Discussion: Critical Success Factors That Accelerate Progress
Meeting the MDG health targets
Worldwide, under-five mortality declined from 93 to 72 deaths per 1,000 live births between 1990 and 2006. Nevertheless, in 62 countries, under-five mortality is not declining fast enough to meet the Millennium Development Goal 4 target of reducing by two thirds the mortality rate for children under 5 years of age. The reduction of maternal mortality also remains a challenging task; the Millennium Development Goal 5 target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015 is the area of least progress among all the MDGs. In many countries, malnutrition, and lack of access to quality primary health care and basic infrastructure, including water and sanitation, continue to be major causes of ill health and death among mothers and children. Having fewer pregnancies and spacing births increase the survival rate of both women and their children, underscoring the importance of the Millennium Development Goal target of universal access to reproductive health.
Infectious diseases continue to inflict a huge burden on developing countries. Globally, about 33 million people were living with HIV/AIDS in 2007. Malaria causes 1 million deaths annually along with 300-500 million episodes of illness. Sub-Saharan Africa bears a disproportionate share of the burden of both these diseases. Affordable access to essential medicines in developing countries is far from adequate. Concerns about global health have sparked a large increase in donor funding since 2000. International health partnerships and funds, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization, are an increasingly important mechanism to pool and channel public and private funds.
MDG 7, target 3 stresses the importance of adequate water and sanitation for sustainable development. They are also vital inputs to improving health, although they are generally outside the purview of the health sector. Current trends suggest that the world may meet the drinking water target, but not that for sanitation.
Issues
- Strengthening health care systems, including sustainable funding, human resource training, improvement of aid effectiveness and harmonization with country priorities.
- Provision of integrated services – primary care, reproductive health, continuum of care for mothers and children, HIV/AIDS prevention and treatment, child health and malaria interventions.
- Strategies to meet the needs of vulnerable populations, especially rural populations and the urban poor.
- Infrastructure needs for health care, water and sanitation.
- Affordable access to essential medicines in developing countries.
As argued by the All Party Parliamentary Group on Population, Development and Reproductive Health in 2007, the impact of population growth was neglected in the original MDGs. Although a new target was set under MDG 5—universal access to reproductive health care by 2015—support to this end remains woefully lackluster, with 200 million women continuing to experience an unmet need for family planning.
Rapid population growth hinders progress on all MDGs.
1. Poverty is perpetuated because weak infrastructures cannot accommodate populations that grow annually by 2-3%.
2. Primary schools cannot keep up with the growing number of school-aged children each year wishing to enter the educational system.
3. Gender equality remains a distant target as long as women are unable to complete their educations and be active members of the workforce. Having many siblings reduces girls’ chances of continuing their educations and having many children keeps women at home instead of allowing them to have paid jobs.
4. High fertility and closely spaced births threaten child survival due to low birth weight, abbreviated breastfeeding, and less attention given to each child during the most critical years.
5. High fertility increases maternal mortality for obvious reasons. Being pregnant and giving birth without modern medicine is risky. According to the All Parliamentary Group, maternal mortality could decrease 35% if unintended pregnancies worldwide were eliminated.
6. Public health care infrastructures that could combat malaria, HIV/AIDS, tuberculosis, and other diseases are unable to improve because population growth stretches existing financial and technical resources so thin.
7. And lastly, population growth damages the environment in countless ways, from exacerbating climate change through increased emissions and deforestation, to species loss and depletion of natural resources.
Where women’s only protection against pregnancy is natural family planning, actual fertility rates are across the board higher than desired fertility. In every country with reasonable access to modern contraception, fertility is approaching, at, or below replacement level. Population stabilization is achievable by realizing women’s human right to reproductive health, including family planning. Until this target under MDG 5 is met, all other MDGs will be impossible to achieve.
Population Connection is working with other groups to urge Congress to “double the money” that the United States spends on international family planning—to one billion dollars. During the last decade, the number of women of reproductive age in the developing world has grown by 275 million. It is simply not enough for funding levels to remain stagnant (or drop, as they have in the U.S.). One billion dollars is the United States’ fair share of the total cost of satisfying unmet need for family planning around the world. Once real efforts toward achieving population stabilization are made, progress on all MDGs will begin to accelerate.
