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Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.
For women around the world, compassionate and competent care from a midwife can mean the difference between life and death. We know that midwives provide life-saving care during pregnancy, childbirth, and in the postnatal period. Midwives, and other mid-level and community health providers, can administer essential medicines, such as oxytocin and misoprostol, which are safe and effective for preventing and treating life-threatening postpartum bleeding or hemorrhage (PPH), the leading cause of maternal death in most developing countries. Access to misoprostol is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used in poorly equipped health facilities and even home births.
In order for midwives to provide life-saving maternal health care, they need the support of policies that enable them to provide a full range of medical interventions. In some countries, however, midwives are not legally authorized to administer oxytocin and/or misoprostol —despite evidence that administration by low and mid-level health providers is feasible and effective. But physicians sometimes resist or oppose expansion of midwives’ scope of practice, based on notions of “professional territoriality” and concerns about their capacity to correctly and safely administer these medications.
Most women in low-resource settings give birth in lower-level health facilities or at home, attended by a midwife or other mid-level health provider. So restrictive policies requiring that administration of medications be carried out only by physicians limits women’s access to essential medicines they need for safe pregnancy and childbirth. Placing misoprostol in the hands of non‐physician providers, for example, can expand access to timely PPH treatment. In remote and rural areas, where transfer for emergency obstetric treatment at a higher-level facility may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.
The global health community can play an important role in addressing and removing policy and regulatory barriers, and ultimately in improving women’s access to essential medicines. Making this happen will require that governments, in many countries, revise policies that allow administration of medications only by physicians. In 2012, WHO issued guidelines on task-shifting for maternal and newborn health. They called for a “more rational distribution of tasks and responsibilities among cadres of health workers …[to] significantly improve both access and cost-effectiveness – for example by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions otherwise provided only by cadres with longer (and sometimes more specialized) training.” This makes excellent sense.
The leading global health professional associations focused on pregnancy and childbirth, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO), can work together to ensure that these international recommendations translate into changes in national norms and in clinical practice. Earlier this year, ICM and FIGO issued a joint statement, Misoprostol for the treatment of postpartum hemorrhage in low resource settings, which called on partners to:
- Promote task-sharing approach
- Ensure that skilled health providers (and not just doctors) can administer uterotonic drugs like misoprostol and oxytocin
- Challenge regulatory and policy barriers that limit access to high quality maternal health care
- Advocate for increasing the midwifery workforce
- Implement innovative strategies to strengthen the role of midwives and non-physician providers in providing high-quality maternal health services
Health professionals, policy makers, and other partners must work together to ensure that every woman has access to the uterotonic medicines that can protect her from the suffering and potential death that can be caused by postpartum hemorrhage.
 Beverly Winikoff, Why misoprostol in the hands of non-physician providers matters, Presentation at the ICM Trienniel Congress, Prague, June 3, 2014.
Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.
Civil society organizations (CSOs) around the world are working to improve maternal health and make a difference in the lives of women, families, and communities. In many countries, CSOs play a critical role in the health sector by providing quality maternal health services, and by supporting advocacy to ensure government policies are implemented, funds invested and tracked, and health outcomes measured and published.
In 2013, with support from Merck Inc. through the Merck for Mothers Program, Family Care International (FCI) completed a comprehensive mapping of the maternal health advocacy environment in two countries, Uganda and Zambia. Data for the mappings were collected at the national level (and at the district level in Uganda) using a multi-dimensional methodology which triangulated data from key informant interviews, focus group discussions, and desk research.
The mapping examined each country’s maternal health policy framework, identified stakeholders working in maternal health advocacy, and analyzed opportunities and challenges for maternal health advocacy organizations. It also highlighted the potential for engaging the private sector on maternal health, and put forward a set of recommendations for strengthening maternal health advocacy efforts, and the role of CSOs in particular.
In Uganda, the mapping found that while there is a relatively active health advocacy sector and strong policy framework in place for maternal health, advocacy organizations are not coordinating efforts well, leading to a fragmented advocacy environment. In addition, maternal health advocacy organizations face critical resource constraints, and are not effectively measuring the impact of their advocacy work. For additional information, the full mapping report can be accessed here.
In Zambia, there exists a favorable policy environment for maternal health, and a strong evidence-based decision-making ethos in government. While Zambia is a signatory to a number of commitments to improve maternal health services, the maternal health advocacy environment is not particularly strong or robust. More information is available in the full mapping report here.
The findings from these mappings revealed a number of common themes and recommendations for supporting the critical role of CSOs in both countries:
- Establish or enhance a coordinating mechanism through which the growing and diverse body of advocacy organizations can work together and advance common messages, agendas, and strategies.
- Support local advocacy organizations, which often operate with limited resources, staffing, and capacity, to build their administrative, management, and planning capabilities in conducting effective advocacy.
- Strengthen monitoring and evaluation of maternal advocacy efforts by supporting maternal health advocacy organizations in the development of tools, indicators, and mechanisms for measuring advocacy outcomes and impact.
Sustained and long-term investments in supporting CSOs to conduct effective advocacy for maternal health are needed now, more than ever. Without these investments, we will continue to be far behind in reaching national and global commitments for maternal health.
By Katie Millar
Katie Millar is a technical writer for the Maternal Health Task Force (MHTF), where this article originally appeared.
Today, at the London School of Hygiene and Tropical Medicine, The Lancet launched its newest series Midwifery. This series provides concrete actions for stopping preventable maternal and newborn death and ensuring perinatal health. The knowledge that midwives are key to preventing perinatal death is not new. However, scaling up the utilization of midwives on a systems level is lacking, which has prevented this solution from becoming a reality.
The Midwifery Series was created to provide concrete guidance and frameworks on how to utilize midwives and a new standard of care for Quality Maternal and Newborn Care (QMNC). At the center of this model of care are the needs of women and their newborn infants. Even though the needs of women across the world seem to differ greatly, this series clarifies that no matter where a woman lives, care led by a midwife is the answer to ensuring health. The series comprises four separate papers which were created by a multidisciplinary group, including academics, researchers, advocates for women and children, clinicians, and policy-makers. This multidisciplinary approach is necessary for addressing current gaps in perinatal care.
The current maternal and newborn health landscape often offers fragmented solutions and interventions to address the needs of women and their newborns. This fragmentation is a barrier to adequate perinatal care. These gaps in care lead to 98% of the annual 289,000 maternal deaths, 2.6 million stillbirths, and 2.9 million neonatal deaths. In order to mitigate these preventable deaths, improvements in the quality throughout the continuum of care and emergency services are imperative. The series supports a whole-system approach to improving perinatal care by ensuring skilled care for all.
The Lives Saved Tool (LiST) was used in the series to model different levels of scale-up of essential interventions for reproductive, maternal, and newborn health (RMNH) which are within the scope of practice of a midwife. In low-resource settings even a 10% increase in the interventions covered by midwifery would decrease maternal mortality by 27%. Therefore, more rigorous scale-up could have an incredible impact on reducing maternal mortality.
The standard for QMNC presented in the series is globally applicable as it not only focuses on the scale-up of essential interventions, but also the harmful effects and necessary mitigation of over-medicalization of birth and perinatal care. Professor Petra ten Hoope-Bender, of the Instituto do Cooperación Social Integrare, Barcelona, Spain, said, “Although the level and type of risks related to pregnancy, birth, postpartum and the early weeks of life differ between countries and settings, the need to implement effective, sustainable, and affordable improvements in the quality of care is common to all, and midwifery is pivotal to this approach. However, it is important to understand that to be most effective, a midwife must have access to a functioning health-care service, and for her work to be respected, and integrated with other health-care professionals; the provision of health care and midwifery services must be effectively connected across communities and health—care facilities.”
