African youth amplify their voices at CPD

By Kigen Korir, National Programme Coordinator, SRHR Alliance in Kenya; Hellen Owino, Advocacy Officer, Centre for the Study of Adolescents in Kenya; and Lara van Kouterik, Senior Programme Officer SRHR, Simavi in The Netherlands

We have the largest generation of young people ever.

The world must listen to young people’s voices. It must ensure that we have the opportunity to influence policies that affect us, especially in setting the new development agenda for the era beyond 2015. It must understand that young people know what they want and need, and are committed to safeguarding their sexual and reproductive health and rights (SRHR).

Too often, the voices of young people are drowned out by those of adult policymakers who think they know what young people need and assume young people are “too young” to articulate their issues effectively. For many years, these assumptions have limited the opportunities and constricted the space for young people to participate meaningfully in the creation of the development programs and policies that will have a direct impact on their lives.

At a recent side event during the Commission on Population and Development, young people voiced their concerns, shared best practices, and discussed key issues with other stakeholders. The event was hosted by Simavi (an NGO based in the Netherlands), the permanent mission of Ghana to the UN, and SRHR Alliances from Ghana, Kenya, Uganda, and Malawi, and was attended by representatives, including youth, from country delegations; SRHR advocates; policy makers; and young people.

Aisha Twalibu of YECE Malawi
Aisha Twalibu of YECE Malawi

“Involving young people in SRHR is a basic right enshrined in the laws of many countries, and it is therefore incumbent for countries to observe the same,” explained Edith Asamani, a youth representative from Curious Minds Ghana.

Aisha Twalibu, a youth representative from YECE in Malawi, explained to the group that young people are a diverse group with different needs, and that listening to their voices will help governments, CSOs and development agencies tailor SRHR programs to their needs.

Three other young Africans shared case studies on youth SRHR programs. First, Chris Kyewe from Family Life Education Programme described his peer education program in Uganda, in which youth peer educators (YPEs) are trained to give SRHR information and education to their peers and refer young people to local health centers where trained healthcare providers offer youth-friendly services. In addition to education, YPEs also provide their peers with condoms and oral contraceptive pills, together with instructions on how to use them. This example showed how young people are meaningfully engaged in the implementation of the program.

Then Hellen Owino from the Centre for the Study of Adolescents in Kenya shared that comprehensive sexuality education programs in Kenya empower young people to make informed choices about their health and sexuality. CSA and the Kenya SRHR Alliance have been engaged in advocacy to include comprehensive sexuality education in the national curriculum of Kenya. She also shared that CSE programs should be appealing and interactive, for example by using ICT and social media, to capture the attention of young people. Justine Saidi, the Principal Secretary for Youth in Malawi also called for the active involvement of parents in demanding that young people have access to sexuality information.

Charles Banda from YONECO shared the last case study that focused on preventing child marriage in Malawi. He shared his experience in working with youth-led organizations to build awareness on the negative impact of child marriages on girls and communities, creating a more enabling environment for young girls to exercise their rights. He also described how civil society organizations in Malawi have advocated successfully to raise the legal age of marriage to 18 years, which was recently made into law by the President of Malawi.

Highlighting lessons from the women’s movement, the side event concluded with a discussion of key strategies for youth advocates, including:

  • Mobilizing a critical mass of young people
  • Holding governments accountable for fulfilling their national and international commitments
  • Investing in ensuring that health data can be disaggregated by age group, especially for young people aged 10 to 14
  • Identifying champions at all levels to advance the youth and SRHR agenda

It is time that young people’s views and concerns are incorporated into the new development agenda. Without listening to young people, no country will be able to realize the potential of the demographic dividend that comes with this generation.

 

 

 

Misoprostol for postpartum hemorrhage: translating promise into reality

By Melissa Wanda, Advocacy Officer, Family Care International – Kenya

This post originally appeared on the Maternal Health Taskforce blog.

In Kenya, where I work as an advocate for women’s health and rights, women continue to die during pregnancy and childbirth at alarming rates. Approximately 25% of these deaths are due to heavy bleeding following childbirth, also known as postpartum hemorrhage or PPH. More than half of women deliver at home; that proportion can be even higher in some counties with limited infrastructure and predominantly rural populations. Even in cases where a woman arrives to a health facility in time, she can still face significant barriers to receive the care she needs:

  • supplies needed for childbirth—such as a blood pressure cuff or clean gloves—may not be available;
  • essential medicines—such as oxytocin or misoprostol, which can prevent or treat postpartum bleeding—may be in short supply; and
  • a skilled health provider may not be present to provide the care a woman needs to have a safe delivery.

A key strategy for improving maternal health is to ensure that every woman has access to effective medicines to prevent and treat PPH during childbirth. Oxytocin and misoprostol are proven, lifesaving medicines for the prevention and treatment of PPH. Misoprostol offers a number of advantages for women living in remote, rural areas: misoprostol does not need refrigeration, is available in tablet form and can, therefore, be administered with no specialized equipment or skills. Misoprostol provides an effective option for preventing and treating PPH in settings such as homes and health facilities lacking electricity, refrigeration and IV equipment.

For these reasons, Kenya’s Ministry of Health established a national-level task force to provide a common forum for addressing policy-level issues related to the use of misoprostol for the prevention and treatment of PPH. While misoprostol is registered in Kenya for the management of PPH, and national guidelines govern its use, studies have shown that misoprostol’s procurement and availability in public health facilities is irregular and inconsistent.

This national, multi-stakeholder task force—composed of government, NGO, research, faith-based and health profession representatives[1]—was tasked with spearheading access to and use of misoprostol for PPH. Beginning in 2014, the Misoprostol Task Force, convened by the ministry of health, met regularly to identify the key policy gaps at the national level and to take concrete action. Key policy priorities identified by the Task Force:

  • Harmonize the national clinical guidelines:  Kenya has numerous clinical management guidelines advising health professionals on how to administer misoprostol for all its indications (PPH, induction of labor and post-abortion care): the 2009 Clinical Guidelines for Management and Referral of Common Conditions at Levels 4-6 and the 2012 National Guidelines for Quality Obstetric and Perinatal Care. While these guidelines recommend the use of misoprostol to prevent and treat PPH when oxytocin is unavailable, they do not reflect the latest evidence and were inconsistent with each other. The Task Force developed a handout that harmonizes these different guidelines and produced a job aid for health workers. Both documents are waiting approval by the ministry of health; once approved, they will be disseminated at the national and sub-national/county levels.
  • Revise the national essential medicine list: While the Kenya Essential Medicine List(KEML, 2010) classifies misoprostol as a complementary and core[2] oxytocic drug, no specification is made for its use in PPH prevention or treatment. The Task Force drafted a letter to the National Medicines and Therapeutics Committee, to call for the addition of misoprostol to the KEML for PPH prevention and treatment at all levels of the health system. This letter will likely be deliberated by the committee when it meets this year to update the KEML.

Continued advocacy is still needed to ensure these positive developments in the Kenyan national policy framework translate into actual improvements in the availability and use of misoprostol. The Task Force has served as a critical forum for bringing together key stakeholders, promoting national level discussion and supporting effective action.

For more information and tools for conducting effective advocacy:

Scaling up Misoprostol for Postpartum Hemorrhage: Moving from Evidence to Action

Advocacy, Approval, Access: Misoprostol for Postpartum Hemorrhage A Guide for Effective Advocacy

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

[1] Membership includes representatives from the Ministry of Health-Reproductive Maternal Health Services Unit, Family Care International-Kenya, PATH, Management Sciences for Health, the Population Council, UNFPA, AMREF, Institute of Family Medicine (INFAMED), Christian Health Association of Kenya (CHAK), Jhpiego, the World Health Organization and professional organizations of gynecologists and nurses.

[2] The Core List represents the priority needs for the health care system. Medicines on the Core List are considered to be the most efficacious, safe and cost‐effective; are expected to be routinely available in health facilities; and should be affordable to the majority of the population.  Complimentary medicines are essential medicines needed for specialized diagnostic or monitoring facilities, and/or specialist medical care, and/or specialist training.

The myth of the meager maternal health market

By Deepti Tanuku, Program Director, USAID-Accelovate

This post originally appeared on the Maternal Health Task Force blog.

pakistan mother maternal health quality care facility smile woman pakistani
Mother in Sindh, Pakistan receiving quality care. Photo: Jhpiego.

When I first entered this line of work, I often heard one thing: the maternal health market is way too small to be sustainable, much less lucrative. Naturally, one can only expect market failure for maternal health drugs and, by extension, a chronic situation of limited access to lifesaving medicines among those most in need.

However, I disagree.

The maternal health market is, of course, comparatively small when looking at the parallel markets for reproductive health, HIV, TB, malaria and even child health.

Take malaria for example. Prepared technical guidance provided by the President’s Malaria Initiative states that the unit cost for delivery of long-lasting insecticidal nets (LLINs) provided free of charge through antenatal clinics in four countries ranged from US $1.61 to $2.35 – which is roughly equivalent to the unit cost of US $1.50 for a delivery package of the three essential maternal health medicines: oxytocin, misoprostol and magnesium sulfate. However, in 2014 an estimated 214 million long-lasting insecticidal nets were delivered to malaria-endemic countries in Africa, while only 36 million women gave birth in the same region that same year. As any business school student can tell you, applying the formula of Price x Quantity = Revenue means that the maternal health market simply doesn’t compare in size.

This is the origin of the myth. For those of us committed to the goal of improved maternal health, we cannot confuse a small market with an unhealthy market – small can still mean healthy. Small can and should still mean a consistent and sustainable supply of high-quality and affordable maternal health drugs to all mothers in all settings.

There is a catch. The maternal health community cannot wait for market realities to drift toward our favor – we must actively and purposefully shape them. This begins with strong political will at both global and national levels. The creation of the UN Commission on Lifesaving Commodities for Women and Children is an excellent start, as is the inclusion of maternal health within the Reproductive Health Supplies Coalition (RHSC) agenda. These actions complement the ongoing efforts of other groups in this space, including the Maternal Health Task Force, itself.

The good news is that in the context of strong political will, there is plenty of research to shape evidence-based next steps. Together, we have built a clear understanding of market access barriers and we even know ways to incentivize around them. We also have market shaping strategies from other priority health areas, such as family planning, that serve as blueprints that we can adapt for our own purposes. As the maternal health community, it is up to us to use these tools to advocate for and help ourselves.

Finally, it’s good to revisit why this issue is critically important. Several studies and reports have demonstrated time and time again that healthy mothers strengthen families, societies and a nation’s economic development, which, in turn, strengthen a nation’s markets. Let’s say that again: Healthy mothers strengthen markets. It’s time markets returned the favor.

Resources used in the writing of this post:

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

Making connections: Ensuring access to reproductive and maternal health supplies

Shafia Rashid is Senior Program Officer for Global Advocacy at Family Care International. This post originally appeared on the Maternal Health Task Force blog.

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

The past ten years have witnessed impressive gains in the availability and use of reproductive health supplies like condoms and oral contraceptives that allow men and women to safely and effectively prevent or space pregnancies. As a result of concerted efforts by many partners, contraceptive prevalence rates have risen over 60% in countries around the world.

These dramatic successes in improving access to reproductive health supplies can shed important lessons and guidance for those working to ensure that life-saving maternal health medicines — including, oxytocin, misoprostol and magnesium sulfate — are available to all women, when they need them and wherever they give birth. These medicines — which can save lives by preventing or treating the leading causes of maternal death — remain out of reach for many women, particularly for poor, rural, indigenous and other vulnerable women. Many countries lack clear, supportive policies and adequate budgets to make essential maternal health medicines widely available, or have weak supply chains and logistical systems. Inadequate regulatory capacity, poor quality of medicines and lack of information and guidance on correct use are other barriers to access.

In order to summarize lessons learned and provide concrete tools to improve access to maternal health supplies, the Reproductive Health Supplies Coalition tasked Family Care International to create seven policy briefs that show policy makers and program managers real-world examples of successful interventions. Importantly, there is a brief dedicated to each of the three most critical maternal health supplies: oxytocin, misoprostol and magnesium sulfate. Other briefs cover the cross-cutting issues of policy and financing, supply and demand generation.

Lessons learned from successful efforts to improve access to family planning commodities can help to effectively address the challenges related to maternal health medicines. Family planning advocates have, for example, tracked government expenditures on reproductive health supplies: in Indonesia, budget analysis and concerted advocacy led the mayors of five districts to increase their family planning budgets by as much as 80%. Similarly, many countries — including Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua and Paraguay — have established contraceptive security committees that bring together multiple supply chain stakeholders to support coordination, address long-term product availability issues and reduce duplication and inefficiencies. These committees have advocated for increased financial support for contraceptives, improved inventory management, developed standard operating procedures, published reports and provided technical assistance. These efforts to increase budgets and ensure commodity security for contraceptives can be effectively adapted and expanded to improve financing and security for maternal health supplies as well.

