief and rehabilitation.” Existing mechanisms to provide development assistance can be used to efficiently deliver goods and services in emergencies, he said. By fostering “true partnerships” international NGOs can help communities and governments should manage reconstruction and relief efforts after disasters using local materials, labor, and technologies, he said. Engaging communities in reconstruction “can be a really important healing process.”
Recovery and Resilience
“When you have a community that has been reduced to ashes, how can you retrieve hope so that transformation can happen?” asked Ubalijoro, stressing the importance of building community resilience after disasters. “We’ve been talking about disasters, but it’s important to remember how we learn to dream again together.”
Baskets of Hope is a project that aims to help Rwandan women recover from the genocide by providing training and jobs weaving baskets that are sold internationally. In addition to providing a source of income, the project also provides information about health and nutrition. With this multi-pronged approach, Baskets of Hope helps families to recover and move forward. “There’s an interesting relationship between weaving these baskets that are allowing these women to have economic empowerment and what it requires after a time of trauma to reweave the fabric of society,” said Ubalijoro.
Youth who have survived man-made or natural disasters are particularly vulnerable, said Ubalijoro. She and her colleagues work to link Rwandan youth with Holocaust survivors so that they can share their memories, pictures, and stories with one another. “Retrieving the wisdom from those who have gone through the unimaginable and having them share their experiences shows youth that even though they’ve lost everything, there are ways to move forward.”
Sources: Conservation International, Institute of Development Studies, International Organization for Migration, USAID.
Photo Credit: “Pakistan Floods” courtesy of flickr user IRIN Photos. -
Watch: Addressing the National Security Implications of U.S. Oil Dependency
›April 27, 2011 // By Schuyler NullBoth the civilian and military sectors have key roles to play in achieving energy security as the United States addresses the national security implications of its oil dependency. Yesterday, the White House hosted a forum with senior officials from both the public and private sector to highlight avenues toward achieving that security. Co-hosts Deputy Energy Secretary Daniel Poneman and Deputy Defense Secretary William Lynn were joined by Woodrow Wilson Center President Jane Harman, John Podesta of the Center for American Progress, and John Deutch of the Massachusetts Institute of Technology.
The panelists discussed ongoing cooperation between the Department of Energy and Department of Defense, and Harman in particular highlighted the power of the military to drive innovation and more efficient production of energy-efficient technologies.
“‘Energy security’…reminds us that important domestic energy developments have international consequences, and important international events have domestic consequences,” said Deutch, pointing out the linked, global nature of energy markets and climate change.
Deputy Secretary Lynn highlighted the tactical tactical benefits of reduced petroleum dependence with the example of a solar panel pilot program being conducted by the Marine Corps in Afghanistan:The regiment selected to try out the solar panels deployed to one of the most violent districts in Helmand province. The operational gains were immediate: Marines ran two patrol bases completely on solar power and cut diesel fuel consumption at a third base by over 90 percent. On one three-week foot patrol, flexible solar panels eliminated battery resupply needs entirely, ending supply drops that previously were required every 48 hours.
Watch the full forum above, and see also the recent National Conversation at the Woodrow Wilson Center that focused on “A New National Security Narrative.” -
Marissa Mommaerts, Aspen Institute
Aspen Institute: The Revolution We Need in Food Security and Population
›April 27, 2011 // By Wilson Center StaffThe first months of this year brought the second global food price crisis in just three years, with soaring food prices against a backdrop of bad weather, poor harvests, and political turmoil in North Africa and the Middle East. This year will see another milestone: the planet’s population is set to surpass seven billion, with most of the population growth occurring in countries least equipped to meet rising demands on agriculture and the environment. As part of its 7 Billion: Conversations that Matter roundtable series, the Aspen Institute’s Global Health and Development Program brought together three experts to discuss “The Revolution We Need in Food Security and Population” on April 12.
A Publication of the Stimson Center.
