Walif was only 16 and his younger sister, Nassim, just 11 when their mother died in childbirth in Butajira, Ethiopia.
Both Walif and Nassim had been promising students, especially Walif, who had hoped to score high on the national civil service exam after completing secondary school. But following the death of their mother, their father left them to go live with a second wife in the countryside. Walif dropped out of school to care for his younger siblings, as did Nassim and two other sisters, who had taken jobs as house girls in Addis Ababa and Saudi Arabia.
Nassim was married at 15, to a man for whom she bore no affection, so that she would no longer be an economic burden to the family. By the age of 17, she already had her first child. Seven years after his mother died, Walif was still caring for his younger siblings, piecing together odd jobs to pay for their food, although he could not afford the school fees.
In all, with one maternal death, four children’s lives were derailed, not just emotionally but economically.
More than 1,000 miles away, in the rural Nyanza province of Kenya, a woman in the prime of her life died while giving birth to her seventh child, leaving a void that her surviving husband struggled to fill. He juggled tending the family farm, maintaining his household, raising his children and keeping his languishing newborn son alive.
But he didn’t know how to feed his son, so he gave him cow’s milk mixed with water. At three months old, the baby was severely malnourished. A local health worker visited the father and showed him how to feed and care for the baby. That visit saved the baby’s life.
The causes and high number of maternal deaths in Ethiopia, Malawi, Tanzania, South Africa, and Kenya — the five countries explored in the research — are well documented, but this is the first time research has catalogued the consequences of those deaths to children, families, and communities.
The studies found stark differences between the wellbeing of children whose mothers did and did not survive childbirth:
Out of 59 maternal deaths, only 15 infants survived to two months, according to a study in Kenya.
In Tanzania, researchers found that most newborn orphans weren’t breastfed. Fathers rarely provided emotional or financial support to their children following a maternal death, affecting their nutrition, health care, and education.
Across the settings studied, children were called upon to help fill a mother’s role within the household following her death, which often led to their dropping out of school to take on difficult farm and household tasks beyond their age and abilities.
How do we use these new research findings to advocate for greater international investment in women’s health?
At a webcast presentation earlier this month, a panel of researchers, reproductive and maternal health program implementers, advocates and development specialists discussed that question.
Central to the discussion was the belief that the death of a woman during pregnancy and childbirth is a terrible injustice in and of itself. The vast majority of these deaths are preventable, and physicians and public health practitioners have long known the tools needed to prevent them. And yet, every 90 seconds a woman dies from maternal causes, most often in a developing country.
The panelists expressed hope that these new data, which show that the true toll of these deaths is far greater than previously understood, can help translate advocacy into action.
It’s important to recognize that, beyond the personal tragedy and the enormous human suffering that these numbers reflect — some hundreds of thousands of women die needlessly every year — there are enormous costs involved as well. -Panelist Jeni Klugman, a senior adviser to the World Bank Group and a fellow at the Harvard Kennedy School of Government.
“So quantifying those effects in terms of [children’s] lower likelihood of surviving, the enormous financial and health costs involved and the repercussions down the line in terms of poverty, dropping out of school, bad nutrition and future life prospects are all tremendously powerful as additional information to take to the ministries of finance, to take to the donors, to take to stakeholders, to help mobilize action,” said Klugman.
Just what does “action” mean? Currently, the countries of the world are debating the new global development agenda to succeed the eight Millennium Development Goals, an ambitious global movement to end poverty. Advocates can use this research to make the case that reproductive, maternal, newborn, and child health should play a central role in this agenda, given that it reveals the linkages between the health of mothers, stable families, and ultimately, more able communities, according to Amy Boldosser-Boesch, Interim President and CEO of FCI.
Panelists also called for more aggressive implementation of the strategies known to prevent maternal mortality in the first place; as well as for the provision of social, educational, and financial support to children who have lost their mothers; and for continued research that outlines the direct and indirect financial costs of a woman’s contributions to her household, and what her absence does to her family’s social and economic well-being.
