Showing posts from category maternal health.
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Maintaining the Momentum: Highlights From the Uganda International Conference on Family Planning
›“Family planning is to maternal survival what a vaccination is to child survival,” said Johns Hopkins professor Amy Tsui, quoting Khama Rogo of the World Bank, at the Woodrow Wilson Center event Maintaining the Momentum: Highlights From the Uganda International Conference on Family Planning on March 16. Rogo made the strong statement during the landmark November 2009 conference in Kampala, which has renewed interest in family planning and reproductive health among African leaders and development partners. Rhonda Smith of the Population Reference Bureau and Sahlu Haile of the David and Lucile Packard Foundation joined Tsui, the director of The Bill & Melinda Gates Institute of Population & Reproductive Health, to discuss their impressions of the Kampala conference and what it means for the future of family planning in Africa.
“An event that happened at the right time”
“Kampala was the work of a community,” said Tsui. More than 50 organizations—the U.S. Agency for International Development, the UN Population Fund, the World Bank, the World Health Organization, and the Gates and Packard Foundations—convened in Uganda, which was chosen not only for its central location, but also to highlight the country’s soaring unmet need for contraception—41 per cent—and rapid 3.1 percent population growth rate.Panels focused on key issues in family planning, including:- Integrating family planning into HIV/AIDS care
- Integrating family planning in post-abortion, postpartum, child, and other primary health care
- Expanding contraception delivery services by community health workers
- Increasing outreach to youth and men
- Capitalizing on private and public innovations in service delivery and financing
- The United States announced its foreign assistance budget will increase support for family planning from $450 million to $715 million for the next fiscal year.
- The Global Health Initiative identified maternal/child health and family planning as one of its main priority themes.
- Secretary of State Clinton positively discussed girls’ education, family planning, and reproductive health at the ICPD + 15 anniversary.
- The Women Deliver 2010 Conference, to be held in June, has identified family planning as a third pillar of maternal health.
Uganda on the MoveRhonda Smith’s presentation “Uganda on the Move”—which she also presented in Uganda—is a prototype of the Population Reference Bureau’s new ENGAGE (Eliminating National Gaps—Advancing Global Equity) project, which is designed to “engage policy audiences and promote policy dialogue around issues of high fertility and high unmet need for family planning and their costs, consequences, and solutions,” she said. By using stunning, innovative graphics and avoiding confounding technical terms, ENGAGE’s products are designed to reach non-technical policy audiences and influential decision-makers.
As one of the Uganda conference’s most talked about presentations, “Uganda on the Move” wows audiences with visuals created using Hans Rosling’s Trendalyzer software. The presentation shows that although Ugandans are increasingly healthier, have a higher life expectancy, and are more educated, maternal health remains in jeopardy. Tellingly, 46 percent of pregnancies in the country are unplanned, 6,000 women die each year from complications related to pregnancy, and 1,200 women die each year from undergoing unsafe abortions.
Maternal deaths, however, do not tell the whole story: For every one woman dying, Smith said, 20-30 women suffer from short-term disability, which places a major strain on economic growth. From 2004 to 2013, maternal death will cost Uganda US$350 million in lost productivity; and disability will cost and additional US$750 million.
What Next? The African Perspective“After 10 years of virtual clandestine work, [family planning] is just coming out of the closet,” said Sahlu Haile. Over the last few decades, family planning advocates have been struggling to: 1) keep family planning alive—without it being affected by political considerations 2) make family planning a health priority, without any associations with rights violations; and 3) be in solidarity with pioneering organizations of the family planning movement, like the International Planned Parenthood Federation, that were victims of discriminatory funding decisions.
The Uganda conference changed all that, said Haile. In Uganda, conference attendees were “talking about family planning…not reproductive health, not maternal/child health.” This, he said, was “probably the single most important lesson…that I took from the Kampala conference.”
Following the conference, Haile said that African government officials stressed family planning as a priority at meetings in Ethiopia and Nigeria—the first time he had witnessed such high-level attention to family planning from those countries in his 30-year career.
In Ethiopia, African leaders pledged to:- Prioritize family planning, since family planning is one of the most cost-effective development investments;
- Ensure access to contraception, as 40 percent of maternal deaths are associated with unwanted pregnancies; and
- Integrate MDG 5b, universal access to reproductive health, into their international development plans and budgets.
