Showing posts from category maternal health.
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Deforestation, Population, and Development in a Warming World: A Roundtable on Latin America
›“Rural development and MCH [maternal child health] in the most remote, rural areas are going to largely explain the future of Latin American conservation, development, population, and urbanization,” said David Lopez-Carr, associate professor of geography at the University of California, Santa Barbara, at a recent Wilson Center roundtable on “Deforestation, Population, and Development in Latin America.”
Nearly 80 percent of Latin America’s people live in urban areas, yet the continent’s rural populations have a disproportionate effect on its forests. Panelists Liza Grandia, assistant professor of international development and social change at Clark University, and Jason Bremner, director of population, health, and environment at the Population Reference Bureau, argued that meeting the needs of these communities is therefore key to conserving Latin America’s forests. [Video Below]
Rural Populations Have Disproportionate Impact on Deforestation
“There are two Latin Americas,” said Carr. Countries like Argentina, Chile, and Uruguay are 90 percent urban, while countries like Guatemala, Ecuador, and Bolivia are about 50 percent urban. However, despite this rapid urbanization and declining population growth at the national level, rural areas in Latin America are still experiencing high fertility rates and significant forest loss. So how are these trends related?
In his analysis of more than 16,000 municipalities in Latin America, Carr found “no statistical significance between population change at the municipal level and woody vegetation change at the municipal level.” Yet this lack of connection does not mean population growth and deforestation are unrelated, but instead indicates “a problem of place and scale,” he said. Within countries or even within municipalities, there are huge variations in fertility rates. Rural areas, which generally have larger families, more agricultural expansion, higher population growth, and lower population density, account for higher impact per capita on forests.
“Less than one percent of the population of Guatemala moves to any rural frontier at all,” said Carr, “yet that small, tiny fraction of the population has a disproportionate impact on the forests, and that is true throughout Latin America.” Carr also distinguished between the private sector primarily converting secondary forest for corporate agriculture and subsistence farmers clearing old growth forest.
Indigenous Lands Are Key to the Future
There are generally two groups of people on the frontier: indigenous people and “colonists,” who move in to take advantage of undeveloped land. Indigenous people, by and large, act as “stewards of the forests,” exhibiting lower rates of deforestation and forest fragmentation then colonists, Bremner said. “They do have a very protective effect, largely because they are excluding others from those lands.”
Indigenous communities tend to be “common property institutions” with an informal or cultural set of rules and traditions facilitating land use, said Bremner. They are “really good at mobilizing against external threats,” he said, which results in a protective effect over the forest. In the Amazon, for example, “indigenous lands, in the context of all of this colonization and deforestation that is happening, are now seen as key to the future,” he said.
However, as indigenous population growth and growing agricultural and industrial expansion change indigenous communities and livelihoods, more formal rules must be developed to govern land use. If indigenous communities “are the protective factor, then we need to know how to protect them,” said Bremner.
There are few demographic surveys of rural communities, but one of nearly 700 women in the Ecuadorian Amazon found the total fertility rate of indigenous women to be seven to eight children per woman. “Fifty percent of indigenous women didn’t want to have another child…of that 50 percent, 98 percent were not using a modern method of contraception,” Bremner said. “Responding to these women’s needs, I think, would go a long way in terms of changing the future of these communities.”
Guatemala: Reducing Fertility By Thinking Outside the Box
Grandia, with support from Conservation International and ProPeten, conducted a study of population and environment connections as part of the Demographic and Health Survey (DHS) of Peten, a sparsely populated and highly biodiverse municipality of Guatemala. The 90,000 people living in the protected area in this park had “literally no family planning services,” said Grandia, and their population was on track to double within 20 years.
Using the DHS data, Grandia and ProPeten created a “somewhat eclectic population and environment program” that integrated many of the concerns of indigenous Maya communities in Peten, called Remedios. Remedios focused on a diverse set of issues, including agriculture, education, maternal and child health, family planning, and gender issues, and included projects like a “traveling education-mobile” and Between Two Roads, a bilingual radio soap opera in Spanish and Q’eqchi’ Maya, which used the story of a conflict between midwife and cattle rancher in a frontier community “to touch on a whole range of social and environmental issues.”