Human rights must be at the centre of all responses to HIV. States, reaffirmed at the United Nations High Level Meeting on HIV and AIDS in 2006 and 2008, the full realization of all human rights and fundamental freedoms in meeting the global response to HIV and AIDS. Many countries are still reporting existing legislation or policies as barriers to providing prevention, treatment and care
There is no evidence that laws, which criminalizes HIV transmission or behavior that place people at risk of HIV transmission, are effective at reducing HIV transmission as these coercive measures increase the stigma associated with HIV, provide the public with a false sense of security and drive such behavior underground.
In light of this, laws criminalizing transmission, sex work, sexual practices and carrying syringes and needles, legal barriers for key populations to access HIV testing, prevention services and information and treatment must be removed.
Recommendations
• HIV policies and programmes must be developed and implemented, consistent with existing commitments and legal obligations related to human rights standards and law, including the 2001 Declaration of Commitment on HIV/AIDS, the 2006 Political Declaration on HIV and AIDS and Universal Declaration of Human Rights.
• HIV legislation, policies and programmes must be implemented to prohibit discrimination against people living with HIV, as well as discrimination on the basis of gender, sexual orientation/identity, occupation (including sex work), location or drug use.
• Legislation that criminalizes HIV transmission or behavior, which place people at risk, must be abolished.
Rathi Ramanathan is the programme officer of Asia Pacific Council of AIDS Service Organisations – a regional network of non-government and community-based organizations which provide HIV/AIDS services within the Asia and the Pacific region.
Strengthening the response to HIV/AIDS – Helping make the MDGs a reality
This year is supposed to be a year of action and an opportunity to redouble our attention, efforts and commitments to achieve the Millennium Development Goals (MDGs). A key factor in determining whether countries can attain the MDGs is their response to HIV and AIDS. The HIV and AIDS pandemic threatens progress in many of the other MDGs, as its severe health repercussions for individuals, families, communities and nations represent a key threat to development. The world must respond with better tools and technologies for both treatment and prevention. IAVI, a not-for-profit product development public-private partnership, is dedicated to accelerating the development of and ensuring access to a safe, effective, accessible preventive HIV vaccine for use throughout the world.
HIV and AIDS and the Millennium Development Goals
Goal 1: Eradicate extreme poverty and hunger
HIV and AIDS increase poverty
Studies have illustrated that HIV and AIDS act to damage social capital and lower GDP growth. In some studies examining HIV highly affected countries annual reductions of GDP growth of between 2-4% have been noted .
Goal 2: Achieve universal primary education
HIV and AIDS compromise efforts to reach universal primary education
Children affected by HIV and AIDS are more likely to delay school enrolment or drop out of school. This is due to increased financial pressure at the household level, including diverting money toward medical treatment and engaging children in the provision of care and income generating activities.
Goal 4: Reduce child mortality
HIV and AIDS negatively impact child mortality
In 2007, an estimated 2.1 million children under the age of 15 were living with HIV. Approximately
50% of all children who contract HIV from their mothers die before reaching their second birthday .
Goal 5: Improve maternal health
HIV and AIDS worsen maternal health
HIV and AIDS limit progress toward achieving this target due to the additional risks that HIV-positive mothers face; this is particularly relevant in sub-Saharan Africa and Southern Asia. HIV-positive women are at 1.5 to 2 times greater risk of maternal mortality than HIV-negative women .
Goal 6: Combat HIV/AIDS, malaria and other diseases
HIV and AIDS undermine global efforts to control tuberculosis
Globally in 2006 there were an estimated 709,000 new HIV-positive tuberculosis (TB) cases . The interplay between these two epidemics has dreadful consequences: TB is the leading cause of death among people living with HIV.
Accelerating progress toward and beyond the MDGs
Tackling HIV and AIDS lies at the heart of not only achieving the MDGs, but sustaining and strengthening long-term progress beyond 2015. Without a preventive HIV vaccine, significantly mitigating the impact of HIV and AIDS may remain forever out of reach.
Member States and delegates should strongly reaffirm their commitments to accelerating research for an HIV vaccine, during roundtable presentations and discussions; during speeches at partnership and other events; and remarks on panels. Specifically, they should commit to:
Acknowledging that an HIV vaccine is our best hope in substantially and sustainably reducing HIV transmission- stopping the pandemic in its tracks. New and better long-term prevention tools are needed, especially methods that children, youth and women can effectively access, initiate or control. An HIV vaccine represents one of the most powerful forward looking health initiatives and equity tools in the world; and
Substantially increasing scientific, political and financial support to developing an HIV vaccine. This includes sustainable financing and incentives for the public and private sectors and product development partnerships to tackle the ever present threat HIV and AIDS pose to millions around the world. Such support strengthens global health partnerships fostered in the spirit of MDG8.