In order to assist the development of health systems and their integration of midwives, the series provides three new tools:
- The Framework for Quality Maternal and Newborn Care is applicable to all countries on not only what needs to be implemented, but how to implement strategies to reduce maternal, neonatal, and infant mortality and morbidity, improve quality of care, and increase efficiency of health systems.
- Country diagrams can be used to identify the most important elements required to strengthen a country’s health systems to provide quality midwifery services.
- Pragmatic steps provide a guide to initiate or further develop their midwifery services.
Midwives not only provide care at the time of birth, but work with women from before their pregnancy through their newborns infancy to prevent death and ensure health. This life course approach is essential for having a large impact on the needless numbers of deaths and morbidities. Check out The Lancet’s Midwifery Series for more details on how midwives will make a large difference in the lives of women and their children in the coming years as the post-2015 agenda is implemented.
By Katie Millar
Katie Millar is a technical writer for the Maternal Health Task Force (MHTF), where this article originally appeared.
Hundreds of thousands of women die every year giving birth. The leading causes of these deaths—hemorrhage, infection, and eclampsia—are mostly preventable and treatable. Yet, proven treatments for these conditions are not reaching the women who need them most. In the poorest parts of the world, one in six women will die giving birth, compared to one in 30,000 in Northern Europe. To die giving birth must not be an expectation; we must make it the rarest exception.
Post-partum hemorrhage (PPH), the leading cause of maternal mortality, is mostly preventable. The onset of PPH is usually sudden, and if a woman is not giving birth in a well-equipped facility, she will face many delays getting care—delays that could cost her life. Since PPH needs immediate and effective treatment, prevention is a better option, especially for women who live far from a facility.
A prevention strategy has been discovered. The drug Misoprostol is a tablet that, when given immediately after the baby is born, can prevent life-threatening PPH. Misoprostol works by causing strong uterine contractions, putting pressure on potentially leaky blood vessels. Although this strategy is simple and inexpensive, there are many controversies surrounding its implementation.
Despite the WHO adding misoprostol to its essential medicines list for all countries, some contest its scale-up. One reason is that misoprostol can be used to cause abortion if taken before the clinically indicated period, or the time immediately following birth. To advocate for this life-saving commodity, Family Care International has created an advocacy tool to facilitate the uptake and scale-up of misoprostol to save lives.
This publication, available in English and soon in French, provides national advocates and civil society organizations guidance in conducting effective advocacy for the successful uptake of misoprostol for prevention and treatment of PPH. Through case studies and an Advocacy for Access Framework, the publication provides concrete examples to support misoprostol’s availability and use at the national level.
If you are working to prevent maternal mortality, please take a moment to explore this resource. Advocating for the scale-up of misoprostol can have a profound effect on decreasing the number of women who die giving birth each year.
Are you currently working in preventing PPH and/or the scale-up of misoprostol? Please contact Katie Millar if you are interested in being a guest blogger for the MHTF. We, and many others in the field, would benefit greatly to hear about your experiences.
Amy Boldosser-Boesch is FCI’s Director of Global Advocacy. This article originally appeared on the Global Motherhood section of Huffington Post.
In 1998, Fatimata Kané was still a practicing midwife, visiting a local village when she met Kadija.* Kadija was pregnant and nearing the end of her third trimester. Fatimata could immediately see that Kadija was not well: she looked exhausted, was severely anemic, and had edema in her lower extremities. If she didn’t seek care right away, both she and her baby could die during labor. Fatimata told the woman and her family that she needed to get to a hospital quickly, but the family did not understand. Kadija had many children and had never once received pre-natal care or been to a hospital. All of her babies had been delivered at home, and she used the traditional medicines available in her village. She lived over 10 miles from a hospital and the trip was expensive.
After a lot of persuading, Fatimata convinced the woman’s family to let her deliver in the hospital. Sadly, they could not get to the hospital fast enough to save the baby, but were able to save Kadija’s life. Fatimata often replays the moment over and over in her head. Had she not been there, and had she not been trained as a midwife, she would not have known that Kadija was in urgent need of care.
Fatimata, now the director of FCI-Mali, is using her firsthand knowledge of the need for quality reproductive, maternal and newborn health care at the community level to advocate full time for improved maternal and newborn health care in Mali. She makes the case for strengthening midwifery through increased investments in training and supportive policies so that midwives can continue to provide lifesaving care to pregnant women and newborns, including pre-natal and post-natal care and family planning, in their communities.
Midwives, like Fatimata, can be a profound and powerful voice for change in their countries. If their services were available and accessible to all women and babies who need them, midwives could help avert two-thirds of the nearly 300,000 maternal deaths and half of the 3 million newborn deaths that occur each year, provided they are well-trained, well-equipped, well-supported and authorized. Midwives understand the health care needs of women and newborns, because they work to meet those needs every day. They see the gaps in the health care system — in resources, staffing, facilities, and policies — because they struggle to fill those gaps, day in and day out. And they are uniquely positioned to speak the truth about midwives’ need for training, for support, and for enabling policies – because they have dedicated their lives to doing this crucial job for women and their families.
In partnership with Johnson and Johnson, the International Confederation of Midwives and UNFPA, Family Care International (FCI) is helping to prepare midwives to advocate for improved maternal and newborn health services using evidence from a new report on The State of the World’s Midwifery. Although providing quality midwifery care will always be their first priority, midwives can also be champions for their profession, helping to hold governments accountable for keeping the promises they’ve made to women and babies, and ensuring that young midwives just starting out in their careers will enter a workplace that recognizes, values and supports their role.
National midwives associations have already been successful in advocating for new policies ranging from a policy for development of a national education system for midwives in Afghanistan to a policy on improving quality family planning services to improve maternal health in Nigeria.
Enis Banda, a midwife from Malawi, said on this year’s International Day of the Midwife that “life starts in the hands of a midwife.” With tools to support their advocacy efforts, stronger policies and programs to improve midwifery care and maternal and newborn health can start in the hands of a midwife too.
How will you help make the case for midwifery in your community?
*not her real name
Catherine Lalonde is FCI’s senior program officer for Francophone Africa.
I just returned from a week in Senegal where I attended a regional workshop to train civil society, parliamentarians and the media on budget analysis and advocacy for maternal and child health.
For years now, countries across the globe have said that maternal health is one of their top priorities; they’ve made statements, built coalitions, and developed strategies. On the surface, it seems as though a lot is happening in the realm of reproductive, maternal, newborn and child health (RMNCH). Despite all the rhetoric, little progress has been made in improving the health of mothers and children, especially in the poorest countries in the world.
Since I started working at FCI a year ago, I have mainly been involved in advocacy projects aimed at keeping governments accountable to their commitments. In Burkina Faso, Mali and Kenya, we and our partners are constantly asking governments to invest in and implement programs that will improve RMNCH in their countries. Whenever we question why contraceptives aren’t available in the villages or why health centers are not staffed with qualified personnel, we almost always gets the same answers: there’s no money, we don’t have the funding, and we can’t afford it.
A budget is the single best indicator of a country’s priorities and the best way to tell whether a country is putting its money where its mouth is and whether or not it has taken steps towards fulfilling its maternal and child health commitments.
Organized by Harmonization for Health in Africa, UNICEF, WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH), Save the Children, the InterParliamentary Union and FCI, the three-day budget advocacy workshop brought together members of local NGOs and reporters, along with parliamentarians and representatives from the ministries of finance and of health from the Democratic Republic of the Congo, Niger, Mali, Burkina Faso and Senegal.
