“We need to think differently about how we invest in our country programs, and what outcomes we are interested in,” said Dr. Koki Agarwal, director of the U.S. Agency for International Development (USAID)’s flagship Maternal and Child Survival Program (MCSP) and a Vice President with Jhpeigo, at a recent Wilson Center event.
USAID’s “Acting on the Call” report recommended 29 evidence-based maternal health interventions, though Kelly Saldaña from USAID’s Bureau of Global Health said that with enough research and data, there are likely many more. “There’s a need to study further interventions…to have a better understanding of how we can link health systems directly to the outcomes we are trying to achieve.”
To improve maternal, child, and adolescent health systems globally, we need to “have the ability to use that data to make changes within a health system,” said Dr. Agarwal.
Strategic partnerships are essential to building stronger health systems. Donors, in tandem with their country partners, have to bring all the players together, said Dr. Agarwal: “Bringing in that partnership, understanding what is happening across the country at the onset, is a much more successful way of building a sustainable program at the country level.”
Supporting country leaders to strengthen health systems is a crucial part of development partners’ jobs, said Mary Taylor, a professor at the Arctic University of Norway. “Country leadership is a process.”
Every day, 7,100 babies are stillborn. A tragic, complicated problem, stillbirth—which the WHO defines as a baby born with no signs of life at or after 28 weeks' gestation—remains difficult to control and to assess. Some hospitals hide data on stillbirth, due to the shame and stigma associated with it. However, as White Ribbon Alliance CEO Betsy McCallon said at a recent Wilson Center event marking the 30th anniversary of the Safe Motherhood Initiative, stillbirth “had been hidden and neglected, but that is changing.”
Distinguishing a stillbirth from a neonatal death can be challenging, particularly when the lack of a skilled birth attendant prevented adequate resuscitation. Despite the complexity, “we need to measure it,” said Barbara Kwast, one of the pioneers of the Safe Motherhood Initiative.
While stillbirth was not included in the original SDGs, after strong advocacy by the international global health community and bereaved families, stillbirth is now part of the SDG’s Every Woman Every Child framework. UNFPA’s Petra ten Hoope-Bender cited a new “people’s movement” that is bringing “dynamism, new energy into that agenda.”
To reduce the rate of stillbirths, Kwast urged the maternal health community to decrease the rate of birth asphyxia and to use a partograph to help make decisions during labor. “The international community has done an extraordinary amount of work around third stage [of labor] to prevent postpartum hemorrhage,” but now “we need to pay more attention to the first and second stages of labor,” where 50 percent of stillbirths occur.
“Women still die…and they die preventable deaths,” said Address Malata, vice chancellor of the Malawi University of Science and Technology, at a recent Wilson Center event honoring the 30th anniversary of the Safe Motherhood Initiative. Malata—a midwife and the former vice president of the International Confederation of Midwives—told the heart-wrenching story of a pregnant woman who, like so many others, died waiting for transportation.
“[Her mother] asked me…‘why was it that we waited for two days before my daughter was transferred to a decent hospital, but it only took a short time to take my daughter back home, and this time she was dead?’” said Malata. “My life has never been the same.”
Malawi’s government has started to build new maternity waiting homes, develop community-based interventions, and provide family planning, as well as other programs intended to improve health outcomes for women and mothers. “At the end of the day,” Malata said, “the question is: Is this good enough progress?”
Malawi still struggles with retaining an adequate health workforce, especially when it comes to midwives. Malawi needs to increase not only the quantity of midwives that stay in the country, but also the quality of their training and working conditions. “Do they have adequate time to practice when they are going through a midwifery program?” Malata asked. “As an advocate for midwifery, I would like to start protecting the profession,” she said.
“There is so much money going to maternal health…but why are women still dying?” she asked, “We are not addressing the core issues that can change women’s lives.” By holding leaders accountable for fulfilling the needs of people on the ground, Malawi can address issues of quality, equity, and dignity for mothers.
“If your dreams don’t scare you, they are not big enough.” Malata’s dream—that no woman dies while giving life—is big. “It is scary,” she said, “but it can be done.”
Peter Yeboah, Executive Director, Christian Health Association of Ghana, offers his perspective on faith-based approaches to global health
Dr. Tonny Tumwesigye, Executive Director, Uganda Protestant Medical Bureau, gives his remarks on faith-based approaches to global health.
