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In Kenya, FCI and our project partners, the International Center for Research on Women (ICRW) and the Kenya Medical Research Institute/Centers for Disease Control (KEMRI/CDC-Kisumu), are conducting focus group discussions to explore the impact on the family of a woman’s death in pregnancy or childbirth. These discussion are part of a three-year research project that seeks to provide the first full accounting of the costs of a maternal death for families and communities: the direct monetary cost, the indirect costs in terms of lost productivity and income, and the “social costs” in terms of changes in household structure and responsibilities. This information will provide critical support for advocacy — in Kenya, in other developing countries, and at the global level — for improvements in the availability, quality, and utilization of maternal health services.
The blog post below, cross-posted from Perspectives: The ICRW Blog, is by Radha Rajan. Radha is an ICRW consultant with expertise in qualitative research and program evaluation, and a participant in these focus group discussions.
Ours is the only vehicle in sight on the bumpy dirt road to the village of Nyamula in Western Kenya. Compounds with semi-permanent houses set far apart from each other dot the landscape, and acres of farmland fill the spaces in between. I’ve come to this remote community to meet a few families who are reeling from an unexpected loss.
It’s quiet as we drive into one family’s compound situated miles away from any town center; the only sound is the bleating of a small goat as our jeep pulls to a stop. Before we leave the vehicle I ask my colleague from the Kenya Medical Research Institute (KEMRI) if a woman wanted to give birth in a hospital or at a clinic, how would she get there?
“After she goes into labor, someone may give the woman a ride on the back of their bicycle,” my colleague tells me. “If it is night, there is cell service and the family knows someone, maybe she can get a ride on a motorcycle. But that is often too difficult. Many women give birth at home.”
I picture a woman in labor faced with the options of riding a bike to the health clinic or delivering at home without the benefit of skilled medical care, and I start to understand the importance of advocating for increased funding to support maternal health. In women of reproductive age, maternal ill health is one of the leading single causes of death and disability. Each year about 358,000 women worldwide die from pregnancy-related causes, and most who die in childbirth suffer one of five preventable or treatable complications, such as severe bleeding. Recent reviews show that while the annual global number of maternal deaths declined by about one-third between 1990 and 2008, a large number of African countries, including Kenya, have made little or no progress in lowering maternal mortality rates over the past two decades.
Here at ICRW, we believe those figures can be reversed, and we’re working to illustrate, through research, the need for more investments to prevent maternal deaths. With the KEMRI/CDC Research and Public Health Collaboration and Family Care International (FCI) our latest research on maternal mortality aims to demonstrate the social, emotional, financial and practical burdens rural Kenyan families experience when a young woman dies during childbirth or pregnancy. Estimating how this combination of burdens – as opposed to just one – affects families and communities makes this study particularly unique. Ultimately, we hope our findings on the costs of maternal mortality will compel policymakers to take action so families can avoid another mother’s preventable death.
In Kenya, we are meeting poor rural families affected by maternal death to better understand their experience. We are collecting data on the financial toll they incur when they have to pay for emergency treatment and funeral services. And we’re learning how families already struggling to make ends meet are sent further into a cycle of poverty when they lose a productive member of their household.
While I was in Nyamula, we visited a house where a woman died, leaving behind one child. The mother of the deceased used to take small jobs outside the home to earn income that helped offset household expenses. Now that her daughter is dead, she must look after her grandchild and cannot work outside the home. As a result there is less money to pay for daily expenses and less flexibility to earn the money the family needs.
The emotional strain of a maternal death also weighs on surviving family members. The same mother told us that since her daughter died she has relied on her school-age children for help with household chores. The children resent having less time to study. Furthermore, the mother also said that she is frustrated because she has to rush through cooking meals so that she can care for her baby granddaughter. She said she feels like she wouldn’t be going through all of this if her daughter were still alive.
Tragically, that mother’s experience is all too common in rural Kenya and poor communities worldwide. But this is more than just about just one mother or one family: ICRW’s study and other efforts striving to curb the rate of maternal mortality can contribute to alleviating ill health, poor education opportunities and poverty worldwide. For instance, studies show that a mother’s health has profound implications for the long term well-being of children – particularly girls – through its effect on their education, growth, and care.
There are solutions for Kenyan families and others around the globe. Maternal deaths can be avoided by anchoring health facilities in locations accessible to the poorest, more remote households. That way, women can easily take advantage of pre-natal, post-natal and other care. We also have to change social norms so that women – young women especially – are allowed by other household members to access this important care. And we need the political will – from health and finance ministries to donor organizations – to invest in these solutions.
There is ample evidence illustrating that the health of a woman and her newborn baby are intimately connected. We know that:
- most maternal and newborn deaths are caused by the mother’s poor health before or during pregnancy or due to inadequate care in the critical hours, days, and weeks after birth
- when a woman dies in childbirth, her newborn baby is less likely to survive
Recent research conducted by Dr. Zulfiqar Bhutta and colleagues at the Aga Khan University in Karachi, Pakistan confirms what we already know, and goes one step further: it identifies which maternal and newborn health interventions benefit both mother and newborn. These include:
- Family planning/birth spacing: Family planning, including counseling on and provision of contraceptive methods, prevents unwanted pregnancies and unsafe abortion, and increases spacing between births. Adequate birth spacing (between 18-23 months) reduces the risk of maternal and newborn-related deaths.
- High-quality antenatal care: Antenatal care provides a critical window to address a range of health care needs, such as treating HIV and sexually transmitted diseases (STDs), and providing counseling and educational support. Well-designed, good quality ANC reduces the risk of preterm birth, perinatal mortality, and low-birth-weight infants
- Detection and management of maternal diabetes: Treating maternal diabetes (through dietary advice, glucose monitoring, and insulin) reduces maternal and perinatal morbidity, specifically antenatal high blood pressure and neonatal convulsions.
- Exclusive breastfeeding during the first six months of life: The benefits of breastfeeding for the mother are both short- and long-term. In the short term, she is likely to recover more rapidly from the birthing process. It also has a significant impact on reducing the risk of breast cancer. For the newborn, exclusive breastfeeding for the first six months of life is recommended for optimal growth, development, and health.
This research is a critical step in better understanding just how deeply interconnected are the health of a woman and that of her newborn baby. It also underscores how vital it is to interconnect health care for women and their newborns — to promote greater efficiency, reduce costs, limit duplication of resources, and achieve greater impact.