A budget is public property; it represents the money that belongs to each and every citizen of a country and therefore, the public should have a genuine say in how the money is distributed and spent. But the countries represented in the workshop had budgets that rank among the least transparent in the world, according to the International Budget Partnership’s Open Budget Survey, which reveals what information is made public and when, as well as who gets to contribute to the process and how often. Of the workshop’s participating countries, Burkina Faso’s budget had the best transparency score– a measly 23 out of a 100; Niger, with the least transparent budget, scored a depressing 4 out of 100, with zero meaningful opportunities for civil society to contribute to the country’s budgeting process.
The workshop facilitators emphasized the important role the budget plays in RMNCH and the financial costs of not investing in RMNCH. It also taught how good health policies are developed and costed, and provided options for increasing fiscal space – the money to fund these policies – within the existing budget. This workshop provided participants with an outline of the budgeting process, and all of the opportunities in which civil society should be able to contribute. At the end, each of the delegations developed advocacy objectives and strategies to improve civil society’s contribution to the budgeting process in order to prioritize health. For example, the Burkina Faso delegation chose to advocate for increased investment in information systems to better track health data while the Malian delegation chose to focus advocacy on ensuring that Mali meets the Abuja declaration pledge to dedicate 15% of its budget to health.
A good friend of mine who works in finance once told me that talking about money scares people, that people often feel as though they don’t have enough knowledge to contribute and are too embarrassed to say so. The organizers and I were afraid that the workshop would be too long, too technical and hard to follow, but we couldn’t have been more wrong. The participants lapped up every word on every slide, and were thrilled to be equipped with the knowledge of the role they can play in ensuring that their country’s budget prioritizes maternal and child health.
The presentation on increasing fiscal space even got a standing ovation!
Advocacy success story: Burkina Faso broadens access to misoprostol, an essential maternal health medicine
By Brahima Bassane, MD
[Version française ci-dessous]
Brahima Bassane, FCI’s national director in Burkina Faso, is a public health physician.
Postpartum hemorrhage (PPH) — excessive, uncontrolled bleeding after childbirth —remains the leading cause of maternal death worldwide. In countries like Burkina Faso, where many births still occur at home, the drug misoprostol offers a number of advantages for preventing and treating PPH because (unlike oxytocin, considered the ‘gold standard’ medicine for PPH) it can be easily administered and does not require cold storage. In settings with limited infrastructure and lack of skilled birth attendants, misoprostol may be a woman’s only chance for surviving PPH.
Access to high-quality medicines is part of every citizen’s right to the highest attainable standard of health. But in spite of misoprostol’s proven safety and efficacy, decision-makers in some countries have been reluctant to authorize its widespread availability, or are unaware of the available evidence. Many governments have not included misoprostol in their national essential medicine list (EML), which is often used as the basis for importation, distribution, and marketing of medicines for the public health system.
FCI works to support wider understanding, acceptance, and use of misoprostol for PPH. This year in Burkina Faso, our efforts — with a range of advocacy partners — to persuade government officials to deem misoprostol for PPH an essential medicine were successful. This success story offers a potential model for effective, collaborative, focused advocacy in other countries where misoprostol’s lifesaving benefits are not yet broadly available.
Our advocacy began in earnest last September, when FCI convened a meeting to share the latest research on misoprostol for PPH and to develop advocacy strategies that would convince the government to take action. These committed and motivated maternal health champions called for the widespread availability of misoprostol, stating that the inclusion of misoprostol in the national EML was an urgent national priority.
Following the meeting, a small advisory committee was assigned the task of reaching key government decision makers. The committee submitted a letter and technical note to the Director-General of Pharmacy, Medicines, and Laboratories (DGPML) requesting inclusion of misoprostol on the EML. A DGPML technical committee then reviewed the submitted application, gathering all available evidence on misoprostol. During this review period, FCI and our partners met again with the Director-General of the DGPML, who stated his support for misoprostol as a critical tool for reducing the burden of PPH in Burkina Faso. FCI and partners also met with the Secretary-General of the Ministry of Health, who affirmed the government’s responsibility for ensuring the availability of misoprostol for PPH at public health facilities. He also came out in support of misoprostol distribution at the community level, and recommended ongoing supervision and training to ensure its correct use.
In February of this year, all of these advocacy efforts paid off: the 2014 revision of the national EML (Liste Nationale Des Medicaments et Consommables Medicaux Essentials, Edition 2014) includes misoprostol both for prevention and for treatment of PPH.
While this is an important step in making misoprostol available in the government health system, FCI and our partners will continue advocating and working to ensure that all women have access to a uterotonic , like misoprostol or oxytocin, for effective prevention and treatment of postpartum hemorrhage. These efforts are critical for countries’ efforts to fulfill the promise of MDG 5 and put an end, once and for all, to preventable maternal death.
Learn more about FCI’s work on misoprostol for PPH here.
To join an online community on misoprostol for PPH, please click here.
Réussite exemplaire du plaidoyer : Le Burkina Faso élargit l’accès au misoprostol, un médicament essentiel de la santé maternelle
Par Brahima Bassane, MD– médecin en titre
Directeur national de FCI au Burkina Faso, Brahima Bassane est médecin de santé publique.
L’Hémorragie du post-partum (HPP) — des saignements excessifs, difficiles à arrêter survenant après l’accouchement — demeure la principale cause de décès maternels à travers le monde. Dans des pays tels que le Burkina Faso où un nombre important des accouchements surviennent encore à domicile, le médicament misoprostol fournit nombre d’avantages pour la prévention et le traitement de l’HPP dans la mesure où il peut être facilement administré et ne nécessite pas une conservation à dans un réfrigérateur (contrairement à l’ocytocine qui est considérée comme le médicament ‘de référence’ pour l’HPP).Le misoprostol peut représenter la seule chance de survie d’une femme en proie à l’HPP dans les milieux communautaires qui disposent d’un nombre insuffisant de centres de santé et d’accoucheuses qualifiées.
L’accès à des médicaments de haute qualité est un des droits de chaque citoyen pour lui permettre de jouir du meilleur état de santé possible. Toutefois, en dépit de l’innocuité et de l’efficacité reconnues du misoprostol, les décideurs ont été dans certains pays, réticents à autoriser sa mise à disposition généralisée ou ils ignorent les données disponibles. Plusieurs gouvernements n’ont pas inclus le misoprostol dans leur liste des médicaments essentiels (LME) qui est souvent utilisée comme critère pour l’importation, la distribution et la commercialisation de médicaments pour le système de santé publique.
FCI œuvre en vue de soutenir une meilleure compréhension, acceptation et utilisation du misoprostol pour l’HPP. Au Burkina Faso, nos initiatives —de concert avec un éventail de partenaires du plaidoyer —visant à convaincre cette année les responsables gouvernementaux de considérer le misoprostol pour l’HPP comme un médicament essentiel, ont été couronnées de succès. Cette réussite exemplaire fournit un modèle potentiel de plaidoyer efficace, mené en collaboration et bien ciblé dans d’autres pays où les avantages salvateurs du misoprostol ne sont pas encore largement disponibles.
Notre plaidoyer a véritablement débuté en septembre 2013 lorsque FCI a organisé une réunion en vue de partager les résultats des toutes dernières recherches sur le misoprostol pour l’HPP et de mettre au point des stratégies de plaidoyer qui convaincraient le gouvernement à prendre les bonnes décisions. Ces défenseurs engagés et motivés de la santé maternelle se sont prononcés pour la mise à disposition généralisée du misoprostol en indiquant que l’inclusion du misoprostol dans la Liste nationale des médicaments essentiels était une priorité nationale.
