Delivering Success: Scaling Up Solutions for Maternal Health

7/27/2019 Delivering Success: Scaling Up Solutions for Maternal Health

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Delivering Success:Scaling Up Solutions for

Maternal Health

ByMargaret E. Greene, Omar J. Robles,

Sandeep Bathala, andLauren Herzer Risi


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ByMargare E. Greee, Omar J. Robles,

Sadeep Bahala, adLare Herer Risi

Ds byLiae Hepler, lead desiger, Saio 10 Creaie

Addiioal iformaio ca be fod a:

.ilsoceer.org/do-mom

.esecribea.org/do-mom

Delierig Sccess:Sa Up Sus f

Maeral Healh


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The Woodrow Wilson Centers Global Health Initiative would like to thank its

colleagues, Katharine Diamond and Schuyler Null, and its interns, Payal Chandiramani,

Jacob Glass, Stuart Kent, Carolyn Lamere, Maria Prebble, and Swara Salih, or preparing

event summaries or the maternal health dialogue series, excerpts o which are included

in this report. Additional gratitude and thanks to the Environmental Change and

Security Program sta who helped coordinate and support the 20122013 series.

Your eorts and hard work helped to make the dialogue series a success. Thank you!

This report was generously unded by the Maternal Health Task Force (MHTF) and

United Nations Population Fund (UNFPA).

Views expressed in this report are not necessarily those o the Centers sta,

ellows, trustees, advisory groups, or any individuals or programs that provide

assistance to the Center.

Coes

1 FOREwORD

5 IntRODuCtIOn: ADvAncing DiAlogUe onMAternAl HeAltHSERIES

9 StREnGtHEn DAtA COLLECtIOn, MAnAGEMEnt, AnD uSE

13 PRIORItIzE EquIty In HEALtH SyStEMS RESPOnSE tOMAtERnAL HEALtH

15 EMPHASIzE quALIty AnD ACCOuntABILIty FORMAtERnAL HEALtH POLICy AnD PROGRAMMInG

21 EnSuRE A RELIABLE SuPPLy OF ESSEntIAL MEDICInESAnD HEALtH wORkERS

25 IntEGRAtE MAtERnAL HEALtH SERvICES ACROSSOtHER SECtORS

31 InvESt In EMPOwERInG wOMEn AnD GIRLS AnDEnGAGInG MEn AnD BOyS

39 COnCLuSIOn

41 AnnEx A: ADvAnCInG DIALOGuE On MAtERnAL HEALtH,SERIES EvEntS (20122013)

45 AnnEx B: ADvAnCInG DIALOGuE On MAtERnAL HEALtHExPERtS (20122013)

48 REFEREnCES

Cover Photo: A mother and her newborn

child, beneciaries of a UK-funded maternal

health and family planning program in

Orissa, one of Indias poorest states. Photo

courtesy of ickr user Pippa Ranger/

Department for International Development


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Foreord

We know a great deal about what it takes to prevent most pregnancy-related deaths

and complications. This collective knowledge, coupled with political commitment and

action, has led to a global reduction in maternal mortality o 47 percent since 1990

(WHO, 2012). Yet, despite this achievement, improvements have not been universal

many countries and areas within countries remain behind. The most underserved com-

munities and marginalized women are still too oten unable to access the resources,

inormation, and services that ensure sae pregnancy, delivery, and recovery.

The rate o decline in maternal mortality is just over hal o what is needed to

achieve Millennium Development Goal 5a 75 percent reduction in the maternal

mortality ratio between 1990 and 2015 (United Nations, 2013b). No single invest-

ment will eliminate the stark dierences in access to quality maternal care that

currently exist, but there is much to be learned rom improved dialogue between

practitioners and policymakers. The Wilson CentersAdvancing Dialogue on Mate rnal

Health series identies strategies to support policymakers and practitioners around

the world in improving these outcomes.

While common approaches to improving maternal health exist, implementation

must account or local contexts. As a representative rom the Rwandan Ministry o

Health stressed at a ser ies event, it is very dicult to do copy-paste; we should do and

think according to the reality in the eld (Learning From Succes s, 2012). A collabo-

ration among the Wilson Centers Global Health Initiative (GHI), Maternal Health

Task Force (MHTF), and United Nations Population Fund (UNFPA), the Advancing

Dialogue on Maternal Health series is rooted in this perspective, acknowledging that

policymakers and practitioners must adapt eective approaches to meet country-

specic challenges. From 2009 to 2011, the initiative highlighted prioriti es or policies,

programs, and research to overcome barriers in social, economic, and health systems

through a series o events in Washington, DC, and around the world.

Recognizing the need to delve deeper into key issues and to identiy opportunities to

maximize the scope and scale o national responses, GHI hosted 15 additional events rom

2012 to 2013 and participated on a panel at the Global Maternal Health Conerence and

in a Congressional Study Tour preceding the Women Deliver Conerence. This secondphase in theAdvancing Dialogue on Maternal Health series convened a diverse cross-section

o panelists rom a number o government agencies, research institutions, NGOs, and

private oundations. Over the course o the meetings, panelists drew on their collective

experiences in more than 10 countries to engage in participatory dialogue to identiy

pathways or making quality maternal care a reality or all women.

This report refects on these dialogues to complement the momentum o recent

years and continue raising the prole o the global maternal health challenge.

A mom and her newborn baby

at the Maternal & Child Health

Training Institute for medically

needy in Dhaka, Bangladesh.

Photo courtesy ickr user UN

Photo/Kibae Park.

Delivering Success: Scaling Up Solutions for Maternal Health 1


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wha do a dierse grop of saeholders

beliee ill maimie effors o redce

dispariies ad accelerae progress i

maeral healh?

StREnGtHEn DAtA COLLECtIOn, MAnAGEMEnt, AnD uSE:

Track maternal mortalities andmorbidities

Investigate maternal deaths, act on ndings

Mandate reporting and collecting data to a multidisciplinary group o s takeholders

Monitor use o reerral mechanisms

PRIORItIzE EquIty In HEALtH SyStEMS RESPOnSE tO

MAtERnAL HEALtH:

Identiy and respond to disparities by geography, urban vs. rural locale, and

socioeconomic status

Include maternal health services in social protection plans and saety net programs

that expand primary care services

Tailor inormation and services or the most vulnerable girls including marr ied

adolescents, minorities, and other marginalized g roups

EMPHASIzE ACCOuntABILIty FOR, AnD quALIty OF,

MAtERnAL HEALtH POLICy AnD PROGRAMMInG:

Seek community input in design o national quality standards and ensure

accountability

Promote principles o respect, non-violence, and non-discrimination

Provide continuing education opportunities or health workers, including midwives

EnSuRE A RELIABLE SuPPLy OF ESSEntIAL MEDICInES AnD

HEALtH wORkERS:

Procure lie-saving medicines (i.e., oxytocin, misoprostol, magnesium sulate, and

manual vacuum aspirators) rom certied manuacturers

Train and assign lead agency to orecast the supply, demand, and use o maternal

health medicines

Train physicians in how to identiy key maternal morbidities, such as obstetric

stula and uterine prolapse and, where possible, build the health systems support,

technical capacity, and resources required to treat these conditions

Expand responsibility, such as reporting and aligning incentives, to a broader cadre o

workers (e.g., midwives, community health/social workers, and community leaders)

Integrate mHealth technologies

IntEGRAtE MAtERnAL HEALtH SERvICES ACROSS SECtORS:

Strengthen links between maternal health inormation and services and: (1) sexual

and reproductive health, (2) newborn and child health, with an emphasis on

nutrition, (3) and HIV

InvESt In EMPOwERInG wOMEn AnD GIRLS AnD EnGAGInG

MEn AnD BOyS:

Women and girls

Ask women and adolescent girls about their maternal health needs and the barriers

to care that they ace; address these barriers

Invest in girls education, in child marriage prevention, and in already-married girls

Inorm women and adolescent girls about their ri ght to live ree rom violence and

the services available to them

Men and boys

Work with men and boys to dene constructive roles in maternal care, and demonstrate

the lie-saving benets that accrue to their partners, children, and themselves

Partner with religious leaders and other infuential male members o a community

Delivering Success: Scaling Up Solutions for Maternal Health2 Delivering Success: Scaling Up Solutions for Maternal Health 3


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IntRODuCtIOn:

Ada Dau Maa

HahSeries

Since 2009, the Wilson Centers Global Health Initiative (GHI) has collaborated with

the Maternal Health Task Force (MHTF) and the United Nations Population Fund

(UNFPA) to acilitate dialogue around what is needed to improve maternal health, with

an emphasis on reducing maternal health disparities. TheAdvancing Dialogue on Maternal

Health series identies strategies to support policymakers and practitioners in maximiz-

ing eorts to improve maternal health outcomes.

