Showing posts from category maternal health.
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Nabeela Ali on How PAIMAN Is Improving Maternal Health in Pakistan
›“Maternal mortality is a very complex thing – it’s not just patient-doctor relationships, it has so much to do with behaviors, with communities, with the household, with family members,” said Nabeela Ali, chief of party for the Pakistan Initiative for Mothers and Newborns (PAIMAN), which received USAID maternal and child health funding from 2004 to 2010.
Pakistan is the world’s sixth most populous country, yet has long held one of the world’s highest maternal mortality rates. Ali spoke at the Wilson Center last fall about strategies to better engage faith-based organizations on maternal and child health issues. In this interview with ECSP, she stressed that despite Pakistan’s very religious society, these interventions are possible with the right messaging.
PAIMAN aims to reach vulnerable and isolated groups, including poor, rural, or conservative women. “The areas where no one can reach [are] where we targeted,” Ali said.
In these areas, ulama – influential religious leaders and scholars – are highly trusted. “It was not a one-size-fits-all strategy,” Ali emphasized. “Religious leaders are not technical people, but they are experts in their own field. You have to approach them with trust and respect.”
“The first step is establishing rapport with them; then they listen to you,” said Ali. This is best done through another alim, not a technical person. Those ulama that were approachable proved to be valuable allies in the promotion of maternal health. PAIMAN has reached over 35 million people in Pakistan over its now eight-year run.
Projects like PAIMAN are necessary in areas of the world where religious leaders are the most respected community authorities. In Pakistan, Ali believes that now that this strategy has been demonstrated to be viable, the government should help bring it to scale. An NGO-funded project ends, but a government-funded program has much more continuity, which in turn helps build trust with local leaders, she said.
Sources: UN Population Division. -
Women’s Rights and Voices Belong at Rio+20
›This summer, world leaders will gather in Rio de Janeiro for the 20th anniversary of the first UN Earth Summit to hammer out a new set of agreements on what sustainable development means and, more importantly, how both rich and developing nations can get there before it’s too late. However, for the scores of women who will be attending (and just importantly for those who aren’t), there are glaring omissions: reproductive health, gender equality, and girls education are nowhere to be found on the Rio+20 agenda.
Women offer many of the most promising levers for the transformation to sustainable development. My experience with the Global Fund for Women tells me that women are full of creative and strategic solutions to the problems facing their communities around the world. Their voices must be included in critical decisions affecting our world. And the fact is, sustainable development isn’t sustainable if it doesn’t include empowering women to plan their families, educate themselves, and their children, and have a voice in government at all levels. Rio+20 must have human rights – and women’s rights – at its core. Earth summit planners haven’t yet done that, but women can make it happen.
Women are 51 percent of the world’s population, yet own only one percent of its assets, are two-thirds of the world’s workers but earn a mere 10 percent of wages. Rio+20 must not become another forum in which women’s issues are not heard. Instead, the summit must demonstrate that women’s voices are integral to all development. Environmental sustainability simply can’t happen without women’s inclusion.
For example, in West Africa, women make up 70 percent of workers in agriculture. In Burkina Faso, deforestation, water scarcity, and soil erosion show us that climate change is already impacting women farmers. Women tend to “sacrifice themselves” in order to care for their families – feeding themselves last. And women are most likely to suffer and die in environmental disasters – particularly in the Asian countries most at risk from climate change.
So how do we support women while supporting the environment that sustains us all?
Simply meeting women’s needs for family planning is one inexpensive and powerful development strategy with a host of environmental benefits. Over 200 million women around the world want the ability to choose the spacing and number of children but don’t have access to, or accurate information about, basic contraceptives like condoms, pills, and IUDs. One-hundred and seventy-nine nations already agree that meeting this need is a top priority, and the Millennium Development Goals (MDGs) reflect a goal of universal access to family planning as well.
Satisfying this demand would dramatically reduce maternal and child mortality and enhance human rights. What’s more, two recent studies show that a reduction of 8 to 15 percent of essential carbon emissions can be obtained by meeting women’s needs for family planning. This reduction would be equivalent to stopping all deforestation or increasing the world’s use of wind power fortyfold.
The Earth Summit presents a major opportunity to ensure that women’s needs and rights are given top priority in plans for sustainable development. In a time of multiple, interlinked human and environmental crises and a very tight funding environment, investing in women is a clear winner.
