Monthly Archives: May 2012

Focus on Maternal Health: The Domestic Agenda by Annie Feighery

Today Mother’s Day is celebrated here in Canada and in several other parts of the world.  The purpose of its inception was to be a day to honour your mother or to be honoured as a mother.  Personally, motherhood has been my most precious gift as well as my biggest challenge. Although cultures may differ globally, one common thread ties all women, and that is our universal love for our children.

I have asked Annie Feighery to write a post for Mother’s Day focusing on maternal health and maternal survival.  Annie, mother of 3 children, is a behavioural health scientist from New York City.  Her current project, The Domestic Agenda, focuses on improving maternal health care by working directly with mothers in lower income countries and using their opinions and experiences to build better health practices.  Below Annie has included two of her videos that showcase interviews with women to find out how they would like to improve their own health care.  I have an incredible amount of respect for Annie’s work and her perspective on improving maternal health care. I am overjoyed that she has agreed to write this post.    

Happy Mother’s Day to Annie and all the mothers around the world, including my own mother (who will always be the most incredible mother I could have ever imagined).

And thank you to my children for teaching me more than I have taught them and for making a mother out of me.

Alyson

Focus on Maternal Health and The Domestic Agenda by Annie Feighery

The global effort to eradicate extreme poverty is, at its core, an effort to make life more livable and joyful on a day-to-day basis for the 1.3 billion people on the planet who live on less than $1.25 a day1. The financial definition of extreme poverty eludes research efforts because poverty impacts a family in so many ways that have nothing to do with money. Health and well-being is intensely personal and has more to do with measures of elasticity and resiliency. Perhaps the worst of the impacts is the insidious way in which poverty can rob a woman of the joy of motherhood.

Maternal health is the world’s greatest social injustice.  Ninety nine percent of the world’s maternal deaths occur in impoverished countries2. The most common cause of maternal death is hemorrhage: bleeding out of control, without clotting during or after birth. The condition is almost entirely preventable with a $1 pill of misoprostal—available if mom gives birth in a clinic, and if her clinic has supplies3. For every maternal death, thousands more women survive birth only to live with a lifelong debilitating birth injury. Among the most common birth-caused disabilities is incontinence, which can result in a woman being shunned from her family and community. Still worse, the conditions of extreme poverty impact mental health at alarming rates, sometimes in excess of 35%4. More widespread than maternal morbidity and mortality is severe depression, which robs a mother of the joy of raising her children, of soothing their cries, of believing their survival is going to make the world a better place.

There has been very little innovation in maternal health in the 65 years of international global health. One system-level problem is that global health interventions are usually contract-based management structures. A contractor or NGO proposes and then measures outputs to produce based on their input of services. There is a management rule: what gets measured gets done. For child health, outputs are plentiful: upper arm circumference, weight for height, hair color changes or distended belly from malnutrition, developmental goals by time, etc. For maternal health, there are pregnancy indicators such as weight gain and delivery date, but aside from maternal death, a woman’s health provides too few measurable outputs. As a result, many maternal and child health programs focus almost entirely on the children. Accordingly, child survival is improving precipitously, while maternal survival lags far behind.

When I am observing a clinic over a period of time, without fail, the clinic is overflowing on market days—days when people drive from the more rural areas to town for buying and selling goods. On those days, I’ve seen clinics so busy that cleaning women are needed to come help the midwives attend the births. On market days, women are able to more easily overcome a significant hurdle to giving birth in a clinic: transportation. Back at the university, I proposed a study to demonstrate maternal mortality in a district reduces on market days. The head of the program said that, although maternal mortality is frequent enough to be a global crisis, on a local level it is too infrequent to easily get a significant sample size for a feasible study. The structural demands of research institutions contribute to the lack of innovation for these women.

I have been working on a film series to try to discover new interventions for maternal health by asking the women most at risk for maternal morbidity and mortality (death and injury) what would make things better for them. This crowd-sourced approach has shown me two things: first, women have amazing insights on their own health; and second, their solutions don’t line up very well with the current approaches in global health.

Women told me they know the standard for care at clinics is very low and there is often not enough equipment for them. I saw this firsthand when I shadowed a midwife in Uganda. There were not enough gloves for her to double glove or even change gloves between patients. Moreover, the gloves are not elbow-high, meaning she risked possible HIV exposure by manually removing placenta—often required to prevent hemorrhage. A ministry of health official told me attendance at clinics increases by a third when the radio stations announce there are Maama Kits at the clinics—the kits that provide the most basic supplies needed to attend a birth, such as gloves.

As a grad student, I once heard a professor talk admiringly about regions of the world where women have such self-control that they give birth silently. When I visit clinics in impoverished areas, I often see women slapped and derided if they yell out in pain. I think it’s not self-control that causes their silence, but fear of abuse and shame. The women I talk to say the treatment they receive in clinics is openly discussed between friends and family when they are deciding whether to go to clinic for birth or use a traditional birth attendant (TBA). As a behavioral scientist, I see a survivor’s bias that also influences the use of TBAs: no women who died in birth are present for those conversations. The women who had good experiences credit their TBA.

In communicating maternal health specifically or global poverty in general, I run into the problem that the women sound like victims of a system beyond their control. People don’t identify with a victim in a narrative. We all want to be heroes. If researchers and policy makers don’t identify with the individuals whose lives they’re working to improve, how can they succeed? My favorite part of crowd-sourcing new solutions to maternal health is this helps us see that these women are heroes. They know how to save their own lives. In fact, I have started gain framing the condition in my own papers: using a new term rather than maternal mortality in order to reinforce a sense of hope among even the research world: Maternal survival.

by Annie Feighery

Annie Feighery is a behavioral health scientist, entrepreneur, and mother of three in New York City. Annie is the co-founder of The Domestic Agenda, which is currently in production of a documentary about the global effort to crowdsource maternal health solutions. More information about the film can be found at http://www.TheDomesticAgenda.org/film. In addition, Annie is the co-founder of mWater.Co, a start-up offering mobile technology for water monitoring in low- and middle-income communities.

Annie can be followed online at twitter.com/anniefeighery

Reference List

(1)   The World Bank. Poverty Reduction and Equity. http://web worldbank org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/0,,menuPK:336998~pagePK:149018~piPK:149093~theSitePK:336992,00 html [serial online] 2012.

(2)   Ghosh MK. Maternal mortality. A global perspective. J Reprod Med 2001;46:427-433.

(3)   Sheldon WR, Blum J, Durocher J, Winikoff B. Misoprostol for the prevention and treatment of postpartum hemorrhage. Expert Opin Investig Drugs 2012;21:235-250.

(4)   Wachs TD, Black MM, Engle PL.Maternal Depression: A Global Threat to Children’s Health, Development, and Behavior and to Human Rights.  Child Development Perspectives 2009;3;1;51-59

Read More: http://informahealthcare.com/doi/abs/10.1517/13543784.2012.647405. web [serial online] 2012.

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