Maternal and Child Health

Emerging Voices features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is by Alicia Ely Yamin, lecturer on global health and policy director of the FXB Center for Health and Human Rights at Harvard University. At the UN General Assembly last month, world leaders moved toward a new development agenda, the Sustainable Development Goals (SDGs), which build upon the soon-to-expire Millennium Development Goals (MDGs). As these discussions continue, policymakers must prioritize creating equitable and effective health and social protection systems, rather than only focusing on stand-alone, single-issue initiatives. As a recent John and Katie Hansen Family Foundation study conducted through Harvard University demonstrates, the challenges of development are complex, often cutting across multiple aspects of wellbeing, including health, nutrition, education, and socioeconomic status.  Over generations, these interrelated problems are too often compounded, and they can persist in the face of narrow interventions that tackle only a single issue and ignore the big picture challenges of developing communities. Consider the broad-reaching impact of maternal mortality: though the actions needed to stop women from dying in pregnancy and childbirth have long been known, approximately every ninety seconds, a preventable maternal death occurs. The Hansen Foundation study investigates the intergenerational impacts of maternal deaths on children in Malawi, South Africa, Ethiopia, and Tanzania and finds that losing a mother can ruin an impoverished child’s chances for future prosperity. Indeed, consequences range from elevated mortality levels in infants and young children to early school dropout and early pregnancy. Isolated programs, such as those focused on nutritional supplementation or ensuring appropriate vaccinations for children, are beneficial, but this piecemeal approach leaves many gaps in the system through which orphans might slip. The study reviews the few programs that exist for maternal orphans in Tanzania, Malawi, and Ethiopia and finds that all three countries lack sufficient coordination both horizontally—among the health, educational, and other sectors—and vertically—between national and local government structures. Even in South Africa—a country with a higher GDP per capita than the others studied and a history of social protection grants—the process of applying to social welfare programs can be fraught with delays. These delays are due, at least in part, to weak linkages within the system, such as the communication between a health facility and social development office. The result is fragmented orphan care; for example, if an orphan was born to an HIV-positive mother receiving prevention of mother-to-child transition (PMTCT) care, that orphan often does not receive follow up care, either medical care for AIDS or other social support. These disconnects and delays place a burden on families in need of more immediate assistance and, in some cases, prevent individuals from accessing government services. Rather than single initiatives, these countries need systemic linkages and multisectoral programs that support both women’s reproductive health and the health, educational, and other needs of orphans and their communities. Social protection programming needs to take a holistic approach to the analysis, planning, and budgeting processes from the beginning of the policy cycle, incorporating orphans’ needs for income, educational support, food security, and health care throughout. These integrated, multisectoral plans of action then need to come to fruition in full and include measures to ensure orphans receive care across the different sectors of social protection, such as referral services. This streamlined approach could remove vulnerable populations’ barriers to accessing services, prevent individuals from falling through the system’s gaps, and empower affected families and communities to make holistic decisions about their needs. Social protection systems are within reach for all countries, even impoverished ones,  and investments in universal social protection systems have high returns. In economic terms, these systems typically generate internal rates of return from 8 percent to 17 percent. Yet their more important effect is on social inclusion and equity. By accelerating progress for the most vulnerable and often excluded populations, social protection systems help to level the playing field across societies, thus promoting more democratic inclusiveness. All of these outcomes—increasing healthy years of life, productivity, and economic growth and improved social equity—have been identified as SDG aims. As the debate continues over the SDG agenda, the full intergenerational costs of failing to prioritize reproductive and maternal health within functioning health systems should be considered, but so too should the broader role that social protection systems can play in improving cross-cutting social and economic rights, substantive equality, and meaningfully “sustainable” development.

