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:

A doctor attends a 10-month-old baby in a public health centre in Bolivia, in one of the regular check-ups that are a requisite for women to receive the mother-child subsidy, one of the mechanisms created to reduce maternal and infant mortality in the country. Credit: Franz Chávez/IPS

By Marianela Jarroud
SANTIAGO, Jun 9 2015 (IPS)

The progress that Latin America has made in reducing child mortality is cited by international institutions as an example to be followed, and the region has met the fourth Millennium Development Goal, which is to cut the under-five mortality rate by two thirds.

But this overall picture conceals huge differences between and within countries in the region.

“There have been major strides in reducing child mortality in Latin America and the Caribbean,” said Luisa Brumana, regional health adviser with the United Nations children’s fund, UNICEF.

“However, that improvement has not benefited everyone equally,” she told IPS from the UNICEF Regional Office for Latin America and the Caribbean, in Panama City.“We tend to think that children in rural areas face the worst conditions. But recently, with the migrations to the large cities and the bad conditions in poor outlying suburbs, things are just as complicated in those areas.” -- Luisa Brumana

In Brumana’s view, “this inequality has given rise to large variations in health indicators, both between and within countries, with results generally based on wealth, education, geographic location, and/or ethnic origin.”

National averages, which in some cases are good, hide enormous inequalities in what continues to be the world’s most unequal region.

Mónica, from Chile, has been fighting for the past three years to keep her fourth child alive. He was born deformed and with brain damage. She asked to remain anonymous, because it is a touchy issue at a family and personal level.

“It has been a constant struggle, but today my son is a survivor,” she told IPS. “We have spent a lot of money, we have gone to the best doctors. I am 100 percent dedicated to his recovery. And he’s doing better every day: he communicates, we go out for walks, we play together,” she said with enthusiasm.

But Mónica admitted that not everyone has access to the best care, and that there are large contrasts despite the technological advances seen in recent years.

In Chile, where GDP stands at over 277 billion dollars, the income of a child who lives in a wealthy household is 8,000 times higher than that of a child born into poverty, according to the Fundación Sol – an example of the challenge of inequality that continues to face the region.

That is reflected in essential areas like education and health.

In 2002, for example, five premature infants from poor families died of septic shock in a public hospital in Viña del Mar, 140 km northeast of Santiago, after the preterm formula they were given through feeding tubes was contaminated by wastewater that dripped from the floor above.

“Inequalities persist and I know that if we didn’t have the means, our son’s health would be much worse. It’s horrible, but it’s true,” Mónica said.

A family in a village on the banks of the Atrato river in the northwestern Colombian department of Chocó, where child mortality is three times higher than in the capital. Credit: Jesús Abad Colorado/IPS

According to UNICEF, between 1990 and 2013 under-five mortality per 1,000 live births was reduced 67 percent in Latin America. This is the region that has made the greatest progress in that regard, along with East Asia and the Pacific, which saw a similar reduction.

According to the MDGs progress chart, the region has met the goal of cutting child mortality by two-thirds, from 54 to 19 deaths of children under five per 1,000 live births between 1990 and 2013.

These advances are linked, among other factors, to economic growth in the region, where some 70 million people left poverty behind in the past decade, according to figures published in late May by the United Nations Food and Agriculture Organisation (FAO).

Worldwide, preventable and treatable causes are the leading culprits in infant mortality. And in this region, child mortality is mainly marked by the persistence of inequalities caused by different factors, such as income level, the population group to which the family belongs, where they live, or the educational level of the parents.

“For example, for a rural family that lives far from a health centre, access to healthcare is much more difficult and that can affect children’s health, such as in terms of keeping to the vaccination schedule,” Brumana explained.

“Other factors in a country that doesn’t have a good social safety net are high medical costs, which are a problem for low-income families, or the quality of health services, which is essential for guaranteeing proper care for children,” she added.

“No less important is for services to take into account cultural differences between regions and to be able to offer services adapted to different customs,” the expert said.

According to UNICEF’s “Committing to Child Survival: A Promise Renewed – Progress Report 2014”, the five countries that stand out the most in the region are Cuba, Chile, Antigua and Barbuda, Costa Rica and St. Kitts and Nevis, which have infant mortality rates below 10 per 1,000 live births.

And the five countries that despite the progress made still face the biggest challenges are Haiti, Bolivia, Guyana, Guatemala and the Dominican Republic, in that order. In the case of Haiti, the poorest country in the hemisphere, 73 children died per 1,000 live births in 2013.

“There are major inequalities within countries,” said Brumana, who added that although certain factors have more of an influence than others, “we can’t generalise about which ones have the strongest influence.

“We tend to think that children in rural areas face the worst conditions. But recently, in the migrations to the large cities and with the bad conditions in poor outlying suburbs, things are just as complicated in those areas,” she said.

One example is Colombia, where the national averages are good, but in the hinterland enormous inequalities are seen from province to province.

For example, she noted, the northwestern department or province of Chocó has an under-five child mortality rate three times higher than the rate in Bogotá: 30.5 per 1,000 live births compared to 13.77, respectively, according to 2011 figures.

“The priority now is to give better access to the most marginalised population groups, which are generally the ones living in remote rural areas, or indigenous or black people,” Brumana said.

She pointed out that there are regional initiatives working towards progress along those lines.

One example is A Promised Renewed for the Americas, whose aim is to reduce inequities in reproductive, maternal, neonatal, child, and adolescent health by means of stepped-up political and technical support for developing countries to detect inequities and raise awareness, bringing together key actors and promoting the sharing of best practices.

Another challenge is reducing neonatal mortality rates among children in their first month of life – one of the most critical stages of development.

Globally, 2.8 million babies die during this stage of their lives. One million of them don’t even live to see their second day of life.

According to the regional initiative, the important thing now is to maintain public policies focused on improving access to healthcare, and to decentralise health policies. And, as always, to guarantee education, a factor that leads to a reduction in infant mortality.

Edited by Estrella Gutiérrez/Translated by Stephanie Wildes

According to an African proverb, “every woman who gives birth has one foot on her grave.” Cameroonians are attempting to make this proverb a historical fact and not a present reality through SMS technology. Credit: Mercedes Sayagues/IPS

By Ngala Killian Chimtom
YAOUNDE, Sep 23 2014 (IPS)

“You can’t measure the joy in my heart,” Marceline Duba, from Lagdo in Cameroon’s Far North Region, tells IPS as she holds her grandson in her arms.  

“I am pretty sure we could have lost this child, and perhaps my daughter, if this medical doctor hadn’t shown up,” Duba says, a smile sweeping her face.

The medic in question is Dr Patrick Okwen. He is the coordinator of M-Health, a project sponsored by the United Nations Population Fund (UNFPA) that uses mobile technology to increase access to healthcare services to communities “when they most need it.”

The World Health Organisation (WHO) recommends that a nurse or doctor should see a maximum of 10 patients a day. But according to Tetanye Ekoe, the vice president of the National Order of Medical Doctors in Cameroon, “the doctor-to-patient ratio in Cameroon stands at one doctor per 40,000 inhabitants, and in remote areas such as the Far North and Eastern Regions, the ratio is closer to one doctor per 50,000 inhabitants.”

Okwen was in Lagdo testing out the SMS system, which was just implemented a few months back, when Duba’s daughter, Sally Aishatou, went into labour.

Okwen and the medical staff at the Lagdo District Hospital received an SMS from Aishatou. She had been in labour for 48 hours with no signs that the baby was about to come.

“What happens when a woman SMSes a particular number, the GPS location blinks on the server, and then the server tries to identify her location, puts it on Google maps; then tells the driver to go there. [The system] also tells the doctor to come to the hospital; tells the nurses to get ready. So everybody gets into motion,” he tells IPS.

Okwen and the ambulance driver traced Aishatou to her home. They found her lying helpless on a mat, almost passed out. By the time the ambulance returned to the hospital, the operation room was ready for her and she was taken into surgery immediately.

Eight minutes later, her 4.71 kg baby boy was born. The midwife Manou nee Djakaou tells IPS: “The joy in me is so great that I don’t even know how to express it. I am so exited; very happy. This system put in place is very efficient. But for this innovation, we stood to lose this baby and its mother.”

