Women’s Lives Matter: The impact of a maternal death on families and communities

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 live webcast 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.Women's Lives Matter_7Oct2014 promo graphic

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:

  • Dr. Ana Langer (moderator), Director of the Women and Health Initiative
  • Alicia ElyYamin, Lecturer on Global Health, Department of Global Health and Population, Harvard School of Public Health; and Policy Director, FXB Center for Health and Human Rights
  • Rohini Prabha Pande, Lead Researcher on A Price Too High to Bear, Independent Consultant on Gender and Health
  • Jeni Klugman, Author of Investing in Women’s Reproductive Health (2013) and lead author, Voice and Agency (2014)
  • Amy Boldosser-Boesch, Interim President and CEO, Family Care International

Please join us on October 7, 2:30 – 3:30 PM! View the webcast live and submit your questions to the panel in real time: bit.ly/WomensLivesMatter

A Price Too High to Bear: Showing Kenya the devastating costs of maternal death

Martha Murdock is FCI’s vice president for regional programs.

Last week in Nairobi, a range of partners — from the Kenyan government, UN agencies, donor countries, and many NGOs and research organizations from the national and county levels — came together for a presentation of new research that 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.

Up until now, however, we haven’t had the hard data to support our case, to help us persuade governments, donors, and policy makers that investments in maternal health are also investments in children, in stable families, in education and community development, and ultimately in stronger national economies. Now, thanks to a study conducted in Kenya by FCI, the International Center for Research on Women (ICRW), and the KEMRI-CDC Research and Public Health Collaboration, we know that the data behind that argument is very powerful indeed.

Based on interviews and focus group discussions with every family, 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.

When this moving and compelling report was launched in Nairobi last Friday, I was proud to stand at the dais and introduce eminent leaders of efforts to improve women’s and children’s health in Kenya, including the U.K. High Commissioner for Kenya, Dr. Christian Turner (representing the U.K. Government, which funded this important research together with the John D. and Catherine T. MacArthur Foundation and the Partnership for Maternal, Newborn & Child Health). Dr. Turner, in turn, introduced Kenya’s Cabinet Secretary for Health, Hon. James Macharia. With us in the room were important policy makers from the Ministry of Health, national parliamentarians, and high-level representatives from UNICEF, WHO, UNFPA, USAID, and a range of other agencies and organizations.

We came together that morning, I said, “because we are all resolved, together with so many colleagues and partners here in Kenya and around the world, to work together to finally put an end to a tragic toll of maternal and newborn death that goes back to the beginnings of human history.” We have long known that far too many women were dying.  What we lacked, until now, was hard data to help us fully understand the financial and social impact of a mother’s death — the costs to the health and well-being of thousands of surviving children, families, and communities. We and our partners undertook this study because we saw that filling this critical knowledge gap will offer advocates and policy makers a powerful tool for bringing further attention and investment to maternal health.

The messages that emerge from this research were expressed clearly and succinctly by Hon. James Macharia as he presided over the official launch of the report:

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.

The cost of a maternal death is, quite literally, a price too high to bear.

 

(An excellent in-depth news report on the study and its launch, by a leading Kenyan television network, can be viewed here:

Building the momentum: Misoprostol for postpartum hemorrhage in Pakistan

By Imtiaz Kamal

Imtiaz Kamal is the president of the Midwifery Association of Pakistan. She has led a “one-woman crusade” to promote the midwifery profession for more than 50 years.

In June 2013, all four provinces of Pakistan—Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan—included misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) on their respective Essential Medicines Lists (EMLs). EMLs indicate medicines that “satisfy the priority health care needs of the population” and should be affordable and available at all times within the context of a functioning health system. As advocates working towards improving reproductive and maternal health in Pakistan, we’ve come a long way in our mission to expand access to misoprostol. In this post, I share our advocacy strategy and the challenges we faced.

The sixth most populous country in the world, Pakistan has an alarmingly high maternal mortality ratio: 260 maternal deaths per 100,000 live births. Every year, almost 12,000 women in Pakistan die from pregnancy and childbirth related complications, accounting for almost 5% of the world’s maternal deaths, and PPH—excessive bleeding after childbirth—causes 27% of these deaths. About 57% of deliveries still take place without a skilled birth attendant present, and in these situations, women often do not have the means to address life-threatening complications when they arise. Fortunately, there is a safe and effective solution to treat and prevent PPH—misoprostol, a low-cost medicine that is practical for use in both facility and home births.

