While poor maternal outcomes among Black women in the U.S. is not new, improving it is imperative. U.S. policymakers can look to sub-Saharan Africa for guidance on reversing this trend. Credit: Ernest Ankomah/IPS

By Ifeanyi Nsofor
ABUJA, Jun 2 2023 (IPS)

New research shows that Black mothers in the United States disproportionately live in counties with higher maternal vulnerability and face greater risk of preterm death for the fetus, greater risk of low birth weight for a baby, and a higher number of maternal deaths.

While poor maternal outcomes among Black women in the U.S. is not new, improving it is imperative. U.S. policymakers can look to sub-Saharan Africa for guidance on reversing this trend.

The problem of poor maternal health for Black women in the U.S. is dire. Too many Black women die during pregnancy and childbirth due to preventable causes. For instance, the 2020 maternal mortality data rates released by the U.S. Centers for Disease Control showed overwhelming maternal deaths among Black women compared to other women over a 3-year period (2018 – 2020).

The 2020 maternal mortality data rates released by the U.S. Centers for Disease Control showed overwhelming maternal deaths among Black women compared to other women over a 3-year period (2018 - 2020). To put it in context, maternal deaths among Black women in the U.S. is worse than African countries like Namibia, Botswana, South Africa, Libya, Tunisia and Egypt.

To put it in context, maternal deaths among Black women in the U.S. is worse than African countries like Namibia, Botswana, South Africa, Libya, Tunisia and Egypt.

Further, according to the Kaiser Family Foundation, maternal and infant health disparities are symptoms of broader underlying social and economic inequities that are rooted in racism and discrimination.

In a previous piece, I wrote about the way that institutionalized racism is keeping Black Americans sick. Therefore, healthcare providers and policymakers across the U.S. must ensure respectful maternity care for all women during pregnancy, childbirth and afterwards.

The United Nations Office of the High Commissioner for Human Rights says respectful maternity care“encompasses respect for women’s basic human rights, including recognition of and support for women’s autonomy, dignity, feelings, choices, and preferences, such as choice of companionship wherever possible”.

Unfortunately, there is overwhelming evidence that Black American women face disrespect and profound indignity during pregnancy and childbirth. Tennis player and businesswoman Serena Williams almost died due to blood clots after giving birth because her nurse refused to listen to her cry for help. That clot could have led to a stroke. Her doctor eventually listened to her, and this saved her. If one of the most influential and most powerful women can have such a near-death experience, what is the fate of other Black American women who are not as privileged? Respectful maternity care is a way to ensure equity irrespective of class and race.

These are three lessons American policymakers can learn from successful maternal health projects across countries in sub-Saharan Africa as they try to save Black American lives.

First, is the continuum of care – prevention of postpartum hemorrhage project, implemented by Pathfinder International in Nigeria. It was a novel project that deployed several evidence-based interventions to prevent excessive bleeding after childbirth across the country.

These included the use of misoprostol to ensure adequate uterine contraction after the delivery of the baby; use of a plastic sheet with a pouch for blood loss estimation and active management of the third stage of labor to ensure the placenta is properly separated after the baby is delivered. These interventions led to a reduction in women who bled excessively after childbirth and improved the overall survival of women in participating health facilities.

For example, a new study on the efficacy of the plastic sheet carried out in 80 hospitals across 4 African countries, showed a reduction in the number of women experiencing severe bleeding by 60%.

A second example is the maternal nutrition program, implemented by Garden Health International in Rwanda. Adequate nutrition during pregnancy is imperative for the wellbeing of the unborn child.

The first 1000 days of life are even more crucial. Through the Maternal Nutrition curriculum, pregnant women are encouraged to attend antenatal classes at least four times in health facilities where they are educated on how to address the factors that can contribute to malnutrition. Women are taught how to prepare a balanced meal, the importance of hygiene and food safety in preventing malnutrition, the importance of the timely introduction of breastfeeding and complementary feeding, and postnatal care.

For instance, through the “one pot, one hour” cooking initiative, families are taught to use readily available foods to prepare nutritious meals is a core component of this program. Its success led to its adoption by the Rwandan Ministry of Health and it was implemented by 44,000 community health workers across the country.

A last example is the Kangaroo Mother Care for very low birth weight infants in South Africa. Very low birth weight infants are prone to hypothermia – a significant and potentially dangerous drop in body temperature.

According to the WHO, Kangaroo Mother Care involves infants being carried, usually by the mother, with skin-to-skin contact. If the mother is unable to fulfill the role, the father or other members of the family can take on the responsibility of skin-to-skin contact and provide warmth for the infant. A study of Kangaroo mother care of 981 very low birth weight infants admitted at Charlotte Maxeke Johannesburg Academic Hospital over a six-year period showed increased weight gain, lower rates of complications of prematurity and low overall mortality.

A multi-country study by the World Health Organization showed that in Ethiopia, government leadership; an understanding by health workers that kangaroo mother care is the standard of care; and acceptance of the practice from women and families helped improve the implementation of kangaroo mother care.

Institutionalized racism over many decades has put Black Americans in the most vulnerable counties in the U.S. Health policymakers, healthcare providers, donors, non-profit organisations and all stakeholders involved in maternal healthcare in the U.S. must implement interventions that are shown to save lives. The African continent is a great place to look.

Dr. Ifeanyi M. Nsofor, MBBS, MCommH (Liverpool) is Senior New Voices Fellow at the Aspen Institute, Senior Atlantic Fellow for Health Equity at George Washington University, 2006 Ford Foundation International Fellow

The First Lady of Kenya, Governor Ali Roba and the Executive Director of UNFPA, Dr Osotimehin, in Mandera County. Credit: UNDP Kenya

By Ruth Kagia and Siddharth Chatterjee
NAIROBI, Kenya, Nov 9 2015 (IPS)

Mandera in northeastern Kenya, has often been described as “the worst place on earth to give birth.” Mandera’s maternal mortality ratio stands at 3,795 deaths per 100,000 live births, almost double that of wartime Sierra Leone at 2,000 deaths per 100,000 live births.

But Mandera also demonstrates what can be achieved with strong political leadership and strategic partnerships. Just under a year ago, on December 2, 2014, we were part of a team from the United Nations, World Bank, charities and the Office of the President of Kenya that undertook the two-hour flight to Mandera to determine what could be done to address this critical development bottleneck.

Minutes before take-off, news came through that 36 Kenyans had been brutally murdered in Mandera by the Somali militant group al Shabaab.

No official briefing could have better highlighted the challenges of the task ahead. Rather than acting as a deterrent, it strengthened our resolve and we continued with our journey.

Marginalization combined with internecine conflicts, pockets of extremism, poor human development and cross border terrorism have trapped so many of Mandera’s people in poverty and misery. In addition, women and girls are subjected to cultural practices such as female genital mutilation and child marriage, which contribute to high school dropouts and complicate delivery.

The government has been focused in its resolve to change the narrative in Mandera and in other historically disadvantaged parts of Kenya. The introduction of free maternity services, for example, has increased the number of Kenyan women giving birth under skilled care from about 40 to 60 per cent since 2013.

Together with the government, the United Nations Population Fund (UNFPA) Kenya mobilised private sector partners to develop innovative strategies to improve maternal and child health, especially in the six counties with the highest maternal and child health burden: Lamu, Isiolo, Wajir, Mandera, Marsabit and Migori.

On October 13, we launched a Community Life Centre in Mandera with the technology company Philips. The centre, equipped with solar lighting, fridges, lab and diagnostic equipment, will provide better healthcare services for about 25,000 people.

UNFPA Executive Director Dr Babatunde Osotimehin has given a very clear message that UNFPA must help the hard to reach and the most vulnerable. With this resolve, UNFPA, together with the World Bank, UNICEF and the World Health Organization, supported by the Ministry of Health, mobilized 15 million dollars to improve maternal, child and adolescent health services in the six counties in March 2015.

These efforts were given a major boost on November 6, 2015, when Kenya’s First Lady H.E. Margaret Kenyatta handed over a fully-kitted mobile clinic to Mandera. The First Lady launched the Beyond Zero campaign in 2014 to reduce maternal and child mortality in Kenya.

Dr. Osotimehin flew in from New York for the event, and was joined by the ambassadors of the European Union, Denmark, Sweden and Finland.

The First Lady said: “For too long, the prospect of childbirth in Kenya, to thousands of women, has been tantamount to a death sentence. No one should die giving life.”

Dr Osotimehin said: ‘‘When we invest in strengthening the health system from the community to the facility, when we invest in strong referral systems and complementary basic services, we save women’s lives but we also underwrite our future as humanity.”

Maternal health is a perfect illustration of the fact that the process of development is multi-dimensional. Poor maternal health affects women, their children and their communities. It affects nutrition, human development, population dynamics and it undermines the quality of the labour force.

When you improve maternal health, you create healthy families, strong communities and strong economies.

Like the tentative steps of an infant beginning to walk, these may seem modest achievements in the face of the significant challenges in these remote counties. The counties require structural changes which can lead women out of poverty, eliminate gender inequalities and build stronger health systems.

The partners’ grit and the commitment demonstrated by the government together with leaders like the First Lady and Mandera County Governor Ali Roba give reason for optimism that these challenges can be overcome.

Improving maternal health is not only achievable, it is a goal worth reaching.

(End)

Excerpt:

The global rate of maternal deaths is reducing faster than any time in history, according to a new report presented to the United Nations on Tuesday.

The ‘Every Woman Every Child’ initiative has saved 2.4 million women and children since its inception in 2010, claims the report Saving Lives, Protecting Futures, presented by U.N. Secretary-General Ban Ki-moon.

The report states maternal mortality has been nearly halved since 1990, and in 2013, 6.4 million fewer children under age five died compared to 1990. Every Woman Every Child states 11 million more women have given birth in a health facility, 8.4 million more women and girls use modern contraception, and post-natal care for women increased 25 percent.

“Our task now is to maintain and build on that momentum, complete the unfinished health MDGs, end the appalling tragedy of preventable deaths and invest in the futures of women, children and adolescents,” Ban wrote in the report’s foreword.

“Yet we can and must do much more to provide access to the health care that women need… we must work to ensure that children are born into a safe environment where they will receive necessary vaccines, nutrition and care. There is still too much needless suffering.”

More than two-thirds of the $60billion pledged to the initiative by partner countries and institutions has been distributed and used. Speaking at the launch of the report, Ban said signs of progress were encouraging.

“More women are giving birth in a health facility, more women and girls are receiving the sexual and reproductive health services they want and need, and more pregnant women are receiving anti-retrovirals to prevent HIV transmission to their babies,” he said.

“Our task now is to maintain and build on that momentum, complete the unfinished health MDGs, end the appalling tragedy of preventable deaths and invest in the futures of women, children and adolescents.”

Every Woman Every Child describes itself as an “unprecedented global movement that mobilizes and intensifies global action to improve the health of women and children around the world.” The programme began in response to Millennium Development Goals (MDGs) four and five, concerning maternal health and child mortality, which were seen as the MDGs “were lagging furthest behind.”

The report urges partner to keep reproductive, maternal, newborn and child health “high on the global agenda in the post-2015 era.” The initiative has set its goal as reducing the global maternal mortality rate to 70 in 100,000 births, and newborn mortality rates to 12 per 1000 births.

Follow Josh Butler on Twitter @JoshButler

Edited by Roger Hamilton-Martin

Of the 100 patients seen at Kashmir’s psychiatric facilities each day, roughly 75 are women. Credit: Shazia Yousuf/IPS

By Shazia Yousuf
SRINAGAR, India, Nov 19 2014 (IPS)

It was almost midnight when Mushtaq Margoob woke up to the incessant ringing of his phone. It was his patient, a young woman whom Margoob, a renowned Kashmiri psychiatrist and head of the department of psychiatry at the only psychiatric hospital in Kashmir, had been treating for depression for many years.

“See me now. I don’t have time till tomorrow,” the patient screamed down the phone. “I might have killed myself by then.”

The woman was educated, had a PhD in Bioscience and came from a rich family. After her marriage last year, the symptoms of her depression had begun to fade away, and she had started crawling back to a normal life.

“I have gifted lifelong sadness to my daughter.” -- Shahzada Akhtar, a Kashmiri woman living with PTSD
But the day she made the hasty phone call to the doctor, she had learned something that shattered her life into fragments all over again.

“I have been diagnosed with Premature Ovarian Failure [POF],” she said to Margoob at his home. “If I cannot have any children, what should I live my life for?”

Although Margoob was able to pacify her with timely counseling and medication, the diagnosis and the constant reminder of being infertile have taken his patient back into deep depression.

“The mental stress due to ongoing conflict has taken a toll on the physical health of young women, especially their maternal health,” explains Margoob.

Downward spiral of mental and maternal health

The conflict here, which dates back to the 1947 partition of India and Pakistan, has claimed some 60,000 lives as Indian armed forces, Pakistani troops and ordinary Kashmir citizens struggle to assert control over the bitterly contested region.

The “pro-freedom” uprising of 1989, launched by Kashmiris who resented the presence of Indian and Pakistani troops, morphed into a long-standing resistance movement that has left deep scars on Kashmiri society.

As a result, the area known as the Kashmir Valley, tucked in between towering mountain ranges in the northern Indian state of Jammu and Kashmir, is witnessing an alarming increase in childlessness and infertility among local women.

Infertility is becoming increasingly common among young Kashmiri women, who are suffering from stress and trauma due to the long-standing conflict in the region. Credit: Shazia Yousuf/IPS

Physical and mental health experts cite conflict-related stress as the main cause of the health crisis among women, which has robbed thousands of their fertility.

The most recent Indian National Family Health Survey (NFHS) indicates that 61 percent of currently married Kashmiri women report one or more reproductive health problems.

This is significantly higher in comparison to the national average of 39 percent. The percentage of POF among infertile women below 40 years of age is also abnormally high – 20 to 50 percent – when compared to the nationwide rate of one to five percent.

“Stress causes structural changes in the brain and disturbs the secretion of various neurotransmitters. These changes lead to various physical ailments including thyroid malfunction, which in turn can cause infertility among women of childbearing age,” Margoob explains to IPS.

According to statistics available with the Government Psychiatric Diseases Hospital, 800,000 Kashmiris are suffering from Post Traumatic Stress Disorder (PTSD) and most of them are women. PTSD, like many other mental health disorders, directly affects women’s childbearing capacity.

Stress and stigma

In Kashmir, psychiatry OPDs are run at two hospitals – the Shri Maharaja Hari Singh (S.M.H.S) facility in Srinagar, and the Government Psychiatric Diseases hospital – six days a week. Of almost 100 patients seen at each OPD every day, 75 are females.

One of the many women who frequents these facilities is 20-year-old Mir Afreen, who grew up watching her mother battling mental illness. In 1996, when Afreen was only two, her mother, Shahzada Akhtar, received a message about the death of her cousin brother in cross-fire.

“I had met him only a day before. I couldn’t believe he had died. I tried to cry out his name but had lost my voice,” recalls Akhtar.

Akhtar never recovered from the sudden, devastating news, and soon developed PTSD.

In consequence, her daughter’s childhood quickly slipped into darkness. Afreen often saw her mother sedated, sleeping for days at a time, going without food, and crying for no apparent reason.

She was always taken along to psychiatric clinics, hospitals and faith healers where her mother searched for a cure for her condition. Happiness was far, far away from their home.

“I have gifted lifelong sadness to my daughter,” Akhtar tells IPS tearfully.

Her statement is not too far from the truth. For the last several years, Afreen has been complaining about chest pains and breathlessness. Akhtar first thought it was due to stress, or her daughter’s recent obesity.

But when Afreen developed facial hair and her monthly cycles became irregular, Akhtar took her to a gynecologist.

“The doctor uttered a long name which I couldn’t understand, so I asked her to explain the [condition] to me,” Akhtar says. “She told me if this is not treated, Afreen will never have children.”

Afreen was diagnosed with Polycystic Ovarian Syndrome (PCOS). Unknown and almost non-existent before the conflict, the syndrome now affects 10 percent of Kashmiri females including teenagers.

A major endocrine disorder in women of reproductive age and one of the leading causes of infertility across the world, PCOS has emerged as another major cause of infertility among Kashmiri women in recent years.

Medical experts have identified stress as one of the main reasons for the emergence of PCOS in Kashmir. A study conducted by Sher-i-Kashmir Institute of Medical Sciences (SKIMS), the major tertiary healthcare facility in Kashmir, on 112 women with PCOS, found that 65 to 70 percent of them had psychiatric illnesses including PTSD, depression and Obsessive Compulsive Disorder (OCD).

Akhtar feels helpless. Unlike other ailments, Afreen’s particular health issue is not up for discussion, not even with her own siblings. If the word spreads, she thinks, it will ruin her daughter’s marriage prospects and thus destroy her life.

“Even when I take her to the doctor, I make sure that no one sees us,” reveals Akhtar. “I first check the place and then let my daughter in.”

Afreen does the same. She has not revealed anything about her condition to her friends. When the girls talk about their grooms and life after marriage, she keeps mum. When it is the time for her medication, she secretly swallows the pills without water.

Current trends predict a bleak future

Nazir Ahmad Pala, an endocrinologist at SKIMS, says that more and more young females visit the endocrinology department for various disorders. A good number of disorders, he says, are born from depression.