Suite à la réunion, la tâche de prendre contact avec les principaux décideurs gouvernementaux a été confiée à un petit comité consultatif. Le comité a présenté au Directeur Général de la Pharmacie, du Médicament et des Laboratoires (DGPML) une lettre et une note technique sollicitant l’inclusion du misoprostol dans la LME. Un comité technique de la DGPML a ensuite examiné la demande soumise en recueillant toutes les données disponibles relatives au misoprostol. Au cours de cette période d’examen, FCI et nos partenaires se sont réunis avec le Directeur Général de la GPML qui a exprimé son soutien pour le misoprostol comme outil crucial pour alléger le fardeau de l’HPP au Burkina Faso. Cette équipe restreinte de FCI et ses partenaires s’est également réunie avec le Secrétaire Général du Ministère de la Santé qui a affirmé la responsabilité du gouvernement à assurer la disponibilité du misoprostol pour l’HPP dans les établissements de santé. Il s’est également prononcé en faveur de la distribution du misoprostol jusqu’à l’échelle communautaire tout en recommandant une supervision suivie et la formation afin de garantir son utilisation adéquate.
En février au cours de cette année 2014, toutes ces initiatives du plaidoyer ont porté leurs fruits : la révision en 2014 de la LNMCE (Liste Nationale Des Médicaments et Consommables Médicaux Essentiels, Édition 2014) comprend notamment le misoprostol pour la prévention ainsi que le traitement de l’HPP.
Bien que la mise à disposition du misoprostol dans le système public de santé constitue une étape importante, FCI et nos partenaires continueront à plaider et à œuvrer pour veiller à ce que toutes les femmes aient accès à un utérotonique tel que le misoprostol ou l’ocytocine pour une prévention et un traitement efficaces de l’hémorragie du post-partum. Ces initiatives sont cruciales pour les efforts des pays à tenir leur promesse pour l’OMD5 et à définitivement mettre un terme aux décès maternels évitables.
Trouvez de plus amples informations relatives aux travaux de FCI sur le misoprostol pour l’HPP.
Veuillez cliquer ici pour intégrer une communauté virtuelle sur le misoprostol pour l’HPP.
Martha Murdock is FCI’s vice president for regional programs.
Last week in Nairobi, a range of partners — from the Kenyan government, UN agencies, donor countries, and many NGOs and research organizations from the national and county levels — came together for a presentation of new research that has the potential to increase the momentum of efforts to save the lives of nearly 300,000 women who die each year (5,500 of them in Kenya) from causes related to pregnancy and childbirth.
Each of these avoidable, premature deaths is a tragedy in its own right, and a terrible injustice. Each of these women — some of them barely more than girls — has a right to life and health, and to a standard of health care that protects her from preventable illness, injury, and death.
But we who work to improve maternal health have argued for years that each of these deaths also brings countless additional layers of loss, pain, and destruction. The tragic, sudden death of a woman in the prime of life — in many cases already a mother and often the most economically productive member of the family — begins a cascade of loss and pain that upends the lives of those around her: her newborn baby (if it survives) and her older children, husband, parents, and other members of her family and community.
Up until now, however, we haven’t had the hard data to support our case, to help us persuade governments, donors, and policy makers that investments in maternal health are also investments in children, in stable families, in education and community development, and ultimately in stronger national economies. Now, thanks to a study conducted in Kenya by FCI, the International Center for Research on Women (ICRW), and the KEMRI-CDC Research and Public Health Collaboration, we know that the data behind that argument is very powerful indeed.
Based on interviews and focus group discussions with every family, across a poor rural area in Siaya County in western Kenya, that had lost a family member to maternal death over a two-year period, we found that:
- When a mother dies in or around childbirth, her newborn baby is unlikely to survive.
- Of 59 maternal deaths in the study, only 15 babies survived their first two months of life.
- A mother’s death harms the educational and life opportunities of her surviving children.
- Many children had to leave school because the loss of a mother’s income meant that they couldn’t pay tuition fees, needed to work for a living, or had to take up essential household chores.
- The cost of emergency care (even when unsuccessful), combined with high funeral costs, puts families under a crushing economic burden.
- Families spent more on funerals than their total annual expenditure on food, housing, and other household costs, after having already spent 1/3 of their annual consumption expenditure on medical costs.
- Loss of income and high, unexpected costs send many families into a spiral of debt, poverty, and instability.
- Many families, under desperate financial pressure, had to sell household property, borrow from moneylenders, or move children out of the family home.
When this moving and compelling report was launched in Nairobi last Friday, I was proud to stand at the dais and introduce eminent leaders of efforts to improve women’s and children’s health in Kenya, including the U.K. High Commissioner for Kenya, Dr. Christian Turner (representing the U.K. Government, which funded this important research together with the John D. and Catherine T. MacArthur Foundation and the Partnership for Maternal, Newborn & Child Health). Dr. Turner, in turn, introduced Kenya’s Cabinet Secretary for Health, Hon. James Macharia. With us in the room were important policy makers from the Ministry of Health, national parliamentarians, and high-level representatives from UNICEF, WHO, UNFPA, USAID, and a range of other agencies and organizations.
We came together that morning, I said, “because we are all resolved, together with so many colleagues and partners here in Kenya and around the world, to work together to finally put an end to a tragic toll of maternal and newborn death that goes back to the beginnings of human history.” We have long known that far too many women were dying. What we lacked, until now, was hard data to help us fully understand the financial and social impact of a mother’s death — the costs to the health and well-being of thousands of surviving children, families, and communities. We and our partners undertook this study because we saw that filling this critical knowledge gap will offer advocates and policy makers a powerful tool for bringing further attention and investment to maternal health.
The messages that emerge from this research were expressed clearly and succinctly by Hon. James Macharia as he presided over the official launch of the report:
A mother’s death ignites a chain of disruption, economic loss, and emotional pain that often leads to the death of her baby, diminished educational and life opportunities for her surviving children, and a deepening cycle of poverty for her family.
The cost of a maternal death is, quite literally, a price too high to bear.
(An excellent in-depth news report on the study and its launch, by a leading Kenyan television network, can be viewed here:
By Imtiaz Kamal
Imtiaz Kamal is the president of the Midwifery Association of Pakistan. She has led a “one-woman crusade” to promote the midwifery profession for more than 50 years.
In June 2013, all four provinces of Pakistan—Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan—included misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) on their respective Essential Medicines Lists (EMLs). EMLs indicate medicines that “satisfy the priority health care needs of the population” and should be affordable and available at all times within the context of a functioning health system. As advocates working towards improving reproductive and maternal health in Pakistan, we’ve come a long way in our mission to expand access to misoprostol. In this post, I share our advocacy strategy and the challenges we faced.
The sixth most populous country in the world, Pakistan has an alarmingly high maternal mortality ratio: 260 maternal deaths per 100,000 live births. Every year, almost 12,000 women in Pakistan die from pregnancy and childbirth related complications, accounting for almost 5% of the world’s maternal deaths, and PPH—excessive bleeding after childbirth—causes 27% of these deaths. About 57% of deliveries still take place without a skilled birth attendant present, and in these situations, women often do not have the means to address life-threatening complications when they arise. Fortunately, there is a safe and effective solution to treat and prevent PPH—misoprostol, a low-cost medicine that is practical for use in both facility and home births.
For many years, the National Committee for Maternal and Neonatal Health, the Midwifery Association of Pakistan (MAP), and the Association for Mothers and Newborns, with support from the Research & Advocacy Fund (RAF), championed the widespread availability of misoprostol in Pakistan.
One step for improving access to this essential medicine was to get provincial governments to include misoprostol on their respective EMLs. Then, the provincial governments can supply it to the public sector health facilities, which would provide this essential medicine at minimal or no cost to women wherever they live.