“As a result of our efforts…the total fertility rate dropped from 6.8 in 1999 to 5.8 in 2002, and in the most recent DHS it had fallen to 4.3,” said Grandia. She credited this success in part to the fact that the programs were “so cross-cutting across many of those schools of thought.” Yet the integration of a diverse range of issues also caused a split between the field-based ProPeten and the DC-based Conservation International, who wanted a more “narrow focus” on family planning and conservation, she said.
“Sometimes working outside the box can have unexpected results,” said Grandia. The population-environment movement could learn from the American environmentalist movement’s evolution from “an elite movement” into a “broader-based socially dynamic movement that involved new constituencies,” she said.
“Population and environment has often begged the articulation of a third field,” said Grandia. “How you fill in that blank often reflects the kind of development interventions you deem appropriate.” Perhaps “justice” should be considered “a new critical third paradigm,” she said.
Sources: Population Reference Bureau, World Bank.
Photo Credit: “Chevron’s Toxic Legacy in Ecuador’s Amazon,” courtesy of flickr user Rainforest Action Network. -
Portraits of Women From Afghanistan to the DRC
A Conversation on Art and Social Change
›“At the core of human rights and artistic behavior is respect for human dignity. It is this that unites art and justice,” said Jane M. Saks, executive director of the Institute for the Study of Women and Gender in the Arts and Media, speaking at an event cosponsored by the Environmental Change and Security Program and the Africa Program at the Woodrow Wilson Center. Lynsey Addario, MacArthur-winning photographer and former Institute fellow, joined Saks to share striking photographs highlighting the effects of conflict on women and girls around the world. [Video Below]
The Power of Art
“Art is inherently political because it has the power to really engage in social justice,” Saks said. The Institute that she helped found promotes art that pushes boundaries and creates conversations about peace and war, so as to “add to the accepted canon of understanding of conflict.” As part of this effort, the Institute created the exhibition, “Congo Women: Portraits of War,” composed of photographs by Addario and others about violence against women in the eastern Democratic Republic of Congo (DRC).
Saks hopes that these “photographs saturated with human dignity” will create awareness and, ultimately, influence policy about the conflict in the DRC. The exhibition has traveled to more than 20 locations since its opening. In May 2009 it was installed at the Senate Rotunda during the Senate Foreign Relations Committee hearings on violence against women in conflict.
Addario, who said her work is drive by a desire to “give the people a voice,” has spent 15 years traveling deep into conflict zones all over the world, including Iraq, Sudan, and Afghanistan.
Women and Childbirth
Addario’s images reveal the often shocking conditions in which women around the world give birth. In Sierra Leone, she documented 18-year old Mamma Seesay, “one of thousands of women who die in childbirth.” Due to a shortage of doctors, lack of transportation, and high rates of child marriage, one in eight women in Sierra Leone die in childbirth. Afghanistan has the second highest rate of maternal mortality in the world, partly because “an Afghan woman will be pregnant up to 15 times in her life,” she said. “When you watch someone who in most other developed nations would survive without question, it’s just not fair.”
Throughout a decade of covering women in Afghanistan, Addario has sought to provide a “balanced picture” of their lives to American audiences. Her photographs show the milestones women have achieved since the fall of the Taliban: graduating college; driving cars; becoming actors, producers, or police officers; getting married; and giving birth.But her coverage of Afghanistan also contains stories like that of Fariba, an 11-year-old girl who doused herself with petrol and set herself on fire after being abused by her parents. The burn ward at the hospital in Kabul is full of such women who commit self-immolation “to escape their lives,” said Addario. An Afghan woman’s life “is worse than a donkey…there is no release for these women.”
“Give Us Your Guns”
In 2009, she went to the tribal areas of Pakistan to meet the Taliban. “Wrapped up like a cigar,” she posed as the wife of former New York Times correspondent Dexter Filkins and went into a room of 30 Taliban fighters “armed to the teeth.” The two spent the day with the Taliban and “by the end, they loved us,” she said. “The whole time they just laughed at us: ‘You Americans, you give money to the Pakistani government and they give it to us!”
