Catharine Taylor, a former practicing midwife, is the Vice President of the Health Programs Group at Management Sciences for Health (MSH). This post originally appeared on MSH’s Global Health Impact Blog.
On December 15, MSH, Gynuity Health Projects and Jhpiego hosted a one-hour webinar to share innovations – interventions, technologies, and distribution approaches – that have the potential to increase access to and use of misoprostol for postpartum hemorrhage (PPH), the leading cause of maternal death. This webinar:
Highlighted innovative ways that countries are expanding access to and use of misoprostol for PPH
Showed how successful innovations can be scaled up for national impact
Knowledge Management Specialist & Associate Program Manager, One Million Community Health Workers Campaign-Millennium Promise, Ghana
Program Associate, Gynuity Health Projects, USA
Saving Mothers Project, Mara Region, Tanzania and University of Ottawa, Canada
Monitoring, Evaluation and Research Director, Jhpiego, Afghanistan
Senior Technical Advisor, FCI Program of Management Sciences for Health (MSH)
Listen to the webinar and download the presentation slides here.
Walif was only 16 and his younger sister, Nassim, just 11 when their mother died in childbirth in Butajira, Ethiopia.
Both Walif and Nassim had been promising students, especially Walif, who had hoped to score high on the national civil service exam after completing secondary school. But following the death of their mother, their father left them to go live with a second wife in the countryside. Walif dropped out of school to care for his younger siblings, as did Nassim and two other sisters, who had taken jobs as house girls in Addis Ababa and Saudi Arabia.
Nassim was married at 15, to a man for whom she bore no affection, so that she would no longer be an economic burden to the family. By the age of 17, she already had her first child. Seven years after his mother died, Walif was still caring for his younger siblings, piecing together odd jobs to pay for their food, although he could not afford the school fees.
In all, with one maternal death, four children’s lives were derailed, not just emotionally but economically.
More than 1,000 miles away, in the rural Nyanza province of Kenya, a woman in the prime of her life died while giving birth to her seventh child, leaving a void that her surviving husband struggled to fill. He juggled tending the family farm, maintaining his household, raising his children and keeping his languishing newborn son alive.
But he didn’t know how to feed his son, so he gave him cow’s milk mixed with water. At three months old, the baby was severely malnourished. A local health worker visited the father and showed him how to feed and care for the baby. That visit saved the baby’s life.
The causes and high number of maternal deaths in Ethiopia, Malawi, Tanzania, South Africa, and Kenya — the five countries explored in the research — are well documented, but this is the first time research has catalogued the consequences of those deaths to children, families, and communities.
The studies found stark differences between the wellbeing of children whose mothers did and did not survive childbirth:
Out of 59 maternal deaths, only 15 infants survived to two months, according to a study in Kenya.
In Tanzania, researchers found that most newborn orphans weren’t breastfed. Fathers rarely provided emotional or financial support to their children following a maternal death, affecting their nutrition, health care, and education.
Across the settings studied, children were called upon to help fill a mother’s role within the household following her death, which often led to their dropping out of school to take on difficult farm and household tasks beyond their age and abilities.
How do we use these new research findings to advocate for greater international investment in women’s health?
At a webcast presentation earlier this month, a panel of researchers, reproductive and maternal health program implementers, advocates and development specialists discussed that question.
Central to the discussion was the belief that the death of a woman during pregnancy and childbirth is a terrible injustice in and of itself. The vast majority of these deaths are preventable, and physicians and public health practitioners have long known the tools needed to prevent them. And yet, every 90 seconds a woman dies from maternal causes, most often in a developing country.
The panelists expressed hope that these new data, which show that the true toll of these deaths is far greater than previously understood, can help translate advocacy into action.
It’s important to recognize that, beyond the personal tragedy and the enormous human suffering that these numbers reflect — some hundreds of thousands of women die needlessly every year — there are enormous costs involved as well. -Panelist Jeni Klugman, a senior adviser to the World Bank Group and a fellow at the Harvard Kennedy School of Government.
“So quantifying those effects in terms of [children’s] lower likelihood of surviving, the enormous financial and health costs involved and the repercussions down the line in terms of poverty, dropping out of school, bad nutrition and future life prospects are all tremendously powerful as additional information to take to the ministries of finance, to take to the donors, to take to stakeholders, to help mobilize action,” said Klugman.