As a child growing up in Nepal’s mountainous Upper Mustang region, Ghana Gurung understood that his survival depended on the mountains and his community. Today, as senior conservation program director at World Wildlife Fund-Nepal, he works to protect the endangered and elusive snow leopard by improving local communities’ livelihoods and the mountains’ ecosystem.
“Survival of the snow leopard is…important for our own survival,” Gurung says in a podcast of his remarks at a recent panel discussion, “Securing the Third Pole: Science, Conservation, and Community Resilience in Asia’s High Mountains,” at the Wilson Center. He didn’t always believe this. As he herded his families’ goats, Gurung knew that in the harsh mountain climate, livestock is livelihood. When a snow leopard attacked and ate his goats, he was angry: “A loss of one animal is a loss of your economy, cash in the bank,” he says. But through his Buddhist faith and his ecological education, he came to see the important role played by snow leopards; as an umbrella species, the leopards are a top predator and indicate the overall health of the ecosystem.
Climate change also threatens the snow leopard and its habitat, says Gurung. The tall grasses of his youth are now degraded, as are the habitats that support wild blue sheep, the snow leopards’ primary prey. “It’s not only wildlife and ecosystem that suffers; it’s people [that] suffer a lot,” says Gurung. To adapt to the changing climate, people are resettling alongside riverbeds that are vulnerable to flooding. And more catastrophically, water from melting glaciers could potentially impact billions of people downstream. Just a few months ago, one day of rain flooded 300,000 households.
Climate change knows no political borders, and neither do snow leopards. They can travels more than 2,000 kilometers between countries, said Gurung. Twelve countries have joined together to create the Global Snow Leopard and Ecosystem Protection Program, a global forum that brings together “countries that don’t normally sit side-by-side to talk too much in political terms,” says Gurung. But the snow leopard—acting as an “ambassador”—brings them together, he says.
“You can call it adaptation, or you can call it mere survival strategies,” Gurung says of community-based efforts to protect snow leopards. For example, citizen scientists from local Sherpa communities set up camera traps, collect scat for DNA analysis, and help put radio collars on the the cats. “It’s not all about ecology of conservation for snow leopards, it’s about community,” he says. “The community holds the key to the survival of the species.”
Climate change poses an undeniable threat to small island states, but many islanders do not even know what climate change is, says Camari Koto, an indigenous Fijian academic and educator at the University of the South Pacific and member of the Resilience Academy, in our latest podcast. “They know it’s happening, they are unconsciously [taking] adaptive responses,” and certainly feel the brunt of its effects, she says. “But they don’t see climate change as an immediate threat.”
As Fiji presides over the 23rd UN Climate Change Conference of Parties (COP-23), perspectives in the South Pacific are beginning to shift. The first island nation to host the conference, Fiji is showcasing its leadership on climate change issues for both the global community and Fijians themselves, Koto says.
“Our government was able to engage right [at] the grassroots level in creating awareness” within Fijian communities, says Koto, an advocate for building sustainable livelihoods and community resilience. It is especially important for the younger generation to be sensitized to climate risks “to start thinking about the threats that we have now,” she says, “and about ways in which they can help to make things better.” We must “prompt them to think about ways forward.”
“It’s the community working together, collaborating, and valuing their relationship” to one another that is at the core of livelihood resilience, says Koto. Community is “the platform of our forefathers.”
“Innovation happens when there are pioneers that stick with it,” says Monica Kerrigan, vice president of innovations at Jhpiego in a podcast from the Wilson Center’s Maternal Health Initiative. At a recent panel discussion on “Reaching the Farthest Behind: Facility-Level Innovations in Maternal Health,” Kerrigan shone a light on some of the challenges facing innovators trying to change the way we care for mothers and their children.
According to Kerrigan, one of the key components of delivering truly innovative solutions is partnership. “We need to use our partnerships to bend the curve,” Kerrigan says. “We at Jhpiego are good at things; other people are better at other things.” Effective partners harness one another’s comparative advantages to plan for scalability and adaptability. “When we think about scaling up,” she says, “we have to think about it now, in the design process.”
Even as these developments are being rolled out, Kerrigan warns against “falling in love with the solution”—investing time, energy, and money into just one idea. Instead, she urges innovators to “fall in love with the problem” first. After years of work in maternal health innovations, Kerrigan admits that one of her biggest challenges is learning to more effectively use data to change plans.