We hope you will join us in helping make the MDGs a reality.
In recognition of the complementarities existing between UNDP and UNICEF interventions in community development, the two organizations decided to use the UNICEF Family Education Project (FEP) to mobilize and raise awareness in 11 communities working with the ELS. The FEP with its vision of integrated early childhood development, was initiated in May 2003 by the Government of Uzbekistan with technical support from UNICEF, in response to the country’s need to empower families to address problems affecting children’s health, growth and development, particularly from birth to 6 years.
The Enhancement of Living Standards (ELS) programme project organized 5 day cycle of training on maternal and child health, water, sanitation and hygiene for advisers of the chairman of the Mahalla Committee on women’s issues, primary health care health workers, patronage nurses, and representatives from ELS supported community initiative groups. The events took place at the local community primary health care structures just rehabilitated by the ELS project. The participants received UNICEF training material, including the well known Facts for Life booklet with information in Uzbek on the different stages of family education and child development.
The training was followed by an evaluation of its impact in the community in April and October 2007. The assessment consists of two stages: the first to identify a baseline consisting of collection of qualitative and quantitative data to assess the level of knowledge of communities and families in health matters. The second, after 5 months, will evaluate the actual impact of the training on the population and the changes that it is brought about through a better access to basic health services and their improved quality. Mother and child health indicators, such as reduction in anemia, iodine deficiency disorders, increase in exclusive breastfeeding, better nutrition, increase in enrollment in state kindergartens and the opening of non-formal voluntary schools are among those which will be used to measure the impact of ELS supported community projects and improved accesses to health infrastructures.
The FEP programme developed, tested and assessed by UNICEF has proved effective in contributing to community mobilization and improved community involvement in local development. The ELS communities that have identified health as their main priority have related to this training well, because the FEP uses a similar approach to the one of the ELS project based on community volunteer efforts, a concept which is part of Uzbek traditions and culture. In addition to involving volunteers in the programme, the FEP also dovetails into the work of Mahalla advisors and patronage nurses who play a vital role in the communities.
This joint activity seeks to encourage mutually beneficial UN interagency cooperation whereby the ELS project applies the same methodology developed and tested by UNICEF in the project districts and coordinates closely with UNICEF to expand the focus areas and results from six to 10 districts.
In addressing MDG 5 on improving maternal health, we must consider maternal mortality both as a public-health and a human-rights issue. It is appalling that we accept a situation in which some 500,000 women die every year in pregnancy and due to maternal health issues, particularly from largely preventable causes. The measures needed include the following:
- Ensure that all women have access to comprehensive sexual and reproductive health information and services, without discrimination of any kind as to age, race, colour, language, religion, political or other opinion, national, ethnic or social origin, property, birth, marital, HIV or other status
- Work with associations of HIV-positive women and women’s groups specifically to develop advocacy around broader sexual and reproductive health rights
- Establish appropriate programmes to respond to the special needs of adolescents regarding sexual and reproductive health, including support mechanisms for adolescent education, counselling and services, and to guarantee full involvement of adolescents in the planning, implementation and evaluation of such information and services
- Ensure reporting on in-country and ODA-based measures to achieve benchmarks for reducing maternal mortality and morbidity and guarantee the existence of accessible, transparent and effective accountability mechanisms
- Ensure the regular collection of reliable and timely data, disaggregated at least on the basis of age, race, ethnicity, socio-economic status and residence (urban/rural) to guide implementation and evaluation of national action plans and global strategies for addressing maternal mortality and morbidity
- Adopt and enact policies and legal frameworks to reduce the incidence of too early, too close and unwanted pregnancies, enabling individuals’ access to comprehensive and factual information and a comprehensive range of contraceptive means and combating all forms of violence against women
- Amend laws containing punitive measures against women who have undergone illegal abortions, provide safe and accessible abortion services to the fullest extent of the law, and in so doing, train and equip health-service providers in the provision of comprehensive safe abortion care services, and ensure prompt access to quality services for the management of complications arising from abortion, including post-abortion counselling, education and family-planning services.
