Joel Cohen, a renowned population expert and professor at Columbia and Rockefeller universities, recently gave a lecture simply titled “Meat.” As it was co-sponsored by the International Food Policy Research Institute and the Population Reference Bureau, I was hoping for an insightful discussion of meat eating and its implications for feeding a world of nine billion. While I think Cohen avoided the question of whether meat eating is ultimately sustainable, I was pleased that he included two key insights: the potential for family planning services to contribute to food security, and the importance of using multidisciplinary approaches to solve today’s global problems.

Family Planning for Food Security

In working to improve food security, Cohen said policymakers and practitioners need to focus on those who are most vulnerable. To this end, he identified five groups and suggested targeted policies for each:

While the healthy eating policies will not surprise food security experts, his recommendations on family planning might. He highlighted what should be–but is not always–apparent: that tackling food security without thought for family planning is like attempting to fill an empty bucket without first plugging the holes.

Feeding the one billion hungry people in the world today is an enormous challenge that cannot be met by any single policy. Instead, it will take an array of partial solutions, and offering family planning services to women and young people is an important part of the package. Such projects can help reduce the number of children being born into hunger by allowing women and couples to assess their economic and food situations and plan according to their needs and wishes. Voluntary family planning services and materials will not solve the food security challenge on their own, but they can make it more manageable, especially in the long run.

Family planning’s potential contribution to food security is just one part of Cohen’s larger take-home message: population, economics, environment, and culture all interact. To meet today’s multidisciplinary challenges, single-sector approaches are not up to task.

The Many Faces of Meat

Cohen offered two competing perspectives on meat eating. On the one hand, average global meat production generates a fraction of the calories and protein, per unit of land, that could be derived from plant sources. It is likely the “largest sectoral source of water pollution,” said Cohen, and is at least partly responsible for the spread of over a dozen zoonotic diseases. It contributes to only 1.4 percent of world GDP while comprising 8 percent of world water consumption.

These hidden “virtual water” costs made headlines in Britain the other week, when a study on global water security published by the Royal Academy of Engineering popularized the Water Footprint Network’s earlier findings that that an average kilogram of beef requires 15,500 liters of water–over eight times the volume needed to produce the equivalent weight in soybeans and greater than 10 times that needed for the equivalent amount of wheat.

On the other hand, Cohen pointed out that meat production provides livelihoods for an estimated 987 million of the world’s rural poor, and has important cultural significance in many societies. And it can provide many essential nutrients, even in small doses.

In one study he cited, children living in Kenya who were provided 1 ounce of meat a day received 50 percent of their daily protein requirements and showed greater increases in physical activity and development, verbal and arithmetic test scores, and initiative and leadership behaviors as opposed to students who received the calorie-equivalent in milk or fat.

The Four Factors: Population, Economics, Environment, and Culture

Clearly, Cohen’s four factors all come in to play when evaluating meat’s role in food security. An analysis of any global health issue that looks at only one factor would miss indispensable parts of the problem.

“Population interacts with economics, environment, and culture,” Cohen concluded. “If you use that checklist when somebody gives you a simple-minded solution to a problem, you can save yourself a lot of simple-minded thinking.”

Photo: Pigs on a farm, courtesy Flickr user visionshare.

Media reports on the neglected discussion of maternal and child health often focus on the problems and projects in sub-Saharan Africa or South Asia, which is understandable, as a disproportionate 90 percent of global maternal deaths occur in these two regions. Last month, however, PBS correspondent Ray Suarez reminded us that maternal and child mortality affects countries all over the world, including Peru, where “maternal death rates has historically been unusually high,” he noted in a report for NewsHour. 

“Few people in the highlands of central Peru own automobiles and it’s hard to know exactly when the next bus is going to rumble by,” said Suarez. “Villagers are a long way from the nearest health clinic, even further from a fully equipped clinic.” Unfortunately, this scene could describe most developing countries struggling to reach the Millennium Development Goal (MDG) 5 target of reducing maternal deaths by 75 percent by 2015. Maternal health advocates argue that MDG 5 does not require a cure, but rather increased political willpower.

“Health officials, obstetricians, nurses, and community activists looked for ways to make better use of existing resources and connect expecting mothers with them,” said Suarez, reporting from the remote town of Vilcashuaman. At the Casa Materna, or “mother’s house,” nurses plot on a felt, bulls-eye map the names, due dates, geographical proximity, and travel times of pregnant women in nearby villages. Utilizing two-way radio communication, Casa Materna stays in contact with these remote villages and can signal the regional hospital, hours away in Ayacucho, for ambulance assistance for women needing emergency obstetric care.

Delivery teams at the Ayacucho hospital are familiar with indigenous languages and cultures, and welcome traditional practices, such as displaying herbs and giving figurines to new mothers. “The medical professionals in the area know bringing delivering mothers to the hospital can mean the difference between life and death and are prepared to be as accommodating as possible to lure women from home delivery,” reports Suarez. In the Ayacucho district, maternal mortality rates have decreased by 50 percent in five years.

