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Posts Tagged ‘human rights’

This post is the first in a series on maternal health in the Seraikela block of Jharkhand, India. 

In 2009, Sarah Blake and I worked together at the Maternal Health Task Force, a Gates Foundation funded maternal health initiative based at EngenderHealth in New York City. Since then, Sarah went on to work as a consultant with several non-profit organizations, including UNFPA and Women Deliver.  I took off for India as a Clinton Fellow with the American India Foundation where I have been working for the past nine months on a maternal and newborn health project in Jharkhand, a state with high levels of maternal and newborn deaths.

A new mom holds her newborn in a small community called Sini, in the Seraikela block, as community members look on.

Sarah and I recently teamed up again (this time, in India) to explore our common interest in maternal health. Over the past two weeks, we have visited hospitals, health centers, government offices, rural villages, and homes in the Seraikela block, a rural area with rugged terrain and limited infrastructure outside the industrial city of Jamshedpur, in the state of Jharkhand.  We conducted a series of interviews with women, families, health workers, and government health officials. We asked questions about pregnancy, childbirth and the postpartum period. We learned about the women’s experiences with home and institutional deliveries–and the factors that influence their decision to deliver at home or in an institution. We explored the implementation of and attitudes toward Janani Suraksha Yojana, a conditional cash transfer program that aims to increase institutional deliveries across India.

A collapsed road on the way from Jamshedpur to the Seraikela Block of Jharkhand.

Conditional cash transfers are trendy. Various governments, non-governmental organizations, and private enterprises across the globe are supporting cash transfer initiatives in efforts to improve school attendance, reduce child under-nutrition, improve maternal and newborn health, and to address other development goals.

What is a conditional cash transfer program? According to the World Bank, “conditional cash transfer programs provide cash payments to poor households that meet certain behavioral requirements, generally related to children’s health care and education”.

Janani Suraksha Yojana (JSY) is a widely discussed (mostly within the global health community but to some extent in mainstream media) and frequently praised cash transfer program. JSY was launched by the Indian government as part of the National Rural Health Mission in 2005, in an effort to reduce maternal and newborn deaths by increasing institutional deliveries.

JSY provides cash incentives to women who deliver in government health institutions as well as accredited private health centers. The program also provides a cash incentive to the health worker who supports the woman throughout her pregnancy and accompanies her to the facility. (For details and FAQs on JSY, click here.)

A community health worker accompanies a pregnant woman to Mahatma Gandhi Memorial Hospital in Jamshedpur, the main referral hospital for the surrounding rural communities.

Maternal and newborn death rates have gradually been declining across India (and the world), but the problem has yet to be resolved. Both maternal and newborn deaths in India continue to make up an extremely large percentage of the overall global burden. According to a study published in the Lancet last year, 20% of global maternal deaths and 31% of global newborn deaths in 2005 occurred in India.

JSY is a big program (the biggest of its kind in the world) that aims to deal with a big problem. The lessons that are drawn from it have the potential to influence global health policy in a big way. The 2010 evaluation of JSY published in the Lancet suggested that the program is having a significant impact on perinatal and neonatal health, but the paper asserted that the verdict was still out in terms of any impact on maternal mortality.

The lesson that has emerged from JSY for newborn health is that giving women money increases institutional deliveries and reduces perinatal and neonatal mortality.  It is likely that the same message will emerge in terms of reducing maternal mortality—and there is a good chance that this approach will be picked up in national health programs in numerous other countries that also have high levels of maternal and newborn mortality.

Our concern is that JSY is far more complex than providing women with money—and reducing maternal mortality is far more complex than increasing institutional delivery.

Given the scope, cost, and potential of JSY; it is incredibly important that we ask questions about the nuances of JSY—the role of money as an incentive for women, families and health workers; the readiness of institutions;  the challenges with transportation; the human rights implications of the program; and a variety of other related factors.

Over the next week (or couple of weeks), Sarah and I will share our experiences and insights from our time with the women, families, health workers, and government health officials of the Seraikela block of Jharkhand, a focus state for JSY. We will highlight stories from the people most impacted by and involved in Janani Suraksha Yojana.

We believe that we have scratched the surface of some interesting issues related to JSY, but our time in Seraikela certainly left us with more questions than answers, and we will be sharing those questions in upcoming posts.

We will also be asking our colleagues working in maternal and newborn health to share their thoughts through guest blog posts. If you are interested in submitting a guest post, contact us at katemitch@gmail.com and sarahcblake@gmail.com.

Tata Steel Rural Development Society, my host organization for my fellowship, provided us with transportation and interpreter services. Many thanks to Shabnam Khaled for her help with translation. 

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The Center for Reproductive Rights has released, Dignity Denied: Violations of the Rights of HIV-positive Women in Chilean Health Facilities, an in-depth investigation into the issue of discrimination against HIV positive women in Chile—specifically when seeking reproductive health services. 

In an email I received from colleagues at the Center for Reproductive Rights, they wrote:

“Over a period of six months, we spoke with 27 women in five different regions of Chile, gathering their stories. The research confirmed what we already knew from a previous study carried out by VIVO POSITIVO—women living with HIV/AIDS were frequently pressured not to become pregnant, were often scolded by healthcare workers for wanting to do so, and were sometimes pressured, coerced or forced to undergo surgical sterilization. The Center wanted to make clear that the abuse and mistreatment suffered by HIV-positive women are violations of their human rights…”

Excerpt from the report:

“In 2004, Julia received the good news that her viral load was undetectable. With this improvement in her health and after witnessing other HIV-positive women give birth to healthy, HIV-negative children, Julia and her partner decided to try for a child in consultation with a private physician. however, despite the low risk of mother-to-child transmission (mTCT), healthcare professionals repeatedly chided Julia after she became pregnant, telling her, ‘What were you thinking? Don’t you see that you are going to have a sick child?’

During the first trimester of her pregnancy, Julia began experiencing an orange-colored vaginal discharge. Concerned, she went to the hospital to have it checked out. Instead of treating her, however, hospital workers turned her away and told her to return for her regularly scheduled check-up. She was admitted to the hospital three days later, hemorrhaging and with severe abdominal pain, but she still sat untreated…”

Download the full report here

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On April 13th 2010, the New York Times published an article,  Maternal Deaths Decline Sharply Across the Globe, about the recent findings published in the Lancet that suggest a dramatic reduction in global maternal mortality. Since then, the paper has published a series of Letters to the Editor. These letters come  from leaders of organizations working on reproductive and maternal health and from health professionals working on maternal health on the ground in countries where maternal mortality continues to be a major problem.

The New York Times

A variety of opinions and sentiments are expressed in these letters that certainly add depth to the initial story published in the Times. Two themes pound through the letters: a new sense of hope that improvements in maternal health are possible and a sense of urgency that this battle has not yet been won–that now, more than ever, is the time for the maternal health community to stick together (despite squabbles among advocates over whether or not the Lancet should have published the paper when they did) and engage in concerted efforts (that include emergency obstetric care, HIV services, and expanded access to family planning) to achieve MDG5.

A careful look at these letters will stimulate a much more robust understanding of the myriad of factors contibuting to global maternal mortality—as well as the potential implications of the findings of the Lancet paper and necessary next steps towards achieving MDG5.

Some authors express cautious excitment that investments are (or might be depending on the author) paying off while simultaneously declaring that it is not yet time to celebrate; far too many women are still dying of pregnancy-related causes!  Joanne Jorissen Chiwaula, director of the African Mothers Health Initiative describes her frustration with Chris Murray (one of the authors of the Lancet paper) for downplaying the importance of emergency obstetric care services in favor of playing up the importance of HIV services, when a comprehensive approach is really what is needed. Mary Robinson, president of Realizing Rights: The Ethical Globalization Initiative, calls attention to the relationship between maternal health and discimination against women, lack of reproductive choices for women, child marriage, sexual violence, unsafe abortions and inability to own property. She emphasizes the importance of considering maternal health in the context of human rights—and also points out the need to focus on strengthening entire health systems. 

Take a look at a group of Letters to the Editor published on April 18th, and more on April 19th.

For readers comments on the initial story in the Times, click here.

And for Nicholas Kristof’s take on the new maternal mortality estimates, click here.

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Five recent stories published on the site have raised various issues impacting maternal health—including leadership and innovation, maternal death audits, access to primary health care and safe delivery, human rights, and even a proposal for a separate maternal health ministry.

allAfrica.com

Namibia: Leadership Development, Social Innovation and Improved System Performance

The Maternal Health Initiative Team,  an offshoot of the African Public Health Leadership and Systems Innovation Initiative, funded by the Bill and Melinda Gates Foundation, is “developing a model for improving public health leadership and system performance.”

“…The project is underpinned by three principles: local leadership development, social innovation and improved system performance.

The initiative applies a business-consulting approach called the Innovation Lab. Through the Innovation Lab, multi-stakeholder teams are guided through an intensive leadership development and problem-based learning experience. The aim is to tackle a complex social and system problem through a multi-stakeholder and innovation response.

When deciding on a priority health problem to tackle as a pilot, it wasn’t hard for Namibian health leaders to choose maternal health. Between 2000 and 2006, maternal mortality jumped to 449 deaths per 100 000 births, an increase of 178 deaths…”

Read the full article,  Namibia:Health Authorities Tackle Maternal Mortality.

Rwanda: A Call for Maternal Death Audits

“…As a strategic move to curb the maternal death rate further and achieve millennium development goal 5, the government recently extended the fight to the village level.

This was announced recently by the Minister of Health, Dr. Richard Sezibera, during a meeting that was held with a visiting US medical team to discuss Rwanda’s health progress.

During the discussions, Sezibera noted that it was imperative to engage the community in fighting maternal death rates so that leaders at the village level can identify the causes of these deaths in bid to find a lasting solution.

‘This year we started maternal death audits in villages because we believe that social audits on death causes will enable authorities identify answers to this problem,’ the minister said…”

Read the full article, Rwanda: Maternal Mortality Control Extends to Village Level.

Nigeria: Improving Access to Primary Health Care and Safe Delivery

“Health System Development Project II, a World Bank assisted project has commissioned two Comprehensive Primary Health Centres at Dagiri community in Gwagwalada and Dabi village at Kwali.

The Health Centres are to address the high rate of maternal and child mortality cases in the country, said Mrs Anne Okigbo-fisher, World Bank task team leader during the hand over ceremony of the centres. She said Nigeria records 10 percent of the world’s maternal mortality rates out of the 524,000 women that die yearly during child birth, adding that approximately 99 percent of the mortality rate is due to child birth complications in developing countries.

According to her the objective of HSDP II is to reduce such complications and improve safe delivery in the country…”

Read the full article, Nigeria: World Bank Commissions N104 Million Hospitals in Abuja.

Kenya: Human Rights Impacting Maternal Health

Amnesty International calls on Kenya’s Parliament to ensure that the draft Constitution of Kenya upholds respect for, the protection and fulfilment of all human rights. The draft Constitution should retain social and economic rights as enforceable rights. In addition, the organization also calls on Parliament to remove the provision stipulating that the right to life begins at conception and if the article on abortion access is retained, provide for abortion for rape victims…

…If the Constitution explicitly limits women’s access to abortion services, it must, at least ensure women’s access to safe and timely abortion services in cases of risk to the life or health of the woman or pregnancy resulting from rape or incest. Such an exemption is required by international law and is required by the Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa, which Kenya signed in 2003. In view of the high number of maternal deaths resulting from abortion complications, the State should protect women’s right to life by ensuring meaningful access to sexual and reproductive health services including information and contraception and commit to address sexual violence and coercion…”

Read the full article, Kenya: New Constitution Must Ensure Rights for All.

Uganda: A Call for an Independent Maternal Health Ministry

“An independent ministry should be set up to handle maternal health, the deputy Speaker of Parliament, Rebecca Kadaga, has said.

‘Who is planning for women’s health in this country? Basic things like antibiotics, oxytocins (drugs that help manage bleeding) which cost sh300 and manual vacuum aspirators to remove retained products from the womb are not there,’ she told journalists at a briefing on the state of maternal health on Friday…”

Read the full story, Uganda: Kadaga Wants Independent Maternal Health Ministry.

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The mobile cinema, backed by UNICEF, is traveling from village to village in Mali screening films that encourage communities to talk openly about maternal and child health issues. After the screening, project leaders hold open discussions with communities about female genital cutting—and the health implications of the practice.

SOS Children’s Villages

“More than 85 per cent of women aged between 15 and 49 in Mali have been circumcised, a practice that has many harmful physical and psychological effects. Across the world, the figure is up to 140 million women and girls in 28 countries, especially in Africa and the Middle East. ‘The female genital mutilation or cutting poses immediate and long-term consequences for the health of women and girls and violates their human rights’, the United Nations Children Fund (UNICEF) said on Friday, before the International Day against Female Genital Mutilation.
The mobile cinema, backed by UNICEF, turned Djènèba Doumbia’s attitudes on the practice on their head. Since seeing the film, she no longer supports female cutting and now does not want to pass the tradition on to the daughters of the community. ‘I tell all women not to circumcise their daughters, to leave them as they are, because we realize that the disadvantages of this practice are numerous and real,’ said Ms Doumbia. ‘So if they let the girls be, the whole family benefits.’ Women at the aftershow discussion hear how those who have been cut are more likely than uncut women to have complications in and after childbirth…”

Read the full story here.

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For over two years, Amnesty International has been researching maternal health and investigating maternal death in Burkina Faso.

Amnesty International

In five days, the organization will release a report on the state of maternal health in Burkina Faso and launch a caravan campaign that will travel throughout the country raising awareness around the issue of maternal mortality.

“Amnesty International went to Burkina Faso four times to conduct research in several cities including the capital, Ouagadougou, as well as Bobo-Dioulasso, Ouahigouya and Kaya. Amnesty International also visited a dozen rural areas throughout the country. Researchers investigated over 50 cases of women who died during pregnancy and childbirth…”

Read the full story here.


Take a look at this video showing highlights of the 2009 Amnesty International maternal mortality caravan campaign in Sierra Leone:

As part of the countdown to the launch of the campaign, Amnesty International is sharing the stories of women who have died of pregnancy complications in Burkina Faso. See below for an excerpt from one of the stories:

“…Safiatou’s husband told Amnesty International: ‘The day of her delivery, she was in good health and worked all afternoon as usual without any problem. She prepared tô [a local dish made from maize flour] for her children and went to get the hay for the animals. In the evening, when her labour began, she left for her mother’s home. Her mother came to warn me that she was not well, that we had to take her to the clinic. I do not have a motorcycle, so I had to go and get one. That made us lose time.’ The husband added that he ‘did not know that she should have delivered at the clinic. When I came to fetch her at her mother’s house, she had lost consciousness.’ The husband borrowed a small motorcycle from his neighbour…”

Learn more about Safiatou here.

A man holding a picture of his wife who died in childbirth, Burkina Faso. Copyright Anna Kari

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Watch and share Pathfinder’s video, Girl2Woman, that outlines the challenges related to sexual and reproductive health that girls face throughout their lives.

Every video shared raises $1 for Pathfinder International programs—-up to $1 million. Visit the Girl2Woman site to see more information about the initiative and an interactive time line that outlines stages of life and highlights the work that Pathfinder International does to help women at each stage. At the Girl2Woman site, you can also fill out a form to share the video with your contacts.

To learn more about Pathfinder International, click here.

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