If donor are committed to attainment of the MDGs they have to put there money where their month is. Family planning and integrated reproductive health services contribute to lower child and maternal mortality and morbidity, combating HIV, better education of women, and protection of the environment. However, funding of family planning is falling far short of commitments made in Cairo and thereafter. The current trend to channel funds through untargeted mechanisms, such as general budget support, or vertical programs need to be reversed in favour of funding of sector strategies with identified interventions and benchmarks.
MDG 5 can be achieved. Experts know how to do. What is missing is a comprehensive coordinated approach to tackle maternal mortality and an exchange of “best practices”. The approach must be comprehensive because of the multiple aspects of this widespread problem:
➣ Social/medical: early marriages and pregnancies of girls often not older
than 11 or 12 years, insufficient medical care especially during labor
➣ cultural: high rate of home deliveries; lacking access to education for girls
➣ economic: insufficient medical infrastructure particularly in rural areas;
poor equipment and training standards of personnel in health clinics.
Our Rotary project “Improvement of Maternal Health” funded by The ROTARY FOUNDATION and co-funded by the German government and Aventis Foundation with a project amount of one million Euro running since 2005 in Northern Nigeria, is such a comprehensive approach including six areas of activity:
➣ Awareness and advocacy to inform the public on how to avoid VVF and
establish responsible parenthood
➣ Education and training of health personnel in Fistula repair and post-operative
care and increase of the number of skilled birth attendants
➣ Equipment for hospitals and health care centers to provide adequate obstetric
care,VVF operations and Caesarean sections
➣ Rehabilitation of patients after clinical recovery with vocational training and
microcredit support programs
➣ Collaboration with local and international NGOs and Foundations
➣ Close cooperation and integration of state officials and administration in
order to guarantee the sustainability of the project, i.e. by introducing a
regulatory action of quality assurance in obstetrics.
In this 4-year-pilot project we focus on two northern states of Nigeria (Kaduna and Kano) with a target group of 5.000.000 women. Our goal is to identify main risk factors for pregnant women and address them through advocacy and by raising awareness at the grass roots level. The elements of our comprehensive approach include radio serials, training of health personnel, delivery of medical equipment and improvement of quality of structure and process and provide routine HIV/AIDS testing to prevent mother-to-child transmission. Two hospitals have been equipped to serve as Fistula Treatment Centers where patients receive necessary reconstructive surgery and post-operative care. Additional satellite Rotary projects, such as education and microcredits for successfully treated fistula patients to enable them to have their own income and safe water management for clinics, are increasing the project´s lasting effects.
The improvement of the quality of structure and of process in hospitals is a prerequisite to better the health of women and children. Our activities are aimed to establish an Institute of Quality Assurance in Obstetrics to improve the outcome. The steps are: analyse the structure of the hospitals, raise the quality of obstetrical service, e.g. to make the operating theatre and delivery rooms functional, train doctors and midwifes to improve the quality of process and outcome, e.g. maternal and child health. Ten selected hospitals in Kaduna and Kano State started to participate in a continuous monthly data collection of maternal and child mortality, maternal disorders during pregnancy and delivery. In quarterly quality circles the doctors and midwifes from the hospitals discuss under supervision of a head midwife and representatives from the department of OB/GYN in Kano and Kaduna University hospitals the “blinded” results of each hospital. Maternal death forms will in addition deliver a profound insight in the causes of maternal death. The analysis of the data provides a continuous awareness of the tragedy and will stimulate discussions among doctors and midwifes and generate ways to prevent MM and FM. Once the quality of services of hospitals and staff is ensured, the next step would be raising awareness among the population on available quality maternal health services. With the help of cultural sensible media campaigns, women will get to know about the offer and advantage of the established services. As a consequence, they will seek reproductive health services before and for delivery.
Good as it is, the idea of achieving MDGs by 2015 remains a dream today.
In order to realize this dream I suggest the following:
1. There is need to have the youth at the center of every conversation and interventions geared towards achieving the MDGs. Though youth form the majority of the world’s population as well as the most vulnerable, they are most times left out on issues that affect them. This requires a very urgent attention at all levels. Youth leadership is key in influencing positive and quick changes.
2. Women empowerment is crucial but the approach lacks the backing of country specific needs identification in order to avoid the problem of ‘One size fits all’ concept. Most of the interventions on the issue have met strong resistance from men because of the feminism attached to the concept of women empowerment. There is need to involve men strategically in fostering the idea of women empowerment. We must answer one simple question fully”To what extent are men empowered within their expected roles and responsibilities?”