But action is also required outside of the realm of health care, said Alicia Ely Yamin, lecturer in Global Health and Population at the Harvard School of Public Health and policy director of the FXB Center.
In fact, the cascade of ill effects for children and families documented by this research doesn’t begin with a maternal death. The plight of the women captured in these studies begins when they experience discrimination and marginalization in their societies: “It [maternal death] is not a technical problem. It’s because women lack voice and agency at household, community, and societal levels; and because their lives are not valued,” she said.
Klugman added that this research adds to work on gender discrimination, including issues like gender-based violence, which affects one in three women worldwide.
It’s a tall order: advancing gender equality, preventing maternal, newborn, and child death, and improving the overall well-being of families. But panelists were hopeful that this research can show policy makers, and the public, that these issues are intertwined, and must be addressed as parts of a whole.
As Aslihan Kes, an economist and gender specialist at ICRW and one of the researchers on the Kenya study concluded, this research is “making visible the central role women have in sustaining their households.”
This is an opportunity to really put women front and center, making all of the arguments for addressing the discrimination and constraints they face across their lives. -Aslihan Kes
On October 7, 2014, a panel of experts in maternal health—moderated by Dr. Ana Langer, the Director of the Maternal Health Task Force—gathered at the Harvard School of Public Health to discuss the socioeconomic impact of a maternal death on her family and community. Several studies were summarized and priorities for how to use this research were discussed by the panel and audience at “Women’s Lives Matter: The Impact of Maternal Death on Families and Communities.”
What does the research say?
In many countries around the world, the household is the main economic unit of a society. At the center of this unit is the mother and the work—both productive and reproductive—that she provides for her family. A study in Kenya, led by Aslihan Kes of the International Center for Research on Women (ICRW) and Amy Boldosser-Boesch of Family Care International (FCI), showed great indirect and direct costs of a mother losing her life. This cost is often accompanied by the additional cost and care-taking needs of a newborn. “Once this woman dies the household has to reallocate labor across all surviving members to meet the needs of the household. In many cases that meant giving up other productive work, loss of income, hiring an external laborer, girls and boys dropping out of school or missing school days to contribute [to household work],” shared Kes. In addition, the study done in Kenya determined that families whose mother died used 30% of their annual spending for pregnancy and delivery costs; a proportion categorized by the WHO as catastrophic and a shock to a household.
Similar research was conducted in South Africa, Tanzania, Ethiopia, and Malawi by Ali Yamin and colleagues. In addition to similar socioeconomic findings to those in Kenya, Yamin found that less than 50% of children survived to their fifth birth if their mother died compared to over 90% of children whose mothers lived. An even more dramatic relationship was found in Ethiopia with 81% of children dying by six months of age if their mother had died. In South Africa, mortality rates for children whose mothers had died were 15 times higher compared to children whose mothers survived.
Increasing the visibility of maternal death
While a family is grappling with grief they are also making significant changes in roles and structure to meet familial needs. Dr. Klugman emphasized this point when she said, “Quantifying [the] effects [of maternal death]… and the repercussions down the line—in terms of poverty, dropping out of school, bad nutrition, and future life prospects—I think are all tremendously powerful. [This] additional information [is] very persuasive—to take to the ministries of finance, to take to donors, to take to stakeholders—to help mobilize action for the interventions that are needed.”
Apart from the economic and social costs, is a foundation of human rights violations and gender inequalities. The high rate of preventable maternal mortality is no longer a technical issue, but a social issue. “Maternal mortality it is a global injustice. It is the indicator that shows the most disparities between the North and the developing world in the South. It’s not a technical problem, it’s because women lack voice and agency at household, community, and societal levels and because their lives are not valued. Through this research of showing what happens when those women die, it shows in a way how much they do [and how it] is discounted,” said Dr. Yamin, whose research focuses on the human rights violations in maternal health.
Leveraging this research for improved reproductive, maternal, newborn, and child health
The research findings are clear: prevention of maternal mortality is technically feasible, the right of every woman, and significantly important for the well-being of a family and a community. Boldosser-Boesch provided three reasons why making the case for preventing maternal mortality is critical at this time.
