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Posts Tagged ‘Lancet’

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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In April, the Lancet published new maternal mortality estimates (out of the Institute for Health Metrics and Evaluation) that showed a significant reduction in global maternal deaths, shaking up the global health community’s understanding of the global burden of the issue–and providing new hope. The report also illustrated the important links between HIV/AIDS and maternal mortality.

In the wake of the Lancet report, maternal health professionals from various organizations engaged in robust dialogue (like this one) about measurement methodologies–and raised questions about when the World Health Organization would release their estimates and how they might differ from the IHME estimates.

On September 15th, WHO, UNICEF, UNFPA, and the World Bank released their new maternal mortality estimates in a report, Trends in maternal mortality. Their report also showed a significant drop in maternal deaths—a 34% decrease between 1990 and 2008.

Excerpt from the WHO press release:

“The new estimates show that it is possible to prevent many more women from dying. Countries need to invest in their health systems and in the quality of care.

‘Every birth should be safe and every pregnancy wanted,’ says Thoraya Ahmed Obaid, the Executive Director of UNFPA. ‘The lack of maternal health care violates women’s rights to life, health, equality, and non-discrimination. MDG5 can be achieved,’ she adds, ‘but we urgently need to address the shortage of health workers and step up funding for reproductive health services’…”

More highlights from the report:

  • Ten out of 87 countries with maternal mortality ratios equal to or over 100 in 1990, are on track with an annual decline of 5.5% between 1990 and 2008. At the other extreme, 30 made insufficient or no progress since 1990.
  • The study shows progress in sub-Saharan Africa where maternal mortality decreased by 26%.
  • In Asia, the number of maternal deaths is estimated to have dropped from 315 000 to 139 000 between 1990 and 2008, a 52% decrease.
  • 99% of all maternal deaths in 2008 occurred in developing regions, with sub-Saharan Africa and South Asia accounting for 57% and 30% of all deaths respectively.

Click here to read the press release and here to read the full report.

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A recent study in the Lancet took a close look at a conditional cash transfer scheme to entice women to deliver in health facilities. The scheme, Janani Suraksha Yojana (JSY), aims to reduce maternal, perinatal, and neonatal mortality.

Published along side the study was a commentary by Vinod K. Paul that summarizes several of the key findings of the study–pointing out successes and challenges with the scheme.

“…In just 4 years, its beneficiaries multiplied 11-fold, from 0·74 million in 2005—06 to 8·43 million in 2008—09 (thus covering nearly a third of the 26 million women who deliver in the country annually). Budgetary allocation for the JSY increased from a mere US$8·5 million to $275 million in the same period. Surely, it is time to ask the question about what health outcomes are achieved by this massive and expensive investment and effort. On the face of it, by promoting a strategy of deliveries in the facilities, attended by skilled providers, JSY should lead to a reduction of maternal, perinatal, and neonatal mortality…”

Click here to read the full commentary. You will need to register (free) with the Lancet to access this article.

Excerpt from a Washington Post story on the study:

“…The payment program seems to be working, according to Indian health workers and researchers who conducted the study for the Lancet.

‘The cash payments mean that India is really starting to invest in women. That trickles out to the rest of the family and the rest of society,’ said Marie-Claire Mutanda, a health specialist with UNICEF, which is supporting the program.

In two of the poorest states in India — Bihar and Uttar Pradesh — the number of women giving birth in medical facilities soared from less than 20 percent in 2005 to nearly 50 percent in 2008, according to the most recent data available.

Doctors here attribute that to the payment program, whose Hindi name translates to ‘women protection scheme’…”

Click here to read the full story in the Washington Post.

Click here to read the study, India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation, in the Lancet. You will need to register (free) with the Lancet to access this article.

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The controversial research reporting unexpected gains in maternal health, published April 12 in the Lancet, has triggered rigorous debate about the measurement tools used to count maternal deaths globally and at a country level. The paper, Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5, was written by Chris Murray and his team of researchers at the Institute for Health Metrics and Evaluation. The study found a dramatic reduction in the number of women dying from pregnancy complications between 1980 and 2008–and these findings have triggered both celebration and skepticism within the global health community. Some global health leaders are cheering the global progress toward MDG5 indicated by the research. Some are expressing cautious optimism. Others are challenging the paper’s methodology, asking whether it really signals big gains in the struggle against global maternal mortality or just flawed means of estimating how many women are dying.

On June 5th, the Lancet published a reply from Chris Murray in which he addresses some of the concerns voiced by his fellow global health researchers regarding the methodology of the study.

“We appreciate the rich set of letters in response to our paper on maternal mortality. The authors of the letters raise many important points, but we focus our short response on four larger themes that have been raised.

The country graphs in the webappendix to our paper show all the available data points for each country and our best estimates based on these data and the modelling strategy. In the case of the Philippines, Indonesia, Burkina Faso, and Peru, the correspondents have noted that our data-points derived from the analysis of sibling histories in household surveys are different from published figures from the same surveys. The differences stem from two sources. First, we correct for problems of survivor bias in sibling histories, following the published methods of Gakidou and Kingand Obermeyer and colleagues...”

Read the full reply by Chris Murray on the Lancet Online. Be sure to take a look at some of the critiques of the study–linked on the right panel next to Murray’s reply.

For more on this topic, take a look at a recent post, New Maternal Mortality Estimates Published in the Lancet: What’s the Buzz?, on the Maternal Health Task Force’s new MedScape Blog, GlobalMama.