Usually, the Pakistani government follows the World Health Organization’s (WHO) EML, but due to misoprostol’s association as an “abortion drug,” we had to sell it to policymakers, highlighting misoprostol’s huge lifesaving potential and the urgency to expand access to women who need it. Misoprostol is an essential part of a package of strategies to improve maternal health, and we must ensure that its use for other indications does not lead to limitations on its availability for PPH.
We devised an advocacy strategy to share the evidence and stimulate supportive policy change through:
- Public education and awareness: fact sheets and case studies in English and Urdu, press conferences, trainings with journalists, and air time on television;
- Advocacy with decision-makers, including high-level Ministry of Health authorities, district health officers, OB/GYNs, and other health providers: face-to-face meetings and dissemination seminars in Punjab, Sindh, and the federal capital, Islamabad, to share guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO).
Our advocacy strategy led to very specific, positive outcomes:
- Endorsements from key champions: The Director General of Health in Sindh province became a close ally and guided us on how to move forward in garnering support from OB/GYNs and district health officers;
- A widely distributed position paper on misoprostol for PPH and post-abortion care (PAC) was signed by six professional organisations working for maternal and neonatal health;
- The National Assembly decided that the federal government should provide training to midwives and other health care providers on the administration of misoprostol to manage incomplete abortion and miscarriage and prevent PPH. In Sindh, the Directorate of Nursing came to us for guidance, and the first misoprostol workshop for midwifery teachers is scheduled for late February 2014.
Our advocacy efforts weren’t without challenges, however. For example, many physicians were cautious or opposed to making misoprostol more widely available. The most senior OB/GYN (from a province with very high maternal mortality) raised a number of concerns after a presentation we held on misoprostol, commenting: “It is not candy. We cannot let it be available freely.” We explained that, given the high prevalence of home births, we need to invest in solutions, such as misoprostol, that save lives now, until we can achieve the long-term goals of strengthening health systems and increasing rates of facility births. Distributing misoprostol doesn’t replace efforts to promote skilled care, but we need to recognize the reality that many women are not able to give birth in well-equipped health facilities with skilled staff. All women, wherever they decide to give birth, need access to effective medicines.
We faced similar comments and questions at every advocacy meeting. But this didn’t stop us; we continued to make our case. Eventually, that very same OB/GYN signed our position paper on misoprostol.
The movement to achieve national recognition of misoprostol for PPH has been challenging, but we are making progress, turning heads, and changing minds. Step by step, we push forward. Now that we have achieved Federal approval of misoprostol, we are working to advance community level distribution of misoprostol to women in their eighth month of pregnancy. As a global community, with partners such as FCI rallying behind the cause, we will succeed in making sure women no longer have to fear for their lives when giving birth.
For more information:
The new frontier of community health care: Health huts in Senegal use misoprostol and oxytocin in Uniject to prevent postpartum hemorrhage
[Version française ci-dessous]
Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.
While Senegal, a coastal West African country, has made considerable progress in decreasing maternal mortality since 1990, it still grapples with high rates of preventable maternal death. Postpartum hemorrhage (PPH)—excessive, uncontrolled bleeding—remains the leading cause of maternal death in Senegal and around the world. In areas of Senegal where there is still a high prevalence of unattended deliveries, women may not have the means to manage PPH or other life-threatening complications.
Regardless of where they give birth, all women need access to uterus-contracting drugs, or uterotonics, for the prevention and treatment of PPH. The recommended uterotonic, injectable oxytocin, requires cold storage and technical skill to administer; oxytocin is also available as a Uniject® device—a pre-filled, single dose, non-reusable injection—which is easier to administer. Misoprostol is a safe and effective alternative in low-resources settings where oxytocin isn’t available or feasible; it doesn’t need refrigeration and is easy to use—particularly important in the absence of a skilled birth attendant.
Between June 2012 and August 2013, Gynuity Health Projects, ChildFund Senegal, the USAID Community Health Program, and the Senegalese government’s Directorate of Reproductive and Child Health implemented a study to compare community-level administration of oral misoprostol and oxytocin in Uniject® to prevent PPH. One of the two interventions was assigned to each of 28 participating community health huts, one- or two-room concrete structures that bring basic healthcare closer to the communities. Project implementers trained matrones, volunteer birth attendants, to assist with deliveries and administer the designated intervention.
Communities played an integral part in encouraging the use of misoprostol and oxytocin. Community members assisted in identifying pregnant women for initial prenatal check-ups, and project staff recruited women by visiting them in their communities.
Since the launch of the project, over 1300 women received either 600 mg (3 tablets) of misoprostol or 10 IU oxytocin via Uniject® intramuscularly for PPH prevention. Both medicines were effective, and the matrones could manage all side effects, which included chills, tremors and fever. Among all the women who received prophylaxis, only one case of postpartum hemorrhage occurred.
“Before this study, we saw a lot of women with heavy bleeding, and it was always difficult to arrange transportation for referrals [to health facilities],” said Fatou Diouf, a matrone from the Koulouk Mbada hut. “Now, we do not see any hemorrhage after delivery.”
Chief nurse Amadou Gueye from the Ndiaganiao health post noted a similar outcome: “Since the start of the study, we have not seen a single case of PPH.”
As a result of the project, home births decreased from 10% to 1%, project leaders effectively maintained drug stocks, health providers demonstrated commitment and motivation, and the matrones administered medications and filled out data management tools successfully. Birth attendance at the community health huts improved because women sought delivery services in order to benefit from a PPH medication.
“When I came to deliver this morning, the matrone asked me if I wanted to take the three tablets. I said yes,” said Mariama Niang who had recently given birth at the Koulouk Mbada health hut. “I bled less than I did in previous deliveries when I bled a lot and had lots of dizziness. […] now, I am doing well.”
In Senegal where access to health facilities may be limited in remote areas, the community health hut system can play an important role in preventing and treating PPH. According to the study, both misoprostol and oxytocin in Uniject® proved to be equally effective and safe in preventing PPH, and matrones posted at the health huts were capable of administering their assigned medicine. Whereas standard oxytocin injections require specialized skills, misoprostol and oxytocin in Uniject® are viable options at the community level. These health interventions can empower communities to protect women’s health and prevent unnecessary maternal death.
Through research and advocacy, Family Care International (FCI) is working with Gynuity Health Projects to support increased access to and availability of misoprostol for prevention and treatment of PPH. Learn more about FCI and Gynuity’s work to make misoprostol available to women around the globe.
Les nouveaux confins des soins de santé communautaire : Au Sénégal, les cases de santé utilisent le misoprostol et l’ocytocine par Uniject en vue de prévenir l’hémorragie du post-partum
S’il est vrai que le Sénégal, pays côtier de l’Afrique de l’Ouest, a réalisé d’énormes progrès dans la baisse de la mortalité maternelle depuis 1990, il est toujours aux prises avec de forts taux de décès maternels évitables. L’Hémorragie du post-partum (HPP) – des saignements excessifs, difficiles à arrêter – demeure la principale cause de mortalité maternelle au Sénégal et à travers le monde. Dans des régions du Sénégal où il existe une forte prévalence d’accouchements en l’absence d’un personnel qualifié, il est possible que les femmes ne disposent pas de moyens pour le traitement de l’HPP ou d’autres complications potentiellement mortelles.
Quel que soit l’endroit où elles accouchent, toutes les femmes ont besoin d’avoir accès aux utérotoniques, les médicaments provoquant la contraction de l’utérus pour la prévention et le traitement de l’HPP. L’ocytocine injectable, l’utérotonique recommandé, nécessite la conservation à froid et des compétences techniques pour son administration ; l’ocytocine est également disponible en tant que dispositif Uniject® — une injection pré-remplie à dose unique et non réutilisable — qui est plus facile à administrer. Le misoprostol est une méthode alternative à l’ocytocine qui est sûre et efficace, particulièrement dans les milieux à faibles ressources où l’ocytocine n’est pas disponible ou faisable. Le misoprostol ne nécessite pas la réfrigération et est facile à utiliser — ce qui est notamment important en l’absence d’une accoucheuse qualifiée.