Two hours after surgery, Aishatou regained consciousness and named her boy after Okwen.

According to the U.N. Children’s Fund (UNICEF), out of every 100,000 live births 670 women in Cameroon die. UNICEF figures also state that for every 1,000 live births, 61 infants died in Cameroon in 2012.

“Many women are dying from child-birth related issues. Women are dying while giving life. And this is something we are really concerned about, but we also know that with the coming of mobile technology, there is hope for women in Africa,” Okwen says.

“Most of the women in Africa today have access to a telephone. It could be her own, her husband’s own, or a neighbour’s. So if we had a way in which women could reach an ambulance using a phone that would guide the ambulance, it could indeed present hope for African women,” he explains.

Okwen says the project has benefitted “close to one hundred women in terms of information, evacuation, arrangements of hospital visits, deliveries and caesarean sections.”

The project has been dubbed “Tsamounde”, which means hope in the local Fufuldé language.

Mama Abakai, the Mayor of Lagdo, says the project’s impact has been far reaching.

“A lot of our sisters, wives and mothers in rural areas lose their lives and suffer a lot, because there is a communication gap, and a problem of rapid intervention and assistance. With this system, it suffices to send an SMS or a simple beep, and all the actors involved in saving lives are mobilised…its formidable,” Abakai tells IPS.

Dr. Martina Baye of Cameroon’s Ministry of Public Health calls the project a “revolution in Cameroon’s health care delivery system.”

She says that as a majority of women in the country’s far North Region have little access to healthcare services, the M-Health Project comes as a huge relief.

According to the 2010 Population census, the Far North Region has a population of three million people, 52 percent of whom are women.

“We look forward to using this technology in other parts of the country,” she tells IPS.

Edited by: Nalisha Adams

The writer can be contacted at: https://www.facebook.com/ngala.killian

Doctors Without Borders (MSF) says Afghanistan is “one of the riskiest places to be a pregnant woman or a young child”. Credit: DVIDSHUB/CC-BY-2.0

By Karlos Zurutuza
KABUL, Sep 16 2014 (IPS)

Nasrin Mohamadi, a mother of four, has promised herself never to set foot in an Afghan public hospital again. After her first experience in a maternity ward, she has lost all faith in the state’s healthcare system.

“The doctors said that I had not fully dilated yet so they told me to wait in the corridor. I had to sit on the floor with some others as there wasn’t a single chair,” Mohamadi tells IPS, recalling her experience at Mazar-e Sharif hospital, 425 km northwest of Kabul.

“They finally took me into the room where three other women were waiting with their legs wide open while people came in and out. They kept me like that for an hour until I delivered without [an] anaesthetic, and not even a single towel to clean my baby or myself,” adds the 32-year-old.

“Immediately afterwards the doctors told me to leave as there were more women queuing in the corridor.”

“Many rural health clinics are dysfunctional, as qualified health staff have left the insecure areas, and the supply of reliable drugs and medical materials is irregular or non-existent." -- Doctors Without Borders (MSF)
Even after she left the hospital, Mohamadi’s ordeal was far from over. The doctors told her not to wash herself for ten days after the delivery, and as a result her stitches got infected.

“I paid between 600 and 800 dollars to give birth to my other three children after that; it was money well invested,” she says.

This is a steep price to pay in a country where the average daily income is under three dollars, and 75 percent of the population live in rural areas without easy access to health facilities.

Many women have no other option than to rely on public services, and the result speaks volumes about Afghanistan’s commitment to maternal health: some 460 deaths per 100,000 live births give the country one of the four worst maternal mortality ratios (MMR) in the world outside of sub-Saharan Africa.

While this represents a significant decline from a peak of 1,600 deaths per 100,000 births in 2002, far too many women are still dying during pregnancy and childbirth, according to the United Nations.

In 2013 alone, 4,200 Afghan women lost their lives while giving birth.

The lack of specialised medical attention during pregnancy or delivery for a great bulk of Afghan women is partly responsible. Few have access to health centres because these are only reachable in urban areas. The lack of both security and proper roads forces many women to deliver at home.

This does not bode well for the 6.5 million women of reproductive age around the country, particularly since Afghanistan only has 3,500 midwives, according to the U.N. Population Fund (UNFPA)’s latest State of the World’s Midwifery report.

This means that the existing workforce of midwives meets only 23 percent of women’s needs. The situation is poised to worsen: UNFPA estimates that midwifery services in the country “will need to respond to 1.6 million pregnancies per annum by 2030, 73 percent of these in rural settings.”

Even women with access to top-level urban facilities, such as the Kabul-based Malalai Maternity Hospital, are not guaranteed safety and comfort.

For instance, Sultani*, a mother of four, tells IPS she is far from satisfied with her experience.

“I gave birth through caesarean section to my four children in this hospital but the doctors who attended to me were unskilled,” she remarks bluntly. “A majority of them had only completed three years of medical [school].

“On a scale of one to 10, I can only give Malalai a four,” she concludes.

Sultani’s opinion may be specific to her own experience, but it finds echo in various reports and studies of the country’s health system. A 2013 activity report by Doctors Without Borders (MSF) labeled Afghanistan “one of the riskiest places to be a pregnant woman or a young child” due to a lack of skilled female medical staff.

“Private clinics are unaffordable for most Afghans and many public hospitals are understaffed and overburdened,” reports the organisation, which runs four hospitals across the country.

“Many rural health clinics are dysfunctional, as qualified health staff have left the insecure areas, and the supply of reliable drugs and medical materials is irregular or non-existent,” continues the report.

This is a sobering analysis of a country that will need to configure its health system to cover “at least 117.8 million antenatal visits, 20.3 million births and 81.3 million post-partum/postnatal visits between 2012 and 2030”, according to UNFPA.

Given that contraceptive use is still scarce, reaching only 22 percent of reproductive-age women, large families continue to be the norm. Afghan women give birth to an average of six children, a practice fuelled by a cultural obsession with bearing at least one son, who will in turn care for his parents in their old age.

A lack of information about birth spacing means mothers seldom have time to fully recover between deliveries, causing a range of health issues for the mother and a lack of milk for the newborn child.

Findings from a 2013 survey conducted by the Afghan Ministry of Public Health indicate that only 58 percent of children below six months were exclusively breastfed.

Still, this is an improvement from a decade ago and represents small but hopeful changes in the arena of women and children’s health. The same government survey found, for instance, that “stunting among children has decreased by nearly 20 percent from 60.5 percent in 2004 to 40.9 percent in 2013.”

Dr. Nilofar Sultani, who practices at the Malalai Maternity Hospital, tells IPS that medical assistance in Afghanistan has improved “significantly” over the last ten years.

“There are more health centres, and [they are] far better equipped. The number of skilled doctors has also grown,” explains Sultani, a gynaecologist.

But the most important change, she says, has been in women’s attitude towards medical care. “Before, very few women would come to the hospitals but today, the majority of women come forward on their own. They’re slowly losing their fear [of] doctors,” notes Sultani, adding that health centres are among the very few places where Afghan women can feel at ease without the presence of a man.

Edited by Kanya D’Almeida

Bosena, 25, sits on the side of a busy road in Addis Ababa, Ethiopia’s capital, with a baby in her arms. Ethiopia is among the countries listed as having made significant progress in reducing child and maternal mortality rates. Credit: Jacey Fortin/IPS

By Nqabomzi Bikitsha
JOHANNESBURG, Jun 30 2014 (IPS)

Every year, three million newborn babies and almost 6.6 million children under five die globally, but if the rest of the world looked towards the examples of two of Africa’s least-developed countries (LDCs), Rwanda and Ethiopia, they would perhaps be able to save these children.

At the 2014 Partners’ Forum being held in Johannesburg, South Africa from Jun. 30 to Jul. 2 – hosted by the Partnership for Maternal, Newborn and Child Health (PMNCH), the South African government and other partners – significant commitments in finance, service delivery and policy were announced that could put an end to these deaths. In total, there were 40 commitments from stakeholders, governments and the private sector who are committed to ending child and maternal mortality were revealed at the forum today.