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Tuesday (6/8) marked day two of Women Deliver 2010. Day two was all about innovation and (high and low) technology to improve the health of women and infants worldwide–in fact, the conference organizers marketed Tuesday’s sessions as a stand-alone symposium called Technology as a Catalyst for Social Transformation.

Take a look at two examples of technologies that were discussed at the conference on Tuesday…

Microbicide Vaginal Rings (High Tech)

“The nonprofit International Partnership for Microbicides (IPM) today announced the initiation of the first trial among women in Africa testing a vaginal ring containing an antiretroviral drug (ARV) that could one day be used to prevent HIV transmission during sex. The clinical trial, known as IPM 015, tests the safety and acceptability of an innovative approach that adapts a successful technology from the reproductive health field to give women around the world a tool to protect themselves from HIV infection…”

Read the full press release here.

Clean Delivery Kits (Low Tech)

Clean Birth Kits–Potential to Deliver?, a publication supported by Save the Children/Saving Newborn Lives, Norwegian Ministry of Foreign Affairs, Immpact (University of Aberdeen), and the Maternal Health Task Force at EngenderHealth, was released at a session at Women Deliver yesterday. The session was chaired by Claudia Morrissey of Save the Children; moderated by Richard Horton, Editor of the Lancet; and presenters included Wendy Graham of University of Aberdeen, and Haris Ahmed of PAIMAN. The goal of the session was to summarise the evidence base for clean delivery kits, discuss practical implementation experiences from the field, and to have a lively debate on the “risks” associated with promoting birth kits. The report will be available online soon.

Subscribe to the MHTF Blog for updates on this project/report–as well as updates on other MHTF projects and commentary on a variety of maternal health issues.

Check out a recent blog post, A Good Idea or an Expensive Diversion: Workshop on the Evidence Base for Clean Birth Kits, by Ann Blanc, Director of the Maternal Health Task Force, on a workshop leading up to the new report on delivery kits.

Click here for the webcast of a session at Women Deliver 2010 that explores “What’s on the Horizon” for new technologies in contraception.

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Dr. Fred Sai is co-host of Women Deliver 2010, former reproductive health and HIV/AIDS advisor to the Ghanaian government, and has spent 40 years working to improve the health of women and children in Ghana and throughout Africa.  In his June 2nd blog post, A New Role For Africans in Maternal Health, on the ONE Blog, Dr. Sai comments on the new maternal mortality estimates published in the Lancet that show a dramatic reduction in global maternal deaths–and asks questions about why Africa (as a whole) has not seen these same reductions. He also expresses confidence that a shift in approach (described in his post) will lead to major improvements in the health of women and children throughout Africa.

The ONE Blog

“…It is an unfortunate truth that progress for the world at large does not necessarily mean progress for Africa. In 1980, almost a quarter of maternal deaths occurred in African countries. Today that figure has doubled to more than half. All but one of the 30 countries with the worst maternal mortality statistics are in Africa. And while countries like Ghana and Rwanda have seen a steady decline in maternal deaths over the past 15 years, others such as Malawi, Lesotho, Zimbabwe, Nigeria and Cote d’Ivoire actually have higher maternal mortality rates than they did in 1990.

Addressing maternal mortality in Africa is complex and challenging. Our countries face increasing rates of HIV, entrenched and debilitating poverty, food shortages, weak education and health care systems, problematic governance, corruption, and civil conflict. These are huge issues in their own right, but they also have significant impact on maternal, newborn and child health. The challenges, however, are not the whole story…”

Read the full post, A New Role For Africans in Maternal Health.

For additional reactions to the Lancet publication from other leaders in the maternal health field, click here.

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Supported by the MacArthur Foundation, the Association of Reproductive Health Professionals (ARHP) and Maternova are partnering on a project aiming to increase access to skilled birth attendants and emergency obstetric care for women in Chiapas, Mexico—through the use of mobile technologies for health (mHealth).

From an email announcement I received from ARHP on Tuesday (5/11):

“All of us who care deeply about reproductive health have been closely following the conflicting data from The Lancet and the WHO on maternal mortality rates.

Regardless of the direction of global rates, we know that women in remote areas of Mexico are facing incredible challenges in giving birth safely. Patients lack a comprehensive clearinghouse directing them to local clinics or differentiating levels of care available at facilities.

With generous support from the John D. & Catherine T. MacArthur Foundation, ARHP and Maternova have partnered on a pilot mobile health (mHealth) initiative in Chiapas, Mexico. We are pleased to be on the leading edge of the mHealth movement, which aims to leverage the growing worldwide popularity of mobile devices to provide critical health services.

This project will create an interactive maternal health mapping tool, allowing women to find skilled providers by geographic area quickly and easily. This SmartMap will be accessible from any web-enabled device and provide detailed information about the quality and types of services offered in each clinic listed. In an emergency obstetric situation, the ability to find skilled attendants and well-equipped facilities via mobile phone can make the difference between life and death.

We are just beginning to work with our partners, Development Seed and the Comite Promotor por una Maternidad sin Riesgos (Committee for the Promotion of Safe Motherhood), on this pilot project identifying and mapping facilities in Chiapas. We are looking forward to launching the populated map by the end of 2010 and to the possibility of future stages of the project, which would make the map accessible via text message.

Get involved in this cutting-edge, lifesaving initiative:

  • Reach out to Aleya Horn at ARHP and let us know if you or your colleagues work in Chiapas, Mexico
  • Provide local contacts for collaboration or local clinics for the map
  • Make a donation to support this critical partnership and help us expand the pilot project to other underserved areas in Mexico and around the world”

Be sure to check out the Maternova blog–that highlights all sorts of innovations in maternal and neonatal health.

Posts I found especially interesting:

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