A wide range of tools and resources can support countries in strengthening their forecasting, procurement and other supply chain functions. Tools originally developed with a sole focus on reproductive health supplies now include or can be adapted to apply to maternal health supplies as well and can be used by country managers working to improve the supply of maternal health medicines.

Finally, many countries are moving toward integrating their supply chains to include family planning commodities and other essential medicines, including medicines for maternal health. In Ethiopia, for instance, the government (with the support of in-country partners) integrated their supply chain to include all health commodities and to connect all levels of the supply chain with accurate and timely data for decision-making. In Nicaragua, where the supply chain was separated vertically by health issue and type of commodity until 2005, the health ministry has integrated the essential medicines system with the contraceptives’ supply chain and has now fully automated the system and expanded it to include all essential medicines.

There are many parallels and potential synergies between reproductive and maternal health supply chains and processes. The reproductive and maternal health communities must take the following actions to address the interrelated barriers that prevent access to and use of life-saving commodities:

  • Advocate for development and implementation of supportive policies at the national and sub-national levels,
  • Advocate for dedicated budget lines to enable monitoring and evaluation of policy implementation
  • Improve government systems and procedures for procuring high-quality medicines and maintaining their quality throughout the supply chain
  • Invest in a streamlined, coordinated supply chain across sectors and levels, reducing inefficiency and duplicative efforts
  • Strengthen the knowledge and skills of health providers so that they are aware of evidence-based policies and guidelines and can effectively administer these essential medicines

More information can be found in Essential Medicines for Maternal Health: Ensuring Equitable Access for All, a set of briefs that highlight challenges and strategies for increasing the availability of these maternal health medicines and identify linkages with reproductive health supplies. You can download the Essential Medicines for Maternal Health policy briefs in English, French and Spanish.

Tracing the money: A new tool to impact the budget process

Kathleen Schaffer is senior program officer for Anglophone Africa at Family Care International.

A dilapidated clinic, falling tiles, a never-ending leak. Barren and disorganized medicine shelves. An overcrowded maternity ward with desperate, soon-to-be mothers crying out for help. One nurse scrambling to meet the needs of the many patients who have come through the doors. When clients lament the clinic’s disrepair, or doctors request more supplies and personnel, they’re met with the same hopeless reply: “There’s no money.”

Through Family Care International’s (FCI) Mobilizing Advocates from Civil Society (MACS) project in Kenya, international, national and grassroots organizations as part of the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Alliance are demanding better facilities, adequate and respectful maternity care, and especially, more health personnel. Kenya has only 11.8 health workers per 10,000 people–more than 40% fewer health workers than the World Health Organization’s minimum recommendation of 22.8 health workers per 10,000 people.

Of course any effort to increase the quantity and quality of health workers will have to be paid for, and that means dealing with the budget. For many of us, budgets seem abstract and intimidating, but it’s vital to engage with them since they reflect the government’s priorities and determine where the public’s money goes.

In order to make realistic demands, we need access to information about Kenya’s budget. However, over the last few years Kenya decentralized many decision-making processes, including budgeting, to the county-level. This recent decentralization has made it difficult for us to intervene effectively during the budget process.

Kenya calendar 2

But now, civil society organizations in Kenya can engage with budget decision-makers at the right moments thanks to a new Annual Budget Cycle Calendar, developed by the MACS project.

This new easy-to-read calendar shows the key dates for the Kenyan Annual Budget Cycle at both the national and county levels, enabling citizens to participate in both the setting of priorities and in accountability processes.

It is a great resource not only for maternal health advocates but also for the broader health community and county government officials, such as those from the Health and Finance Committees. The RMNCH Alliance will distribute the calendar in counties all over the country, and we hope to see it on many office walls as a constant resource for advocacy opportunities.

Ultimately, by being able to participate in and monitor the budget process more effectively, we will ensure that the government fulfills its commitments to maternal, newborn, and child health, and that the budget reflects the needs and priorities of the community and not just politicians.

Budget accountability in the midst of the Burkina Faso revolution

By Manuela Garza

Manuela Garza is an independent consultant and is co-founder of Colectivo Meta. She is currently engaged as a consultant to FCI’s Mobilizing Advocates from Civil Society (MACS) project, on which she works to build the budget analysis skills of health-focused civil society organizations in Burkina Faso.