It was noted that while remarkable progress has been made in reducing maternal and child mortality rates globally, over the last two decades the reduction in the rates of newborn deaths has lagged behind considerably.

However, Rwanda and Ethiopia were among 10 countries across the globe listed as having made significant  progress in reducing child and maternal mortality rates, according to a new global action plan launched at the forum.

The Every Newborn Action Plan (ENAP) provides evidence on the effective interventions needed to end preventable stillbirths and newborn deaths. It also outlines a strategy to prevent 2,9 million newborn deaths and 2,6 million stillbirths annually.

These countries invested in high-impact health interventions, including immunisation, family planning, education and good governance.

Tedros Adhanom Ghebreyesus, Ethiopian Minister of Foreign Affairs, told IPS that multi-sectoral investments, and not just direct investments in the health sector, would help reduce maternal and child mortality.

“If we don’t invest in agriculture, water and sanitation as well as the health sector then any gains we make in reducing child and maternal mortality will be futile.

“Community-based health care workers helped reduced Ethiopia’s mortality rates for mothers and children.”

According to the ENAP, newborn deaths account for 44 percent of all under five deaths worldwide, and investments in quality care at birth could save the lives of three million women and children each year.

“Now is the time to focus on action and implementation, to ensure more lives are saved,” said Graça Machel, co-chair of the PMNCH.

“Other countries have made progress and others have not, we need to learn from them, so we keep momentum.”

Accompanying the launch of the ENAP, was the launch of Countdown to 2015 report titled “Fulfilling the Health Agenda for Women and Children”, which serves as a scorecard of gains made in maternal and child health.

According to the report, which studied the progress of 75 countries in child and maternal mortality efforts, substantial inequities still persist.

“The theme of the Countdown report is ‘unfinished business,’” said Machel. “Too many women and children are dying when simple  treatment exists.”

Over 71 percent of newborn deaths could be avoided without intensive care, and are usually a result of three preventable conditions; prematurity, birth complications and severe infections.

Dr. Mariame Sylla, United Nations Children’s Fund (UNICEF) regional health specialist, told IPS that countries needed to learn from one another.

“Community-based approaches, where governments bring health services to the people and people to the services, have shown to be effective,” she told IPS.

“Monitoring of results is also very important to ensure accountability in the health sector.”

Dr. Aaron Motsoaledi, South Africa’s Minister of Health, said “having professional midwives would also help new mothers understand motherhood better and help reduce mortality rates among women and children.”

However,  Ethiopia’s Minister of Foreign Affairs pointed out that “these  efforts are are simple but often hard to deliver.”

“Least-developed countries like Ethiopia were able to make strides in curbing child and maternal mortality through their political will,” Dr. Janet Kayita, health specialist for maternal, newborn and child health for UNICEF, told IPS.

But she pointed out that “Ethiopia’s key to success, was not just about the leadership making the decision to reduce child and maternal mortality rates, but also organising at community level.”

“Ethiopia is one of the few LDC’s to institutionalise quality improvement in the health sector, using the mechanism of rewarding good quality health services and holding accountable those not performing.”

Naz Bibi is awaiting treatment for fistula at the Koohi Goth Women’s Hospital in Pakistan. Credit: Zofeen Ebrahim/IPS

By Zofeen Ebrahim
KARACHI, Jun 17 2014 (IPS)

The word on the street was that if there were one place on earth that could treat Mohammad Lalu’s wife, it would be the Koohi Goth Women’s Hospital in Pakistan’s port city of Karachi.

The 50-year-old stone crusher hailing from the remote village of Dera Bugti in the southwest Balochistan province had spent 30 years searching for a facility that would treat his wife, Naz Bibi, who suffers from obstetric fistula.

Sitting upright on a plastic sheet draped over one of the hospital beds, Bibi told IPS, “It took us two days of non-stop travel to get here and we spent 12,000 rupees (roughly 120 dollars) on the bus fare alone.”

It is a princely sum for a family of extremely modest means, in a country where the average income is less than 1,200 dollars a year. But for Lalu and his wife, the expenditure will be worth it if it can cure Bibi of her terrible affliction.

“Obstructed labour is especially common among young, physically immature women giving birth for the first time.” – United Nations Population Fund (UNFPA)
While virtually unheard of in the developed world, obstetric fistula is still common in many Asian and African countries: the World Health Organisation (WHO) estimates that it affects nearly three million women annually.

While country-specific data is harder to find, local experts suggest that anywhere from 4,000 to 5,000 women in Pakistan are suffering from fistula.

Caused by prolonged or stressful labour, the condition arises when the baby’s head puts undue pressure on the lining of the woman’s birth canal, eventually ripping through the wall of the rectum or bladder and resulting in urinary or faecal incontinence.

Medial professionals say young women, whose bodies have not yet matured enough to endure the birthing process, are most vulnerable, as well as those who lack adequate nutrition or live too far away from modern healthcare facilities.

Because fistula causes a woman to lose control over her bodily functions, there is a huge stigma around the condition. Those afflicted by it often smell bed, and are sequestered away from their communities and families, forced to suffer in silence.

This is particularly traumatic for young mothers, who end up spending the better parts of their lives having little to no contact with the outside world.

Lalu told IPS that Bibi’s trouble started soon after she delivered a stillborn baby boy when she was just a teenager during her first marriage.

“I am her second husband,” he said. “Her parents married her to me after her husband left her, but did not disclose she was suffering from this dreadful problem.”

Unlike many other husbands, Lalu did not turn away from his new wife; instead, he has gone to great lengths to find her the necessary treatment. This hasn’t been easy, since fistula can only be managed through reconstructive surgery, which is cost-prohibitive for thousands of women.

Koohi Goth is one of 12 centres set up under the United Nations Population Fund’s (UNFPA) Fistula Project that offers the service for free.

Now in its eighth year, and assisted by the Pakistan National Forum on Women’s Health (PNFWH), it has trained 38 doctors to carry out the surgery. These numbers, experts say, pale in comparison to the scale of Pakistan’s maternal health crisis.

‘100 percent preventable’

According to the country’s latest Demographic and Health Survey, 276 women out of every 100,000 die during childbirth.

“All these deaths are 100 percent preventable if we can provide quality of care and stop child marriages,” Dr. Sajjad Ahmed, head of the Fistula Project in Pakistan, told IPS.

He believes that delaying the age at which a woman experiences her first pregnancy would be a huge step forward in preventing conditions like fistula.

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

But changing the mindset that sees nothing wrong with the idea of a child bride will not be easily accomplished, especially in rural Pakistan.

Dr. Suboohi Mehdi (Surgeon at Koohi Goth Hospital, Karachi) on Fistula Cases from IPS News on Vimeo.

Thirteen-year-old Shahbano, hailing from the village of Sanghar in Pakistan’s Sindh province, occupies the bed next to Bibi. She tells IPS she was married at 11 and developed fistula three weeks ago, during prolonged labour involving her first child.

Luckily, both Shahbano and her baby son survived the ordeal, but she must now hope that her surgery goes well, so she is not afflicted by incontinence for the rest of her life.

“In our culture, when a girl first begins to menstruate, her parents are obliged to marry her off,” Shahbano’s husband, Abid Hussain, told IPS.

Neither he nor his teenage wife had any idea that the Sindh provincial assembly passed the Child Marriage Restraint Act last month, prohibiting the marriage of children under 18 years of age. Violation of the bill could earn offenders a three-year prison term or a 450-dollar fine.

In 1929, the official marriage age stood at 14 years, and in 1965 the law changed, making it illegal to marry anyone under the age of 16. Today, Sindh is the only province to have recognised 18 as the bare minimum age for marriage – a decision that has elicited vehement opposition from religious groups.

Maulana Muhammad Khan Sherani, chairman of the Council of Islamic Ideology, which acts as an unofficial parliamentary advisor, said in reference to the amendment: “Some people want to please the international community [by going] against Islamic teachings and practices.”

“Such proclamations act as a spanner in our fight against early marriage and early pregnancy,” Ahmed asserted.

He says if he could give girls like Shahbano one piece of advice it would be to educate their children, especially their daughters.

“It will take a generation to put things right, but education will automatically bring about a cultural change, which could delay marriages. I see that as the only way to eradicate this condition,” he stressed.

Currently, the country only has the capacity to handle 2,000 cases of fistula, but doctors end up treating just 500 to 600 women a year.

Ahmed says this is largely due to the fact that people do not know the condition is preventable or treatable, and so avoid seeking out medical assistance. Many women live in rural areas without access to televisions, radios or cell phones, making it hard to spread awareness.

To circumvent the problem, hospitals have mobilised ‘lady health workers’ – women who go door-to-door in remote areas delivering information on sexual reproductive health and rights.

“We have a huge brigade of almost 100,000 lady health workers,” Ahmed said. Although they cover just 60 percent of the country, they act as a bridge between rural populations and urban-based care providers.

Perhaps these sustained efforts will enable Pakistan to see the day when conditions like fistula are nothing but a distant memory.

(END)

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.

Beatrice Mudachi does not like delivering in hospital because she says her first baby was neglected by hospital staff. Courtesy: Miriam Gathigah

By Miriam Gathigah
NAIROBI , Jul 9 2013 (IPS)

It has been a month since the Kenyan government waived the maternity fee at public health facilities, but Millicent Awino is still one of the many expectant mothers in favour of a home birth.

“During childbirth my uterus comes out, a traditional birth attendant has the knowledge of how to push the uterus back into position, unlike at the hospital,” Awino tells IPS.

Alice Anyango, a traditional birth attendant from Nairobi’s Mathare slums, tells IPS: “The uterus should not be touched with hands as they do in hospital, hence damaging it. One should throw a pitcher of cold water at it and it will retreat back to position.”

But her treatment is not medically sound. Professor Joseph Karanja, a gynaecologist and obstetrician, dismisses the treatment. “Indeed there are cases where … the uterus can come out and it is a very serious situation.

“But medically, the uterus is simply pushed back to its position with hands,” he explains.

Until now, Kenyan mothers had to pay anything from 12 dollars in rural clinics to 90 dollars in local hospitals for maternity care. If a woman had a caesarean section, it cost 150 dollars. But these fees were scrapped on Jun. 1 and hospitals, health centres and clinics across this East African nation are offering maternity services free of charge.

But according to Teresia Wangai, a qualified midwife at a regional hospital, the fee waiver has not led to an increase in women giving birth at hospitals.

“We expected to receive more expectant mothers, but I have delivered fewer babies this month. Many women seem to have stayed clear of government health facilities for fear that the fee waiver will worsen the quality of health care,” she tells IPS.

While medical doctors like Dr. Joachim Osur believe that scrapping the maternity fee is a step in the right direction, myths and misconceptions still held by mothers like Awino continue to influence their decision to use traditional birth attendants and deliver at home.

“The World Health Organization does not recommend that traditional birth attendants assist in delivery. In fact, a woman is more at risk of dying at the hands of a traditional midwife than if nobody was attending to her,” Osur, a reproductive health speacialist, tells IPS.

He says that while up to 92 percent of expectant mothers in Kenya attend antenatal care, more than half of them do not deliver in hospitals.

“When only about 46 percent of expectant mothers are delivering in hospital, the risk of death as a result of a pregnancy will remain high,” he says.

“In some regions such as Kenya’s Nyanza and Western provinces, about 75 percent of women do not deliver in hospital,” he says.

Karanja says that every country that has been able to reduce its maternal mortality rate has done so primarily by ensuring that expectant mothers deliver in the care of skilled health attendants.

“Maternal mortality seems to be on the rise, the 2008/2009 Kenya Demographic and Health Survey shows that maternal mortality rose from 414 deaths per every 100,000 live births to 488,” Karanja says.

Acting senior director in the Ministry of Medical Services, Dr. Simon Mueke, says the country’s maternal mortality rate is currently closer to 500 deaths per 100,000 live births. In fact, Kenya’s maternal mortality rate is higher than the rate in one of the most troubled countries in the world. According to figures from the World Bank, war-torn Afghanistan recorded 460 deaths per 100,000 live births in 2010.

“While maternity care is now free, Kenya has reduced its health budget to 2.5 percent of the national budget. This is way below 15 percent recommended by the African Union’s Abuja declaration,” he tells IPS. In 2001, African heads of states met in Abuja, Nigeria and pledged to commit 15 percent of their national budgets to health.

Aside from its high maternal mortality rate, Kenya has not managed to lower new HIV infections among children by 50 percent since 2009, according to a report released in June by the United States President’s Emergency Plan for AIDS Relief, the United Nations Children’s Fund and the Joint United Nations Programme on HIV/AIDS.

Government statistics show that in Kenya at least one in five babies born to HIV-infected mothers also have the virus.

“Delivering in hospital is very significant, precautions can be taken to prevent mother-to-child transmission of HIV,” says Karanja.

Karanja adds that traditional midwives are also placing themselves at risk of contracting HIV “since they often do not have the necessary supplies required during delivery, not even gloves.”

But Angelas Munani, a traditional birth attendant, is not oblivious to this risk. “We wear two polythene bags and tie a string around the wrist to avoid coming into contact with a mother’s blood during delivery,” she tells IPS.

But myths and misconceptions, as well as the lure of traditional birth attendants’ supposed knowledge, are not the only reasons why expectant mothers shun hospital delivery.

“Usually we have about three infants sharing a bed in the maternity ward. Mothers give their beds to their infants while they sit or sleep on the floor. That is a nightmare for a woman who has just delivered,” Wangai says of the lack of facilities.

One mother, Evelyn Bosibori, adds that women in public hospitals are either neglected by nurses or are attended to by medical trainees. “At almost 5.4 kgs, my baby was not only too big for a normal delivery, but the baby came out with its legs first,” she tells IPS.

“I delivered in a government hospital with a medical trainee who could not tell that the baby had not turned properly for delivery. I should have delivered by caesarian section, my baby was almost twice the size of a new baby,” she says.

Allegations of abuse, even the physical hitting of expectant mothers by nurses, are also rife. Osur confirms that there have been cases of expectant mothers being mistreated, and even beaten, in health facilities.

“The entire health system requires an overhaul. Strikes have occurred on and off with health workers demanding better pay and better working conditions,” he says.

“Health facilities are generally understaffed and in some regions, particularly in rural areas, you will find three or four nurses attending to children and the general public while at the same time delivering babies.”

While the maternity fee waiver is a progressive step, more needs to be done to care for Kenya’s expectant mothers. “Health facilities require more staff, and to be provided with the necessary drugs and equipment,” Osur says.

In Malawi, 16 women die every day of pregnancy-related complications. But Charity Salima says that she is yet to record a single pregnancy-related death at her clinic in Area 23, a township on the outskirts of Malawi’s capital, Lilongwe. Courtesy: Mabvuto Banda

By Mabvuto Banda
LILONGWE, Jul 3 2013 (IPS)

Charity Salima, 54, has helped to deliver over 4,000 babies in her maternity clinic in Area 23 – one of Malawi’s poorest and most populous townships – and has yet to record a single pregnancy-related death.

In Malawi, the lifetime risk of a woman dying in pregnancy or childbirth is one in 36, compared to one in 4,600 in the United Kingdom, according to the Malawi Safe Motherhood Programme, an initiative to reduce maternal mortality in this southern African nation.

“I used to witness pregnant women scramble for public transport or hitchhike for a lift just to reach a hospital. In most cases, some would die or lose their babies or develop post-delivery complications that could have been avoided if they had transport and got timely medical help,” Salima tells IPS.  

Salima used to work as a research nurse. But in 2008 she quit her job to set up her clinic, Achikondi Women Community Friendly Services, in a rented house near Malawi’s capital, Lilongwe. And thanks to the help of the National Organisation of Nurses, a solidarity fund for retired nurses and midwives, which donated an ambulance to her clinic, she has been saving lives ever since.

“In Malawi, just like many African communities, when a woman is pregnant, everyone is anxious and filled with fear because they have seen so many women die while giving birth. And yet in developed countries, when a woman is pregnant, she and her family celebrate and are truly expectant,” says Salima.

The Ministry of Health puts it simply: 16 women die every day in Malawi from preventable pregnancy-related complications. The country is behind on delivering two of the key United Nations Millennium Development Goals (MDGs) – reducing maternal deaths by 75 percent by 2015, and ensuring universal access to reproductive healthcare. Eight MDGs were adopted by all U.N. member states in 2000, and aim to curb poverty, disease and gender inequality by 2015.

But Salima’s clinic and her maternal health success rate here may prove a model for Malawi as the country grapples with saving the lives of its pregnant mothers.

Martin Msukwa, executive director for the MaiKhanda Trust, an NGO focusing on reducing maternal mortality here, tells IPS: “Salima has managed to make a difference in her community because she has done two things; introduced an efficient system to deal with normal deliveries at her clinic and managed to have another efficient system of referring complicated cases to hospital on time.”

Her methods to combat maternal mortality are simple and low cost. She encourages women to grow vegetable gardens to increase the diversity in their diet, and she registers every pregnant woman in the community so that she can monitor their pregnancy.

Her strategies, she says, have helped her identify high-risk pregnant women within the community, who in turn are referred to the main hospital in Lilongwe for treatment.

“The other thing we have been doing is to change cultural beliefs in our community that play a major role in maternal deaths, like the belief that if a woman has obstructed labour, it’s a sign of infidelity,” she says.

Salima offers a complete range of other services at the clinic, including outpatient services for children under five. Her clinic, however, is not for free. Patients pay a fee of about three dollars to help cover the cost of medicines from the government’s central medical stores.

National coordinator for the Malawi Safe Motherhood Programme, Dorothy Ngoma, says that although recent trends show a decline in maternal mortality – from 675 deaths per 100,000 live births from 2006 to 2010, to 460 deaths per 100,000 live births in 2012 – Malawi still has a lot of work to do to meet the MDG on reducing maternal mortality.

The Malawi Safe Motherhood Programme is trying to replicate some of the practices in Salima’s clinic.

“From an advocacy point of view, we have taken on board initiatives such as Salima’s in our programmes and we are mobilising resources to build waiting homes for pregnant women who live far from health facilities,” says Ngoma.

In addition, the programme has recruited 200 young women from 20 districts across the country for an 18-month midwife-training programme. Upon graduation, the midwives will work for their respective communities for five years.

“The aim is to ensure that mothers do not travel long distances to seek maternal healthcare services, thereby averting possible pregnancy complications,” Ngoma says.

But as word of Salima’s success spreads, it brings with it challenges too.

“I have more and more people coming to my clinic but I don’t have enough volunteers with the needed skills to meet the demand,” Salima says.

A mother and her child from West Point, a low-income neighbourhood of Monrovia, Liberia. The 10-worst countries to be a mother in are all in sub-Saharan Africa. Credit: Travis Lupick/IPS

By Agnes Odhiambo and Gauri Van Gulik
NAIROBI , May 19 2013 (IPS)

Victoria J. married in 2009 at age 14, and became pregnant shortly after. “I started labour in the morning on a Friday …. The nurse kept checking and saying I would deliver safely. On Monday she said I was weak.

“The doctor decided to operate on me. (During the) operation they found the baby was dead. The doctor said the baby had died due to the long labour. After that, I found out that urine was coming out all the time,” she said.

Women and girls like Victoria in Kenya, South Africa and South Sudan also spoke to us about pregnancy and childbirth. Sadly, too many of their stories were not about the joy of having a child, but about abuse, neglect and pain.

In interviews and reporting across Africa, Human Rights Watch heard from girls who knew too little about sexuality and family planning when they were forced into marriage and pregnancy.

We spoke to girls who were married and conceived when their bodies were not mature enough to go safely through pregnancy and delivery. Women and girls also told of health centres that were poorly staffed and ill-equipped to handle obstetric complications.

They described not having enough money for transportation to government health facilities or to pay the high cost of giving birth there. Women described the shortage of ambulances to transport them when they needed specialised care, abuse and negligence by health workers, and the absence of a complaints process to notify the facilities of mistreatment and other problems.

Sadly, we spoke with the families of those women and girls who did not survive pregnancy and could not tell their own stories.

Significant global and regional progress has been made to reduce the number of preventable maternal deaths: data released in 2012 by the United Nations shows that the number of women worldwide dying of pregnancy and childbirth-related complications has almost halved in the last 20 years.

Human Rights Watch researcher Agnes Odhiambo. Courtesy: Human Rights Watch.

The report, “Trends in Maternal Mortality: 1990 to 2010”, shows that sub-Saharan Africa saw a 41 percent reduction in maternal death. Despite these promising results — in a region that bears a disproportionate burden of maternal mortality — the progress is still too slow and uneven.

The 10-worst countries to be a mother in, according to Plan International’s “State of the world’s mothers report”, are all in sub-Saharan Africa. In addition to the unacceptably high numbers of women who die, African women also suffer disproportionately from childbirth injuries.

One of the most devastating is the obstetric fistula that Victoria suffered from, which leads to constant leakage of urine and stool. Fistula can be prevented or treated and hardly exists in the developed world.

As the African Union (AU) celebrates 50 years of existence on May 25, it should put a spotlight on the human rights of African women and girls.

The AU adopted the Maputo Protocol in 2003. Of the 54 AU member countries, 36 have ratified it. The protocol is unique in that it focuses on issues that affect women in Africa the most and covers topics that are not included in international treaties, including CEDAW (Committee on the Elimination of Discrimination against Women), the women’s rights convention.

It is in the area of reproductive rights that the protocol is most ground-breaking. Article 14 calls on governments to provide adequate, affordable and accessible health services and to establish and strengthen existing health and nutritional services for women during pregnancy and while they are breast-feeding.

Importantly, it calls on governments to protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where there is a risk to the health or life of the mother or the foetus.

There are many other commitments and declarations, at least on paper, promoting maternal health in Africa. In 2008, the AU passed a resolution on maternal mortality in Africa, well before the U.N. Human Rights Council did so, that recognised that preventable maternal mortality is a violation of women’s right to life, health and dignity. It included recommendations to improve health financing and accountability.

The AU’s campaign on Accelerated Reduction of Maternal Mortality in Africa features the theme “Africa Cares: No Woman Should Die While Giving Life,” to mobilise political commitment and resources to help reduce maternal deaths.

The campaign includes a focus on improving monitoring of health systems. Since its launch in 2009, 37 countries have joined the campaign and signed on to its pledge.

While these commitments are important, it is time African governments be held accountable for failing to meet them.

To date, accountability has not been one of the AU’s strong points — but that can change. While the AU recognises that member states have not done enough to reduce maternal deaths, there is no effective monitoring and reporting mechanism at the regional level on what countries are doing to fulfil their promises, and where they are lacking. Establishing such a mechanism could enable countries to identify failings and needs, and to learn from each other’s best practices.

It is time for the governments and leaders of Africa to honour their commitments to women. It is time for Africa and the AU to ensure that no woman should die while giving life.

* Agnes Odhiambo and Gauri Van Gulik are researchers with the Women’s Rights Division at Human Rights Watch.

There are 135 million live births every year, with only 11 million benefitting from quality care. Credit: Photo stock

By Joan Erakit
UNITED NATIONS, May 8 2013 (IPS)

The story goes like this: a young mother lies quietly in a dimly lit room having just given birth to her baby. For the next seven days she watches over the child with caution, nursing and swaddling it patiently. Fearful that the infant will not survive past a few days, she refuses to give it a name.

Unfortunately, this scenario remains the reality for many women across the globe. There are 135 million live births every year, with only 11 million benefitting from quality care – a divide not only between rich and poor but also between life and death.“We’re not going to solve all these issues without involving and engaging men.” -- CEO of Save the Children Carolyn Miles

On Tuesday, Save the Children launched their annual report State of The World’s Mothers 2013: Surviving the First Day. The report emphasises the need for quality care around pregnancy, delivery and postnatal care.