Anxiety over the possibly loss of male breadwinners is prompting many women to choose education and employment over marriage. Credit: Shazia Yousuf/IPS

“In the past, the department received mostly older patients but now around 20 percent of our patients are school and college going girls with endocrine abnormalities. This trend is disturbing,” Pala tells IPS.

The young girls mostly complain of obesity and ovulatory disturbances that bring a temporary halt in their menstrual cycles.

The condition is called Central Hypogonadism and is common in depressed women, explains the doctor. Another equally frequent ailment is galactorrhea, a spontaneous secretion of milk from the mammary glands due to an abnormal increase of prolactin levels in the body caused by antidepressant intake.

“Unfortunately most of the [conditions], in one way or the other, lead to infertility. And the root cause of all these [conditions] is the stressful life that women have been living in the post-conflict era,” Pala asserts.

Experts here are sounding warnings about the catastrophic shape that women’s health in the Valley is taking. A study conducted at SKIMS on maternal health indicates that 15.7 percent of Kashmiri women of childbearing age will never have an offspring without clinical intervention.

Another conflict-related cause of infertility among Kashmiri women is late marriages. Over the war years, the marital age has risen from an average of 18-21 to 27-35 years. Because of economic insecurity and anxiety over the prospect of losing male breadwinners, women are choosing education and employment over marriage.

“Economic instability and insecurity is eating our society like termites,” says Margoob.

The doctor reveals that cut-throat competition in schools and colleges to earn a secure future has hugely disturbed the mental health of young girls as well.

Dissociative Disorders (DD), marked by disruptions or breakdowns in identity, memory or perception, are rapidly increasing in young school- and college-going girls, along with conditions like Panic Disorder, all of which interrupt the “smooth journey to motherhood”, Margoob says.

*Patients’ names have been changed on request.

Edited by Kanya D’Almeida

Indigenous women hauling water in Chiapas, Mexico. Credit: Mauricio Ramos/IPS

By Purnima Mane
WASHINGTON, Aug 6 2013 (IPS)

In the last decade, several countries in the Latin America and Caribbean (LAC) region have had the opportunity to experience economic growth and establish redistributive fiscal policies aimed at reducing poverty, reducing inequality and improving the coverage and quality of health, education and social protection services.

And yet significant gaps exist in the area of reproductive health and rights, both between countries and as a whole, when it comes to some of the key objectives of the Cairo Programme of Action.

Let us take one of the basic indicators of reproductive health, the maternal mortality ratio. The decline overall in the region is not enough to guarantee the achievement of the target set for 2015.

The average maternal mortality rate in LAC is 80 maternal deaths per 100,000 live births, according to estimates by WHO, UNFPA, UNICEF and World Bank, 2011. Moreover, there are significant inequities between countries.

For example, the estimated maternal mortality rate in Uruguay was 29 deaths per 100,000 live births in 2010, while it was 120 in Guatemala; Haiti exhibits the highest ratio in the region, with 350 maternal deaths per 100,000 live births.

A significant proportion of maternal deaths are caused by unsafe abortions, which represent a serious public health concern in the region.

In 2008, the annual rate of unsafe abortion estimated for the region was 31 abortions per 1,000 women aged 15-44. In 2008, 12 percent of all maternal deaths in Latin America and the Caribbean (1,100 in total) were due to unsafe abortions, according to the World Health Organisation.

Abortion is only legal in six countries, and together, these countries account for less than five percent of the region’s women aged 15-44. (Guttmacher Institute, 2012).

In addition to the discrepancies noted in regard to maternal mortality and access to safe abortion between countries, there are also intra-country disparities.

For example, while the total fertility rate has reduced considerably, in Bolivia (DHS, 2008), the total fertility rate of women with no education was 6.1 compared to 1.9 for women with higher education, and the urban-rural difference is 2.8 to 4.9, respectively; in Panama, maternal mortality is five times higher among indigenous women.

What is even more tragic is that Latin America and the Caribbean has the second highest rate of adolescent pregnancy in the world, with approximately 70 live births per 1,000 women aged 15-19. On an average, 38 percent of women in the region become pregnant before they reach the age of 20 and nearly 20 percent of live births in the region are by adolescent mothers.

The conclusion is clear: universal access to reproductive health is still far from being a reality in the LAC region.

Looking specifically at the seven components of the programme of action, the LAC countries have achieved much higher rates of contraceptive prevalence than Africa or Asia as a whole.

For example, in 2012, the average contraceptive prevalence rate (CPR) among married women in Africa was only 26 percent and 47 percent in Asia (excluding China); in Latin America and the Caribbean it was as high as 67 percent of married women [Population Reference Bureau].

As I said before, the LAC countries have brought down their collective maternal mortality rate to 80 deaths per 100,000 live births – a striking improvement over the Sub-Saharan African average of 500 per 100,000 live births and the South Asian average of 220 per 100,000 live births (UNICEF, 2010).

However, in other key areas of the Programme such as expression of and protection for sexual and reproductive rights including access to safe abortion, post-abortion care, and expression of gender identity or sexual orientation, the LAC region continues to be challenged.

The reasons for the progress in this region were mentioned earlier – development as a whole, higher rates of education and access to contraception have helped considerably.

Let us not forget however, that the lack of progress in ensuring reproductive rights and access to safe abortion in particular comes from the fact that a large number of LAC countries stated formal reservations to many of the rights components in the Programme of Action, including concern over abortion, a national belief and/or laws asserting a need to protect life from the moment of conception, and concern over alternate expressions of family beyond that of formal marriage between a man and a woman.

In contrast, while several other countries in other regions expressed similar reservations (notably many Islamic and Catholic countries), only one African and one Asian country (Djibouti and Philippines) presented formal reservations to this effect. These reservations have continued to hamper progress in these areas and produced the situation we see today in this region.

Purnima Mane, PhD, is President and Chief Executive Officer of Pathfinder International, a global leader in sexual and reproductive health.

A government decree in Armenia that bars pregnant women who are not residents of Yerevan from receiving free childbirth services in the capital is causing discontent in outlying regions.

In a bid to boost population numbers, the state covers the costs for childbirth services in Armenia. Seeking better facilities and medical personnel, pregnant women from the regions often travel to Yerevan to give birth. In 2012, 64 percent of the 70,648 women registered for state-provided childbirth assistance gave birth in Yerevan, according to the National Statistical Service.

The May 1 decree issued by the Ministry of Health was designed to encourage improvements at hospitals in the country’s 10 regions. Under the measure, women will only be able to obtain state-paid birthing services at hospitals in regions where they have an official address.

Health Minister Derenik Dumanian, the author of the decree, maintains that budgetary funds to improve care at public hospitals in regions will be forthcoming. The government currently pays 135,000 drams (329 dollars) per delivery in Yerevan hospitals, and 97,000 drams (236 dollars) at facilities in rural locations.

“One-third of the pregnant women from the regions come to Yerevan to give birth; hence, the money designated for rural hospitals is transferred to hospitals in Yerevan, leading to reduced financial resources in the regions, as well as an outflow of professionals from rural communities to Yerevan,” Dumanian told EurasiaNet.org.

Despite government assurances, some pregnant women from rural areas remain wary about the decree. Thirty-three-year-old Gohar Minasian, an expectant mother living in Abovian, 16 kilometers outside of Yerevan, fears the consequences of giving birth in her local hospital.

In 2011, she noted, an Abovian anesthesiologist’s mistake led to the death of a pregnant woman from heart failure. “If this had been in the capital, under the supervision of skilled professionals, both the mother and the child would have survived,” Minasian claimed, without providing supporting details.

Under the decree, pregnant women from the regions will still be able to receive free medical care in Yerevan in emergency situations. The health ministry’s chief obstetrician-gynecologist, Razmik Abrahamian, insists that pregnant women in most of Armenia’s regions already have access to adequate care.

“If a few years ago we did not have rural maternity hospitals with modern facilities and it was understandable why they had to come to Yerevan, now six out of the 10 regions have fully equipped hospitals, but people keep coming to the capital out of habit,” Abrahamian said.

“The new decree will make them at least familiarise themselves with the facilities and conditions available at their new local hospitals, and only then make a decision.”

Independent MP Edmon Marukian, who strongly opposes the decree, argues that it could end up fueling corruption.

“If there are exceptions [made to the decree] for high-risk births and [women] will be sent to deliver in Yerevan, it is quite possible that women with a normal or no-risk pregnancy might bribe someone into getting permission to give birth in Yerevan,” reasoned Marukian, who represents the northern region of Lori.

“Or a pregnant woman from a rural community might be in Yerevan and need to give birth, but a hospital might check her in only in exchange for money.”

Abrahamian dismissed corruption concerns, promising close supervision of the decree’s implementation. All hospitals have a ministry hotline number by which they can report attempted bribery, he added. “Let them call and everyone will be punished.”

Based on infant mortality statistics alone, the regions might appear a better choice to give birth than a hospital in Yerevan. In 2011, the latest year for which data is available, the capital recorded 118 infant deaths, the highest level in the country. But Abrahamian maintained that 70 percent of those deaths were of children born to women from the regions, where, he claimed, public knowledge of prenatal care is spotty.

Nationwide over the past decade, the number of infant deaths has declined steadily. From 2006-2012, the number of infant deaths per 1,000 live births dropped by half to 12. The maternal mortality rate also has fallen to a just a handful, compared with as many as 35 per year a decade ago.

Senior regional hospital staffers say public perceptions of medical care in the regions still lag behind the statistical evidence. For example, in Artashat, a town 29 kilometres southeast from Yerevan, the birthrate at the local hospital has fallen by 50 percent since 2008, when the state began paying for childbirth services.

“Our conditions are good, too, the medical personnel are highly professional, but we cannot compete with the hospitals in the capital equipped with the newest facilities,” said Dr. Zemfira Navasardian, head of the Artashat hospital’s obstetrics and gynecology department.

Obstetricians who earlier moved to Yerevan for work may now be tempted to return home, hospital executives said, but that process requires time. In the meantime, some Armenian women are not willing to wait. Barred from state-funded childbirth in Yerevan, Minasian, a kindergarten teacher, is saving to pay for the services herself.

*Editor’s note: Gayane Abrahamyan is a reporter for ArmeniaNow.com in Yerevan.

This story originally appeared on EurasiaNet.org.

Pakistan needs affordable solutions to reducing maternal deaths. Credit: Zofeen Ebrahim/IPS

By Zofeen Ebrahim
KARACHI, Sep 12 2012 (IPS)

“I can’t imagine life without misoprostol,” says Dr. Azra Ahsan, a gynaecologist and obstetrician who has, for more than a decade, been using the controversial drug to stop women from bleeding to death after delivery.

Originally intended for treating gastric ulcers misoprostol has since 2000 been gaining in popularity for its ability to induce labour and stop post partum haemorrhage (PPH).

“I knew that it can save women from dying long before 2009 when it was registered for use in Pakistan,” said Ahsan, a member of the government’s National Commission on Maternal and Neonatal Health.

WHO guidelines advocate the use of misoprostol against PPH, while the International Federation of Gynaecology and Obstetrics (FIGO) suggests using the drug in situations where regular ‘uterotonic’ drugs like oxytocin and ergometrine are not available.

Doctors like Ahsan are dismayed at moves to get WHO to reverse its listing in April 2011 of misoprostol among essential medicines that “satisfy the healthcare needs of the majority of the population” and are  “available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford.”

Findings of scientific studies published in the August issue of the Journal of the Royal Society of Medicine are being cited in suggesting that WHO should “rethink its recent decision to include misoprostol on the essential medicines list.”

Allyson Pollock, who led the study, stated that there is insufficient evidence to suggest that misoprostol works in preventing PPH. Instead, she urges poor countries to improve primary care and prevent anaemia to lower the risk of haemorrhage following delivery.

Ahsan, however, says that in Pakistan some 80 percent of pregnancy cases end up with the mother’s uterus failing to contract naturally after delivery, calling for the use of uterotonic medicines to reduce bleeding.

“Nearly 27 percent of maternal deaths in Pakistan are caused by excessive blood loss after childbirth,” Ahsan explained to IPS.

According to the latest Pakistan Demographic and Health Survey (2006), Pakistan’s maternal mortality ratio stands at 276 for every 100,000 live births, and is among the highest in South Asia.

Bleeding, the leading cause of maternal deaths worldwide, is defined by the WHO as blood loss greater than 500 ml following a delivery.

The fact that misoprostol is also misused in Pakistan – and other developing countries like Brazil – to induce abortion cheaply, has added to controversies over the drug.

“I don’t care if people think it is used, misused or even abused…I know it saves mothers from dying,” says Ahsan.

Unlike other uterotonics, misoprostol has the advantage that it does not need refrigeration for storage and can be easily administered orally by trained birth attendants, Ahsan said.

A joint statement by FIGO and the International Confederation of Midwives states: “… in home births without a skilled attendant, misoprostol may be the only technology available to control PPH.”

Zulfiqar Bhutta, head of women and child health at the Aga Khan University, Karachi, and member of the independent expert review group for maternal and child health to the United Nations secretary-general, agrees with Pollock that misoprostol needs to be evaluated more robustly.

“But I wouldn’t throw out the baby with the bath water yet,” Bhutta told IPS. “There is a need to increase its use in the right circumstances and also carefully monitor misuse. It is no magic bullet and should not lead to complacency in provision of essential maternal services,” he said.

“I think the point of the paper published recently is to try and separate  science from messianic zeal,” says Bhutta who is also co-chair of ‘Countdown to 2015’, a global scientific and advocacy group tracking progress towards the U.N. Millennium Development Goal Five pertaining to maternal health.

“Misoprostol is promising and we should do our best to evaluate its safe use,” said Bhutta. “But, there are people in Pakistan who are recommending large scale distribution to families for use in all births. Will this be cost-effective or indeed safe?”

Pollock’s study has stirred international concern. International Planned Parenthood Federation’s Upeka de Silva told IPS in an e-mail that if WHO withdraws misoprostol, it would mean “countless women will be denied life-saving care and forced to suffer pregnancy-related complications which are entirely preventable.”

“We are fully aware that all studies have limitations and that continued research on best practices for maternal care is needed,” de Silva said.

“However, for the purposes of meeting the urgent needs of women, particularly in rural, underserved communities, we are confident about being guided by the abundant literature and expert evidence supporting the safety and effectiveness of misoprostol for multiple reproductive health indications,” de Silva said.

Further, she said: “The increasing number of clients provided with safe abortion services, treatment for incomplete abortion and PPH through clinics run by our member associations is further evidence that misoprostol should remain available and accessible.”

“It’s alright to stir confusion sitting in cushy offices, but the ground reality in Pakistan is quite different,” said Ahsan. “The conditions we work under are very, very constrained…let’s not forget the hot temperatures and long power outages (causing refrigeration failure).”

At the Kakonko Health Centre, about 250 kilometres from the nearest hospital in Kigoma Region, Western Tanzania, assistant medical officer Abdu Mapinduzi prepares to operate on Joanitha, a young pregnant mother.

She has given birth via caesarean section three times before at a regional hospital. But now, for her fourth child, she is able to have the baby at her nearest medical health centre.

Despite the fact that the Kakonko Health Centre is 150 km away from Joanitha’s home village, it is still closer than her nearest regional hospital, which is the only other facility able to conduct caesareans. Health centres here cater for 50,000 people, approximately the population of one administrative division, but are not equipped to perform surgeries. They are the third level of health care in the country after village health and dispensary services.

But the Kigoma Region has become one of the first places in East Africa to train assistant medical officers to conduct life-saving c-sections at its rural health centres.

After her caesarean, Joanitha told IPS that she was grateful to be able to deliver her baby safely at a health centre.

The Kakonko Health Centre in rural Tanzania is now equipped to perform surgeries, including caesarean sections. Credit: Erick Kabendera/IPS

“A friend of mine died while giving birth at a traditional birth attendant’s home last year, and about four months ago another one gave birth to a dead child as she travelled to the hospital.”

The World Lung Foundation renovated nine rural health centres in Kigoma Region, including the Kakonko Health Centre, under a pilot project in 2009. As part of the initiative, assistant medical officers were trained in basic surgery.

“We have successfully handled all our complicated cases and mothers have delivered safely,” Mapinduzi, who is also the supervisor of the centre, told IPS.

“When we have a complicated birth, it is like everything has stopped so as to save a life,” he said.

Mapinduzi said that when the centre began operating on expectant mothers in 2010, the number of deliveries at the health centre went up to 120 per month from 20, and an average of six caesarean sections were conducted every week.

“We have established a network at the grassroots level where women with complications are advised to deliver at the health centre or district hospital.

“Previously, some mothers didn’t see the need to come to the health centre, especially those with complications, because they knew that we were unable to help them then. Some would stay at home and wait for the grace of God, while others went to other places,” he said.

Tanzania has a high maternal mortality rate: 578 deaths per 100,000 live births. According to the World Health Organization “the maternal mortality ratio in developing countries is 240 per 100,000 births versus 16 per 100,000 in developed countries.” Kate Gilmore, assistant secretary-general and deputy executive director (Programme) of the U.N. Population Fund said that South Sudan had the highest rate in the world with over 2,000 deaths per 100,000. But at one point the Kigoma Region had the highest rate in the country, at 933 per 100,000 live births in the early 1980s.