Haile credited the Kampala conference for spurring these efforts. In December, he joined a task force of 14 Ethiopian organizations to plan the next steps. They will jointly develop research capacities, generate evidence, and strengthen monitoring and evaluation practices, especially with regard to integrating population, health, and environment efforts. In addition, they will engage with wider audiences via new tools such as the blog RH RealityCheck and Gapminder Foundation’s Trendalyzer program.
Haile believes we need to “work together to encourage national-level efforts…to make sure family planning stays where it is now and make sure it is not abandoned.”
To be a part of the new online family planning community, join the Kampala Conversation.
Photo 1: A women and her children in Jinja, Uganda. Courtesy Flickr user cyclopsr. Photos of Amy Tsui, Rhonda Smith, and Sahlu Haile courtesy of Dave Hawxhurst, Woodrow Wilson Center. -
Maternal and Newborn Health as a Priority for Strengthening Health Systems
›Among the many initiatives that have recently been launched to strengthen health systems in the developing world, there is little consensus on execution. Traditional strategies for improving the health system, such as the vertical approach, which prioritizes communicable diseases, or the horizontal approach, which prioritizes non-communicable diseases, are limited in scope and fail to include a comprehensive gender lens.
To overcome the shortcomings of these two health financing approaches, the “diagonal” strategy combines them by “clearly defining priorities and utilizing these priorities to drive general improvements of the health system,” said Julio Frenk, dean of the Harvard University School of Public Health, at the Global Health Initiative’s third event in the “Advancing Policy Dialogue on Maternal Health” series.
Along with panelists Helen de Pinho of Columbia University, and Agnes Soucat of the World Bank, Frenk discussed how prioritizing key maternal health indicators can improve health systems and support the implementation of evidence-based interventions.Putting Women and Health First
Drawing on his experience as Mexico’s minister of health, Frenk said that clearly defining a set of priorities grounded in “women and health” drove the improvement of Mexico’s health system. “Picture three concentric circles. The core of these concentric circles is the prevention of maternal mortality and disability; the second circle [includes] other aspects of sexual and reproductive health in addition to pregnancy and delivery; the third circle includes other fundamental areas of women’s health and the intersection of women with the health system,” said Frenk.
Mexico used maternal mortality rates to measure quality of care and rectify weaknesses in the health system. “Every maternal death triggered an audit that could lead to a hospital losing its license to operate,” said Frenk. Additionally, these audits helped to identify gaps and prioritize investments in “equipment and supply of drugs…and networks [for] obstetric emergencies,” he added.
“This illustrates how you can take a specific set of priorities and drive them through,” argued Frenk. “Global health needs to get out of the traditional confines that have split the community between vertical and horizontal and adopt more integrated frameworks like the notion of women and health,” he said, which “will leave behind a better health system to deal with the next challenge.”
Measuring Maternal Health
The maternal health community agrees that to reduce maternal mortality rates, access to emergency obstetric care (EmOC) must be improved. “A simple assessment of an emergency obstetric care facility combines a number of aspects that are core to strong health systems,” said de Pinho. To reduce maternal mortality, a strong health system must be able to positively answer these key questions:
These questions monitor the availability, utilization, and quality of care, which signals whether “the health system is actually responding to the woman’s needs when they need it,” said de Pinho. These maternal health indicators “paint a picture for where next steps need to be taken,” she said.- Are there enough facilities providing EmOC and are they well distributed?
- Are women with obstetric complications using these facilities?
- Is the quality of the EmOC services adequate?
Rwanda’s Innovations in Health Financing
“When we talk to ministries of health we ask them what are the low-hanging fruits we can reach in the six years” until the deadline for meeting the Millennium Development Goals (MDGs), said Soucat. To implement methods with proven results, additional research data, monetary support, and political will are all necessary. Rwanda’s ministry of health used the health-related MDGs—particularly MDG 5 to reduce maternal deaths by 75 percent—to reform the health system and hold institutional and individual actors accountable.