Just what does “action” mean? Currently, the countries of the world are debating the new global development agenda to succeed the eight Millennium Development Goals, an ambitious global movement to end poverty. Advocates can use this research to make the case that reproductive, maternal, newborn, and child health should play a central role in this agenda, given that it reveals the linkages between the health of mothers, stable families, and ultimately, more able communities, according to Amy Boldosser-Boesch, Interim President and CEO of FCI.
Panelists also called for more aggressive implementation of the strategies known to prevent maternal mortality in the first place; as well as for the provision of social, educational, and financial support to children who have lost their mothers; and for continued research that outlines the direct and indirect financial costs of a woman’s contributions to her household, and what her absence does to her family’s social and economic well-being.
But action is also required outside of the realm of health care, said Alicia Ely Yamin, lecturer in Global Health and Population at the Harvard School of Public Health and policy director of the FXB Center.
In fact, the cascade of ill effects for children and families documented by this research doesn’t begin with a maternal death. The plight of the women captured in these studies begins when they experience discrimination and marginalization in their societies: “It [maternal death] is not a technical problem. It’s because women lack voice and agency at household, community, and societal levels; and because their lives are not valued,” she said.
Klugman added that this research adds to work on gender discrimination, including issues like gender-based violence, which affects one in three women worldwide.
It’s a tall order: advancing gender equality, preventing maternal, newborn, and child death, and improving the overall well-being of families. But panelists were hopeful that this research can show policy makers, and the public, that these issues are intertwined, and must be addressed as parts of a whole.
As Aslihan Kes, an economist and gender specialist at ICRW and one of the researchers on the Kenya study concluded, this research is “making visible the central role women have in sustaining their households.”
This is an opportunity to really put women front and center, making all of the arguments for addressing the discrimination and constraints they face across their lives. -Aslihan Kes
On October 7, 2014, a panel of experts in maternal health—moderated by Dr. Ana Langer, the Director of the Maternal Health Task Force—gathered at the Harvard School of Public Health to discuss the socioeconomic impact of a maternal death on her family and community. Several studies were summarized and priorities for how to use this research were discussed by the panel and audience at “Women’s Lives Matter: The Impact of Maternal Death on Families and Communities.”
What does the research say?
In many countries around the world, the household is the main economic unit of a society. At the center of this unit is the mother and the work—both productive and reproductive—that she provides for her family. A study in Kenya, led by Aslihan Kes of the International Center for Research on Women (ICRW) and Amy Boldosser-Boesch of Family Care International (FCI), showed great indirect and direct costs of a mother losing her life. This cost is often accompanied by the additional cost and care-taking needs of a newborn. “Once this woman dies the household has to reallocate labor across all surviving members to meet the needs of the household. In many cases that meant giving up other productive work, loss of income, hiring an external laborer, girls and boys dropping out of school or missing school days to contribute [to household work],” shared Kes. In addition, the study done in Kenya determined that families whose mother died used 30% of their annual spending for pregnancy and delivery costs; a proportion categorized by the WHO as catastrophic and a shock to a household.
Similar research was conducted in South Africa, Tanzania, Ethiopia, and Malawi by Ali Yamin and colleagues. In addition to similar socioeconomic findings to those in Kenya, Yamin found that less than 50% of children survived to their fifth birth if their mother died compared to over 90% of children whose mothers lived. An even more dramatic relationship was found in Ethiopia with 81% of children dying by six months of age if their mother had died. In South Africa, mortality rates for children whose mothers had died were 15 times higher compared to children whose mothers survived.
Increasing the visibility of maternal death
While a family is grappling with grief they are also making significant changes in roles and structure to meet familial needs. Dr. Klugman emphasized this point when she said, “Quantifying [the] effects [of maternal death]… and the repercussions down the line—in terms of poverty, dropping out of school, bad nutrition, and future life prospects—I think are all tremendously powerful. [This] additional information [is] very persuasive—to take to the ministries of finance, to take to donors, to take to stakeholders—to help mobilize action for the interventions that are needed.”
Apart from the economic and social costs, is a foundation of human rights violations and gender inequalities. The high rate of preventable maternal mortality is no longer a technical issue, but a social issue. “Maternal mortality it is a global injustice. It is the indicator that shows the most disparities between the North and the developing world in the South. It’s not a technical problem, it’s because women lack voice and agency at household, community, and societal levels and because their lives are not valued. Through this research of showing what happens when those women die, it shows in a way how much they do [and how it] is discounted,” said Dr. Yamin, whose research focuses on the human rights violations in maternal health.