These findings strengthen our messaging globally and in countries with the highest rates on the importance of preventing maternal mortality, by increasing access to quality care, which includes emergency obstetric and newborn care.
This research supports integration across the reproductive, maternal, newborn, and child health (RMNCH) continuum to break down current silos in funding and programs.
“We are at a key moment… for having new information about the centrality of RMNCH to development, because… the countries of the world are working now to define a new development agenda, beyond the MDGS, post-2015. And that agenda will focus a lot on sustainable development… and we see in these findings… , connections to the economic agenda…, questions of gender equality, particularly what this means for surviving girl children, who… may experience earlier marriage or lack of access to education,” shared Boldosser-Boesch.
In order to move the agenda forward on preventing maternal mortality and ensuring gender equality, ministries of health and development partners must be engaged. In addition, donors can fund the action of integration to address a continuum approach and media outlets should be leveraged to disseminate these findings and hold governments accountable for keeping promises and making changes. The prevention of maternal mortality is a human rights-based, personal, and in the socioeconomic interest of a family, community, and a society.
This panel included:
Ana Langer, Director of the Maternal Health Task Force
Alicia Yamin, Lecturer on Global Health at the Harvard School of Public Health
Amy Boldosser-Boesch, Interim President & CEO, Family Care International
Jeni Klugman, Senior Adviser at The World Bank Group
Aslihan Kes, Economist and Gender Specialist, International Center for Research on Women
Amy Boldosser-Boesch is the Interim President and CEO at Family Care International. This article originally appeared on the Healthy Newborn Network (HNN) blog.
This year’s UN General Assembly was full of high-profile moments that reinforced the need for investment and action to improve reproductive, maternal, newborn and child health (RMNCH): the launch of a Global Financing Facility to Advance Women’s and Children’s Health; the release of reports tracking stakeholders’ fulfillment of commitments to Every Woman Every Child; new data on maternal, newborn and child survival from Countdown to 2015; and a plethora of side events focusing on strategies and country progress toward MDGs 4 and 5. For Family Care International, which advocates for improved reproductive, maternal, and newborn health, this unprecedented level of attention to women’s and children’s health is a welcome sign that our advocacy is having an impact, and that global commitment to ending all preventable maternal and child deaths is stronger than ever.
RMNCH was a key theme in many other important discussions during the week, demonstrating the centrality of the health of mothers and newborns to a range of development challenges.
Events began with a Climate Summit that brought together leaders from more than 120 countries. The Partnership for Maternal, Newborn & Child Health noted during the Summit that “women and children are the most vulnerable to the effects of a changing climate, and those who are more likely to suffer and die from problems such as diarrhoea, undernutrition, malaria, and from the harmful effects of extreme weather events such as floods or drought.”
There was a special session to review progress towards achieving the International Conference on Population and Development Programme of Action. The ICPD agenda highlights the importance of ensuring universal access to sexual and reproductive health and rights and the importance of quality and accessible maternal health care, recognizing that healthy girls and women can choose to become healthy moms of healthy babies.
The UN Security Council held an emergency meeting where President Obama called for swift action on the Ebola epidemic that is destroying lives and decimating African health systems. This crisis highlights already-fragile health systems that lack sufficient health workers, supplies, and essential medicines–the same failures that contribute to maternal and newborn mortality. A recent news story details how pregnant women who are not infected with Ebola risk dying in West Africa due to lack of access to maternal health services, and the same risk exists for newborns and young children. The loss of skilled healthworkers, particularly midwives, could have enormous long term impacts on the ability of women, newborns and children to access life-saving care.
Finally, the UNGA week included high-level meetings on humanitarian crises in Syria, South Sudan and many other countries. According to the State of the World’s Mothers 2014 report, more than half of all maternal and child deaths occur in crisis-affected places. Discussions of humanitarian response in crisis settings included recognition of the disproportionate impact on women and children of violence, including gender-based violence, displacement, lack of access to food and lack of access to crucial maternal health services and early interventions for newborns. These crises and fragile health systems make achieving theEvery Newborn Action Plan recommendations on ensuring quality care for mothers and newborns during labor, childbirth and the first week of life more difficult, but also more critical.