But in the 1980s, a newly qualified gynaecologist, Dr. Godfrey Mbaruku, who is now the Deputy Director of the Ifakara Health Institute, Tanzania’s main health research institution, developed successful initiatives that led to a huge drop in the maternal mortality ratio here – to 186 per 100,000 live births in 1991.

While recent statistics are unavailable, maternal mortality in this region is considered to be lower than in the rest of the country.

It was Mbaruku’s work here that inspired development partners to set up the project. He told IPS that it made perfect sense to equip health centres to perform surgeries.

“The majority of Tanzanians live in rural areas, and you must be joking to suggest that they should access health services at the regional and district hospitals. Mothers are not dying due to chronic illnesses, but because of emergencies,” Mbaruku said.

Dr. Amri Mulamuzi, coordinator of the project in Kigoma Region, told IPS that a combination of factors helped reduce maternal deaths here recently.

“We have also provided ambulances to all the health centres so they can refer complicated cases to the district or regional hospitals…We also started campaigns on the ground, in collaboration with local government authorities, to ensure that each expectant mother realises that it is important for her to receive antenatal care,” said Mulamuzi.

While the Kigoma Region health centres have become a success story, health activists fear that programmes like this are unlikely to be sustainable because they are donor-driven, and will collapse when donors phase out their initial financial commitments.

For example, the government’s “Support to Maternal Mortality Reduction Project” that began in 2006, and is being implemented as a trial in three regions, only receives 10 percent government funding. The rest comes from donors.

Irenei Kiria, the executive director of Sikika, a non-governmental organisation that advocates for the provision of quality health services, told IPS that there would be no significant change in the country’s maternal mortality rate until the government invested more in it, and translated policies into action.

“Things on the ground must change for the government to be seen as serious in addressing maternal health,” said Kiria.

Mbaruku agreed.

“You can’t expect donors to help you with this – forget about reducing the deaths. The government must commit its own resources to reduce maternal deaths,” he said.

A 2009 report on the assessment of Tanzania’s progress in achieving the United Nations Millennium Development Goals (MDGs) entitled “Tanzania Midway Assessment at a Glance” showed that the country was unlikely to cut its maternal mortality rate or increase the number of births attended by skilled health personnel by 2015. The eight MDGs are promises that 189 U.N. member countries “made to free people from extreme poverty and multiple deprivations.”

For example, maternal mortality in Kilwa District, in south eastern Tanzania, is glaringly high. In 2008, Kilwa District statistics showed that the maternal mortality rate was 442 per 100,000 deaths.

This is despite the fact that the Kilwa municipal council allocates 40 percent of its budget to health, part of which is for addressing maternal mortality. According to Joanitha Mangosongo, the reproductive health coordinator at Kilwa Kivinje District Hospital, the money is largely spent on purchasing essential drugs for pregnant women and delivery kits.

But a lack of medication is not the reason for the high number of deaths in this region. In Kilwa District, unlike other parts of the country where most deaths occur in communities before mothers reach health facilities, over 90 percent of maternal deaths here occur at registered health facilities.

It is partially because health facilities have an acute shortage of skilled health workers, said Mangosongo. District statistics show that 80 percent of health staff is relatively unskilled.

“This affects almost all our efforts to fight maternal deaths. We are trying to provide on-the-job training and distance learning, but it is proving to be tough,” said Mangosongo.

Mbaruku believes that the solution to the high number of maternal deaths in Kilwa can only come after authorities acknowledge that there is a problem.

He told IPS that all districts have the same health budget and that Kilwa needs to formulate its own plan to combat the high maternal mortality before it asks for external support.

Girls’ and women’s access to contraceptives is both a right and a transformational health and development priority. Credit: Patrick Burnett/IPS

By Julio Godoy
PARIS, Jul 18 2012 (IPS)

Improving family planning to avoid unwanted pregnancies in developing countries, as well as assuring girls’ access to education, and women’s participation in the economy, are essential components of a sound development policy, according to Western experts and African activists.

During a summit on family planning in London last week numerous economic development experts, government delegates from industrialised and developing countries, and private donors agreed to raise some 4.3 billion dollars by 2020 to allow 120 million women and girls in the world’s poorest countries, particularly in the continent of Africa, to access contraceptives and other family planning materials.

The summit underscored the importance of girls’ and women’s access to contraceptives as both a right and a transformational health and development priority.

Simultaneously, gender activists attending the second African Women’s Economic Summit, which concluded on Jul. 14 in Lagos, Nigeria, urged policy makers, corporate organisations and political leaders to step up measures to promote women’s empowerment and remove barriers impeding their economic development.

“I don’t want my daughters … in the coming years discussing these same issues (of women’s education and economic empowerment),” Cecilia Akintomide, vice president of the African Development Bank (AfDB), co-organiser of the African summit, told the audience in Lagos. “I want to see a change in my lifetime.”

During the meeting in Lagos, Nigeria’s finance minister, Ngozi Okonjo-Iweala, emphasised that women’s economic empowerment is no longer simply an option “because investing in women, who constitute half of the continent’s population, is the only way to sustain the growth” recently recorded across the African continent.

“Women are the third largest emerging market in the globe.  Women are the third largest source of growth. One of the fastest ways to sustain current growth is to invest in women,” Okonjo-Iweala said.

Participants at the London summit echoed these views, with an emphasis on the health risks associated with unwanted pregnancies.

“Enabling an additional 120 million women in the world’s poorest countries to access and use contraception, something women in the developed world take for granted, will save millions of lives and enable girls and women to determine their own futures,” said Andrew Mitchell, British secretary of state for international development.

Mitchell called the commitments of the summit a “breakthrough for the world’s poorest girls and women, which will transform lives now and for generations to come.”

By 2020, the collective efforts announced in London will allegedly result in 200,000 fewer women dying during pregnancy and childbirth, more than 110 million fewer unintended pregnancies, over 50 million fewer abortions, and nearly three million fewer babies dying in their first year of life.

Avoiding unwanted pregnancies also allows girls and women pursue their own education and improve their professional opportunities.

Numerous studies show that the investment of a single dollar in family planning leads to savings of up to six dollars in health, housing, water, and other public services.

Contraceptive use also leads to more education and greater opportunities for girls, helping to end the cycles of poverty that millions of women and their families are trapped in. Up to a quarter of girls in sub-Saharan Africa drop out of school due to unintended pregnancies.

Based on such evidence, the United Nations Millennium Development Goals (MDGs) call for gender equality, universal education, and improving maternal and child health, setting specific objectives to be met by 2015.

According to the U.N. 2012 MDG report, released Jul. 2, meeting these goals by 2015, while challenging, is possible, “but only if governments do not waiver from their commitments made over a decade ago.”

In the foreword of the report, U.N. secretary-general Ban Ki-moon, warned that the current economic crises battering much of the developed world “must not be allowed to decelerate or reverse the progress that has been made.”

“Let us build on the successes we have achieved so far, and let us not relent until all the MDGs have been attained,” he urged.

The U.N. report points out that the world has achieved parity in primary education between girls and boys. Driven by national and international efforts, many more of the world’s children are enrolled in school at the primary level, especially since 2000.

Girls have benefited the most. There were 97 girls enrolled per 100 boys in 2010 – up from 91 girls per 100 boys in 1999.

Such improvements, as well as improving maternal health and reducing unwanted pregnancies, coincide with women’s demands across the world.

Melinda Gates, co-chair of the Bill & Melinda Gates Foundation, told participants at the London summit that women she meets on her travels tell her that “access to contraceptives can often be the difference between life and death”.

“Today is about listening to their voices, about meeting their aspirations, and giving them the power to create a better life for themselves and their families,” Gates added.

In Lagos, in a video message addressed to the Second African Women’s Economic Summit, AfDB President, Donald Kaberuka said that women have always played a pivotal role in the socio-economic development of Africa.

As farmers, entrepreneurs, traders and innovators, they are key economic actors in the continent, he added. “I believe, strongly believe, investing in women…is essential to revitalising our economies,” Kaberuka pointed out.

(END)

Population pressure in Pakistan. Credit: M. Fahim Siddiqi/IPS

By Zofeen Ebrahim
KARACHI, Pakistan, Jul 11 2012 (IPS)

“No scalpel, no stitch and no rest needed,” guarantees Dr. Ghulam Shabbir Sudhayao, referring to the surgical procedure called vasectomy – the least popular method of birth control around the world, including Pakistan.

“People confuse vasectomy with castration (surgical removal of the testicles) and that scares them away,” Sudhayao, who works for the government’s population welfare department, tells IPS.

Vasectomy involves a minor procedure to snip the sperm ducts.  Sudhayao himself resorted to the method when he decided that his family was complete. “We had two daughters and wished for a son, and the third  time, my wife delivered twin boys.”

“Compared to vasectomy, tubaligation (tying a woman’s fallopian tubes) is a complex surgical operation and is done under general anaesthesia,” says Sudhayo, explaining why he did not ask his wife to get herself sterilised.

Sudhayao says he has carried out over 6,000 of these minimally invasive, “ten minute” surgeries performed under local anaesthesia in the last 20 years.

But, Sudhayao is frustrated that the 2,000 social mobilisers working for the department are unable to meet their quotas. “We get no more that 80 to 90 clients in a month though the operation is  free and the patient gets Pakistani rupees 500 (five dollars) for nutrition, and the introducer can collect 1.59 dollars as incentive money.”

Over the last two decades, Sudhayao has trained 18 other doctors to perform this simple operation, but few of them are interested in promoting it.

“Despite being trained to spread the message, they say they are scared of being ridiculed in the community. To popularise this method, we need to use the electronic media, the quickest way to get the message across,” says Sudhayao.

Interestingly, men from the low economic strata appear to be quicker to realise the benefits of this procedure.

Syed Jeal Shah, 42, a biology teacher in a government school in Khairpur, underwent vasectomy after he had 10 children. “Things were getting out of hand. We could not afford to feed so many mouths on my meagre salary.”

While his operation was carried out eight years ago, he is still the butt of friends’ jokes that centre around impotency. “My colleagues say family planning (FP) is a woman’s problem,” says Shah.

“Men don’t think FP is their problem,” says Sherhshah Syed, former president of the Society of Obstetricians & Gynaecologists of Pakistan and currently president of the Pakistan National Forum on Women’s Health.

Syed says vasectomy is associated with impotency. Men find the subject embarrassing and often seek advice from clerics, most of whom are opposed to birth control.

But with Pakistan’s population expanding rapidly and family planning  methods focused on women alone failing, population experts are taking a second look at vasectomy as a means of birth control.

Pakistan’s population stands at 180 million, and with each woman bearing four children on average the projections are that the population could cross  450 million by 2050.

Studies by the Islamabad-based Research and Development Solutions (RADS), in collaboration with United States Agency for International Development, show six million Pakistani couples needing contraception annually while the public sector covers just 33 percent of them.

Dr. Ayesha Khan who heads RADS tells IPS that “some 53 percent of these couples buy FP services, while 15 percent access them through non-governmental organisations.”

According to the Population Reference Bureau (PRB), a Washington D.C.-  based research organisation that monitors population trends around the world, Pakistani women ususally think about FP only after they have had five or more children.

“Women are often required to have large families to improve their social standing and ensure their economic survival,” says Tewodros Melesse, director general of International Planned Parenthood Foundation.

“In many countries girls marry at a very young age, become pregnant too early and out of necessity  drop education to take care of their young family,” Melesse said in an interview with IPS.  In Pakistan, he added, only 22 percent of married women of reproductive age use a modern contraceptive method.

Farid Midhet, a demographer and founder of the Safe Motherhood Alliance cites “illiteracy, in particular female illiteracy”, and bad governance as the two main reasons why family planning programmes have never worked in Pakistan.

“Contraceptive use works as part of an enlightened and educated culture where women have some autonomy,” he told IPS.

Over the years the emphasis and pressure to bring down the number of babies has fallen on women, a majority of whom are illiterate and not empowered to take decisions concerning family size.

“The numbers for both male sterilisation (0.33 percent of all contraception) and condom use reflect the gender power imbalance – women bear a disproportionate burden when it comes to pregnancy prevention,” says Melesse.

“We need to proactively engage men as clients, as partners and as change agents in the sexual and reproductive health programme in Pakistan,” emphasizes Melesse.

“Religious prohibition and husband opposition are the main reasons identified for non-use of contraception in Pakistan so we need to engage with religious leaders to increase access to sexual and reproductive health services among most conservative communities in Pakistan,” Melisse said.

The case of Abdul Ghaffar Khosa, 55, who teaches in a madrassah (religious seminary) in Nawabshah, Sindh province, typifies the difficulties as well as the potential of roping in the clerics.

Khosa says there are different schools of thought in Islam regarding family planning and that while it remains a controversial issue he has set an example by undergoing the procedure himself about eight years ago.

But Khosa accepted vasectomy only after begetting 22 children from two wives. “In between pregnancies, my wives were miscarrying and they were getting weaker – I was scared of losing them.”

Khosa waited three years, to make sure that the procedure had not impaired his sexual functioning, before recommending it to friends and relatives. He has even referred several of his fellow clerics to Sudhayao.

A nurse attends to an expectant mother at Walgak Primary Health Care Centre in South Sudan's Jonglei State. Credit: Charlton Doki/IPS

By Charlton Doki
JUBA, Jul 9 2012 (IPS)

One year after the formation of South Sudan, the country’s women say that independence has not resulted in the positive political, economic and social changes that they had hoped for.

Women activists worry that even after separation from Sudan on Jul. 9, 2011, when South Sudan became the world’s newest country and Africa’s 54th nation, the government has not done enough to improve the lives of its women.

But as people across the country celebrate the first anniversary of independence from Sudan, after a 21-year civil war, the year has been fraught with crises.

The country is in the midst of an economic crisis after South Sudan’s decision in January to shut down oil production, which accounts for 98 percent of the its revenue, following a dispute with Sudan over fees charged to use its pipelines.

There is also dire food insecurity here. In June, the United Nations World Food Programme said that more than half of the country’s 8.2 million people would need food aid by the end of the year.

In the country’s Upper Nile state, the Jamam refugee camp is on the verge of a humanitarian crisis. The camp is home to some of the 200,000 refugees who, according to the U.N., have fled the conflict in Sudan’s Blue state.

However, Médecins Sans Frontières has warned that the mortality rate among children at the camp was 2.8 per 10,000 per day. This figure is above the emergency threshold of two per 10,000.

Amidst all of this both women leaders and activists admit that they had high expectations of the country’s first year. Some feel that the reality of independence has failed to live up to the hype and euphoria.

“We had high expectations, but I think they are not unrealistic and should not be pushed aside. Women are doing badly politically, economically, socially and education wise. The government needs to take measures to address the challenges facing women so that they can truly enjoy life in their new independent country,” Lorna Merekaje, of the South Sudan Domestic Election Monitoring and Observation Programme, told IPS.

Others disagree.

The Central Equatoria state Governor’s advisor on conflict resolution, Helen Murshali Boro, said that women’s concerns would be addressed.

“There is freedom of speech to allow women to express themselves and this means women’s concerns will not go off the radar until they are addressed in the coming years of our country’s independence,” she said.

Though the reality still remains far different.

“Like in the past when South Sudan was still part of Sudan, today women live in poverty,” said Lona James Elia, executive director of a local women’s rights agency, Voice For Change.

The National Baseline Household Survey (NBHS), conducted in 2009 and released in June 2012, indicates that over half of South Sudan’s 8.2 million people live below the poverty line on less than a dollar a day. The majority of the poor are women.

Elia added that South Sudan is still unable to provide maternal health services to the country’s women, especially in rural areas.

According to the U.N. Children’s Fund only 19 percent of births are attended by a skilled health worker. According to the NBHS, 30 percent of the population has no access to basic health services.

The few available health facilities lack supplies and qualified personnel to provide the required services. And in some rural areas women cannot receive maternal and antenatal care because they live too far from the nearest maternity clinic. Thirty-seven percent of poor households have to travel for more than an hour to reach their nearest most-used health facility, according to the NBHS.

“Women are still dying while giving birth. They are still not accessing maternal health services. A woman is not supposed to die because she is giving birth to a new life, a new baby. This is not acceptable,” Elia told IPS.

According to the National Bureau of Statistics, in 2011 the country recorded that 2,054 out of every 100,000 women died during childbirth. The high mortality rate has not changed much a year later, according to the U.N. Population Fund (UNFPA).

In June, Kate Gilmore, assistant secretary-general and deputy executive director (Programme) of the UNFPA, told reporters in Juba that maternal mortality rates in South Sudan remained the worst in the world.

“The latest evidence that we have is that using standard figures in every 100,000 births there are over two thousand women who die from preventable causes in South Sudan. In Afghanistan, which surely is one of the most troubled countries in the world, it is half that. Across Africa it is five hundred,” she had said.

Elia said the government needed to invest in maternal health services to ensure that women could participate in developing the country.

“A mother should not have to travel all the way from Gondokoro to Juba to deliver a baby because there is no hospital in her home city,” Elia said. Gondokoro is about 20 km from Juba and also within Central Equatoria state. She added that because the nearest health care centre was too far, some women died along the way.

However, government spokesman Barnaba Marial Benjamin said that the government had worked hard to improve living standards.
“We have initiated projects, including building schools and health centres, which will benefit all South Sudanese citizens, including women,” he told IPS.

