Photo Essay: Afghanistan, the Worst Place to Be a Mother

Tuesday, May 31st, 2011 by Christopher Lindahl

Save the Children’s Mothers Index was published earlier this month and ranks Afghanistan as the worst place for mothers. The following photo essay was originally published on the Health Newborn Network blog. It is reposted here with permission.

 


A newly pregnant woman (centre) sits with two mothers waiting for vaccines in Guldara's Basic Health Centre, one of the few health centres providing trained birth assistants in the area, Kabul Province, Afghanistan. Save the Children's new Mother's index rankings reveal Afghanistan to be the world's toughest place to be a mother. Lalage Snow/Save the Children”

 

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Weekend Reading

Friday, May 27th, 2011 by Christopher Lindahl

This week on the MHTF blog:

  1. We posted reactions from FCI and Gynuity, VSI and RHTP to the approval of misoprostol to prevent PPH
  2. Global Health Visions wrote a report on maternal health donors
  3. We listened to Esther Duflo at the Population Council
  4. Why evidence matters

Some reading for the weekend:

  1. A lawsuit in Uganda over maternal deaths
  2. Health workers in conflict settings
  3. Barriers to accessing maternal health care in northern Nigeria
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Why Evidence Matters

Friday, May 27th, 2011 by Christopher Lindahl

At the MHTF, we have a mandate to build consensus within the maternal health community on a variety of issues based on evidence.

 

A recent trial in Africa, publish in the New England Journal of Medicine has found that a routine treatment for children suffering from shock (often due to meningitis) may lead to higher child mortality. Children receiving the treatment, known as fluid resuscitation, were nearly 50% more likely to die within 48 hours. Approximately 10.5% of the children who received the treatment died compared to 7.3% in the control group. While the difference is only three percentage points, because of the large sample size (N=3141), the findings are statistically significant at a 95% confidence interval.

 

According to the Guardian, “Fluid resuscitation for shock was introduced in Europe and the US several decades ago without a trial, on the basis that it worked for children in shock who were seriously dehydrated from conditions such as gastroenteritis.” However, the authors of the study conclude: “the results of this study challenge the importance of bolus resuscitation as a lifesaving intervention in resource-limited settings for children with shock who do not have hypotension and raise questions regarding fluid-resuscitation guidelines in other settings as well.”

 

Cases such as these illustrate the need for evidence based practices to ensure not only the efficient use of scarce global health resources, but also to ensure that interventions that seem effective are not causing harm.

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Esther Duflo at the Pop Council

Thursday, May 26th, 2011 by Christopher Lindahl

Yesterday, we had the opportunity to go to the Population Council’s New York office for a Poverty, Gender and Youth Seminar with Esther Duflo from MIT. As a coauthor (along with Abhijit V. Banerjee) of the recently published Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty, Duflo discussed the chapter of the book that focuses on population and family. She argued that many of the family planning and population policies internationally and at the country level are based on two assumptions, for which, the evidence is perhaps not as strong as we think.

 

1. Big families are bad
Because of the easy to see association between fertility rates and gross domestic product per capita, assumptions are made that smaller families will lead to richer people. However, there isn’t evidence that the causal relationship is in that direction. It’s possible that getting richer leads to smaller families. Duflo discussed two types of studies (”fertility shocks”1 and study on China’s one-child policy2) to provide evidence as to why big families are not necessarily bad for children. However, given that a fixed number of resources must be spread out between a larger number of people, they suggest that it is, in fact, mothers who often lose out as family size grows. Larger families sizes are associated with a reduced opportunity for women to work and control finances within the family.

 

2. Lack of access to contraceptives leads to large families
Duflo argued that low usage of contraceptives is not necessarily an indication of a lack of access to contraceptives.3,4 She and Banerjee conclude on the topic: “Contraceptive access may make people happy by giving them a much more convenient way to control their fertility than the available alternative. But it appears to do, in itself, little to reduce fertility” (110).

 

Duflo and Banerjee argue that some of the major causes of large families are cultural norms, the fact that children are “financial instruments” who may care for parents in old age, and a lack of agency within the family for women.

 

Overall, the book and discussion challenge assumptions we have about the poor and how to improve the lives of the poor. While getting policies, institutions and systems right can be extremely difficult, Duflo and Banerjee identify a number of surprising interventions that can improve people’s lives. Taken as a whole, the book shows the interconnectedness of many factors relating to poverty alleviation. The chapter on population concludes that proper policies and interventions that will most effectively address population having little to do with it directly:

The most effective population policy might therefore be to make it unnecessary to have so many children (in particular, so many male children). Effective social safety nets (such as health insurance or old age pensions) or even the kind of financial development that enables people to profitably save for retirement could lead to a substantial reduction in fertility and perhaps also less discrimination against girls (125).