While covering the conflict in Darfur, Addario had to convince UN peacekeepers to drive into a Janjaweed-occupied village so that she could verify how many people had been killed. “Every time we would go towards the village, the Janjaweed would shoot at us and so [the peacekeepers] would turn the cars around and go,” Addario said. To convince the peacekeepers to go in anyway, she said to the commander: “Just give us your guns. We’re gonna go in ourselves if you don’t.” When they finally drove towards the village, “the Janjaweed set it on fire right in front of us, and we just kept driving, and when we got there they had left,” she said.
Addario has spent years as a single woman traveling around the world and throughout conflict zones. “Women in Afghanistan think I’m insane,” she said. “They think I have a lonely, miserable life.” But she believes that as a woman working in conflict zones, she has a unique ability to access places that a man could not and a mission to tell the stories that she hears. “For me it’s about showing the greater American public what’s happening.”
Sources: Institute for the Study of Women and Gender in the Arts and Media, National Geographic, The New York Times, Public Radio International, Slate, UNICEF, and the U.S. Senate Committee on Foreign Relations.
Photo Credit: Woman in labor with her mother on the way to the hospital in Afghanistan and a U.S. Marine in Afghanistan, used with permission courtesy of Lynsey Addario and the VII Network. -
Reality Check: Challenges and Innovations in Addressing Postpartum Hemorrhage
›Heavy bleeding after childbirth, also known as postpartum hemorrhage (PPH), is one of the leading causes of maternal deaths worldwide. Globally, approximately 25 percent of all maternal deaths are caused by postpartum hemorrhage, and many mothers bleed to death due to delays in seeking health care services. On January 25th, 100 representatives from the maternal health community – a majority working directly in developing countries – convened for an all-day meeting at the Wilson Center to discuss experiences in the field and perform “reality checks” on the challenges and successes of PPH programs.
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Watch: Amy Webb Girard on Integrated Development Strategies for Improved Women’s Nutrition
›“When women become pregnant…their nutrient needs shoot through the roof,” said Amy Webb Girard of Emory University’s School of Public Health in this interview with ECSP and the Global Health Initiative. Girard explains that under-nutrition is a major problem for women – especially pregnant women – in resource-poor settings.
“For example, iron requirements almost double during the course of pregnancy, but iron is one of those nutrients that are really difficult to get,” Girard explained. Meat is not readily available in many developing countries and the iron in non-meat foods is not absorbed as completely. As a result, “women by and large are unable to meet those nutrient needs,” she said.
Fortunately, there is “an arsenal of nutritional interventions available,” noted Girard, including micro-nutrient supplements, behavior change strategies, and integrated facility- and community-based delivery methods.
“Additionally I think it’s very important that we also look at food production. This is a key, key thing,” said Girard. “Women who are able to produce their own foods [and] households that can produce their own foods have greater food security.”
“A lot of these agricultural strategies serve double purposes,” Girard said. “They not only increase the available food and the quality of that food, they improve women’s livelihoods, they give them a source of income, they give them – as some studies have shown – greater ability to negotiate within their own households for how money should be spent [and] whether they should access care or not. So they actually empower women in ways beyond nutrition.” -
Evidence, Links, and Solutions
Maternal Undernutrition
›“Maternal undernutrition is often overlooked as a strategy for reducing poverty and as a key intervention to reduce maternal mortality and morbidity,” said Mary Ellen Stanton, senior maternal health advisor at the U.S. Agency for International Development. Stanton was joined by Dr. Doyin Oluwole, director of the Africa’s Health in 2010 program, and Amy Webb Girard, assistant professor at the Emory University School of Public Health, in the final meeting of the Advancing Policy Dialogue on Maternal Health series on December 15 where they addressed the linkages between poverty, undernutrition, and poor maternal health outcomes.
The Cycle of Malnutrition and Poverty
Many factors contribute to a woman’s nutritional status, including lack of capital, access to land, and poverty; thus, said Oluwole, “we must adopt a multi-pronged and multi-sectoral response.”“General malnutrition is usually associated with iron-deficiency anemia, which leads to poor cognitive function and educational achievement, poor health, and fatigue.” Oluwole said. “These three factors lead to low worker productivity, and low worker productivity leads to income poverty.”