In addition, the government has implement an affirmative action policy that ensures 25 percent women’s representation in all government jobs at national, state and county levels.

“You see after independence the president appointed six women to the cabinet and about nine to 10 assistant ministers. I think with about 16 women in the national government, the government has responded positively,” said Boro.

Currently there are four female ministers out of a total of 29, and eight female assistant ministers from a total of 27.

However, activists say that this has not directly affected the lives of the country’s women.

“When you look at the middle-class women and those at the grassroots they are still not in positions where they can make decisions that benefit women,” Merekaje told IPS.

Boro admitted that women still occupy low entry positions in the work field.

“Although these days you see more women coming to work in the morning, at the end of the day they go home with peanuts because they work in the less-paid, low positions,” Boro said.

Elia said that women were unable to find employment because the majority are illiterate and do not have the vocational skills required by employers. According to the National Bureau of Statistics, 88 percent of South Sudanese women are illiterate. In addition, the U.N. says that only one percent of girls complete primary school.

“Women are the most illiterate and because, despite the independence of our country, women at the grassroots level still remain the most underprivileged segment of society as they have to depend on men for survival,” Elia told IPS.

Jerisa Yide is one such example. The 65-year-old grandmother earns a living breaking stones and rocks into gravel, which she sells to builders.

“I used to crash stones before independence to enable me to pay my grandchildren’s school fees. We are now independent, but we are even paying more fees for our children to go to school,” said Yide.

Primary and secondary school education are not free in South Sudan. And as a result of the shut down on oil production, the government introduced an austerity budget in January where it scrapped free university education.

Yide said that when she voted for independence she expected the government to provide better services, including education and health.

Selina Modong agreed that not much had changed. She said that the cost of living in Juba had increased since independence. As a result of the economic crisis, inflation has soared to a staggering 80 percent in May.

“I was eating one meal per day before independence. Today I still eat one meal per day and sometimes we hardly eat good food these days,” Modong said.

“I think independence has not changed anything for us poor people,” Modong concluded.

Elia said that everyone should participate in ensuring that the women’s agenda is addressed.

“If you want this independence to benefit everyone, the issue of women should not be for women alone. It should be for everybody. Let us ensure that our daughters have a bright future. That they will get the education they want, that they will get the employment they want and that they will get the health services they deserve to build healthy families for themselves,” said Elia.

Fifteen million babies, or more than one in 10 infants, are born prematurely each year. Over one million die soon after birth, or survive to face a lifetime of health complications, says a new report by the World Health Organisation and co- sponsors.

Preterm births are rising in almost all countries and are now the single most important cause of neonatal deaths. Credit: UN Photo/Mark Garten

Preterm births, defined by 37 weeks of completed gestation or less, are rising in almost all countries and are now the single most important cause of neonatal deaths of babies under 28 days.

“Being born too soon is an unrecognized killer. Preterm births account for almost half of all newborn deaths worldwide and are now the second leading cause of death in children under five, after pneumonia,” Joy Lawn, co-editor of the report “Born Too Soon: The Global Action Report on Preterm Birth,” and director of Global Evidence and Policy for Save the Children, said in a press release.

“The numbers of preterm births are increasing. In all but three countries, preterm birth rates increased in the last 20 years. Worldwide, 50 million births still happen at home and many babies die without birth or death certificates.”

Fifteen countries account for two-thirds of the world’s preterm births, with India and China in the lead. Out of all live births, preterm births account for 11.1 percent, 60 percent of which occur in sub-Saharan Africa and South Asia. On average, 12 percent of preterm births occur in low-income countries compared to nine percent in high-income countries.

“What I found shocking is (the difference) geographically and within countries when we look at the rates of preterm birth in Asia and sub- Sahara Africa… What really struck me is the equity gap of preterm birth,” Christopher Howson, co-editor of the report and head of Global Programs for March of Dimes, told IPS.

“You take a baby that is less than 28 weeks, if the baby is born in a rich country, it has a 90 percent chance to live. If born in a poor country, it only has a 10 percent chance to live.”

However, the problem is not confined to the developing world. The United States and Brazil both rank among the top countries with the highest number of preterm births. In the U.S., at sixth place, more than one in nine births, about 12 percent, are preterm.

There are disparities within groups in the U.S. too. In 2009, the preterm birth rate for white citizens was 10.9 percent, while it was as high as 17.5 percent for black citizens. The age of the mother also mattered, with the birth rate between 11 and 12 percent for women aged 20 to 35 and over 15 percent for women under 17 and over 40.

The report links a number of factors to the increase in preterm births, which in general remain unexplained though a number of risk factors have been identified such as a prior history of preterm birth, underweight, obesity, diabetes, hypertension, smoking, genetics and pregnancies spaced too closely together.

In high-income countries, causes include older women having babies, increased use of fertility drugs resulting in multi-fetal pregnancies, and medically unnecessary inductions and Cesarean deliveries before full-term.

Main causes identified in low-income countries include infections, malaria, HIV, and high adolescent pregnancy rates.

Preterm births have been a largely overlooked and neglected problem, health experts admit. This report is the first ever to provide comparable country-level estimates for preterm births.

“Ten years ago, I was working as a pediatrician in Ghana and it was very obvious every day…I was in charge of the baby nursery with about 11,000 births a year and there were babies dying every day of things that they did not need to die of. I started looking around and at the time there were no U.N. estimates of death or clinical guidelines of what to do or donors interested in it,” Lawn told IPS.

According to the report, two-thirds of premature births could be prevented with “feasible, cost-effective care.” Prevention is the key to reduce preterm numbers, and an estimated three-quarters of babies born too soon could survive if only a few proven and inexpensive treatments were more widely available.

Empowering and educating girls, family planning, screening women for known medical conditions, assuring good nutrition before and during pregnancy, and better access to healthcare are effective measures in reducing premature births.

Essential and extra newborn care, including feeding support, neonatal resuscitation, and Kangaroo mother care, a method involving infants being carried with skin-to-skin contact, could help in reducing the number of premature deaths.

The report also recommends that healthcare providers collaborate with businesses and civil societies to advocate, invest and provide funding to reduce preterm births. Even adding a dollar for each woman in prenatal care can make a difference, Lawn told IPS. “There are a couple of things that people can do to make the Millennium Development Goal (MDG) reachable. Even if the countries just picked two methods, like Kangaroo care and prenatal steroid shots, that can be a major game changer.”

MDG 5 aims to reduce by three-quarters the maternal mortality ratio, as well as achieve universal access to reproductive health care.

There’s an action gap in what is being done, Howson said. Civil society groups, for example, are an untapped resource that can be powerful in the community.

“We all have a role to play. I think in particular that groups like parent groups are so incredibly important in really creating noise. They are able to advocate from the ground up and that can be much more effective than trying to change from the top down,” he said.

*Stephanie Parker reported from United Nations headquarters in New York.

By Carey L. Biron
WASHINGTON, Apr 25 2012 (IPS)

Within a decade, “most” of the global population could have access to affordable basic health care – if a series of “ambitious” programmes are put into action around the world. This is according to a new report released by the Council on Foreign Relations (CFR) here on Tuesday.

By 2008, nearly 50 countries had succeeded in implementing near- universal health coverage, according to International Labour Organization statistics cited in the report. At the moment, almost 100 countries are reportedly looking into how to put in place government- funded health-care programmes.

One notable exception to this trend, of course, is the United States, where the political wrangling over universal health coverage has ratcheted up significantly since President Barack Obama passed a series of reforms to the country’s health-care system in 2009, extending coverage to tens of millions of additional citizens. The U.S. Supreme Court is currently weighing the reforms in a highly anticipated case.

According to one of the CFR researchers, Yanzhong Huang, the “new wave” of potential universal coverage includes China, India, Indonesia and South Africa, accounting for some 40 percent of the world’s population. Both China and India have made pledges to provide some form of universal coverage within the next decade.

These middle-income countries have been experiencing strong growth in recent years and have built up some of the largest middle classes in the world. This economic confidence, coupled with the newfound push from below, has led several governments to embark on strengthening their health systems.

Yet Huang notes that success in introducing national health-insurance programmes has not necessarily been defined by a country’s gross domestic product. These include not only higher-performing economies such as Brazil, Thailand and Taiwan, but also lower-income countries such as Bangladesh, the Philippines and Sri Lanka.

The CFR report coincides with a resounding new focus on universal health coverage among the international community. In 2010, the biannual World Health Report put out by the World Health Organization (WHO) focused on financing for health systems.

In early April this year, 21 countries (including the U.S.) signed onto the Mexico City Political Declaration on Universal Health Coverage, which calls on governments to “Work to promote the inclusion of universal health coverage as an important element in the international development agenda…”

This followed on a declaration in Bangkok released by representatives of 60 countries in January, which committed “to advocate the importance of integrating it into forthcoming United Nations and other high-level meetings related to health or social development.”

The New York-based Rockefeller Foundation, which sponsored the CFR report, has also become well known for its focus on championing universal health coverage as an international cause.

Much of this new focus began since 2008, as the international economic downturn constricted donor purses. A lead writer on the CFR report, Laurie Garrett, notes that a “tremendous escalation” in global health funding took place between 1990 and 2008.

This trend was motivated particularly by concerns over the spread of HIV and other specific individual infectious diseases, particularly in poor and developing countries. At the same time, however, this aid prioritisation typically eclipsed much effort given to the strengthening of health systems generally.

Since 2008, Garrett suggests, “Donor states have sought ways to spend less money while managing to save the same number of, or more, lives.”

In general, global health is very subject to fads, says Victoria Fan, a research fellow with the Center for Global Development here in Washington. “This year, it’s universal health coverage,” Fan notes, “but generally the field is filled with donors that give money for very specific issues, typically very specific diseases.”

That means that, beyond the World Health Organization, which does not engage in funding, donors are unused to thinking about issues as broad-based as country-wide health systems.

“Healthcare systems operate perfectly fine without external assistance,” she says. “It would be absurd if another developed country would give the U.S. money, for instance.”

While there is widespread consensus on the basic thrust of expanding health coverage, the details of implementation behind the new push for universal coverage are endlessly tricky.

“Universal health coverage in developing countries usually implies new resources for health – more sources or more money from the same sources,” says James Bump, an assistant professor with the Department of International Health at Georgetown University. “The demand for health-care services is unlimited in any setting, but the financials are fixed. So, fundamentally, this is a rationing issue – an ethical one.”

Historically, Bump says, health systems typically grew organically, rising around those who could pay for them before eventually being expanded to those who cannot pay. In the current international push for universal coverage, however, funders are increasingly looking for ways in which external actors can become involved in assisting this process, either through technical or financial assistance.

“The main hazard would be that because it’s a rationing question, it has to be answered with the input of the people in the system,’ Bump cautions. “If you’re asking what health-care choices are best for a certain population, that population has to be the one to offer the solutions.”

For many years, Bump says, aid agencies have been accused of foisting rigid formulas onto developing countries. “That’s not something you’d want here,” he says. “It’s not the place of external actors to answer questions related to universal health coverage – it’s not for the rich world to dictate.”

In times of political and financial crisis, the rights women thought they had secured decades ago are once again under attack. Credit: Karlos Zurutuza/IPS

By Jennifer Hattam
ISTANBUL, Apr 23 2012 (IPS)

The world’s recent financial and political upheavals have not been kind to women. In Libya’s Tripoli, female suicide rates increased tenfold during the revolution, while dismal job prospects have young Greek women abandoning their career aspirations, participants in a global forum on women’s rights said over the weekend. “Many people say this is a time for transformation and moving forward but we know from our work that it’s also a time of instability and uncertainty,” Jamaican activist Mariama Williams, a senior programme officer at the South Centre, said at the closing session of the 12th International Forum on Women’s Rights and Development in Istanbul. “In times of crisis, the solidarity we thought we had, the rights we thought were secured are again being questioned. Whatever is not convenient for growth is being questioned,” Williams said. Participants in the Apr. 19-22 forum, organised by the Association for Women’s Rights in Development (AWID) around the theme of transforming economic power, engaged in questioning, among other things, how economic growth and development should be measured and defined. “If we were to account for inequality, the average Human Development Index would be 23 percent less than it is currently,” Associate Administrator of the United Nations Development Programme (UNDP) and former Vice-President of Costa Rica, Rebeca Grynspan, told the more than 2,000 attendees from 140 countries. From national budgets to financial-stimulus packages, economic policy typically fails to address women’s needs – or to recognise the contributions they make through their unpaid labour, participants said.

But forum organisers also expressed optimism that amid these challenges, the global climate is becoming more receptive to the demands for gender and social justice that activists have been making for decades. “What the financial crisis has provided is an (environment) where even mainstream actors have begun questioning the dominant economic model, (asking) whether there is a way to regulate the financial sector so it works in the service of everything else,” Lydia Alpízar Durán, executive director for AWID, told IPS. “Before, the system’s failures were only felt by the very poor. Now they’re starting to create a new poor, to hit the middle class, and people are beginning to wake up,” AWID Board President Lina Abou-Habib, the director of the Collective for Research and Training on Development-Action in Lebanon, told IPS. Durán cautioned, however, that women, especially women activists, face an elevated risk of backlash in many parts of the world. “One of the biggest challenges is increased violence and repression; those struggling for change are becoming targets of attacks,” she told IPS. One area of the conference venue was adorned with dozens of memorial photographs of women the movement has lost over the years – some dead of natural causes, many others mysteriously vanished or violently murdered. In another corner, the face of Galila Khamis Toto, a Sudanese activist from the Nuba mountain region, stared out from a poster, the text informing participants that she was supposed to be there among them but was instead being detained in inhumane conditions in her home country. During the forum, activists from Egypt, Tunisia, Syria, Morocco, Libya, and other countries in the Middle East and North Africa (MENA) spoke about their ongoing battles to enshrine women’s rights into new constitutions and increase female participation in new political systems – while often facing renewed challenges to their personal freedoms. “Polygamy has been abolished for more than 50 years in Tunisia, but now we’re talking about it again. Traditional marriages, how women dress, abortion limitations, even female circumcision, which we never had before, are all being discussed,” said Ahlem Belhadj, the president of the Tunisian Association of Democratic Women.

“These are all things happening after the revolution.” Creating solidarity with women’s movements in the MENA region was one of the reasons AWID chose Istanbul as the 2012 location for its triennial forum, Durán said on the opening day of the event. “In the post-Arab-Spring phase, we need to be clear that what happens in this region has major implications for women around the world,” she told attendees. “Cultural relativism is growing and we cannot allow respect for cultural traditions to justify the violation of women’s rights.” Woman who participated in toppling Arab regimes sometimes think their countrywide struggles should take precedence over stronger pushes for women’s rights, speakers from the region admitted, adding that there can be no democracy without equality between men and women. Neither can there be “economic rights without also looking at bodily rights, at political rights,” Durán told IPS. “Women’s realities are determined by their ability to make decisions.” Tying all these different threads together into a cohesive movement is no small task. “What we see all around us at this conference, civil society, the women’s movement – that resource has to be really fostered and advanced,” U.N. Women Deputy Executive Director Lakshmi Puri told IPS.

“We’re trying to get resources directly into the hands of women who are working to bring changes about in their own areas.” At the AWID forum, those areas ranged from demilitarisation to the rights of domestic workers, religious fundamentalism to climate change, topics covered in the more than 200 different sessions on the conference program. Participants’ diverse interests were also represented in the hallways of the Haliç Conference Centre, where indigenous crafts, black-and-white nude portraits of Chilean transsexuals, and Egyptian graffiti art were all on display. The coming together of what one speaker called “the most diverse group of women outside the U.N.” is the most important outcome of the forum, Abou-Habib told IPS. “The idea of the ‘one percent’ is such a powerful one because the rest of us let it happen. We give them that power by not resisting,” she said. “There is a strong body of critical feminist economic analysis but we need to take it out of the journals and the classrooms and onto the streets,” Radhika Balakrishnan, the executive director of the Centre for Women’s Global Leadership, said at the forum’s closing session. Following her remarks, attendees did just that, massing in Istanbul’s central Taksim Square for a protest march in solidarity with their Turkish counterparts.

While the number of women dying in childbirth globally declined by 34 percent between 1990 and 2008, that number doubled in Papua New Guinea over the same time period.

The number of women dying in childbirth in rural Papua New Guinea doubled between 1997 and 2008. Credit: Catherine Wilson/IPS

Shocking maternal mortality rates have prompted national plans to accelerate healthcare reform and women’s access to medical services, but their implementation in the Pacific Island nation remains the greatest challenge.

A full 99 percent of maternal deaths occur in developing countries with the risk increasing in rural areas. In Papua New Guinea (PNG), a rural-based population, gender inequity, poor use of family planning and decaying state rural health services have contributed to alarming maternal deaths.

According to the United Nations Development Programme (UNDP), the nation’s maternal mortality ratio is 250 deaths per 100,000 live births. But the National Demographic Health Survey in 2006 revealed the more startling rate of 733 deaths per 100,000 births, the second highest after Afghanistan in the Asia Pacific region.

World health experts claim that lives of expectant mothers can be saved by medical supervision of births combined with antenatal and postnatal care. Yet this is a profound challenge in PNG, where the World Bank estimates 17 percent of people do not have access to a road and two fifths of health facilities lack electricity and basic medical equipment.