Rwanda’s health system was reformed through five key pillars:
“The heart of the reform is to increase accountability to its citizens,” said Soucat. Rwanda’s results-based financing offered “incentives and salary supplements to workers who saw more patients and provided higher quality of care,” she said. Impact assessments demonstrate that all income groups in Rwanda benefited from this health care scheme; in three years family planning tripled and assisted deliveries increased by 13 percent –“something that has never been observed in Africa,” she said.- Fiscal decentralization increased community participation and allocated funds to district governments
- Performance contracts were established between the president and district mayors
- A performance-based financing system distributed money to health facilities based on results
- Community health insurance increased access and reduced out-of-pocket expenditures
- Autonomous health facilities were allowed to hire and fire personnel
Rwanda’s Ministry of Health conducted rigorous assessments to ensure quality services and demonstrate impact to the Ministry of Finance. “When talking about maternal health a strong dialogue between the Ministry of Health and Ministry of Finance is needed more than ever and centered around the production of results,” argued Soucat. Scaling up the results-based finance scheme in other African countries is possible, she said, but additional research is needed to better understand this scheme at the decentralized level. -
Family Planning and Reproductive Health
›Adding it Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, a report by the Guttmacher Institute, asserts that “sustained and increased investment in sexual and reproductive health services in developing countries” would “contribute to economic growth, societal and gender equity, and democratic governance.” The report presents cost-benefit analyses of family planning and maternal and newborn health strategies in an effort to “guide decision makers, at the global, regional and country levels, in making investments that would reap the greatest returns for individuals and societies.”The Interagency Gender Working Group recently released Gender Perspectives Improve Reproductive Health Outcomes: New Evidence, argues for the importance of taking gender into consideration when developing interventions related to unintended pregnancies, maternal health, STIs, harmful practices (e.g. early marriage, genital cutting, and gender-based violence), and youth. The report, a follow-up to 2004’s The “So What?” Report: A Look at Whether Integrating a Gender Focus into Programs Makes a Difference to Outcomes, includes 40 specific examples of programs successfully integrating gender to improve reproductive health. -
VIDEO—Pape Gaye: Improving Maternal Health Training and Services
›February 12, 2010 // By Julia Griffin“Training is probably one of the biggest interventions in terms of making human resources available,” says Pape Gaye, President and CEO of IntraHealth International, to ECSP’s Gib Clarke in this interview on improving maternal health services in developing countries. “Unfortunately, there are a lot of problems associated with training.”
Gaye says obstacles to scaling up maternal health services in rural areas include employee gender inequalities, poor coordination of supplemental training, and a tendency to only offer in-service training in urban areas. Properly emphasizing pre-service education, he underscores, could remedy some of the problems associated with service provider training.
Increasing retention of medical practitioners is also critical to improving maternal health services in developing countries, Gaye explains. In his experience, however, attempts to address perceived security and financial compensation inadequacies produced mixed results. Instead, Gaye suggests that positive recognition may be one of the best methods for retaining health care workers. “We’re seeing some very good successes in places where we have just simple ways to recognize the work… because if people feel valued in a community, then they are likely to stick it out.” -
Point of View: Investing in Maternal Health
›Every minute, a woman dies in pregnancy or childbirth. But the overwhelming majority of these more than 500,000 deaths a year are avoidable.
“We know how to save women’s lives, we don’t need a cure…this is a political problem and political will is essential,” said Theresa Shaver, the director of White Ribbon Alliance.
Addressing longstanding issues like political will could jumpstart progress toward Millennium Development Goal 5, which seeks to reduce maternal deaths by 75 percent by 2015. We face daunting challenges, but there are some clear steps we can take to meet this critical goal. We must strengthen health systems in the developing world.Increasing women’s access to quality health services during pregnancy, and ensuring they are attended by skilled providers during childbirth, can help to reduce preventable causes of death, such as hemorrhage, pre-eclampsia, and obstructed labor—which together account for 80 percent of maternal deaths.
Scaling-up family planning services are a cost-effective way of preventing unwanted pregnancies, delaying the age of first pregnancy, increasing the time between pregnancies, and facilitating important relationships between women and health care providers. However, many societal and cultural factors dissuade women and girls from seeking contraception. Culturally sensitive education programs can help overcome this barrier, especially if they include men and local leaders, in addition to women and girls.
We should recognize that improving the well-being of mothers is inseparable from the health of newborns. Efforts to reach Millennium Development Goal 4, reducing under-5 mortality by two-thirds, are integral to improving maternal health. Skilled birth attendants could decrease both maternal and child mortality.
In the United States and abroad, momentum is growing to make the investment necessary to scale up these interventions. In January, Secretary of State Hillary Clinton renewed a commitment of $63 billion for the Obama Administration’s Global Health Initiative, which will include significant resources for maternal and child health.
According to the U.S. Agency for International Development, maternal and newborn deaths cost the world $15 billion a year in lost productivity. Researchers conclude that maternal health services would cost only a $1 per day per woman. That’s a small price to pay for such a high return—saving not only dollars, but also women’s lives.