While Suarez said “cultural competence, a welcoming atmosphere, and low-cost, high-result treatment strategies” may seem “pretty smart and straightforward,” it is important to evaluate the regional health system at a larger level, and consider additional factors, such as access to family planning, that may have contributed to Ayacucho’s success in reducing maternal mortality.

Another part of the solution is improving transportation and referral strategies, but increased research is needed to evaluate best practices and scalability of programs such as the one in Ayacucho. On May 19-20, as part of the Maternal Health Dialogue Series, the Wilson Center’s Global Health Initiative will host a two-day conference on “Improving Transportation and Referral for Maternal Health.” Speakers working on transportation and referral strategies in Bolivia, Ghana, and India will share their experiences and best practices.

Calyn Ostrowski is the program associate for the Wilson Center’s Global Health Initiative.

Photo Credits: Mothers in Peru learn to identify risk factors during pregnancy. Courtesy of Flickr user International Women’s Health Coalition

“The Canadian government should refrain from advancing the failed right-wing ideologies previously imposed by the George W. Bush administration in the United States, which made humanitarian assistance conditional upon a ‘global gag rule’ that required all non-governmental organizations receiving federal funding to refrain from promoting medically-sound family planning,” said the Canadian Liberal Party about the country’s Conservative government in a Parliamentary motion last week.

Though Prime Minister Stephen Harper had pledged to include a voluntary family planning initiative in Canada’s foreign aid plan at last year’s G8 meeting in Italy, the Conservative government recently said that the initiative will not be part of its G8 plan at the upcoming meeting in Canada this June.

This move has surprised both Canadians and Americans. U.S. President Obama overturned the Mexico City policy last year, and has fully supported the inclusion of family planning methods as part of foreign aid.

Harper’s government has maintained that maternal and child health services, such as vaccinations and nutrition, will be a priority, but various components of family planning, including birth control and abortion, will not be included in the Canadian initiative.

The Tories, as along with three Liberal MPs, voted down the Liberal motion 138-144, which requested clarification of Harper’s maternal health initiative and pushed for the inclusion of the full range of family planning options. The Tories focused solely on what they called “anti-American rhetoric” in the motion, which drew attention away from the divisive issue of abortion.

The issue has got caught up in domestic Canadian politics, with opposition Liberals trying to equate the Conservatives with the George W. Bush administration and the Conservatives trying to avoid discussion of intra-party debates on the contentious issue of abortion.

Now it seems likely like that Harper will go to the G8 summit in Ontario with a foreign aid plan for maternal health that makes no reference to issues of contraception. According to Canada’s International Co-operation Minister Bev Oda, “saving lives” of women and children is a higher priority than family planning.

But most international maternal health advocates don’t agree. “Maternal mortality rates are high among women who do not have access to family planning services. Contraception can reduce the number of unplanned pregnancies,” said Calyn Ostrowski, program associate for the Wilson Center’s Global Health Initiative. “For example, at a recent event on our Maternal Health series, Harriet Birugni of the Population Council in Kenya described how integrating reproductive health services such as family planning can reduce maternal mortality rates, particularly for poor young women who have the least access to contraception.”

In response to Canada’s announcement, U.S. Secretary of State Hilary Clinton said that the United States will be promoting global health funding, including access to contraception and abortion, at the G8. “You cannot have maternal health without reproductive health,” she said during a news conference with other G8 ministers. Britain has also agreed with this position, which has led Canadian Liberal Party Leader Michael Ignatieff to say that Canada’s G8 position goes against the international consensus.

Laura Pedro is the program assistant for the Canada Institute, and a graduate of the University of Vermont.

Photo.: Prime Minister Stephen Harper, courtesy Flickr user Kashmera

“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 conference also made a splash in the media. “If you want it to get a lot of media hype, you have to have someone ready to say ‘I’m giving money to X,’” said Tsui. Thus, the Johns Hopkins Bloomberg School of Public Health, David and Lucile Packard Foundation, USAID, and the Bill and Melinda Gates Foundation announced a new three-year, $12 million Advance Family Planning project to advance reproductive health and family planning efforts in regions with the greatest need—particularly, sub-Saharan Africa and Asia. The conference generated palpable excitement and renewed energy for family planning. Uganda was “an event that happened at the right time,” said Tsui. Conference organizers, who have been asked to replicate it in other parts of the world, are already looking for locations for 2011. The conference was not just a success in theory, but also in action, and several developments emerged in its wake:

• 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 Move

Rhonda 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.

In Nigeria, West African ministers of health agreed that making abortion safe was essential to reducing maternal mortality. Across the board, at each meeting, family planning was discussed as “an investment, not an expenditure,” said Haile.

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.

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.

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.”

“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.”

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.

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