As part of efforts to promote investment in and implementation of health interventions that can save the lives of both women and their newborn babies, FCI developed two publications summarizing the findings from this research and its impact on advocacy, policy, research, and programming:
- A pocket card for non-technical audiences including policy makers, health officials, and civil society groups.
- An Executive Summary for program managers and implementers working in low-resource settings.
With only three years remaining until the 2015 deadline for achievement of the Millennium Development Goals (MDGs), this year will be a critical moment for efforts to improve global health. Because the health-related MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) — are furthest off-track, advocates, researchers, programmers, and policy makers must work together to develop, support, and implement effective, integrated policies and programs.
TEDxChange, a partnership of TED and the Gates Foundation, was created to spark global conversations about social issues. An event in Berlin this Thursday TEDxChange: The Big Picture, will challenge traditional thinking around a critical global issue — contraception.
Speaking at the event, which will be webcast live, Melinda Gates will kick off a long-term initiative to change the global conversation around family planning, leading up to a major global summit on family planning in London this July. FCI is a partner in the global coalition supporting this campaign.
TEDxChange: The Big Picture
Thursday, April 5 at 12:30p EST
Webcast live in 7 languages | http://tedxchange.org
- Chris Anderson, curator of the TED conference
- Jeff Chapin, designer and engineer for IDEO
- Melinda Gates, co-chair of the world’s largest private philanthropy
- Sven Giegold, German EP Member and environmental advocate
- Baaba Maal, Song writer and artist
- Theo Sowa, Head of African Women’s Development Fund
This will be a truly global event, bringing together an online audience of thousands, as well as 190 local simulcast events in 60 countries.
Connect with the TEDxChange network on Facebook at http://facebook.com/tedxchange and on Twitter by following at http://twitter.com/tedxchange. Join the Twitter conversation on the hashtag #TEDxChange.
Basic medicines, contraceptives, and other health commodities can save millions of lives, but only if people can access them.
A thousand women die needlessly every day from preventable or treatable complications of pregnancy and childbirth. Every year more than 7.6 million children die before reaching their fifth birthday, from preventable and treatable conditions like diarrhea and pneumonia: a child who lives in a poor country is about 18 times more likely to die than one who lives in a wealthier country. And the family planning needs of 215 million women who want to prevent or delay pregnancy remain unmet — meeting this need would prevent 53 million unintended pregnancies and 100,000 maternal deaths every year. Too often, affordable, effective medicines and health supplies do not reach the women and children who need them most.
To address these gaps, UNICEF and UNFPA today launched the Commission on Life-saving Commodities for Women and Children, with a mandate to improve access to essential but overlooked health supplies. President Goodluck Jonathan of Nigeria and Prime Minister Jens Stoltenberg of Norway will serve as founding co-chairs of the Commission, with UNICEF Executive
Director Anthony Lake and UNFPA Executive Director Dr. Babatunde Osotimehin serving as its vice-chairs. The launch announcement said that the Commission will “focus on high-impact health supplies that can reduce the main causes of child and maternal deaths, as well as innovations that can be scaled up, including mechanisms for price reduction and supplies stability.”
Much of FCI’s work focuses on “building the evidence base” on reproductive, maternal, and newborn health, in order to expand access to lifesaving medicines, commodities, and services. Included on the initial list of 12 essential, overlooked medicines and health supplies identified for consideration by the Commission are two medicines that have been focuses of FCI’s advocacy work:
- Misoprostol for post-partum hemorrhage (PPH): The Commission aims to ensure that all women, at the time of delivery, have access to medicines that cause the uterus to contract — or uterotonics — in order to prevent or treat the post-partum bleeding that is the leading cause of maternal death in the developed world. The most commonly-used uterotonics are oxytocin and misoprostol, both of which are on the Commission list. In collaboration with Gynuity Health Projects, FCI has been working on a multi-year project that aims to increase understanding, use, and acceptance of misoprostol for PPH in low-resource settings. Research has shown that misoprostol is safe and effective for preventing and treating PPH, and is particularly useful in settings without refrigeration, electricity, IV therapy, and skilled health providers. Unlike oxytocin, misoprostol can be delivered in tablet form, and is temperature stable, so it does not have to be refrigerated or delivered intravenously.
- Emergency contraception (EC): EC is one of a suite of three particularly overlooked family planning commodities, also including female condoms and contraceptive implants, identified for Commission discussion. FCI serves as host organization for the International Consortium for Emergency Contraception (ICEC), an alliance of non-governmental organizations working to expand access to emergency contraception (EC), with a focus on developing countries. FCI and our colleagues in ICEC and in the broader reproductive health community worked together during the preparatory work prior to the Commission’s launch to ensure that it re-affirms the critical role of family planning in averting maternal and newborn deaths and the importance of ensuring access to EC and other contraceptive methods that are neglected, underutilized, and orphaned.
FCI welcomes the launch of the Commission, and looks forward to working closely with it and with our advocacy and program partners to ensure its effectiveness in improving access to misoprostol, emergency contraception, and other essential health supplies.
For the past five years, FCI has been a key partner in Countdown to 2015, a global coalition of academics, governments, international agencies, health-care professional associations, donors, and NGOs that uses country-specific data to stimulate and support country progress towards achieving the health-related MDGs. FCI shares (with the secretariat of the Partnership for Maternal, Newborn & Child Health—PMNCH) overall responsibility for Countdown’s advocacy and communications, working with partners to ensure that Countdown’s data, analysis, and key messages are seen and used by policy makers to effect real change.
This week, Countdown released a new publication, Accountability for Maternal, Newborn & Child Survival: An update on progress in priority countries, which contains updated profiles on high-burden priority countries that account for over 95% of the world’s maternal and child deaths. The report will be launched at the 126th Assembly of the Inter-Parliamentary Union, which takes place in Kampala, Uganda next week. These profiles highlight how well each country is doing in increasing coverage of high-impact interventions — key elements of the reproductive, maternal, newborn, and child health (RMNCH) continuum of care — that can save the lives of millions of women and children. The charts and graphs in each country profile provide an easy-to-read, attractive, and succinct portrait of whether these high-burden countries are making progress (or not) in increasing women’s and children’s access to essential services like antenatal care, skilled attendance during childbirth, immunization, and prevention of mother-to-child transmission of HIV.