For more information about maternal health and the Global Health Initiative’s Advancing Policy Dialogue on Maternal Health Series please see this month’s issue of Centerpoint. -
Watch: Harriet Birungi: Challenges Facing HIV-Positive Adolescents in Kenya
›“Services are not necessarily very adolescent-friendly, so when you get children who are HIV-positive they are likely to face discrimination,” says Harriet Birungi, an associate in the Reproductive Health Program with the Population Council in Kenya, in this interview with ECSP’s Gib Clarke following the Global Health Initiative’s Integrating HIV/AIDS and Maternal Health Services panel.
According to Birungi, medical service censoring and targeted exclusion from schools are among the top challenges facing Kenyan adolescents living with HIV/AIDS. She hopes better support systems and intervention strategies, especially for pregnant individuals, will help medical personnel more quickly identify HIV-positive young adults needing critical medical services. -
Human Resources for Maternal Health
›“Pregnancy is not a disease, a woman should not die of pregnancy…it doesn’t need a new drug…it doesn’t need research – we just need skilled workforce at different levels,” argued Seble Frehywot, assistant research professor of Health Policy and Global Health at George Washington University, at the Global Health Initiative’s second event of the Advancing Policy Dialogue on Maternal Health Series.
Research shows that increased access to skilled health workers during pregnancy and delivery, including midwives and other practitioners, can significantly reduce maternal mortality in developing countries. One solution to the current human resource crisis is to expand, and in many cases, acknowledge, the skills and responsibilities of non-physician health workers.
Task-Sharing: Who, What, and How
“There are too many preventable deaths…if we look at the data, quality maternal health services are not available,” argued Frehywot, as she presented the following evidence:
There are four common types, or levels, of task-shifting:- Countries that have the highest maternal mortality rates are those that also have the greatest worker shortage
- In Africa, for every 10,000 births, only 2 physicians and 11 nurses or midwives are present at delivery.
- According to the World Health Organization, there needs to be at least 53 skilled health care workers (nurses, doctors, midwives) per 10,000 births to meet Millennium Goal 5 which seeks to reduce maternal deaths by 75 percent by 2015.
1. Doctors to non-physician health clinicians
“All [task-shifting] needs to be done through a sound regulatory framework…it is very important to match tasks that are needed at the ground level with the competency needed to back it up,” maintained Frehywot. Regulatory issues such as the scope of practice, standard of care, training, licensure, and supervision must be addressed to ensure safe and high-quality treatment. Additionally, political buy-in and commitment from the Ministry of Health, medical universities, and professional councils and associations are necessary for long-term development, argued Frehywot.
2. Health clinicians to registered nurses and midwives
3. Nurses/midwives to community health care workers
4. Community health care workers to expert patients
Policies for scaling-up human resources should start at the district level, as these localized hospitals are geographically closest to the need, argued Frehywot. “If one really wants to decrease the maternal mortality ratios, especially by 2015, this is where most of the people live.”
Applying Task-Shifting in Afghanistan“Maternal mortality ratios in Afghanistan are the second highest in the world,” declared Jeffrey Smith, regional technical director for Asia at Jhpiego. In 2002, when Smith arrived in Afghanistan, there were limited health workers, most with out-of-date skills, and no functional schools for training. “The most important decision made early in the reconstruction [of] Afghanistan was that midwives would be the backbone of the reproductive health workforce and they would be empowered with the skills to perform the tasks necessary for provision of basic emergency obstetric care,” shared Smith.
Making the case for task-shifting, Smith discussed the importance of empowering health workers on the front line so that they may provide services in the most peripheral areas. “Task shifting should not be a temporary fix until we have more doctors,” argued Smith, as this framework disenfranchises a cadre of health workers and fails to build long-term solutions for human resources. Instead, Smith advocated for the “Health Center Intrapartum Care Strategy” that makes midwives the foundation of care and includes strategies for training, staffing, and linkages to the overall health system.
In this post-conflict setting, task-shifting began as an emergency approach. However, it rapidly became a development strategy for professionalizing the workforce and rebuilding the health system. Afghanistan’s Ministry of Public Health was imperative to the success of scaling up midwives as they clearly defined from the beginning what was needed and who would provide care, taking steps to ensure that the midwifery schools maintained legitimacy and received formal accreditation.
“Keep it clinical and keep it local,” shared Smith. The midwifery schools made efforts to recruit individuals from the provincial level, teaching specific life-saving skills applicable in the field. This framework has successfully retained 86% of its graduates, and many of the women report that the program has provided them with a sense of community and ownership.
