The economic and social impacts of maternal death  

Guest post by Tezeta Tulloch, communications manager at the FXB Center for Health and Human Rights at Harvard University. This post originally appeared on the BMC Blog.

What happens when a mother dies? In the West, the most ready and obvious answer is grief – the harrowing emotional and psychological toll of losing a loved one. A mother’s death is largely viewed as a private tragedy that will grow more manageable in time.

But in many developing countries, a mother’s death is much more than an emotional crisis, often leading to long-term social and economic breakdown, both for her immediate family and the wider community. This topic is explored in new depth, in a special issue launched today in Reproductive Health (an open-access journal).

“The True Cost of Maternal Death: Individual Tragedy Impacts Family, Community and Nations” focuses exclusively on the immediate and longer-term effects of maternal death on surviving children, households, and communities. It features seven studies, with data drawn from four African countries – Ethiopia, Kenya, Malawi, and South Africa.

The research was conducted by two research groups, one led by Harvard’s FXB Center for Health and Human Rights, and the other a consortium made up of Family Care International, the International Center for Research on Women, and the Kenya Medical Research Institute (KEMRI)-CDC Research and Public Health Collaboration. The results provide hard evidence that a mother’s loss can devastate the livelihoods, quality of life, and survival chances of those she leaves behind.

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The supplement features seven studies, with data drawn from four African countries – Ethiopia, Kenya, Malawi, and South Africa. Photo via Pixabay

Continue reading “The economic and social impacts of maternal death  “

Advocacy success story: Burkina Faso broadens access to misoprostol, an essential maternal health medicine

By Brahima Bassane, MD

[Version française ci-dessous]

Brahima Bassane, FCI’s national director in Burkina Faso, is a public health physician.

Postpartum hemorrhage (PPH) — excessive, uncontrolled bleeding after childbirth —remains the leading cause of maternal death worldwide.  In countries like Burkina Faso, where many births still occur at home, the drug misoprostol offers a number of advantages for preventing and treating PPH because (unlike oxytocin, considered the ‘gold standard’ medicine for PPH) it can be easily administered and does not require cold storage. In settings with limited infrastructure and lack of skilled birth attendants, misoprostol may be a woman’s only chance for surviving PPH.

Access to high-quality medicines is part of every citizen’s right to the highest attainable standard of health. But in spite of misoprostol’s proven safety and efficacy, decision-makers in some countries have been reluctant to authorize its widespread availability, or are unaware of the available evidence. Many governments have not included misoprostol in their national essential medicine list (EML), which is often used as the basis for importation, distribution, and marketing of medicines for the public health system.

FCI works to support wider understanding, acceptance, and use of misoprostol for PPH. This year in Burkina Faso, our efforts — with a range of advocacy partners — to persuade government officials to deem misoprostol for PPH an essential medicine were successful. This success story offers a potential model for effective, collaborative, focused advocacy in other countries where misoprostol’s lifesaving benefits are not yet broadly available.

Our advocacy began in earnest last September, when FCI convened a meeting  to share the latest research on misoprostol for PPH and to develop advocacy strategies that would convince the government to take action. These committed and motivated maternal health champions called for the widespread availability of misoprostol, stating that the inclusion of misoprostol in the national EML was an urgent national priority.

Following the meeting, a small advisory committee was assigned the task of reaching key government decision makers. The committee submitted a letter and technical note to the Director-General of Pharmacy, Medicines, and Laboratories (DGPML) requesting inclusion of misoprostol on the EML. A DGPML technical committee then reviewed the submitted application, gathering all available evidence on misoprostol. During this review period, FCI and our partners met again with the Director-General of the DGPML, who stated his support for misoprostol as a critical tool for reducing the burden of PPH in Burkina Faso. FCI and partners also met with the Secretary-General of the Ministry of Health, who affirmed the government’s responsibility for ensuring the availability of misoprostol for PPH at public health facilities. He also came out in support of misoprostol distribution at the community level, and recommended ongoing supervision and training to ensure its correct use.

In February of this year, all of these advocacy efforts paid off: the 2014 revision of the national EML (Liste Nationale Des Medicaments et Consommables Medicaux Essentials, Edition 2014) includes misoprostol both for prevention and for treatment of PPH.

While this is an important step in making misoprostol available in the government health system, FCI and our partners will continue advocating and working to ensure that all women have access to a uterotonic , like misoprostol or oxytocin, for effective prevention and treatment of postpartum hemorrhage. These efforts are critical for countries’ efforts to fulfill the promise of MDG 5 and put an end, once and for all, to preventable maternal death.

Learn more about FCI’s work on misoprostol for PPH here.

To join an online community on misoprostol for PPH, please click here.