This publication is one of the significant contributions that Countdown is making to the global accountability agenda around the Global Strategy for Women’s and Children’s Health, an unprecedented plan to save the lives of 16 million women and children by 2015, which was launched by UN Secretary-General Ban Ki-moon in September 2010. The country profiles in this publication, customized to showcase the core indicators selected by the Commission on Information and Accountability for Women’s and Children’s Health, are adapted from the full, two-page Countdown country profile, which Countdown produces on a roughly two-year cycle. Full country profiles will be included in Countdown’s 2012 Report, which will be published in June 2012.
FCI is also working on a number of other Countdown initiatives, including the launch of a new Countdown website and the development of a toolkit to assist high-burden countries in developing their own country-level Countdown conferences and publications.
Please join FCI and our partners at a side event to this week’s meetings of the UN Commission on the Status of Women. 1,000 Days: Improving the Nutrition of Rural Women will focus on the crucial time between a woman’s pregnancy and her child’s 2nd birthday. These 1,000 days offer a unique window of opportunity to shape healthier and more prosperous futures. By investing in improving nutrition for mothers and children in this 1,000-day window, we can help ensure that a child can live a healthy and productive life, and we can also help families, communities and countries break out of the cycle of poverty.
Friday, March 2, 2012 10:30 a.m. – 12:00 noon
Salvation Army (Downstairs Conference Room)
221 E. 52nd Street (between 2nd and 3rd Avenues)
New York City
Free and open to the public.
RSVP at www.thp.org/csw56
Questions? Please contact Carolyn Ramsdell at 212-251-9130 or Carolyn.firstname.lastname@example.org
In many developing countries, national health systems don’t always effectively reach certain groups of people with the information and services they need to stay healthy. Too often, the health services that are available are designed without sufficient regard for the cultures, beliefs, and traditions of those they aim to reach, and the result is that essential information doesn’t get through to its intended audiences, and that urgently important health services don’t get utilized. Many members of particularly marginalized groups — which can include teenagers who have left school or their home villages to seek work in the city, or indigenous populations living in poor, underserved rural communities — don’t know what they need to know about their sexual and reproductive health, and are particularly vulnerable to HIV infection.
FCI works with our local partners to address this challenge by developing culturally-sensitive programs for reaching vulnerable groups with the information and services they need. Working with out-of-school young people in the port city of Mopti, on the Niger River in Mali, West Africa, and with women and young people in remote indigenous villages in Ecuador, we have partnered with Interarts, with support from the Spanish Agency for International Development Cooperation (AECID), to promote sexual and reproductive health and prevent HIV.
In mid-February, Fatimata Kané, FCI’s country director in Mali, and Maritza Segura, our national coordinator in Ecuador, together with representatives from our local partner organizations, presented this work at a conference in Barcelona, Spain. This meeting, entitled “Culture and Sexual and Reproductive Health—towards a new interconnection: A day to think, discuss and act,” was organized by Interarts as an opportunity for 50 NGOs, development agencies, migrant organizations, health workers, anthropologists, and educational professionals to share best practices and exchange ideas on the links between cultural rights, sexual and reproductive rights, and health. Meeting participants emphasized that integrated programs must focus on community needs, guarantee health rights, and respect local cultures and cultural rights. Understanding a community’s culture is essential to any health project’s success and sustainability, and is particularly important in efforts to modify behaviors that may have a negative impact on sexual and reproductive health, enabling programmers to identify bottlenecks and address issues in a participatory way.
For the Barcelona conference, the representatives from FCI-Mali and FCI-Ecuador were accompanied by youth leaders from FCI’s project partners: AEJT (the Association of Working Children and Youth) in Mopti, Mali, and Ecuarunari (the Kichwa Confederation of Ecuador). The team from Mali described their work with young people in Mopti’s ‘informal sector’ (domestic workers, market vendors, artisanal apprentices, etc.), and with the traditional leaders, employers, and parents who can influence them, to raise awareness about the consequences of negative and high-risk practices and to encourage cultural change for better sexual and reproductive health. (At first, taboos about discussions of sexuality made it difficult to involve religious leaders in the project; by sensitively integrating culture and religion into our approach, however, FCI was able to facilitate constructive dialogue by showing that religious texts do not actually support female genital mutilation and other negative practices.) The team from Ecuador discussed their work with indigenous women’s and youth groups to identify the traditions, beliefs, and cultural factors that lead to increased vulnerability to HIV, and to strengthen cultural values that can help prevent HIV and its attached stigma in indigenous communities.
Ann Starrs is FCI’s president. The remarks below were delivered by Ann at the United Nations Association of the USA’s Members’ Day, at the UN on February 10, 2012.
I’m going to start this talk with a story. It’s the story of a family in Afghanistan, several years ago. The wife was pregnant for the seventh time; she died of postpartum hemorrhage, the most common cause of maternal death in poor countries. Because her husband couldn’t cope with the responsibilities and cost of caring for a large family on his own, one of their daughters, aged 13, was married off, to a much older man. At the age of 15, she gave birth to twins. One of the infants died right after birth, and the young mother developed fistula, a horrifying complication in which a woman develops a hole between her urethra and vagina, and leaks urine for the rest of her life unless the hole is surgically repaired. Because of her smell, her husband sent her back to her father, with the weak and ailing surviving infant. They had to spend what was, for them, a significant amount of money trying to get care for the baby.
This is just one family’s story, but it is representative of millions more. Around the world, a woman dies from preventable causes related to pregnancy and childbirth a thousand times every day. A child dies, of similarly preventable causes, every 3 seconds. Add these stories up, and the annual death toll is staggering: 350,000 maternal deaths a year, each one leaving grieving parents, husbands, or children, and 7.6 million children dying before the age of 5. Forty percent of these children are lost in their first month of life, and again, nearly all of these deaths are preventable.
The tragedy of this Afghan family is representative in another way. It portrays, in a nutshell, the multiple reasons why the world must invest in women’s and children’s health. There is a clear moral imperative to prevent these needless deaths, but no less clearly there is an economic imperative. A healthy woman — who is able to decide on the number and spacing of her children, who can deliver them safely, who can see them through childhood in good health — is someone who can contribute to the economic productivity, and to the social and cultural stability, of her family, her community, her nation, and the world. A family destroyed by the loss of a mother or daughter, made desperate by the loss of a breadwinner, or burdened by the tragedy of a lost child, is far too often a family that finds itself trapped in an inescapable cycle of poverty.