A greater understanding of the impact of environmental degradation, pollution, and climate change on women, coupled with solid public policy that respects and protects women’s reproductive rights, is essential to the “Sustainable Development Goals” that many believe will emerge from Rio+20 to replace the MDGs, which expire in 2015.
As the summit approaches, it’s time to reflect on why women’s full participation and inclusion is so important and call for world leaders to harness the power of women as we launch the era of sustainable development.
Musimbi Kanyoro is president and CEO of the Global Fund for Women, which advances women’s human rights by investing in women-led organizations worldwide.
Sources: Food and Agriculture Organization, Guttmacher Institute, Moreland et al. (2010), O’Neill et al. (2010), Princeton Environmental Institute, UN, UNEP, World Bank, World Health Organization.
Photo Credit: “Reokadia Nakaweesa Nalongo,” courtesy of Jason Taylor/Friends of Earth International. -
Uganda’s Demographic and Health Challenges Put Into Perspective With Newfound Oil Discoveries [Part One]
›April 26, 2012 // By Kate DiamondUganda’s population is the second youngest in the world, with half of the country younger than 15.7 years old (just older than Niger’s median age of 15.5 years). In the past 10 years, the country – about half the size of France in land area – has added 10 million people, growing from 24 to 34 million. That growth, paired with other factors like poor governance and long-standing insecurity, has made providing basic services a difficult task for a government that is one of Africa’s most aid-dependent.
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Karen Newman: Population and Sustainable Development Links Are Complex, Controversial, and Critical
›April 23, 2012 // By Kate Diamond“The one child family norm in China has fixed the global imagination around population to be around doing something which constricts people’s and women’s choices, rather than expands women’s possibilities to take control of their lives,” said Karen Newman, the coordinator for the UK-based Population and Sustainability Network. But contemporary population programs are about educating people on and providing access to voluntary reproductive, sexual, and maternal health services.
Newman spoke to ECSP, during the Planet Under Pressure conference this year, about family planning efforts and the connection between population dynamics and the environment.
“You have what I would describe as a sort of kaleidoscope of complexity” between climate change and population dynamics – not just growth, said Newman, but urbanization and migration.
For example, China recently overtook the United States as the world’s largest emitter of carbon, and although China has 1.3 billion people compared to the United States’ 310 million, population can hardly be credited as the most important driver for the country’s emissions. “How fair is it [to credit population growth] without in the same nanosecond saying, ‘but most of the carbon that was emitted in China was to manufacture the goods that will of course be consumed in the West?” said Newman.
“It makes it more difficult to say in a sound bite that ‘OK, population and sustainable development, it’s the same conversation,’ which I believe it to be.”
The Population and Sustainability Network, working through the Population and Climate Change Alliance, collaborates with international organizations from North America, Europe, Ethiopia, and Madagascar to support on-the-ground groups working on integrated population, health, and environment programming. These programs address environmental issues, like marine conservation and deforestation, while also providing reproductive health services, including different methods of contraception, diagnosis and treatment of sexually-transmitted diseases, antenatal and postnatal care, and emergency obstetric care.
“As a result of people wanting to place a distance between those coercive family planning programs in the ‘60s and the way that we do reproductive health now…because it’s such a large package, there is a sense that…this reproductive health thing is too much, we can’t really get ahold of this,” said Newman.
“What I think we need to do is keep people focused on the fact that these are women’s rights,” she said. “But we at the same time have to say ‘this is relevant if you care about sustainable development and the world’s non-renewable resources.’”
Sources: United Nations Population Division. -
Food Security in a Climate-Altered Future, Part Two: Population Projections Are Not Destiny
›March 20, 2012 // By Kathleen MogelgaardRead part one, on the food-population-climate vulnerability dynamics of Malawi and other “hotspots,” here.
Too often, discussions about future food security make only a passing reference to population growth. It is frequently framed as an inevitable force, a foregone conclusion – and a single future number is reported as gospel: nine billion people in 2050. But adhering to a single path of future population growth misses the opportunity to think more holistically about food security challenges and solutions. Several recent food security reports illustrate this oft-overlooked issue.
Accounting for Population a Challenge
Oxfam International’s Growing a Better Future: Food Justice in a Resource-Constrained World is a thorough and fascinating examination of failures in our current food system and future challenges related to production, equity, and resilience. It reports newly-commissioned research, carried out by modelers at the Institute of Development Studies, to assess future agricultural productivity and food prices given the anticipated impacts of climate change.
