Making change happen is in the air

13/07/2012 Comments Off on Making change happen is in the air

Marge Berer

Editor, Reproductive Health Matters

Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.

Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…

The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…

Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…

In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…

In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…

Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).

In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.

Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).

The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).

full editorial

Trends in maternal mortality 1990-2010: latest data

18/06/2012 Comments Off on Trends in maternal mortality 1990-2010: latest data

by Marge Berer

Editor Reproductive Health Matters

Thanks to the Millennium Development Goals and much work on the part of the UN, WHO, many governments and NGOs globally and nationally, the press and media are now highly attuned to what is happening as regards maternal mortality. An announcement by WHO on behalf of the United Nations of the latest global estimates, published in May 2012, showed that the trend in maternal deaths appears to be falling overall, and resulted in many newspaper articles sharing this very good news. The global data were as follows:

  • The number of women dying due to complications of pregnancy, childbirth and unsafe abortion decreased from 543,000 in 1990 to 358,000 in 2008, and 287,000 in 2010.

This excellent news masks the fact that there has been a lot of change in some countries and virtually none in others. Here are some of the details of those differences, taken from the report:

  • Deaths are falling quickly in East Asia but the reduction is attributed largely to China.
  • Southern African countries have seen the beginnings of a reversal, but sub-Saharan Africa (56%) and southern Asia (29%) accounted for 85% of the global burden in 2010.
  • India (19%) and Nigeria (14%) alone accounted for a third of deaths globally.
  • 40 countries (20 % of the total number of countries) still have maternal mortality ratios greater than 300 deaths per 100,000 live births.
  • Countries with the highest maternal mortality ratios were: Chad, Somalia, Sierra Leone, Central African Republic, Burundi, Guinea-Bissau, Liberia, Sudan, Cameroon, and Nigeria; Lao PDR, Afghanistan, Haiti, Timor-Leste – these are among the world’s poorest countries, many of which are also sites of conflict, war and other crisis situations, such as earthquakes and flooding.

In other words, many countries still have very high maternal mortality ratios, including two very large countries, which account for a large proportion of deaths. Moreover, there is a growing gap between countries where improvements have taken place and many of the poorest countries, where most women are still simply not benefiting. Furthermore, as the May 2012 edition of RHM shows, there are differences within countries and between women (according to socioeconomic status, rural vs urban status, age and marital status) that are sometimes great and must not be ignored. The paper by Shah and Ahman, for example, shows that unsafe abortion deaths remain high in many countries and that young women are at the greatest risk of death and complications from unsafe abortion. A study in Nigeria shows that women in northern Nigeria are at far greater risk of maternal death than women in the south of the country. Given that the primary aim of the Millennium Development Goals is to reduce poverty and the consequences of poverty, celebration is perhaps not yet in order. However, countries where improvements have clearly taken place, such as Rwanda and Cambodia, as shown in other RHM papers, certainly deserve credit for enormous efforts.

Maternal health: hospital delivery does not guarantee good care

25/05/2012 Comments Off on Maternal health: hospital delivery does not guarantee good care

Hospital delivery does not guarantee good care: recent cases of women who died in a referral hospital in a sub-Saharan African country

Published on the British Medical Journal Guest Blog, 17 May 2012

A key focus of work in the field of safe motherhood has been on increasing deliveries in medical facilities with access to skilled birth assistants and emergency obstetric care. In many places more and more women are reaching clinics to deliver. However, there has been too little focus on the quality of services, on the capacity of health centres to provide care to all who need it, and training of staff to provide timely, skilled and compassionate care. Stories of women dying preventable deaths and enduring serious injury in health facilities demonstrate that accessing a hospital is not enough if the health professionals women depend on for their care are callous, negligent or corrupt.

We hope by sharing these true stories of women who were injured and died we are honouring the desire of the doctor who sent them to us to share them and to shine a light on what is happening in his region.

Case 1
A woman, aged 29,  is languishing in  hospital after losing both her baby and her uterus and rupturing her bladder while trying to give birth. She was rushed to hospital three months ago after she failed to deliver her six-pound baby. According to her best friend, on arrival at this referral hospital, she was not attended to as the medics on duty said the theatre was closed for the day and there was not much they could do. With the baby halfway out, she had to bear the pain till midday the following day when the by-then dead baby was removed. By that time her uterus had ruptured and also had to be removed, while her bladder muscles were so damaged that she can no longer control the flow of urine or stools. Although she was sent home after the ordeal, she had to return three weeks ago after her condition worsened. She needs urgent surgery, and a nurse on duty said she was on the list for a surgery camp currently in northern Uganda, which is expected this week. Meanwhile, she is experiencing a lot of pain in her abdomen, private parts and legs. She does not understand why she can’t be operated on in the hospital. According to her friend, doctors said that she would need to pay (equivalent to USD 1,223) for the operation. Often, such cases are transferred to other areas.

Case 2
The contractions had started at dawn. C, a school teacher, knew it was time, so she did what was expected – checked into a hospital at 6am so she could give birth with expert attention at her disposal. But that was not to be. For more than 10 hours after she checked in, she was ignored, neglected and writhing in pain in the Labour Ward until 8pm when she breathed her last. Her crime? She did not have the money (equivalent to USD 122) the medical staff demanded before they would attend to her. So she wasted away as her husband ran desperately around the village to raise the money. It was only the hospital cleaners who tried to help remove the baby from her womb. A neighbour, who had help transport her to the hospital, said she and C’s husband could not raise the money as they had spent the little money they had to purchase surgical equipment. “When I came back, I found her in pain, crying, there was no help. The medical workers looked on as they asked for money,” the neighbour added. After three hours of waiting and sensing that C was deteriorating, the neighbour approached a midwife and asked her to attend to her but the midwife and a doctor allegedly also declined. “At about 6pm, C started gasping; she fell on the floor and was bleeding. “That was when the doctor responded and took her into the theatre, but it was too late; her life could not be saved and she died.” The doctor emerged from the theatre after about 10 minutes and announced that both C and the baby had died. C had been going with her husband for antenatal check-ups at the hospital and the midwives had told them the baby was big, and that it would be difficult for her to have a normal birth, and they had apparently recommended a caesarean section. Causes of death were obstructed labour, uterine rupture and haemorrhage. A complaint was filed with the police and the doctor was being investigated for neglect. The police surgeon who carried out the autopsy said this was not the first case at this hospital; many women had died in labour due to neglect. The district Police Commander said he had summoned the medical staff on duty that night and day to furnish evidence. However, the hospital director said at the time of C’s death, there was another woman in the operating theatre and that it had been inadvisable to halt that operation. “And in any case,” he said, “it is not the patient who asks for theatre but we examine the patient and recommend. Doctors on duty examined her and by the time they recommended her for theatre she had already ruptured her uterus… She was bleeding and we could not save her life. I can’t rule out the issue of [staff] asking for money. Some staff do it but we need to investigate this further because it has no proof.” He said the people who operated on her to remove the baby were not hospital workers but imposters who had sneaked into the hospital.

Case 3
A woman 39 year old woman died after giving birth and failing to expel the placenta for several hours. She called for the help of the nurses on duty, according to eye witnesses, but got no attention. In an interview with the local newspaper, the doctor on duty said that after the call, he had rushed to the hospital to save the situation but it was already late to save her life. He denied the claim that the woman died out of negligence because an unqualified hospital staff member had helped her instead. The District Chairman said serious action must be taken against the implicated health workers to serve as a warning, as negligence in hospitals is forcing women to visit traditional birth attendants.

Case 4
Another tragedy has occurred in A. An expectant mother of five, aged 37, died in the regional referral hospital having just been admitted at 9 pm and died due to unprofessional conduct by the health workers. Not even the simplest effort was made to help the poor women. The doctor was raised on the phone to come and attend to her, but she kept saying that she was too tired to come that night and that she would attend her the next day. The next morning, however, no one attended to her till she met her death. When she asked for help, the midwives were shouting at her, and the poor women fell off the bed due to severe labour pain. The nurses panicked and pretended to work on her to save her life but she died together with her baby still in the womb. As one enters the maternity ward at this hospital, there is a smell of death and fear among the expectant mothers. Her death has left many of them wondering if they will survive delivering in the hospital.

*****************

Though these stories are sent from sub-Saharan Africa, they are a perfect echo of the case studies from India(1) in RHM’s May Issue on Maternal Mortality in which discrimination and neglect led to preventable deaths . In India human rights law has been used for the first time to bring compensation to the family of a woman who died a preventable death and to enshrine the principle that a woman has the right to lifesaving treatment during and after childbirth (2) . In Uganda, human rights organisations and families of women who died in childbirth are filing a landmark lawsuit to hold the government accountable for maternal deaths (3); while in Latin America landmark decisions by the Committee on the Elimination of Discrimination Against Women (CEDAW) have called for appropriate maternal health care, in Brazil, and decriminalisation of abortion to safeguard women’s health in Peru (4).

To read more about how people are using the law and human rights conventions to commit governments to improving maternal health care see May’s issue of Reproductive Health Matters Maternal Mortality or Women’s Health: time for action
(1)Subha Sri B, et al. An investigation of maternal deaths following public protests in a tribal district of Madhya Pradesh, central India. Reproductive Health Matters 2012; 20(39). In press.

(2)Kaur J. The role of litigation in ensuring women’s reproductive rights: an analysis of the Shanti Devi judgement in India. Reproductive Health Matters 2012; 20(39). In press.

(3)Ugandan Government to be held accountable for maternal deaths

(4) Kismödi E, et al. Human rights accountability for maternal death and failure to provide safe, legal abortion: the significance of two ground-breaking CEDAW decisions. Reproductive Health Matters 2012; 20(39). In press.

A guest blog by Lisa Hallgarten: Social Media Manager at Reproductive Health Matters; sexual health trainer, educator, and blogger at Education For Choice; and advocate for better sex education for all young people.

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An unholy alliance: religion, neo-liberal economics and good old fashioned patriarchy – restricting women’s abortion rights in Eastern Europe

11/05/2012 Comments Off on An unholy alliance: religion, neo-liberal economics and good old fashioned patriarchy – restricting women’s abortion rights in Eastern Europe

A report from guest blogger Charlotte Gage on ‘How much does abortion cost?’ a session organised by ASTRA Central and Eastern European Women’s Network for Sexual and Reproductive Health and Rights at the AWID Forum in Istanbul.

I attended this session where speakers from Poland, Romania, Hungary and Slovakia outlined the economic dimension of sexual and reproductive rights in their countries, and the increasing restrictions on access to abortion.

Provision of abortion and other reproductive health services are under threat from neo-liberal economics which is increasingly restricting state-funded services throughout the region. This is being fuelled, by ideological opposition to abortion from both the Catholic and Orthodox Churches, sometimes with funding and support from US anti-choice organisations which is thought may include the US-based Human Life International and Opus Dei.

Most countries in the region have experienced reforms to health systems following democratic transition from Communism, but the results of these vary. The restrictive abortion laws in countries such as Romania and Albania under Communism were seen as a social experiment to increase the population and provide new generations of workers, and have since been relaxed. More recently however, Ukraine and Russia have tried to implement restrictive laws, to reverse a decline in population.

The influence of religion varies throughout the region. In Poland the Catholic Church still has a strong influence, and as its access to public resources increases, through provision of adoption services, it has a vested financial interest – as well as ideological one to opposing reproductive rights. In other countries it is the influence of, and funding from, the US anti-choice movement that is driving forward an anti-choice agenda.

The increasing reluctance by governments to pay for contraception and abortion services is also having an impact.

In Hungary, an advertising campaign in which images of fetuses asked not to be murdered was funded by PROGRESS EU funding – a fund aimed at supporting equality. The Government was forced to stop the campaign after feminist organisations complained to the European Parliament.

In tandem with ideological tactics aimed at creating attitudinal change, the budget for reproductive health in Hungary, which supported women who could not afford to pay for an abortion, has been significantly reduced with no explanation. Women seeking home birth are subject to unaffordable insurance premiums and in one case a midwife has been imprisoned for supporting a woman to give birth at home. For PATENT – People Opposing Patriarchy these were all cited as examples of the continued repression of women’s reproductive rights in Hungary, patriarchy in action, and the denial of women’s autonomy.

Freedom of Choice, Slovakia,  has campaigned against the lack of unbiased and accurate information on family planning. It also takes on the  influence of the Catholic Church hierarchy which is opposing progressive policies such as inclusion of more information in school textbooks and making contraception more affordable.

The Polish Federation for Women and Family Planning described how in 1993 Poland became the first country in Eastern Europe radically to restrict abortion and is now, regrettably, serving as a model for other  Governments in the region. Official figures show just 600 abortions were performed in Poland in 2010 (compared to 8,000 in 1989), but this figure hides the large number of privately performed abortions and those provided to Polish women abroad.

In many of the countries it is the actual cost of abortion for women that creates the main barrier to accessing services. Women on low wages sometimes pay the equivalent to the average monthly wage for an abortion. In Slovakia, where there are no state controls on the maximum price of contraception, prices are rising and contraception is becoming unobtainable for many women. Moreover, across the region professional resistance to medical abortion combined with high costs means women are denied the option of choosing this extremely safe method of abortion.

An interesting response to the economic and ideological squeeze on abortion access came from a speaker from the Romanian organization European Centre for Public Initiatives (ECPI) which said that Romania has not yet fully learned the lessons from its past. Though the liberalisation of abortion in Romania has led to significant reductions in maternal mortality there have been recent attempts to restrict and limit abortion in Romania, including proposing mandatory (biased) counselling and a three day waiting period before a woman is able to have an abortion.

