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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:
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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
On October 4th and 5th, 2012, the International Consortium for Emergency Contraception (ICEC), which is hosted by FCI, and the American Society for Emergency Contraception (ASEC) held the annual EC Jamboree in New York City. The EC Jamboree brought together more than 100 advocates, researchers, pharmaceutical representatives, and other leaders in the field to discuss expanding efforts to ensure access to emergency contraception (EC) nationally and globally. EC is a crucial contraceptive tool for women, as it is the only available means to prevent a pregnancy after unprotected intercourse. It offers women an important second chance to prevent pregnancy when a regular method fails, no method was used, or sex was forced. Emergency contraceptive options include several kinds of EC pills (ECPs) as well as insertion of an intrauterine device (IUD). You can learn more about methods of emergency contraception here.
At the meeting, honors were presented to three “EC Champions.” ICEC and ASEC staff were delighted to present the Felicia Stewart Lifetime Achievement Award to Dr. James Trussell of Princeton University. This award, which honors the leadership of the late Felicia Stewart, is presented to “an outstanding leader who, through a substantial and prolonged body of work, has changed the face of, access to, and understanding of EC through programs, policy advocacy and/or research.” The Steering Committees of both organizations agreed that Dr. Trussell, a pioneer in the EC world, embodies the spirit of this award. He has published extensively on EC, developed the website www.not-2-late.com, and personally responds to consumer questions about EC that are received through the website. He also created the contraceptive effectiveness chart that is mandated to appear on all birth control labeling in the US.
The Charlotte Ellertson Award, established in honor of the late Charlotte Ellertson and supported by Ibis Reproductive Health, which she founded, was presented to the Venezuela Ministry of Health and the British Pregnancy Advisory Service. This award specifically recognizes innovation and goes to an individual or organization that has made a “bold EC move.” The Ministry of Health of Venezuela registered EC as an over-the-counter, non-prescription product with no age restrictions, making Venezuela the only country in the Western Hemisphere to have such unimpeded access to EC. The British Pregnancy Advisory Service spearheaded a nurse-led advance EC provision service over the Christmas holidays and during the London Olympics. The manager of this service, Karen Beechey, and the nurse who ran the program, Tracey Forsyth, attended the EC Jamboree to present on their program and accept the award.
ICEC and ASEC are grateful to all three of these leaders for their impressive work to expand women’s access to EC.
You can learn more about emergency contraception and ICEC’s work to expand access to EC on the ICEC website, and you can join the International Consortium for Emergency Conception by submitting this form.
Keep up with the latest news on EC by following ICEC on Facebook.
Last week, I joined over 8,000 obstetricians/gynecologists, midwives, public health practitioners, and women’s health advocates, as they gathered for the 20th World Congress of Gynecology and Obstetrics on the outskirts of Rome, Italy. Convened by the International Federation of Gynecology and Obstetrics (FIGO), the meeting focused on the vital role health professionals and health professional organizations can play in advancing women’s health and well-being, especially during pregnancy and childbirth.
At a press conference on the first day of the conference, Professor Gamal Serour, outgoing President of FIGO, noted that “Professional organizations can do a tremendous amount… from influencing policy decision-making to raising awareness of issues and their solutions, to setting standards, to educating and training healthcare professionals and providers.”
The FIGO World Congress included the global premier of a short film, “Why Did Mrs X Die, Retold.” Originally released in 1987 by the World Health Organization at the first global safe motherhood conference, “Mrs. X” told the story of a woman’s journey through pregnancy and childbirth, and the many cultural, social, and economic factors which contributed to her death. “Why Did Mrs. X Die, Retold” updates the story and shows that many of the factors which contributed to maternal mortality 25 years ago are unfortunately still causing maternal deaths today. The updated animated short film is compelling and worth watching, it can be viewed here.
Also during the World Congress, the World Health Organization (WHO) and FIGO launched updated, evidence-based guidelines and clinical recommendations for the prevention and management of postpartum hemorrhage (PPH), the major cause of maternal deaths worldwide. The new WHO guidelines include the recommendation for lay health workers to administer misoprostol after childbirth for prevention of PPH. FIGO issued new clinical recommendations for dosing, route of administration, and contra-indications for misoprostol’s use in PPH prevention and treatment.
Throughout the conference, the importance of partnership, with other health professionals such as midwives, and across sectors, was underscored: “We can’t do it alone,” said Professor Sir Sabaratnam Arulkumaran, the incoming President of FIGO. He called for support from advocacy groups to intensify global efforts toward achievement of Millennium Development Goals 4 (reduce child mortality) and 5 (improve maternal health).