Despite having reduced maternal mortality by nearly hal since 1990, global gains in

maternal health outcomes have been uneven across and within countries. The inorma-tion, services, and resources that ensure sae pregnancy, delivery, and recovery are too

oten not reliably accessible or the most underserved communities and marginalized

women. Nearly 80 percent o all maternal deaths are concentrated in 21 countries, and

six countries account or more than hal o all maternal deaths: India, Nigeria, Pakistan,

Aghanistan, Ethiopia, and the Democratic Republic o Congo (World Bank, 2013).

Between 2009 and 2011, theAdvancing Dialogue on Materna l Health series addressed

critical and neglected maternal health topics. This earlier iteration o the series raised

awareness about the social, economic, and health systems actors that must receive

increased attention in policy and programming, including critical maternal health

topics that are oten overshadowed by the resources and attention earmarked or

reducing maternal mortality. These rst 25 events produced specic recommenda-

tions, highlighted research gaps, and reinvigorated the ocus on maternal health in

Washington, DC, and globally.

The second installment o theAdvancing Dialogue on Maternal Health series continued

to convene experts who work in maternal health, health systems strengthening, donor,

and policymaking communities. The events in this series delved deeper into key issues,

identiying opportunities to maximize national responses to pressing maternal health

challenges. The aim was to leverage participants collective knowledge and identiy

common strategies or priorities that might be adapted across settings to prevent preg-nancy-related deaths and complications. The events complemented recent international

meetings aimed at improving the access to and quality o care or women worldwide.

This report consolidates key ndings rom this latest installment o the Advancing

Dialogue on Maternal Health series and ties them to discussions taking place in global

orums. The ndings are organized around six major categories:

Strengthen data collection, management, and use

Prioritize equity in health systems response to maternal health

Emphasize quality and accountability or maternal health policy and programming

In Nigeria, after losing two children

through complications during childbirth

when delivering at home, Hauwau,

25, gave birth safely to a baby boy,

Muktar, after a skilled birth attendant

recognised a headache and fevertwo of

the key danger signsand got Hauwau

to a hospital where she gave birth with

the help of a midwife. Photo courtesy

ickr user Lindsay Mgbor/DFID



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Ensure a reliable supply o essential medicines and health workers

Integrate maternal health services across other sectors

Invest in empowering women and g irls and engaging men and boys

This report is intended or policymakers and development practitioners to use based

on their specic needs, interests, or priorities. As such, each major category is written as

a stand-alone brie that both contextualizes and explores key ndings in g reater detail.

Even though it is unreasonable to conclude that investment in any one area will

solve the maternal health challenges, the collective objective o all series participants and

this report is to call attention to the steps that key stakeholdersdonors, policymakers,

development practitioners, NGOs, and communitiesshould consider taking to accel-

erate the progress.

Global gais i maeral healh

are ee

When the international community engages in dialogue about maternal health, a

consensus emerges: a great deal is known about what it takes to prevent almost all

pregnancy-related deaths and complications. Some key steps include expanding access

to basic, lie-saving primary care with standardized policies and guidelines; making

essential medicines reliably available; increasing the number o trained practitioners,

especially recruiting and training midwives at the community level; integrating emer-

gency obstetrical care; and introducing community-based interventions that involve

communities in dening quality standards. Despite what we know, high quality

maternal inormation and services is not a reality or all women.

Every woman is at risk or experiencing sudden and unexpected complications dur-

ing pregnancy, childbirth, and ollowing delivery. Investing in initiatives that expand

womensand communitiesknowledge o, access to, and use o quality antenatal,

obstetric, and post-natal care can reduce the risk o maternal death and morbidities.

Millennium Development Goal 5improving maternal healthhas helped leverage

political support and nancial resources.

And yet, disparities across and within countries are alarming. The act that 99

percent o maternal deaths and morbidities occur in developing countries indicates

that these resource-constrained settings lack adequate and accessible resources and

services (WHO, 2012). Additionally, it is estimated that or every woman who dies

o pregnancy-related causes, an estimated 20 women experience acute or chronic

morbiditymaternal health outcomes such as obstetric stula and uterine prolapse

that, while not resulting in death, can have severe health, social, and livelihood con-

sequences or women, their children, and their amilies (Firoz et al., 2013). A narrow

ocus on the prevention o maternal deaths misses the opportunity to reduce the

number o maternal morbidities.

One principle o the post-2015 development ramework is that actions that rein-

orce other development goals should receive particular emphasis. Maternal mortality

and morbidity are not only health issues, they are core to a host o other aspects odevelopment. The consequences o maternal death and illness can ripple through ami-

lies or years. Studies in many low-income countries have ound that poor amilies who

have maternal healthrelated expenses may use savings or incur debt to make payments,

which reduces their ability to purchase ood or invest in education. Investments and

actions to improve maternal health also saeguard these other areas. For these reasons,

maternal health must remain central to the post-2015 development ramework.

we are liel o see commoaliies haare feared i he sccess of hese

programs. these are impora becase

[he] ca reall iform he or i

other countries. But Im also condent

ha e are goig o see cosiderable

differeces i he pahas o sccesses

based po he special siaiosihere i [all] cories.May e Sa, S Maa Hah Ads, U.S. Ay f

iaa Dpm (la Fm Suss, 2012)

Delivering Success: Scaling Up Solutions for Maternal Health 7Delivering Success: Scaling Up Solutions for Maternal Health6


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Inside the maternity ward, Dr. Veena Kundra is Shivpuri District Hospitals only

gynaecologist. Since 2004 the number of institutional births in health facilities in Madhya

Pradesh has doubled. Safe delivery and newborn care is reducing the number of women and

children who die as a result of child birthand infant deaths have reduced by 14% since

2004. Photo courtesy ickr user Nick Cunard/Department for International Development

Sreghe daacollecio,

maageme, ad se

Quality data are a prerequisite or targeted, cost-eective action to improve mater-

nal health outcomes. Throughout the ser ies, representatives rom government and the

public sector repeatedly stressed the importance o strengthening the collection, man-

agement, and use o data to inorm national policies and programming. To ensure that

resources, personnel, and medicines are equitably allocated across a population requires

that a national health inormation sys tem be able to track, analyze, and use local data in

a timely manner. Data tracking and analysis should be conducted not only on maternal

deaths, but also near-miss morbidity, rates o caesarean section, contraceptive preva-

lence rates, unmet amily planning need, and proportion o births handled by skilled

birth attendants. For relevant indicators, these data should be disaggregated by key

characteristics including age and location.

Track maternal mortalities and morbidities.Establishing a comprehen-

sive surveillance system is a critical step or improving maternal health. At the local

level, governments should (and in many cases have) set up this system to track and

monitor maternal deaths. Yet additional inormation i s needed to drive improvements

in maternal care.

Drawing rom national eorts to improve maternal care in Aghanistan, the

Dominican Republic, Cambodia, and Rwanda, policymakers emphasize the importance

o concurrently collecting data on maternal mortality and morbidities (Learning From

Success, 2012). Some sample indicators include those listed above: rates o caesarean

section, contraceptive prevalence rates, unmet need or amily planning, and proportion

o births handled by skilled birth attendants. Additional data can help illuminate gaps in

maternal care that exist, even where maternal deaths have been averted. These indicators

are among the most closely aligned with maternal mortality outcomes.

Mandate reporting across disciplines. Collecting quality data is important

or guiding a governments response to meet womens maternal health needs, but pol-icies must also establish mechanisms that drive the use o these data. In the context o

competing priorities within health inormation systems at both the local and national

levels, policies should support mandatory reporting across a standard set o indicators.

Systems should inc lude a broader cadre o workers, such as midwives and social work-

ers, into tracking and reporting systems. Even though no consensus emerged about

the appropriate timing o mandatory reportingsome countries require local clinics

to report data to national agencies on a weekly basispanelists highlighted its impor-

tance (Learning From Success, 2012).



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CIDA supports a wide range of projects that

are improving maternal and child health

care, especially in areas with high needs in

southern Afghanistan. Photo courtesy ickr

user Canada in Afghanistan.