Entre juin 2012 et août 2013, Gynuity Health Projects, ChildFund Senegal, Programme de santé communautaire de l’USAID et la Direction de la Santé de la Reproduction et de la Survie de l’Enfant du gouvernement sénégalais ont mené une étude visant à comparer l’administration à l’échelle communautaire du misoprostol oral à celle de l’ocytocine par Uniject® en vue de prévenir l’HPP. Une des deux interventions était assignée à chacune des 28 cases de santé communautaires participantes, des structures en béton d’une à deux pièces, qui fournissent des soins de santé de base aux collectivités. Les exécutants du projet ont fourni une formation aux matrones, accoucheuses bénévoles, à apporter leur aide durant les accouchements et à administrer l’intervention désignée.
Les collectivités ont assumé un rôle essentiel en encourageant l’utilisation du misoprostol et de l’ocytocine. Les membres de la collectivité ont aidé à identifier les femmes enceintes pour les consultations prénatales initiales et le personnel du projet a recruté les femmes en leur rendant visite au sein de leur communauté.
Depuis le lancement du projet plus de 1 300 femmes ont reçu soit 600 mcg (3 comprimés) de misoprostol ou 10 UI d’ocytocine par Uniject® par voie intramusculaire pour la prévention de l’HPP. Les deux médicaments étaient efficaces et les matrones ont pu traiter tous les effets secondaires qui comprenaient notamment les frissons, les tremblements et la fièvre. Seul un cas d’hémorragie du post-partum est survenu parmi les femmes ayant reçu le traitement préventif.
« Avant cette étude, un grand nombre de femmes présentaient des saignements profus et il était toujours difficile d’assurer le transport pour leur acheminement [aux établissements de santé], » dit Fatou Diouf, une matrone de la case Koulouk Mbada. « Désormais, nous n’observons plus d’hémorragie après l’accouchement. »
Amadou Gueye, Infirmier en chef du poste de santé de Ndiaganiao, a noté un résultat analogue : « Nous n’avons observé aucun cas d’HPP depuis le début de l’étude. »
En raison du projet, le nombre d’accouchements à domicile a baissé de 10 % à 1 %, les responsables du projet ont effectivement maintenu les stocks de médicaments, les prestataires de santé ont démontré leur engagement et leur motivation et les matrones ont administré les médicaments et rempli les formulaires de gestion des données de manière adéquate. La présence des accoucheuses dans les cases de santé communautaire s’est renforcée parce que les femmes ont sollicité des services d’accouchement afin de bénéficier des médicaments de l’HPP.
« Ce matin, lorsque je suis venue pour accoucher, la matrone m’a demandé si je voulais prendre les trois comprimés. J’ai répondu oui, » dit Mariama Niang qui a récemment accouché à la case de santé de Koulouk Mbada. « Mes saignements étaient plus légers que ceux de mes accouchements précédents où ils étaient abondants et accompagnés de vertiges. […] maintenant, je me sens bien. »
Au Sénégal où l’accès aux établissements de santé peut être limité dans les zones reculées, le système des cases de santé communautaire peut jouer un rôle important dans la prévention et le traitement de l’HPP. Selon l’étude, le misoprostol ainsi que l’ocytocine par Uniject® se sont tous les deux avérés tout aussi efficaces et sûrs dans la prévention de l’HPP et les matrones affectées aux cases de santé étaient en mesure d’administrer les médicaments qui leur étaient assignés. Alors que les injections standards d’ocytocine nécessitent des compétences particulières, le misoprostol et l’ocytocine par Uniject® constituent des options viables à l’échelle communautaire. Ces interventions médicales peuvent habiliter les collectivités à protéger la santé des femmes et à prévenir des décès maternels évitables.
Family care International (FCI) collabore avec Gynuity Health Projects au moyen de la recherche et du plaidoyer en vue de favoriser un accès accru au misoprostol et sa disponibilité pour la prévention et le traitement de l’HPP. Trouvez de plus amples informations relatives aux travaux de FCI et de Gynuity visant à mettre le misoprostol à la disposition des femmes à travers le monde.
Adama Sanogo is Program Officer at FCI-Mali, working at our national office in Bamako and supervising FCI’s programs in Mopti, a city on the Niger River an 8-hour drive to the north.
Over the past two years, northern Mali has suffered a series of repeated and increasingly devastating crises. Long-term drought that has plagued the Sahel region of Mali and its neighboring countries – the area that borders on the Sahara desert – led to a dramatic rise in food insecurity in 2011; this was followed in 2012 by a worsening security situation, culminating in an invasion of armed rebel groups that declared the independence of the country’s three northernmost regions of Timbuktu, Gao, and Kidal. In March 2012, the national government in Bamako was overthrown in a military coup, and fighting between the military and the northern rebels continued into 2013.
The result has been a humanitarian disaster, as nearly half a million Malians fled their homes to escape fighting and hunger. The city of Mopti, where FCI has been implementing adolescent sexual and reproductive health programs for several years, is the gateway to the northern part of the country, and it has seen a massive influx of people displaced from the north, seeking refuge or transit to other parts of the countries.
To help address this crisis, in a post-coup environment in which it was difficult or impossible for international agencies to work with an unstable new government, UNICEF asked FCI’s team in Mopti to take on emergency projects to provide support to the many women who had experienced gender-based violence when war convulsed their home region, and to help protect the rights of children among the large displaced population.
Working in partnership with local grassroots organizations, FCI supported the formation of 10 “protection teams,” in Mopti and more than 30 villages in the surrounding rural areas, to identify women and children who had been victims of gender-based violence and to refer them for medical care and psychological support. About three dozen health care workers in the area were trained in how to provide appropriate care to survivors of sexual violence. At a women’s center in Mopti, the project provides a safe space where social services are provided, children have a place to play, and theater programs (featuring young people from FCI’s adolescent health programs) help to raise awareness about issues of gender-based violence.
The team psychologist and social workers also visit women and children in their homes when needed. “In Mali,” says FCI outreach worker Aïssata Cissé, “when there’s been a rape it is dealt with inside the family. There is no going to a tribunal or to the police. Often girls do not even tell their mothers what has happened. If it becomes known that a girl has been raped, she will have a problem. Even at school, her friends or other pupils will tease her.”
During 2013, this FCI program has provided emergency financial aid to more than 1,600 displaced families that have taken refuge in the Mopti region, and has provided medical, social, and psychological services to 200 women and children who had fallen victim to sexual violence. Here are three of their stories:
Nana, 35 years old, from Timbuktu:
“I sell cosmetics. One day, seven Islamist rebels came into my shop and they burned all the wigs and cosmetics. I was wearing a wig, so three of the men beat me with a whip, and kicked and punched me. Then they drove me to their base, and held me for three days. Every night, three men raped me.
“I was released because the village chief intervened. But I had nothing more to do in Timbuktu. I had no livelihood since my business had gone up in smoke, and I was humiliated. So with the help of my older brother, I managed to get to Mopti.
“When I arrived in Mopti, I became very sick with sexually-transmitted infections. I had back pains, and terrible pain from being punched in the stomach, and especially from the gang rape violence I was subjected to during those three days. For me, I felt like it was all over.
“One day in April 2013, I met two women who worked for UNICEF and Family Care International to identify displaced people who were victims of violence. They interviewed me, and arranged for me to receive medical care from the Sominé Dolo Hospital in Mopti, and psychosocial care from the Family Care International psychologist within their project financed by UNICEF.