To learn about how FCI works with partners to help achieve MDGs 4 and 5, visit FCI’s home page.
This item, featuring an interview with FCI president Ann Starrs, is cross-posted from the website of the Partnership for Maternal, Newborn & Child Health.
8 OCTOBER 2012 | ROME – Countdown to 2015 partners hosted a side event at the end of the first day of FIGO 2012 [the World Congress of Gynecology & Obstetrics]: “Reproductive, Maternal and Newborn Health: Are Countries Making Progress?” Participants heard about the newest Countdown to 2015 data on 75 highest-burden countries and received information on why and how countries should work with Countdown to amass data and tools to promote evidence-based policy change.
In her presentation on the Countdown initiative and its value, Dr Joy Lawn, Director of Global Evidence and Policy with Save the Children’s Saving Newborn Lives program, used recent child mortality findings to demonstrate how presenting clear and meaningful data is helpful for hammering home the need to address remaining challenges urgently even if progress is being made.
Among children under five years old, data shows deaths from diarrhea have come down and malaria as well, meanwhile there has been very little progress on neonatal causes of death. If countries were to continue making progress at their current rates (the global annual rate of reduction for neonatal death is 1.8 percent), it would take the following regions quite a long time to meet their Millennium Development Goal targets: the Americas would achieve their target in 2040, Southeast Asia not until 2085 and Africa not until 2165.
“It is so important to present data in a way that is understandable and has an impact,” said Ann Starrs, President of Family Care International, one of the partner organizations behind the Countdown Initiative who also spoke at the event. “Graphs are great, but they can be confusing. It’s helpful when you can look at indicators and they tell you a story — this can lead very directly to policy and funding changes.”
Ms Starrs said it is crucial that health professionals are brought on board when advocating for change.
“If the medical community resists then it’s very, very hard to get a new policy adopted and implemented,” she said, which is why initiatives like Countdown are essential for helping RMNCH champions within government or civil society make the case for adopting or investing in proven solutions to reduce preventable deaths.
Maritza Segura is FCI’s national coordinator in Ecuador.
On October 18 and 19, 2012, in Quito, Ecuador, in partnership with the Spanish NGO Interarts, FCI is organizing a national advocacy event — Our Life, Our Rights: HIV Prevention for the Good Life — to strengthen political commitment and support for implementation of specific HIV prevention and treatment strategies for indigenous peoples and communities. We have seen firsthand that access to accurate information is critically important for preventing the spread of HIV among indigenous populations, and especially among young people in indigenous communities. To be effective in helping young people embark on safe and healthy adult lives, this information must be provided in way that is culturally appropriate and relevant to their cultural context.
Much of FCI’s work in Ecuador in recent years has focused on preventing HIV among young people and women in indigenous communities. In the villages of the Amazon jungle, young people’s access to information about their reproductive health, including HIV and AIDS, is limited. Even though these communities are seeing more and more cases of HIV each year, national surveillance systems — which don’t record ethnicity — don’t reflect the magnitude of the problem among the indigenous population.
FCI and Interarts are working with indigenous organizations in Ecuador to train young indigenous people on HIV prevention. The training uses a participatory, youth-centered methodology, adapted to the local culture, to provide information on a range of critically important topics, including how HIV is transmitted, means of prevention, and correct use of a condom. Participants also learn about the importance of solidarity, about non-discrimination, and about their sexual and reproductive rights.
To date, FCI has trained more than 5,000 young people in five Ecuadorian provinces. In 2011, at the request of the Ministry of Public Health, we implemented a pilot project on sexuality and vulnerability to HIV among the indigenous Shuar and Achuar peoples; we also proposed the development and implementation of a national strategy to respond to HIV and AIDS among the country’s indigenous populations. The October event in Quito will help to build support for this strategy.
This initiative is implemented with support from Interarts Foundation, through a grant from the Spanish Agency for International Development Cooperation (AECID).
You can directly support FCI’s work educating young people in Ecuador’s indigenous communities! Visit catapult.org to learn how.
La prevención del VIH en jóvenes y mujeres indígenas del Ecuador
Maritza Segura es la coordinadora nacional de FCI en Ecuador.