Innovations are not always shiny and new products; they may be restructured business models or processes. For example, the Low Dose High Frequency model, developed by Jhpiego, incorporates “targeted spurts of training that would allow people to learn faster, better, more affordably, and sustainably,” she says, preventing the loss of productivity often caused by removing healthcare personnel from their positions to train in classrooms.
“[Change] is part of prototyping and adapting, and willingness to look at what you are doing well and continue to do it,” says Kerrigan. “Let’s deliver on our promises to mothers and newborns.”
Maps help us to grasp complex ideas, such as patterns of risk and vulnerability, but the stories they tell can have significant implications. “It’s very difficult to validate that what you’re capturing in the maps is representative of real-world phenomenon,” says Joshua Busby in this week’s “Backdraft” episode, describing his efforts to map climate and security hotspots in Africa and Asia. “You have to be modest in what you think the maps can tell policymakers, but also realize there is some seductive power in the way maps simplify complex reality.”
The maps produced by Busby’s Climate Change and African Political Stability and Complex Emergencies and Political Stability projects are designed to help planners, donors, and national governments “shore up resilience on the ground.”
“The real question that we have to ask and answer all the time is, ‘Do the maps have any basis in reality? Are they useful?’ ” says Busby, associate professor from the LBJ School at the University of Texas, Austin.
When Busby and his team traveled to East Africa, they found that some of the challenges associated with chronic water scarcity were missing from their work, so they incorporated new indicators and updated the maps to more accurately represent the current situation. Without this “groundtruthing,” the maps could be misinterpreted and used to support interventions and other policy actions that could produce negative results, such as conflict.
Building Consensus on Climate Action
With proper groundtruthing, maps can be useful tools for reaching new audiences—and for reaching across the aisle. To build political consensus on climate change in the United States, Busby suggests focusing on related challenges, like water’s connection to security. “Because of its centrality to human wellbeing, [water] creates a reservoir of political goodwill that goes across political ideologies, and that’s why we’ve had great success in the U.S. government in creating a groundswell of sustained support for water and sanitation projects.”
However, a focus on water is not a silver bullet, especially if that focus is primarily on providing infrastructure, or “taps and toilets,” without supporting the governance mechanisms needed to manage resources sustainably. “What’s been lost in this wider discussion are concerns about water and security and the institutions both at the national and international [level] that can shore up the ability of countries to manage water resources on their own,” says Busby.
Donors should support efforts to build the capacity of countries to sustainably manage their water resources, particularly resources that are shared with other countries. As climate change increases both floods and droughts, poorly managed water resources could spur political instability both within and between countries.
“How do we present things in a responsible way?” asks Dr. Doris Chou of the World Health Organization (WHO) during a Wilson Center panel discussion on “Maternal and Women’s Health, Two Years In: Measuring Progress Towards Meeting the SDGs.” “My job is to make sure things don’t get misinterpreted,” says Chou.
WHO’s Ending Preventable Maternal Mortality (EPMM) strategy, which was published in 2015, informed the Sustainable Development Goals’ (SDGs) indicator index for maternal health. Chou explains that the EPMM’s themes “speak to empowering women and girls, ensuring country engagement and leadership, and…improving metrics and measurement.”
To ensure accuracy, we need to use have clear shared definitions of maternal health terminology. “What do we mean by maternal death?” Chou asks. “There is a definition, but the interpretation of that definition, we found in the MDG monitoring, varied widely.” Miscommunication and misunderstanding between English and Spanish definitions of the term led to “three years of political discussion—on one word,” she explains.
Accuracy also requires seeking input from the most important people: the women and adolescents who are at the center of the data. “Can we make sure that everybody who needs to be at the table is at the table to think this through? For instance…when we talk about measuring essential adolescent services, what is essential? ‘Essential’ to you and me might be very different than ‘essential’ to the adolescent that we are trying to reach,” says Chou.
“We have to take stock of the old, while we are moving forward and trying to look really far in the future so that we can really always make sure that things are harmonized,” Chou explains, but sometimes it is necessary to stop and understand why we are doing what we are doing.
“We are really in a fantastic time that we can really think about this and make a change,” says Chou. “Everyone, everywhere, has something to do.”