Emerging Voices features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is by Becky Allen, former intern in the Women and Foreign Policy program. Female genital mutilation (FGM)—a practice that poses severe health risks to women and girls—is widespread in the developing world: of the women and girls living in the twenty-nine African and Middle Eastern countries where the practice is most prevalent, more than 125 million have been cut. Widely considered a form of violence against women, studies indicate that FGM can result in both psychological and physical consequences. Yet FGM occurs in the Western world as well. Activists claim that FGM has been on the rise in both Britain and the United States in recent years, especially given increased rates of immigration from countries where the practice is prevalent. A 2014 study by the City University London and Equality Now found that over 137,000 women in England and Wales have undergone FGM. Another 20,000 girls are at risk each year in the United Kingdom. In the United States, where the practice is masked in greater secrecy, the numbers are difficult to determine, though some estimates put the figure in the hundreds of thousands. In response to this growing issue, the British government and UNICEF co-hosted Britain’s first annual Girl Summit to raise awareness of FGM on July 22. The summit aimed to launch a movement to eradicate the practice within a single generation. As Susan Bissell, chief of child protection for UNICEF, affirmed: it’s time to “up our game”—even in the West. So far, the British government is following through on its mission. Prime Minister David Cameron announced that tougher legislation will make it illegal for parents to subject their daughters to FGM. The existing 1985 British law banning the practice targets the performer of FGM or the guardian responsible for taking a girl to undergo the procedure abroad. Even so, local authorities have knowingly overlooked perpetrators of FGM. It was not until this year—thirty years after the law was enacted—that a successful prosecution occurred in Britain. The British government has also pledged £1.4 million (about $2.4 million) to establish an effective system for identifying girls who are at risk for FGM in Britain. Under the new system, special training will be provided to teachers, social workers, health professionals, and police officers. Moreover, the country’s citizens have been mobilized to act on this front: just last week two doctors teamed up to open the world’s first clinic for child victims of female genital mutilation. In addition to providing medical and psychological support, the clinic will liaise with police, social services, and community groups to identify and safeguard girls who are at risk for the procedure. Lastly, Britain has increased training sessions for airport personnel, teaching them to identify both potential victims and performers of FGM. Not only do parents take their daughters to their native countries to be cut, but a new trend in which “cutters” come to Britain to perform the practice has also recently emerged. Since the launch of this operation in July, thirty families have been stopped according to Gatwick Airport officials. The United States has joined Britain in the campaign to end FGM. Last month, the Obama administration announced plans to conduct a national study that will research the consequences and risks of FGM in the United States. The U.S. government also recently developed a preliminary working group on FGM, which is expected to devise strategies for fighting the practice through education. The strategy taken by the Obama administration will help policymakers develop a nuanced understanding of FGM before enacting relevant legislation. The approach stands in contrast to a 2010 proposal by the American Academy of Pediatrics, which suggested that the United States legalize a “ceremonial pinprick” of girls to dissuade families from taking their daughters abroad to undergo the full procedure. The 2010 proposal sparked an uproar, raising questions about the nature of FGM and parents’ intentions. As one critic pointed out, “We don’t let people… beat their wives a little bit because they’re going to do it anyway.” The United Kingdom and the United States have the opportunity to step up in the fight against FGM in their countries. Through new legislation, enforcement of existing laws, and training programs for personnel who are in the position to identify girls at risk, these nations can address the growing issue of FGM in their own backyards.

The third annual International Conference on Family Planning (ICFP) closes today in Addis Ababa, Ethiopia with new and increased commitments from countries around the world to bolster local and global family planning initiatives. The conference, under the theme “Full Access, Full Choice,” was co-hosted by the The Bill & Melinda Gates Institute for Population and Reproductive Health at The Johns Hopkins Bloomberg School of Public Health and the Federal Ministry of Health of Ethiopia. This year’s conference was the largest family planning conference in history; thousands of policymakers, researchers, and advocates came together to increase awareness of the benefits of family planning, such as improving maternal and child health, education rates, economic growth, and social stability. In April 2011, Gayle Tzemach Lemmon and I published a CFR report titled Family Planning and U.S. Foreign Policy that discusses similar themes. The report emphasizes how investing in family planning supports a myriad of U.S. foreign policy and international development objectives. Allowing women to make decisions about the size of their families and the timing of their pregnancies has positive health outcomes such as reduced maternal and child mortality, improved child health, and fewer safe and unsafe abortions. Moreover, family planning is highly cost effective: for every U.S. dollar spent on family planning, six are saved, and communities reap substantial economic benefits. When women are given access to contraceptives and other modern methods of family planning, they are able to stay in school -- and extended education is directly correlated with increased income. These women are also more likely to join the workforce and run their own businesses, allowing them to contribute to their local economies and fulfill their potential to be productive members of their communities. For decades, the United States has played a leading role in promoting access to contraceptive education and resources in developing countries. Since the launch of its first family planning program in 1965, USAID has continued to expand its international family planning efforts and now operates in more than fifty countries around the world. USAID has helped countries that previously struggled to provide family planning services– such as Indonesia and Mexico – reduce fertility rates and improve community health by providing financial and technical assistance. Through USAID, the State Department, and other government agencies, the United States has helped millions of women around the world plan their pregnancies, and their lives. An estimated 220 million women want but do not have access to safe, effective, affordable, modern methods of contraception. This wide and unmet need results in 80 million unplanned pregnancies, 30 million unplanned births, and 20 million unsafe abortions every year. But despite these troubling numbers, progress is being made, especially in high-need countries. According to the Family Planning 2020 progress report released at ICFP 2013, the countries with the greatest unmet need for family planning have committed to dramatically increasing access to contraceptive information, services, and supplies. Five such countries – Benin, the Democratic Republic of Congo, Guinea, Mauritania, and Myanmar – announced new pledges to their domestic family planning campaigns, and the conference ended with “A Call to Action” asking governments to push for universal access to contraceptives and for the international community to make the issue a priority on the post-2015 development agenda. In our 2011 CFR report, Gayle and I recommended that ensuring universal access to family planning remain a U.S. foreign policy priority. This week’s meeting in Ethiopia underscores the importance of investing in family planning. Not only does it save the millions of lives, it also helps create healthy, resilient families in some of the most vulnerable parts of the world: a positive outcome for U.S. security interests. As international development funding becomes increasingly strained, the United States and governments around the world should remember the social, economic, and political benefits they stand to gain from investing in family planning.