For many years, the National Committee for Maternal and Neonatal Health, the Midwifery Association of Pakistan (MAP), and the Association for Mothers and Newborns, with support from the Research & Advocacy Fund (RAF), championed the widespread availability of misoprostol in Pakistan.

One step for improving access to this essential medicine was to get provincial governments to include misoprostol on their respective EMLs. Then, the provincial governments can supply it to the public sector health facilities, which would provide this essential medicine at minimal or no cost to women wherever they live.

Usually, the Pakistani government follows the World Health Organization’s (WHO) EML, but due to misoprostol’s association as an “abortion drug,” we had to sell it to policymakers, highlighting misoprostol’s huge lifesaving potential and the urgency to expand access to women who need it. Misoprostol is an essential part of a package of strategies to improve maternal health, and we must ensure that its use for other indications does not lead to limitations on its availability for PPH.

We devised an advocacy strategy to share the evidence and stimulate supportive policy change through:

  • Public education and awareness: fact sheets and case studies in English and Urdu, press conferences, trainings with journalists, and air time on television;
  • Advocacy with decision-makers, including high-level Ministry of Health authorities, district health officers, OB/GYNs, and other health providers: face-to-face meetings  and dissemination seminars in Punjab, Sindh, and the federal capital, Islamabad, to share guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO).
Advocates conducted seminars with health care providers to present evidence on the life-saving potential of misoprostol for PPH and post-abortion care (PAC). (Image: Midwifery Association of Pakistan)

Our advocacy strategy led to very specific, positive outcomes:

  • Endorsements from key champions: The Director General of Health in Sindh province became a close ally  and guided us on how to move forward in garnering support from  OB/GYNs and  district health officers;
  •  A widely distributed position paper on misoprostol for PPH and post-abortion care (PAC) was signed by six professional organisations working for maternal and neonatal health;
  • The National Assembly decided that the federal government should provide training to midwives and other health care providers on the administration of misoprostol to manage incomplete abortion and miscarriage and prevent PPH.  In Sindh, the Directorate of Nursing came to us for guidance, and the first misoprostol workshop for midwifery teachers is scheduled for late February 2014.
Midwives will receive training 0n the administration of misoprostol for PPH and PAC. (Image: Midwifery Association of Pakistan)

Our advocacy efforts weren’t without challenges, however. For example, many physicians were cautious or opposed to making misoprostol more widely available. The most senior OB/GYN (from a province with very high maternal mortality) raised a number of concerns after a presentation we held on misoprostol, commenting: “It is not candy. We cannot let it be available freely.”  We explained that, given the high prevalence of home births, we need to invest in solutions, such as misoprostol, that save lives now, until we can achieve the long-term goals of strengthening health systems and increasing rates of facility births. Distributing misoprostol doesn’t replace efforts to promote skilled care, but we need to recognize the reality that many women are not able to give birth in well-equipped health facilities with skilled staff. All women, wherever they decide to give birth, need access to effective medicines.

We faced similar comments and questions at every advocacy meeting. But this didn’t stop us; we continued to make our case. Eventually, that very same OB/GYN signed our position paper on misoprostol.

The movement to achieve national recognition of misoprostol for PPH has been challenging, but we are making progress, turning heads, and changing minds. Step by step, we push forward. Now that we have achieved Federal approval of misoprostol, we are working to advance community level distribution of misoprostol to women in their eighth month of pregnancy. As a global community, with partners such as FCI rallying behind the cause, we will succeed in making sure women no longer have to fear for their lives when giving birth.

For more information:

Mapping Misoprostol for Postpartum Hemorrhage Regional Perspectives on Challenges and Opportunities South Asia

Advocacy for PPH Prevention and PAC: PowerPoint Presentation at the Research and Advocacy Fund 2nd Annual Conference

The new frontier of community health care: Health huts in Senegal use misoprostol and oxytocin in Uniject to prevent postpartum hemorrhage

[Version française ci-dessous]

Shafia Rashid is a senior program officer for Global Advocacy at Family Care International.