3.The HIV/AIDS response must avoid global slogans and focus more on country -specific interventions in order to come up with simple, easy to implement and cost effective HIV/AIDS interventions. This is highly lacking. Policies around HIV/AIDS are generally weak to bring about the desired impact. Globalization of HIV/AIDS has increased funding but has reduced ownership of programs on HIV/AIDS and sustainability of HIV/AIDS programs especially in developing countries of Africa. Planning just follows the $$$ and not necessarily the needs on ground. The high level meeting with the state leaders must look into how they can rectify this problem that could be one of the key reasons why HIV/AIDS remains out of control when it is actually 100% preventable.
I thank you.
Rev. Evatt Muhwezi Mugarura
Executive Director,
Africa Youth Leadership Development and Health (AYLDH) Initiative
Willis Rd, Namirembe
P.O. Box 27597, Kampala, Uganda
+256 772 322 103
Response to MDG 5. Our small charity “Hope for Grace Kodindo” has, by providing basic medications such as Magnesium Sulphate and antibiotics in one single maternity hospital in Chad, reduced the maternal mortality rate from 14% to 2.3% in one year. This meets and exceeds MDG 5. This one place cannot be unique in this basic need, which would have such an instant impact on these terrible MM figures worldwide. Furthermore, it has been relatively easy to achieve which makes it all the more tragic. The neonatal mortality rate in that same hospital has treduced from 23% to 7.3%. By providing basic resources, we have achieved 2 of the MDGs, thus proving that saving the mother will bring other benefits. Keeping mothers alive will save the world billions of $s. If for no other reason than financial, we must do it. The woman lying in the bed in Afghanistan, Liberia or Chad won’t care why she has been saved, be it humanitarian or financial. All she will know is that she has been returned to the family and the world, all of whom need and value her.
Education is the first pillar of the progress, and, surely, it is unavoidable.
But how to realize it if in some countries the illiteracy rate is around 80% ? Why it has not been realized already? As a teacher and as a geographer, involved in international educational projects, I would like to share some words.
Geographers are strictly involved in sustainable development problems and they are able to afford issues in an interdisciplinary way; they can link different aspects in a synthetic manner. They can relate education to the environmental and social constraints. After my last visit in sub-Sahara Africa, I strongly reflected on this topic, so I think that the most effective methods should start from a micro economic approach, because they may be more people-friendly.
According to Mohammad Yunnus, some reasons of failure probably derive from the top-down decisions and from organizations distant from the popular traditions and opinions. For this reason I would like propose the following solutions.
Women are considered in poor countries as procreation tools, not as human beings. Since they should have many children, why not pretend from them to educate and to teach to their progeny?
Surely the idea of sending and sustain girls into school has already been presented and realized by UNESCO, but some excellent projects are weakening along the time and space. For that we propose to ask local governments to require that people who wish marry possess literacy skills and an adequate age. Surely we know that children born even without formal contracts, but steps in this direction have been proved to be effective in developed countries, even if in long terms.
In order to proceed along the required time, we would suggest a more real project, because one of the highest constraints is the price of education other than the lack of educators.
We propose, as the first step of our project, to begin to educate one class of students with the existent teachers. After one year every student develops himself into a teacher of another entire class, whose students in turn become new teachers for a new class each, even if they can teach only the elementary elements. This means that, after one year, we’ll have 30 teachers if one class is composed by 30 students and after two year we’ll have 900 teachers; in one year more they’ll become 27,000. The new young “teachers” may be paid being further educated some years more by the ruler official teachers, developing in this way their career towards even more skilled teachers.
We recognize that this method will furnish only the primary elements of literacy, but it is suggested as momentary and it will serve only to escape from large rates of illiteracy. It will also function as a way to reduce the number of children in developing countries’ classrooms, where usually stay even 60 learners or more.
Naturally the project needs to expect some involvements from governments such as the current economic expenses for paying the official existent teachers and an effort more, consisting in providing a free access to schools, without fees. The project surely will necessitate many rooms, so the solutions consist in: rotations, open air classrooms, or utilizing stuents own homes.
Contributed by Adriana Galvani, University of Bologna
MDG 5
The Maternal Health Working Group of the UK Sexual and Reproductive Health and Rights Network wrote a letter to Gordon Brown in light of the upcoming High Level Event.
The key asks were as follows:
· Highlight the importance of a comprehensive approach to reproductive health in tackling maternal death and mention the new target, by name, and recommit to it in your speech at the High Level Event.
· Use your political weight to lead and influence donors to:
- Demonstrate actionable follow up of recent G8 commitments to making reproductive health accessible to all, and to placing maternal, newborn and child health at the centre of health systems strengthening;
- Ensure that safe abortion is recognised within the pillars of safe motherhood, along with skilled birth attendance and access to emergency obstetric care;
- Commit the additional $10.2 billion per year needed to comprehensively tackle maternal, newborn and child health;
- Make concrete plans to fill the current shortage of more than 4 million health workers and reach the ratio of 2.3 doctors, nurses and midwives per 1,000 needed to make 80% skilled birth attendance possible;
- Finance in-country communication, advocacy and mobilisation work to promote the cultural attitudes and political will needed to support action on mother and child health;
- Strengthen vital registration systems and make maternal mortality the health system performance indicator.
This letter links closely with the key messages from the Action for Global Health (www.actionforglobalhealth.eu) policy report ‘Healthy Aid’. This report stresses the need for long term predictable support for health systems strengthening and the particular need to prioritise human resources for health. Strong systems with trained workers to deliver services are integral to efforts to reduce maternal mortality and more broadly in providing a comprehensive package of interventions to reach the health MDGs.
Contributed by Amy Kesterton, Interact Worldwide and Action for Global Health
While it is accepted that the health MDGs are unlikely to be met without functioning health systems and there have been extensive efforts to secure commitment to and funding for strengthening health systems, insufficient attention is paid to the value of community mobilisation as an effective process in addressing maternal and newborn mortality and improving maternal and newborn health. Women and Children First supports initiatives which empower women and their wider communities to devise and implement low cost strategies to address the problems women face during pregnancy and childbirth and during the neonatal period, including addressing the three delays in receiving skilled care during pregnancy and childbirth.
1. Introduction
1.1 Maternal and newborn health
Every minute one woman dies from a pregnancy related problem and eight newborn babies die, 98 per cent of these deaths are in developing countries while half of all births take place in the home without skilled birth attendance. Many of these deaths can be prevented by improving the health and knowledge of the mother, especially during pregnancy, delivery and the early post-delivery period. The health of a newborn baby is directly linked to the health of its mother during pregnancy and childbirth newborn. A child whose mother dies during childbirth is 3-10 times more likely to die before his or her second birthday.
It is widely recognised that women in developing countries do not have access to healthcare during pregnancy because they face a series of delays in reaching skilled care in a safe and clean environment. The first delay is making a decision to seek care, the second delay is transporting the mother to a health facility and the third delay is receiving good quality care after arrival at the hospital or health centre. Women need help to overcome these barriers to ensure they receive a continuum of care not only during their pregnancy but before pregnancy, and after the birth.
When problems occur during pregnancy, labour or the post-natal period decisions on what to do are often based on advice from family members, neighbours or traditional healers. In addition, the pregnant woman is often too shy to speak out because pregnancy is seen to be an unclean or shameful occurrence, and pain is thought to be normal and so she does not ask anyone for help. Therefore it is not only the pregnant women that need to understand the best form of care but also the wider community.
1.2 Community mobilisation
It has long been advocated that communities should come together to make lasting improvements to their health and have a right to access high quality healthcare, as recognised by the Alma Ata Declaration made at the International Conference on Primary Health Care in 1978: “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care”.
Local communities can be strengthened by coming together to plan, carry out, and evaluate activities to make sustained improvements to their health. This strengthening process is often referred to as community mobilisation, which can make deep and lasting improvements to the health and well-being of communities. Communities can achieve improved health through increased knowledge to identify and address important healthcare needs.
Women’s groups help to achieve community mobilisation. In many developing countries women do not have regular contact with other community members, nor an opportunity to voice their opinions. Women’s groups are therefore effective in bringing women together to discuss key issues affecting them during pregnancy and childbirth.
2. Evidence to demonstrate the effectiveness of women’s groups
There is growing evidence to suggest that women’s groups can significantly improve maternal and newborn health and reduce unnecessary deaths.