Investigate maternal deaths and act on ndings. Data just to have data

is not the point, emphasized Dr. Bautista Rojas Gmez, the Minister o Health o

Dominican Republic, as he described in detail how the country acts on the data it col-

lects (Learning From Success, 2012). Dr. Bautista was among several participants who

described how their countries investigate maternal deathsa step that requires a timely

national response to local-level outcomes.

Despite the act that virtually all (97 percent) o women in the Dominican Republic

receive prenatal care and bir ths occur in hospitals attended by skilled health proession-

als, in 2009 the Dominican Republic reported a maternal mortality rate (MMR) o 215

per 100,000 live births. According to Dr. Bautista, a combination o real-time tracking,

mandatory reporting, ollow-up investigations, and government commitment to act on

the ndings helped to lower MMR to 140 per 100,000 live births in 2012.

Monitor use of referral mechanisms in complementary ways. Expertsnot only highlighted the role that community-to-clinic reerral mechanisms play in

improving maternal health outcomes, but also the need to monitor and track their

use. Young and adult women who live in r ural, hard-to-reach areas oten cannot rely

on timely transportation to and rom health clinics. The integration o reerral systems

has helped to connect many women to essential, lie-saving services during the pre-

natal phase, and most especially, during labor and recovery. As countries establish reerral

mechanisms, they should eed into data collection systems that track outcomes.

Iformaio is poer ad ha gesmoiored, ges doe.

D. Abhay Ba, D, Sy f edua, A ad rsah cmmuy Hah (Maa Hah ida, 2013)



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Women and their children

wait to receive maternal

child health services at a

health center in Tanzania.

Photo courtesy ickr user

Nathan Golon/ICAP.

Prioriie quyi healh ssems

respose o maeral healh

Women at higher risk o dying or experiencing pregnancy-related complications

oten also ace the pressures o poverty, poor inrastructure, and restrictive gender

norms that undermine their ability to care or their health (Smith et al., 2009). These

women oten lack access to maternal health inormation that resonates with the reali-

ties o their lives. By prioritizing equity in health systems response to maternal health,

governments can support policies and programs that address key barriers. Equity in

health highlights, or example, access to maternal care across social groups and geo-

graphic regions within a country. Accelerating progress in maternal health requires

that governments disaggregate maternal outcomes in ways that provide the data or

better, more targeted resource allocation.

Identify and respond to disparities by geography, urban vs. rural

locale, and socioeconomic status. During theAdvancing Dialogue on Maternal

Health series, panelists identied sub-populations with consistently poor maternal

outcomes and suggested that targeted actions to make maternal inormation and ser-

vices available to the most in-need, underserved communities is essential to meeting

development goals.

In most countries, women rom the poorest households in rural communities are

less likely to benet rom lie-saving maternal health care. Even as countries progress

with their economic development, disparities in maternal health outcomes between

urban and rural areas oten persist. Moreover, rural to urban migration has led to

rapid urban growth, and the growth o large, poorly-planned and poorly-served

peri-urban communities. Governments have a responsibility to channel resources in

accordance with needs on the basis o data disaggregated by age, geography, wealth

quintile, and ethnicity.

Include maternal health services in social protection plans and

safety net programs that expand primary care services. All governmentrepresentatives who participated in theAdvancing Dialogue on Maternal Health series linked

their gains in improving maternal outcomes with the expansion o primary care services.

Experts noted the critical role that social protection schemes have played in

expanding essential services to sub-populations who might not otherwise be able to

access or aord services. Social protection schemes generally aim to reduce out-o-

pocket expendituresa key barrier to services. For example, a multi-sectoral group

o stakeholders that outlined priorities to reduce the high levels o maternal mor-

tality and morbidities in India discussed the need or greater integration o mater-

nal health into social protection schemes (Maternal Health in India, 2013). In the

Dominican Republic, social protection schemes decreased out-o-pocket expenditures

LInk tO GLOBAL DIALOGuE

un Geeral Assembl

In December 2012, the UN General Assembly adopted a resolution urging govern-

ments to move towards providing allpeople with access to aordable, quality health-

care services, including primary care and maternal health services. Primary care saves

livesrom maternal care, immunizations, and newborn health to a consistent supply

o sexual and reproductive health services (United Nations, 2013c).



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or maternal care by almost 25 percent in 10 years. In Cambodia, health equity unds

or low-income amilies cover the cost o transportation, prenatal and delivery care,

transportation, and a ood allowance or expectant mothers and an accompanying per-

son (Learning rom Success, 2012).

Tailor information and services for the most vulnerable girls,

including married adolescents, minorities, and other marginalized

groups.Governments should publish and deliver reproductive health and maternal

health inormation and services in ways that both resonate with specic high-risk

population groups and reduce stigma and discrimination. Promoting adolescent-

riendly services in South Arica, or example, improved provider attitudes, quality o

services and outcomes among a population at a relatively higher risk o experiencing

pregnancy-related complications (Dickson et al., 2007).


Ieraioal Da of he Girl Child

Child marriage was the main theme or the United Nations rst International Day o

the Girl Child (October 11, 2012).

Worldwide, the United Nations hosted events that raised awareness o the preva-

lence o child marr iage, the harmul consequences or child brides, and the need to end

the harmul practice. In New York City, UNFPA Executive Director Dr. Babatunde

Osotimehin highlighted the maternal health risks that young married girls ace.

During the Advancing Dialogue on Maternal Health series, the magnitude o these

links received considerable attention. More than 16 million girls (1519) in devel-

oping countries give birth every year, and nine out o ten o them are married.

Compared to their non-married, older peers, these girls ace greater risks o maternaldeath and complications.

Emphasie quayad auaby

fmaeral healh polic ad

programmig

Even though the scale and reach o maternal health services have increased in recent years,

the quality o those services has not necessarily kept pace with international guidelines and

standards. Eorts to improve maternal health cannot ocus solely on expanding services.

Sae motherhood programs must also improve and standardize the quality o inorma-

tion and services that women receive. Quality o care in countries that have increased the

number o skilled health personnel to achieve MDG 5 continues to vary considerably

without improved inormation and services (United Nations, 2013b). As governments

work to ensure that women enter health acilities or deliver their inants in the presenceo a skilled birth attendant, a concurrent ocus must be the content and quality o care

that young and adult women receive beore, during, and ater labor. This ocus on quality

extends beyond preventing maternal deaths; it includes enorcing national standards that

make the health system (institutions and sta) respectul and accountable to all persons

during labor and delivery, as well as able to address maternal morbidities.

Seek community input in design of national quality standards and

ensure accountability. Establishing national standards and guidelines or qual-

ity o maternal care makes clear to all stakeholders (institutions and sta) the expec-

tations to which they are held accountable. A lesson learned rom Aghanistans push

to improve maternal health is the inclusion o communities in the development o

these national standards (Learning From Success, 2012). Over the last ten years,

the Ministry o Public Health reviewed international concepts and best practices

and developed an Aghanistan-specic orm o community-based health care.

Volunteer Community Health Workers (CHWs) are the backbone o this eort,

each supporting about 150 households and promoting healthy behaviors, reerring

the sick to the closest health clinic, and providing lie-saving health services includ-

ing amily planning, inormation on essential maternal and newborn care, including

the importance o birth spacing.

Community-level participation, coupled with good governance, can increase the

likelihood that national standards on paper will translate into real-lie improvements in

the care that women receive. Good governance structures can elevate accountability by

incorporating quality indicators into data collection systems. These steps help ensure

that institutions and health workers are held accountable to national guidelines and

standards o quality maternal care.

Provide continuing education opportunities for health workers,

including midwives.Educating and training health proessionals is an ongoing

endeavor that requires timely and consistent investment. As maternal health guidelines,



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methods, and medicines to ensure sae pregnancy and labor change, the health system

must ensure that the ull cadre o health workers is inormed about the latest policies

and best practices.

Continuing education or proessionals, including midwives, through national pro-

essional associations has helped ll this need in India and Bangladesh (Preventing

Injuries During Childbirth, 2012). In Guatemala and El Salvador, the use o in- service

training curricula or proessional and volunteer health care providers, community

health workers, and other health sector proessionals has helped to ensure quality mater-

nal health at acilities and within communities (USAID, 2009).

Promote principles of respect, non-violence, and non-discrimination.