While Senegal, a coastal West African country, has made considerable progress in decreasing maternal mortality since 1990, it still grapples with high rates of preventable maternal death. Postpartum hemorrhage (PPH)—excessive, uncontrolled bleeding—remains the leading cause of maternal death in Senegal and around the world.  In areas of Senegal where there is still a high prevalence of unattended deliveries, women may not have the means to manage PPH or other life-threatening complications.

Regardless of where they give birth, all women need access to uterus-contracting drugs, or uterotonics, for the prevention and treatment of PPH. The recommended uterotonic, injectable oxytocin, requires cold storage and technical skill to administer; oxytocin is also available as a Uniject® device—a pre-filled, single dose, non-reusable injection—which is easier to administer. Misoprostol is a safe and effective alternative in low-resources settings where oxytocin isn’t available or feasible; it doesn’t need refrigeration and is easy to use—particularly important in the absence of a skilled birth attendant.

Matrones, or volunteer birth attendants, received training on administration of their assigned intervention.

Between June 2012 and August 2013, Gynuity Health Projects, ChildFund Senegal, the USAID Community Health Program, and the Senegalese government’s Directorate of Reproductive and Child Health implemented a study to compare community-level administration of oral misoprostol and oxytocin in Uniject® to prevent PPH. One of the two interventions was assigned to each of 28 participating community health huts, one- or two-room concrete structures that bring basic healthcare closer to the communities. Project implementers trained matrones, volunteer birth attendants, to assist with deliveries and administer the designated intervention.

Communities played an integral part in encouraging the use of misoprostol and oxytocin. Community members assisted in identifying pregnant women for initial prenatal check-ups, and project staff recruited women by visiting them in their communities.

Since the launch of the project, over 1300 women received either 600 mg (3 tablets) of misoprostol or 10 IU oxytocin via Uniject® intramuscularly for PPH prevention. Both medicines were effective, and the matrones could manage all side effects, which included chills, tremors and fever. Among all the women who received prophylaxis, only one case of postpartum hemorrhage occurred.

“Before this study, we saw a lot of women with heavy bleeding, and it was always difficult to arrange transportation for referrals [to health facilities],” said Fatou Diouf, a matrone from the Koulouk Mbada hut. “Now, we do not see any hemorrhage after delivery.”

Chief nurse Amadou Gueye from the Ndiaganiao health post noted a similar outcome: “Since the start of the study, we have not seen a single case of PPH.”

As a result of the project, home births decreased from 10% to 1%, project leaders effectively maintained drug stocks, health providers demonstrated commitment and motivation, and the matrones administered medications and filled out data management tools successfully. Birth attendance at the community health huts improved because women sought delivery services in order to benefit from a PPH medication.

“When I came to deliver this morning, the matrone asked me if I wanted to take the three tablets. I said yes,” said Mariama Niang who had recently given birth at the Koulouk Mbada health hut. “I bled less than I did in previous deliveries when I bled a lot and had lots of dizziness. […] now, I am doing well.”

In Senegal where access to health facilities may be limited in remote areas, the community health hut system can play an important role in preventing and treating PPH. According to the study, both misoprostol and oxytocin in Uniject® proved to be equally effective and safe in preventing PPH, and matrones  posted at the health huts were capable of administering their assigned medicine. Whereas standard oxytocin injections require specialized skills, misoprostol and oxytocin in Uniject® are viable options at the community level. These health interventions can empower communities to protect women’s health and prevent unnecessary maternal death.

Through research and advocacy, Family Care International (FCI) is working with Gynuity Health Projects to support increased access to and availability of misoprostol for prevention and treatment of PPH. Learn more about FCI and Gynuity’s work to make misoprostol available to women around the globe.

 

Les nouveaux confins des soins de santé communautaire : Au Sénégal, les cases de santé utilisent le misoprostol et l’ocytocine par Uniject en vue de prévenir l’hémorragie du post-partum

Shafia Rashid est la Responsable du Programme Global Advocacy – « Plaidoyer mondial » auprès de Family Care International.

S’il est vrai que le Sénégal, pays côtier de l’Afrique de l’Ouest, a réalisé d’énormes progrès dans la baisse de la mortalité maternelle depuis 1990, il est toujours aux prises avec de forts taux de décès maternels évitables. L’Hémorragie du post-partum (HPP) – des saignements excessifs, difficiles à arrêter – demeure la principale cause de mortalité maternelle au Sénégal et à travers le monde. Dans des régions du Sénégal où il existe une forte prévalence d’accouchements en l’absence d’un personnel qualifié, il est possible que les femmes ne disposent pas de moyens pour le traitement de l’HPP ou d’autres complications potentiellement mortelles.