“Since I have benefited from these treatments, I feel like I did before the attacks. I see that there is hope in front of me, that I can continue to live. I am free in my movements, I present myself as I want to, and I wear wigs. I can only thank FCI-Mali and its partner UNICEF, who allowed me to start over and live a happy life.”
Ada, 50 years old, from the village of Douentza (northeast of Mopti):
“When the rebels came to Douentza in October 2012, they shot in the air at the entrance to the town where I lived with my children: my daughter Tata, 13 years old, and my sons Moussa, 20 years old, and Amadou, 10 years old. I am a widow, and I have heart problems that cause me to faint at even the slightest of loud noise.
“Two rebels came to our house. I offered them my belongings but they didn’t want them. They tied up my two sons, Moussa and Amadou, and raped my daughter in front of me. I fainted two times. When they finished their dirty work, they took my two sons with them and kept them hostage for three days. They let them go after the chief of Douentza intervened.
“I fled with my children for Mopti. I stayed with my uncle, who provided some medical care for my daughter. After the incident she was very quiet, didn’t speak to anyone, barely ate, and refused any help. She didn’t want to think about what happened.
“At the slightest noise, I faint. I have no ways to take care of my children’s health, and my uncle no longer has the means. Every night I relive the nightmare. I don’t know how much longer I can stand this. I need help.”
An FCI protection team found Ada and her family and referred them for medical, social, and psychological treatment.
Dada, from Bambaramoudé (Timbuktu):
“After the war, my husband, my children and I left Timbuktu. We had a very difficult time on the journey. We were attacked by an armed group who stole all our belongings. The attack on Konna (a town an hour north of Mopti) arrived just as we did, so we retraced our steps. We spent three days in the bush without water or food. After the French liberation of Konna, we continued on our way towards Sévaré (a village near Mopti). It was very difficult for us. In Sévaré, I am staying with the family of my deceased grandmother. We live day-to-day – I didn’t know how I would survive all of these hardships.”
On a Friday afternoon in June, 2013, Dada left her 9-month-old son, Hamadi, with her oldest daughter, 11-year-old Aicha, so she could go to fetch water from the well. Aicha was also watching over her mother’s stall where she sold dried fish and fried sweet potatoes. When Aicha made a sale, she placed the money on the mat where Hamadi was playing. Suddenly, a piercing scream rang out. The baby was crying as hard as he could, writhing in pain and vomiting. When Dada returned from the well, Aicha said that nothing had happened — Hamadi had suddenly started to cry as he was playing. Dada asked Aicha how much fish and potatoes she had sold; she said she had made about 350 CFA francs (72 US cents). Counting up the money, Dada found only 300 CFA — a 50 CFA coin was missing. She examined Hamadi,and realized that he had swallowed the missing coin. “Oh my God!” she screamed. “What am I going to do? I don’t even provide enough for my children, and now this disaster. What am I going to do?”
“I started asking around for help, and was able to raise 16,000 CFA (US$33). I brought Hamadi to the Sominé Dolo Hospital in Mopti. After a consultation with a pediatrician and reviewing the results of the x-rays, it turned out that the coin was lodged in his stomach. They referred Hamadi to the Gabriel Touré Hospital in Bamako, 400 miles away, so he could be operated on to remove the coin that might kill him.
“Desperate and stunned, I returned to the house and waited for my son to die. I then learned that there was a local NGO who was helping displaced persons. I went to see this NGO, and they directed me to Family Care International, which helped me get him the care he needed, with the help of another NGO in Bamako, Sini Sanuman (Healthy Tomorrow). Hamadi was operated on by the NGO’s pediatrician. He was saved from death, and we returned to Mopti the next day. My husband, myself, and everyone who helped us cannot at this moment afford the amount of support, which cost more than 300,000 CFA (over US$600). When my parents and I set out to thank the 2 NGOs, they both said they received funding from another organization that works for children around the world: UNICEF. We will never be able to give enough thanks to these generous organizations and hope to God that they will always exist to continue saving the lives of thousands of children.”
While the fighting in northern Mali has lessened, the refugee situation in Mopti remains serious, and FCI’s work there continues. To learn more about this partnership between FCI and UNICEF to provide services to victims of gender-based violence, click here.
In the Sahel region in northern Burkina Faso, a remote, arid area on the edge of the Sahara Desert, maternal and newborn mortality levels are substantially higher than in the rest of country. The majority of women, particularly in the Sahel’s hundreds of small, semi-nomadic villages, still give birth at home, without the help of a skilled birth attendant. Family Care International has been working in the Sahel for several years, in partnership with the UN Population Fund—UNFPA, the national Ministry of Health, and local grassroots organizations, to educate women about their maternal and reproductive health, increase use of the maternal health services that are available at the health center in the provincial capital, ensure that women with childbirth complications are able to access the emergency care that can save their lives, and arrange for surgical treatment for women living with obstetric fistula, a devastating injury that results from prolonged or obstructed labor.
Over the course of this work, it has become increasingly clear that local leaders — clergymen, traditional chiefs, elected officials — have the potential to influence women and their families to utilize available health services and avoid harmful beliefs and practices that are rooted in the religious and cultural traditions. Because these leaders play crucial roles in the promotion and preservation of traditional practices and beliefs, it will be difficult to spark meaningful change — like the abandonment of child marriages — until traditional leaders are educated and mobilized to promote the cause.
FCI has therefore focused on working with approximately 30 religious and traditional leaders in each of the four districts that make up the Sahel region. At a series of training workshops, they have learned about all aspects of maternal health care, and have come to better understand the community determinants of maternal health and the ways that encouraging uses of health services, and particularly skilled attendance at birth, could play a large role in saving women’s and babies’ lives. At the end of the workshops, leaders were asked to implement what they learned in their communities. Some time later, a feedback meeting was organized. Here are some stories that the leaders shared at that meeting:
- Bani is a rural town in the Seno province, located about 25 miles outside of Dori, the regional capital. After attending an FCI training session, the Imam of one of Bani’s mosques was committed to promoting maternal and infant health. With educational materials in hand, the Imam held awareness meetings at his mosque and in each of the town’s five neighborhoods, where he discussed the importance of prenatal care, of giving birth at the health center, of preventing obstetric fistula, and of treating fistula when it does occur. The Imam also approached Bani’s mayor to arrange for discussions with the members of the town council, brought health workers to meet with representatives of the five neighborhoods and of 16 surrounding villages, and invited the Dori “Khoolesmen” Association (a grassroots group that works in the community to improve maternal and newborn health) to lead discussions at four mosques and 21 adult literacy centers.
- Diguel is a town located about 37 miles outside of Djibo, capital of the Soum province, and almost 100 miles from Dori. After attending a training workshop in Djibo, Diguel’s Imam also led a series of community discussions, focusing on the critical importance of prenatal care and skilled birth attendance. He spoke about the importance of protecting women health at the end of Friday prayers, at the special Walima marriage ceremony, and at baptisms. During a special prayer for rain, in June 2013, the Imam shared with the worshippers in his mosque what he had learned about pregnancy danger signs, emphasizing the need for husbands and other men to be involved in health issues affecting women and children. As he spoke with the men, the Imam arranged for female community outreach workers to speak with the women in another corner of the mosque’s courtyard. He also spoke with traditional chiefs in order to engage them in these efforts, and is planning to begin visiting families un their homes and to travel into more remote surrounding villages, in order to ensure that lifesaving information gets to those harder-to-reach populations.
One day, when I returned home after a short errand, I met a suffering pregnant woman wandering the street, probably returning from the fields. She was writhing in pain and I quickly recalled the signs of danger that we were shown during the training in Djibo. I went up to the woman and asked her which family she was from. I quickly drove her back to her home and when we arrived I asked for her husband, but he was not there. I then asked if the woman had received any prenatal care; but she had not, so I urged her to go to the health center to get checked out. Our religion teaches us to always care for the well-being of others to the best of our ability. I think, with the knowledge I’ve received from the training, it would be unjust not to use it to help others.
- Imam of Diguel town, Soum province, Burkina Faso
- During May and June, 2013, the radio station of the Ahmadiyya Muslim community in Dori broadcast a program called “Health Mission,” covering topics on maternal and newborn health; the Ahmadiyya community also conducted outreach to several villages through its network of mosques.
- The Sunni Muslim community in Dori held three awareness sessions, after the afternoon prayers in the mosques, concerning women’s health, the responsibility of men in issues of maternal and infant health, and the importance of prenatal care.
- Leaders of the evangelical Christian community were also engaged in these efforts: 65 pastors from the towns of Dori, Sebba, and Gorom-Gorom attended a training meeting, after which they to shared what they had learned about maternal health with the congregants in their network of churches.
- Dori’s Catholic Mission participated as well: after the chaplain and priest received training, they conducted 25 awareness programs after Saturday and Sunday masses. They then held programs with three grassroots Christian Committees, including both women and men; two awareness meetings in the rural villages of Karo and Koumbri; and a meeting with members of the Association of Catholic Women.
These few examples show these leaders’ commitment to raising awareness in their communities about women’s and newborns’ health, and their potential influence on traditional practices that are deeply rooted in social and religious norms and customs. This commitment is durable and sustainable, and they will continue working – with FCI’s partnership – to make these efforts to encourage healthy practices bring real change in the lives and health of women in their communities.
Catherine Lalonde is FCI’s senior program officer for Francophone Africa.
Each year in Burkina Faso, more than 2,000 women die from pregnancy-related complications. Many of these deaths are due to severe and uncontrolled bleeding (postpartum hemorrhage, or PPH) that occurs following childbirth. The vast majority of these deaths can be effectively prevented or treated if women have access to high-quality maternal health care. Essential medicines, such as oxytocin and misoprostol, are safe and effective for preventing and treating PPH; however for many women in Burkina Faso, and in countries around the world, these essential medicines are not available or easily accessible. Access to misoprostol, a safe and effective medicine for preventing and treating PPH, is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used even in poorly-equipped health facilities and home births.
In early September, FCI convened a meeting in Burkina Faso with 40 high-level officials from the Ministry of Health, local and international NGOs, and national professional societies to share the latest evidence and research and identify strategies for making misoprostol more affordable and accessible for preventing and treating PPH. A room full of champions for improved maternal health in Burkina Faso, the participants called for widespread availability of misoprostol, particularly in regions where women may not be able to reach health facilities for delivery. At the same time, participants identified a number of challenges for making misoprostol more widely available; these included:
- High cost of the drug: As it is now, women in Burkina Faso cannot purchase a single dose of misoprostol; only larger packages — 4 or 5 doses, depending on whether it will be used for prevention or treatment — are available, and they cost more than US$5, a considerable sum in Burkina Faso.
- Use for other indications: Some meeting participants were also concerned about the possibility that, if it were made available for PPH, untrained or unskilled health workers could use misoprostol for abortion or to induce labor.
- Conflicts with health facility deliveries: Participants raised the fear that making misoprostol available in community settings could discourage women from going to a health facility for delivery.
- Need for more research/data: Meeting participants discussed whether more research in regions like the Sahel — remote, rural areas, where skilled care is unavailable or very far away and home birth is consequently very common — is needed.
Women in my district die from postpartum hemorrhage, so we can’t be against the use of misoprostol [for PPH] in rural areas. In the Sahel only 38% of births are attended by a skilled professional, and it’s not because women don’t want to deliver in a clinic. Here, travelling 2 kilometers takes as long as it would to travel 30 kilometers somewhere else.- Chief Medical Officer, Gorom-Gorom District, Sahel Region, Burkina Faso
Participants identified a number of agreements and strategies for moving forward. They agreed that:
- The potential use of misoprostol for other indications, including abortion, is not a reason to restrict access to it for PPH. A safe and effective medicine should not be withheld from women who need it simply because it can also be used for other, more controversial indications. Further, evidence suggests that making misoprostol more widely available for PPH does not increase the rate of abortion. Women who want to have an abortion will have one, whether or not they have access to misoprostol.
- Misoprostol should be added to the national Essential Medicines List (EML) for use in peripheral health centers. A small group was established to work on a proposal for including misoprostol for PPH in the national EML.
- There is a need to lower the cost of the drug, either through government funding or social marketing.
FCI works at the global level and in select countries such as Burkina Faso and Kenya, in collaboration with our partners, to support wider understanding, acceptance, and use of misoprostol for PPH. FCI maps advocacy efforts, publishes case studies, articles, and information briefs, disseminates new information, and brings together experts through online events and conferences to discuss evidence and challenges related to misoprostol’s access and availability.
This year’s Women Deliver conference made a strong call for investing in the health and development of adolescents and young people: they were at center-stage, and their health and development needs were discussed in dozens of sessions on different topics. And they were a notable physical presence. In addition to a youth pre-conference that brought together one hundred young leaders from around the world, adolescents and young people spoke on panels, moderated discussions, and chaired a youth networking zone. The conference highlighted the unique problems faced by adolescent girls and young women–some of the most vulnerable and neglected individuals in the world–and stressed the importance of addressing their needs and rights, not only for their individual benefit, but also to achieve global goals such as reducing maternal mortality and HIV infection.
In response to an invitation from the editors of the peer-reviewed journal Reproductive Health, 16 experts from WHO and other UN agencies, academic institutions, and a range of NGOs — including FCI’s global advocacy director Amy Boldosser-Boesch — coauthored a commentary that lays out the key themes that reverberated throughout the conference, on the health and development needs of adolescents and young people, and promising solutions to meet them.
“The time to act,” the authors write, “is now.” With increasing recognition that meeting the needs of young people is essential to achievement of the Millennium Development Goals, and a growing understanding of the challenges faced by adolescents and the interventions that are effective in addressing them, “the real imperative is to apply the knowledge and understanding that we already have.” They conclude:
There is widespread acceptance of the need to address the sexual and reproductive health of adolescents and young people. There is a groundswell of support from national and international bodies to translate words into action. We need to leverage this collective commitment and expertise. For the world’s 1.2 billion adolescents to survive, grow and develop to their full potential, the small scale, time limited, piecemeal projects of yesterday must be transformed into the strong, large scale and sustained programmes of today.
To read the full article, click here.
Every two minutes, a woman in a developing country dies from pregnancy and childbirth complications. Postpartum hemorrhage (PPH) and pre-eclampsia/eclampsia (PE/E) are the leading causes of maternal death. Although these conditions are preventable, too often life-saving medicines do not reach women in developing countries.
On September 26th, Family Care International, USAID’s Maternal and Child Health Integrated Program (MCHIP), PATH, and Jhpiego hosted a Twitter expert hour to discuss how increasing access to simple, affordable maternal health commodities — misoprostol, oxytocin, and magnesium sulfate — has the potential to save millions of women’s lives.
MCHIP Maternal Health Team staff Sheena Currie and Jeff Smith led the Twitter conversation on misoprostol; PATH’s Maternal, Newborn, and Child Health Program Leader Catharine Taylor discussed oxytocin; and Jhpiego and Jeff Smith tweeted about magnesium sulfate. The Twitter chat stimulated an exchange of compelling information and evidence and generated provocative questions from the community. You can check out the discussion in the Storify below and continue the conversation by visiting Twitter and including #supplylife in your tweets.