While this long list of world crisis may seem overwhelming, there is some good news on maternal, newborn and child survival. As the UN Secretary-General reminded us, the world is reducing deaths of children under the age of five faster than at any time in the past two decades and significant declines in maternal mortality have occurred in the past 10 years. As the world works together to shape the post-2015 development goals, these experiences during UNGA show that the new agenda must prioritize continuing to address maternal, newborn and child mortality which is linked to many of the world’s pressing development challenges, including poverty. As a recent editorial in The Lancet says, “As governments slowly come to an agreement about development priorities post-2015, it is clear that maternal and newborn health will be essential foundations of any vision for sustainable development between 2015 and 2030.”
The sudden death of a woman from largely preventable causes during pregnancy or childbirth is a terrible injustice that comes at a very high cost. Her death is not an isolated event, but one that has devastating repercussions on her newborn baby (if it survives), her children, husband, parents, other relatives, and community members.
On October 7th, 2014, FCI will join with the FXB Center for Health and Human Rights and the International Center for Research on Women (ICRW) to host a livewebcast to explore new research documenting the dramatic economic and social impacts of a woman’s death during pregnancy or childbirth. We will feature new findings from Tanzania, Kenya, Ethiopia, Malawi and South Africa, which advocates can use to argue for efforts to save the lives of nearly 300,000 women who die each year from pregnancy- or childbirth-related causes, almost all of which are preventable.
A mother’s death, tragic in its own right, impacts her family’s financial stability and her children’s health, education, and future opportunities. According to the Kenya study we conducted with ICRW and the KEMRI-CDC Research and Public Health Collaboration, when a mother dies in or around childbirth, her newborn baby is unlikely to survive. Surviving children are often forced to quit school or if they continue their studies, they become distracted from grief or new household responsibilities. Also, when a woman dies, funeral costs present a crippling hardship to her family, while the loss of a productive member disrupts the family’s livelihood.
The studies conducted by the FXB Center also revealed increased child mortality. Qualitative research illustrated a link between maternal mortality and the survival, health, and well-being of children. In Tanzania, for example, the FXB Center’s researchers found that children whose mothers had died during pregnancy or childbirth have a higher risk of being undernourished. The loss of a mother, the central figure responsible for the care and education of her children, often results in the dissolution of her family.
Although countries have made great strides to improve maternal health, too many countries still have a high burden of maternal death. The most recent Countdown to 2015 report noted that of the 75 Countdown countries, which together account for more than 95% of all maternal, newborn, and child deaths, half still have high maternal mortality ratios (300–499 deaths per 100,000 live births), and 16 countries—all of them in Africa—have a very high maternal mortality ratio (500 or more deaths per 100,000 live births). The studies that will be presented in this webinar provide urgently-needed evidence that advocates can use to persuade governments, donors, and policy makers that investments in women’s health and maternal health are also investments in newborns and children, in stable families, in education and community development, in stronger national economies and, ultimately, in sustainable development. As the report, Investing in Women’s Reproductive Health, notes:
[I]nvestments in reproductive health are a major missed opportunity for development. Effective and affordable interventions are available to improve reproductive health outcomes in developing countries, and the challenge is less about identifying these interventions but rather in implementing and sustaining policies to put proven packages of interventions and reforms into practice.
Pregnancy and childbirth should never cost a woman her life. But this research shows that the true price of a maternal death is even higher than that. It is a premium her family will continue to pay long after she’s gone.
The live webcast will include the following panelists:
Amy Boldosser-Boesch is the Interim President and CEO at Family Care International. This article originally appeared on the MDG456Live Hub, curated coverage of women and children during the UN General Assembly.
During the UNGA this week, many partners are committing to deliver on promises to accelerate progress on MDGs 4 and 5. There has also been a renewed focus on the importance of solid data to track progress on reproductive, maternal, newborn and child health and to hold governments and other stakeholders accountable for meeting their commitments. New research conducted in Kenya by Family Care International (FCI), the International Center for Research on Women (ICRW), and the KEMRI-CDC Research and Public Health Collaboration has the potential to increase the momentum of efforts to save the lives of nearly 300,000 women who die each year (5,500 of them in Kenya) from causes related to pregnancy and childbirth.