Leveraging this research for improved reproductive, maternal, newborn, and child health
The research findings are clear: prevention of maternal mortality is technically feasible, the right of every woman, and significantly important for the well-being of a family and a community. Boldosser-Boesch provided three reasons why making the case for preventing maternal mortality is critical at this time.
These findings strengthen our messaging globally and in countries with the highest rates on the importance of preventing maternal mortality, by increasing access to quality care, which includes emergency obstetric and newborn care.
This research supports integration across the reproductive, maternal, newborn, and child health (RMNCH) continuum to break down current silos in funding and programs.
“We are at a key moment… for having new information about the centrality of RMNCH to development, because… the countries of the world are working now to define a new development agenda, beyond the MDGS, post-2015. And that agenda will focus a lot on sustainable development… and we see in these findings… , connections to the economic agenda…, questions of gender equality, particularly what this means for surviving girl children, who… may experience earlier marriage or lack of access to education,” shared Boldosser-Boesch.
In order to move the agenda forward on preventing maternal mortality and ensuring gender equality, ministries of health and development partners must be engaged. In addition, donors can fund the action of integration to address a continuum approach and media outlets should be leveraged to disseminate these findings and hold governments accountable for keeping promises and making changes. The prevention of maternal mortality is a human rights-based, personal, and in the socioeconomic interest of a family, community, and a society.
This panel included:
Ana Langer, Director of the Maternal Health Task Force
Alicia Yamin, Lecturer on Global Health at the Harvard School of Public Health
Amy Boldosser-Boesch, Interim President & CEO, Family Care International
Jeni Klugman, Senior Adviser at The World Bank Group
Aslihan Kes, Economist and Gender Specialist, International Center for Research on Women
The sudden death of a woman from largely preventable causes during pregnancy or childbirth is a terrible injustice that comes at a very high cost. Her death is not an isolated event, but one that has devastating repercussions on her newborn baby (if it survives), her children, husband, parents, other relatives, and community members.
On October 7th, 2014, FCI will join with the FXB Center for Health and Human Rights and the International Center for Research on Women (ICRW) to host a livewebcast to explore new research documenting the dramatic economic and social impacts of a woman’s death during pregnancy or childbirth. We will feature new findings from Tanzania, Kenya, Ethiopia, Malawi and South Africa, which advocates can use to argue for efforts to save the lives of nearly 300,000 women who die each year from pregnancy- or childbirth-related causes, almost all of which are preventable.
A mother’s death, tragic in its own right, impacts her family’s financial stability and her children’s health, education, and future opportunities. According to the Kenya study we conducted with ICRW and the KEMRI-CDC Research and Public Health Collaboration, when a mother dies in or around childbirth, her newborn baby is unlikely to survive. Surviving children are often forced to quit school or if they continue their studies, they become distracted from grief or new household responsibilities. Also, when a woman dies, funeral costs present a crippling hardship to her family, while the loss of a productive member disrupts the family’s livelihood.
The studies conducted by the FXB Center also revealed increased child mortality. Qualitative research illustrated a link between maternal mortality and the survival, health, and well-being of children. In Tanzania, for example, the FXB Center’s researchers found that children whose mothers had died during pregnancy or childbirth have a higher risk of being undernourished. The loss of a mother, the central figure responsible for the care and education of her children, often results in the dissolution of her family.
Although countries have made great strides to improve maternal health, too many countries still have a high burden of maternal death. The most recent Countdown to 2015 report noted that of the 75 Countdown countries, which together account for more than 95% of all maternal, newborn, and child deaths, half still have high maternal mortality ratios (300–499 deaths per 100,000 live births), and 16 countries—all of them in Africa—have a very high maternal mortality ratio (500 or more deaths per 100,000 live births). The studies that will be presented in this webinar provide urgently-needed evidence that advocates can use to persuade governments, donors, and policy makers that investments in women’s health and maternal health are also investments in newborns and children, in stable families, in education and community development, in stronger national economies and, ultimately, in sustainable development. As the report, Investing in Women’s Reproductive Health, notes:
[I]nvestments in reproductive health are a major missed opportunity for development. Effective and affordable interventions are available to improve reproductive health outcomes in developing countries, and the challenge is less about identifying these interventions but rather in implementing and sustaining policies to put proven packages of interventions and reforms into practice.
Pregnancy and childbirth should never cost a woman her life. But this research shows that the true price of a maternal death is even higher than that. It is a premium her family will continue to pay long after she’s gone.
The live webcast will include the following panelists: