María dos Prazeres de Souza has lost count of the number of births “without a single death” she has attended as a midwife, an occupation that there is renewed interest in strengthening in traditional communities in Brazil where state services are not available or are not entirely acceptable for cultural reasons.

In countries like Mexico, where this indigenous baby was born, and Brazil, many mothers still give birth at home, attended by midwives. Credit: Mauricio Ramos/IPS

The 74-year-old de Souza says that prior to 2008 she attended 1,000 births in her home city of Jaboatão dos Guararapes, in the rest of the state of Pernambuco, and in neighbouring states in Brazil’s impoverished Northeast.

She said she never ceases to be amazed every time a mother’s expression changes from pain to joy.

“A woman in labour feels pain, but when her baby is born she smiles and cries with happiness,” she told IPS, recalling the tears of emotion she has shed herself at each birth she has attended.

De Souza, an indigenous woman, learned her skills as part of her cultural heritage. Her mother, grandmother and great-grandmother taught her the skills from childhood.

“At first I would attend the births of cats, dogs and other animals, but later on in emergency situations, when my mother was not available, I began to attend women in their homes,” she said. Subsequently she trained as an obstetric nurse and worked in hospitals for 20 years.

Now retired, she still attends home births, sometimes “in exchange for just a thank-you hug,” like many of her colleagues who are midwives in the poorest parts of the country.

“It is undeniable that the technologies and practices of the official health model have brought great advances, but we must try to achieve a balance between the traditional and the biomedical approaches if we want to guarantee the health of mothers and children, not just physically but also mentally and spiritually,” said Paula Viana, coordinator of the Curumim Group Midwives Programme in Pernambuco.

Because of their wisdom and experience, midwives should be integrated in, not excluded from, the health system, Viana said in an interview with IPS.

The Curumim programme has shown that traditional midwives contribute to earlier identification of problems in pregnancy, and that as natural leaders they help in cases of women who have been raped, in vaccination campaigns or in HIV/AIDS prevention programmes.

Midwives have contributed to the increase in prenatal checkups at public health facilities and healthy practices like breastfeeding, while they provide therapies such as massages, relaxing baths and emotional support.

The Curumim Group, on the occasion of International Day of the Midwife this Saturday May 5, is launching a campaign for recognition of the value of the role of traditional midwives among indigenous people and in “quilombolas”, communities of descendants of escaped slaves.

The campaign is also seeking recognition of home births attended by midwives within the Sistema Único de Saúde (SUS), the Brazilian national public health system, as well as the designation of midwives’ knowledge and practices as part of Brazil’s intangible cultural heritage.

“Traditional midwives are the bridge between the community and the health services. In many places where there are no doctors, they provide primary health care for the general population, and at other times they are the only person with the connections to get a sick person to hospitals or health clinics in nearby cities,” Viana said.

De Souza has personal experience of the isolation of many rural, riverside or jungle communities. Once she attended a birth on the second floor of a half-built house that still did not have a stairway, so she had to climb up a rope rigged precariously by two police officers.

“After the birth I had a lot of trouble getting down on my own, because one of the police officers was carrying the baby and the other was carrying the mother,” she said.

According to Health Ministry statistics, 41,000 women a year give birth at home in this country of 192 million people, most of them attended by midwives. But the authorities admit the number may be higher.

Although health policies and projects officially take home births into consideration, “the fact is that these births mostly take place in marginalised and isolated communities, without the involvement of the SUS,” Viana said.

“Traditional midwives can probably teach more than they can learn,” but like any other health professionals they must train to improve and update their skills, and must have access to adequate materials and equipment, as well as means of transport for emergencies, she said.

De Souza said many of her colleagues in Brazil have no social benefits or labour rights, and receive no recognition for their work.

“The government has to address this issue, especially as we have had a Brazilian president who was brought into the world by a traditional midwife,” the expert said, referring to former president Luiz Inácio Lula da Silva (2003-2011), who is from the Northeast.

Viana emphasised that “risk is inherent to childbirth, whether it takes place in a woman’s home or in a hospital.” But the danger of a serious health complication would increase if “women in labour were deprived of the support of traditional midwives,” she said.

That is why the Curumim Group’s representative is calling for “both healthcare models, the traditional and the biomedical, to join together,” especially in remote and isolated communities.

In de Souza’s view, pregnancy is a natural process, but “many women have got it into their heads that they are ill, or else they don’t want to suffer pain and they ask for a caesarean.” SUS figures for 2008 show that half of the three million births registered that year were by caesarean section.

The maternal mortality rate has declined steadily in Brazil since 1990, when there were 140 maternal deaths per 100,000 live births. By 2010 the figure was 58 per 100,000 and it is expected to drop still further. The main causes of childbirth-related death among women are hypertension, haemorrhages and postpartum infections.

The infant mortality rate has also fallen, to 15.6 per 1,000 live births in 2010, 47 percent lower than in 2000, according to the latest census.

In these circumstances, Viana said, the full range of regional obstetric care should be considered in order to achieve further improvement.

“The more the scientific community endeavours to establish the biomedical model of health, the more we need to analyse the consequences of the excessively interventionist and medicalised nature of childbirth,” she said, pointing out that the number of traditional midwives is in decline.

De Souza, the midwife who has brought more than 1,000 babies into the world, says: “We have been blessed, and we continue to be blessed. We have thousands of years of history behind us, and that must command respect.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abuse and rape fuel the crisis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Teenage pregnancies are on the rise in Guatemala, along with the drop-out rate in schools, family breakdown and many other related social ills.

More and more girls in Guatemala are having babies. Credit: Fiat Luxe/CC BY-ND 2.0

A graph of statistics from the Ministry of Health and Social Assistance shows a rising trend, with 41,529 pregnancies in girls aged 10 to 19 in 2009, 45,048 in 2010 and 49,231 in 2011, giving an average of 135 a day last year.

A long list of factors contribute to early motherhood, ranging from lack of sex education to the influence of the Catholic Church’s ban on contraceptive use, and impunity for statutory rape, according to Mirna Montenegro of the Sexual and Reproductive Health Observatory, a local NGO.

“Imagine! In 2011 there were 21 babies born to 10-year-old girls! What’s more, we have no social protection system for them,” she told IPS.

“We are one of the few countries where there are so many pregnancies among 10 to 14-year-old girls. In 2011 alone there were 3,046 births to such young mothers in Guatemala,” she said. “Pregnancy in an underage girl is the product of statutory rape, so logically there should be an equal number of court prosecutions under way, but this is not so,” she complained.

Montenegro said the Guatemalan justice system finds it problematic to punish offenders in these cases. “The younger the victim, the closer the family ties between herself and the rapist,” she said.

The Catholic Church’s opposition to using birth control methods and to a comprehensive approach to sexuality that includes avoiding unplanned pregnancy and sexually transmitted diseases is also a hurdle, Montenegro said. “It affects the development of attitudes within the family,” she said.

The Health and Education Ministries signed a cooperation agreement in 2010 to implement programmes to prevent unwanted pregnancies in the six provinces with the highest HIV/AIDS incidence, maternal mortality rates and other indicators of concern.

“Progress has been made in raising the awareness of teachers, developing teaching materials and learning modules, and analysing the context of the situation in the provinces. But these things have not yet reached classrooms, as they are bogged down in provincial and ministerial head offices,” Montenegro said.

The Family Planning Law, regulations for which were adopted in 2009, brought sex education into primary schools and facilitated access to contraceptive methods. The following year the Healthy Maternity Act was approved, which obliges health authorities to provide basic services and care before, during and after pregnancy.

But the new laws have not been successful in curbing teen pregnancies.

One out of five Guatemalan mothers are aged between 10 and 19, the highest adolescent fertility rate in Latin America, according to a 2011 study on the state of the world’s girls, titled “Because I Am a Girl: So, What About Boys?” by Plan International, a child protection agency.

Deep-rooted cultural factors also encourage pregnancies and prevent women from taking advantage of opportunities for a better life.

Cecilia Fajardo, a psychologist with the Family Welfare Association of Guatemala (APROFAM), told IPS, “We are still taught that women’s role is to be wives and mothers, which is our right, but we are not told about other avenues of self-improvement.”

Fajardo said there could be more child and teen pregnancies than those reported by the Health Ministry, since “many of the births take place at home, or pregnancies are terminated without the authorities’ knowledge.”

To help teenagers, APROFAM has created innovative programmes in schools for young people of both sexes to come to grips with practical aspects of pregnancy, fatherhood and motherhood, using aids like the electronic baby and the pregnancy simulator.

“The pregnancy simulator is a strap-on garment with an enlarged bust and belly weighing 25 pounds (11 kilograms), the average weight gain a woman experiences in pregnancy. It enables teenagers to experience 26 different signs and symptoms of pregnancy,” Fajardo described.

The electronic baby is a computerised infant-sized doll that mimics the behaviour of a newborn, including crying to signal that it is hungry or tired.

“We give young girls these experiences to give them knowledge about sexuality and reproductive health. We do not impose on them the idea that they should not be mothers,” Fajardo said.

This impoverished Central American country of 14 million people has an adolescent (under-20) birth rate of 114 per 1,000 women in rural areas, according to the National Mother and Child Health Survey for 2008-2009.

Silvia Maldonado of the National Alliance of Indigenous Women’s Organisations for Reproductive Health (ALIANMISAR) told IPS that dropping out of school, malnutrition and discrimination are among the consequences of teen pregnancies.

She said education was one of the most important factors for the prevention of adolescent pregnancy, which severely curtails life opportunities for thousands of teenagers and creates the phenomenon of “kids having kids.”

“It is essential to talk about sexuality in schools, and for parents to talk to their children in depth about this issue in order to prevent more teen pregnancies,” Maldonado said.

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

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

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

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

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

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

Development commitments lagging

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reproductive justice boosts development

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It is also where their circumcisions happen.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Excerpt:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Excerpt:

By Kristin Palitza
ABIDJAN , Mar 15 2012 (IPS)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*Name changed to protect identity of interviewee

Excerpt:

By Marcela Valente and - -
BUENOS AIRES, Mar 2 2012 (IPS)

For over 90 years, a law in Argentina has allowed women who become pregnant as a result of rape to have an abortion. However, hospitals often refuse to carry out the procedure, instead referring the women to the justice system.

Argentine law penalises doctors who carry out abortions and the women who have them, with certain exceptions.

The 1921 criminal code states that abortion is not punishable when a doctor performs it because the life or health of the mother is in danger, or “if the pregnancy is the result of rape or sexual assault of a feeble-minded or demented woman.”

Nevertheless, cases periodically crop up where sexually abused or raped girls, teenagers and women are referred to the justice authorities for a decision about a procedure that in fact does not require authorisation.

“Abortion is a medical procedure. Doctors, not judges, should decide whether it needs to be done,” Natalia Gherardi, a lawyer and head of the Latin American Group for Gender and Justice (ELA), told IPS.

In spite of the legal ban, between 460,000 and 600,000 abortions a year are performed in this country, according to NGOs, and an estimated 100 women die every year from clandestine abortions performed in unsanitary conditions.

Aware of the difficulties in obtaining approval of a law legalising abortion, women’s organisations have long campaigned for at least an effective right to abortion in cases in which it is already legal.

Gherardi said “there is great uncertainty among doctors on how to interpret the article” in the law that establishes which cases of abortion are not punishable. And their confusion is understandable, given what happens when cases are referred to the justice system.

Some judges authorise the abortion; others rule that authorisation is unnecessary; and some judges rule, against the law, to prevent the procedure.

To avoid the referral of these cases to the justice authorities, in 2007 the Health Ministry issued a Technical Guide for the Comprehensive Care of Non-Punishable Abortions.

The guide book acknowledges that “for many decades” women have been prevented from exercising their right, enshrined in the criminal code, “to have access to an abortion in authorised circumstances.”

“The state is obliged to guarantee the exercise of that right,” says the guide, which adds that hospitals “have the legal obligation to carry out the procedure, and are not required to call for judicial intervention and/or authorisation” before acting, even in cases of under-age girls.

Nevertheless, there are regular instances of girls attending a hospital with their parents and being denied an abortion. The most recent case to have come to light occurred in January, in the province of Entre Ríos, where an 11-year-old girl who had been sexually abused became pregnant.

Doctors at the public hospital insisted on judicial authorisation, and a judge refused permission for the procedure. Furthermore, the provincial health minister, Hugo Cettour, publicly said that if the girl was capable of conceiving, she was capable of being a mother.

In the face of this pressure, and even more pressure from both the Catholic and evangelical churches, families give up the right to legal abortions. “This almost always happens to women who are poor or marginalised,” Gabriela Filoni, a lawyer, told IPS.

Filoni is in charge of the regional litigation programme of the Latin American and Caribbean Committee for the Defence of Women’s Rights (CLADEM), which in conjunction with other organisations succeeded in taking one of these cases to the international arena.

As a result of their intervention, in 2011 the United Nations Human Rights Committee ordered the Argentine state to provide “reparations, including an indemnity” to a mentally disabled young woman who was denied an abortion.

“The time period allowed for the state to respond has expired. We know the government asked for an extension, but what we want is a public policy or a legal measure that would prevent a repeat of these cases,” said Filoni.

The 2006 case involved a 20-year-old woman identified in the records as LMR, in Guernica in the province of Buenos Aires, who has a mental age of between eight and 10 as certified by her physicians. The young woman was raped by her uncle, and became pregnant. But when her mother took her to the hospital for an abortion, the doctors refused and sent her to another facility.

At the second hospital, the bioethics committee met and referred the case to the justice system. A court denied permission for the abortion, and the ruling was upheld on appeal.

The provincial Supreme Court finally recognised the young woman’s right to a legal abortion. Furthermore, the court stated that judicial authorisation should not have been required in the first place.

But even then, the hospital refused to carry out the procedure, claiming this time that the pregnancy was too advanced. In the end, the family had to arrange an illegal abortion to terminate a 20-week pregnancy.

By this time, LMR’s mother and sister had both lost their jobs because they stayed by her side throughout the whole process, and they had been harassed by Catholic groups applying pressure to prevent the abortion.

“Authorisation was not necessary in this case, yet the health providers washed their hands of the matter, and the problem here is that referring the case to the justice system takes time, and the pregnancy continues to advance,” said Filoni.

In a survey carried out by Ibarómetro, a polling firm, seven out of 10 respondents asked about the case of the 11-year-old girl in Entre Ríos said she should have been given a legal abortion.

When asked about the legalisation of abortion, 60 percent of respondents said it should be a woman’s right, and access should be guaranteed by the state.

Excerpt:

By Marcela Valente and - -
BUENOS AIRES, Feb 29 2012 (IPS)

In Latin America, Argentina spends the most on healthcare. It has a vast infrastructure, highly qualified health professionals and the necessary material resources. But other countries in the region are achieving better and faster health outcomes with fewer resources.

This is one of the main conclusions of the study “Retos postergados y nuevos desafíos del sistema de salud argentino” (Postponed and New Challenges to the Argentine Health System) by Federico Tobar, Sofía Olaviaga and Romina Solano of the independent Centre for the Implementation of Public Policies Promoting Equity and Growth (CIPPEC).

The authors also point to inequities in access to health care in the provinces, and the need for health policies adapted to the new epidemiological challenges in the country, where mortality due to non-infectious diseases is now greater than that caused by infectious diseases.

“Argentina is losing its status as the regional leader in health care,” Tobar, a sociologist and researcher, as well as a former chief of staff of the Argentine Health ministry and a consultant on health policies in 14 Latin American countries, told IPS.

Tobar emphasised that Argentina is the country with “the highest numbers of beds, doctors and dentists per head and the most resources invested in health as a proportion of GDP.”

It also has an extensive network of hospitals and primary health care centres that are “very well distributed throughout the country,” he said. “Some of them do not work as well as they should, but the capacity is there.”

Tobar is very familiar with the network of health centres because he designed and coordinated Plan Remediar (“Remedy Plan”), launched 10 years ago to guarantee free distribution of some 50 medicines for ambulatory patients at every public health centre in the country.

He also highlighted “the high quality of health professionals in all specialties,” and said that, in contrast to the situation in the past, hospitals are now well supplied with necessities like medicines and disposable products.

“During the economic crisis in 2001 and 2002 it was a commonplace to say that the public hospitals did not even have gauze, but now there is everything, everywhere,” he said, including a variety of high-quality contraceptives for free distribution.

He said, however, “there is a lack of proactive health policies, and the state should use its resources to reduce inequalities in the provinces, instead of increasing the gaps.”

Unlike the situation in education, there is no federal health law to determine how state funds should be distributed to the provinces.

The budget is shared out arbitrarily, with some provinces benefiting more than others, regardless of their objective needs, Tobar said.

The researchers also indicated that the country should adapt to the new epidemiological challenges facing the population.

The study points out that the health system is structured efficiently to combat infectious diseases and injuries, but that more people in Argentina are now suffering from non-infectious diseases, mainly cardiovascular disease and cancer.

“These challenges need to be better addressed,” say the authors, who warn that the latest national surveys of risk factors, carried out by the Health Ministry in 2005 and 2009, found a deterioration in the behaviour patterns essential for physical wellbeing and illness prevention.

The surveys found that while smoking and exposure to tobacco smoke had fallen, so had the consumption of fruit and vegetables, while salt intake had increased, and a lower percentage of people engaged in physical activity.

In their cost-benefit analysis, CIPPEC states that Argentina spends 10 percent of its GDP on health, yet the progress made in life expectancy and infant and maternal mortality is slower than in other countries with similar incomes.

“Every country in the region spends less per capita on health than Argentina, but Costa Rica, Cuba, Chile and Uruguay, for example, get better results in terms of infant mortality, maternal mortality and life expectancy at birth,” said Tobar.

The study notes that Costa Rica and Uruguay, with lower health expenditure per head, have higher life expectancy rates than Argentina, where average life expectancy at birth is 75.4 years.

Furthermore, in Argentina there is a wide gap between provinces. For instance, in Chaco province in the northeast, life expectancy is 69.9 years.

As for child health, the neonatal mortality rate and the under-five mortality rate fell by 5.5 percent and 6.4 percent, respectively, over the last decade.

However, over 50 percent of mortality could be reduced through early diagnosis and timely treatment, and again, in comparison with other countries, indicators are poor and progress is slow.

“Brazil, which historically trailed Argentina in health indicators, will overtake this country in a few years if the present rate of decline is maintained” for infant mortality rates, says the study, which displays comparative results by country in tables and graphs.

Geographical inequalities are again evident in infant mortality. In the Argentine capital and the southern provinces of Neuquén and Tierra del Fuego, the under-five mortality rate is less than eight per 1,000 live births, while in Formosa, in the northeast, it is 25 per 1,000 live births.

For maternal mortality, the study found “no improvement” and “enormous disparities” between provinces. Tobar said 99 percent of births take place in hospitals or other health facilities; however, only 33 percent of pregnant women have had five prenatal check-ups, the minimum recommended, by the time they go into labour. “The country’s advances in maternal and child health are below its potential, in terms of its infrastructure, available human and financial resources, and level of economic development,” the study says.

The authors state that there has been little or no progress towards reducing the inequalities that persist between different provinces in terms of access to health care and treatment outcomes, and recommend “strengthening the regions that are lagging the most, in order to reduce the gaps.”

For example, the province of Santa Cruz receives 7.2 times the public expenditure on health per capita than Misiones. “The state does not compensate for, but exacerbates the differences,” complained Tobar.

The study points out that the health system is highly fragmented, and this blurs lines of responsibility. Thirty percent of the population uses the public health care service, while nearly 64 percent has health insurance through contributions to a trade union, or by contracting a private service.

The per capita health expenditure for people who have insurance is, on average, double that of people using only the public health system.

Excerpt:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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