 


1. Joshua Angrist, Victor Lavy, and Analia Schlosser, “New Evidence on the Causal Link Between the Quantity and Quality of Children,” NBER Working Paper W11835 (2005).
2. Nancy Qian, “Quantity-Quality and the One Child Policy: The Positive Effect of Family Size on School Enrollment in China,” NBER Working Paper W14973 (2009).
3. Mark Pitt, Mark Rosenzweig, and Donna Gibbons, “The Determinants and Consequences of the Placement of Government Programs in Indonesia,” World Bank Economic Review 7(3) (1993): 319-348.
4. Lant H. Pritchett, “Desired Fertility and the Impact of Population Policies,” Population and Development Reivew 20(1) (1994): 1-55.

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mHealth Tools101: Turning Ideas Into Action

Wednesday, May 25th, 2011 by Christopher Lindahl

un foundation logo     UNF_Logo_jpeg.jpg      VFlogo.png     mhealth logo

 

DataDyne, the United Nations Foundation,
the Vodafone Foundation, and the mHealth Alliance

invite you to join us in person or via webinar for:

 

mHealth Tools 101: Turning Ideas Into Action

 

with special guests

 

Peter Benjamin
General Manager, Cell-Life

 

Mike Frost
Director, mHealth, John Snow, Inc.

 

Xoli Mahalela
Director, Monitoring, Evaluation & Research, University Research Corporation

 

and

 

Gustav Praekelt
Founder, Praekelt Foundation

 

Monday, June 6, 2011
14:00 GMT
The Westin Grand, Cape Town, Arabella Quays

Convention Square
Lower Long St.
Cape Town, South Africa

 

or via webinar

 

R.S.V.P.
To attend in person, please respond to rdonna@datadyne.org.
To participate via webinar, please visit https://www3.gotomeeting.com/register/845878438.

 

Participants of the “mHealth Tools 101: Turning Ideas into Action” workshop will meet four mHealth practitioners who have used mobile tools to improve outcomes of health projects. Practitioners will describe how they used the tools, what outcomes this generated, and answer questions.

 

The GSMA-mHA Mobile Health Summit conference and exhibition will take place on June 7 and 8, with additional meetings, working groups and other sessions being held the day prior and after. For more information and to register, please visit: www.mobilehealthsummit.com.

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U.S. Maternal Health Donors: A Landscape Analysis

Tuesday, May 24th, 2011 by Christopher Lindahl

Insufficient funding for maternal health has been identified as a major obstacle in achieving MDG5, so the MHTF commissioned Global Heath Visions to conduct a landscaping of all the existing and potential maternal health donors based in the US. Some experts have called for a new maternal health donor affinity group, and this landscaping explored that feasibility. As global advocacy and activism for improved maternal health outcomes accelerates, so should funding. But this report found that is not the case, at least in the US. Further explorations into non-US funding for maternal health might yield more encouraging results. The report of the GHV landscaping exercise is found here, along with some annexes that identity specific activities and portfolios of current and potential MH donors.

 

Maternal Health Donor Landscape Analysis Report / Annex IIIA / Annex IIIB / Annex IIIC

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WHO approves misoprostol to prevent hemorrhage

Monday, May 23rd, 2011 by Christopher Lindahl

Written by: Shafia Rashid, Senior Program Officer, Global Advocacy, FCI

 

The following was originally published on the FCI blog. It is reposted here with permission

 

Last week, the WHO Expert Committee on the Selection and Use of Essential Medicines approved the inclusion of misoprostol for the prevention of postpartum hemorrhage (PPH) on the WHO List of Essential Medicines. PPH,or severe bleeding following childbirth, is one of the major causes of maternal death and disability in developing countries. The Expert Committee noted that “600 micrograms [misoprostol] given orally is effective and safe for the prevention of PPH” in settings where oxytocin, currently the standard of care to prevent PPH, is not available or feasible. Moreover, the committee moved misoprostol from the complementary to the core list of essential medicines, validating the drug’s important role in women’s health.

 

Structure of the misoprostol molecule/www.3dchem.com

Structure of the misoprostol molecule

Misoprostol, a prostaglandin, offers several potential advantages over oxytocin for managing PPH in resource-constrained settings. It is widely available in developing countries, is relatively inexpensive, can be transported and stored without refrigeration, and can be administered without an injection.

 

The addition of misoprostol to the WHO List of Essential Medicines is an important step forward in making the drug more widely available for PPH, and provides a critical opportunity for disseminating clear, evidence-based information to ministries of health, regulatory authorities, health system managers, health workers, and other audiences.

 

Strong, effective, and consistent advocacy at the global, regional, and country levels is critical for improving women’s access to misoprostol for both prevention and treatment of PPH. FCI is working with Gynuity Health Projects and other partners to develop an evidence-based advocacy agenda and communications plan to harmonize and disseminate messages on the use of misoprostol for preventing and managing PPH.

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Decision on Addition of Misoprostol to WHO EML for Treatment & Prevention of Postpartum Hemorrhage

Monday, May 23rd, 2011 by Christopher Lindahl

May 19, 2011

 

Dear Colleagues:

 

It has been several months since you lent your support to add misoprostol for prevention and treatment of post-partum hemorrhage (PPH) to the World Health Organization’s (WHO) Model List of Essential Medicines. The 18th Expert Committee on the Selection and Use of Essential Medicines met in Accra, Ghana in March 2011 to review the applications for misoprostol to be added to the WHO’s essential medicines list (EML) for the prevention and treatment of PPH. There was a huge outpouring of support for the inclusion of misoprostol for both indications by international policy-making and programmatic agencies and outside expert reviewers that positively reviewed both applications.