The Ministerial Taskforce on Maternal Health noted back in 2009, “The decentralisation of government roles, responsibilities and financing (in the 1980s) has seriously compromised the quality and functionality of health services, including maternal health.”

Between 1987 and 2000, rural health staff were slashed by 25 percent.

The Australian Burnet Institute of Medical Research proposes that almost one third of maternal deaths in PNG could be prevented by wider implementation and sustained central support for family and community healthcare, administered by trained Village Health Volunteers (VHVs).

Glen Mola, chair of obstetrics and gynaecology at the University of Papua New Guinea, stressed, “Women can deliver (by) themselves safely at home with their mothers and sisters in support, as long as nothing goes wrong, but if something does go wrong, then it can be mortal for that woman if she is in her house in the village. The (reason) why PNG has such a horribly high (maternal mortality rate) is that 67 percent of women deliver at home.”

“Having a professional midwife or obstetrician present in the house is not going to make any difference to her chances of surviving a labour and delivery complication unless there is backup emergency obstetric care, drugs and facility support,” he continued.

Government expenditure on health is only 2.6 percent of the country’s gross domestic product (GDP), yet it decreased by 9.4 percent between 1997 and 2004. The Department of Health has also been under investigation for misappropriation of government funds. The Ministerial Taskforce found that “women do not trust the health system to look after them.”

In contrast, health services run by church organisations, which account for 60 percent of health facilities in Papua New Guinea, have been praised.

The Church of the Nazarene operates a district hospital in Mount Hagen in the Western Highlands Province, and rural health services in the province of Jiwaka. Medical workers visit 16 rural health clinics every month offering prenatal examinations, child health clinics, family planning and health education while referring complicated pregnancies to the hospital.

Abuse and rape fuel the crisis

According to Nazarene Hospital Administrator Scott Dooley, pregnancy complications in rural communities account for most fatalities, but sexual violence is also a contributing factor.

“Many women experience forced sexual relationships, even within marriage,” Dooley said, “Pregnant women are also particularly high-risk for physical domestic abuse. We have seen this result in the loss of pregnancy many times.”

“Rape and unplanned pregnancies also lead many women to seek illegal abortions, which are very dangerous,” he continued, “We see many women who are very ill from incorrect procedures done by nurses or others trying to provide abortions for money.”

A review of maternal mortalities at the Goroka General Hospital, Eastern Highlands Province, in 2008 found that unsafe abortions accounted for 48 percent of maternal deaths.

Professor Mola said key strategies to improve maternal health included family planning, more training for doctors and health workers and public education.

“Forty percent of pregnancies are unplanned and the maternal mortality rate for unplanned pregnancies is higher,” Mola said, “Family planning should be available in all health facilities every day.”

“Reproductive health and understanding population issues should be part of the compulsory school curriculum at primary and secondary levels,” he continued, “So the next generation understand how we can do better.”

Dooley highlighted the urgent need for developing rural communication and roads, and addressing social and cultural fears about institutional care during childbirth.

“Many women prefer to deliver at home, even if they live near a health facility,” he recounted, “We have heard many reasons why women did not come to the hospital for delivery. These include shame of another seeing them naked, fear that a male nurse or doctor will be present, concern about the financial cost of coming to the hospital and concern about enemy tribes on the way to or in the area of the hospital.”

Dooley also believes men should take more responsibility during family pregnancies.

“It is rare to see a husband present at delivery,” he claimed. “Cultural ideas of gender roles are a big part of this. If husbands would help pay for delivery and encourage their wives to deliver in a health facility, we would see dramatic changes in the number of supervised deliveries.”

Dame Carol Kidu, the nation’s only female parliamentarian, believes the government must incorporate lessons from successful non-governmental sector health services and display greater political commitment to women’s health and development. The NGO Susu Mamas, which provides specialised care for mothers and infants, is presently working to support state health services in this area.

The government’s National Health Plan 2011-2020 promotes advancing maternal health by improving public access to supervised deliveries, emergency obstetric care and family planning. However, Mola says lack of resources is impeding implementation.

“We are doing our very best to train competent midwives to provide quality midwifery and maternal care, but it will be decades before we have sufficient numbers,” Mola said.

There is a likelihood that future maternal healthcare could be boosted by the recently announced Rural Primary Health Services Delivery Project, partly funded by the Asian Development Bank (ADB) and international donors, which aims to rebuild health facilities and health staff capacity across the country in coming years.

The Aditmari Maternity Centre (AMC) is unpretentious but hygienic, and its staff of paramedics welcomes pregnant women from the poor farming villages of this district, 375 km northwest of Dhaka.

Nurse Afroz counsels an expecting mother at the Aditmari centre. Credit: Naimul Haq/IPS

Asphalt roads lead up to the single storey, located in the centre of Aditmari sub-district, that has a labour room equipped for normal deliveries, a ten-bed post-labour room, two rooms for counselling and a waiting room with a wide porch for men.

Best of all, the charges for a normal delivery at the AMC are just 2.4 dollars, affordable in impoverished Bangladesh where the per capita income in 2011 was 818 dollars, according to official figures in the Bangladesh Economic Review.

It was at the AMC that Sajeda Begum gave birth to a healthy baby girl two weeks ago. “My daughter had no signs of pre-delivery complications,” says a smiling Tahmina, Sajeda’s 53-year-old mother.

Affordable but reliable maternal health services are what allowed Bangladesh to bring down the resource-poor country’s maternal mortality rate (MMR) from 322 deaths per 100,000 live births in 2001 to 194 deaths in 2010.

Bangladesh’s achievement is impressive considering its classification by the United Nations as a least developed country. Also, better-off neighbours, India and Pakistan, are faring worse with MMR ratios of 212 and 260, respectively.

Improved access to obstetric care, more institutional deliveries and better use of family planning methods are expected to help Bangladesh achieve the United Nations Millennium Development Goal (MDG) of reducing MMR by three-quarters during the 1990–2015 period.

Also encouraging is the fact that the rate of decline in maternal mortality, at an average of 5.5 percent per year, is better than the 5.4 percent required for reaching the MDG by 2015.

As in many other LDCs, the gap between rich and poor in Bangladesh’s maternal health can be stark. Had Sajeda gone to a private clinic her delivery would have cost at least 60 dollars.

Sajeda also did not have to worry about access to care during pregnancy as she regularly received antenatal checkups.

“Sajeda attended the clinic eight times and followed instructions. It is quite amazing that she delivered on due date,” said Shaheen Afroz, chief staff nurse at the AMC, run by the Rangpur Dinajpur Rural Services (RDRS), a non-government organisation (NGO), since 1981.

There are now eight outreach maternity centres in Aditmari sub-district where pregnant women are referred to for examination, but deliveries are done only at the AMC. Patients are registered in coordination with regular government healthcare services to avoid duplication.

Mosammet Elifa, a community health worker at the Mohishkhocha outreach centre, said: “We go from door-to-door to meet pregnant women and invite them to register for antenatal care.”

“We also explain the risks of delivery at home at the hands of untrained birth attendants,” said Elifa. “In the last ten years we have had no records of maternal deaths in our community.”

“We charge only 24 cents for registering a pregnant woman. Thereafter, the consultations, drugs, such as those for sexually transmitted infections, iron and vitamin supplements, blood tests and routine examinations are given free of cost,” said Afroz.

Deepali Rani, 28, now in her second trimester, told IPS that she comes from Durgapur village for regular clinics at the AMC. “My relatives and friends told me about this centre and I find the treatment here good and systematic.”

Project coordinator at RDRS, Komol Kumar Joardder, told IPS that on average 30 women avail of the facilities daily at the AMC. “While the women are waiting to be examined we run awareness programmes on safe motherhood and try dispel traditional myths and old wives tales.”

Aditmari has handled 35,000 successful deliveries with no record of maternal deaths, although 464 cases with complications were referred to larger hospitals.

Aditmari’s is just one of thousands of stories of efficient maternity services that are helping Bangladesh reduce MMR and increase skilled birth attendance.

The proportion of women delivering at a facility or with assistance from a professional birth attendant has increased from nine percent in 2001 to 23 percent in 2010 and may well reach the 50 percent target by 2015. However, some 2.4 million deliveries still happen at home, annually.

The directorate of health services (DHS), the key agency implementing reproductive health programmes in collaboration with NGOs like RDRS, holds that the key lies in training a cadre of community health workers who are now gradually replacing untrained or traditional birth attendants.

DHS chief, Khondhaker Shefyetullah, told IPS, “Maternal deaths are decreasing in rural areas as expecting mothers are now more conscious of safety and prefer delivery at professional hands rather than at the hands of untrained birth attendants.”

Arthur Erken, United Nations Population Fund (UNFPA) representative in Bangladesh, told IPS, “The decline in maternal deaths suggests that many pregnancies with complications are now being selectively sent to facilities, as intended.”

Erken noted a substantial increase in women with obstetric complications seeking treatment at a facility – 29 percent in 2010 compared to 16 percent in 2001. “This indicates that both awareness and referral systems are improving.”

Prof. Nasima Begum, secretary-general of the Obstetrical and Gynaecological Society of Bangladesh (OGSB), attributes a major part of Bangladesh’s success to trained community skilled birth attendants (CSBAs) who are in direct contact with villagers and play a vital role in MMR decline.

“About 12 percent of all deliveries in the rural areas are caesarean, which means that the CSBAs are properly identifying the risk cases and sending them to the right place for emergency deliveries,” Nasima said. “Earlier, expecting mothers with complications simply died for lack of professional guidance.”

Training programmes run by the OGSB receive support from UNFPA. The UN agency also provides support for improved facilities at the health centres in rural areas and for emergency obstetric care at some 70 hospitals.

There are currently some 7,000 CSBAs serving 10,000 community clinics across Bangladesh and more are being trained to fill up vacant posts in community clinics – the first tier of health and family planning services at the village level.

Women in Pakistan's tribal areas show signs of mental stress. Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Apr 16 2012 (IPS)

Collateral damage caused by the ‘war on terror’, prosecuted by the United States and its allies in Afghanistan since 2001, may well extend to psychological trauma sustained by thousands of women in the bordering areas of northwestern Pakistan.

“The prolonged war has caused psychological problems to a majority of the residents of the Federally Administered Tribal Areas (FATA), especially the women,” says Prof. Syed Muhammad Sultan at the psychiatry department of the Khyber Teaching Hospital (KTH) in this northwestern city.

Lying between the provinces of Khyber Pakhtunkhwa and Balochistan and bordering Afghanistan to its west, the FATA comprises seven agencies (tribal districts) and six frontier regions and has a population of 3.3 million people, most of them from various Pashtun tribes.

Of the 15,000 people from the FATA treated by psychiatrists at the KTH last year, 9,833 were women, Sultan tells IPS. “Many of these women had lost relatives or friends either at the hands of the Pakistan army or Taliban militants.”

Last year the World Health Organisation (WHO) said there were about 451,377 people, including 345,899 women, suffering from psychological problems in the FATA.

Dr. Jamal Shah, who works with the WHO, told IPS that doctors look out for signs of psychiatric problems while examining patients from the FATA since many in the territory are prone to depression over the loss of loved ones and property.

According to Sultan, most women who seek psychiatric help at the KTH are put on anti-depressants and tranquillisers and are given counselling.

Mushtari Bibi, 45, from North Waziristan agency, was brought to KTH with acute mental trauma caused by a mortar shell landing on her house and killing her 10-year-old son. “She cries for her son at night and cannot sleep until she is given sedative medication,” Sultan said.

Rekhana Bibi, 49, a resident of Khyber agency, told IPS that her son Abdul Salam, a 9th standard student, went out of the house one evening in January and was never seen alive again. “The next day we found his bullet-riddled body dumped by unknown people near our home.”

Now under treatment at KTH, Rekhana told IPS that her husband died two years ago when he was caught in a firefight between the army and Taliban militants.

Prime Minister Yousaf Raza Gillani said at a press briefing recently in Islamabad that, since 2005, some 35,000 persons, including 5,000 soldiers, have died as a result of the logistical and military support given by Pakistan to the war. However, after U.S. airstrikes killed 24 Pakistani soldiers on Nov. 26, 2011, Islamabad closed the border with Afghanistan and demanded an apology – which Washington has pointedly refused to give.

Pakistan’s parliamentary committee on national security reiterated on Apr. 12 the demand for an apology, making it a condition for reopening the border. The committee has also called for a halt to U.S. drone strikes in the FATA where Taliban leaders are said to be holed up.

According to the London-based Bureau of Investigative Journalism, since drone strikes were first launched in 2004, more than 2,500 people may have died in the unmanned aerial attacks over the FATA and nearby areas of Pakistan.

The strikes have added to the trauma of the local population in the FATA, an idyllic tourist destination until late 2001 when the Taliban began pouring over the border after their government in Kabul was ousted by coalition forces led by the U.S.

Once ensconced in the FATA, the Taliban unleashed a reign of terror on the local population, attacking music shops, girls’ schools and government installations, provoking the Pakistan army to launch punitive raids in 2007.

“Our people are caught between the army and the Taliban and that has made the lives of ordinary people miserable,” said Saleema Bibi, who lost her husband and two sons in the hostilities.

On Mar. 30, the United Nations refugee agency (UNHCR) said in a press note that since January more than 100,000 people have been displaced, mainly from the Khyber agency, as a result of a “recent increase in the intensity of fighting.”

According to the UNHCR, the Jalozai refugee camp outside Peshawar now houses 62, 818 people. “Most of the people moving out of Khyber agency are opting to live with friends and relatives,” the press note said.

Unsettled conditions have meant that women in the FATA are unable to participate in social functions like marriages or religious festivals, which foster cohesion in their tribal communities, according to psychiatrists.

Doctors at the Sarhad Hospital for Psychiatric Diseases (SHPD), a government facility in Peshawar, confirm that many women from the FATA are suffering from depression and anxiety due to the deteriorating law and order situation there.

“Last year, we received a total of 49,000 patients which included 9,432 women from the FATA,” Naureen Wakeel, a psychiatrist at SHPD, said. “The problems that many of these female patients face require strong family and social support along with medical aid,” she said.

Lubna Hassan, president of the Society of Obstetricians and Gynaecologists of Pakistan, estimates that 50 percent of pregnant women in the FATA suffer from stress, depression and trauma.

“Last month, we saw 3,455 pregnant women from different areas of the FATA at the SHPD and found that nearly all require psychological support.

“Pregnant women should not be mentally stressed if they are to deliver normal babies,” Hassan said. “These women, who are used to staying in proper homes, are now sheltered in tents or makeshift accommodation in school buildings because of the ongoing military operations.”

It was personal experience that turned Gul Bano and her cleric husband, Ahmed Khan, into ambassadors against early marriage and its worst corollary – obstetric fistula which allows excretory matter to flow out through the birth canal.

Bano and her cleric husband campaigning against child marriage. Credit: Zofeen Ebrahim/IPS

As is the custom in the remote mountain village of Kohadast in the Khuzdar district of Balochistan province, Bano was married off as soon as she reached adolescence, at 15, and was pregnant the following year.

There being no healthcare facility near Kohadast, Bano did not receive antenatal care and no one thought there would be complications. But, events were to prove different.

After an extended labour lasting three days, Bano delivered a dead baby. “I never saw the colour of my son’s eyes or his hair. I never held him once to my bosom,” recalls Bano, now 20.

Her troubles had only begun. A week later, Bano realised she was always wet with urine and reeking of faecal matter. “I was passing urine and stools together.”

Unable to handle the prolonged labour, Bano’s young body had developed a fistula caused by the baby’s head pressing hard against the lining of the birth canal and tearing into the walls of her rectum and the bladder.

Bano’s family attributed her condition to fate, her father refusing to visit “due to the bad odour coming from me.” However, through those trying times, Khan stood by his young wife and sought medical help.

After Bano spent a year in a perpetually “wet and stinky” condition, her husband finally discovered a hospital in Karachi specialising in treating fistula and other conditions related to reproductive health.

Koohi Goth Women’s Hospital, where fistula victims are treated free, was started by Dr. Shershah Syed, one of Pakistan’s first gynaecologists to train in repairing a painful and socially embarrassing condition.

In addition to incontinence, the medical consequences of fistula include frequent bladder infections, painful genital ulcerations, infertility and kidney failure.

In 2006, the United Nations Population Fund (UNFPA) launched a four-year fistula repair project as part of a programme to improve maternal health.

According to UNFPA, at least two million women in the world live as Bano did – in shame and misery. Most are not even aware that fistula can be repaired.

A major challenge for healthcare professionals is that the number of women suffering from fistula in the world is increasing by about 75,000 cases annually.

In Pakistan the true prevalence of fistula is unknown, but Syed estimates that there are about 5,000 new cases every year.

With only 500 – 600 women undergoing corrective surgery annually, Pakistan needs to put more resources into addressing fistula – which falls under the Millennium Development Goal (MDG) of reducing maternal mortality by three-quarters by 2015.

The MDGs are eight United Nations targets to be met by 2015 and, according to studies published by the International Youth Council, a major civil society organisation, Pakistan is unlikely to meet the fifth that deals with maternal health.

Pakistan, according to IYC figures released in 2010, has a maternal mortality rate (MMR) of around 500 per 100,000 births that is sought to be reduced to three-quarters from 1990-2015.