El 18 y 19 de octubre de 2012, a Quito, Ecuador, FCI y la ONG española Interarts están organizando un evento de incidencia nacional — Nuestra Vida , Nuestros Derechos: Prevenir el VIH para el buen vivir — para fortalecer los compromisos políticos en respuesta al VIH, asegurando estrategias específicas para pueblos y nacionalidades indígenas.
FCI ha visto de primera mano la importancia del acceso a información verídica y completa en la prevención de la propagación de la epidemia del VIH en poblaciones indígenas, especialmente jóvenes, y la pertinencia de material culturalmente adecuado para fortalecer la construcción de un proyecto de vida saludable, en un contexto cultural diverso.
En los últimos años, FCI ha centrado sus esfuerzos en la prevención del VIH en jóvenes y mujeres indígenas del Ecuador. A menudo, en lugares remotos del país, adolescentes y jóvenes tienen acceso limitado a información y educación sobre salud reproductiva, incluido el VIH/SIDA. Trágicamente, aunque cada año se identifican más y más casos de VIH en estas mismas poblaciones, los sistemas nacionales de vigilancia no permiten un registro por pertenencia étnica por lo tanto las estadísticas no reflejan la magnitud de este problema. Como parte de un proyecto con Interarts, FCI trabaja con organizaciones indígenas de Ecuador para capacitar a jóvenes indígenas en la prevención del VIH utilizando una metodología participativa centrada en la juventud: El recorrido participativo para la prevención del VIH, que incluye los temas de formas de transmisión, el camino de la protección, el uso correcto del condón, solidaridad, no discriminación y derechos. Hasta la fecha, FCI ha capacitado a más de 5.000 jóvenes en cinco provincias. En 2011, y a solicitud del Ministerio de Salud Pública, FCI desarrolló un estudio en una provincia piloto sobre la sexualidad y la vulnerabilidad al VIH en población Shuar y Achuar y realizó una propuesta de estrategia para dar respuesta al problema del VIH/SIDA entre las poblaciones indígenas.
Esta iniciativa es posible en coordinación con la fundación Interarts, y a través de fondos de la Agencia Española de Cooperación Internacional para el Desarrollo (AECID).
Family Care International was proud to partner with Merck for Mothers and Women Deliver to host a stimulating and provocative discussion on The Role of Private Providers in Expanding Access to Affordable, Quality Maternal Healthcare. At this side event to the 2012 UN General Assembly, held in New York on September 25, 2012, a distinguished panel of speakers highlighted the crucial role that private providers play in ensuring access to quality maternal health care, especially for the most marginalized populations, and the important contribution they can make in accelerating progress towards achieving Millennium Development Goal (MDG) 5, which aims to reduce maternal mortality by 75% and achieve universal access to reproductive health.
“There is a consensus in most parts of the world that it is the responsibility of governments to ensure that all people have access to basic preventative and curative health care. But that doesn’t mean that governments have to provide those services themselves. Partnership is the key.”
— Ann Starrs, FCI
While there has been notable progress in reducing maternal mortality globally over the past decade, only 10 countries are currently on track to reach the 75% reduction target, and more than a quarter-million women continue to die each year from complications of pregnancy and childbirth. Approximately 99% of maternal deaths occur in the developing world, most of them in sub-Saharan Africa and South Asia, and almost all of these deaths could be prevented with better access to skilled care before, during, and after childbirth. In many countries, the private health sector — including independent physicians, nurses, and midwives; traditional practitioners; private clinics and hospitals; pharmacies, health shops, and drug outlets; and health insurers — plays a central role in helping governments accelerate efforts to reach women with essential, lifesaving care. Non-health businesses, including transportation operators, mobile service providers, and financial institutions, also play an important role in facilitating health care.
Speakers at the event, moderated by Diane Brady of Bloomberg Businessweek, included Nigerian Minister of Finance Ngozi Okonjo-Iweala; Dr. Flavia Bustreo, Assistant Director-General of the World Health Organization; Sweta Mangal, co-founder and CEO of Ziqitza Health Care Limited, a private ambulance service in India; and Karl Hofmann, CEO of Population Services International (PSI), an NGO that focuses on “social marketing” of family planning and other essential health supplies and services.
Jill Sheffield, president of Women Deliver, provided the context for the discussion and introduced Geralyn Ritter, Merck’s Senior Vice President of Public Policy and Corporate Responsibility, who noted the vital, but often overlooked, role that private healthcare providers and health businesses play in delivering health care in local communities. Roughly half of Africans and up to 80% of South Asians now receive care from the private sector, she said; independent midwives, private clinics, and local pharmacies are trusted by the communities they serve, and are key partners in government efforts to improve maternal health. The Merck for Mothers initiative, a 10-year, $500 million initiative to reduce maternal deaths, is working with private providers and health businesses at the local level to ensure that the care they provide is accessible, affordable, and of high quality.