Quel que soit l’endroit où elles accouchent, toutes les femmes ont besoin d’avoir accès aux utérotoniques, les médicaments provoquant la contraction de l’utérus pour la prévention et le traitement de l’HPP. L’ocytocine injectable, l’utérotonique recommandé, nécessite la conservation à froid et des compétences techniques pour son administration ; l’ocytocine est également disponible en tant que dispositif Uniject® — une injection pré-remplie à dose unique et non réutilisable — qui est plus facile à administrer. Le misoprostol est une méthode alternative à l’ocytocine qui est sûre et efficace, particulièrement dans les milieux à faibles ressources où l’ocytocine n’est pas disponible ou faisable. Le misoprostol ne nécessite pas la réfrigération et est facile à utiliser — ce qui est notamment important en l’absence d’une accoucheuse qualifiée.

Entre juin 2012 et août 2013, Gynuity Health ProjectsChildFund SenegalProgramme de santé communautaire de l’USAID et la Direction de la Santé de la Reproduction et de la Survie de l’Enfant du gouvernement sénégalais ont mené une étude visant à comparer l’administration à l’échelle communautaire du misoprostol oral à celle de l’ocytocine par Uniject® en vue de prévenir l’HPP. Une des deux interventions était assignée à chacune des 28 cases de santé communautaires participantes, des structures en béton d’une à deux pièces, qui fournissent des soins de santé de base aux collectivités. Les exécutants du projet ont fourni une formation aux matrones, accoucheuses bénévoles, à apporter leur aide durant les accouchements et à administrer l’intervention désignée.

Matrones, or volunteer birth attendants, received training on administration of their assigned intervention.

Les collectivités ont assumé un rôle essentiel en encourageant l’utilisation du misoprostol et de l’ocytocine. Les membres de la collectivité ont aidé à identifier les femmes enceintes pour les consultations prénatales initiales et le personnel du projet a recruté les femmes en leur rendant visite au sein de leur communauté.

Depuis le lancement du projet plus de 1 300 femmes ont reçu soit 600 mcg (3 comprimés) de misoprostol ou 10 UI d’ocytocine par Uniject® par voie intramusculaire pour la prévention de l’HPP. Les deux médicaments étaient efficaces et les matrones ont pu traiter tous les effets secondaires qui comprenaient notamment les frissons, les tremblements et la fièvre. Seul un cas d’hémorragie du post-partum est survenu parmi les femmes ayant reçu le traitement préventif.

« Avant cette étude, un grand nombre de femmes présentaient des saignements profus et il était toujours difficile d’assurer le transport pour leur acheminement [aux établissements de santé], » dit Fatou Diouf, une matrone de la case Koulouk Mbada. « Désormais, nous n’observons plus d’hémorragie après l’accouchement. »

Amadou Gueye, Infirmier en chef du poste de santé de Ndiaganiao, a noté un résultat analogue : « Nous n’avons observé aucun cas d’HPP depuis le début de l’étude. »

En raison du projet, le nombre d’accouchements à domicile a baissé de 10 % à 1 %, les responsables du projet ont effectivement maintenu les stocks de médicaments, les prestataires de santé ont démontré leur engagement et leur motivation et les matrones ont administré les médicaments et rempli les formulaires de gestion des données de manière adéquate. La présence des accoucheuses dans les cases de santé communautaire s’est renforcée parce que les femmes ont sollicité des services d’accouchement afin de bénéficier des médicaments de l’HPP.

« Ce matin, lorsque je suis venue pour accoucher, la matrone m’a demandé si je voulais prendre les trois comprimés. J’ai répondu oui, » dit Mariama Niang qui a récemment accouché à la case de santé de Koulouk Mbada. « Mes saignements étaient plus légers que ceux de mes accouchements précédents où ils étaient abondants et accompagnés de vertiges. […] maintenant, je me sens bien. »

Les membres de la communauté jouent un rôle essentiel dans l’amélioration de la santé maternelle.