Pakistan’s maternal mortality ratio is wide-ranging, from 286 per 100,000 births in Karachi’s urban areas to 756 in rural Balochistan, where child marriages are compounded by non-existent health services.

“For both physiological and social reasons, mothers aged 15-19 are twice as likely to die of childbirth than those in their 20s,” says a UNFPA document. “Obstructed labour is especially common among young, physically immature women giving birth for the first time.”

Obstetric fistula is now generally acknowledged to be another burden on the girl child, deprived of basic education and forced into marriage – for which she is neither physically nor mentally prepared.

Pakistan’s Child Marriages Restraint Act passed in 1929 permits girls to be married at 16, but poverty, illiteracy and socio-cultural practices result in girls being married off as soon as they reach puberty.

Syed’s team continues to hold fistula repair camps in the remote areas of Pakistan that include training programmes for doctors and paramedics in fistula management. “The complicated cases come to Koohi Goth and simple repair is done in the field hospitals.”

The camps provided an opportunity to reach out to affected women and their families and encourage them to avail themselves of the free treatment in Karachi, where necessary.

Getting Bano to Karachi was not easy. Khan gathered a group of able-bodied men who took turns carrying her on a rope bed for three days just to reach a motorable road.

“It’s been almost three years and she has gone through six operations,” says Dr. Sajjad Ahmed, who worked at Koohi Goth as manager of UNFPA’s fistula project from June 2006 to February 2010. “She would not speak at all and she did not understand Urdu.”

Today Bano and Khan are regular visitors at Koohi Goth and vocal advocates of the campaign against fistula. They travel across Pakistan, spreading the word about how to prevent the injury and what to do about it.

“Khan is a cleric and yet he does not conform to the stereotype of a religious person,” said Syed. “He tells parents that fistula can be avoided if they stop marrying off their daughters at a very early age.”

Bano shares her story and tells married women about the importance of birth spacing, antenatal checkups and timely access to emergency obstetric care.

Syed says Pakistan badly needs a mass awareness campaign on fistula prevention and stresses the importance of social support for victims. “That’s the only way we can eradicate fistula from this region.”

“I smell nice now and it’s all because my husband wanted me to get well,” said Bano, who may have spent many more years in a miserable state if not for the treatment at Koohi Goth.

Melinda Gates (right), co-chair of the Bill and Melinda Gates Foundation, pressed for gender-sensitive development aid at a conference on Apr. 4 Credit: A. D. McKenzie/IPS

By A. D. McKenzie
PARIS, Apr 5 2012 (IPS)

Though United Nations experts agree that governments should focus on empowering girls and women as a key to managing a world of seven billion people, not enough is being done for women’s rights in developing countries, aid advocates say.

“There are 215 million women around the world who would like access to some kind of birth control tool who don’t get it today,” said Melinda Gates, co-chair of the Bill and Melinda Gates Foundation, at a conference on development aid held here on Apr. 4.

“This is particularly true in many of the countries (with which France has bilateral aid agreements), in West Africa, for instance,” said Gates, the wife of Microsoft’s founder. “If women have access to contraceptive tools, they can save their own lives, because we know it will decrease the number of women dying in childbirth and also save children.”

She added that the whole idea of aid is “not to have people on aid forever.” It’s to build countries that provide the right products and services to their people. “That’s what leads to sustainability, and that’s when a society can lift (itself) up.”

Development commitments lagging

On the same day that Gates spoke in France, the Paris-based Organisation for Economic Cooperation and Development (OECD) issued a report showing that global development aid declined by nearly three percent in 2011 for the first time in more than 10 years.

The organisation said that in 2011, members of the Development Assistance Committee of the OECD provided 133.5 billion dollars of net official development assistance, representing 0.31 per cent of their combined gross national income (GNI). This was a 2.7 percent drop in real terms compared with 2010.

Meanwhile, total net official development assistance provided by all 27 member states of the European Union was 73.6 billion dollars in 2011, which represents 0.42 percent of their combined GNI, down from 0.44 percent in 2010, the OECD report said.

The drop came despite the EU’s pledge to allocate 0.7 percent of member states’ GNI to development assistance by 2015. French aid, for instance, fell from 0.51 percent of GNI in 2010 to 0.46 percent last year.

“This is a major cause for concern, ” said Guillaume Grosso, director of the French branch of ONE, the anti-poverty group co-founded by Irish musician Bono.

“France is one of the most important players in terms of how much money they put on the table. So if France is starting to move backwards, it can have a domino effect,” he told IPS.

He added, “Each reduction in the aid budget prevents children from going to school, prevents treatment for the sick, and prevents families from having access to clean drinking water.”

ONE wants France to take a leading role in championing development aid, because of the country’s status as a “driver” (with Germany) in the EU, and as a member of the Group of 8 (G8) major global economies.

French president Nicolas Sarkozy has supported a tax on financial transactions (FTT) to aid development, and the French government plans to implement the tax without waiting for its European or G8 partners to come on board.

But Sarkozy faces a two-round presidential election in April and May, and there is no guarantee that he will be around to see new policies through. He currently trails in the polls to Socialist challenger Francois Hollande.

“The situation of Africa and development has been largely overlooked in the election campaign, but it should be an essential part because what France will do or will not do in the next five years can have a tremendous influence in the world for good or for bad,” Grosso told IPS.

Marie-Do Aeschlimann, national secretary for the ruling Union for a Popular Movement (UMP) party’s international humanitarian and solidarity action, told IPS that Sarkozy “was the first to fight for innovative financing”. She said that the FTT will be implemented in August of this year in France, and will be used to fund development from 2013.

“The stronger France is financially, the more (it) can help to aid development overseas,” she said, adding that Sarkozy and his party were “very attached” to the goals of promoting gender equality and women’s rights as outlined in the Millennium Development Goals (MDGs).

“We will continue to support programmes that enable women to become more autonomous, particularly through professional training, but also in their function as mothers, which is very important,” Aeschlimann added. “We also support the right of women to choose to have or not to have children, and at their own timing.”

Reproductive justice boosts development

Many NGOs, U.N. agencies and parliamentarians continue to call on governments around the world to do more for women’s reproductive rights.

The United Nations Population Fund (UNFPA) says that reproductive health and women’s empowerment are linked to the eight MDGS. Regarding poverty reduction, for example, the UNFPA says, “Countries that support desires of their citizens for fewer children and longer time between births, while simultaneously reducing mortality, reap benefits in social and economic development”.

At last year’s G8 summit in France, parliamentarians from 35 countries also appealed to leaders of the world’s major economies to focus on the role of women and girls in development.

“We wish to draw the world’s attention to two aspects of human rights that are the most neglected – the situation facing girls and adolescent women and the challenges posed by global population dynamics at present,” said a resolution issued at the end of the Global Parliamentarians’ Summit held at France’s National Assembly last May.

The resolution said that 600 million girls and young women in the developing world “are in a vulnerable situation, facing injustices and inequities that constitute a major obstacle to social and human development, both at a personal and a societal level.”

The parliamentarians, from European Union member countries as well as from Africa, Asia and other regions, called for changing the policies that see women receiving less than two cents of every development dollar.

This week, Gates added her own support to the push for more development assistance to women.

“Women are the fabric of society and they lift their families up,” she told IPS. “We know that every extra little bit of income a woman gets, they invest it back in the heath and education of their families, so they are absolutely fundamental towards getting a society to grow and develop.”

But even if development aid to women were to increase significantly over the next years, NGOs worry that investment will be undercut by the EU’s own corporate policies. Groups such as ONE are pushing for strong legislation on the extractive industries, for instance.

“We need legislation at the EU level so that Europe can take a strong stance and force European companies to publish what they pay to countries in which they exploit resources,” Grosso told IPS.

He said this was to avoid situations such as in Equatorial Guinea, which is one of the richest countries in Africa, with a GDP equivalent to that of Portugal, but where “two people out of three live on less than a dollar a day”.

“The contracts between petroleum companies and governments are so opaque that there can be all kinds of corruption and misuse of funds,” Grosso said.

“It’s very important that development aid is not some kind of excuse for running atrocious commercial or agricultural policies that close the door to access to markets for African farmers, for instance, two- thirds of whom are women,” he told IPS.

“There were three people. One person was holding me down; one person was holding my hand; and the other person was doing the job. They lay me down, and…” Fatu said of the female genital mutilation she underwent as an eight- year-old in Liberia.

FGM is a taboo and complicated topic in Liberia and it is dangerous for women to speak out about it. Credit: Travis Lupick/IPS

According to the World Health Organization, Fatu endured what is classified as a type II female circumcision (on a scale of one to three), where her clitoris and labia minora were cut away.

Now 23 and a student at the University of Liberia, Fatu’s circumcision was part of her initiation into the secretive Sande Society, a pseudo-religious association to which most Liberian women – depending on which tribe and part of the country they are from – are members.

The Sande and its male counterpart, the Poro, shape many aspects of culture, tradition, and society as a whole in this West African nation. The Sande “bush” schools are where young Liberian women – some as young as two years old – are supposed to receive instruction on the traditions of respect, how to run a household, and how to prepare for marriage.

It is also where their circumcisions happen.

The Sande society believes this rite of passage makes a woman strong and prevents her from becoming promiscuous.

International organisations such as the United Nations Children’s Fund argue that FGM is a human rights violation that denies women “their physical and mental integrity, their right to freedom from violence and discrimination, and in the most extreme case, their life.”

FGM’s central position in the Sande makes it particularly difficult to curtail, explained Minister of Gender and Development Julia Duncan-Cassell. But through cooperative efforts with traditional leaders, the government of Liberia is quietly moving to shut down the Sande schools and bring an end to female genital cutting in Liberia.

“Government is saying, ‘This needs to stop’,” stated Duncan-Cassell. “I can’t tell you that it stopped completely, but the process is ongoing.”

In the past the Liberian government has been unwilling to comment on FGM and Duncan-Cassell outlined the clearest position on the practice to date. She affirmed her office’s commitment to putting an end to female circumcision in the country. FGM is a taboo and complicated topic here in Liberia.

While Fatu mostly spoke positively of her experiences with the Sande, many women interviewed by IPS refused to discuss the society or FGM.

“It hurt. Seriously, it hurt. And there was a lot of blood,” Fatu said, contorting her facial muscles as she recalled the experience. Yet Fatu maintains she does not regret the time she spent in the Sande bush school.

“From that time till now, I feel like a woman. I feel proud,” she said, her last word spoken slowly, drawn out, and punctuated with the same emphasis she used to describe the pain she felt during her initiation.

Duncan-Cassell conceded that eradicating FGM in Liberia will take time.

“There has been a statement put out by the Ministry of Internal Affairs asking all of our mothers, our aunts, our sisters, to desist from such practices,” Duncan-Cassell said. “Government wants to respect the beliefs of the people but, at the same time, is telling them not to infringe on the right of someone else.”

There are no reliable statistics on the number of Liberian women circumcised; however, it is estimated that as many as two-thirds of women in the country have undergone the procedure.

The cessation of Sande initiations and FGM remains a highly sensitive issue for the government, and officials interviewed maintained that it would take years to put an end to the practice. However, an alleged deal exists that could see the Sande sidelined sooner than most expect.

Assistant Minister of Culture at the Ministry of Internal Affairs Joseph Jangar said that a deal has been struck between the Sande and Poro societies, whereby the Sande would hand over land used for initiations to the Poro.

“The women agreed,” Jangar said. “With that understanding, the women cannot practice Sande. Because of that, we are not issuing permits (to operate Bush schools) to any Sande Society.”

Jangar said that an official letter, sent on Dec. 9, 2011 to district superintendents and heads of both the Sande and Poro societies, requested that all Sande groves be closed down by the end of that year. “They all received the letter,” he said. “If we find any zoes (traditional spiritual leaders) practicing Sande school, we will fine them.” Monitors are scheduled to go out into the counties by the start of April, he added.

However, Minister of Internal Affairs Blamo Nelson claimed that he was not aware of the letter, but said that he sees FGM slowly becoming a thing of the past.

“The advocacy calling for an end to FGM should continue,” he said. “And I’m sure that in time these practices, that more and more Liberians are beginning to find obnoxious, will go away.”

Mama Tormah, head of all the Sande’s female zoes, said the society is currently undergoing a number of changes, including placing an emphasis on more formalised studies into the culture. Another is addressing a criticism often levied at the Sande – that it enrolls and circumcises girls far too young to take part on their own free will. Tormah acknowledged that 17 or 18 years should be the minimum age for students of the “bush” schools.

She, however, denied that grove schools were ever involved in FGM and chastised Duncan-Cassell for speaking publicly about this taboo subject. “You’re not supposed to ask me that question under lights,” Tromah protested.

Meanwhile, Nelson cautioned that traditions and beliefs are difficult things to change and, when it comes to an issue as culturally sensitive as FGM, are complicated to even debate.

A conversation on genital cutting in Liberia has no doubt begun. But for some, it has arrived too late.

In December 2011, 17-year-old Lotopoe Yeamah underwent her Sande initiation in Nimba County. According to media reports, complications left her bleeding for a week. When Yeamah was finally taken to a clinic, she was pronounced dead on arrival.

By Andrew Green and - -
JUBA, Mar 24 2012 (IPS)

Martha Borete Angela’s gaze sinks to the ground as she admits neither of her two children was delivered by a midwife or doctor. The 28-year-old South Sudanese woman shared this fact in front of her classmates: first-year students in a programme for midwives at the Catholic Health Training Institute in Wau, a city in the western part of the country.

Martha Borete Angela is a first-year students in a programme for midwives at the Catholic Health Training Institute South Sudan. Credit: Andrew Green/IPS

South Sudan has the highest rate of maternal mortality in the world, according to the United Nations Population Fund. The government estimates that more than 10,000 women die every year giving birth and 76,000 experience severe complications. Here, women constitute 60 percent of the country’s eight million people.

The high mortality rate is exacerbated by a widespread shortage of professional midwives to consult with women during their pregnancies and identify potential risks. A national survey from three years ago reported less than 150 midwives in the national health system.

“Our mothers, some of them, they pass away from delivering,” said Ropani Raship, a 20-year-old classmate of Angela’s at the Catholic Health Training Institute. “They don’t have a chance.”

Instead of trained care, mothers turn to traditional birth attendants, like Angela did when she had her second child. Some do not get any assistance at all.

Everyone, from the South Sudanese government to the NGOs propping up the country’s nascent health system acknowledge that developing the sector generally – and its response to maternal deaths, specifically – depends on getting more trained workers into the system as quickly as possible.

Angela, Raship and their classmates represent that possibility: A cadre of young, fully trained midwives, who will be placed in clinics and hospitals around the country once they finish the programme and achieve government certification.

But it will be three more years before they can start filling that gap. And they will do it – along with graduates from the country’s two other certificate programmes – a handful at a time, in a country where thousands of midwifes are needed. That means, for the foreseeable future, many pregnant women will be left to rely on traditional birth attendants and other frontline health workers.

These are often neighbours who “believe they have a gift of healing, or they learned midwifery through mentorship,” said Alaa El-Bashir, the country coordinator for the Maternal, Newborn & Child Survival Initiative (MNCSI) out of Massachusetts General Hospital. Most are not trained to identify or treat serious complications.

The situation reveals a larger debate in this new country: How do you allocate finite resources to save lives now, while also making the long-term investments that will build a sustainable health system?

For its part, MNCSI has decided to do what it can to improve the skills of the frontline workers. The initiative is reaching out to them with trainings and a bag of basic health supplies – scissors, gloves, a string for tying the umbilical cord.

Over a year and a half, MNCSI has put 72 trainers through a master course. They, in turn, have reached out to train more than 700 frontline health workers across seven of the country’s 10 states. An eighth state will be brought into the fold in a few months.

The idea, according to El-Bashir, is to get health workers trained to a level where they can at least recognise potential complications and refer people to a health facility early. MNCSI provides a pictorial checklist for the health workers to consult during the course of the pregnancy to recognise warning signs. And if no complications are apparent, they can help safely deliver the child.

MNCSI has also introduced a cheap tool to help women who start haemorrhaging after birth: a uterine balloon kit. It’s a simple innovation – a catheter with a condom attached to the end. The condom is inserted into the uterus and a syringe used to fill it with water. This can help staunch the bleeding until the woman is taken to a health facility.

After a recent tour of some of the areas where the uterine balloon kit has been distributed, El-Bashir said the frontline health workers have been able to use the tool without any problems. Of the recorded cases, MNCSI reported only one mother had passed away.

“We are saving lives,” El-Bashir said.

There are always going to be unexpected complications among delivering mothers, though, said Susan Purdin, the country director for the International Rescue Committee (IRC). And they cannot always be anticipated by observing risk factors. South Sudan’s best option is to ensure all pregnant women have access to qualified health workers.

“Everybody needs to know that any woman could have a complication and needs to get care,” Purdin said. That requires rallying, not just mothers, but fathers, traditional birth attendants and taxi drivers. It also requires making them aware that, if problems arise as the woman goes into labour, they should be poised to take her to a health clinic.

IRC has been working in what-is-now South Sudan for more than two decades, with many of its programs centred around healthcare. It currently supports 30 health centres in the west and north of the country, five of which offer maternal health services.