This is a challenge that advocates, NGOs, and UN agencies have been working on tirelessly, for decades. My organization, Family Care International, has been working in partnership with governments, other NGOs, donors, academics, and others to raise attention and mobilize commitment — and funding — to address the multiple causes and prevent the horrifying consequences of maternal death. Much of our work is done through and with the Partnership for Maternal, Newborn, & Child Health (known as PMNCH), which has worked to great effect to focus the world’s attention on the powerful and crucial concept of the continuum of care.
The Global Strategy for Women’s and Children’s Health was launched by UN Secretary-General Ban Ki-moon at the General Assembly in September 2010. The Global Strategy was an expression of the Secretary-General’s recognition that the health MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) — were headed for failure, and that this dire circumstance presented the world with an urgent moral imperative. The Global Strategy, and the Every Woman Every Child effort that aims to generate commitments to the Global Strategy, represents the compelling moral power of the UN and its Secretary-General to mobilize the world into focused action. Its stated goal was to save 16 million lives between 2010 and 2015.
The Global Strategy has, so far, provided a much-needed jumpstart to international efforts to bring about real progress on women’s and children’s health. It has bought together key UN and other multilateral agencies (including WHO, UNICEF, UNFPA, UNAIDS, and the World Bank) around a coherent, comprehensive vision of what needs to be done to save lives. The Global Strategy set clear, measurable targets, and mechanisms have been established to keep track of whether targets are being met and to ensure accountability. It has mobilized a broad range of stakeholders — from civil society organizations to corporations, from all of the most important international donors to the governments of dozens of developing countries — to commit themselves to take specific, concrete, and significant actions. Many of these commitments have been pledges of money, which is desperately needed, but many have also been commitments in kind: pledges to build new midwifery schools, to achieve specific increases in national skilled childbirth attendance or immunization rates, to institute free emergency obstetric and child health care, or to increase access to and use of contraceptives.
This is a multi-year effort, and one whose goals are both ambitious and urgently necessary, and much more still needs to be done. In this time of limited and constrained resources, we must bring about greater efficiency and effectiveness in the ways that aid is allocated and programs are implemented, with a particular focus on the integration of services, so that women and families can meet their health care needs at a single health center offering high-quality, comprehensive services across the continuum of care. We must work in a targeted way, focusing our resources and efforts on key countries, where the burden is highest, and on key, proven interventions. We must ensure that governments, donors, and all other stakeholders are held to account for fulfillment of their commitments: the Global Strategy only becomes truly meaningful when its promises are kept, and advocates (including my organization) are working hard to make sure that they are. And we must have sustained, vocal, visible, high-level leadership — from the Secretary-General himself, from heads of state, and from celebrities; but also from dedicated and often unsung individuals in ministries of health, in civil society organizations like the United Nations Association, in hospitals and clinics, and in the villages and communities where so many women and children are still dying.
So what am I —an advocate from an NGO, and not a representative of the UN — doing here, in front of the United Nations Association, describing an initiative of the UN Secretary-General? I’m here because a great part of the power of this initiative is the way it focuses on the value of partnership to get things done. An engaged, empowered civil society — both here at the global level, and at the grass roots in every country with a high burden of maternal and child death — must play, and is playing, a central role in that partnership. The voice of civil society is key to making change happen, in every corner of the world.
In 2000, the world committed itself in the Millennium Declaration to bring about momentous change by the year 2015, to address the historic challenges of poverty, hunger, disease, inequality, and environmental degradation that deform or end so many lives in the developing world. Much progress has been made, but it is clear that the goals related to health will not be fulfilled. And MDG 5 is the furthest from success. As we begin to talk about an international framework for continued, and accelerated, progress beyond 2015, that framework must include special attention to the health, well-being, and education of children and women. The United Nations, under the leadership of Ban Ki-moon, has set a visionary, progressive agenda. It is our obligation to build on that legacy, to build a world where no woman and no child dies a preventable death, simply because they were born in the wrong place, because they are poor, because we pretend we can’t afford to save them. The Global Strategy has been an essential first step, and its urgent, essential work will continue until it is done.
Robinson Karuga is research coordinator at FCI-Kenya.
In Kenya, when someone in a poor, rural community needs health care, she goes to a health center — a facility in a nearby market town, offering a broad range of primary health services — or to a dispensary — a lower-level facility, typically staffed by a single nurse and providing only limited services. For most Kenyans, health centers and dispensaries are their only contact with the health system, and the only available source of primary care. For Kenya to make meaningful progress in reducing its high rates of maternal and child mortality, the services offered in these primary-level facilities must be strengthened, and more Kenyans must be persuaded to use them: more than half of Kenyan women still give birth without help from a skilled attendant, a statistic that has actually become worse over the past 20 years.
Unfortunately, primary-level facilities often have not had the money they need to support consistent, high-quality services — in Kenya’s centralized national health system, allocated funds rarely filtered down to facilities through inefficient district disbursement channels characterized by leakages and mismanagement. In recent years, this funding shortfall was made worse by the government’s reduction and ultimate abolition of official user fees for many essential health services: ironically, a policy designed to increase poor people’s access to services often resulted in poorer service quality, as the facilities’ lost revenue was not replaced.
Beginning in 2010, the Ministry of Health addressed this problem with a program of ‘Direct Facility Funding’ (DFF), by which funds are provided directly from the national government to cover facilities’ core expenses, so that they can provide high-quality services that are responsive to communities’ needs. This is a potentially powerful reform, but facilities face significant challenges in implementing it, including managers with insufficient budgeting and money management skills and a lack of transparency in how money is allocated and spent. There is also a lack of community awareness and monitoring of the DFF process, which minimizes community input on priorities for quality‐of‐care improvements.
This year, with support a from the Transparency and Accountability Program of the Results for Development Institute, FCI-Kenya will evaluate communities’ knowledge and understanding of the direct facility funding system and their level of satisfaction with health facilities’ quality of service and accountability. FCI will work in two counties (one rural and one urban), using “citizen report cards” to collect quantitative and qualitative data from health facility clients and from members of Health Facility Management Committees, community-based groups that are charged with managing funds at the facility level.