 

Réussite exemplaire du plaidoyer : Le Burkina Faso élargit l’accès au misoprostol, un médicament essentiel de la santé maternelle

Par Brahima Bassane, MD– médecin en titre

Directeur national de FCI au Burkina Faso, Brahima Bassane est médecin de santé publique.

L’Hémorragie du post-partum (HPP) — des saignements excessifs, difficiles à arrêter survenant après l’accouchement — demeure la principale cause de décès maternels à travers le monde. Dans des pays tels que le Burkina Faso où un nombre important des accouchements surviennent encore à domicile, le médicament misoprostol fournit nombre d’avantages pour la prévention et le traitement de l’HPP dans la mesure où il peut être facilement administré et ne nécessite pas une conservation à dans un réfrigérateur (contrairement à l’ocytocine qui est considérée comme le médicament ‘de référence’ pour l’HPP).Le misoprostol peut représenter la seule chance de survie d’une femme en proie à l’HPP dans les milieux communautaires qui disposent d’un nombre insuffisant de centres de santé et d’accoucheuses qualifiées.

L’accès à des médicaments de haute qualité est un des droits de chaque citoyen pour lui permettre de jouir du meilleur état de santé possible. Toutefois, en dépit de l’innocuité et de l’efficacité reconnues du misoprostol, les décideurs ont été dans certains pays, réticents à autoriser sa mise à disposition généralisée ou ils ignorent les données disponibles. Plusieurs gouvernements n’ont pas inclus le misoprostol dans leur liste des médicaments essentiels (LME) qui est souvent utilisée comme critère pour l’importation, la distribution et la commercialisation de médicaments pour le système de santé publique.

FCI œuvre en vue de soutenir une meilleure compréhension, acceptation et utilisation du misoprostol pour l’HPP. Au Burkina Faso, nos initiatives —de concert avec un éventail de partenaires du plaidoyer —visant à convaincre cette année les responsables gouvernementaux de considérer le misoprostol pour l’HPP comme un médicament essentiel, ont été couronnées de succès. Cette réussite exemplaire fournit un modèle potentiel de plaidoyer efficace, mené en collaboration et bien ciblé dans d’autres pays où les avantages salvateurs du misoprostol ne sont pas encore largement disponibles.

Notre plaidoyer a véritablement débuté en septembre 2013 lorsque FCI a organisé une réunion en vue de partager les résultats des toutes dernières recherches sur le misoprostol pour l’HPP et de mettre au point des stratégies de plaidoyer qui convaincraient le gouvernement à prendre les bonnes décisions. Ces défenseurs engagés et motivés de la santé maternelle se sont prononcés pour la mise à disposition généralisée du misoprostol en indiquant que l’inclusion du misoprostol dans la Liste nationale des médicaments essentiels était une priorité nationale.

Suite à la réunion, la tâche de prendre contact avec les principaux décideurs gouvernementaux a été confiée à un petit comité consultatif. Le comité a présenté au Directeur Général de la Pharmacie, du Médicament et des Laboratoires (DGPML) une lettre et une note technique sollicitant l’inclusion du misoprostol dans la LME. Un comité technique de la DGPML a ensuite examiné la demande soumise en recueillant toutes les données disponibles relatives au misoprostol. Au cours de cette période d’examen, FCI et nos partenaires se sont réunis avec le Directeur Général de la GPML qui a exprimé son soutien pour le misoprostol comme outil crucial pour alléger le fardeau de l’HPP au Burkina Faso. Cette équipe restreinte de FCI et ses partenaires s’est également réunie avec le Secrétaire Général du Ministère de la Santé qui a affirmé la responsabilité du gouvernement à assurer la disponibilité du misoprostol pour l’HPP dans les établissements de santé. Il s’est également prononcé en faveur de la distribution du misoprostol jusqu’à l’échelle communautaire  tout en recommandant une supervision suivie et la formation afin de garantir son utilisation adéquate.

En février au cours de cette année 2014, toutes ces initiatives du plaidoyer ont porté leurs fruits : la révision en 2014 de la LNMCE (Liste Nationale Des Médicaments et Consommables Médicaux Essentiels, Édition 2014) comprend notamment le misoprostol pour la prévention ainsi que le traitement de l’HPP.

Bien que la mise à disposition du misoprostol dans le système public de santé constitue une étape importante, FCI et nos partenaires continueront à plaider et à œuvrer pour veiller à ce que toutes les femmes aient accès à un utérotonique tel que le misoprostol ou l’ocytocine pour une prévention et un traitement efficaces de l’hémorragie du post-partum. Ces initiatives sont cruciales pour les efforts des pays à tenir leur promesse pour l’OMD5 et à définitivement mettre un terme aux décès maternels évitables.

Trouvez de plus amples informations relatives aux travaux de FCI sur le misoprostol pour l’HPP.

Veuillez cliquer ici pour intégrer une communauté virtuelle sur le misoprostol pour l’HPP.

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.