“The first hours and days of a baby’s life are especially critical,” it says. “About three-quarters of all newborn deaths (over 2 million) take place within one week of births. Thirty-six percent of newborn deaths (1 million) occur on the day a child is born.”

Sometimes it is as simple as not having access to an educated midwife or community nurse. Other times it’s as complicated as having to wait for a husband’s approval in order to go to the hospital to deliver the baby.

Then there are the infections that newborns are prone to when they come into this world, and also the health of the mother during and after pregnancy.

Empowered mothers

“An empowered and educated mother is the best thing for a child,” President and CEO of Save the Children Carolyn Miles said as the report was launched at the United Nations.

The report cites three major causes of newborn mortality: severe infections, pre-term birth and complications during childbirth.

At the heart of the problem is the fact that millions of women lack access to a physician or healthcare facility.

“As we start to do more for newborns, the quality of care is also really critical, because we want babies not just to survive, but to survive without disability,” said Professor Joy Lawn, director of the MARCH Centre at the London School of Hygiene and Tropical Medicine.

This means making maternal and child health a priority for government officials and community leaders. It means having conversations with husbands and fathers about the need to have a birthing plan.

“We’re not going to solve all these issues without involving and engaging men,” Miles told IPS.

“We have got to work in communities to actually engage husbands, make them part of the plan. A woman develops a plan to get to the hospital to be able to deliver; engage her husband in that plan. Make sure he’s expected to be part of the plan and has put away a little money if there’s a transportation need. He’s actually part of that.”

Growing midwifery

Losing a baby during childbirth has become commonplace in the developing world. It is understood that childbirth is a terribly difficult thing with sometimes devastating results, but still a natural order.

“There is this sense of, ‘this is just what happens’. Babies die, babies are born too early, and they’ll die. Mothers don’t name their children for seven days because so many will die,” Miles told IPS. “So it’s changing that idea that every mother and every child deserves to live through birth.”

According to the report, 800 women die during pregnancy or childbirth and 8,000 newborn babies die during their first month of life. It all seems to boil down to two essential factors: education and access.

Those few midwives or birth attendants who are available – especially in rural areas – usually lack adeqate training in prenatal and postnatal care. What little education on the topic they have, they’ve learned along the way from previous childbirths, some not so successful.

Public health advocates say these providers need proper training and tools to carry out basic tasks like cleaning the umbilical cord after childbirth and teaching new mothers about infection.

This leads to access, another issue preventing pregnant women from receiving the best care during such a critical time. Rural areas are hard to reach, community workers are not paid enough to allow travel, and resources are scant.

“Part of the solution is to train more community midwives and health workers,” says Catherin Ojo, a chief nursing officer at Ahmadu Bello University Teaching Hospital in Zaria, Nigeria.

Over 57 percent of maternal deaths occur in Africa. Credit: Patrick Burnett/IPS

By Blain Biset
ADDIS ABABA, Jan 27 2013 (IPS)

Every single day, 452 women in sub-Saharan Africa die from pregnancy-related causes; that’s 18 women every hour.

Against this backdrop, heads of state gathered in Ethiopia’s capital Addis Ababa for the African Union Summit met at a side event on Sunday, Jan. 27 to renew their commitment to reducing the maternal mortality rate on the continent.

Back in May 2009, the African Union and the United Nations Population Fund (UNFPA) launched CARMMA, the Campaign for Accelerated Reduction of Maternal Mortality in Africa, with the aim of expanding the availability of reproductive health services and moving Africa closer to achieving Millennium Development Goal (MDG) 5: reducing the maternal mortality rate by three-quarters and ensuring universal access to reproductive health care by 2015.

Ahead of the CARMMA meeting, United Nations Secretary-General Ban Ki-moon urged African heads of state to commit to the MDGs.

But although pledges and promises have been made, the continent still has a long way to go before it reaches the 2015 target – so far, sub-Saharan Africa has seen an average reduction rate of just 41 percent.

UNFPA Executive Director Dr. Babatunde Osotimehin believes that, while sub-Saharan Africa has made significant progress, this high-level meeting with African heads of state is urgently needed.

“Africa knows what to do and how to do it,” he told IPS, “but there are still challenges.”

African Union Commissioner of Social Affairs, Dr. Mustapha Kaloko, is not convinced Africa will reach the set goal by 2015 but he does believes CARMMA has the capacity to accelerate the reduction.

“The unique nature of this campaign is that it is not asking for anything new,” Kaloko told IPS. “We are not developing new plans, but improving the instruments we already have.”

He added that most maternal deaths in Africa could have been prevented by using already existing practices and interventions.

A recent study by the renowned medical journal ‘The Lancet’ shows that a woman in sub-Saharan Africa is almost 100 times more likely to die because of pregnancy and childbirth complications than a woman in a wealthy country.

The same study also states that eight out of ten countries with the highest numbers of maternal deaths are in Africa with Nigeria and the Democratic Republic of Congo topping the list.

Another major challenge, according to Osotimehin, is the level of political commitment from nations to reduce the rate of maternal mortality on the continent.

He stressed,“This event is not about money but about commitment. We are here to ensure that no women dies giving life.”

A vast majority of maternal deaths – roughly 57 percent – occur on the continent of Africa, giving it the world’s highest maternal mortality ratio.

And the mortality rate is not the only thing of concern to development experts and local medical practitioners — for every pregnancy-related death, there are about 20 women who suffer complications before, during and after childbirth, leaving mothers and children alike with lifelong disabilities or medical conditions.

Severe bleeding after childbirth, infections, high blood pressure during pregnancy and unsafe abortions are the most common causes for pregnancy-related complications and deaths according to the UNFPA.

According to Dorothee Kinde Gazard, Benin’s Health Minister, these numbers are exorbitant: “All levels of society, notably on the communal level, have to be involved and committed to making sure no woman dies or becomes handicapped unnecessarily.”

Benin has taken steps towards reducing pregnancy-related deaths by improving data collection services in clinics and hospitals. Gazard told IPS, “Every death is now registered so we can learn why women die and how we can prevent (unnecessary deaths).”

The increased use of family planning services has been successful in several countries such as Malawi, Tanzania and Zambia.

Another solution is to reduce the maternal mortality rate by preventing child marriages, Osotimehin said.

“Early child marriages create a situation where children are bearing children, when they are physically and psychologically not ready.”

In Niger, over three-quarters of women get married in their teens. Pregnant girls between the ages of 10 and 14 are five times as likely to die during pregnancy than women in their twenties, according to a UNICEF rapport, while pregnant girls between the ages of 15 and 19 are twice as likely to die during pregnancy than women in their twenties.

Though CARMMA is primarily focused on women’s health, men do play an important role in this campaign. Osotimehin says everybody needs to realise that the high rates of maternal mortality are not acceptable.

“So we must talk to men because they are the ones who are causing all these problems,” he stressed.

Minister Gazard agreed that men’s participation is crucial. “Without them we will not be successful in reducing the maternal mortality rate,” she said. In a bid to involve men in these efforts, Benin recently started a project whereby men are encouraged to attend prenatal consultations with their wives during the pregnancy.

So far, Equatorial Guinea is the only African nation among ten countries worldwide to have reached MDG 5.

Leading experts like Michelle Bachelet, executive director of UN Women, are convinced that few, if any, African countries will be able to reduce maternal deaths by 75 percent in 2015.

“We have to focus on increasing the efforts but we should already start thinking about what is going to happen after 2015,” Bachelet told IPS.

In 2011, 300,000 women, almost all of whom live in developing countries, died from issues related to pregnancy and childbirth. Credit: Patrick Burnett/IPS

By Sarah McHaney
WASHINGTON, Oct 26 2012 (IPS)

In most developing countries, where a woman gives birth still determines whether she lives or dies, despite the availability of inexpensive new medication that is proven to save lives.

Most women dying from childbirth complications in developing countries do so simply because their need for medication is unknown, according to PATH, an international non-profit organisation focused on global health.

“We know maternal health medicines are safe, and we know they are effective and essential to keeping women healthy throughout pregnancy and childbirth. We also know these medicines are frequently not reaching women and community-based health facilities,” Kristy Kade, the primary author of a new PATH report, told IPS.