Au Sénégal où l’accès aux établissements de santé peut être limité dans les zones reculées, le système des cases de santé communautaire peut jouer un rôle important dans la prévention et le traitement de l’HPP. Selon l’étude, le misoprostol ainsi que l’ocytocine par Uniject® se sont tous les deux avérés tout aussi efficaces et sûrs dans la prévention de l’HPP et les matrones affectées aux cases de santé étaient en mesure d’administrer les médicaments qui leur étaient assignés. Alors que les injections standards d’ocytocine nécessitent des compétences particulières, le misoprostol et l’ocytocine par Uniject® constituent des options viables à l’échelle communautaire. Ces interventions médicales peuvent habiliter les collectivités à protéger la santé des femmes et à prévenir des décès maternels évitables.

Family care International (FCI) collabore avec Gynuity Health Projects au moyen de la recherche et du plaidoyer en vue de favoriser un accès accru au misoprostol et sa disponibilité pour la prévention et le traitement de l’HPP. Trouvez de plus amples informations relatives aux travaux de FCI et de Gynuity visant à mettre le misoprostol à la disposition des femmes à travers le monde.

Community leaders in Burkina Faso leading on women’s and children’s health

Alain Kaboré is Program Officer with FCI-Burkina Faso, based at our office in Ouagadougou, whose previous blogs can be read here, here and here.

In the Sahel region in northern Burkina Faso, a remote, arid area on the edge of the Sahara Desert, maternal and newborn mortality levels are substantially higher than in the rest of country. The majority of women, particularly in the Sahel’s hundreds of small, semi-nomadic villages, still give birth at home, without the help of a skilled birth attendant. Family Care International has been working in the Sahel for several years, in partnership with the UN Population Fund—UNFPA, the national Ministry of Health, and local grassroots organizations, to educate women about their maternal and reproductive health, increase use of the maternal health services that are available at the health center in the provincial capital, ensure that women with childbirth complications are able to access the emergency care that can save their lives, and arrange for surgical treatment for women living with obstetric fistula, a devastating injury that results from prolonged or obstructed labor.

Over the course of this work, it has become increasingly clear that local leaders — clergymen, traditional chiefs, elected officials — have the potential to influence women and their families to utilize available health services and avoid harmful beliefs and practices that are rooted in the religious and cultural traditions. Because these leaders play crucial roles in the promotion and preservation of traditional practices and beliefs, it will be difficult to spark meaningful change — like the abandonment of child marriages — until traditional leaders are educated and mobilized to promote the cause.

Community leaders at a maternal health workshop

FCI has therefore focused on working with approximately 30 religious and traditional leaders in each of the four districts that make up the Sahel region. At a series of training workshops, they have learned about all aspects of maternal health care, and have come to better understand the community determinants of maternal health and the ways that encouraging uses of health services, and particularly skilled attendance at birth, could play a large role in saving women’s and babies’ lives. At the end of the workshops, leaders were asked to implement what they learned in their communities. Some time later, a feedback meeting was organized. Here are some stories that the leaders shared at that meeting:

  • Bani is a rural town in the Seno province, located about 25 miles outside of Dori, the regional capital. After attending an FCI training session, the Imam of one of Bani’s mosques was committed to promoting maternal and infant health. With educational materials in hand, the Imam held awareness meetings at his mosque and in each of the town’s five neighborhoods, where he discussed the importance of prenatal care, of giving birth at the health center, of preventing obstetric fistula, and of treating fistula when it does occur. The Imam also approached Bani’s mayor to arrange for discussions with the members of the town council, brought health workers to meet with representatives of the five neighborhoods and of 16 surrounding villages, and invited the Dori “Khoolesmen” Association (a grassroots group that works in the community to improve maternal and newborn health) to lead discussions at four mosques and 21 adult literacy centers.

    Woman leader spreading the word
  • Diguel is a town located about 37 miles outside of Djibo, capital of the Soum province, and almost 100 miles from Dori. After attending a training workshop in Djibo, Diguel’s Imam also led a series of community discussions, focusing on the critical importance of prenatal care and skilled birth attendance. He spoke about the importance of protecting women health at the end of Friday prayers, at the special Walima marriage ceremony, and at baptisms. During a special prayer for rain, in June 2013, the Imam shared with the worshippers in his mosque what he had learned about pregnancy danger signs, emphasizing the need for husbands and other men to be involved in health issues affecting women and children. As he spoke with the men, the Imam arranged for female community outreach workers to speak with the women in another corner of the mosque’s courtyard. He also spoke with traditional chiefs in order to engage them in these efforts, and is planning to begin visiting families un their homes and to travel into more remote surrounding villages, in order to ensure that lifesaving information gets to those harder-to-reach populations.