On a recent visit to one of the centres, Purdin said she witnessed a midwife save five lives. One mother, after giving birth to twins, started to haemorrhage. The midwife stopped the bleeding just as another woman in labour arrived, her baby coming arm first. As she cared for the first mother, the midwife got the second into an ambulance bound for a hospital that could assist her.

“It happens every day,” Purdin said. “It’s not always that dramatic, but having qualified midwives in health facilities where there are supplies and equipment and a referral system is the way to save mothers’ lives. And it can be done.”

It will not be done quickly, though. It requires raising awareness within the community and then working to make sure that the promised services are available. That means building more health facilities and getting more midwives, like Angela and Raship, into the system.

But back in Wau, the students at the Catholic Health Training Institute realise that even as they are deployed, the reliance on traditional birth attendants isn’t going away anytime soon. Instead of presenting an either-or approach, many said they were prepared to offer training to frontline health workers and to take advice from them on how to work in the community.

That, they agreed, is the best way to save the most mothers’ lives.

*Andrew Green is reporting from South Sudan on a fellowship from the International Reporting Project, an independent journalism programme based in Washington, D.C.

Excerpt:

By Kristin Palitza and - -
ABIDJAN , Mar 20 2012 (IPS)

Political instability, civil strife and humanitarian crises in Africa have over the past decades reversed countless maternal health development gains on the continent, health experts warn.

Maternal health is not a priority in Africa. Credit: Kristin Palitza/IPS

Natural resource-rich but conflict-ridden Nigeria and Democratic Republic of Congo, for instance, continue to struggle with high maternal mortality rates of up to 1,000 deaths per 100,000 live births, according to 2011 World Health Organization (WHO) statistics. In war-torn countries like Somalia, maternal mortality is even higher, at more than 1,200 deaths per 100,000 live births.

“Regions like West and Central Africa, that experience a lot of political instability, have the lowest indicators for maternal health on the continent, despite the fact that most of them are rich in terms of natural resources,” Kouakou explained.

As a result, more than 550 women die in childbirth every day in sub-Saharan Africa, according to the WHO, compared to five deaths per day in high-income countries. The risk of a woman in a developing country dying from a pregnancy-related cause during her lifetime is 36 times higher compared to a woman living in an industrialised nation.

If a mother dies, the whole community feels the negative impact of the gap she leaves. “High maternal mortality has grave consequences not only for families but also for communities,” said Dr Edith Boni- Ouattara, deputy country representative of the United Nations Population Fund (UNFPA) in Ivory Coast.

Since mothers are usually the main caregivers, their health status, and especially their death, stands in direct correlation with the well-being of their immediate and extended family. “A mother’s death has a negative impact on all aspects of a child’s life, including nutrition, health and education,” the UNFPA representative noted.

Countries even experience national economic setbacks when mothers die, Boni-Ouattara further explained: “Worldwide, we lose 15 billion dollars in productivity per year due to maternal deaths.”

But despite these indicators, maternal health is far from being made a national priority in African nations. As soon as governments are faced with political threats or humanitarian emergencies, investments in maternal and infant health as well as family planning are the first to be cut, according to Kouakou.

More than a third of women in sub-Saharan Africa do not have access to any pre-natal health services today, while 70 percent do not receive any post-natal care, according to UNFPA. In West and Central Africa, less than 15 percent of women have access to contraception and family planning.

Sadly, this was largely the case because available budgets were disproportionately targeted towards defence, noted Kouakou: “Most public hospitals struggle with health service provision and continuously run out of medicines, but if you visit a military camp in that same country, you’ll see the latest weapons.”

Second on the priority list of governments is usually the fight against poverty and hunger, which is also the first of the eight United Nations Millennium Development Goals (MDGs) that nations have committed themselves to reach by 2015.

In sub-Saharan Africa, the proportion of people living on less than 1.25 dollars a day has only decreased marginally in the past two decades, from 58 percent in 1990 to 51 percent in 2005, according to the latest World Bank statistics.

As long as African nations remain poor, investments in maternal, sexual and reproductive health will remain minimal, experts say. Many countries will therefore struggle to reach the three health-related goals – MDG 4 (the reduction of under-five child mortality by two-thirds), MDG 5 (reducing maternal mortality by three-quarters and achieving universal access to reproductive health) and MDG 6 (combating HIV/AIDS, malaria and other diseases) – within the next three years.

“Most countries focus on the eradication of poverty and hunger, while maternal health gets neglected. It’s a matter of priorities,” said United Nations Development Programme (UNDP) Ivory Coast MDG specialist, El Allassane Baguia.

Few governments are conscious enough of the tight link between maternal health and poverty, he said. It takes strong leadership at the country level to shift those priorities and spend more on maternal and child health, and more effective implementation of existing policies and international agreements, he added.

The right to family planning and thereby to sexual and reproductive rights has, for example, been included in the U.N. human rights framework since 1974. But such services have until today not been included in the public health care provision in many African countries.

“Yet, family planning services could reduce maternal and infant mortality by a fifth. Access to qualified medical care could reduce deaths during the birthing process by 75 percent,” Boni-Ouattara noted.

In the southern and eastern regions of the continent, the situation looks slightly different. Here, most nations have enjoyed relative political stability and been affected by fewer humanitarian disasters compared to their neighbours in West and Central Africa. As a result, maternal and infant mortality rates were on the decrease – until HIV and AIDS started to pose a threat to maternal health in those countries.

Consequently, politically stable countries with relatively low HIV-infection rates, like Botswana, have the lowest maternal mortality rates on the continent, at under 300 deaths per 100,000 live births, according to the WHO.

But in countries like South Africa, HIV/AIDS has undermined efforts. Despite strong political and economic stability, its maternal mortality rate is at up to 549 maternal deaths per 100,000 live births.

Excerpt:

By Kristin Palitza
ABIDJAN , Mar 15 2012 (IPS)

“I would like to use contraception, but my husband is against it,” says Bintou Moussa*. The 32-year-old mother has just given birth to her sixth child at the Abobo General Hospital in Cote d’Ivoire’s commercial capital Abidjan.

A health worker explains the sexual transmission of infections at the family planning clinic in Yopougon. Credit: Kristin Palitza/IPS

The family barely survives from the money Ibrahim earns from odd jobs here and there. But despite their difficult economic situation, Ibrahim refuses to consider family planning.

“My husband does not want to use condoms. He says it’s against nature. And I don’t dare to take the birth control pill because I am afraid he might find out about it,” Moussa explains.

When asked if she knows about her rights to sexual and reproductive health, the woman shakes her head. “As head of the family, it’s my husband who makes decisions about the health of the family,” she explains. That includes her body, she says.

Moussa is not aware of the option of having a contraceptive injected once a month, if she so wishes, and that she can do so without her husband’s consent. She also does not know how to access such health services because there is no family planning service at the hospital or any public clinic in Abobo, Abidjan’s biggest slum with an estimated population of one million.

In fact, Cote d’Ivoire’s commercial capital, which counts at least five million people, has only one clinic that offers family planning services free of charge. It is located within the premises of the public hospital in Yopougon, one of Abidjan’s largest suburbs, which lies about 15 kilometres south-west of Abobo and is run by the non-governmental health organisation Ivorian Association for Family Well- Being (AIBEF).

Here, staff counsel about 80 patients a day on issues relating to sexual and reproductive rights, including contraception, safe sex, HIV and other sexually transmitted infections, teenage pregnancies, and maternal and infant health. The clinic also runs outreach programmes through a mobile clinic to raise awareness about the services it provides.

“Our main hurdle is to overcome the patriarchal and cultural perception that the man makes all the decisions at home. But at the same time, men say it’s the woman’s responsibility to take care of the children and their health, including their own pregnancy, birth and post-natal care,” explains Dr. Nathalie Yao-N’Dry, the clinic’s programme manager.

“When effectively women cannot make decisions about accessing health services without the permission of their husbands, that’s a dangerous contradiction.”

Many women share Moussa’s experience in Cote d’Ivoire, a West African country where family planning is widely regarded as a “women’s issue” that husbands do not have to concern themselves with. As a result, very few men use the small number of public services on offer, while women continue to struggle to realise their sexual and reproductive rights.

AIBEF is trying to slowly change this. “Whenever a man is ill and comes to access general health services in the hospital, we try to recommend family planning services as well. But it’s very difficult to get men interested,” says Yao-N’Dry.

The other hurdle is availability of services. While AIBEF struggles to get men to buy into the concept of family planning, most other public health facilities in the country do not even offer such services. One of the reasons is that government has not made any specific allocation for family planning in its already low national health budget.

Only 4.5 percent of the country’s budget goes towards health, despite the fact that Cote d’Ivoire is one of the African Union countries that committed itself through the Abuja Declaration of 2001 to spend at least 15 percent of its national budget on health services.

“Health facilities throughout the country lack funds, skilled health workers and resources,” laments Germaine Moket, the medical services director of the local branch of the International Planned Parenthood Federation, an international organisation assisting with reproductive health and family planning services in more than 180 countries worldwide.

“As a result, most public health centres in the country don’t have contraceptives in stock, at least not regularly,” she explains. “And even if they do, they sell them at prices that the general population cannot afford, since those drugs aren’t given out free of charge.”

In the 10 months since Cote d’Ivoire has been trying to recover from its violent post-electoral crisis, the country’s new government has put into place a number of measures to improve health services in the country.

When Ouattara was instated in May 2011, he implemented nationwide free health care services to help the population recover from the effects of the post-election violence. Since Mar. 1, the scheme has been limited to free services for pregnant women, children under five and malaria patients.

“Mother and infant health are a priority of the health ministry that needs to be addressed urgently,” said Professor Allou Assa, ministerial spokesperson for the national Department of Health. But sexual and reproductive health services, which are preventative rather than curative, are currently not part of the free package.

That means women like Bintou Moussa continue to be left with few options. In a few days, she will return with her newborn to her small shack, knowing fully well that she might soon fall pregnant again. “We hardly manage to bring through five children. Now we have another mouth to feed. I really don’t know how I could cope with another pregnancy,” Moussa says.

*Name changed to protect identity of interviewee

Excerpt:

By Kristin Palitza
ABIDJAN , Mar 14 2012 (IPS)

One-year-old Angama Ouattara lies on a rusted hospital bed, a drip attached to her tiny, left foot. Her mother, Minata, sits on the edge of the mattress, smoothing out the sheets she had to bring from home.

Dr. Tenedia Soro-Coulibaly (right) with patient Angama Ouattara, and her mother Minata (left). Credit: Kristin Palitza/IPS

Six days ago, Angama was admitted to the paediatric ward of Abobo General Hospital in Cote d’Ivoire’s economic capital Abidjan. The little girl suffers from a severe case of meningitis, a dangerous inflammation of the membranes around the brain and the spinal cord. She is too weak to sit up or to even hold up her head.

A new national health regulation, which came into effect on Mar. 1, that offers free health services to pregnant women, children under five years and people suffering from malaria has saved her life.

“I just make enough money to put food on the table for me and my two children. I don’t have money to pay for hospital fees,” says the 27-year-old mother, who works as a fish vendor in a market in Abobo, Abidjan’s biggest slum. She could have not brought her daughter to the hospital if it wasn’t for free.

Ten months after the West African country started to emerge from a presidential election crisis during which almost all hospitals and clinics had to shut down for a good six months because they had been vandalised, looted and occupied, the new government under President Alassane Ouattara is trying to make public health care a priority.

Ouattara came to power in May 2011, six months after the country’s presidential elections, which were followed by a violent struggle for power between him and his predecessor Laurent Gbagbo, during which 3,000 people were killed and at least half a million displaced, according to the United Nations Refugee Agency.

One of the new president’s first actions was to ensure hospitals reopen their doors by implementing an emergency health care plan, called the Gratuité, which offered free health care to all citizens for nine months. This policy has now been replaced with a more permanent regulation targeting solely mothers, small children and malaria patients.

But in a country recovering from 12 years of political instability since a military coup in December 1999 that was followed by 10 years of Gbagbo’s autocratic rule, rebuilding a crumbling public health care system takes time. Hospitals have been suffering from lack of skilled staff, basic equipment and technology for years.

Last year’s post-election crisis made health care provision even worse, as armed forces and citizens stole whatever they could carry: medications, laboratory equipment, computers, beds and mattresses. Even ambulances were stolen, says Dr. Mamadou Keita, the national health department’s director of Abobo district. The slum, home to an estimated one million people, has currently only one ambulance.

“We haven’t been able to replace all equipment yet because we had to rebuild from zero. It’s a process that will take time since it’s very expensive,” he explains. “At the moment, we can only provide minimum services. We still don’t have lab equipment and lack basics like needles and thermometers. We often run out of drugs.”

Little Angama is a case in point. Even though the hospital does not charge for medical services and the bed, her mother has to purchase the girl’s IV liquids and medicines from a nearby pharmacy – because the hospital is out of stock. This costs her 20 dollars a day, while her average daily income is about four dollars.

“My daughter has been here for six days already. I have to borrow money from different family members. And while Angama is in hospital, I don’t work, so I don’t have an income at all. It will take me a long time to repay this debt,” Ouattara sighs.

The population’s need for good health services is greater than ever. During the post-election crisis between November 2010 and May 2011, many Ivorians were injured during clashes, and thousands of displaced persons lacked access to clean water, sanitation and were exposed to malaria.

In 2011, four million children were hospitalised in Abobo General Hospital alone, almost twice as much as the year before, says Dr. Tenedia Soro-Coulibaly, the hospital’s paediatrician.

“About 90 percent of those children had malaria. That was remarkable,” she says, even for a country like Cote d’Ivoire where malaria is the number one cause of child mortality, with about half of all child deaths caused by the disease, according to the World Health Organisation.

To make matters worse, markets and banks had to close when the country fell into crisis, meaning that people could neither access money nor food. As a result, malnutrition rates shot up, especially among children, the most vulnerable. “We also saw an increase in cases of cholera, meningitis and measles as well as diarrhoea and respiratory infections,” adds Keita.

The combination of looting and increased illness placed a burden on an already struggling health system that will take many more months to fix. “We often don’t have urgently necessary equipment to save patients’ lives,” laments Soro-Coulibaly. The paediatric ward’s oxygen bottles stand empty, while broken generators prevent doctors from doing their job during frequent power outages, she says. The impact of the post-election violence on children’s health has in fact been so severe that U.N. Children’s Fund (UNICEF) is worried the situation might have lasting negative consequences for Ivorian children – especially if the government does not manage to rebuild the health system quickly throughout the country.

While health service provision in Abidjan, the country’s economic centre, is improving slowly but surely, access to services remains extremely limited in Cote d’Ivoire’s western and central regions, which until today continue to suffer from sporadic violence.

“We lobby government for bigger budgets, but also urge them to decentralise the system. Currently, the majority of funds go to three hospitals in Abidjan, while there is still very little health service provision in rural areas,” says UNICEF Cote d’Ivoire deputy representative Christina de Bruin.

“The coming months will be a critical period regarding the long-term impact of the crisis on children’s future and well-being,” she adds. “A quick return to providing health and other social services is a key step to stabilise the country.”

Excerpt:

When the world’s rising population hit the historic seven billion milestone last October, the United Nations predicted that population growth will continue to increase, reaching an estimated 9.3 billion by the year 2050.

A banner outside U.N. Headquarters promotes a global campaign by the U.N. Population Fund. Credit: UN Photo/Rick Bajornas

But keeping pace with this growth is the increasing south-south cooperation among developing nations who are sharing innovative experiences in reproductive health, family planning, gender empowerment and the integration of population into development planning.

Sethuramiah L. Rao, permanent observer of Partners in Population and Development (PPD) to the United Nations, told IPS, “It is internationally recognised that south-south and triangular development cooperation continues to grow in importance, accounting for around 10 percent of total development cooperation today.”

It is also well appreciated, he said, that south-south cooperation is not a substitute for, but is complementary to north-south cooperation and that south-south cooperation is an important element of international cooperation for development.

Among others, Rao singled out Brazil, China, India and South Africa as some of the countries making significant contributions to south-south cooperation.

The PPD, which he represents in New York, was launched at the 1994 International Conference on Population and Development (ICPD) specifically for promoting and strengthening south-south cooperation in population and reproductive health.

Accounting for close to 70 percent of developing countries’ population, PPD’s current membership comprises 25 developing countries: (Bangladesh, Benin, China, Colombia, Egypt, Ethiopia, Gambia, Ghana, India, Indonesia, Jordan, Kenya, Mali, Mexico, Morocco, Nigeria, Pakistan, Senegal, South Africa, Thailand, Tunisia, Uganda, Viet Nam, Yemen and Zimbabwe), and is growing.

A book titled “Sharing Innovative Experiences”, jointly published by the Special Unit for South- South Cooperation at the U.N. Development Programme (UNDP), the U.N. Population Fund (UNFPA) and PPD, acknowledges that growth in world population is “phenomenal”.

“While on the one hand it reflects mankind’s enormous success in reducing mortality and improving quality of life for billions of people, on the other, it raises the serious challenge of the social, political, environmental and developmental implications of adding additional billions of people so rapidly,” the book says.

According to the 260-page publication, the world population did not reach one billion until 1804.

It then took 123 years to reach two billion in 1927, 33 years to reach three billion in 1960, 14 years to reach four billion in 1974, 13 years to reach five billion in 1987 and 12 years each to reach six billion in 1999 and seven billion in 2011.