Building a Sustainable Health Workforce“We invite the maternal health community to take advantage of the incredible momentum that human resources for health is having right now,” shared Pape Gaye, president and CEO of IntraHealth. While there are many issues within the health system that need to be strengthened, Gaye maintained that “we must pick our battles” and advocated for an emphasis on scaling-up the training and availability of midwives.
In order to scale-up midwives for maternal health we must avoid the same old traps, particularly the lack of donor coordination shared Gaye. “If we do a better job of improving coordination we will start solving the problem.” Additionally, Gaye discussed the implications for training generation “Y,” emphasizing the importance of including new technologies available for training, including PDA’s and e-learning courses.
Performance outcomes and training are the two key pillars of effective scale-up, shared Gaye. Task-shifting also requires legal support and the endorsement from medical associations to help legitimize this new health system framework. “This is not simple work; you really need to have a systems approach. What we seek in the end is good integration. Integration across systems, integration across roles, courses, learning processes, and training for maximum adaptability,” shared Gaye. -
Welcome Back, Family Planning
›January 8, 2010 // By Gib Clarke“When women and girls have the tools to stay healthy and the opportunity to contribute to their families’ well-being, they flourish and so do the people around them,” Secretary of State Hillary Clinton declared today in a speech renewing U.S. support for universal access to reproductive health services and supplies around the world. “Investing in the health of women, adolescents, and girls is not only the right thing to do; it is also the smart thing to do.”
Introduced by Melanne Verveer, the first ever ambassador-at-large for global women’s issues, Clinton’s much anticipated statement marked the 15th anniversary of the International Conference on Population and Development (ICPD) and reconfirmed a U.S. commitment to meeting Millennium Development Goals 4 (reducing child mortality) and 5 (reducing maternal mortality and increasing the proportion of births attended by skilled health personnel). Reproductive health and development luminaries Nafis Sadik, UN Foundation President and former Senator Tim Wirth, and newly installed USAID Administrator Rajiv Shah were also in attendance.
Clinton began with a look back to the ICPD—which she called the “first ever global forum that recognized the connection between women’s health, the quality of women’s lives, and human progress on a broader scale”—and the progress since. Declaring that “we have made measurable progress since 1994 in improving the health and the lives of women and children, especially girls,” she cited a number of improvements, including higher child survival rates, use of modern contraceptives, and female education enrollment.
Switching from the past to the present, Clinton described how women and girls continue to bear the brunt of a variety of social ills: they have higher rates of poverty, illiteracy, and malnutrition, and are the most adversely affected by conflict, “from the Congo to Bosnia to Burma.”
After reciting the data on unsafe abortions, STDs and HIV/AIDS, fistulas, and female genital cutting, she declared that “these numbers are not only grim…they are intolerable.” She added, “We can not accept it morally, politically, socially, economically.”
But Clinton’s remarks were not solely focused on health and family planning issues. Echoing arguments made by Nicholas Kristof and others, Clinton described how women’s health and women’s rights directly and significantly impact most major problems in the world, including economics, natural resource conflicts, and national security.
These challenges will require sustained effort and funding, said Clinton, adding that the Obama Administration’s $63 billion Global Health Initiative would address the health challenges of HIV/AIDS and maternal and reproductive health in an integrated manner. All of the administration’s programs would seek to help countries strengthen their own health systems to meet their unique needs—both of their women and girls, but also their populations in general. In all of these efforts, she said including men and boys as “advocates and allies” remains important.
Praise for the speech has been swift—a letter of commendation from a number of foundations was sent to the secretary immediately afterwards.
Maternal and reproductive health have experienced elevated and perhaps unprecedented funding and attention in recent years, especially over the last few months. Secretary Clinton’s impassioned speech is almost certain to keep this momentum alive.
Photo: Courtesy SEIU International
Putting Women and Health First
The 
Every minute, a woman dies in pregnancy or childbirth. But the overwhelming majority of these more than 
“Pregnancy is not a disease, a woman should not die of pregnancy…it doesn’t need a new drug…it doesn’t need research – we just need skilled workforce at different levels,” argued Seble Frehywot, 
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“We invite the maternal health community to take advantage of the incredible momentum that human resources for health is having right now,” shared Pape Gaye, president and CEO of IntraHealth. While there are many issues within the health system that need to be strengthened, Gaye maintained that “we must pick our battles” and advocated for an emphasis on scaling-up the training and availability of midwives.
“When women and girls have the tools to stay healthy and the opportunity to contribute to their families’ well-being, they flourish and so do the people around them,” Secretary of State 