“All of these aggravate malnutrition and so the vicious cycle of malnutrition and poverty continues,” said Oluwole. To break this cycle, she pointed out that countries like Malawi and Mexico have implemented various multi-sectoral interventions that have “stimulated economic growth; implemented targeted social, health, and nutrition programs; and put in place safety nets.”
“In the window of opportunity during pregnancy and the first two years of life, we can make a big difference,” Oluwole said. She advocated for an “integrated anemia package” that provides anti-malarials, de-worming medicine, iron folic acid tablets, and extra food during pregnancy. She also noted the importance of family planning and targeted high-coverage interventions, such as salt iodization, vitamin A supplementation, and breastfeeding promotion.
In conclusion, Oluwole provided several recommendations for the development community to improve maternal mortality rates and undernutrition of women:
Maternal Undernutrition: Our Global Disgrace- Promote universal primary and secondary education, especially for girls
- Stimulate economic growth with a focus on gender and equity
- Invest in infrastructure to reduce transportation time to hospitals
- Postpone age of marriage and of first pregnancy
- Provide targeted and effective nutrition and health interventions
- Encourage private sector participation and government leadership
- Integrate the maternal health and nutrition communities and services
“We don’t tend to look at maternal nutrition and its impacts on the woman herself,” said Girard. The lack of data on the relationship between nutrition and maternal health outcomes “hampers our ability to move maternal nutrition onto the health and development agenda,” she added.“Anemia is widespread; worldwide, it is a significant public health burden, both in women of reproductive age as well as in pregnant women,” said Girard. Studies have shown that moderate anemia increases risk of hemorrhage and may also increase the risk of sepsis, while severe anemia has been shown to directly contribute to maternal mortality. Targeted interventions can help reduce these risks greatly. “For every one gram per deciliter increase in hemoglobin level, you can reduce maternal mortality by approximately 25 percent, but the mechanisms by which this occurs are not well elucidated,” noted Girard.
“We need to include women not as just targets of nutritional interventions, but as beneficiaries in their own health,” said Girard. Key nutritional interventions such as micronutrient supplementation, fortification, and behavior change communication can help to improve not only fetal, infant, and child health, but can also reduce maternal morbidity and mortality. In addition, Girard recommended the following strategies to achieve greater impact:
Together, these strategies can help improve access to nutrition and health services, as well as adequate food for women throughout their lives. “We need to integrate health and nutrition – they are actually the same pillar, complementing each other,” Girard concluded.- Improve nutrition throughout the life cycle, not just during pregnancy
- Look for alternate strategies for micronutrient delivery
- Integrate maternal nutrition into food security and agricultural strategies
- Collect indicators specific to women’s health impacts
- Recognize and address gender bias
Photo Credit: “Bangladesh mothers, kids,” courtesy of flickr user Bread for the World. -
Watch: Joel E. Cohen on Solving the Resource-Population Equation in the Developing World
›December 14, 2010 // By Wilson Center Staff“It’s very hard to put a number on a quantity that depends on future events, processes we don’t understand, and values that may change over time,” said Joel E. Cohenof the Rockefeller University in this interview with ECSP. “That doesn’t mean we have no problems and it doesn’t mean there’s nothing we can do.”
There are three schools of thought or proposed “panaceas,” when it comes to balancing natural resources and population, said Cohen: a bigger pie (new technology to increase productivity), fewer forks (reduced consumption), and better manners (reduced irrational market inequities and better governance).
In the 15 years since his book How Many People Can the Earth Support? was published, Cohen’s approach has changed. While the 1996 book lacked a definitive policy recommendation, he is now analyzing options. “The evolution of my thought has moved from ‘how many people can the Earth support?’ to ‘what do we need to solve problems?’” he said.
You need adequate child and maternal nutrition to produce potential problem solvers and you need education to give them the tools to do it with, said Cohen, who studied the impact of universal primary and secondary education with colleagues at the American Academy of Arts and Sciences.
“If you look at a map of stunting in the world, there are parts of South Asia and sub-Saharan Africa where more than half the children are stunted – that means two standard deviations [of] height below normal for their age,” said Cohen. “Those populations are handicapped at the starting gate because they don’t have the problem solvers.” -
An Integrated Climate Dialogue
COP-16 Cancun Coverage Wrap-up
›December 13, 2010 // By Schuyler NullAfter focused last-minute negotiations, the UNFCCC COP-16 parties meeting in Mexico finally reached an agreement on a package being called “The Cancun Agreements” on Saturday. One of the most important impacts of the agreement (also referred to as the “balanced package”) is the establishment of a green climate fund which will help developing countries adapt to and mitigate the effects of climate change.
For more on the green fund as well as the integration of gender, population, development, and even a little bit of security in the broader climate dialogue, see The New Security Beat’s coverage of Cancun below.- Interview with Karen Hardee: Climate-Proofing Development
- Pop Audio: From Cancun: Roger-Mark De Souza on Women and Integrated Climate Adaptation Strategies
- Guest Contributor Alex Stark: From Cancun: Getting a Climate Green Fund
- The Number Left Out: Bringing Population Into the Climate Conversation
Kicking off our coverage was an email interview with Karen Hardee, visiting fellow with the Population Reference Bureau, on “climate-proofing” development. Hardee gives a brief overview of the UN National Adaptation Programmes of Action system and the current state climate adaptation integration in international development. She points out that one of the enduring positives from COP-15 was a renewed focus on financing tools that has permeated to the top levels of the UN.
Hardee also touched on the nascent but largely unfulfilled connection between population growth and resilience, noting that “of the first 41 programs submitted to the UNFCCC…37 noted that population growth exacerbated the effects of climate change, but only six explicitly stated that meeting an unmet demand for RH/FP should be a key priority for their adaptation strategy and only two proposed projects that included RH/FP.”
Next, Population Action International’s Roger-Mark De Souza was kind of enough to speak with us briefly over the phone from the conference itself, providing a run-down on a PAI-sponsored side event focusing on empowering women in climate debates.
“When you look at the negative impacts of climate change, the impacts on the poor and the vulnerable – particularly women – increase, so investing in programs that put women at the center is critical,” De Souza said.
Leaving gender issues, like child and maternal health and education, out of deliberations like those COP-16 are missed opportunities to get more “power for your peso,” he said.
Alex Stark, formerly of CNAS and now with the Adopt a Negotiator program in Cancun, provided an update and a strong argument for one of the most critical elements of the “balanced package” that many are hoping will come out of Cancun – the establishment of an international fund to help pay for adaptation and mitigation programs in developing countries.
Stark provides an insight into some of the chatter on the floor at COP-16 and also outlines the moral, development, and security advantages to supporting a green fund, pointing out that “by managing displacement, migration, and violent conflict driven by the effects of climate change, such as water scarcity, climate change adaptation can help bolster international security and stability.”
“Within the UN process itself,” she writes, “a robust, well-run, equitable green fund would help rebuild the trust lost between developed and developing countries at Copenhagen last year.”
Lastly, Bob Engelman, of the Worldwatch Institute, provides a broad argument for more inclusion of a key variable in climate debates – population (and not in the Ted Turner mold). He enumerates the common pitfalls of population debates, from sensitivities about personal choices to squeamishness about sexuality and reproductive health, and just plain gender bias.
But despite these barriers, says Engelman, population – and not just growth but demographics too – matters in the climate debate and therefore needs to be part of the conversation (an argument he makes more comprehensively in a new report, Population, Climate Change, and Women’s Lives). Echoing De Souza, he concludes by pointing out that although the discussion may be difficult, the solution is relatively simple: “On population, the most effective way to slow growth is to support women’s aspirations.”
“As societies, we have the ability to end the ongoing growth of human numbers – soon, and based on human rights and women’s intentions,” Engelman said. “This makes it easy to speak of women, population, and climate change in a single breath.”
Sources: Population Action International, Slate, UN Framework Convention on Climate Change, The Washington Post, Worldwatch Institute.
Photo Credit: Adapted from “Trees Dead on Shore of Timor-Leste Lake,” courtesy of flickr user United Nations Photo; Roger-Mark De Souza, courtesy of David Hawxhurst/Wilson Center; “Will you back a climate fund?,” courtesy of flickr user Oxfam International; and “Met Office Climate Data – Month by Month (September),” courtesy of flickr user blprnt_van. -
Expanding Access to Maternal Health Commodities
›“This is not just about getting quantities of drugs out, this is about saving women’s lives with really simple products that work,” said Julia Bunting, team leader of AIDS and reproductive health at the UK Department for International Development and coalition chair of the Reproductive Health Supplies Coalition, at the ninth meeting of the Global Health Initiative’s 2009-2010 Advancing Policy Dialogue on Maternal Health series. Joined by panelists Melodie Holden, president of Venture Strategies Innovations (VSI), and Elizabeth Leahy Madsen, senior research associate at Population Action International (PAI), the panel discussed the challenges and strategies for expanding access to maternal health commodities.
Integrating Maternal Health and Family Planning Supply Chains“It is often said that the family planning and the maternal health communities have very different views of supplies… but actually [both communities] recognize that we need to explore the continuum,” said Bunting, addressing the need to integrate maternal health commodities into existing reproductive health supply chains. “I really think the stars are aligned right now for advancing this agenda,” added Bunting.
“Many of the commodities that we talk about in terms of reproductive and maternal health cost tiny amounts to deliver, but actually save lives and are some of the most cost-effective interventions we have both in public health and in broader development,” said Bunting.
No Product, No Program
“Supplies are a key element in programs to improve maternal health and they are also a tangible and visible hook to increase awareness and commitment,” said Madsen. “Policymakers whose eyes glaze over when they hear the term ‘health systems strengthening’ can grasp… much better when they learn that supply shelves in clinics are bare and that women are making great efforts to reach facilities, only to leave empty- handed,” said Madsen.
Presenting research conducted by PAI, Madsen discussed the availability of four key maternal health medicines and products in Bangladesh and Uganda including:
By focusing on supplies that target the three leading causes of maternal mortality, Madsen and her colleagues identified factors that inhibit access to these commodities and developed recommendations for strengthening maternal health supply chains.- Oxytocin: used to prevent post-partum hemorrhage
- Misoprostol: used to prevent post-partum hemorrhage
- Magnesium Sulfate: used to treat pre-eclampsia
- Vacuum Aspirators: used for treatment of early and incomplete abortion
Madsen identified several strategies to strengthen supply chains for maternal health commodities including forecasting and preparing for growing demand, advocating for government and donor support, encouraging scaling-up of community-based approaches, promoting family planning, and focusing on human resource training.
“In maternal health, if a supply to prevent or treat a life-threatening complication is in stock, there must also be a way for a woman to reach it in time… and in most cases a provider who knows how to administer it,” said Madsen.
“This research is intended to lay the groundwork for future advocacy and policy initiatives by providing an evidence base that is informed by local expertise,” said Madsen. “We hope that this information will inform program implementation, funding decisions, and awareness raising.”
Getting the Product to People: The Case of Misoprostol
“The story of Misoprostol is still being written. The goal is to invest in creating access to interventions that are low-cost and relatively simple to use,” said Holden. By sharing lessons learned, Holden described VSI’s experience registering and procuring Misoprostol and demonstrated how community mobilization is imperative to overcoming major challenges for large-scale implementation.“Making products available is not without challenges,” said Holden. To increase access to Misoprostol in rural communities, maternal health experts must work to “engage communities, educate and mobilize women, train providers at all levels of the health care system, and provide support to distributors to jump start sales,” said Holden. “By looking holistically across entire health systems, bringing in great interventions, addressing the components of supply and demand, and working with local partners, we can have lasting impact.”
While the price of Misoprostol has decreased significantly, Holden stressed the need to identify creative ways along the supply chain that reduce costs to the end user. Additionally, “establishing policies around this new intervention not only establishes its reach, but also makes its use institutionalized, which means it will be part of the system even if governments or individuals change,” said Holden.
“If there is a gap between what could be achieved with Misoprostol and what is being achieved, we need to go back to the model and figure out what pieces aren’t working,” concluded Holden. “The work is complex and takes time, but it’s worth it.”
Photo Credit: “Rapid HIV testing,” courtesy of flickr user DFID – UK Department for International Development.