Not all women who see a medical provider during pregnancy and labor have an opportu-

nity to interact with a provider who creates a supportive environment where women can

make inormed decisions about their health. Caring, empathetic, supportive, trustworthy,respectul, and empowering are among the adjectives that would describe the ideal skilled

birth attendant. Far too many women and adolescent g irls do not receive care that matches

these terms, despite the act that every woman has the right to privacy and condentiality.

In a series event on disrespect and abuse during childbirth, Charlotte Warren, an asso-

ciate or the Population Council, spoke about a project shes involved in to understand

maternal health care conditions. In Kenya, we are working in 13 private, public, and

aith-based acilities to gain a deeper story o womens experiences. To establish a clearer

picture o maternal health care conditions, they surveyed women rom admission all the

way through to post-natal care. The results were dramatic (Address Disrespect and Abuse

During Childbirth, 2013).

Warren reported that women were consistently subjected to non-condential,

non-consensual, and non-dignied care. For example, Kenyan women recalled being

scolded or screaming during childbirth, slapped by the medical sta, and orced

to walk around the ward naked. Further, only 38 percent o providers responded

that women have the right to be inormed o the procedures being perormed and

only 37 percent responded that inormation condentiality was important (Address

Disrespect and Abuse During Childbirth, 2013).

In 2010, a landscape report by Diana Bowser and Kathleen Hill, Exploring Evidence

for Disrespect and Abuse in Facility-Based Childbirth, summarized the available knowledge

and evidence on this topic. Disrespect and abuse o women seeking maternity care is

becoming an urgent problem. The imbalance o power between women and their pro-

viders is oten a barrier to respectul, quality care. In some countries, providers may eel

that women have no recourse. The lack o oversight and accountability also uels appre-

hension among women who might access services, and mistrust o providers among

women do access maternal care. In addition to greater government oversight, partnering

with proessional associations to link guidelines with consequences or their violation

could promote more respectul patent-provider interaction.

However, in an event at the Wilson Center Hill cautioned against an oversimplied

explanation o poor service, noting that abuse oten arises when providers and sta are


Global Maeral Healh Coferece

Jaar 2013, Arsha, taaia

The 2013 Global Maternal Health Conerence brought together researchers, scientists,

and policymakers to build on progress toward eradicating preventable maternal mor-

tality and morbidity. The conerence was organized around ve themes:

Implementing program approaches and tools to improve the quality o

maternal health care

Measuring the quality o maternal health care

Strengthening health systems or improving the quality o maternal health care

Providing access to and utilization o quality maternal health care

Supporting evidence-inormed policy and advocacy or quality maternal health care

Key points that emerged rom this meeting:

1. There is a huge gap in reliable information on maternal deaths and health outcomes.

The lack o data creates a gap in measurement, inormation, and accountability and

must be prioritized in the coming years.

2. How to position and track maternal health in the post-2015 sustainable development

framework.The Maniesto or Maternal Health proposed at the meeting, and

subsequently co-authored by MHTF Director Ana Langer, LancetEditor Richard

Horton, and the Executive Director o Management and Development or Health,

Guerino Chalamilla, highlights the connections between maternal health and

womens human rights: political, economic, and social. One key element o this is to

make womens rights central to reproductive, maternal, newborn and child health

an eort that will contribute to improvements in quality.

3. The importance of respectful maternity care. Relating to the connections between

maternal health and womens human rights, the conerence emphasized how

important it is to reach women who are socially excluded by virtue o their culture,

geography, education, disabilities, or other aspects o their experience and identity.

As part o this eort, the voices o women themselves must be incorporated into

writing the uture o maternal health (Langer et al., 2013).

Source: Langer et al., 2013



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themselves eeling overwhelmed by workorce shortages, scarcities o essential supplies,

or a lack o promotional opportunities. There are multiple points o suering and

complexity here, she said (Address Disrespect and Abuse During Childbirth, 2013).

How do you expect a midwie to be in a good mood i she works with no breaks

and has many clients to attend to in a dirty working environment? asked Warren. These

conditions lay the groundwork or disrespect and help explain why patient neglect is so

prevalent, particularly in countries that lack enorceable national laws and oversight over

health services, said Hill.

One Kenyan nurse told Hill, by the ninth, tenth, eleventh delivery o the night,

I would have been rated minus zero. I you care or the nurses, they will care or the

patients (Address Disrespect and Abuse During Childbi rth, 2013).

To address such issues, the White Ribbon Alliance works to improve the quality

o care provided to Nigerian women by training medical sta on the ethics and

etiquette o health care work (Woman-Centered Maternity Care, 2013). Healthworkers should see their jobs as a call to service, said Philippa Momah, board direc-

tor o Nigerias White Ribbon Alliance. We have started a three-year campaign to

advocate or policymakers and health workers to provide respectul maternity care

to all women. To date, the White Ribbon Alliance has trained 85 percent o rural

health workers in Nigeria in right-based maternity care.

Similarly, the Last Ten Kilometers Project has worked since 2007 to strengthen

interactions between Ethiopian women and their primary health care units. Project

workers convene community members and health workers to identiy barriers to

improving quality care and train providers to improve interpersonal skills, Project

Director Wuleta Betemari am said. Working in Ethiopias our most populous regions,

she said they have reached an estimated 3.5 million women o reproductive age

(Woman-Centered Maternity Care, 2013).

IMPROvE quALIty

A key nding from a cash-incentive

scheme i Idia

The Government o India initiated a cash-incentive scheme called, Janani Suraksha

Yojana (JSY). The scheme was designed to reduce maternal deaths by promoting institu-

tional deliveries, particularly among the rural poor. Several studies have concluded that

JSY achieved its stated goals: increased antenatal care and in-acility births. JSY, however,

has not necessarily improved the quality o care that women receive as measured by

maternal morbidities and qualitative studies. A lesson learned rom JSY i s that, in addi-

tion to creating incentives or people to access healthcare at acilities, making sure health

workers are trained to deliver quality care when women arrive is key.


wome Delier

The Women Deliver 2013 Conerence was one o the largest gatherings ever o

policymakers, advocates, and researchers ocused exclusively on womens health and

empowerment, bringing together over 4,500 participants rom 149 countries in

Kuala Lumpur. At the con erence, UN representatives noted that disempowerment o

women and girls is the single biggest driver o inequality and poor health outcomes.

As noted in Wilson Center sta blogs rom the conerence participants rearmed

the critical role that midwives play at the rontlines o service delivery. Their contri-

butions are oten undervalued and the opportunities to scale up their positive con-

tributions are underunded. Midwives are the rontline and backbone o maternal

health, said Pat Brodie o the Papua New Guinea Maternal and Child Health Initiative

and WHO Collaborating Center or Nursing, Midwiery, and Health Development

(Bathala, 2013). For midwives, and or other diverse sta who have a role in reducing

maternal mortalities and morbidities, there is a need or improved training and certica-

tion; or quality services and medicines; and or adequate investment to expand upon

what is already known to end what are largely preventable outcomes.

In addition to underscoring the benets or women and girls, the Women Deliver

Conerence linked poor maternal health to the harmul consequences or individual

women and girls themselves and also to economic and human development.

Both the conerence and the Advancing Dialogue on Maternal Health series have

called attention to the need or maternal health to eature prominently in the in the

next round o development rameworks: the post-2015 development agenda and the

ICPD Beyond 2014 process.



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In Rwanda, community health care

workers get visual instructions on

the mobile phone. Photo courtesy

ickr user Ericsson Images.

Esre a absuppyof esseial

medicies ad healh orers

A key determinant o whether a woman will survive childbirth is whereshe gives birth.

Nearly 80 percent o all maternal deaths are concentrated in 21 countries, and six

countries account or more than hal o all maternal deaths: India, Nigeria, Pakistan,

Aghanistan, Ethiopia, and the Democratic Republic o Congo (World Bank, 2013).

The availability o essential medicines and skilled birth attendants can determine a

womans ate. Despite the increased availability o essential medicines and health work-

ers, almost 300,000 women die each year. Most o these deaths occur in developing

countries. In most circumstances, such poor maternal health outcomes are prevent-

able. In addition to governments having recruited more community health workers

to expand ser vices to underserved areas, manuacturers have also developed aordable,

eective medicines to treat and prevent the leading causes o maternal deathsexcessive

bleeding ater childbirth and seizures during pregnancy. During theAdvancing Dialogue

on Maternal Health series, panelists identied some specic priorities to align the supply

o essential maternal heath medicines and workers with the national demand or care.

Procure life-saving medicines from certied manufacturers. Estimates

suggest that making oxytocin and misoprostol available to all women during delivery could

avert 41 million cases o postpartum hemorrhage and save 1.4 million lives. Magnesium sul-

ate is the most eective medicine or preventing and treating pre-eclampsia and eclampsia,

which are the second leading causes o maternal death (WHO, 2011b).

Government policy should encourage the purchase o essential maternal health

medicines rom certied manuacturers. At the national level, governments can lead

national certication eorts. Innovation and rapid increases in product development

and market opportunitiescould rapidly improve the aordability, availability and

use o selected medicines, medical devices and supplies. But [governments] dont have

enough pre-qualied manuacturers, said Jagdish Upadhyay, UNFPA Chie o the

Global Program to Enhance Reproductive Health Commodities Security (Strategic

Steps or Global Action, 2012).Since many national and local governmental and NGO procurement organizations

purchase medicines in their country, it is important to identiy and strengthen the capacity

o smaller, local manuacturers. At the international level, representatives rom NGOs and

academia encouraged government and international agencies to certiy a select number o

manuacturers able to produce quality maternal health medicines on a global scale.

Train and assign a lead agency to forecast the supply, demand, and

use of maternal health medicines. Four major commoditiesoxytocin, miso-

prostol, magnesium sulate, and manual vacuum aspiratorsaddress the three leading

causes o maternal mortality. We know this, yet demand or these drugs outpaces supply



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within and across countries. A lead agency must be trained and held responsible or ore-

casting (and budgeting or) the supply, demand, and use o maternal health medicines at

the national and local levels. This requires integrating data tracking and analysis o mater-

nal health medicines into existing national logistics management inormation systems.

Train physicians on how to identify key maternal morbidities,

such as obstetric stula and uterine prolapse, and, where possible,

build the health systems support, technical capacity, and resources

required to treat these conditions. In addition to collecting data on maternal

morbidities, governments must train medical personnel to identiy and treat pregnancy-

related complications. Especially important are eorts to build the knowledge and

skills o skilled birth attendants to reer cases o obstetric stula and uterine prolapse

or surgical treatment.

The UN End Fistula Campaign, the Fistula Foundation, and the USAID-undedFistula Care initiative are all working to reduce the shortage o medical sta who are

equipped to treat these and other conditions that signicantly impact womens health,

reduce womens quality o lie, and leave women vulnerable to stigma and discrimina-

tion. Most physicians in resource-poor countries have been exposed to stula or uterine

prolapse, though they do not always have the knowledge and tools necessary to treat it.

Expand responsibility to a broader cadre of workers. A common theme

throughout the Advancing Dialogue on Maternal Health series was the importance o

leveraging the use o midwives, community health workers, and emale community

leaders to extend the coverage and reach o maternal health services. In addition to

ormal midwiery training curricula, governments can expand community-based mid-

wiery training programs. These community-based reorms should be careul to not

overwhelm already weak systems, coupling their reerral with equipped sta that can

deliver high-quality maternal care.

Integrate mHealth technologies. The use o mobile technologies, such as

cell phones, has helped with real-time health inormation exchange. In general, the

benets and consequences (intended and unintended) o using mHealth technologies

remain uncertain. However, mHealth applications include their use to strengthen track-

ing o patients through reerral systems, to improve the dissemination o up-to-date

dosage inormation and health records, and to expand community access to health

inormation hotlines.


Eer woma, Eer Child

The Every Woman, Every Child Campaign is a global movement to improve the

health and well-being o women and children. Every Woman Every Child aims to

save the lives o 16 million women and children by 2015. The movement recognizes

that a strong ocus on reproductive, maternal, child, and newborn health (RMCNH) is

integral to improving global health. Working with a broad cadre o national and inter-

national stakeholders, Every Women Every Childsupports integrated service delivery

or mothers and childrenrom pre-pregnancy to delivery, the immediate postnatal

period, and childhood (United Nations Foundation, 2012).

This campaign, and theAdvancing Dialogue on Maternal Health,series call attention to

the importance o providing quality maternal health s ervices along a continuum o care.Two publications that describe eective interventions and priority medicines

along the continuum o care include that can reduce maternal mortalities and

morbidities are: (1) The Essential Interventions, Commodities and Guidelines or

Reproductive, Maternal, Newborn and Child HealthA Global Review o the

Key Interventions Related to Reproductive, Maternal, Newborn and Child Health

(Partnership or Maternal, Newborn & Child Health, 2011), and (2) Priority

Medicines or Mothers and Childrens Health, 2011 (WHO, 2011a), which also

identiy medicines that are in need o enhanced attention and utilization in order to

avoid preventable deaths o women and children.



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Esseial medicies for maeral healh

A short list o essential medicines would make a huge dierence to improving maternal

health, yet these aordable, eective medicines and simple health supplies are not readily

available to the women who need them the most. The United Nations Commission on

Lie-Saving Commodities or Women and Children, part o the Every Woman Every

Child movement, was created to highlight these important supplies and to remove

barriers to accessing them. The Commission developed 10 recommendations clustered

under three key themes:

Improved markets or lie-saving commodities

Improved national delivery o lie-saving commodities

Improved integration o private sector and consumer needs

In support o the Commission, PATH brought together over 100 maternal health

expertsincluding health proessionals, program implementers, advocates, donor country

representatives, and ministry o health ocialsto identiy and prioritize common chal-

lenges and potential solutions to specically improve the quality o and access to mater-

nal health medicines, which have oten been overlooked (Kade & Moore, 2012, p. 5).

Coming together rom around the world, they participated in ve roundtable events in

Bangladesh, Tanzania, and the United States, including one event at the Wilson Center.

Their ndings ocused particularly on three medicines:

Oxytocin, or the prevention and treatment o excessive bleeding ater childbirth;

Misoprostol, or the prevention and treatment o excessive bleeding ater childbirth

when oxytocin is unavailable; and

Magnesium sulate, or the prevention and treatment o pre-eclampsia and eclampsia.

Removing the barriers to access these three medicines must happen through actions

in our main areas:

Data collection

Eective use

Saety and ecacy

Systems strengthening

Sources: United Nations, 2012; Kade & Moore, 2012; Maternal Health Task Force, 2012.

iamaeral healh serices

across oher secors

As a concept, integration is not new nor does the term mean the same thing to all

stakeholders. According to the World Health Organization, integrated service delivery

reers to the organization and management o health services so that people get the

care they need, when they need it, in ways that are user-riendly, achieve the desired

results and provide value or money (WHO, 2008). In general, there is consensus that

many health-related challenges, including those related to maternal health, cannot be

tackled in isolation rom each other. Initiatives that support better health, rom sexual and

reproductive health (SRH) and HIV prevention, to inant and child nutrition, are logically

linked and aected by similar constraints, such as nancing and skilled physicians.

While integration is not a panacea or limited capacity and resources, it might help

to save lives, money, and time. Dialogue around integration, however, arouses skepticism

that important, issue-specic expertise and nuance is compromised when institutions

integrate services under the rationale that improved health systems will help countries

achieve their development goals. More research on the eectiveness o integration, par-

ticularly what actors infuence maternal health outcomes, is needed.

During theAdvancing Dialogue on Maternal Health series, participants discussed links

between maternal health and:

SRH services.Making it standard practice to oer women a broad set o amily plan-

ning and maternal and child health services during the same appointment, at the same

service delivery site, and rom the same provider improves maternal health outcomes rom

a prevention andtreatment perspective. This was strongly emphasized at the India con-

sultation in April 2013. A womans ability to control her pregnancy intentionsto access

contraception, to prevent unintended pregnancies, and to have access to sae and legal

abortion servicesis associated with better outcomes or mothers and newborns.

Governments and organizations working to reduce the number o high-risk pregnan-

cies, especially among married and unmarried adolescent girls, are ocused on ending child

marriage, and on delaying pregnancy intervals. Eorts to delay very early marriage andto mitigate its eects on the lives o young girls have become much more common in

recent years (Vision, Innovation, and Action to Address Child Marriage, 2013). Since

lengthening the interval between pregnancies could greatly reduce the newborn deaths,

promoting birth-spacing has received increased attention. A consensus has developed

around the need or all women to wait 36 months ater a live birth beore becoming

pregnant again (Rutstein, 2005); i this goal were achieved, governments could prevent an

estimated 1.8 million deaths among children under 5 years o age (Rawe, 2012).

Newborn and child health, with emphasis on nutrition. Capitalizing

on opportunities to empower women with inormation and options to attain sexual



17/31

and reproductive health has helped health systems prevent maternal mortalities and

morbidities. Also, whether health systems ail to provide primary and maternal care to

expectant mothers aects inant survival. The level o quality care that mothers receive is

oten linked to the availability and quality o newborn and child health. Taken together,

poor maternal health and limited services or newborns, especially nutrition, can have

intergenerational implications, aecting childrens long-term development.

HIV. A 2012 Cochrane Review o more than 10,000 research articles concluded that

integrated maternal health and HIV/AIDS services are easible to implement and show

promise towards improving a variety o health and behavioral outcomes (Lindegrin et

al., 2012). Global investments in HIV prevention, particularly as they relate to promot-

ing knowledge about HIV transmission (e.g., prevention as related to womens health

and mother-to-child transmission), and sae-sex practices provide opportunities to

address maternal health issues.


Famil Plaig 2020 Smmi

The Family Planning 2020 Summit (FP 2020) in July 2012 mobilized global interest

and increased unding to provide contraception to the millions who currently want to

use it but do not have access to it.

At both the FP 2020 Summit and throughout the Advancing Dialogue on Materna l

Health series, stakeholders ramed amily planning as a valuable, cost-eective tool or

improving maternal health at scale through the prevention o unplanned pregnan-

cy. During the maternal health series, several panelists underscored the barriers that

women, especially adolescent girls, have to overcome in order to plan and space their

pregnancies. Barriers include provider bias, social norms, and limited access to tailored

health inormation and services.

whe e do hae commiparicipaio ad commi

ioleme, e fail i ma of or

healh idicaors.D. Fd nab, D f Maa ad chd Hah, Msy f

Hah, rwada (la Fm Suss, 2012)

USAID supports maternal and child health through training and technical assistance to

government health extension workers. Pictured here is a mother and baby outside a health

post in Oromia Region. Photo courtesy ickr user Nena Terrell/USAID Ethiopia.

Delivering Success: Scaling Up Solutions for Maternal Health26


18/31

Link to GLobaL DiaLoGue

Mrl hlh id: plcy dlg

l mrgg prrs

The collective vision emerging rom the dialogue is to expand existing

rameworks, create new paradigms. We want to see a uture that views maternal

rom the perspective o overall health and well-being. Womens empowerment,

dignity, rights, justice, are values integral to this approach.

Poonam Muttreja, Executive Director, Population Foundation of India

I you have good governance, we can have quite a jump in the healthoutcomes in India.

Dr. H. Sudarshan, Honorary Secretary of Karuna Trust

All o these ideas lead us back to an over-arching notion o how we might be

accountable to quality.

Dr Gita Sen, Professor of Public Policy at the Indian Institute of Management

Bangalore (IIM-B), and Adjunct Professor of Global Health and Population,

Harvard School of Public Health

As part o theAdvancing Dialogue on Maternal Health series, the Wilson Center, MHTF, and

UNFPA collaborated with Population Foundation o India to convene a multi- sectoral

group o stakeholders to outline emerging prioritiesthe steps the government should

make to reduce its high levels o maternal mortalityin India, where 20 percent o the

worlds maternal deaths occur each year. This private workshop, held on April 3, 2013,

brought together leading development practitioners, senior government ofcials, and a

wide range o donors and media representatives. Following the private workshop, par-

ticipants publicly shared their recommendations during a three-city videoconerence

between Boston, New Delhi, and Washington, DC on April 4, 2013.

Emerging priorities included:

Promote a lie-cycle approach to maternal health, which builds upon calls or

greater integration o maternal health across other sectors such as amily planning

Support sexual health education, with a ocus on reaching adolescents Account or social determinants o womens and g irls health in India, including the

gender norms and harmul practices that shape the social realities girls ace

Strengthen governance structures, inclusive o combating corruption and improvingdata collection or improved decision-making, quality o care, and accountability

Emphasize the importance oquality of careas related to preventing both maternaldeaths and maternal morbidities, e.g., disproportionately high rates o complications

due to anemia during pregnancy, among others

Champion maternal health as an integral piece o national and internationaldevelopment agendas, including its role in the post-2015 ramework

Kabita gives advice on contraception to mother-of-two, Tuni, so she can plan the size of her family.

Local community health workersor ashaslike Kabita are trained to give care and support to

mums-to-be in every village across the state of Odisha, India. They are also on hand to give advice on

family planning. Photo courtesy ickr user Pippa Ranger/Department for International Development



19/31

Ies i mpwome ad girls

ad ame ad bos

Women and girls who are empowered with quality education, lie skills, and social

networks are more likely to use contraception, less likely to marry young, and are at

lower risk o experiencing pregnancy-related complications (Temin & Levine, 2009;

Lloyd, 2009). While complex, these associations are strong. Investing in young women,

who ace a higher risk o death and pregnancy-related complications, is critical. The

barriers that girls ace are especially prominent during adolescence. As girls approach

adulthood they can nd that their lives are constrained by a lack o early learning oun-

dations, harmul gender norms, violence, inadequate nutrition and anemia, poor sexual

and reproductive health (SRH), and discriminatory treatment at school. For their part,

maternal health policies and programming can encourage womens participation and

work in coordination with broader initiatives that promote gender equality, womens

agency, and their decision-making.

Policies and programs should concurrently engage men and boysamily members,

and community and religious leaders. Many initiatives regarding womens empower-

ment, maternal health, and education tend to ocus on women and girls in isolation o

the male stakeholders who infuence their lives, directly or indirectly. However, men and

boys can adopt gender-equitable attitudes and behaviors that are associated with better

maternal health outcomes, less violence against women, and higher school enrollment

and achievement or girls.

Ask women about their maternal health needs and the barriers to

care that they face and address them. Data are good or identiying key

associations and gaps in maternal health coverage. As important is an understanding o

how adolescent girls and women perceive their roles in their amilies, in their schools,

and in society. Collecting this inormation requires asking questions about their rou-

tines, attitudes, and practices as they relate to their health and well-being. This inorma-

tion helps to strengthen maternal health programs in ways that consider womens daily

roles, responsibilities, and opportunities to access services.From Aghanistan and the Dominican Republic to Cambodia and Nigeria, gov-

ernment representatives stressed the importance o directly asking women about their

maternal health needs. Numerous countriesIndia, or examplehave reported on

the benets o community monitoring and the solicitation o womens views via ocus

group discussions and local advocacy NGOs to inorm national maternal health prior i-

ties and service-delivery standards (Maternal Health in India, 2013).

Invest in girls education, in child marriage prevention, and in

already-married girls. Educating girls and delaying marriage are avenues through

which governments can leverage their investments into womens health and well-being

Bishop Earl Bledsoe gently

touches a tiny preemie baby

girl while her mother watches

in the maternity ward of

Mpassa Hospital in Kinshasa.


Lynne Dobson/United

Methodist New Service.



20/31

across their lietimes. Girls level o education is one o the most important actors associ-

ated with good health, including their SRH and the maternal care they receive. Greater

numbers o girls in schools is also associated with a higher median age at rst marriage.

Policies and programs cannot overlook millions o girls who are already married,

divorced or widowed. Programs such as Tesfa in Ethiopia are demonstrating that tailored

interventions aimed at these girlsout-o-school education initiatives, lie skills train-

ing, peer and adult counselingcan signicantly improve their well-being, sel-esteem,

and livelihoods (Vision, Innovation, and Action to Address Child Marriage, 2013).

Inform women and adolescent girls about the services available to

them and their right to live free from violence. Pregnant women who

experience intimate partner violence are less likely to access the inormation and ser-

vices that ensure sae pregnancy and delivery. Compared to women who do not report

suering rom violence, these expectant mothers have higher rates o miscarriages andlow-birth weights, and are less likely to receive comprehensive antenatal care.

Physical, sexual, or psychological harm by a spouse or partner is a major actor in

maternal and reproductive health, said Jay Silverman at a series event (The Impact o

Violence Against Women on Maternal Health, 2013).

Silverman, a proessor o medicine at the University o Caliorni a, San Diego, cited

a 15-country study o both developed and developing countries that ound 25 to 75

percent o women have suered rom intimate partner violence at least once (Garcia-

Moreno et al., 2006). The eects are very signicant, both in terms o the health o

mothers and their children.

According to Silverman, abusive partners are 83 percent more likely to coerce a

pregnancy, through orced intercourse or birth-control sabotage. Women suering rom

abuse are twice as likely to have a miscarriage and their children are 3.9 times more

likely to have a low birth weight, while inant diarrheal diseases are 38 to 65 percent

more common in children born to mothers suering rom abuse (The Impact o

Violence Against Women on Maternal Health, 2013).

Eorts to reduce maternal mortality and morbidity should not sidestep broader

eorts to empower women with knowledge about the legal and health services that

can support them and their rights to live ree rom violence. For example, health pro-

essionals, including midwives, should be trained in how to identiy and condentially

reer victims o gender-based violence to appropriate services.

Work with men and boys to redene their roles in maternal care and

demonstrate the life-saving benets that accrue to their partners,

children, and themselves. Men and boys have a key role to play in changing the

negative impact o gender norms on maternal and child health; our out o ve men

worldwide will be athers at some point in their lives (United Nations, 2011). National

eorts to reduce maternal mortality have supported newlywed counseling that prepares

couples or pregnancy-related health needs. Some countries have launched campaigns

that promote engaged atherhood and equality in caregiving.


Some Righs wo, b More

Challeges Ahead

The UN Commission on the Status o Women (UN CSW) met or its 57th session

in March 2013. The title o the eventSome Rights Won, but More Challenges

Aheadhighlighted the act that while there have been advancements in how govern-

ments and communities work to eliminate violence against women, there is still more

to be done. The same holds true or global eorts to improve maternal health.

During theAdvancing Dia logue on Maternal Health series, eatured topics included

the disrespect and abuse some women ace when they access health acilities, and

the impact o intimate partner violence on maternal health. A consensus emergedrom these discussions: (1) improving maternal health outcomes will require greater

accountability to ensure health workers provide respectul treatment to allpersons,

independent o age, ethnicity, disability, or any other social characteristic that may

marginalize a woman, and (2) improving maternal health requires substantial com-

mitments to reduce violence against women, through programming that empowers

women and girls with the inormation and education to assert their rights, as well as

through initiatives that give providers the tools and training to condentially identiy

and reer pregnant women and adolescent girls to the appropriate services.

Among its list o agreed conclusions, the 57th Session o the UN CSW includes

strong language against violence and or greater integration between eorts to end vio-

lence and improve maternal health: Expand the availability o health-care ser vices, and

in particular, strengthen maternal and reproductive health centers, as key entry points

that provide support, reerrals to services and protection to amilies, women and girls

at risk o violence, especially sexual violence, and which provide support to adolescents

in order to avoid early and unintended pregnancies and sexually-transmitted inections,

through education, inormation, and access to sexual and reproductive health-care ser-

vices. The Advancing Dialogue on Maternal Health series armed and expanded upon

why these links matter.



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Partner with religious leaders who are often inuential male mem-

bers of a community. When religious leaders speak, communities tend to listen;

their buy-in makes mens constructive involvement in girls and womens lives credible.

Working with religious leaders, oten men, to support womens health and to cham-

pion attitudes and behaviors in support o womens and girls health, rights, and well-

being is integral to longstanding social change. Religious leaders have tremendous

power o speech, Nigerian Urban Reproductive Health Initiatives Kabir Abdullahi

said. Because they speak the same language, they understand them, they know them,

[and] they have trust in them (Nigeria Beyond the Headlines, 2012).

Relying on tradition, customs, and aith does not justiy the perpetuation o harm-

ul practices, human rights violations, and the lower social status o women and girls

relative to men and boys. Ayscha Hamdani, ormer special adviser and chie o sta to

the European Union special representative to Aghanistan, said at the Wilson Center

that or the sustainability o womens health programsand international developmentprograms in generalits important to work within Aghanistans cultural parameters.

We ought to use the very religion o Islam, that is currently being used against women,

to actually reinorce the position o women, she said, Lets talk about the rights that

woman have according to Islam and use this in a positive manner, to give women a

greater access to education, to health, and to the basic provisions that they require

(Aghanistan Beyond the Headlines, 2013).


Bali Global yoh Form

In December 2012, the UN convened youth in Bali, where they outlined priority issues,

needs, and recommendations in the Bali Global Youth Forum Declaration. Collecting

more data and supporting targeted health services or young people eature prominently

in the declaration, which will inorm the implementation o the Program o Action o

the International Conerence on Population and Development (ICPD) beyond 2014

(United Nations, 2013a).

During theAdvancing D ialogue o n Mater nal Healt h series, policymakers, advocates,

and attendees routinely reerenced the need to ensure that the catch-all phrase

community participation was inclusive o youth, women, and other marginalized

groups. It is understood that substantive participation by dierent social groups is

linked to greater accountability.

A skilled birth attendant

travels three hours from

the Mawa Village in Nepal

to deliver babies and check

on her pregnant patients.


Gates Foundation.



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LInkS tO GLOBAL DIALOGuE

visio, Ioaio, ad Acio o

Address Child Marriage

On June 17, 2013, GHI collaborated with USAID and the Interagency Gender Working

Group Task Force on Gender-Based Violence, and its co-chairs Population Reerence

Bureau and CARE, to lay out key actions that can help end child marriagea practice

that UNFPA estimates will aect more than 140 million girls between 2011 and 2020

(UNFPA, 2012). These numbers translate into an estimated 14.2 million young girls

marrying beore their 18th birthday every year, or 39,000 daily. The majority o these

girls do not receive access to education or reproductive health services. Moreover, the

sexual and reproductive health consequences o child mar riage or g irls are many: girlsare more likely to get pregnant early, more likely to die during pregnancy, and more

vulnerable to HIV.

A combination of primary and secondary education, life-skills train-

ing, and positive reinforcement though social and peer networks can

build girls resilience to becoming brides before they can freely con-

sent to marry. In Egypt, a program called Ishraq, which means sunrise in Arabic, is

ocused on reducing girls vulnerability to child marr iage by encouraging communities

to prioritize girls education. Reaching hundreds o girls through its 18-month cur-

riculum, Ishraq currently teaches l iteracy, lie skills, and recreational activities (Program

implementers: Save the Children and Population Council).

Community engagement and investment in girls themselves is key.

A oundation in Ethiopia called Tesfa (meaning hope in Amharic) has reached more

than 5,000 married, divorced, and widowed girls between the ages o 10 and 19. In

Ethiopiawhere 41 percent o girls marry by age 18, and 14 percent o girls marry by

age 15policies and programs oten overlook already-married girls. This is common

in many countries, and Tesfa has been able to demonstrate these already- and once-

married girls, when given access to lie skills and education, are measurably moreable to resolve conficts, discuss money, use contraception, and work or pay (Program

implementers: CARE and ICRW).

Panelists afrmed that laws are insufcient for preventing child

marriage. Countries like Bangladesh, India, and Indonesia, or example, passed

minimum age at marriage laws decades ago but still have high rates o child mar-

riage (66.2, 44.5, and 22.0 percent, respectively). Program evidence nds that work-

ing with communities and girls themselves to shit cultural norms and to champion

girls education is key to ending child marriage. Leveraging additional resources to

monitor policy implementation and build upon what works will require greater

political will and attention.

Families economic concerns around child marriage also merit

attention. Since amilies oten marry their girls young to oset economic bur-

dens, one program has worked to demonstrate how empowering gir ls need not be an

economic drain on amilies. In Ethiopia, the program Berhane Hewan (Amharic or

light o Eve) oers amilies a goat to o-set the short-term benets o marrying

girls, ollowed by two chickens, 12 months later, and another two chickens, anoth-

er 12 months lateralways on the condition that their daughters remain in school

(Population Council). This approach calls attention to the importance o addressing

parents concerns, while making sure to keep young girls at the center o program

design, implementation, and evaluation.



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Coclsio

TheAdvancing Dialogue on Maternal Health series seeks to stimulate discussion to help

leverage collective knowledge and reduce the disparities we see in maternal health.

Greater investment in documented solutions is needed to ensure that millions o

women and girls do not suer largely preventable complications and deaths related to

pregnancy and childbirth.

Every woman is at risk or experiencing unexpected complications during preg-

nancy, childbirth, and ollowing delivery. The risks o pregnancy, labor, and delivery exist

everywhere; despite increased investment in maternal health, persistent disparities across

and within countries are o g reat concern.

Like the report on the rst series, this report o the second wave o discussions that

were part oAdvancing Dialogue on Materna l Health highlights key actions that need to

be taken to overcome social, economic, and cultural barriers and gender inequality,

strengthen health systems, and improve research and data collection. One key dierence

between the rst and second reports, however, is the emphasis in the rst on the need

to make the case or investing in maternal health. That case has largely been made in the

development eld; certainly, the ocus among advocates in the maternal health eld has

moved on, since the evidence or investing in maternal health is so clear.

The second series has thereore gone into more detail on howto bring about change

and the practical steps required to improve maternal health and reduce maternal mor-

bidity and mortality. This report strongly emphasizes the specic ways in which services

can become more responsive, including expanding access to basic, lie-saving primary

care with standardized policies and guidelines; making essential medicines reliably avail-

able; expanding human resources, especially recruiting and training midwives at the

community level; integrating emergency obstetrical care; and introducing communi-

ty-based interventions and improving service quality, with community engagement in

dening standards. In recognition o the persistent social constraints to maternal health,

the series again highlights the need to invest in women and girls, while at the same time

engaging men and boys to be supportive partners and agents o change or women and

girls in their communities.

What direction should the next iteration o the Dialoguetake? One important empha-sis could be on the establishment o the systems o accountability that make these concrete

steps possible. How are budgets allocated and who is accountable or ensuring they are

spent in the right way? How can maternal health and the programs to improve it best be

monitored, and by whom? How is maternal health addressed in the global trend toward

universal health coverage? Where does maternal health t into the post-2015 development

ramework so that it is consistently and systematically prioritized in national investments?

Preventable maternal morbidity and deaths are violations o the human rights o

girls and women and a measure o their low status around the world. Investing in path-

ways the world knows to be eectiveand ensuring the level and consistency o that

investmentis the measure o our humanity.

A midwife treating a patient in Parwan

Province, Afghanistan. Photo courtesy

ickr user Graham Crouch/World Bank



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AnnEx A

Adacig Dialoge o Maeral Healh,

Pael Series (20122013)

APRIL 23, 2012: Learning From Success: Ministers o Health Discuss Accelerating

Progress in Maternal Survival with Mary Ellen Stanton, Senior Maternal Health

Adviser, U.S. Agency or International Development; Honorable Dr. Suraya Dalil,

Minister o Public Health, Aghanistan;Honorable Dr. Mam Bunheng, Minister

o Health, Cambodia; Honorable Dr. Bautista Rojas Gmez, Minister o Health,

Dominican Republic; Dr. Fidele Ngabo, Director o Maternal and Child Health,

Ministry o Health, Rwanda

APRIL 25, 2012: Nigeria Beyond the Headlines: Population, Health, Natural

Resources, and Governance with Scott Radlo, Director o Population and

Reproductive Health, USAID; Bolatito Ogunbiyi, Atlas Fellow, Population Action

International;Volker Treichel, Lead Economist, Operations and Strategy, World Bank;

Anthony Carroll, Vice President, Manchester Trade, Ltd.;Jacob Adetunji, Lead

Technical Ocer, Oce o Population and Reproductive Health, U.S. Agency or

International Development; Peter Lewis, Fellow Associate Proessor and Director

o the Arican Studies Program, Johns Hopkins University, School o Advanced

International Studies;Judy Asuni, Director, Academic Associates PeaceWorks; Akwe

Amosu, Arica Policy Analyst, Open Society Institute; Pauline Baker, President

Emeritus, Fund or Peace

MAy 21, 2012: Family Planning and Results-Based Financing Initiatives:

Opportunities and Challenges with Ben Bellows, Associate, Reproductive Health,

Population Council Kenya; Beverly Johnston, Senior Policy Advisor, USAID;

Lindsay Morgan, Senior Health Analyst, Broad Branch Associates

JunE 07, 2012: (PRIVATE ALL-DAY MEETING) GHI co-hosted a private

working meeting with 20 participants rom the policy, donor, research, and NGOcommunities to strategize on how the UN Commission on Lie-Saving Commodities

can move the maternal health agenda orward. The action steps identied at this

meeting and other similar dialogues in the U.S. and abroad were presented to the UN

Commission in Sept 2012 and during the series public event on October 23rd (reer-

enced below).

AuGuSt 28, 2012: Adolescent Reproductive Health: The Challenge and Benets

o Delaying Sex with Laurette Cucuzza; Senior Technical Advisor or Reproductive

Health, CEDPA; Cate Lane, Youth Health Advisor, USAID; Gene Roehlkepartain,

Vice President o Research and Development, Search Institute

UK aid is funding breastfeeding counsellors like Varshna (right) in nutrition

rehabilitation clinics across Madhya Pradesh, as part of efforts to educate pregnant

women and new mothers about the importance of breastfeeding from birth to

combat malnutrition. Photo courtesy ickr user Russell Watkins/Department for

International Development



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SEPtEMBER 17, 2012: Maintaining the Momentum: Highlights rom the

2012 London Summit on Family Planning withJulia Bunting; Department

or International Development; Reproductive Health Supplies Coalition; Karen

Hardee, Senior Fellow, Futures Group; Win Brown, Senior Program Ocer,

Family Health Program, Bill and Melinda Gates Foundation;Jill Shefeld,

President and Founder, Women Del iver;Scott Radlo, Director o Population and

Reproductive Health, USAID

SEPtEMBER 27, 2012: Preventing Injuries During Childbirth: Programmatic

and Policy Recommendations or Addressing Obstetric Fistula and Uter ine Prolapse

with Kate Grant, Executive Director, Fistula Foundation; Gillian Slinger, Technical

Specialist Obstetric Fistula and Coordinator o Campaign to End Fistula, UNFPA; Dr.

Luc de Bernis, Senior Maternal Health Advisor, Technical Division, UNFPA; Dr.

Lauri Romanzi, Clinical Associate Proessor, New York University Langone MedicalCenter;Celia Pett, Medical Associate, Fistula Care, EngenderHealth

OCtOBER 23, 2012: Strategic Steps or Global Action on Maternal Health

Medicines with Deborah Armbruster, Senior Maternal and Newborn Health

Advisor, USAID; Dr. Kennedy Chibwe, Deputy Director o Promoting the Quality

o Medicines Program, United States Pharmacopeial Convention (USP); Ann Starrs,

Executive Vice President, Family Care International; Chair, Global Partnership or

Maternal and Newborn Health; Kristy Kade, Family Health Advocacy Ocer,

PATH;Jagdish Upadhyay, Chie o the Global Program to Enhance Reproductive

Health Commodities Security, UNFPA

JAnuARy 17, 2013: [Arusha, Tanzania] The role o policy in eorts to improve

maternal health c are with Sandeep Bathala, Senior Program Associate or GHI,

WWICS;Crystal Lander, Director, Policy and Advocacy , Management Sciences or

Health;Steve Solter, Global Technical Lead or Fragile States, Management Sciences

or Health; Ruthpearl Nganga, Communications Manager at Arican Population

and Health Research Center

APRIL 03, 2013: [New Delhi, India] Maternal Health in India with Population

Foundation o India. The in-country meeting brought together more than 70 experts

rom the maternal health, health systems, donor, and policymaking communities

to identiy best practices, gaps, and areas requiring ocused interventions in mater-

nal health. Ater plenary discussions on Maternal Health in India, Neglected

Areas in Maternal Health, and Maternal Health: Making Strategies More

Eective, the participants broke out into roundtable discussions or more ocused

conversation on the ollowing topics:

Quality o care, moderated by Dr. Sharad Iyengar, ARTH Society

Connecting maternal health, amily planning and reproductive health, moderated

by Dr. Leela Visaria, Gujarat Institute o Development Research

Social determinants and maternal health, moderated by Dr. Abhay Bang, SEARCH

Knowledge gaps and research needs, moderated by Dr. Priya Nanda, ICRW

Accountability o the public health system on maternal health, moderated by

Dr. H. Sudarshan, Karuna Trust

Following the roundtable discussions, moderators shared the recommendations that

emerged rom each roundtable in a plenary session.

APRIL 04, 2013: Maternal Health in India: Emerging Priorities (New Delhi,

Boston, Washington DC) with Dr. Abhay Bang, Director, Society or Education,Action and Research in Community Health;John Townsend, Vice President

Reproductive Health Pro

Documents

Delivering Success: Scaling Up Solutions for Maternal Health