Emerging Voices features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is by Lynn ElHarake, research associate for CFR’s Women and Foreign Policy Program. Here she discusses why Washington should support international family planning efforts. Today marks the seventh annual World Contraception Day – a campaign organized by a coalition of non-governmental, scientific, and medical organizations, which aims to raise awareness about the benefits of universal access to family planning tools. For the most part, Washington supports this cause: the United States has played a leading role in international family planning efforts for more than five decades and has provided roughly half of total donor funding for family planning in foreign countries. The United States Agency for International Development (USAID), which leads many international family planning efforts, launched its first family planning program in 1965 and has been enabling the distribution of contraceptives in developing countries since 1968. Today, USAID’s family planning programs operate in more than 50 countries around the world and have helped millions of women access the life-saving contraceptives they need to plan their pregnancies. Washington has much to gain from investing in international family planning programs. In their 2012 report, Adding It Up: Costs and Benefits of Contraceptive Services, the United Nations Population Fund (UNFPA) and the Guttmacher Institute estimated that adequate access to contraceptives in developing countries would prevent 54 million unintended pregnancies, 26 million abortions (16 million of which would be unsafe), 21 million unplanned births, and 7 million miscarriages. And the benefits of family planning extend beyond women. Universal access to contraceptives could prevent more than one million infant deaths, improve child nutrition and general health, and reduce the spread of HIV/AIDS. Furthermore, when a woman is able to plan pregnancy, she is more likely to stay in school, join the workforce, gain an income, and fulfill her potential as a productive citizen. Female education and employment help close the gender gap, spur economic growth, and stabilize societies. Expanding access to family planning could also save billions of dollars in global healthcare costs, freeing up resources for other health and development initiatives. And family planning programs could help curb worrying demographic trends in developing countries, where many weak economies and governments are not yet able to support burgeoning youth populations. The Obama administration has demonstrated a strong commitment to international family planning goals, increasing family planning funding by forty percent from 2008 to 2012. The Obama administration has also lifted funding restrictions on family planning programs and reissued funding to the UNFPA in 2009, which was suspended under the Reagan and both Bush administrations. Recognizing that access to family planning helps women live healthy and productive lives, the United States included family planning as a primary objective in its Global Health Initiative – a development strategy seeking “to achieve significant health improvements and foster sustainable, effective, efficient and country-led public health programs that deliver essential health care.” The United States also supports the aspirations of the 2012 London Summit on Family Planning, a global partnership committed to providing 120 million women in developing countries with reproductive health resources by 2020. In recent years, the United States and other countries have made family planning a global development priority. However it is likely that contraceptives and other modern methods of family planning will remain subjects of heated debate. Even though the United States has been a leader in the field for decades, the country’s policies on family planning are not always straightforward. Family planning funding has been historically controversial and executive branch support of international programs has been inconsistent. Therefore it is essential that U.S. policymakers are continually reminded of how universal access to family planning can further U.S. interests by improving the lives of women, growing economies, accomplishing international development goals, and securing stable societies worldwide.

Yesterday on my blog, Democracy in Development, I discussed the London Family Planning Summit and the importance of family planning for the health of mothers and children. As I write: I’m often asked, what is the single most important intervention to improve the lives of women and girls in developing countries? I usually answer by urging investment in girls’ education. But a close second—and in some cases I would put first—is birth control. Access to family planning is a matter of survival for many of the world’s women, and their children too. You can read the full post here.