FCI will then work with government partners to develop an advocacy and community mobilization strategy to provide Health Facility Management Committee members with the knowledge and skills to manage funds effectively, and to ensure that community members have input into how funds are spent. Based on lessons learned from the project, the Ministry of Health — which enthusiastically supports this first-ever evaluation of the DFF reforms —plans to introduce the citizen report card throughout the country. It will serve as a continuous social accountability tool, creating a feedback loop between the national health financing structure and the community, and giving users of the health system a real voice in the services it provides. By empowering communities and building financial management capacity in the facilities themselves, this project offers a new and meaningful opportunity both to improve the quality of care and to increase demand for high-quality services.
Forgotten But Not Gone: Childhood TB meeting brings together advocates to combat the global childhood TB epidemic
Amy Boldosser is Senior Program Officer for Global Advocacy at Family Care International.
Many people, including advocates who work on maternal, newborn and child health, may be surprised to learn that tuberculosis (TB) is the third leading killer of women of reproductive age worldwide and that globally over 1 million children become sick with TB each year. In fact, one-third of the world’s population is currently infected with TB. Tuberculosis is an infectious disease caused by bacteria that often attack the lungs but may also spread to the brain or other areas of the body. TB is spread through the air when an infected person coughs, sneezes or even laughs. Children are at particular risk for contracting TB due to their weaker immune systems and are likely to become infected if their mothers are sick. Vulnerable children, such as those whose families are living in poverty, who are orphans, or who already have HIV or other diseases, are even more susceptible since they are more likely to be malnourished, lack access to good health care, and are likely to be living in cramped quarters with their families. In addition, women with TB are two times more likely to have premature babies or experience stillbirth.
On January 5, 2012, a group of concerned advocates, researchers, and medical professionals came together in Washington, DC for a community dialogue and strategy session on combating this global epidemic. The meeting was organized by the Treatment Action Group (TAG), the Center for Global Health Policy, ACTION, Stop TB Partnership, and the American Thoracic Society. As Coco Jervis, Senior Policy Associate at TAG said, the meeting was a way to “sound the alarm” about this leading killer of mother and children, to raise awareness of the impact of TB on global health, and to develop advocacy and research agendas.
Speakers at the event highlighted that most cases of TB in children and women could be easily prevented with simple, inexpensive measures and increased detection. The lack of integration of TB care into HIV and maternal and child health services in many health systems means that mothers and children are frequently not tested for TB at pre-natal or well-woman visits, a huge missed opportunity. If TB is detected early in a child it can almost always be cured. But delays caused by poor access to healthcare or parents not being able to afford the 6 months of treatment with multiple different drugs required to treat TB results in more than 200,000 children dying from TB each year (a number which is likely much higher due to underreporting). Family Care International is working with partners across Africa to increase integration of maternal, newborn and child health services with programs for HIV/AIDS, tuberculosis and malaria to address these delays in diagnosis and treatment.
Dr. Jeffrey Starke, a professor of pediatrics at Baylor College of Medicine and Director of the Children’s Tuberculosis Clinic at Texas Children’s Hospital, and Dr. Sharon Nachman, a professor of pediatrics at SUNY Stony Brook University Medical Center in Long Island, highlighted the significant research and treatment needs that exist noting that many drug trials do not include a focus on developing pediatric versions of TB medicines and do not include pregnant women. The mother of a 6 month old TB patient at Texas Children’s Hospital shared the heartbreaking story of how her son, who did have access to high quality medical care in the US, was misdiagnosed and developed TB meningitis, an extremely dangerous brain infection. He suffered through months of painful treatments and surgeries before beginning to recover. She called on public health authorities and drug companies to make simple changes like creating chewable tablets of TB medication that would be easier for children to take and conducting routine testing in children. She reminded participants in the meeting that TB is not only a problem in the developing world but is also a very real health threat here in the United States.
The good news is that treatments are available for TB and new drugs are in development. The US government also increased its development aid for tuberculosis programs worldwide by 5% for 2012, an important success considering the current economic climate. But more must be done. Check out the Stop TB Partnership’s website for ways that you can get involved with World Tuberculosis Day on March 24, 2012 to help raise awareness of the need to stop TB: www.stoptb.org
Learn more about the impact of TB on women and children through ACTION’s issue briefs below, and consider sharing this information through Facebook, Twitter, or email to help raise awareness of tuberculosis among your family and friends.
Ann Starrs is president of Family Care International.
Every five minutes, somewhere in the developing world, a woman who has just given birth bleeds to death. Almost all of these cases of postpartum hemorrhage (PPH) can be prevented or effectively treated if every woman has access to essential health services and medicines, and particularly to uterotonic drugs.
Misoprostol is one such drug. Research has shown it to be safe and effective for stopping postpartum bleeding, the leading cause of death in childbirth. Misoprostol offers several unique advantages, particularly for use in low-level health facilities and in community and home birth settings: it doesn’t require refrigeration, is simple to administer, is inexpensive, and is widely available. But many women still do not have access to this critical medicine – even though misoprostol is on the World Health Organization’s Model List of Essential Medicines for the prevention of PPH, is on the national essential drug lists in many countries, and is included in many global and national clinical practice guidelines.
In “Misoprostol for postpartum hemorrhage: Moving from evidence to practice,” a commentary we co-authored for the January 2012 issue of the International Journal of Gynecology & Obstetrics (IJGO), Beverly Winikoff (president of Gynuity Health Projects) and I note the “growing consensus that misoprostol is a safe and effective option for preventing and treating PPH, particularly in settings where oxytocin — the gold standard drug — is not available or where its administration is not feasible.” This article grew out of a multi-year collaboration between Gynuity and FCI to evaluate misoprostol and to promote wider understanding, use, and acceptance of misoprostol for preventing and treating PPH. In it, we outline the unique challenges to expanding women’s access to and use of misoprostol, including:
- Misoprostol’s use for a range of indications, which has resulted in controversy about its possible “misuse.” Misoprostol can be used to induce abortion early in pregnancy, and can cause complications if used incorrectly before or after delivery, which has made some governments, donors, and health care professional reluctant to promote it even for appropriate uses.
- Evidence-based guidelines and clinical protocols that, in many countries, do not reflect the latest research, and a lack of provider training in its proper use.
- Misconceptions and misperceptions held by policy makers and health practitioners, including a fear — unsupported by the evidence — that promoting misoprostol’s use in home births could deter women from giving birth at health facilities.
There is no panacea for reducing maternal mortality: as we point out in the article’s conclusion, “no drug can replace the need for strengthened basic and emergency obstetric care services; for more and better-trained health workers; for clean, well-equipped facilities; and for culturally-sensitive, high-quality maternal health care.” But misoprostol is an essential tool, one that can help us to deliver on the world’s promise to improve maternal health. To make progress in ensuring that every woman has access to a uterotonic to prevent or treat PPH, the medical and health policy communities must work together to translate research findings on misoprostol into changes in policy, knowledge, and clinical practice.
Read the full article here.
Learn more about FCI’s work on misoprostol and PPH here.
Today, on World AIDS Day 2011, Family Care International has partnered with Save the Children to help policymakers across Africa understand and act on the urgent need to eliminate new HIV infections among children, and to provide comprehensive HIV services for their mothers.
Three decades into the AIDS pandemic, new HIV infections among children are virtually zero in high income countries. Yet in middle and low-income countries, an estimated 370,000 children were born with the HIV virus in 2009, while 60,000 pregnant women died because of HIV. “This is unacceptable. Urgent and exceptional efforts should be made to eliminate new infections among children and to keep their mothers alive,” said Thomas J. McCormack and Fatimata Kané, Country Directors in Mali for Save the Children and FCI, respectively, in a joint statement supporting the Getting to Zero campaign to eliminate new HIV infections. “Save the Children and FCI agree: Getting to zero is possible in Mali and in countries across Africa.”
With over 2.5 million children and 1.4 million pregnant women living with HIV, action must be taken to ensure the survival of children and mothers. Weak health systems, insufficient numbers of health workers, limited health financing, and inadequate focus on health issues within national development frameworks all must be addressed urgently in order to save women’s lives, protect their health, and help them avoid passing on the virus to their children. This requires action by governments, in partnership with the private sector and development partners.
FCI and Save the Children are joining UNAIDS and a global coalition of NGOs in supporting the Global Plan Towards Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive. The Global Plan has two important targets:
- Reduce the number of new HIV infections among children by 90%
- Reduce the number of AIDS-related maternal deaths by 50%.
African leaders have made a number of commitments to address HIV/AIDS among women and children, most recently at the United Nations High Level Meeting on AIDS in June, 2011, when the Global Plan was launched.
In Mali, Burkina Faso, and Kenya, FCI is working, in collaboration with many partners, to hold policymakers accountable for keeping these promises. Increased efforts to eliminate new infections for children and keep their mothers alive are crucial to improving child survival and maternal health, and to achieving Millennium Development Goals 4, 5 and 6. FCI is proud to partner with Save the Children and other advocates around the world on World AIDS Day to urge policy makers and donors to help us “get to zero.”
Alain Kaboré is Program Officer with FCI-Burkina Faso, based at our office in Ouagadougou.
In Burkina Faso, as in too many developing countries, giving birth is one of the riskiest things that a woman can do. In this poor and largely rural country, one in 28 women dies from complications of pregnancy or childbirth, and many more suffer from serious childbirth injuries or disabilities. One of the most common and devastating of these injuries is obstetric fistula,an injury to the birth canal caused by obstructed and prolonged labor. It results in a lifetime of pain, humiliation, and social ostracism, as the fistula causes incontinence and odor and makes it impractical or impossible to have more children.
FCI-Burkina Faso, with support from the United Nations Population Fund—UNFPA, is working with communities and partner organizations in the Sahel region, on the edge of the Sahara, to prevent obstetric fistula by improving access to and utilization of emergency obstetric care, to provide treatment for women living with fistula, and to support the reintegration of fistula survivors into their communities. This is the story of two of those survivors.
Maïrama Tamboura, is a 40-year old woman from a village in the Sahel. She married as a teenager, and had her first baby at the age of 17. When she was 25, giving birth for the third time — at home, without the help of a skilled birth attendant, as is typical in this region — a prolonged and painful labor culminated in the loss of her baby and the development of an obstetric fistula. This began almost 15 years of pain and humiliation.
Maïrama’s husband banished her, and her neighbors excluded her from weddings, funerals, and the other social events of the village. In these rural West African communities, a woman’s social status depends almost entirely on her marital status: an abandoned woman, who smells bad and is perceived as a failure, quickly becomes an outcast. Luckily, her mother remained loyal to her. Maïrama went back to live in her parents’ home, and her mother tirelessly tried to find a way to help her daughter. She consulted traditional healers, to no effect, and had surgery performed by a medical practice in the nearby town of Djibo, the capital of the province Soum, but the doctor there lacked the skills and resources to successfully address the problem.
Mariama Boureima-Diallo is a much younger woman — she is only 27 — but she too lived with obstetric fistula for more than a decade. Originally from the neighboring country of Mali, Mariama Boureima-Diallo also married young and was pregnant at age 16. Obstetric fistula is most common in adolescents, because a small, undeveloped pelvis increases the risk of obstructed labor, and this is what happened to Mariama Boureima-Diallo. After developing fistula and being banished by her husband, she crossed the border into Burkina Faso and arrived in Djibo. There, she underwent two surgical procedures, both unsuccessful, with the same medical practice. Like the older Maïrama Tamboura, she seemed destined for a lifetime of pain and isolation.
FCI-Burkina Faso’s obstetric fistula program works to find women like Maïrama Tamboura and Mariama Boureima-Diallo, and to help them get their lives back. This is not a simple task, as many women with fistula live quietly and in the shadows. We found Maïrama Tamboura because her mother came to an outreach meeting led by one of our partners, a local grassroots organization. After learning about our program, she asked that her daughter have an opportunity to participate. MariamaBoureima-Diallo became known to us because a fisherman she knew participated in a similar awareness-raising meeting. He took our community mobilizer to visit with Mariama Boureima-Diallo in her isolated hut.
Both women were brought into the program, and both were ultimately taken to Dori, the capital city of Sahel region and site of its only hospital, where they received surgical care and were successfully treated.
Today, Maïrama Tamboura and Mariama Boureima-Diallo both live in the rural village of Djao-Djao, about 10 miles outside of Djibo. Both are now happily remarried, and are healthy, have fully reintegrated with the community, and have gained back their social lives and status. A new beginning awaits them.
La seconde vie des survivantes de la fistule obstétricale : une histoire de succès au Burkina Faso
Alain Kaboré est chargé de programme à FCI-Burkina Faso, basé dans notre bureau à Ouagadougou.