Dr. Bustreo, who heads WHO’s programs for Family, Women’s and Children’s Health, described WHO’s work, in partnership with governments and the private sector, to identify and promote innovative solutions to the maternal health challenges faced by countries, health providers, and women. She also highlighted the high cost of maternal health services as a critical barrier that limits women’s access to the services they need, and discussed approaches that countries are using to address it.
The Honorable Dr. Okonjo-Iweala, who has served as Nigeria’s Minister of Finance and as its Foreign Minister, and is a former Managing Director of The World Bank, focused on empowering women and girls: “Women are the next emerging market and are a force to reckon with. If we invest in women, we can move the world.” In Nigeria, she noted, 43% of health care facilities are private, so the government understands the importance of engaging private providers and ensuring that they are appropriately regulated. Scaling up midwifery services is a key to ensuring increased coverage in rural areas, she said, and Nigeria’s conditional cash transfer scheme, which provides women with financial incentives for attending a certain number of antenatal visits, is a key policy for expanding access to care. Dr. Okonjo-Iweala reported that, in the areas where these cash transfers have been offered, there has been a 16% decline in maternal deaths.
Karl Hofmann discussed social franchising, a “cousin of social marketing,” as a channel for ensuring that quality services and technologies reach women and their families. Social franchising efforts work to build recognition for providers who serve poor and vulnerable women: a key element of their “brand” is ensuring that all franchisees meet improved service standards and provide good quality care. PSI has, to date, provided support for franchising 10,000 providers in 24 countries; these providers reach 10 million people with essential health care services each year.
Sweta Mangal shared Ziqitza Health Care’s experience operating more than 860 advanced and basic life support ambulances across India, filling a gap in government services and increasing access to quality, lifesaving care for poor patients. One-third of Ziqitza’s patients are pregnant women needing transport to health facilities that offer skilled delivery care. In addition, she said, more than 5,000 babies have been born in Ziqitza’s ambulances, since government hospitals are often too overcrowded to immediately accommodate all of the pregnant women who arrive by ambulance.
A lively discussion followed these presentations, focusing on how to ensure that private providers and health businesses comply with government regulations and protocols, meet quality standards, and provide services that are affordable and accessible for users from all income levels.
At the meeting’s conclusion, Family Care International’s president Ann Starrs referenced recent remarks by Dr. Margaret Chan, Director General of WHO, that universal health coverage is an idea whose time has come. “There is a consensus in most parts of the world that it is the responsibility of governments to ensure that all people have access to basic preventative and curative health care,” she noted. “But that doesn’t mean that governments have to provide those services themselves.” The private sector offers clear advantages, she said, in terms of pioneering innovative approaches, their connection to the community, efficiency and cost-effectiveness, and sustainability. Enabling the private sector to maximize its potential contributions requires governments to provide a normative and regulatory framework to ensure that quality standards are met; financing mechanisms to make services affordable; training and support of private sector providers; and sharing learning, experiences, and evidence. “Partnership,” she said, “is the key.”
Alain Kaboré is Program Officer with FCI-Burkina Faso, based at our office in Ouagadougou.
In the West African country of Burkina Faso, FCI — with support from the UN Population Fund (UNFPA) and the Luxembourg Agency for Development Cooperation — is addressing the suffering of women who live with obstetric fistula, a devastating injury to the birth canal caused by obstructed and prolonged labor. If left untreated, fistula’s damage is permanent. It makes it impractical or impossible to have more children, causes leaking of urine or feces, and leads to a lifetime of pain, stigma, and social ostracism. Working with communities and grassroots organizations in the remote Sahel region, on the edge of the Sahara Desert, FCI’s program seeks to prevent obstetric fistula by improving women’s access to emergency obstetric care. We also provide surgical treatment for women living with fistula (see part 1 of this series to learn more), and support the reintegration of fistula survivors into their communities.
In the poor, semi-nomadic villages of the Sahel, women with obstetric fistula are often treated as if it is their own fault, and not the result of inadequate access to maternal health services. It is widely believed that fistula is a punishment for adultery or other moral transgressions, or that it is a sign that the woman is cursed. A woman living with fistula cannot hide it, because her chronic incontinence brings with it a constant odor. These women are often thought unworthy of living with their families, associating with friends, or participating in the life of the community. Many are rejected by husbands and in-laws, and forced to live in the shadows, with a triad of suffering: physical, psychological, and economic.