But both the modeling work and the report text utilize a single projection for population growth: the UN’s 2008 medium variant projection of 9.1 billion by 2050 (which has since been revised by the UN up to 9.3 billion). Early on, the report does recognize some degree of uncertainty about this number: “Greater investment in solutions that increase women’s empowerment and security – by improving access to education and health care in particular – will slow population growth and achieve stabilization at a lower level.” But such investments do not appear in the report’s overall recommendations or Oxfam’s food security agenda. This is perhaps a missed opportunity, since the range of possibilities for future population growth is wide: the UN’s low variant for 2050 is 8.1 billion, and the high variant is 10.6 billion.
Food Security, Farming, and Climate Change to 2050: Scenarios, Results, and Policy Options is another frequently-cited report published by the International Food Policy Research Institute in 2010. In recognizing that economic growth and demographic change have important implications for future food security, IFPRI researchers modeled multiple scenarios for the future: an “optimistic” scenario which embodies high GDP growth and low population growth, a “pessimistic” scenario with low GDP growth and high population growth, and a “baseline” scenario which incorporates moderate GDP growth and the UN’s medium population projection. Each of these scenarios was then combined with five different climate change scenarios to better understand a range of possible futures.
Using different socioeconomic scenarios enabled researchers to better understand the significance of socioeconomic variables for future food security outcomes. The first key message from the report is that “broad-based economic development is central to improvements in human well-being, including sustainable food security and resilience to climate change.” This focus on economic development is based in part on the “optimistic scenario,” which counts on high GDP and low population growth (translating to high rates of per capita GDP growth).
Unfortunately, the socioeconomic scenario construction for this analysis doesn’t allow for an independent assessment of the significance of slower population growth, since high population growth is paired only with low GDP and lower population growth is paired only with high GDP. Therefore, none of the report’s recommendations includes reference to reproductive health, women’s empowerment, or other interventions that would contribute directly to a slower population growth path.
Expanding the Conversation to Better Inform Policy
Without a more nuanced treatment of population projections in technical analysis and popular reporting on food security, decision-makers in the realm of food security may not be exposed to the idea that population growth, a factor so critical in many areas where food security is already a challenge, is a phenomenon that is responsive to policy and programmatic interventions – interventions that are based on human rights and connected to well-established and accepted development goals.
There are some positive signs that this conversation is evolving. A new climate change, food security, and population model developed by the Futures Group enables policymakers and program managers to quickly and easily assess the impact of slower population growth on a country’s future food requirements and rates of childhood malnutrition. In the case of Ethiopia, for example, the model demonstrates that by 2050, a slower population growth path would make up for the caloric shortfall that is likely to arise from the impact of climate change on agriculture and would cut in half the number of underweight children.
And recently, we’ve begun to see some of this more nuanced treatment of population, family planning, and food security linkages in a riveting, year-long reporting series (though perhaps unfortunately named), Food for 9 Billion, a collaboration between American Public Media’s Marketplace, Homelands Productions, the Center for Investigative Reporting, and PBS NewsHour.
In January, reporter Sam Eaton highlighted the success of integrated population-health-environment programs in the Philippines, such as those initiated by PATH Foundation Philippines, that are seeing great success in delivering community-based programs that promote food security through a combination of fisheries management and family planning service delivery. Reporting from the Philippines in an in-depth piece for PBS NewsHour, Eaton concluded:So maybe solving the world’s food problem isn’t just about solving the world’s food problem. It’s also about giving women the tools they want, so they can make the decisions they want – here in the world’s poorest places.
Making clear connections of this nature between population issues and the most pressing challenges of our day may be the missing link that will help to mobilize the political will and financial resources to finally fully meet women’s needs for family planning around the world – an effort that, if started today, can have ongoing benefits that will become only more significant over time. Integrating reproductive health services into food security programs and strategies is an important start.
Back in Malawi, just before we turned off the highway to the Lilongwe airport, I asked the taxi driver to pull over in front of a big billboard. We both smiled as we looked at the huge government-sponsored image of a woman embracing an infant. The billboard proclaimed: “No woman should die while giving life. Everyone has a role to play.” Exactly. The reproductive health services that save women’s lives are the same services that can slow population growth and bring food security within closer reach. -
Kavita Ramdas: Why Educating Girls Is Not Enough
›“I’m a big proponent of girl’s education. I believe that it’s a very important and a very valuable human rights obligation that all countries should be meeting,” said Kavita Ramdas, executive director for programs on social entrepreneurship at Stanford University, at the Wilson Center. However, “in the past seven to eight years we have found ourselves in a situation where there’s kind of an enchantment with girl’s education, as though it were the new microenterprise magic bullet to solve everything from poverty, to malnourishment, to inequality.”