One day, when I returned home after a short errand, I met a suffering pregnant woman wandering the street, probably returning from the fields. She was writhing in pain and I quickly recalled the signs of danger that we were shown during the training in Djibo. I went up to the woman and asked her which family she was from. I quickly drove her back to her home and when we arrived I asked for her husband, but he was not there. I then asked if the woman had received any prenatal care; but she had not, so I urged her to go to the health center to get checked out. Our religion teaches us to always care for the well-being of others to the best of our ability. I think, with the knowledge I’ve received from the training, it would be unjust not to use it to help others.

– Imam of Diguel town, Soum province, Burkina Faso

 

  • During May and June, 2013, the radio station of the Ahmadiyya  Muslim community in Dori broadcast  a program called “Health Mission,” covering topics on maternal and newborn health; the Ahmadiyya community also conducted outreach to several villages through its network of mosques.
  • The Sunni Muslim community in Dori held three awareness sessions, after the afternoon prayers in the mosques, concerning women’s health, the responsibility of men in issues of maternal and infant health, and the importance of prenatal care.
  • Leaders of the evangelical Christian community were also engaged in these efforts: 65 pastors from the towns of Dori, Sebba, and Gorom-Gorom attended a training meeting, after which they to shared what they had learned about maternal health with the congregants in their network of churches.
  • Dori’s Catholic Mission participated as well: after the chaplain and priest received training, they conducted 25 awareness programs after Saturday and Sunday masses. They then held programs with three grassroots Christian Committees, including both women and men; two awareness meetings in the rural villages of Karo and Koumbri; and a meeting with members of the Association of Catholic Women.
Bringing lifesaving information to their community

These few examples show these leaders’ commitment to raising awareness in their communities about women’s and newborns’ health, and their potential influence on traditional practices that are deeply rooted in social and religious norms and customs. This commitment is durable and sustainable, and they will continue working – with FCI’s partnership – to make these efforts to encourage healthy practices bring real change in the lives and health of women in their communities.

Burkina Faso: Expanding Access to Misoprostol for Postpartum Hemorrhage

Catherine Lalonde is FCI’s senior program officer for Francophone Africa.

Each year in Burkina Faso, more than 2,000 women die from pregnancy-related complications. Many of these deaths are due to severe and uncontrolled bleeding (postpartum hemorrhage, or PPH) that occurs following childbirth. The vast majority of these deaths can be effectively prevented or treated if women have access to high-quality maternal health care. Essential medicines, such as oxytocin and misoprostol, are safe and effective for preventing and treating PPH; however for many women in Burkina Faso, and in countries around the world, these essential medicines are not available or easily accessible. Access to misoprostol, a safe and effective medicine for preventing and treating PPH, is particularly important in developing countries, and especially in rural areas, because (unlike oxytocin) it requires neither refrigeration nor injection: it can be used even in poorly-equipped health facilities and home births.

Home births are still very common in Burkina Faso
A third of all births in Burkina Faso still take place at home; in poor villages on the edge of the Sahara, this figure exceeds 60%

In early September, FCI convened a meeting in Burkina Faso with 40 high-level officials from the Ministry of Health, local and international NGOs, and national professional societies to share the latest evidence and research and identify strategies for making misoprostol more affordable and accessible for preventing and treating PPH. A room full of champions for improved maternal health in Burkina Faso, the participants called for widespread availability of misoprostol, particularly in regions where women may not be able to reach health facilities for delivery. At the same time, participants identified a number of challenges for making misoprostol more widely available; these included:

  • High cost of the drug: As it is now, women in Burkina Faso cannot purchase a single dose of misoprostol; only larger packages — 4 or 5 doses, depending on whether it will be used for prevention or treatment — are available, and they cost more than US$5, a considerable sum in Burkina Faso.
  • Use for other indications: Some meeting participants were also concerned about the possibility that, if it were made available for PPH, untrained or unskilled health workers could use misoprostol for abortion or to induce labor.
  • Conflicts with health facility deliveries: Participants raised the fear that making misoprostol available in community settings could discourage women from going to a health facility for delivery.
  • Need for more research/data: Meeting participants discussed whether more research in regions like the Sahel — remote, rural areas, where skilled care is unavailable or very far away and home birth is consequently very common — is needed.