“What we do not know is the precise number of women for whom these essential maternal health medicines are not available – that is, women with an unmet need.”

This lack of data has led to a significant potential funding shortage. It is simply unknown how much money is being spent by affected countries and, therefore, how much more they need.

“It is very difficult to advocate for more supplies when we have almost no data on when, where, how much, how correctly, and to what standards these drugs are being used,” Kade said.

Last year, 300,000 women, almost all of whom live in developing countries, died from issues related to pregnancy and childbirth. The most common causes are postpartum haemorrhage, excessive bleeding after childbirth, and pre-eclampsia, hypertension during pregnancy.

Childbirth complications are almost nonexistent in the developed world because of effective medicines and high-quality health facilities. As these facilities are often rarely available in many developing countries, however, other medical means have been developed to address this need.

For years, Oxytocin and magnesium sulphate have been used as the primary drugs to treat complications. However, both drugs require specific storage temperatures and trained professionals to administer them, making these drugs inaccessible or even counterproductive at times.

There is also the chance that no one present at the birth will be trained in the correct way to treat the mother.

Misoprostol, a drug commonly used to treat stomach ulcers, has recently been hailed as a solution. It has the potential to reach women whose needs are currently unmet due to a lack of storage ability or trained medical professionals.

“Misoprostol is proven effective, proven safe, it is temperature stable, and no special training is required,” Adam Deixel, director of communications at Family Care International, told IPS. “This means it can be used when women birth at home or rural health facilities or where there is unreliable electricity for storing purposes.”

This drug is distributed in tablet form in the correct dosage needed if postpartum haemorrhage were to occur.

“Six million lives can be saved over the next few years with these new commodities,” Jagdish Upadhyay, with the United Nations Population Fund, told IPS. “We know the problem, we know the solution – we just need to work harder.”

Misoprostol has a fair share of complications as well, however. Although there are written instructions with the medication, it is not always in local languages and assumes the user is literate.

As with any new drug, the medical community is reluctant to see it become widespread without an appropriate level of oversight. There is also concern that women will see these pills as a lifesaving solution at home and fail seek out proper medical attention for their childbirth complications.

“The clear long-term solution is that every woman has access to the best care, well-trained medical staff and high-quality facilities,” Deixel said. “However, we cannot just write off the lives of those women because right now those facilities are just not there. This is a lifesaving option that can save lives right now.”

Misoprostol, similar to the other drugs, is easily manufactured, and developing countries, such as Ghana, have manufacturers making the drug locally. This keeps the drugs inexpensive to transport and sell.

The standards at these local manufacturers, however, often do not meet international regulation.

“Though these drugs are inexpensive, they are often sub-standard,” Kennedy Chibwe, from the U.S. Pharmacopeial Convention, told journalists in Washington earlier this week. “We need to demand quality products and keep the same standard for developed and undeveloped countries. To die from sub-standard medicine is just inexcusable.”

There is hope that these inexpensive and easily applied drugs will soon reach everyone who needs them.

“We have seen the incredible gains that can be made when there is the public support and the political will to save lives such as the millions of people receiving (drugs) as a result of HIV/AIDS activism,” Kade told IPS. “We have not seen the same amount of outrage and mobilisation for maternal mortality.”

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.

A year after the Laotian government launched a safe pregnancy programme news of this initiative,  involving the dispatch of teams of midwives across the country, is yet to reach women in the remote  communities.

A 30-year-old mother of three from the Akha ethnic minority in the Baan Monlem village of the northern province of Bokeo told Mona Girgis, director of Plan International’s local office, that she has never heard of the National Skilled Birth Attendance programme.

But, Girgis told IPS, the woman who identified herself as Noi welcomed the prospect of trained midwives coming to her village to support women in their pregnancies and deliveries.

Noi’s community of 60 families, that makes a living by growing rice on the hilly slopes of Bokeo, currently depends on the experience of older village women rather than a skilled birth attendant or midwife.

The situation of pregnant women in Baan Monlem is true for most other rural communities in Laos. A majority of the country’s 6.5 million people live in rural communities scattered across this mountainous Southeast Asian nation, and over 80 percent of the women give birth at home, according to studies by the United Nations Population Fund (UNFPA).

Laos’s mountain communities include some 100 ethnic minorities, forming one-fourth of the population and contributing heavily to the country’s high maternal mortality ratio (MMR) of 470 deaths per 100,000 live births.

Laos currently has the worst national record in Asia, topping even war-torn Afghanistan which has a MMR of 460 for every 100,000 live births, according to ‘Trends in Maternal Mortality: 1990-2010’, a study by the World Bank, World Health Organisation and UNFPA released this year.

“Families living in remote ethnic communities are usually very poor, and do not have the financial resources to pay for transport or fees to receive (health care) services,” explains Girgis.

“I have frequently heard this from women in different parts of Laos,” Girgis said. “We are aware that there are other obstacles, such as the condition of roads, language barriers and awareness of the need to seek medical care,” she added.

Lack of professional help has resulted in an average of two women dying every day in Laos from pregnancy-related complications and childbirth, notes the UNFPA in a report. “For every woman who dies many more suffer from illnesses or disability from complications during pregnancy and childbirth.”

It was to overcome Laos’s notoriety as the most dangerous place in Asia for a woman to give birth that drove Vientiane to aggressively advance the cause of safe pregnancies.

June saw 80 midwives graduate from a special programme shaped by the ministry of health, international donors and the UNFPA. This second graduating class added to the initial group of 140 midwives who qualified last year, pioneering a professional cadre of community midwives in the communist-ruled country.

The programme received a shot in the arm when the government declared June as the “Month of Midwives,” going beyond just the one day, on May 5, when the world annually marks the International Day of Midwives.

“Every community needs to have its own professional midwife to work with community leaders, families,individual women and adolescent girls to improve knowledge of safe pregnancy, childbirth and care of mothers and babies after birth,” Som Ock Kingsada, vice-minister of health, was reported saying at an event to mark the special month.

The current midwives training programme comes after a lapse of two decades during which no midwives were produced in the country. It has a curriculum that addresses a national weakness – low use of health facilities.

“We had to build in a lot of skills with laboratory work as trainees have limited access to cases, given the low utilisation of health facilities,” says Della Sherratt, international programme coordinator for skilled birth attendance at the Laos office of UNFPA.

“They are required to do a lot of hands on practice and case loads, as would be expected in other countries, (and) we have to send them to clinical areas with some exposure first,” Sherrat said.

And as the community midwives programme forges ahead, focus is shifting to more professional care in isolated communities in the mountainous areas and rural lowlands. “We are focusing this year on those areas where there are no health workers,” Sherrat told IPS.

These efforts are expected to help Laos meet one of the targets in the United Nations Millennium Development Goal of reducing MMR by 75 percent between 1990 and 2015.

According to the World Bank,  women dying while giving birth represents  a “determinant of poverty as well as a constraint to overcoming poverty.”

“Broader interventions that improve the macroeconomic and socioeconomic environment in the country are needed,” Ajay Tandon, the Bank’s senior economist focusing on health-related issues in Laos, said in an interview.

“Many of the determinants of poor maternal health are due to factors outside the health system, (such as) poor road connectivity, poor education, inadequate water and sanitation facilities, as well as low income levels.”

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.

Experts say that underfunded pilot universal healthcare sites to be set up by South Africa as part of its proposed national health insurance may be doomed to fail as debate rages about how the move to more equitable healthcare will be funded.

In March, South Africa announced 10 districts across the country that will pilot universal healthcare under its proposed national health insurance (NHI).

Pilot sites have only been allocated an additional R11 million (or 1.3 million dollars) to implement the NHI, according to Di McIntyre, professor at the School of Public Health and Family Medicine at South Africa’s University of Cape Town.

“The NHI is actually about comprehensive reform of the healthcare system…you can’t do anything with R11 million,” said McIntyre, speaking at the South African National Health Assembly in Cape Town on Jul. 6.

“We have to apply pressure to the national treasury to actually start funding the rebuilding of the public health system.”