Au Burkina Faso, comme dans beaucoup de pays en développement, accoucher est une des choses les plus dangereuses qu’une femme puisse faire. Dans ce pays pauvre et très largement rural, une femme sur 28 meurt suite à des complications survenues durant sa grossesse ou son accouchement, et beaucoup d’autres souffrent de blessures ou d’handicaps dus à l’accouchement. Une de ces blessures la plus répandue et dévastatrice est la fistule obstétricale, une blessure de la filière génitale causée par un accouchement prolongé ou par son arrêt. Il en résulte une vie de douleur, d’humiliation et d’exclusion sociale car la fistule entraîne l’incontinence et des odeurs qui rendent impossible ou très compliqué pour une femme d’avoir d’autres enfants.
FCI-Burkina Faso, avec le soutien du Fonds des Nations Unies pour la Population (UNFPA), travaille en collaboration avec les communautés et des organisations partenaires dans la région du Sahel, au bord du Sahara, pour prévenir les fistules obstétricales en améliorant l’accès aux soins obstétricauxd’urgence ; fournir un traitement aux femmes vivant avec une fistule ; et soutenir la réintégration des survivantes de la fistule au sein de leur communauté. Voici l’histoire de deux de ces survivantes.
Maïrama Tamboura est une femme de 40 ans habitant dans un village du Sahel. Elle s’est mariée alors qu’elle n’était qu’une adolescente et elle a eu son premier bébé à 17 ans. A 25 ans, alors qu’elle donnait naissance pour la troisième fois — à la maison, sans l’aide d’une sage-femme, comme fréquemment dans la région — un accouchement prolongé et douloureux a abouti à la perte de son bébé et au développement d’une fistule obstétricale. A partir de là, ont commencé presque 15 années de souffrance et d’humiliation. Le mari de Maïrama l’a répudiée et ses voisins l’ont exclue des mariages, funérailles et autres événements sociaux du village. Dans les communautés rurales d’Afrique de l’Ouest, le statut social d’une femme dépend presque intégralement de son statut marital : une femme abandonnée, qui sent mauvais, est perçue comme un échec et devient rapidement exclue. Heureusement, sa mère lui est restée fidèle. Maïrama est retournée vivre chez ses parents et sa mère a essayé sans relâche de trouver un moyen d’aider sa fille. Elle a consulté les soignants traditionnels sans succès. Elle a obtenu qu’un cabinet médical effectue une chirurgie sur sa fille dans la ville proche de Djibo, la capitale de la province Soum, mais le docteur n’avait pas les ressources et compétences nécessaires pour résoudre le problème.
Mariama Boureima-Diallo est une femme beaucoup plus jeune — 27 ans — mais elle aussi a vécu avec une fistule obstétricale pour plus d’une décennie. D’origine malienne, un pays voisin, Mariama Boureima-Diallo s’est aussi mariée très jeune et était enceinte à 16 ans. La fistule obstétricale est très commune chez les adolescentes car leur bassin est petit et peu développé ce qui augmente les risques de dystocie. C’est ce qui est arrivé à Mariama Boureima-Diallo. Après avoir développé une fistule et avoir été répudiée par son mari, elle a traversé la frontière pour aller au Burkina Faso et est arrivée à Djibo. Là, elle a eu deux chirurgies, toutes les deux sans succès, avec le même cabinet médical. Comme Maïrama Tamboura, elle semblait être condamnée à une vie de souffrance et d’isolement.
Le programme de lutte contre la fistule obstétricale de FCI-Burkina Faso cherche les femmes comme Maïrama Tamboura et Mariama Boureima-Diallo et les aide à retrouver une vie normale. La tâche n’est pas facile car beaucoup de femmes ayant une fistule vivent en retrait et dans l’ombre. Nous avons rencontré Maïrama Tamboura car sa mère a assisté à une causerie éducative sur le sujet menée par un de nos partenaires, une association communautaire. Après avoir appris l’existence de notre programme, elle a demandé que sa fille puisse y participer. Mariama Boureima-Diallo a été identifiée parce qu’un pêcheur qui la connaissait a participé à une animation similaire. Il a amené notre animateur pour rendre visite à Mariama Boureima-Diallo dans sa maison isolée.
Les deux femmes ont rejoint le programme et ont toutes les deux été amenées à Dori, la capitale du Sahel où elles ont pu recevoir la chirurgie et les soins nécessaires à leur guérison dans le seul hôpital de la région.
Aujourd’hui Maïrama Tamboura et Mariama Boureima-Diallo habitent toutes les deux le village de Djao-Djao, à environ 16 kilomètres en dehors de Djibo. Toutes les deux sont maintenant remariées, heureuses, en bonne santé et pleinement réintégrées au sein de leur communauté. Elles ont retrouvé leur statut et leur vie sociale. Un nouveau départ les attend.
Amy Boldosser is Senior Program Officer, Global Advocacy, at Family Care International.
On Sept. 20, 2011, while world leaders met across the street in the United Nations, leaders from the field of maternal health came together in New York City for the standing room-only event, Maternal Health in Crisis: Health Workers on the Frontline. Co-sponsored by Family Care International with Every Mother Counts, the International Confederation of Midwives, Jhpiego, The Lancet, Merck, and Save the Children, the event drew attention to the critical role of frontline health workers in achieving Millennium Development Goal (MDG) 5, to improve maternal health.
Across the developing world, many countries are experiencing a dramatic — and life-threatening — shortage of health workers. The World Health Organization estimates that 3.5 million additional health workers are needed globally, including 350,000 midwives and one million community health workers. Midwives and other health workers with midwifery skills are critical to getting women and newborns safely through pregnancy, delivery, and the postnatal period: an adequate midwifery workforce could prevent as many as 3.6 million maternal, fetal, and newborn deaths each year.
The panel, moderated by Dr. Richard Horton, Editor-in-Chief of The Lancet, brought together Ann Starrs, President, Family Care International; Dr. Willibrord Shasha, AIDSTAR project, Jhpiego; Dr. Julie Gerberding, President, Merck Vaccines, Merck; Mugara Joseph Mahungururo, Nurse-Midwife, Muhimbili National Hospital, Tanzania; Donald Steinberg, Deputy Administrator, USAID; and Christy Turlington Burns, Founder, Every Mother Counts to discuss the role of civil society, government and the private sector in promoting and supporting the health workforce.