ECPI believes that calculating the financial benefits of providing reproductive health care may be a powerful tool in opposing further restrictions. To this end, it is attempting to estimate the full cost of unsafe abortion including:  the health care costs following unsafe procedures; social costs including sick leave and disability benefits if the woman is injured; the costs of childcare if the woman dies;  and violence against women services for those who experience violence following abortion.

It may ‘leave a bad taste in the mouth’ to try to put a monetary value on women’s lives, but in the face of ideological opposition to women’s reproductive autonomy, and governments’ focus on cutting budgets, it might be the most powerful argument we can make.

Charlotte Gage

With thanks to Katarzyna Pabijanek – ASTRA Network Coordinator

Does midwifery have to be privatised to provide continuity of care for women?

30/03/2012 Comments Off on Does midwifery have to be privatised to provide continuity of care for women?

Published on the British Medical Journal Guest Blog, 29 March 2012

Earlier this year we received news of a social enterprise, Neighbourhood Midwives, providing midwifery services in the community in London, and a private company providing midwifery services for NHS Wirral Primary Care Trust. One to One, in the Wirral, promotes itself as offering the kind of continuity of care in pregnancy and maternity that midwives have wanted to provide but have often been unable to, for decades. It heralds its high rates of home births—part of which it, bizarrely, appears to attribute to the launch of the BBC drama Call the Midwife set in the East End of London in the 1950s. Of course women would prefer a single familiar and friendly midwife to see them through pregnancy and labour, instead of a roll call of harassed and overworked ones who they may only meet once, or one who barks commands as she flits between different women on the labour ward (a la real life in One Born Every Minute, Channel Four). Of course what women most want is a safe delivery and a healthy baby.

It is hardly necessary to revisit all the ways in which midwifery is failing women and midwives are being failed in turn by the health system. The Royal College of Midwives has long been calling for the urgent recruitment of 5,000 more midwives to deal with a spiralling birth rate amid great uncertainty about future resourcing in the wake of cuts and NHS reforms. In this context it is certainly worth considering the opportunities and pitfalls presented by independent organisations of midwives providing services to exploit the new liberalised health commissioning environment.

Different questions arise:

Will midwives be attracted to leave the NHS and join groups of independent providers? Which ones? Will they be those who are highly motivated to provide a good quality of service for women, continuity of care, and women-centred midwifery; or those who are unhappy or ill equipped for providing the spectrum of care women need including support through complex or high risk pregnancies and obstetric emergencies (which happen in some 15% of all pregnancies); or those who seek better or easier working conditions. This is strongly related to the question about why there is such a shortfall of midwives in the NHS, where independent organisations will find the midwives to staff their services, and—if they can find them—why the NHS can’t recruit and retain them instead?

How will these services be linked in, and relate to, services in NHS settings? It is clear that such services will be set up to support women only through low-risk pregnancies, but inevitably a proportion of those women will end up in NHS maternity units through choice or necessity. What will the impact be on NHS service planning for emergency and unplanned admissions from independent providers?

How will the comparative effectiveness and efficiency of these services be assessed when they, by their nature, will cream off the low-risk cases and have greater capacity to provide home-births which are less costly? It is not hard to see how attractive this kind of low-risk provision might be to the private sector and how essential it would be for them to return women back to the NHS as soon as it might cost them a penny more than expected.

Will the NHS—as in so many areas of care—be expected to treat only the complex and expensive cases, or handle the mistakes of the private sector? If so, what are the implications for NHS midwives who also need to look after low risk cases as part of the spectrum of care they offer, and enjoy doing so? If private provision leads to even more medicalisation of NHS services could it result in a further haemorrhaging of good midwives from the NHS?

If NHS maternity services are at risk of becoming a dumping ground for complex cases and obstetric emergency, how will this impact on options for those women who may want a more low-intervention approach, but with the safety net of doing so in a hospital setting?

Will the independent, community-based service be open to and promoted to all women, or will we end up with two tiers of provision? Will women who are well-versed in what they want get shiny new community services, while everyone else—including teenagers, those with language or learning difficulties, the poor, and those simply lacking in knowledge and confidence—is expected to “like it or lump it” in the local hospital?

How have these new groups managed to organise NHS support to arrange professional insurance when this is something independent midwives have often struggled or failed to do?

Finally, the question we are asking about all NHS services: is it just a matter of time before we are expected to pay fees for some services, and could privately provided midwifery be one of these?

We would all like to see services providing continuity of care for pregnant women in the community. If this is to be provided by independent organisations it must be freely available, and must not be provided at the expense of good quality, comprehensive NHS maternity provision by midwife-led units, whether within or attached to NHS hospitals.

A guest blog by Lisa Hallgarten: social media manager at Reproductive Health Matters; sexual health trainer, educator, and blogger at Education For Choice; and advocate for better sex education for all young people.

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