 

On May 6th, the Expert Committee published its results which “add misoprostol to the [Essential Medicines] List, for the prevention of PPH in settings where parenteral uterotonics are not available or feasible.” Additionally the committee moved the drug from the complementary to the core list of essential medicines. The committee’s report cited a recently completed study from Pakistan, demonstrating that “there may be a benefit from use of misoprostol by traditional birth attendants or assistants trained on the use of the product at home deliveries. Unfortunately, the committee did not approve the inclusion of misoprostol for its specific PPH treatment indication at this time. The unedited draft report is available on the WHO website at: http://www.who.int/medicines/publications/unedited_trs/en/index.html.

 

Regarding misoprostol for PPH treatment, the committee expressed some concerns which led to their decision to withhold approval at this time. The major stumbling blocks noted by the committee appear to be concerns about the very limited (e.g. no) data to support the use of misoprostol for treatment of PPH among women who have previously received prophylactic misoprostol to prevent PPH as well as about possible side effects after 800 micrograms (mcg) of sublingual misoprostol. . The committee also indicated a worry that any recommendation to use misoprostol for both PPH prevention and treatment could reduce attempts to make oxytocin more available. It is important to underscore however, that the committee also noted in its report that WHO guidelines and other internationalguidelines recommend misoprostol for both the prevention and treatment of PPH due to atony, where parenteral uterotonics are not available.

 

We are pleased that the EML will now include the 200-mcg tablet of misoprostol for its PPH prevention indication, in addition to:

  1. a 25‐mcg vaginal tablet, for use in induction of labor;
  2. a 200‐mcg tablet to be used in combination with mifepristone, for termination of pregnancy (where legally permitted and culturally acceptable);
  3. a 200‐mcg tablet for the management of incomplete abortion and miscarriage.

Moreover, the addition of misoprostol to the Core List is a strong validation of the drug’s role in women’s health. Future research will address misoprostol use for PPH treatment after its use for PPH prevention. Such use of the drug is certainly already a reality in places where oxytocin is not yet available and/or feasible to use. These results and other supportive data will be submitted to the Expert Committee on the Selection and Use of Essential Medicines again for consideration in two years.

 

Many organizations, including Gynuity Health Projects and Venture Strategies Innovations, continue to support the addition of misoprostol to the Model List of Essential Medicines for its specific post-partum hemorrhage treatment indication and will continue to advocate for its inclusion in the future.

 

We thank you again for your support of this issue.

 

Sincerely,

 

Jennifer Blum, M.P.H., Gynuity Health Projects
Ndola Prata, M.D., M.Sc., Venture Strategies Innovations, Associate Professor in Residence, University of California, Berkeley
Kirsten Moore, Reproductive Health Technologies Project

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Weekend Reading

Friday, May 20th, 2011 by Christopher Lindahl

This week on the MHTF blog:

  1. Dr. Yetnayet Asfaw of EngederHealth was interviewed on PBS
  2. Kate Kerber and Ribka Amsalu of Save the Children wrote about maternal and newborn survival in crises
  3. We discussed income shocks and birth outcomes
  4. Comments on misoprostol’s addition to the WHO Essential Medicines List

Some reading for the weekend

  1. Women and mobiles phones, part 2
  2. Institutional birth in low income countries
  3. Mortality reduction from interventions for hypertensive diseases
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Misoprostol added to WHO list of essential medicines for PPH

Thursday, May 19th, 2011 by Christopher Lindahl

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality, accounting for about 25% of all maternal deaths. Misprostol is an easy to use drug that is shown to be successful in preventing PPH. Earlier this month, the World Health Organization added misoprostol to its List of Essential Medicines for the prevention of PPH. The news is the culmination of years of research and advocacy.

 

Jill Sheffield of Women Deliver writes:

Now that misoprostol is recognized as an essential medicine, we must take the next step and help translate this development into increased awareness, approval, and access in every country with a high rate of maternal death. The small white pill is inexpensive, stable even in warmer climates, and is easy-to-use, making it ideal for community-level delivery where oxytocin is not available or cannot be safely used. Simply put, this pill can save lives by preventing women from bleeding to death during and after delivery.

 

Krishna Jafa of PSI also lauds the decision:

The WHO’s designation of misoprostol in its List of Essential Medicines is significant because many national governments follow WHO guidelines when drawing up their own national essential medicines list; drugs on national essential medicines lists are often prioritized by governments for budgetary allocations and procurement. We can now expect that misoprostol will be more widely available in the places it is most needed.

 

Finally, Melanie Holden of Venture Strategies Innovations says:

Within VSI we are elated. This is a tremendous boon for women’s health and solidifies misoprostol’s role in making childbirth safer. As co-authors of the application with Gynuity Health Projects, we are enormously proud of this accomplishment and how it will translate to lives saved around the globe.

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