Each of these avoidable, premature deaths is a tragedy in its own right, and a terrible injustice. Each of these women — some of them barely more than girls — has a right to life and health, and to a standard of health care that protects her from preventable illness, injury, and death.
But we who work to improve maternal health have argued for years that each of these deaths also brings countless additional layers of loss, pain, and destruction. The tragic, sudden death of a woman in the prime of life — in many cases already a mother and often the most economically productive member of the family — begins a cascade of loss and pain that upends the lives of those around her: her newborn baby (if it survives) and her older children, husband, parents, and other members of her family and community. The cost of a maternal death is, quite literally, a price too high to bear.
This new study provides urgently needed data to help persuade governments, donors, and policy makers that investments in women’s health and maternal health are also investments in newborns and children, in stable families, in education and community development, in stronger national economies and, ultimately, in sustainable development.
Based on interviews and focus group discussions with families, across a poor rural area in Siaya County in western Kenya, that had lost a family member to maternal death over a two-year period, we found that:
When a mother dies in or around childbirth, her newborn baby is unlikely to survive. Of 59 maternal deaths in the study, only 15 babies survived their first two months of life.
A mother’s death harms the educational and life opportunities of her surviving children. Many children had to leave school because the loss of a mother’s income meant that they couldn’t pay tuition fees, needed to work for a living, or had to take up essential household chores.
The cost of emergency care (even when unsuccessful), combined with high funeral costs, puts families under a crushing economic burden. Families spent more on funerals than their total annual expenditure on food, housing, and other household costs, after having already spent 1/3 of their annual consumption expenditure on medical costs.
Loss of income and high, unexpected costs send many families into a spiral of debt, poverty, and instability. Many families, under desperate financial pressure, had to sell household property, borrow from moneylenders, or move children out of the family home.
At the national launch of the research findings, Kenya’s Cabinet Secretary for Health, Hon. James Macharia, said, “A mother’s death ignites a chain of disruption, economic loss, and emotional pain that often leads to the death of her baby, diminished educational and life opportunities for her surviving children, and a deepening cycle of poverty for her family.” As the MDG deadline approaches and the post-2015 development agenda is defined, we hope this research will help to catalyze renewed commitment to ending preventable maternal mortality, so that no woman has to pay the high price of losing her life, and so that families, communities and nations no longer have to bear the burden of maternal death.
Learn more: On October 7th, 2014 (2:30 – 3:30 PM EDT), Harvard’s FXB Center for Health and Human Rights, Family Care International (FCI), and the International Center for Research on Women (ICRW) will host Women’s Lives Matter: The impact of a maternal death on families and communities, a live webcast. The webcast will feature research findings from the Kenya study as well as those from four other African countries which document the dramatic economic and social impacts of a maternal death. Panelists will also discuss opportunities and strategies for using these important findings to advocate for political commitment, policy change, and sustained investment in reproductive, maternal, and newborn health in the context of the evolving post-2015 global health and development agenda.
Catherine Lalonde is FCI’s senior program officer for Francophone Africa.
I just returned from a week in Senegal where I attended a regional workshop to train civil society, parliamentarians and the media on budget analysis and advocacy for maternal and child health.
For years now, countries across the globe have said that maternal health is one of their top priorities; they’ve made statements, built coalitions, and developed strategies. On the surface, it seems as though a lot is happening in the realm of reproductive, maternal, newborn and child health (RMNCH). Despite all the rhetoric, little progress has been made in improving the health of mothers and children, especially in the poorest countries in the world.
Since I started working at FCI a year ago, I have mainly been involved in advocacy projects aimed at keeping governments accountable to their commitments. In Burkina Faso, Mali and Kenya, we and our partners are constantly asking governments to invest in and implement programs that will improve RMNCH in their countries. Whenever we question why contraceptives aren’t available in the villages or why health centers are not staffed with qualified personnel, we almost always gets the same answers: there’s no money, we don’t have the funding, and we can’t afford it.