For the past seven years, it was my good fortune to work at a job that allowed me to work with brave and committed activists in interesting and beautiful places. As a staff member of the International Budget Partnership, I found myself in Mombasa, Kenya, where ordinary citizens conducted ‘social audits’ to claim their communities’ fair share of government financial resources; in Abbottabad, Pakistan, where 500 women and men voiced their priorities for spending of earthquake rehabilitation funds; in Beijing, where civil society groups were trained to pursue budget transparency and accountability in a context where silence rules; and in Abbra, a remote region in the Philippines, where rural villagers have advocated for and achieved truly participatory budgeting.

In recent months, FCI’s MACS initiative has been working in Burkina Faso to strengthen the capacity of civil society groups to effectively advocate for more and smarter spending of public funds to improve reproductive, maternal, newborn, and child health in their communities. Last October, I was engaged, together with my Malian colleague Boubacar Bougodogo and Burkinabé budget researcher Hermann Doanio, to develop and facilitate a weeklong workshop to train grassroots advocates to understand and engage with public budgets. We arrived in Ouagadougou, Burkina’s capital, on a calm and warm West African evening, all of us ready with our slides on the budgeting process, our spreadsheets, our budget calculation formulas, and our case studies. Business as usual, or so we thought.

Little did we know that, in the course of that week, the citizens of Burkina Faso would overthrow the dictator who had been ruling the country for the past 27 years. Thousands of people (young people, mostly) took to the streets with a very clear message for President Blaise Campaoré: they wanted him out, for good. They were no longer willing to tolerate corruption and abuse of power, they declared: Burkina is ready for democracy.

In the midst of these historic events, you may be wondering, what did our Burkinabé colleagues, who had put this week aside for budget training, do? Was the workshop still relevant during these revolutionary days? Of course, every participant was closely watching the dramatic events taking place outside the training venue; each participant was concerned and worried about what they would mean for their families and their country. At the same time, however, they remained committed to take full advantage of this unique opportunity to learn about a new tool that will enable them to carry out evidence-based advocacy. They stuck around, they learned, and they questioned; they talked about their country, about change, and about what these new skills could help them achieve. They discussed the potential for how things could change, including in the way that the government sets priorities and spends public money— that is, the people’s money!

Civil society plays a key role in ensuring that governments prioritize spending on women’s and children’s health.
Civil society plays a key role in ensuring that governments prioritize spending on women’s and children’s health.

Is budget accountability still relevant in a context of earthshaking change? My experience says that it is. Revolutions are tricky things: countries and their institutions can change either for better or for worse, and conditions may take a long time to stabilize. If change is managed wisely and stability returns quickly, as seems to be happening in Burkina, revolution can provide an opportunity for a fundamental shift in the balance of power—toward the people. This can vastly increase the possibility of reshaping inefficient and corrupt institutions, of fostering new structures that institutionalize transparency and accountability. In a country like Burkina Faso, accountability for public resources is an essential element of overall accountability.

In this context, investing in building the skills of civil society groups is crucial, because the significance and sustainability of positive change largely depends on a well-organized and well-prepared civil society. These are the times when advocates and grassroots organizations most need support, when citizens most need to develop new knowledge and skills in civic participation, when accountability and participation-related processes are more necessary than ever. The MACS project is doing just that, and FCI’s local partners in Burkina Faso will continue to arm themselves with new tools such as budget analysis, so that their advocacy has more impact, their voices are heard, and they can be effective forces for real, sustainable change.

Good luck to them and to Burkina Faso–a country that many people cannot even locate on a map but which has a lot to teach us when it comes to citizen power!

 

Health workers in many Kenyan clinics brave community health care alone

By Melissa Wanda

Melissa Wanda is Advocacy Program Officer for FCI Kenya. This article originally appeared on the blog for the Frontline Workers Health Coalition

In a village in rural Kenya, a woman in labor travels miles along rutted dirt roads to get to the nearest health center. She wants to give herself and her baby the greatest possible chance of surviving childbirth and returning home to begin new and healthy lives. When she arrives however, the gates are locked; the nurse has gone home.

Kenya, with only 11.8 health workers per 10,000 people (more than 40% below WHO’s recommendation of 22.8 per 10,000), is one of 57 countries — including 36 in Sub-Saharan Africa — with a critical shortage of health workers.

Many local health facilities have only one health worker, often a nurse, to provide all patient care. This puts a heavy strain on the health worker, and means that many intended 24-hour health facilities are often closed for extended periods of time. Kenya’s news media has also reported recent health worker strikes in reaction to late or non-payment of wages.