“The outcomes that we ascribe to girl’s education…are not anything that I would argue with,” she said, yet, this enchantment “has happened simultaneously with a significant drop in both funding and support for strategies that give girls and women access to reproductive health and choices, particularly family planning.”
This is a problem, said Ramdas, because we cannot rely on education alone to do all the heavy lifting required to empower women.
“I think it’s important for us to recognize that there are societies where girls and women have achieved significantly high levels of education in which gender inequality remains,” she said, “for example, places like Japan and Saudi Arabia, where you have high per capita income, high levels of education, and yet…where women and girls are still marginalized and on the edges in terms of decision making.”
“I don’t think we have to wait for one to be able to do the other,” she said. “As we support programs for girls’ education, we also need to demand that those programs be buttressed by strong programs in adolescent health, strong programs in sex education, strong programs that actually provide girls and women with access to family planning and contraception.” -
USAID’s Donald Steinberg on Futures Analysis for International Development
›February 28, 2012 // By Stuart KentJust as the science fiction writer Isaac Asimov explored the idea of predicting the future to influence the world towards a more prosperous, democratic, and peaceful track, so too must USAID try to better understand the challenges of tomorrow, said Donald Steinberg, deputy administrator for the U.S. Agency for International Development, during an address at USAID’s “Future of Development” symposium at the Wilson Center late last year. “Development now is too important to the United States to be left to actions that occur over 1, or 2, or 5, or even 10 years,” he continued. Looking beyond budgetary cycles, Steinberg asserted that “we have to prepare for future development patterns” by analyzing the present.
Why Aid Matters
Drawing on the President’s remarks during the UN’s 2010 Millennium Development Goals Summit in New York, Steinberg outlined three reasons why development aid is central to U.S. foreign policy.
First, we all stand to benefit from living “in a world that’s peaceful, that’s democratic, that’s prosperous, that’s respectful of human rights and respectful of human dignity,” he argued.
Second, “a world that is developing is in our economic interest,” he said. “Developing nations are our fastest growing markets abroad,” providing lucrative outlets for U.S. trade and investment. Eighty-five percent of new U.S. exports over the next two decades will find their way to recipients of U.S. foreign aid, he said.
Third, aid impacts national security. Countries that are developing and prospering “don’t spew out large numbers of refugees across borders or across oceans,” he said, “they don’t transmit pandemic diseases, they don’t harbor terrorists, or now even pirates” – in short, “they don’t require American forces.”
Looking to the Future
According to Steinberg, we can take hold of the future by being prepared to grasp opportunities, even if they come in the midst of challenges.
“We’re seeing demographic shifts that are complicating once steady development patterns,” he said, “and we’re seeing more uneven distribution of wealth within countries and between countries.” But “maternal and infant mortality have plummeted [and] literacy rates are skyrocketing.”
“We still see rampant corruption and we still see crackdowns on civil society all around the world,” however Steinberg pointed out that 17 new democracies have emerged in Africa in the last 15 years alone.
On climate change, he drew from recent events in the Horn of Africa. “A changing rain pattern – from a drought every 10 years to what is now basically a drought every year – has brought together a perfect storm of famine, war, and drought,” he said. Yet across the border from Somalia, the situation is markedly different – in part because “USAID has had the capability to work with eight million Ethiopians over the past decade to strengthen their resiliency.”
Each of these shows the opportunity for positive change amidst difficult challenges, if we are prepared.
“We went through a period where we had eliminated our office of policy and planning,” said Steinberg, but over the last few years the newly established Policy, Planning, and Learning Bureau at USAID has brought back an emphasis on futures analysis. “We are now seeking to become…the thought leader in the development field,” he said.
Overall, the total amount of official government aid is small compared to other sources from the United States, said Steinberg – around $30 billion a year (compared to $36 billion in private giving, $100 billion in remittance flows, and $1 trillion in private capital flows). To make the most of that, USAID should be “a catalyst for development,” he said, working in partnership, encouraging technological innovation, and advancing cross-sectoral understanding.
“We at AID like to think in terms of budget cycles,” said Steinberg. “We’re starting to think about fiscal year [20]14, but I want you to start thinking about fiscal year 25 and fiscal year 30. I won’t challenge you to think 30,000 years ahead like Isaac Asimov did, but I think we do have to consider what the lessons of today are teaching us about the future.”