Women in my district die from postpartum hemorrhage, so we can’t be against the use of misoprostol [for PPH] in rural areas. In the Sahel only 38% of births are attended by a skilled professional, and it’s not because women don’t want to deliver in a clinic. Here, travelling 2 kilometers takes as long as it would to travel 30 kilometers somewhere else.– Chief Medical Officer, Gorom-Gorom District, Sahel Region, Burkina Faso

Participants identified a number of agreements and strategies for moving forward. They agreed that:

  • The potential use of misoprostol for other indications, including abortion, is not a reason to restrict access to it for PPH. A safe and effective medicine should not be withheld from women who need it simply because it can also be used for other, more controversial indications. Further, evidence suggests that making misoprostol more widely available for PPH does not increase the rate of abortion. Women who want to have an abortion will have one, whether or not they have access to misoprostol.
  •  Misoprostol should be added to the national Essential Medicines List (EML) for use in peripheral health centers. A small group was established to work on a proposal for including misoprostol for PPH in the national EML.
  •  There is a need to lower the cost of the drug, either through government funding or social marketing.

FCI works at the global level and in select countries such as Burkina Faso and Kenya, in collaboration with our partners, to support wider understanding, acceptance, and use of misoprostol for PPH. FCI maps advocacy efforts, publishes case studies, articles, and information briefs, disseminates new information, and brings together experts through online events and conferences to discuss evidence and challenges related to misoprostol’s access and availability.

“Improving Access, Saving Lives: Essential Maternal Health Medicines” Twitter Expert Hour

Every two minutes, a woman in a developing country dies from pregnancy and childbirth complications. Postpartum hemorrhage (PPH) and pre-eclampsia/eclampsia (PE/E) are the leading causes of maternal death. Although these conditions are preventable, too often life-saving medicines do not reach women in developing countries.

On September 26th, Family Care International, USAID’s Maternal and Child Health Integrated Program (MCHIP), PATH, and Jhpiego hosted a Twitter expert hour to discuss how increasing access to simple, affordable maternal health commodities — misoprostol, oxytocin, and magnesium sulfate — has the potential to save millions of women’s lives.

MCHIP Maternal Health Team staff Sheena Currie and Jeff Smith led the Twitter conversation on misoprostol; PATH’s Maternal, Newborn, and Child Health Program Leader Catharine Taylor discussed oxytocin; and Jhpiego and Jeff Smith tweeted about magnesium sulfate. The Twitter chat stimulated an exchange of compelling information and evidence and generated provocative questions from the community. You can check out the discussion in the Storify below and continue the conversation by visiting Twitter and including #supplylife in your tweets.


 

Action on the global stage: Life-saving reproductive health commodities getting much-needed attention

Ann Starrs is FCI’s president and co-founder.

During the third week of May, I was in Geneva — together with an impressive collection of global health leaders from governments, UN agencies, and civil society — for the 66th session of the World Health Assembly (WHA). I am in Geneva fairly often, for meetings with WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH) and other partners, but the annual World Health Assembly meeting is unique. The WHA is the governing body of the World Health Organization, and so it is attended by high-level delegations – usually led by the Minister of Health – from WHO’s member states. That makes WHA a great opportunity for networking and strategizing: finding an available seat, much less a table, in the famous (but oddly named) Serpent Bar at the Palais de Nations is always a challenge, as many conference participants spend virtually all of their time huddled there in intense discussion.

WHA delegates at work in the Serpent Bar (WHO/Pierre Albouy)

Issues around reproductive, maternal, newborn, and child health featured strongly in this year’s agenda, which is why I was there. The MDGs, and development goals beyond 2015universal health coverage; life-saving commodities; and frameworks for holding countries and donors accountable for fulfilling their health commitments were all on the agenda, for formal discussion, side events, and hours of conversation at the Serpent Bar.

Perhaps most importantly, this year’s WHA considered, and ultimately passed, a resolution to implement the recommendations of the UN Commission on Life-Saving Commodities for Women and Children. The resolution commits countries to improving the quality, supply, and delivery of underutilized and essential commodities for RMNCH, and tasks WHO with reporting back to WHA each year through 2015 on progress in implementing the Commodity Commission recommendations as well as those of Commission on Information and Accountability for Women’s and Children’s Health. The WHA resolution is a clear, global endorsement of the Commodity Commission recommendations, and represents a commitment by the world’s nations to ensure that life-saving medicines and technologies get to the women and children who need them. It is a significant achievement for our community, and it provides an important mechanism for ongoing advocacy, and for holding governments and development partners accountable for keeping their promises.