The Government of Kenya has committed to strengthening human resources for health in the public health system. Several civil society organizations (CSOs) working to improve reproductive, maternal, newborn, and child health (RMNCH) have come together to advocate for the fulfillment of this urgently important promise. This alliance, co-led by Family Care International (FCI) and the African Women’s Development and Communication Network (FEMNET) under FCI’s Mobilizing Advocates from Civil Society (MACS) project, is conducting advocacy at the county level in Kenya, since counties are responsible for making many health spending decisions in Kenya’s recently decentralized administrative structure and health system.

With support from the MACS project, Deutsche Stiftung Weltbevoelkerung (DSW), a member of the advocacy alliance in Kenya, has surveyed community perceptions of the need for more health workers, and explored how effectively county governments have invested in addressing those needs. Working in two urban and two rural counties, DSW conducted research at various levels of the health system, including outpatient dispensaries, health centers, and hospitals. DSW found that counties are not budgeting or investing spending adequately enough to ensure that facilities have enough health workers to provide high-quality services. Although special funding has been set aside nationally to hire new health workers, counties have mainly been spending this money to pay current staff. DSW is sharing these findings with MACS and county health authorities, leading to one county already committing to hire an additional 72 nurses.

Kenyan health workers share frustrations and challenges of working at understaffed health centers.
Kenyan health workers share frustrations and challenges of working at understaffed health centers.

DSW also brought together community members and health facility staff to discuss the state of care at local health facilities. Community members complained that lack of staff meant an absence of essential services, especially at night and on weekends. Health workers expressed the frustrations of working alone, often lacking the drugs and supplies they need to treat their patients, and the low morale that comes from working under those conditions. For example, one nurse described a recent evening when she was the lone nurse caring for six women in labor!

These community meetings opened new channels of communication, fostering greater understanding and accountability between health workers and the communities they serve. This enabled health system users and health workers to join together in search of practical solutions.

Peter Ngure, DSW’s project lead, shared with me a story about one community in which participants said they prefer to come to the hospital — a long distance from their homes —in the afternoon, so they have time in the morning to travel there. In response, the hospital rearranged staff work schedules, deploying more nurses in the afternoon than morning hours. Similarly, community members learned that the hospital holds Monday afternoon staff meetings, helping to explain why appointments are often unavailable at that time, which had been a repeated source of frustration and confusion.

“This dialogue between community members and health workers helped to build much-needed goodwill during these very challenging times,” said Mr. Ngure.

FCI, DSW and the members of the civil society advocacy alliance will use these findings and experiences to hold county governments accountable for addressing the health worker shortage. When the Kenyan Ministry of Health releases its upcoming human resources for health strategy, which will provide specific guidance on exactly how many health workers should be assigned to each health facility, alliance members will work to make sure that counties follow that national policy, so that every Kenyan mother, seeking care for herself and her baby, will be greeted by open gates and a health worker with the skills and resources to ensure their survival and good health.

 

The true cost of a mother’s death: Calculating the toll on children

By Emily Maistrellis

Emily Maistrellis is a policy coordinator at Harvard University’s FXB Center for Health and Human Rights and a research study coordinator at Boston Children’s Hospital. This article originally appeared on Boston NPR station WBUR’s CommonHealth blog. 

COPE Tharaka August 07  049_FamilyCareInternational
A health worker interviews a client at a health care facility in Tharaka, Kenya. (Photo: Family Care International)

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.

As these stories illustrate, the impact of a woman’s death in pregnancy or childbirth goes far beyond the loss of a woman in her prime, and can cause lasting damage to her children — consequences now documented in new research findings from two groups: Harvard’s FXB Center for Health and Human Rights, and a collaboration among Family Care International, the International Center for Research on Women and the KEMRI-CDC Research Collaboration.

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

 

Making a human-rights and socioeconomic case for preventing maternal mortality

By Katie Millar
Katie Millar is a technical writer for the Maternal Health Task Force (MHTF), where this article originally appeared. 
Panel at Women's Lives Matter
Photo: MHTF

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.

  1. 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.
  2. This research supports integration across the reproductive, maternal, newborn, and child health (RMNCH) continuum to break down current silos in funding and programs.
  3. “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

Watch the webcast here.

UNGA week shows maternal and newborn health are central to development challenges

Amy Boldosser-Boesch is the Interim President and CEO at Family Care International. This article originally appeared on the Healthy Newborn Network (HNN) blog.  

CD cover 2This 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 the Every 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.”