Successful surgery can heal fistula’s physical effects, but its psychosocial and economic impacts often last far longer. FCI works with our community-based partner organizations to meet this challenge by helping women, after their fistula has been repaired, to emerge from the shadows and rejoin their families and communities. In these villages, establishing a means of earning an income is a crucial way for a woman to regain her confidence, demonstrate her value to the family, and achieve status in the community.
Mariama Boubacar Diallo is one of these women. Mariama lives in the village of Kriollo Ourarsaba, 25 kilometers (16 miles) from Dori, the region’s capital. In 2009, already a 27-year old mother of two, she developed a fistula while giving birth to her third child (who survived, unusual in fistula cases). Mariama’s husband did not reject her, but her in-laws were less kind. “His parents did not want me anymore — every day there was strife… and they openly abused me in spite of my husband,” she said. Fortunately, one of FCI’s partners found her and arranged for her surgery at the hospital in Dori only a few months later. “Today,” Mariama says, “thank God, I no longer suffer. I’m healthy; I am healed.”
The healing that Mariama needed was not only physical; her position in the family and community also needed repair. So in the months after her surgery, she received training in modern methods of livestock farming. Raising cattle and sheep is the primary economic activity in many parts of the Sahel, and 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, and thereby 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.”
Mariam Sawadogo suffered for much longer: now 35 years old, she was still in her teens when her second pregnancy resulted in obstructed labor, stillbirth, and obstetric fistula. After 16 years of humiliation and isolation, the FCI program arranged for her repair surgery at the Dori hospital. Now a widow, she too was trained in farming techniques and small business management skills. With her small reintegration grant, Mariam has developed two small but successful businesses. Like Mariama Boubacar Diallo, Mariam used her grant to buy two ewes; after fattening them for a year, she sold them for a profit, using the proceeds to purchase two more young sheep and to begin making and selling beignets (donuts) in the village market.
These two small businesses have enabled Mariamto emerge from extreme poverty — she now has both assets (her livestock) and a steady income, and can pay her child’s tuition at the village school. She also is able to buy jewelry, an important marker of social status for women of her generation in her community. At her market stall, Mariam, no longer a social pariah, chats and gossips with the many customers who come to buy her delicious cakes. In line with tradition — and a clear sign of her successful reconciliation with her in-laws — she now lives in the household of her late husband’s younger brother.
Mariama and Mariam are just two of the hundreds of women whose lives have been transformed through a simple surgery and a $200 grant.
La seconde vie des survivantes de la fistule obstétricale (suite): 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, pays de l’Afrique de l’Ouest, FCI – financé par le Fonds des Nations Unies pour la Population (UNFPA) grâce à des fonds du Grand-Duché du Luxembourg – est en train de répondre aux souffrances des femmes qui vivent avec une fistule obstétricale, une blessure à la filière génitale causée par un accouchement obstrué et prolongé. Sans traitement, la fistule provoque l’incontinence et l’odeur, et rend difficile voire impossible d’avoir encore des enfants, ce qui résulte en une vie de douleur, de stigmatisation, d’ostracisme social pour les femmes victimes. En collaboration avec les communautés et les organisations locales du Sahel, un projet de FCI vise à prévenir les fistules obstétricales (en améliorant l’accès aux soins obstétricaux d’urgence), fournir un traitement chirurgical aux femmes vivant avec une fistule (voir la partie 1 de cette série), et soutenir la réintégration des survivantes de la fistule au sein de leurs communautés.
Dans les villages pauvres et semi-nomades du Sahel, les femmes souffrant de fistule obstétricale sont traitées comme si elles étaient responsables, alors qu’en réalité l’accès inadéquat aux services de santé maternelle est responsable.
Beaucoup croient que la fistule est une punition de l’adultère, d’autres transgressions morales, ou est un signe que la femme est maudite. Les femmes qui vivent avec une fistule ne peuvent pas le cacher : leur incontinence chronique apporte une odeur constante d’urine et/ou d’excréments, et elles sont souvent perçues comme n’étant pas dignes de vivre avec leurs familles, de voir leurs ami(e)s, ou de participer à la vie de leur communauté. De nombreuses femmes sont rejetées par leurs époux et leurs beaux-parents et forcées de vivre dans l’ombre, et à subir une souffrance physique, psychosociale et économique.