Sources: The White House. -
Afghanistan and Pakistan: Demographic Siblings? [Part Two]
›February 15, 2012 // By Elizabeth Leahy MadsenLate last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. My first post on the survey focused on the methodology and results, which found that Afghanistan is not as much of a demographic outlier as many observers had assumed. But perhaps the most surprising finding is how the results compare to those of Afghanistan’s neighbor, Pakistan.
The political future of each country depends largely on the other and, with Afghanistan making progress on reproductive health issues that remain stalled in Pakistan, their demographic trajectories are heading toward closer synchronization as well. In one key measure – use of contraception among married women – Afghanistan is almost identical to Pakistan. The modern contraceptive prevalence rate is 19.9 percent, slightly lower than the rate of 21.7 percent in Pakistan.
While Pakistan faces its own serious political instability, it is widely regarded as more developed than its neighbor. Afghanistan is included in the UN’s grouping of least developed countries, and Pakistan is not. Pakistan’s GDP per capita is almost twice as high. On the surface, this should suggest lower fertility. There is a general negative relationship between economic development and fertility, though demographers are quick to point out its complexities, and David Shapiro and colleagues have found that countries with larger increases in GDP actually experience slower fertility declines.
Pakistan’s fertility rate of 4.1 children per woman is in fact 20 percent lower than Afghanistan’s, but the similarities in contraceptive use, which is one of the direct determinants of fertility, suggest that this gap could be shrinking. If Afghanistan’s median age at marriage (18 compared to 20 in Pakistan) was higher and more women were educated (76 percent of women have never been to school compared to 65 percent in Pakistan), the two fertility rates might be closer.
Pakistan’s Entrenched Challenge
Why are these indicators closer than might be expected? Relative to the other countries in South Asia, Pakistan has had considerably less success in promoting family planning use. Bangladesh has a per capita income about half that of India and one-quarter that of Sri Lanka, yet the three countries’ fertility rates are identical. Nepal has the lowest income in the region – even slightly below Afghanistan – yet more than 40 percent of married women use modern contraception and fertility is three children per woman. And then there is Pakistan. Despite a per capita income 90 percent that of India, only 22 percent of married women use modern contraception and fertility remains persistently high at over four children per woman.
The weaknesses of Pakistan’s family planning program have been well-documented. Government commitment has been lacking and cultural expectations and gender inequities are a powerful force to promote large family size. The country’s most recent DHS report cited disengagement with the program among local agencies, low levels of outreach into communities, and weak health sector support as likely causes for the stagnation of contraceptive use. In summer 2011, the Pakistani government abolished the federal Ministry of Health and empowered provincial governments with all responsibilities for health services. This transfer of authority could pay dividends by increasing local ownership of health care, but some in and outside Pakistan have raised concerns about the loss of regulatory oversight and information sharing entailed in total decentralization.
Compared to the Afghanistan survey, the most recent Pakistan Demographic and Health Survey provides more detail on women’s motivations and preferences regarding fertility and family planning. Overall, 55 percent of married women in Pakistan have a “demand” for family planning; that is, they wish to avoid pregnancy or report that their most recent pregnancy or birth was mistimed or unwanted. More than half of these women are using family planning, while the remaining 25 percent of married women have an “unmet need.”
Unintended pregnancies and births play a major role in shaping Pakistan’s demographic trajectory. The DHS survey finds that 24 percent of births occur earlier than women would like or were not wanted at all. If unwanted births were prevented, Pakistan’s fertility rate would be 3.1 children per woman rather than 4.1. Yet 30 percent of married women are using no contraceptive method and do not intend to in the future. The most common reasons for not intending to use family planning are that fertility is “up to God” and that the woman or her husband is opposed to it.
Linked Destinies
Just as Afghanistan and Pakistan’s political circumstances have become more entwined, their demographic paths are more closely in parallel than we might have expected. For Afghanistan, given the myriad challenges in the socioeconomic, political, cultural, and geographic environments, this is good news; for Pakistan, where efforts to meet family planning needs have fallen short of capacity, it is not. While Afghanistan is doing better than expected, Pakistan should be doing better.
Regardless, both countries are at an important juncture. With very young age structures and the attendant pressures on employment and government stability, each government must reduce unmet need for family planning or face mounting difficulties to providing for their populations in the future. In addition to rolling out health services, turning the share of women without education from a majority into zero would be an excellent way to start.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.
Image Credit: Chart arranged by Elizabeth Leahy Madsen, data from MEASURE DHS.