Notably, the Commodity Commission’s list of 13 priority commodities includes two that are advocacy priorities for FCI: misoprostol, a drug that is highly effective for preventing and treating postpartum hemorrhage (PPH), the leading cause of maternal death; and emergency contraceptives, which help women prevent unintended pregnancy after unprotected sex. (FCI is host organization for the International Consortium for Emergency Contraception—ICEC.)  At a very well-attended side event during the WHA, hosted by the delegations from Nigeria, Norway, and the U.S., along with World Vision International and PATH, speakers focused on the importance of innovation in overcoming barriers to access to essential health commodities. Presentations highlighted the substantial achievements that have already been made, and the important step forward represented by the Commodity Commission’s recommendations. Representatives from various countries also noted the significant challenges that remain, including those related to health commodity distribution systems, manufacturing, and supply. Several countries expressed a preference for purchasing and distributing locally-manufactured commodities, although this approach can sometimes raise concerns about quality assurance; further study, and advocacy, will be needed to address this challenge.

Only a few days later, and half a world away, I was one of a dozen FCI staff members who attended Women Deliver 2013, in Kuala Lumpur, Malaysia. This week was even busier – in fact, much crazier – than the previous week in Geneva; there were meetings and events starting at 7 in the morning, and organized social events went until 8 or 9 pm every night. The conference was amazing, bringing together 4,500 leaders, clinicians, program managers, and advocates representing over 2,200 organizations and 149 countries. I could not take full advantage (or anywhere near it) of everything the conference had to offer; there was an endless variety of stimulating plenary and concurrent sessions (including six sessions presenting the latest findings from Countdown to 2015, in which FCI is a leading advocacy partner), as well as Speaker’s Corner (where FCI and WHO presented new tools for strengthening countries’ policies on adolescent sexual and reproductive health). There was a youth corner and a cinema corner, a busy and bustling exhibition hall, and many, many other activities going on at all times. The cumulative value of all the connections made, facts and ideas conveyed, materials disseminated, and plans and strategies developed was immeasurable but immense.

FCI country directors (Fatimata Kane, Mali; Angela Mutunga, Kenya; Brahima Bassane, Burkina Faso) meet at the FCI booth at Women Deliver 2013

Here, too, essential health commodities were on the agenda. On the Monday morning just before the conference officially started, FCI co-sponsored a side event called “In Our Hands: Successful Strategies to Prioritize Essential Maternal Health Supplies,” at which the Maternal Health Supplies Working Group and the Maternal Health Supplies Caucus of the Reproductive Health Supplies Coalition brought together global and national advocates and program implementers in an interactive forum – including advocacy case studies from Africa, Asia and Latin America – to network, strategize, and exchange ideas for elevating maternal health supplies onto global and national health agendas. At the same time, ICEC co-sponsored a session on “Emergency Contraception: New Research Findings, Programmatic Updates, and Advocacy Strategies,” at which advocates, researchers, pharmaceutical representatives, and other leaders in the field discussed efforts to ensure access to EC globally, with a focus on developing countries.

That afternoon, FIGO and Gynuity Health Projects (our partners in misoprostol advocacy) co-hosted a discussion of misoprostol for PPH: “New Evidence and the Way Forward.” Presenters offered the latest information on ways that the current evidence can help inform and develop effective policies and service delivery programs across varying levels of the health system, and on lessons learned from innovative programs in Afghanistan and Nepal. I concluded the session with a presentation on advocacy opportunities and challenges for “Making Misoprostol an Operational Reality.”

At these and related sessions the level of discussion, the enthusiastic participation by advocates and health workers, and the clear attention that these issues are getting from policy makers, made for an inspiring and energizing two weeks. “Making sure that women and children have the medicines and other supplies they need is critical for our push to achieve the MDGs,” said Secretary-General Ban Ki-moon when he launched the Commodities Commission 15 months ago. Progress is being made, and we, together with our advocacy partners, are working hard to make sure that essential commodities are available to all who need them.