2.1 The Warmi Project, Bolivia
The Warmi Project, located in a rural area of Bolivia with little health infrastructure and widespread poverty, was the first published account of using women’s groups to improve maternal and newborn care. It developed the use of community action cycles focused on mother and infant care. After three years, the project noted a reduction in perinatal mortality of nearly 50 per cent and improved practices related to prenatal care, breastfeeding, immunisation and other behaviours. In addition, women increased their participation in community planning and decision-making processes, and commented that they had never spoken to one another about these types of problems before.
2.2 Makwanpur Study, Nepal
To evaluate rigorously the effects of the Warmi women’s group approach, a study was undertaken to improve the health of pregnant mothers and their newborn infants among 170,000 villagers living in rural Makwanpur district, central Nepal. The study was conducted by the International Perinatal Care Unit (IPU) in London and the Mother and Infant Research Activities (MIRA) in Nepal. Building on the Warmi approach and MIRA’s experience, they examined the potential of women’s groups to bring about improvements in perinatal health outcomes in a randomised controlled trial. It demonstrated a 30 per cent reduction in newborn mortality and a three quarters reduction in maternal mortality over a two-year period.
Secondary outcomes included changes in care provided for the mother and newborn at home and improved health seeking and referral patterns. Women who attended women’s groups were more likely than non group members to have had antenatal care, given birth in a health facility with a trained attendant or a government health worker, used a clean home delivery kit or a boiled blade to cut the umbilical cord, and for the birth attendant to have washed her hands. In addition, the women were more likely to attend a health facility if they or their infant was ill.
3. Women and Children First’s Women’s Groups Methodology
Women’s groups bring women with similar needs together to discuss topics that are of concern to them, for example a lack of access to high quality healthcare facilities and skilled birth attendants. A group is formed by 15-20 female members, who meet on a regular basis, usually monthly. Each group is facilitated by a local woman who has been selected and trained to run the group. The facilitator supports the group to identify and prioritise problems during pregnancy, childbirth and the newborn period, and to develop and evaluate strategies to overcome these problems.
Initially the whole community is briefed on what women’s groups are and consent is obtained from village elders, chiefs or leaders to ensure the initiative is supported by the women’s social network, following which women volunteer to become a group member. The initial meetings facilitate discussions on why mothers and newborns die in the community, and introduce the concept of ‘learning together’ to encourage the women to discuss problems within the group but also with their neighbours and friends. The women therefore bring problems faced by the wider community rather than just their own experiences.
The meetings enable women to develop their own knowledge about maternal and newborn health, which is used to educate others and challenge existing power structures. After each meeting, women return to their community to present their work at a community meeting stimulating wider health discussions. Therefore the impact of a women’s group is not just confined to group members but on the health of the community as a whole. Women and Children First estimates that in Bangladesh one woman who regularly attends meetings only has to interact with 2-3 pregnant women in her district to ensure that all women of child-bearing age are being regularly contacted and given the opportunity to benefit from peer learning.
4. Examples of Low Cost Strategies to Improve Maternal and Newborn Health
Women’s groups have developed various low cost strategies to meet their healthcare needs, for example:
Emergency funds
Rural women often give birth at home with assistance from family members or a local traditional birth attendant (TBA). When these women face complications during their pregnancy, they often cannot afford transport to a healthcare professional. The groups have therefore developed an emergency fund in Bangladesh, Nepal and Malawi, which can be used by any member in an emergency.
Making healthcare facilities more woman-friendly
When women can access healthcare facilities they often lack privacy and comfortable furniture. In response, groups contacted a local forester and ordered resources to make new furniture and gathered material to make curtains. In this situation women are building links between the health service staff and user.
Stretchers
Women’s groups have managed to collect money to purchase a second hand stretcher for the village to ensure pregnant women can be moved easily to a clean and safe delivery place when they go into labour. In Nepal, where many villages are remote, half the women’s groups ran stretcher schemes. This had an additional benefit for the community because 90 per cent of the time the stretchers were used for other sick people not just mothers in labour.
Picture card game
Picture cards are used to assist women in learning about appropriate care measures when faced with problems during pregnancy and childbirth. Group members then use the cards with other women in the community to share knowledge and promote learning. Cards are developed with inputs from women and community members to accurately depict healthcare messages in a culturally appropriate way, and are designed by local artists.
5. Summary and recommendation
Women’s groups enable women to identify and prioritise maternal and newborn health issues, have the support to find local and low cost solutions and build links with local health services. Women’s groups are a cost effective and evidence based intervention, which have the potential to be scaled up to reach out to all women and make a significant impact on their lives, their babies and the lives of their community members.