A budget is the single best indicator of a country’s priorities and the best way to tell whether a country is putting its money where its mouth is and whether or not it has taken steps towards fulfilling its maternal and child health commitments.
Organized by Harmonization for Health in Africa, UNICEF, WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH), Save the Children, the InterParliamentary Union and FCI, the three-day budget advocacy workshop brought together members of local NGOs and reporters, along with parliamentarians and representatives from the ministries of finance and of health from the Democratic Republic of the Congo, Niger, Mali, Burkina Faso and Senegal.
A budget is public property; it represents the money that belongs to each and every citizen of a country and therefore, the public should have a genuine say in how the money is distributed and spent. But the countries represented in the workshop had budgets that rank among the least transparent in the world, according to the International Budget Partnership’s Open Budget Survey, which reveals what information is made public and when, as well as who gets to contribute to the process and how often. Of the workshop’s participating countries, Burkina Faso’s budget had the best transparency score– a measly 23 out of a 100; Niger, with the least transparent budget, scored a depressing 4 out of 100, with zero meaningful opportunities for civil society to contribute to the country’s budgeting process.
The workshop facilitators emphasized the important role the budget plays in RMNCH and the financial costs of not investing in RMNCH. It also taught how good health policies are developed and costed, and provided options for increasing fiscal space – the money to fund these policies – within the existing budget. This workshop provided participants with an outline of the budgeting process, and all of the opportunities in which civil society should be able to contribute. At the end, each of the delegations developed advocacy objectives and strategies to improve civil society’s contribution to the budgeting process in order to prioritize health. For example, the Burkina Faso delegation chose to advocate for increased investment in information systems to better track health data while the Malian delegation chose to focus advocacy on ensuring that Mali meets the Abuja declaration pledge to dedicate 15% of its budget to health.
A good friend of mine who works in finance once told me that talking about money scares people, that people often feel as though they don’t have enough knowledge to contribute and are too embarrassed to say so. The organizers and I were afraid that the workshop would be too long, too technical and hard to follow, but we couldn’t have been more wrong. The participants lapped up every word on every slide, and were thrilled to be equipped with the knowledge of the role they can play in ensuring that their country’s budget prioritizes maternal and child health.
The presentation on increasing fiscal space even got a standing ovation!
Adama Sanogo is Program Officer at FCI-Mali, working at our national office in Bamako and supervising FCI’s programs in Mopti, a city on the Niger River an 8-hour drive to the north.
Over the past two years, northern Mali has suffered a series of repeated and increasingly devastating crises. Long-term drought that has plagued the Sahel region of Mali and its neighboring countries – the area that borders on the Sahara desert – led to a dramatic rise in food insecurity in 2011; this was followed in 2012 by a worsening security situation, culminating in an invasion of armed rebel groups that declared the independence of the country’s three northernmost regions of Timbuktu, Gao, and Kidal. In March 2012, the national government in Bamako was overthrown in a military coup, and fighting between the military and the northern rebels continued into 2013.
The result has been a humanitarian disaster, as nearly half a million Malians fled their homes to escape fighting and hunger. The city of Mopti, where FCI has been implementing adolescent sexual and reproductive health programs for several years, is the gateway to the northern part of the country, and it has seen a massive influx of people displaced from the north, seeking refuge or transit to other parts of the countries.
To help address this crisis, in a post-coup environment in which it was difficult or impossible for international agencies to work with an unstable new government, UNICEF asked FCI’s team in Mopti to take on emergency projects to provide support to the many women who had experienced gender-based violence when war convulsed their home region, and to help protect the rights of children among the large displaced population.
“Women and their families,” she says, “have to be active, they have to understand what their rights are in terms of access to health care, in terms of access to information, and they have to demand that their political leaders, locally and nationally, make these services available and make these services high quality. If you don’t have that kind of demand and that kind of momentum in place, then any changes that get implemented are not going to be sustainable.”