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In the midst of a long and busy week of discussions and events around the annual meeting of the United Nations General Assembly, FCI president Ann Starrs sat down for an interview on the critical role of communities in demanding accessible, high-quality health services.
“Women and their families,” she says, “have to be active, they have to understand what their rights are in terms of access to health care, in terms of access to information, and they have to demand that their political leaders, locally and nationally, make these services available and make these services high quality. If you don’t have that kind of demand and that kind of momentum in place, then any changes that get implemented are not going to be sustainable.”
Watch the video:
Ann Starrs is president and co-founder of Family Care International.
In the developing world, uncontrolled postpartum bleeding or hemorrhage (PPH) is the leading cause of death in childbirth, killing a woman every five minutes. Misoprostol has been shown to be a safe and effective medicine both for the prevention and for the treatment of PPH. While another drug, oxytocin, is generally recognized as the “gold standard” among uterotonic drugs for preventing or treating PPH, misoprostol has significant advantages for use in settings where maternal mortality is high and most births take place outside of hospitals: misoprostol is delivered in tablet form, and — unlike oxytocin — requires neither refrigeration nor intravenous administration.
In “New global guidance supports community and lay health workers in postpartum hemorrhage prevention,” a commentary I co-authored, along with Dr. Clara Ladi Ejembi of Ahmadu Bello University in Zaria, Nigeria, Pamela Norick of Venture Strategies Innovations, and Dr. Kusum Thapa of Jhpiego, Nepal, for the June 2013 issue of the International Journal of Gynecology & Obstetrics (IJGO), we welcome the release of new global recommendations for misoprostol from the World Health Organization (WHO), the International Federation of Gynecology and Obstetrics (FIGO), and International Confederation of Midwives (ICM). While FIGO and ICM recognize the life-saving benefits of misoprostol to prevent PPH in low-resource settings, the WHO recommends that community and lay health workers administer misoprostol when skilled birth attendants and oxytocin are not available. However, these high-level recommendations aren’t enough: community involvement is crucial to the success of misoprostol interventions. Community members should be active participants in conversations that directly affect their healthcare, and misoprostol programs should empower them to lead implementation and distribution efforts. Our commentary presents two case studies that illustrate the important role of communities in misoprostol programs.
In Nigeria, women’s chances of surviving childbirth are dire: a woman’s lifetime risk of maternal death is 1 in 23, and in the Northwest region where fertility rates are high and cultural and religious beliefs restrict women’s freedom of movement, women are twice as likely to die in childbirth than Nigerians in other regions of the country. More than 90% of births happen at home with only family members or a traditional birth attendant to assist with delivery. With stark statistics such as these, women would have more of a fighting chance if they had access to misoprostol – and that’s where the community comes in.
A team of researchers from Ahmadu Bello University and the University of California, Berkeley, led a series of dialogues with community members concerning maternal health issues as well as PPH warning signs and misoprostol, resulting in community leaders’ support for misoprostol. Through these discussions, the community designated drug keepers, who would give the pills free of charge to traditional birth attendants, pregnant women and family members in the last month of pregnancy, and developed criteria for appointing community members as health educators and birth attendants. Surveys following the program’s implementation revealed that 79% of women who gave birth at home took misoprostol to prevent PPH after delivery. Three years have passed since these dialogues, and community members are still requesting misoprostol from the research team at rates exceeding supply, indicating that a community’s active participation can produce promising results.
A case study from Nepal reveals a similar outcome: community involvement and ownership can lead to an intervention’s success. Because of geographic and cultural barriers, only 1 in 5 Nepalese women attain timely, skilled care for the delivery of their babies. The Nepal Family Health Program II, funded by USAID, and the Government of Nepal sought to remedy Nepal’s high maternal and neonatal death rates by engaging communities in the distribution of misoprostol, renamed Matri Surakchya Chakki or “mothers’ safety pills.” The program recruited the established Female Community Health Volunteers (FCHVs), a group of trusted advocates and community members, to visit homes and provide pre-natal care, educate women and their families on misoprostol, address misconceptions and fears, and give the medication to women during their last month of pregnancy. As a result, there were noticeable increases in use of misoprostol for PPH, as well as an increase in deliveries in health care facilities. FCHVs were proud to provide these services to their neighbors.
When community members have a direct influence on improving the health of their fellow neighbors, a program is more likely to be successful and sustainable. During a community meeting in Nigeria, one woman was relieved she would no longer have nightmares during pregnancy and a proud village chief said, “‘On this day…the joy is immeasurable as we share what we have done.’” As these case studies demonstrate, community members in Nigeria and Nepal decided the progress their own healthcare and became staunch advocates for misoprostol, playing a key role in saving the lives of their neighbors.
You may read the abstract to the commentary here, but subscription is required to read the full text.
Alain Kaboré is Program Officer with FCI-Burkina Faso, based at our office in Ouagadougou, whose previous blogs on this obstetric fistula project can be read here and here. This article is cross-posted from the blog of the Frontline Health Workers Coalition.
“Today,” Mariama Boubacar Diallo says, “Thank God, I no longer suffer. I’m healthy; I am healed.” Mariama, a resident of the village of Kriollo Ourarsaba, located in the northern Sahel region of Burkina Faso, reflects on her recent surgery to repair the obstetric fistula she developed while giving birth to her third child four years ago.
Obstetric fistula, an injury to the birth canal resulting from an obstructed or prolonged birth, causes long-term, physical pain. Mariama, like many women suffering fistula, also experienced emotional distress from losing the respect of her family and community.
Burkina Faso, a land-locked West African country, struggles against chronic poverty like many of its neighbors in the Sahel, the southern band of the Sahara Desert that stretches across the width of the African continent. Most recently, Burkina Faso has been working to overcome the severe food shortage that has plagued the region since 2011.
Recognizing the urgency of the food security crisis, USAID has reserved more than $56.5 million to fund projects working in areas of agriculture, livelihoods, health and water, sanitation and hygiene in the region. To counteract the food security crisis and mobilize productive members of society, policymakers should address the unnecessary loss of life that occurs when mothers suffer or die from preventable pregnancy and childbirth complications. Frontline health workers are a key part of the solution, both for preventing fistula from occurring and for ensuring that survivors receive the treatment they need.
Through our programs in Burkina Faso and around the developing world, Family Care International (FCI) has worked to raise awareness of the causes of and treatment for obstetric fistula. FCI-Burkina Faso, with support from the United Nations Population Fund (UNFPA), has worked with communities and partner organizations in the Sahel region to prevent fistula by improving access to and utilization of emergency obstetric care, which is provided by midwives and doctors in health centers and hospitals that are too often inaccessible to women in rural villages.
In order to get these women to the urgent care they need, FCI and our partners have helped more than 700 villages establish emergency procedures for transporting pregnant women to the nearest health clinic when faced with life-threatening complications. We have also trained hundreds of community health and outreach workers to visit people in their communities, hold meetings to raise awareness of pregnancy complications and their treatment, and bring fistula survivors out from isolation so they can reclaim their lives. Mariama is one of those brave women who, thanks to the tenacity and commitment of frontline health workers, has triumphed over her injury and succeeded in becoming a leader in her community.
Although Mariama wasn’t rejected by her husband when she suffered from obstetric fistula, her in-laws blamed and abused her. A community outreach worker affiliated with an FCI partner found Mariama and helped her arrange surgery in a hospital in the regional capital, Dori. In the months after her surgery, she received training in modern methods of raising cattle and sheep, the primary economic activity in many parts of the Sahel.
At the end of 2010, Mariama received a grant of 100,000 CFA francs (about $200) to purchase a ram and a ewe, along with some feed, in order to establish her own breeding business. Mariama now owns four head of cattle, making her one of the village’s most prosperous and successful citizens, and she generously shares her new agricultural knowledge with her neighbors. She is fully included in baptisms, weddings, and other social events of the village — something that was inconceivable only a year ago — and has fully reunited with her in-laws. “Today,” she says, “thanks to this program, my in-law family has truly accepted me.”
Policymakers must come to better understand the impact of frontline health workers, with the resources and the know-how to empower women and get them to the care they need , on the lives of women like Mariama.
Ann Starrs is president and co-founder of Family Care International. This article has been cross-posted on RH Reality Check, the Kaiser Daily Global Health Policy Report, and the Maternal Health Task Force blog.
Two years ago, in July 2011, UNAIDS launched a joint initiative with PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, to help achieve the goal of an AIDS-free generation. The ambitious, if clumsily named, “Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive” included two global targets:
- Reduce the number of new HIV infections among children by 90%
- Reduce the number of AIDS-related maternal deaths by 50%
Today, UNAIDS and PEPFAR released a new report on progress in this important initiative. The report and accompanying press release highlight the very welcome news that seven countries (Botswana, Ethiopia, Ghana, Malawi, Namibia, South Africa and Zambia)have reduced mother-to-child-transmission of HIV by 50% or more, with two additional countries (Tanzania and Zimbabwe) close to achieving that rate of reduction.
UNAIDS, PEPFAR, and all of their global and country partners deserve sincere congratulations for this tremendous accomplishment, achieved in a relatively short span of time. Progress toward the Global Plan’s first target has been truly impressive.
But their report almost completely ignores the plan’s second target, and in fact the second part of its long title — “…and keeping their mothers alive.” Perhaps a more accurate title for the initiative, at least as reflected in this report, would have been “Global plan towards the elimination of new HIV infections among children, and keeping their mothers alive just as long as they are pregnant or breastfeeding (but after that, not our concern…)”
Ok, maybe I’m being a bit too harsh. But in the report’s 15 pages of text, there is at best one glancing reference (being generous) to the fact that women with HIV who are eligible for treatment should receive antiretrovirals because they have a right to treatment for the sake of their own lives and health. And the target for reducing maternal deaths is not even mentioned in the report’s text (though, to be fair, it is included as an indicator in the country profiles that make up the second part of the report).
Well, the report makes it clear. “Many more women,” it states, have access to antiretroviral medicines to reduce the risk of HIV transmission to their children than four years ago [my emphasis, here and below].” And again, “Special attention is needed in all countries to ensure access to and retention on antiretroviral medicines for pregnant and breastfeeding women living with HIV to cut these numbers of children acquiring HIV infection.” The report betrays, alarmingly, a view of women exclusively as bearers and feeders of children.
It does, at a couple of points, vaguely acknowledge that women’s lives have value even when they are not carrying or breastfeeding babies. “The number of women acquiring HIV infection has to be reduced,” the report states, “and all women living with HIV eligible for antiretroviral therapy must have access to it for their own health.” But this commitment, for which many advocates have fought long and hard, must be translated into concrete action to prioritize ARV treatment for HIV-positive women who are not pregnant, or who have finished breastfeeding. Too often, still, these women do not have access to the life-saving medicines they need, or are dropped from programs when they no longer qualify through their children.
The report does, thankfully, acknowledge the significance of access to family planning as a means of preventing unintended pregnancy, and thereby of preventing infants from being born with HIV:
Reducing unmet need for family planning will reduce new HIV infections among children and improve maternal health. Increasing access to voluntary and noncoercive family planning services for all women, including women living with HIV, can avoid unintended pregnancies. Family planning enables women to choose the number and spacing of their children, thereby improving their health and wellbeing.
Kudos to UNAIDS and PEPFAR for being forthright about this crucial element of PMTCT programs, even though family planning is still far too rarely included in HIV/AIDS prevention efforts.
But in other respects, the agencies need to do better, both in their programs and in the messages they send through reports like this one. Michel Sidibé and Eric Goosby, the heads of UNAIDS and PEPFAR, have both, in many speeches and statements, acknowledged the importance of women, and the right of women living with HIV to get ARV treatment for their own health. This report should have reflected that awareness, and that principle (as, for instance, this one in 2012 did). I hope and expect that the next progress report for the Global Plan will include a clear discussion of the link between HIV infection, maternal mortality, and women’s health more generally, and what the agencies are doing to address it.
Action on the global stage: Life-saving reproductive health commodities getting much-needed attention
Ann Starrs is FCI’s president and co-founder.
During the third week of May, I was in Geneva — together with an impressive collection of global health leaders from governments, UN agencies, and civil society — for the 66th session of the World Health Assembly (WHA). I am in Geneva fairly often, for meetings with WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH) and other partners, but the annual World Health Assembly meeting is unique. The WHA is the governing body of the World Health Organization, and so it is attended by high-level delegations – usually led by the Minister of Health – from WHO’s member states. That makes WHA a great opportunity for networking and strategizing: finding an available seat, much less a table, in the famous (but oddly named) Serpent Bar at the Palais de Nations is always a challenge, as many conference participants spend virtually all of their time huddled there in intense discussion.
Issues around reproductive, maternal, newborn, and child health featured strongly in this year’s agenda, which is why I was there. The MDGs, and development goals beyond 2015; universal health coverage; life-saving commodities; and frameworks for holding countries and donors accountable for fulfilling their health commitments were all on the agenda, for formal discussion, side events, and hours of conversation at the Serpent Bar.
Perhaps most importantly, this year’s WHA considered, and ultimately passed, a resolution to implement the recommendations of the UN Commission on Life-Saving Commodities for Women and Children. The resolution commits countries to improving the quality, supply, and delivery of underutilized and essential commodities for RMNCH, and tasks WHO with reporting back to WHA each year through 2015 on progress in implementing the Commodity Commission recommendations as well as those of Commission on Information and Accountability for Women’s and Children’s Health. The WHA resolution is a clear, global endorsement of the Commodity Commission recommendations, and represents a commitment by the world’s nations to ensure that life-saving medicines and technologies get to the women and children who need them. It is a significant achievement for our community, and it provides an important mechanism for ongoing advocacy, and for holding governments and development partners accountable for keeping their promises.
Notably, the Commodity Commission’s list of 13 priority commodities includes two that are advocacy priorities for FCI: misoprostol, a drug that is highly effective for preventing and treating postpartum hemorrhage (PPH), the leading cause of maternal death; and emergency contraceptives, which help women prevent unintended pregnancy after unprotected sex. (FCI is host organization for the International Consortium for Emergency Contraception—ICEC.) At a very well-attended side event during the WHA, hosted by the delegations from Nigeria, Norway, and the U.S., along with World Vision International and PATH, speakers focused on the importance of innovation in overcoming barriers to access to essential health commodities. Presentations highlighted the substantial achievements that have already been made, and the important step forward represented by the Commodity Commission’s recommendations. Representatives from various countries also noted the significant challenges that remain, including those related to health commodity distribution systems, manufacturing, and supply. Several countries expressed a preference for purchasing and distributing locally-manufactured commodities, although this approach can sometimes raise concerns about quality assurance; further study, and advocacy, will be needed to address this challenge.
Only a few days later, and half a world away, I was one of a dozen FCI staff members who attended Women Deliver 2013, in Kuala Lumpur, Malaysia. This week was even busier – in fact, much crazier – than the previous week in Geneva; there were meetings and events starting at 7 in the morning, and organized social events went until 8 or 9 pm every night. The conference was amazing, bringing together 4,500 leaders, clinicians, program managers, and advocates representing over 2,200 organizations and 149 countries. I could not take full advantage (or anywhere near it) of everything the conference had to offer; there was an endless variety of stimulating plenary and concurrent sessions (including six sessions presenting the latest findings from Countdown to 2015, in which FCI is a leading advocacy partner), as well as Speaker’s Corner (where FCI and WHO presented new tools for strengthening countries’ policies on adolescent sexual and reproductive health). There was a youth corner and a cinema corner, a busy and bustling exhibition hall, and many, many other activities going on at all times. The cumulative value of all the connections made, facts and ideas conveyed, materials disseminated, and plans and strategies developed was immeasurable but immense.
Here, too, essential health commodities were on the agenda. On the Monday morning just before the conference officially started, FCI co-sponsored a side event called “In Our Hands: Successful Strategies to Prioritize Essential Maternal Health Supplies,” at which the Maternal Health Supplies Working Group and the Maternal Health Supplies Caucus of the Reproductive Health Supplies Coalition brought together global and national advocates and program implementers in an interactive forum – including advocacy case studies from Africa, Asia and Latin America – to network, strategize, and exchange ideas for elevating maternal health supplies onto global and national health agendas. At the same time, ICEC co-sponsored a session on “Emergency Contraception: New Research Findings, Programmatic Updates, and Advocacy Strategies,” at which advocates, researchers, pharmaceutical representatives, and other leaders in the field discussed efforts to ensure access to EC globally, with a focus on developing countries.
That afternoon, FIGO and Gynuity Health Projects (our partners in misoprostol advocacy) co-hosted a discussion of misoprostol for PPH: “New Evidence and the Way Forward.” Presenters offered the latest information on ways that the current evidence can help inform and develop effective policies and service delivery programs across varying levels of the health system, and on lessons learned from innovative programs in Afghanistan and Nepal. I concluded the session with a presentation on advocacy opportunities and challenges for “Making Misoprostol an Operational Reality.”
At these and related sessions the level of discussion, the enthusiastic participation by advocates and health workers, and the clear attention that these issues are getting from policy makers, made for an inspiring and energizing two weeks. “Making sure that women and children have the medicines and other supplies they need is critical for our push to achieve the MDGs,” said Secretary-General Ban Ki-moon when he launched the Commodities Commission 15 months ago. Progress is being made, and we, together with our advocacy partners, are working hard to make sure that essential commodities are available to all who need them.
by Gary L. Darmstadt, France Donnay, and Ann Starrs
Gary Darmstadt and France Donnay are, respectively, Director of Family Health and Senior Program Officer, Maternal, Neonatal and Child Health, at the Bill & Melinda Gates Foundation. Ann Starrs is president of FCI. This post first appeared on Impatient Optimists, the blog of the Bill & Melinda Gates Foundation, on June 3, 2013.
This month, the Journal of Maternal-Fetal and Neonatal Medicine published a special issue that sheds new light on the indissoluble links between the health of a mother and that of her newborn baby. Its release comes just weeks after the Global Newborn Health Conference, and simultaneously with a State of the World’s Mothers 2013 report revealing that a baby’s first day is the most dangerous of its life.
That interconnections exist between maternal and newborn health is well known. Most maternal deaths are caused by the woman’s poor health before or during pregnancy, or by inadequate care in the critical hours and days during and just after childbirth; the same is true for most newborn deaths. And when a woman dies after giving birth, her death is far too often followed by the death of her newborn baby. And we know, based on substantial evidence, which interventions are best for improving maternal health and saving women’s lives, and which are effective for improving newborn survival.
What we didn’t sufficiently understand, until now, was the range of interventions that bring health and survival benefits to both mother and newborn. In this new study, a research team from Aga Khan University in Pakistan, working in collaboration with Family Care International and with support from the Bill & Melinda Gates Foundation, looked at more than 150 interventions, assessing them for impact on both maternal and neonatal outcomes. They then grouped the interventions into “packages of care” that can be effectively delivered at each of the key levels of care: community, health center, and hospital.
This study advances our knowledge in important ways. It reinforces the widely-recognized benefits, for women and their babies, of high-quality antenatal care, skilled birth attendance, and postpartum care, which are still too often insufficiently, ineffectively, or inequitably delivered. It highlights the crucial role of family planning, which can be used to delay and space pregnancies. It identifies a number of areas — including management of preconception diabetes, treatment of maternal depression, and community-based approaches for improving birth preparedness and care-seeking — which are currently neglected but could significantly improve maternal and newborn outcomes.
Most importantly, the findings send a clear message: that greater integration of maternal and newborn care — and, more broadly, of services across the reproductive, maternal, newborn, and child health (RMNCH) continuum of care — is one of our most promising strategies for strengthening efforts to save women’s and children’s lives.
This kind of integration may sound like an obvious step, but it is not always easy. Integration of services is critical if countries are to make substantial progress towards national health goals. It forces policy makers, donors, program managers, and health workers to find common ground among their varying constituencies, goals, and agendas; to understand the needs of women and their babies in new and different ways; and to design services that respond to these needs. It requires that the physical, financial, and human architecture of the health system be designed and constructed to efficiently and equitably deliver high-quality services across the continuum of care.
And yet, Progress on reducing maternal and newborn deaths has been too slow, and far too many women and babies die every day. Recognizing and acting on the crucial interconnections between maternal and newborn health revealed by this study, and the broader linkages that tie together the RMNCH continuum, can help save the lives of millions of women and children. The time to take action is now.
by Beverly Winikoff and Ann M. Starrs
Beverly Winikoff and Ann Starrs are the presidents of, respectively, Gynuity Health Projects and Family Care International. This commentary is cross-posted from the MHTF Blog, the blog of the Maternal Health Task Force.
While support for the use of misoprostol to prevent postpartum hemorrhage (PPH) has been growing steadily, governments, donors, and implementing agencies have not given equal emphasis to treating PPH when it does occur. Indeed, the response to PPH — the single leading cause of maternal mortality — has been vigorous, but incomplete. In a series of regional surveys conducted in 2011 and 2012, organizations were asked to describe their programs and activities involving misoprostol for PPH: a broad range of prevention projects was reported. Yet, despite substantial published evidence of the potential for misoprostol use in PPH treatment, not one agency indicated current or planned work focused on use of misoprostol for treating PPH.
Health ministries, implementing agencies, and donors have recognized that addressing PPH could reduce the number of maternal deaths in the highest-burden countries. Indeed, they have developed and promoted strategies for preventing PPH by actively managing the third stage of labor where skilled staff and appropriate medications (uterotonics such as oxytocin and misoprostol) are available. Yet in low-income countries, well-equipped, professionally-staffed health facilities are not accessible to many – sometimes most – women, who still give birth without a skilled attendant, mainly at home. A number of countries in Africa and Asia, including Bangladesh, Nepal, and Zambia, have developed pilot projects to distribute misoprostol for use at home deliveries, as an interim approach for reaching women who lack access to skilled care. Nepal and other countries are scaling up these programs, seeking to ensure that every woman, regardless of where she gives birth, receives a uterotonic to prevent PPH.
While active management and administration of uterotonics can reduce blood loss and prevent many cases of PPH, at least 10% of women who receive preventive care will still experience significant post-partum blood loss that may require additional medical interventions. The lack of concerted attention and support for treatment of PPH at the community level will mean that even women who receive prophylaxis with a uterotonic may be at risk of dying from excessive blood loss. And, at least in the short term, many women are still unlikely to receive uterotonics for preventive care; for these women, the availability of effective treatment options for PPH can be critically important. For a woman who hemorrhages at home or in another setting where lack of refrigeration or skilled staff makes use of IV oxytocin (the gold standard for PPH treatment) not feasible, access to treatment with misoprostol, which has few contraindications or side effects, could mean the difference between life and death.
Community-based PPH prevention programs using misoprostol could provide the platform on which to build an approach for treatment of hemorrhage. In remote and rural areas, where transfer to a higher level of care may be delayed, difficult, or impossible, misoprostol could be administered by a low-level provider as a “first aid” treatment to stop bleeding.
In many countries, making this happen will require that governments reconsider policies that require administration of medications be carried out only by physicians. These policies are generally promulgated with the argument that lower-level health personnel do not have the expertise to know when to initiate treatment. However, these same personnel are often entrusted with the decision to refer women for treatment, a judgment that requires the same level of discrimination. Because providing treatment would be easy with a pre-packaged dose of misoprostol, it seems both feasible and sensible to provide lower-level health personnel with medicines that can be a critical first aid tool for women who face immediate risk of death.
The emphasis on prevention over treatment is common in public health. “An ounce of prevention,” goes the old adage, “is worth a pound of cure.” But when prevention is not 100% effective, treatment also needs to be available. A well-functioning health system addresses public health challenges by pursuing both prevention and treatment, working to provide universal access to information and services that will keep people healthy while also providing care for those who do become ill. The question for policy makers is how to balance attention to and investment in prevention and in treatment in order to ensure the fewest mortalities and morbidities at the lowest possible cost. A more balanced approach to postpartum hemorrhage could prove to be a critical tool in countries’ efforts to accelerate progress toward achievement of MDG 5.
To learn more about misoprostol and its role in PPH prevention and treatment, join an online community on the Knowledge Gateway. Or visit Family Care International and Gynuity Health Projects to learn more about their work.
Ann Starrs is FCI’s president.
Yesterday at the United Nations, FCI joined with the UN Missions of Bangladesh, Canada, and Malawi, and a dozen partner organizations, to sponsor a moving, inspiring, and often infuriating discussion on child marriage. Too Young to Wed, a side event to this week’s annual meeting of the UN’s Commission on the Status of Women, shed light on an issue that affects tens of millions of young women — 39,000 women under 18 are married every single day — but is too seldom discussed.
For FCI, this issue hits right to the heart of our mission. When a girl is married off too early, she begins sexual activity without giving any meaningful consent, and is soon faced with a pregnancy for which she is not prepared either physically or emotionally. The risk that a pregnant teenager will experience complications that threaten her life or health is much higher than for an adult woman. Adolescent girls account for about 10% of all marriages but nearly a third of all maternal deaths. Complications of pregnancy and childbirth are the leading cause of death for young women between 15 and 19 in the developing world.
Speakers at the UN event included Dr. Babatunde Osotimehin, the Executive Director of UNFPA, and Michelle Bachelet, Executive Director of UN Women and former president of Chile; senior representatives of the governments of Namibia and Malawi; and a number of advocates. One moving highlight was an appearance by video link (because she was unable to procure a US visa) by Mereso Kiluso, a young Tanzanian who was married off at the age of 14 to a man in his 70s.
A number of panelists emphasized that child marriage is often a form of sexual violence. Nyaradzayi Gumbonzvanda, General Secretary of World YWCA, moderated the discussion, noting that it is rape when a young girl has to sleep with a man she doesn’t know, even if it is on her wedding night. And Michelle Bachelet pointed out the vast power inequality that exists between a young bride, with no legal or social support to rely on, and her older husband, who often paid for her and views her as a piece of property.
“The problem of child marriage,” according to Lakshmi Sundaram of Girls Not Brides, “is underlaid by the fundamental belief that girls and boys are not equal.” A world in which women are second-class citizens is a world that will continue to tolerate sexual violence, genital mutilation, and early marriage. When parents see national and community leaders who are women, said Bachelet, they will begin viewing their own daughters differently.
Several speakers highlighted the need not only for stronger government policies – notably an increase in the age of marriage – but also for implementation and enforcement of the policies that are in place. Girls – and boys – must have access to information about their sexual and reproductive health and rights, and to health services, including family planning. Religious leaders should be engaged on this issue: for example, before presiding at a marriage ceremony, they should take the bride aside privately to ascertain her consent, and ask to see her birth certificate to ensure she is of age.
As Catherine Gotani Hara, Malawi’s Minister of Health, pointed out, policies must be put in place not only to discourage or prevent child marriage, but also to mitigate its effects: for instance, Malawi now allows girls to stay in school even if they are married and/or pregnant.
The discussion came back, again and again, to the vast challenges that still exist in our efforts to protect girls and young women from being forced to marry too soon. But there was also reason to hope. “It’s possible to prevent child marriage,” said Nyaradzayi Gumbonzvanda. “It’s possible to protect against child marriage, and it’s possible to end child marriage.”
- Watch a video of the event
- Read the press release
- Read a blog by Carole Presern of the Partnership of Maternal, Newborn & Child Health
Family Care International is one of only 13 extraordinary nonprofit organizations around the world selected to receive the 2013 MacArthur Award for Creative and Effective Institutions, announced today by the MacArthur Foundation. This $1 million one-time capacity-building award represents MacArthur’s recognition of FCI’s achievements and their investment in a strong foundation for FCI’s future work. Read more here…
Edwinah Arwah Orowe is Advocacy Program Officer with FCI-Kenya, based at our office in Nairobi. Last week, she was one of three young people invited to represent African youth at a high-level ‘working lunch’ on the Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality in Africa (CARMMA), as part of the 20th African Union Summit. Here is Edwinah’s report:
Nearly thirty African heads of state attended this important side event; countries whose head of state couldn’t be present were represented by their Ministers of Health. UN Secretary-General Ban Ki-moon sat at the dais, together with Dr. Babatunde Osotimehin, Executive Director of the UN Population Fund—UNFPA. A range of other influential stakeholders also attended, including AU Commissioners, representatives of regional and international organizations, diplomats, and civil society representatives, so the table was set for a meaningful and important discussion. In his welcoming remarks, the African Union’s Commissioner for Social Affairs, Dr. Mustapha Sidiki Kaloko, said that achievement of the Millennium Development Goals (MDGs) and of Africa’s post-2015 objectives depends on member countries addressing preventable maternal, newborn, and child death and illness.
This event was a celebration of all of the progress that has been made since CARMMA — a continent-wide effort to mobilize national action to save women’s lives — was launched in 2009. It was also, however, a call to press on with even deeper commitment, because it is still possible to achieve a 75% decrease in maternal and child mortality by the MDG deadline in 2015. Every speaker —from the Chair of the AU Commission to the UN Secretary-General — echoed the same call, which resonated throughout the room: no woman should die while giving life.
As the African Union celebrates its Jubilee, the gift of safe motherhood is a special one that African governments must give to African women. In Africa, giving birth is a celebration, and life itself is a celebration. Every African country must ensure that every woman has access to the skilled care that she needs, and that every woman can deliver her child in a setting where she is treated with dignity.
The fact that more than half of all African heads of state attended this working lunch demonstrates that there now is a real commitment, across Africa, to meeting the maternal health needs of women. The commitment by so many African leaders to re-ignite CARMMA is a crucial step in the right direction. Now, African women and young people need to see this commitment translate into real action.
Ann Starrs is FCI’s president, and is a founding member and former co-chair of the board of the Partnership for Maternal, Newborn & Child Health (PMNCH), of which FCI is a leading advocacy partner. In this post, cross-posted on the PMNCH website, Ann reports on the Global Maternal Health Conference 2013, which took place in Arusha, Tanzania on January 15th through 17th.
Last week’s Global Maternal Health Conference (GMHC), held in Arusha, Tanzania, was both inspiring and sobering. Twenty-five years after the Safe Motherhood Initiative was launched at an international conference held in neighboring Kenya, maternal mortality has finally begun to decline, and there are many and diverse examples of how countries are addressing the challenge of preventing deaths of women and newborns from complications of pregnancy, childbirth, and the postnatal period. But as the conference highlighted, huge challenges remain — in improving the quality of care, the conference’s core theme; in strengthening the functionality and capacity of health systems; in addressing major inequities in access to care, within and across countries; and in ensuring that maternal and newborn health receives the political support, increased funding, and public attention that it needs.
The majority of the conference’s breakout sessions featured informative and often fascinating presentations on research findings and promising programmatic and technical innovations. One session, however, took a different tack — a debate on “Has the ascendance of the RMNCH continuum of care framework helped or hindered the cause of maternal health?” I proposed this session to the Maternal Health Task Force, which organized the GMHC, because for me and the organization I head, Family Care International, maternal health has been at the core of our institutional mission since we planned the first Safe Motherhood conference in 1987. For much of the past decade, however, I have been closely involved with the Partnership for Maternal, Newborn and Child Health (PMNCH) and Countdown to 2015, two coalitions that are dedicated to promoting an integrated, comprehensive approach to the reproductive, maternal, newborn and child health (RMNCH) continuum of care. Have our efforts to define and advance the continuum of care framework contributed to progress in improving maternal health? If so, how much? If not, what can be done about it?
These questions were debated by a stellar panel I moderated, which included Wendy Graham, Professor of Obstetric Epidemiology at the University of Aberdeen; Marleen Temmerman, the new head of the Department of Reproductive Health and Research at WHO; Friday Okonofua, Professor of Obstetrics and Gynaecology at the University of Benin, Nigeria; and Richard Horton, Editor in Chief of The Lancet, as well as a fantastic and diverse audience. (You can view a video of the entire discussion here.) To start the discussion I shared the definition of the continuum of care that PMNCH has articulated, based in part on the World Health Report 2005: a constellation of services and interventions for mothers and children from pre-pregnancy/adolescence, through pregnancy, childbirth and the postnatal/postpartum period, until children reach the age of five years. This continuum promotes the integration of services across two dimensions: across the lifespan, and across levels of the health system, from households to health facilities. Key packages of interventions within the continuum include sexuality education, family planning, antenatal care, delivery care, postnatal/postpartum care, and the prevention and management of newborn and childhood illnesses.
It is, of course, impossible to conduct a randomized control trial on the impact of the RMNCH continuum of care on maternal health, so the discussion was based more on perceptions than on hard evidence. Nevertheless, there are a few data points to consider in debating the question. From an advocacy perspective, panelists generally agreed, the adoption of the continuum of care framework has helped the cause by appealing to multiple constituencies related to women’s and children’s health. Attribution is always a challenge; there are many other developments over the past 5-7 years that have also had an impact, such as the two Women Deliver conferences held in 2007 and 2010 (with the third one taking place in May of this year). But participants generally agreed that linking women’s and children’s health, and defining their needs as an integrated whole, has appealed to policy-makers and politicians on an intuitive and practical level, as demonstrated by the engagement of heads of state, celebrities, private corporations, and other influential figures.
Let’s look at the money: during the period 2003-2010 overseas development assistance (ODA) has doubled for MNCH as a whole, according to Countdown to 2015 (Countdown’s analysis did not look at funding for reproductive health, but a new report later in 2013 will incorporate this important element). Maternal and newborn health, which are examined jointly in the analysis, have consistently accounted for one-third of total ODA, with two-thirds going to child health. Given the significant funding that GAVI has mobilized and allocated for immunization over this time period, the fact that maternal and newborn health has maintained its share of total MNCH ODA is noteworthy.
And let’s look at how maternal health has fared within the UN Secretary General’s Every Woman Every Child initiative, launched in September 2010: a recent report summarizes each of the commitments made to Every Woman Every Child in the two years since it was launched. Of the 275 commitments included, 147, or 53%, had specific maternal health content. If we look at the commitments according to constituency group, developing country governments had by far the largest percentage of commitments that had specific maternal health content — 84% — compared to 39% for non-governmental organizations, 24% for donors, and 52% for multilateral agencies and coalitions. Clearly, maternal health has not been marginalized within the continuum from a broad policy, program and funding perspective, despite the fear some had expressed that it would be pushed aside in favor of child health interventions that are perceived as easier and less costly to implement.
Another benefit of the continuum of care framework, as noted by Dr. Okonofua, has been increased collaboration among the communities that represent its different elements. While there were tensions and rivalries when PMNCH and Countdown were first established, especially between the maternal and child health communities, today groups working on advocacy, policy, program implementation, service delivery, and research within the continuum generally work together more frequently, cordially and effectively than they did before, especially at the global level. PMNCH and Countdown, as well as Every Woman Every Child, have brought together key players to define unified messages and strategies that have achieved widespread acceptance.
That was the good news; but panelists and participants at the session also saw a number of problems with the continuum of care concept. The concern articulated by Richard Horton, and echoed by many of the session participants, was that the continuum views women and adolescents primarily as mothers or future mothers. This narrow view contributes to a range of gaps and challenges; it means crucial cultural, social and economic determinants of health and survival, including female education and empowerment, are not given adequate weight. Gender-based violence deserves much more attention, both for its own sake and for its impact on maternal, newborn and child health. Politically sensitive or controversial elements of the continuum, especially abortion but also, in some cases, family planning and services for adolescents, may be neglected in policy, programming, and resource allocation.
The fragmentation inherent in the continuum of care also contributes to what Wendy Graham called the compartmentalization of women. As Countdown’s analysis of coverage has demonstrated, the continuum of care doesn’t guarantee continuity of care; coverage rates are much higher for interventions like antenatal care and child immunization than for delivery or postnatal/postpartum care. Women’s needs for a range of interventions and services, available in a single health facility on any day of the week, are not being met in many countries.
Other concerns that emerged during the discussion were that the RMNCH continuum of care framework does not explicitly or adequately reflect the importance of quality of care, which in turn depends on a range of factors: skilled, compassionate health care workers, functional facilities, adequate supplies and equipment, and an effective health information system that tracks not just whether interventions are being provided, but also whether individual women and their families are receiving the care they need throughout their lives.
Dr. Okonofua, in his comments, focused on how the continuum of care concept has been implemented, or hasn’t, in countries. The implications of the continuum of care for on-the-ground program implementation have not been fully articulated and communicated; more effort, he noted, needs to be invested in making the concept relevant and useful for policy-makers, program managers, and service providers.
Despite these gaps, however, participants in the session – and the panelists themselves – agreed that the continuum of care is a valid and valuable concept, and that the inadequacies identified should be addressed. “Don’t throw the baby out with the bathwater,” said one member of the audience. The continuum of care, as a concept, has already evolved; initially, for example, it did not fully integrate reproductive health elements. As Marleen Temmerman commented, the continuum of care concept is a tool; what is important is what is done with it.
As 2015 approaches, the global health community is struggling to articulate a health goal for the post-2015 development framework that will resonate widely and guide accelerated, strategic action to prevent avoidable deaths and improve health of people around the world. The RMNCH community — or communities — needs a framework that more fully reflects the realities and complexities of the lives of women and children, and that enables us to reach out to other health and non-health communities, including HIV/AIDS, NCDs, and women’s rights and empowerment, for a common cause. To do this, we need to revise the continuum of care framework to maximize its relevance and utility for countries, and to incorporate the following missing elements:
- Recognition of the importance of quality of care
- Responsiveness to the needs of girls and women throughout the life cycle, not just in relation to pregnancy and childbirth
- Links to the cultural, social and economic determinants of women’s and children’s health
Richard Horton’s call for a manifesto to emerge from the GMHC included 10 key points; redefining the RMNCH continuum of care was one of them, inspired by the panel. The challenge has been issued; it is now up to us to meet that challenge.
Martha Murdock is FCI’s Vice President of Regional Programs.
Last week in Arusha, Tanzania, scientists, researchers, advocates, and policy-makers came together to share knowledge and experiences at the Global Maternal Health Conference 2013. The conference was co-sponsored by the Maternal Health Task Force (based at the Harvard School of Public Health) and Management and Development for Health (in Dar es Salaam, Tanzania).
Each day of this 4-day conference started with a plenary session; there were then 3 sets of parallel session, during which there were a daily total of 13 concurrent sessions — a wealth of fascinating content and information about technologies and strategies for eradicating preventable maternal mortality and morbidity and improving quality of care.
At the conference, I presented a Rapid Assessment of Skilled Birth Attendants in Eight Latin American & Caribbean Countries, a study examining the role of skilled birth attendants in reducing maternal mortality. The rapid assessment gathered information on who is providing maternal and newborn care in selected health care facilities in Guatemala, Honduras, Bolivia, Panama, Peru, Colombia, Chile, and Guyana, and assesses the quality of that care. The study was conducted in 2011 with funding from UNFPA and UNICEF.
The assessment found that midwife performance rated highest overall in quality and competency, a finding that is consistent with the outcomes of prior studies of midwives and others with midwifery skills. However, study results indicate a need to increase quality of care across all maternal and newborn health care providers. Recommendations for improving quality of care included the following:
- developing and using a uniform definition of skilled birth attendant
- promoting maternal-infant bonding and immediate and exclusive breastfeeding
- reviewing and promoting hand washing
- promoting the increased availability and use of clean equipment, especially in the absence of potable water
- establishing mechanisms to systematically monitor and improve the quality of care in the LAC region
Your contribution will help ensure that FCI — in this, our 25th anniversary year — will have the resources we need to continue and expand our important work. When you make a donation to Family Care International, every dollar broadens and deepens our impact. We need your support; we cannot do our work without you. Please give as generously as you can.
or send a check to:
Family Care International
588 Broadway, Suite 503
New York, NY 10012
Your contribution will help ensure that FCI — in this, our 25th anniversary year — will have the resources we need to continue and expand our important work. When you make a donation to Family Care International, every dollar broadens and deepens our impact. We need your support; we cannot do our work without you. Please give as generously as you can.
or send a check to:
Family Care International
588 Broadway, Suite 503
New York, NY 10012