Asked about the highlights of south-south cooperation in reproductive health, Rao said the governments of Egypt, India and Morocco have offered long-term fellowships for graduate education in population and public health.

At the same time, China, India, Thailand, Egypt, Morocco, Tunisia, and South Africa are offering short-term fellowships to train demographers and population and health experts.

Meanwhile, China, Indonesia, Thailand, Kenya, Egypt and Tunisia have hosted a large number of familiarisation tours of their population and reproductive health programmes for member country professionals.

A successful interregional network of about 25 premier partner institutions (PIs), all active in the area of population, reproductive health, public health and development, have been established by PPD, for capacity building in its member countries and others.

The PIs are collaborating in adapting each other’s training programmes and have signed letters of understanding on collaboration.

Rao said experience indicates that first-rate technical capacities exist in the population and reproductive health fields at the PPD network of PIs, and greater efforts should be made in the future to fully capitalise on such capacities through south-south and triangular cooperation.

In the important area of information exchange and experiences, PPD has succeeded many times in the past and most recently has catalogued, in collaboration with UNFPA and the Special Unit for South-South Cooperation at UNDP, innovative experiences that have led to success in member countries’ addressing population, reproductive health and development challenges.

He also said that advocacy and policy dialogue activities undertaken by PPD on urgent topics in population, reproductive health and development in the form of international conferences and workshops for member and non-member countries have been most successful.

Asked about shortcomings, Rao told IPS, “To my mind, there are at least two programmatic or practical limitations.”

Firstly, the successful experience is almost always documented retrospectively and thus, many important decisions crucial to its success are missed out due to recall lapse, while documenting the experience.

There is often a lack of recorded details, made worse by turnover over time of staff responsible for design and implementation of the practice in the country.

And most importantly, managers and documenters of the practice are not always the same people, making it difficult to achieve a balance in substance and narration.

Secondly, designing and implementation of programmatic interventions are frequently fine-tuned to dovetail with the political, cultural, administrative and human capital imperatives of a given country, making adaptation of the approach to other contexts sometimes challenging, he noted.

If the United Nations Children’s Fund (UNICEF) had 1.28 billion dollars it could help 97 million people around the world.

UNICEF's funding shortfall could leave millions of children like these searching for a living in garbage. Credit: Ashfaq Yusufzai/IPS

It could relieve five million drought-affected children in Ethiopia, give 360,000 children in Kenya access to quality education and treat 16,000 children for acute malnutrition in Madagascar. It could provide 2.2 million Somalis with safe drinking water and give a million children in the Republic of South Sudan basic health care.

And those figures are for Eastern and Southern Africa alone, just two regions of the world that UNICEF aims to reach.

Sadly, the U.N. agency secured less than 50 percent of its funding in 2011, suggesting that it will meet only half its expected goals this year.

Each January UNICEF releases its Humanitarian Action for Children report, which identifies children around the world in the most acute need of aid as a result of humanitarian emergencies – be they “natural disasters, human conflicts or chronic crises.”

The report is rife with pictures of children clinging perilously to survival; high-resolution images depict the protruding ribcages of malnourished boys and girls and the harsh realities of whole populations that are slowly starving to death.

Everything about the report is a desperate call for help. But help comes at a price, which, in this case, is a high one.

Released this year on Jan. 27, the appeal – 80 pages long and spanning 25 countries across seven regions – called for 1.28 billion dollars in aid, and breaks each country’s needs into categories such as nutrition, health, water sanitation and hygiene, education, child protection, HIV/AIDS and others.

UNICEF initially appealed for 1.4 billion dollars to be dispersed among 38 countries but revised its request mid-year to account for unprecedented crises like the famine in the Horn of Africa, among other disasters.

According to the report, 44 percent of funding for 2011 was funneled into the Horn of Africa, for which UNICEF activated its highest level of emergency response.

Meanwhile, other countries present new and equally dire needs. For example, UNICEF has appealed for more than 289.1 million dollars for Somalia in 2012, the largest funding requirement for a single country. The organisation has also called for 143.9 million dollars for the Democratic Republic of Congo (DRC) and 98.1 million dollars for Sudan.

The report adds that, as of October 2011, UNICEF had only received 48 percent of its projected needs, amounting to 854.7 million dollars, for all its humanitarian activities. Final numbers for the entire year are expected to be higher, but only moderately so.

For UNICEF, this means making heart-breaking decisions about which children to provide with life- saving services.

“Sadly, we never really (manage) to respond to all of the humans that are in need,” Marika Hofmeister, an emergency specialist at UNICEF told IPS.

Though a depleted resource pool is a setback for any organisation, a dearth of funding for UNICEF will have particularly severe repercussions, some bordering on disastrous for at-risk populations.

For example, South Sudan received just 36 percent of its projected needs last year, leaving its goal of providing 500,000 people with clean drinking water only partially met. Over 130,000 were excluded from planned supply since many water schemes could neither be rehabilitated nor constructed on the agency’s limited budget.

Meanwhile, armed with just 18 percent of its expected funding for the region, UNICEF’s plan to provide 75,000 children in the Philippines with schools supplies that had been lost or damaged due to floods failed woefully, leaving over 50,000 students without supplies.

Madagascar, Uganda, Congo, Iraq and Iraqi refugees, and Tajikistan were among several countries that received less than 10 percent of their planned funding, according to an October 2011 report.

Despite funding shortfalls, UNICEF reported helping millions of people worldwide during 2011, including providing de-worming, vitamin A supplementation and vaccinations for more than 36 million children; treating 1.2 million children for acute malnutrition; providing nutritional support for 19 million women and children; providing access to sanitation and hygiene facilities and safe drinking water for 16 million people and providing access to improved education for four million children.

Funding for UNICEF runs in two parallel streams, one of which contributes to development and programming for the achievement of long-term goals, while the other focuses on humanitarian action. Country offices have some “wiggle room” to divert funds from one stream to another, depending on specific needs.

Hofmeister explained this allows for flexibility in the event of an emergency.

“The import part is to strike the balance between huge emergencies that draw media attention… and the “silent emergencies” that very rarely hit the media and go unfunded for years and years,” Hofmeister said.

However, UNICEF’s efforts are not universally applauded.

In a Jan. 18 report entitled, “A Dangerous Delay“, Oxfam and Save the Children argue that governments, the U.N., NGOs and private donors need to change their approach to drought situations by “managing the risks, not the crisis.”

Referencing the famine in the Horn of Africa, the report claims, “It is clear that the opportunity to avert a crisis was missed.”

Oxfam and Save the Children further noted that the drought and subsequent famine, which has impacted 13 million people, displayed clear warning signs that indicated an impending crisis, including clues from measured rainfall and weather conditions linked to La Niña.

“If an early response had saved even a small proportion of these lives, then thousands of children, women and men would still be alive,” the report stated.

Hofmeister refuted the claim, asserting that unexpected disasters often lay waste to even the best laid plans.

UNICEF’s Global Support section in the funding requirements for 2012 – appealing for 21.9 million dollars – aims to scaffold a degree of preparation against such uncertainties by maintaining a reserve pool of funds that is not earmarked for a particular country or cause, but can be drawn upon for severely under-funded areas.

But this measure, too, is contingent on fund-raising. Last year, Global Support obtained only three percent of projected total funds.

As of October 2011, UNICEF’s 10 largest donors had contributed 74 percent of total donations, according to the report. The European Commission stood as the largest contributor, with 115.8 million dollars, followed by the government of the United States at 98.2 million dollars, the Japanese government with 97.4 million dollars and the U.N. Central Emergency Response Fund with 97.1 million dollars.

Hofmeister said that UNICEF is encouraging donors to increase or maintain their commitments, in order to protect the basic rights of women and children.

“We are aiming for 100 percent funding, (which is) the only way we can achieve the results that we have planned,” Hofmeister stressed.

The primitive Juang tribe in remote Nola village on Chandragiri hill experienced its first three institutional childbirths only a month ago.

Male Health Activists at a strategy session. Credit: Manipadma Jena/IPS

Credit for the safe deliveries goes to Malay Ranjan Juanga, a ‘male health activist’ (MHA) entrusted with mother and child health in his community of 94 households in Nola.

Set eight km away from the main road, Nola and is best reached by trekking up the treacherous slope of Chandragiri. Four-wheelers balk at the rain-eroded roads and bicycles fare little better.

Yet, tribal mothers Rasamali Juanga, Chinu Mahakud and Kuiri Juanga, could deliver their babies at the government-run community health centre at Harichandanpur, 30 km away, thanks to support from the MHA.

Odisha is one of India’s least developed provinces and almost 40 percent of its 20.7 million people are indigenous or belong to extremely marginalised Hindu castes that live in remote hamlets or inaccessible areas.

In Odisha more than 258 women die each year for every 100,000 deliveries, while 65 infants die in every 1,000 live births, according to the latest Sample Registration System (SRS) – India’s largest demographic sample survey, covering 1.4 million households and a population of 7.01 million, during the period 2007-2009.

“The government of India has identified an essential package of interventions that are known to save lives of mothers, infants and children,” says project director Patricia Dandonoli, from Concern Worldwide’s New York headquarters.

“Those interventions are simple and cost effective, but the challenges in implementing those interventions are tremendous,” says Dandonoli.

To help get closer to United Nations’ millennium development goals (MDG) 4 and 5, to reduce child and maternal mortality respectively, Concern Worldwide launched an initiative called ‘Innovations’ in Odisha (and also in Malawi and Sierra Leone) to generate fresh ideas and out-of-the-box thinking in finding healthcare solutions.

One idea that came up was a role for MHAs to support the existing cadre of female accredited social health aActivists (ASHAs) in mother and childcare.

“Through Innovations’ unique and exciting project we reached out to the people of Odisha to understand problems better and to seek their ideas and solutions to these problems,” says Robert Mulhall, Concern Worldwide’s Bhubaneswar-based country manager.

In February 2011, the project implemented in Keonjhar district, brought 205 MHAs into the healthcare sector in Odisha.

These MHAs were paired with ASHAs who already formed the cornerstone of the Indian government’s National Rural Health Mission (NRHM)’s strategy to address mother and child-related MDGs.

Under NRHM, one ASHA is identified per 1,000 rural population to help the community through awareness building and increased utilisation of existing health services, with emphasis on increasing institutional childbirths.

However, in remote areas like Nola, security is a real concern for female ASHAs who are expected to be on call even at night to attend to women in labour and move them to distant health facilities.

In Melani village, MHA Singari Munda is already helping in this respect. When Rashmita Murmu went into labour after midnight and hospital transport was unavailable, Munda walked a kilometre before finding a vehicle to move her to a health facility 15 km away.

When Rashmita became complicated, Munda transferred her to a better equipped district health centre in Keonjhar town, stayed by her side for seven days, and returned mother and child home, safely.

In a patriarchal society, ASHAs face challenges in engaging with menfolk on pregnancy and family planning issues. According to the state health and family welfare department, in 2011, Odisha’s male-to-female sterilisation ratio was a highly skewed 1:44.

“Family planning and mother and childcare advocacy have become lopsided, too mother-targeted, and not bringing desired attitudinal change because young mothers are not the decision makers,” says Dharitri Rout, secretary of the non-profit Women’s Organisation for Socio-Cultural Awareness, Innovations partner in Keonjhar district.

“While the men decide the number of children, they think they have no role to play in women’s nutrition during pregnancy and lactation,” Rout rues.

“Now, with MHAs accompanying the ASHAs on door-to-door rounds, the husbands come out and participate in information sharing and are no longer barriers to healthcare-seeking behaviour,” says Rout.

Says Singari Munda, an MHA in the 298-family Melani village: “Already, a village committee of married men now meets monthly to discuss family planning and vaccination – though attendance was thin in the beginning.”

“The ASHA cadre is overburdened since the responsibility for many primary health programmes converge on these grassroots health workers,” observes Raj Kumar Ghosh, a senior government health official.

After Puspanjali Nayak, 22, ASHA in Bhandaridihi village, had to cut down her home visits after she became pregnant, MHA Ramesh Mohanta stepped in to help.

When Santi Munda, a villager, had to be moved to a government facility, and no transport was available in Bhandaridihi, Mohanta rushed her on his motorcycle to a private hospital in Joda town, 40 km away.

“What we learn from testing these creative solutions will be shared with the government and other stakeholders,” says Dandonoli.

Dr. Ashish Kumar Sen, health specialist with the United Nations Childrens Fund in Odisha, suggests “training the MHAs for a broader role, since the state is woefully short of health personnel.”

The proportion of abortions deemed unsafe rose from 44 percent in 1995 to almost half (49 percent) in 2008, according to a new study released Thursday.

Launched in London, “Induced Abortion: Incidence and Trends Worldwide from 1995 to 2008″ by the Guttmacher Institute and World Health Organisation (WHO) notes that in 2008, the global abortion rate was 28 per 1,000, virtually unchanged since 2003.

However, in hard numbers, there were 2.2 million more abortions in 2008 (43.8 million) compared with 2003 (41.6 million) due to the growing global population. Since 2003, the number of abortions fell by 0.6 million in the developed world, but increased by 2.8 million in developing countries.

According to a WHO report from March 2011, unsafe abortion is one of the three leading causes of maternal mortality, along with haemorrhage and sepsis from childbirth.

“The number of unsafe abortions has increased from 19.7 million in 2003 to 21.6 million in 2008,” Dr. Iqbal Shah from the WHO’s Department of Reproductive Health and Research in Geneva and one of the report’s co-authors, told IPS.

“The numbers have gone up primarily because of the increase in the size of women’s population in the reproductive age of 15-44 years, without accompanying a rise in modern contraceptive uptake or access to safe abortion,” he explained.

“One can safely say that the unsafe abortion rate of 14 per 1,000 women in ages 15-44 years has not gone down from 2003 to 2008,” he added.

Researchers found that nearly half of all abortions worldwide are unsafe procedures, and almost all unsafe abortions occur in the developing world, placing the health and lives of millions of women and adolescent girls at risk.

Unsafe abortion is defined by WHO and the authors of the report as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both.

Shah also stressed that the reason for the lack of progress in reducing unsafe abortions has been the lack of progress in contraceptive uptake in recent periods, and lack of progress in improving access to safe abortion.

Nevertheless, the study points out that some countries are trying to address the problem, especially in Southern Africa and South-Central Asia.

“Within the developing world, abortion is becoming safer in South Africa,” Dr. Gilda Sedgh of the Guttmacher Institute, a co-author of the study, told IPS.

“After the law was liberalised in 1997, many providers were trained in how to do abortions and abortion services were established at public facilities. Between 1994 and 2000, the number of maternal deaths from unsafe abortion fell by 90 percent.”

“It happens that the overall abortion rate in Southern Africa (a region comprised largely of South Africa), fell from 19 to 15 abortions per 1,000 women aged 15-44 between 1995 and 2008,” she added. “Southern Africa is the only region in Africa where the rate has fallen sharply; it is also the region where the level of contraceptive use has risen most dramatically between 1990 and 2009.”

Abortion remains, particularly in the developing world, a broadly polarising issue, and in many countries it is illegal.

“Most people on both sides of the abortion debate would agree that fewer abortions are preferable. Stakeholders can help reduce the level of abortion – whether safe or unsafe – by taking measures to ensure that women have access to family planning services, so they can avoid unintended pregnancies in the first place,” Sedgh told IPS.

“Evidence shows that, in order to be effective, these services need to provide not just contraceptives, but also information and counselling to help women be satisfied users of contraception,” she added.

Asked about the importance of wider access to contraception in reducing abortion rates, Shah said, “A wider access to contraception, especially modern methods of contraception, is very important in reducing abortion rates. Countries where prevalence of modern contraceptives is high show one of the lowest abortion rates.”

“Just meeting the unmet need for modern methods of family planning for women wishing to postpone or cease further childbearing can reduce the number of abortions and 90 percent of global mortality and morbidity due to unsafe abortion,” he added.

“Our findings on abortion rates across sub regions and over time, taken together with United Nations estimates of contraceptive levels and trends, add to the body of evidence that contraceptive use is one of the strongest known predictors of abortion levels,” Sedgh told IPS. “Where contraceptive use is high, abortion rates are low.”

“Still, about 215 million women in the developing world have an unmet need for contraception – that is, they are having sex, they don’t want to get pregnant, and yet they are not using a modern method of contraception,” she added.

In the report, the authors conclude that “restrictive abortion laws are not associated with lower abortion rates.”

“Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.”

Dr Beverly Winikoff and Dr Wendy R. Sheldon, Gynuity Health Projects, New York also said: “The study shows that it is precisely where abortion is illegal that it must become safer. The public health community will not be able to address maternal mortality adequately and attainment of Millennium Development Goals is questionable until we directly confront the issue of unsafe abortion.”

“These latest figures are deeply disturbing. The progress made in the 1990s is now in reverse,” Dr Richard Horton, editor of the British medical journal The Lancet which published the study, said in a release.

“Promoting and implementing policies to reduce the number of abortions is now an urgent priority for all countries and for global health agencies, such as WHO,” Horton said. “Condemning, stigmatising, and criminalising abortion are cruel and failed strategies. It’s time for a public health approach that emphasises reducing harm – and that means more liberal abortion laws.”