Ann Starrs opened the event by noting that, despite increasing global visibility and focus on maternal health, and newly released data showing continued reductions in maternal and child mortality, MDG 5 is still far off track. “There are enormous disparities in access to health workers with midwifery skills, and the countries with the highest burden of maternal death have the lowest concentrations of these essential personnel,” Ms. Starrs said. She also noted that the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, launched a year ago, would be announcing a range of new commitments that afternoon at an event called Every Woman Every Child, including significant commitments to train more midwives in a number of countries. Ms. Starrs also announced that The Partnership for Maternal, Newborn and Child Health has produced two groundbreaking reports, one analyzing the commitments made to women’s and children’s health within the framework of the Global Strategy, and a second report, to be made available shortly, examining the aid architecture for reproductive, maternal, newborn and child health.
Dr. Shasha highlighted the importance of integrating maternal, newborn and child health care with HIV/AIDS, tuberculosis and malaria services. He noted that while it is possible in most African countries to get a haircut, have a cup of tea and buy a phone card in one place, it is difficult or impossible for women to get family planning services, immunization, and antenatal care in one health facility at one time. Health workers trained and equipped to provide integrated services could significantly improve access to maternal, newborn and child health services, and reduce the total cost of providing essential interventions.
Dr. Gerberding announced the launch of Merck for Mothers, a long-term effort to create a world where no woman has to die from complications of pregnancy and childbirth. The initiative will start with a 10-year, $500 million commitment to helping the United Nations tackle Millennium Development Goal 5 and improve maternal health worldwide as part of the United Nation’s Every Woman Every Child campaign.
Mugara Joseph Mahungururo, who became a nurse-midwife herself after a midwife saved her life when she had complications delivering her twins, shared her experience working in the main national hospital of Dar es Salaam, Tanzania. She described the maternity ward as having only three graduate-level trained nurses, even though they have already delivered more than 6,000 babies in 2011. Mugara called on stakeholders to support additional training for midwives, some of whom have not had the opportunity to upgrade their skills in over 10 years, and highlighted that, in addition to training, midwives need access to basic supplies, equipment, infrastructure, and fair pay for their work. In order to provide lifesaving care, they also need and deserve a policy and social environment where they are supported, recognized, and valued.
Deputy Administrator Steinberg discussed the importance of women’s political, social, and economic empowerment for improving maternal health. He highlighted USAID’s support for new technologies (including through the Saving Lives at Birth Initiative) and expanding access to lifesaving maternal and child health services, including essential medicines and supplies, and to family planning.
Christy Turlington Burns explained that she experienced postpartum hemorrhage after the birth of her first child. If she had been in rural Africa or Latin America, without the care of a midwife and a skilled obstetric team, she would have died. That realization led her to begin advocating to raise awareness about maternal health, to make a film on the experiences of women in Tanzania, Bangladesh, Guatemala, and the US, and eventually to found an advocacy and outreach initiative called Every Mother Counts. Every Mother Counts launched its newest Public Service Announcement entitled Choices, which emphasizes the importance of health workers in improving maternal and child health. Click here to watch the PSA.
The discussion highlighted the links between maternal health and non-communicable diseases (the focus of this week’s UN High Level Meeting), retention and training of health workers, strengthening aid architecture in order to better support expansion of the health workforce, and the importance of partnerships with a range of stakeholders – donors, UN agencies, governments, NGOs, health care professional associations, and academic and training institutions – all of whom have a role to play in addressing health workforce challenges. Dr. Horton closed the panel with a call echoing the outcome of 29th Triennial Congress of the International Confederation of Midwives in Durban, South Africa. He called for a world in which all health workers come out of the shadows, and where midwives are no longer invisible, so that all women will have access to lifesaving care for themselves and their children. FCI looks forward to working with all of the attendees of the event to make this a reality.
Shafia Rashid is a senior program officer in FCI’s Global Advocacy program.
Estimates released earlier this month, based on research by WHO, Save the Children, and the London School of Hygiene and Tropical Medicine, indicate that 3.3 million newborn babies died in 2009. This reflects a substantial reduction over the past two decades: the authors estimate that 4.6 million newborns died in 1990, so newborn mortality has declined by 1.7% per year. While this is good news, the fact remains that maternal and child mortality have both been falling more rapidly, at 2.1% and 2.3%, respectively. (The child mortality figure includes newborns, meaning that mortality rates for children more than one month old can be assumed to have declined at an even higher rate.) As our colleague Flavia Bustreo, WHO’s Assistant Secretary-General for Family, Women’s and Children’s Health, has noted, “Newborn survival is being left behind despite well-documented, cost-effective solutions to prevent these deaths.”
At present, 41% of all children who don’t make it to their fifth birthday die during their first four weeks of life. This percentage has been rising, and will keep rising as long as child survival improves faster than newborn survival. Most newborn deaths, of course, occur in developing countries; Africa has shown the slowest progress, with newborn mortality falling by only 1% per year. Clearly, the world needs to more effectively address the continuing epidemic of newborn death — this is an essential key to meeting MDG 4’s goals for overall child survival.
Addressing these challenges requires concerted effort to improve both maternal and newborn health and survival. We know that the health of a woman and that of her newborn are closely linked: most maternal and newborn deaths are caused by the mother’s poor health before or during pregnancy or due to inadequate care in the critical hours, days, and weeks after birth. Improved, more accessible, and integrated services for both mother and baby can efficiently and effectively save both of their lives.
Last year, FCI collaborated with Dr. Zulfiqar Bhutta and a research team from Aga Khan University in Pakistan to review the research available on the impact of potential interventions on maternal and newborn outcomes, with a particular emphasis on linkages between the two. Initial results were presented at the Women Deliver conference and the Global Maternal Health Conference in 2010, and the final report will be published in BioMedCentral in January 2012.
The findings from this review highlight how health care for women and newborns is an interconnected continuum — many of the same clinical interventions benefit both mother and baby. It is therefore vital to interconnect care for women and for their newborn children — to promote greater efficiency and lower costs, and to reduce duplication of resources. Perhaps most importantly, integrating interventions can maximize impact on the health and survival of women and their newborns.
This research will be a helpful first step in better understanding why newborn survival is lagging, and — more importantly — in FCI’s efforts to promote investment in and implementation of health interventions that can save the lives of both women and their newborn babies.