Une chirurgie réussie peut guérir les effets physiques de la fistule, mais ses impacts psychologiques et économiques peuvent durer plus longtemps. En collaboration avec nos partenaires locaux, FCI répond à ce défi en aidant les femmes, après la réparation de la fistule, à sortir de l’ombre et à rejoindre leurs familles et communauté. Dans ces villages, avoir une activité génératrice de revenus (AGR) est un moyen crucial par lequel une femme peut reprendre confiance en elle, démontrer sa valeur à la famille, et obtenir un statut au sein de la communauté.
Mariama Boubacar Diallo est une de ces femmes. Mariama vit dans le village de Kriollo Ourarsaba à 25 km de Dori, chef-lieu de la région du Sahel. En 2009, déjà mère de deux enfants à 27 ans, elle a développé une fistule pendant l’accouchement de son troisième enfant (qui a survécu, événement rare dans le cas des fistules). Bien que son époux ne l’ait pas rejetée, ses beaux-parents étaient moins compréhensifs : « … mes beaux-parents ne voulaient plus de moi, chaque jour avait ses épisodes de querelles, on me lançait des proverbes et des injures ouvertes et tout cela au mépris de mon époux ». Heureusement, un des partenaires de FCI l’a trouvée et a pris toutes les dispositions nécessaires pour qu’elle puisse être opérée à l’hôpital de Dori quelques mois plus tard. « Aujourd’hui » dit-elle, « Dieu merci je ne souffre de rien ; je suis bien portante, je suis guérie, même en me voyant vous savez que je suis en bonne santé ». Une fois le mal physique guéri, Mariama avait également besoin d’aide pour retrouver sa position au sein de sa famille et sa communauté. Dans les mois qui ont suivis l’opération chirurgicale, Mariama a reçu une formation sur les techniques modernes d’élevage (l’élevage des bovins et des moutons est la principale activité économique dans de nombreuses parties du Sahel), et à la fin de l’année 2010, elle a reçu 100 000 francs CFA (environ 200 dollars). Les fonds lui ont permis d’acheter un bélier, une brebis, et de la nourriture pour établir sa propre entreprise de l’élevage.
Aujourd’hui, Mariama est propriétaire d’un élevage de quatre bêtes, ce qui fait d’elle une des personnes les plus prospères du village. Elle partage son nouveau savoir-faire agricole avec ses voisins et elle participe pleinement aux baptêmes, mariages, et autres évènements sociaux du village – quelque chose d’inconcevable il y a un an. Elle est aussi pleinement réunifiée avec sa belle-famille : « Aujourd’hui, je peux dire que c’est grâce aux AGR que ma belle-famille m’a acceptée réellement. » Après l’avoir exclue dans le passé, maintenant ils viennent vers elle pour des conseils et de l’aide.
Mariam Sawadogo a souffert pendant bien plus longtemps : aujourd’hui âgée de 35 ans, elle était adolescente quand sa deuxième grossesse a abouti à une fistule obstétricale. Après 16 ans d’humiliation et d’isolation, le projet de FCI a facilité sa chirurgie à l’hôpital de Dori. Maintenant veuve, elle aussi a bénéficié d’une formation en techniques d’élevage et en gestion de petit commerce. Avec sa subvention de 100 000 francs CFA, Mariam a commencé deux petites entreprises pleines de succès. Comme Mariama Diallo, Mariam s’est acheté deux brebis et un an plus tard, elle les a revendues à profit pour acheter deux jeunes moutons. Les bénéfices engendrés lui ont également permis de démarrer un petit commerce de vente de beignets sur le marché du village.
Ces deux entreprises ont permis à Mariam d’échapper à la pauvreté extrême –elle possède actuellement un patrimoine (ses animaux) et un revenu stable qui lui permet de payer les frais de scolarité de son enfant qui fréquente l’école du village. Ses revenus lui permettent également de s’offrir des bijoux, un signe important du statut social pour les femmes de sa génération dans sa communauté. Devant son étal au marché, Mariam, qui n’est plus un paria social, bavarde avec ses nombreux clients qui défilent autour de son étal à la recherche de ses succulents beignets. Selon la tradition –et un signe clair de sa réconciliation réussie avec sa belle-famille – elle vit dans la famille du jeune frère de son défunt époux.
Mariama et Mariam ne sont que deux des centaines de femmes dont la vie a été transformée par une chirurgie simple et une subvention de 200 dollars.