Researcher Daygen Eagan, with the South African pro-bono human rights law organisation, SECTION27, estimated that pilot sites could need at least several hundred million rands to roll out the necessary healthcare improvements as part of the pilot, including district-based interventions to reduce maternal and child mortality, and expanded school-based health service.

South Africa released a draft policy document on the NHI in August 2011, and is hoping universal healthcare will not only increase access but also improve health outcomes and value for money.

According to the World Health Organization (WHO), South Africa spends about 400 dollars per person on healthcare, roughly the same amount as Cuba but charts much poorer results for this investment than the island nation.

Maternal mortality in South Africa, for instance, is about seven times higher than that in Cuba, according to the WHO. Now, researchers say that not only are pilot sites underfunded but that they have serious concerns as to how the country will fund the NHI.

Who will foot the bill?

Government has proposed that the NHI be funded through a National Health Insurance Fund, a public entity outside of the Department of Health but accountable to government. This pool of money may be funded through increased health budget allocations from general tax, or though increased personal income tax or the value added tax (VAT) placed on most purchased goods, which many argue would allow the country to tap into its huge informal economy.

However, McIntyre warned that increasing VAT would shift the burden of funding the NHI to poorer households, while the middle class and wealthy have enjoyed successive cuts to personal income tax since the country ushered in democratic rule in 1994.

Associate researcher with the Alternative Information and Development Centre in Cape Town, Dick Forslund issued a similar warning regarding the possible introduction of a payroll tax. While taxes like these initially draw on private sector resources, employers quickly begin to factor these kinds of taxes into wage negotiations, shifting the to employees.

McIntyre argued that government’s draft policy document, or Green Paper, is deliberately ambiguous on the issue of NHI funding, largely because National Treasury – not the Department of Health – will ultimately decide how universal healthcare will be funded. She called on health activists to be strategic in advocacy around the NHI.

“Treasury is going to kill the NHI dead so (we) have to be strategic,” she told IPS. “At a minimum, we should be calling for no further tax reductions.”

Breaking the rules

Both McIntyre and Forslund argued that more could come from South Africa’s existing tax base.

“For most countries, 70 percent or more of healthcare costs comes from public funds,” McIntyre told IPS.

“In South Africa, about 40 percent of money spent on healthcare comes from public funds with contributions from private insurance companies representing as bit or bigger of a share and there’s still quite a bit that comes out of (patients’) pockets.”

Despite signing onto the 2001 Abuja Declaration, in which African governments pledged to commit 15 percent of national budget to health, South Africa currently dedicates about 12 percent of its national budget to health.

If South Africa is going to up the ante for health, Forslund said the country will have to abandon neo-liberal economic policies ushered in as part of the country’s negotiated settlement as part of its transition to democracy.

These policies dictate tax revenue should not exceed 25 percent of the country’s Gross Domestic Product (GDP), said Forslund, arguing that what he called the “25 percent rule” was a strategy by the former Apartheid government to ensure that the political revolution did not become an economic one.

But with increasing social welfare demands on the state, including commitments to free education and healthcare, South Africa will need to break its 25 percent rule.

“The 25 percent rule means a small state,” he said. “It’s a much more conservative percentage than even that applied in the United States.”

By 2025, the NHI’s cost will equate to about six percent of GDP, he estimated.

Finance Minister Pravin Gordon announced early this year that the National Treasury would release a discussion paper on NHI funding in April but has not yet done so.

Family planning in the LDCs is crucial to lowering birth rates, reducing poverty and protecting vulnerable populations against climate change. Credit: SERP/IPS

By Julio Godoy
PARIS, May 30 2012 (IPS)

The reproductive rights agenda, from improving women’s access to education to systematic family planning to reducing birth rates and combating poverty, has become a cornerstone of most industrialised nations’ development policies toward the least developed countries (LDCs), comprised primarily of sub-Saharan African states.

This sharpening of focus comes just in time for the Rio+ 20 summit on sustainable development, slated to run from Jun. 20-22 in Brazil, where the question of climate change will be discussed alongside the development agenda.

It is no surprise that LDCs with the lowest gross national income per capita, weakest human resources and highest economic vulnerability are also the most affected by climate change.

This double challenge, of mitigating climate change and combating crushing poverty, makes improving reproductive rights and promoting gender equality goals that can no longer be delayed, according to several recent reports and agreements.

During a meeting of the United Nations Entity for Gender Equality and the Empowerment of Women – U.N. Women – with the Organisation Internationale de la Francophonie (OIF), which took place in Paris this week, delegates agreed to put the empowerment of women and reproductive rights at the centre of their joint action.

The agreement, signed by Michelle Bachelet, executive director of U.N. Women, and Abdou Diouf, secretary general of the OIF, aims at tackling gender inequality in the 75 OIF member states, most of which are also LDCs.

Gender inequality, typified by violence and discrimination against women, also leads to higher birth rates and poverty, according to experts.

The agreement between U.N. Women and the OIF is but one of several other covenants launched in recent weeks, in the hopes of improving women’s access to education and promoting reproductive rights and family planning.

Last April, U.N. Women set up another agreement with the European Union to strengthen cooperation between the two organisations in their work on gender equality.

Simultaneously, the Royal Society of London (RS) released its new People and the Planet report, which focuses on reproductive rights and social justice as cornerstones of global economic sustainability.

The report called attention to LDCs’ urgent need to “improve women’s access to education and family planning if they are to achieve sustainable development”.

The report recalled that even though global population growth is slowing, rates in LDCs — particularly in sub-Saharan African countries — are expected to remain high for the rest of the century, hampering efforts to reduce poverty.

On the other hand, the report deplored disproportionately high consumption levels in industrialised countries, the root cause of global warming and climate change.

British biologist John Sulston, co-author of the report, said that “population growth and high consumption must be considered together” while searching for solutions to climate change.

Sulston, who headed a working group at the RS while preparing the newest People and the Planet report, said that family planning is indispensable in countries with the highest fertility rate, mostly LDCs.

He also pointed out that populations in industrialised countries, which consume resources at a rate that the planet cannot afford, must realise that their way of life is not sustainable.

The report is extremely timely, coming just ahead of the Rio + 20 summit, which is poised to deal with sustainable development and the planet’s future.

The report stressed the world must meet the challenge of lifting “the 1.3 billion people living on less than 1.25 dollars per day” out of absolute poverty.

To fulfil this objective, international inequality must be eliminated, a process that “will require focused efforts in key policy areas including economic development, education, family planning and health.”

The report also emphasised that “the most developed and the emerging economies must stabilise and then reduce material consumption levels through … improvements in resource-use efficiency, including reducing waste; investment in sustainable resources, technologies and infrastructures; and systematically decoupling economic activity from environmental impact.”

Sulston told IPS, “An enormous injustice affects the human world, as expressed by extremely high consumption in some areas, a consumption of food for instance, that is unhealthy for the very people consuming (the foodstuffs), while other people (in LDCs) consume too little, and suffer malnutrition, diseases and even death due to poverty.”

Sulston lamented, “Humanity is the victim of a system of global economics based on an (inadequate) measurement of gross domestic product (GDP), which drives consumption, and pushes people to compete against each other.”

“The one thing that governments all over the world say is: we must grow, we must grow, more than the others,” Sulston said.

To actually measure human development, “We must add the cost of the Earth, the price of its resources, into our economic models, in order to have a more stable socio-economic structure, not only for the present, but also for the wellbeing of humans in the future,” he said.

Sulston added that climate change is making clear that humanity “is running out of space.” Evidence of climate change and of social injustice fuels the crucial need “to put all these issues – population growth, human consumption and environment – on top of the agenda of the forthcoming Rio + 20 summit.”

Eliya Msiyaphazi Zulu, executive director of the African Institute for Development Policy and president of the Union for African Population Studies, recalled that there is a well-established link between low education levels and high birthrates.

Education delays the onset of childbirth, but also empowers women, “because once you’re more educated, you can have more autonomy, more say in decision making processes in your marriage,” Zulu said.

The report notes that educated women are also more likely to seek out healthcare for their children and get jobs, thereby contributing to their economies. Consequently, instead of waiting for development to slow population growth, Zulu said, countries should focus on reducing fertility rates to promote development.

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