Maternal Health and Empowerment

What exactly is empowerment? Although the term empowerment is frequently used, there is much confusion about what empowerment is.

Empowerment can according to the UNDP be defined in economic, social and political terms. In economic terms, this means being able to engage freely in any economic activity. In social terms, this means being able to join fully in all forms of community life, without regard to religion, colour, sex or race. And in political terms, this means having the freedom to choose and change governance at every level, from the Presidential palace to the village council.[i]

Photo: Simone Periere

Women's empowerment has according to the UN a total of five components: Women’s sense of self-worth; their right to have and to determine choices; their right to have access to opportunities and resources; their right to have the power to control their own lives, both within and outside the home; and their ability to influence the direction of social change to create a more just social and economic order, nationally and internationally.[ii]

The core of empowerment therefore lies in the ability of a woman to control her own destiny. This implies that to be empowered women must not only have equal capabilities (such as in regard to education and health) and equal access to resources and opportunities (such as access to health resources), they must also have the agency to use those rights, capabilities, resources and opportunities to make strategic choices and decisions. And to exercise agency, women must live without the fear of coercion and violence.[iii]

Empowered women experience increased political participation, control of resources including land, access to employment and education - all which are crucial for promoting maternal health. Empowered women are more likely to have fewer children, more likely to access health services and have control over health resources, and less likely to suffer domestic violence. Their children are more likely to survive, receive better childcare at home and receive health care when they need it. At the same time, improved health outcomes for women can help to strengthen their own agency and empowerment. Healthy women are more able to actively participate in society and markets and take collective action to advance their own interests. They are likely to have greater bargaining power and control over resources within the household.

Empowered women understand their value in society and can therefore demand their right to access quality maternal health services, which in return might influence and even improve maternal health practice and policy.[iv]

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[i] UNDP (1993) 'Human Development Report 1993: People's Participation', (New York, NY: Oxford University Press).

[ii] UN Secretariat, Inter-agency Task Force on the Implementation of the International Conference on Population and Development’s Programme of Action, ‘Guidelines on Women’s Empowerment’

[www.un.org/popin/unfpa/taskforce/guide/iatfwemp.gdl.html].

[iii] Millennium Project Task Force on Education and Gender Equality (2005) 'Taking action: achieving gender equality and empowering women.'

[iv] Partnership for Maternal Newborn and Child Health (2013) 'Promoting Women's Empowerment for Better Health Outcomes for Women and Children.' (New York, WHO Press)

WHO launches programme to improve maternal health in Mozambique

Mozambique has been short of medical supplies, which meant that some clinics would turn women away in their first trimester, unless they could visually confirm the pregnancy or pay for a test. This drove women away from clinics; making them miss out on basic testing before they delivered. Moreover, it was hard to get to the clinics: a lack of time and transport kept many women from using clinic services. And even if they were able to get there to have a test, they were often unable to get back to get their results.

Photo: World Health Organisation

Now women have better access to maternal health care. Each clinic receives complete antenatal care packages with all of the necessary medicines and laboratory supplies. WHO medical officer, Dr. Ana Pilar Betrán, explains that with the streamlined approach: “Waiting times are shorter and women are more positive and prompt to come in for their antenatal care visits.”

By the end of 2015, 10 clinics across Mozambique will be providing full antenatal care services under the programme. Dr. Betrán says that, “…if the intervention is proved efficient, then the next steps will be to expand the process and the intervention to the whole country.”

Dr. Betrán visited the first antenatal care clinic in the Nampula Province in Mozambique on 1 June 2014, for the launch of the programme, and was overwhelmed: “It was really incredible the amount of women that were in the waiting room.” Dr. Betrán and her team designed the programme, trained health care providers, and established storage and tracking systems for the equipment and medicine. 

Antenatal care is an important factor in ensuring women deliver their babies safely, and that those babies are healthy. Women in the 10 pilot project areas are beginning to see why they need to visit health-care professionals during their pregnancy.

Women-centred health care

The new one-stop shop approach resulted from research carried out in 2011 through focus groups with women who experienced the clinics first-hand. Dr. Marleen Temmerman, Department Director of Reproductive Health and Research at WHO, explained the importance of this “person-centred” approach to health care and ensuring that everyone has access to the services they need, when they need them: “One of the cornerstones of achieving universal health coverage is to not only utilize evidence-based decision making, but to also speak with and understand the population affected.”

Read more here

Maternal Health from a Medical Anthropological Perspective

According to the WHO, maternal health refers specifically to the health of women during pregnancy, childbirth and the postpartum period,[i] but what exactly do we mean by maternal health from a medical anthropological perspective?

Photo: Simone Pereira

Medical anthropology is concerned with health issues, such as those that affect maternal health, throughout the whole world as well as through time. Medical anthropologists investigate health as a biological condition, as well as the cultural construction of symptoms and treatments, and the nature of international between biology, society, and culture. At the same time, medical anthropologists do not just accept one particular health care system, such as Western biomedicine, as holding monopoly on health knowledge and effective treatment, but rather investigate all health systems as cultural products.[ii]

Medical anthropologists seek to understand maternal health as:

• Cultural conceptions, such as culturally constituted ways of experiencing pregnancy and childbirth;
• social connections, such as the type of relations that exist within the family or within society and the world political and economic system generally;
• human biology, such as the threat of microscopic pathogens on the mother's bodily system and the body's immune responses to such threats.[iii]

Even though pregnancy and childbirth seem to be biological, objective occurrences, the handling of such, can be coloured by its cultural context. E.g. Emily Martin found that metaphors derived from industrial production are used by biomedicine to describe childbirth. In this biomedical cultural model of birth 1) the doctor is portrayed as the manager of the labouring process; 2) the uterus is portrayed as the machinery of reproduction; 3) the mother is some kind of labourer, and 4) the baby is the production. Martin explains that this metaphor of labor dehumanizes the experience. The women are not taken into account as a human being, instead her uterus is seen as a tool that allows doctors to get closer to producing a new product.[iv]

Another medical anthropologist, Brigette Jordan has found that different cultures have different ideas about pregnancy, delivery, and maternal health. In many non-biomedicine health care systems, traditional birth attendants provide support to women in childbirth, whereas Western biomedicine has created a full medicalization and high-tech childbirth. Here 1) high-tech machinery is used to monitor pregnancy and birth; 2) surgery may be used to widen birth portal and remove the baby, and 3) medications are used to deal with the pain or speed up the birthing process. Jordan describes how the roles often differ in the different health care systems, whereas the role of the traditional birth attendants often is to assist the family in fulfilling their decisions, birth often becomes viewed as an "illness" in biomedicine/hospitalised systems which needs to be "treated," whereby the mother becomes the patient, and the doctor takes charge.[v]

Despite the fact that maternal health is culturally relative, as illustrated above, the reality remains that maternal mortality and morbidity remain a problem for many women worldwide. In 2014 about 800 women died due to complications of pregnancy and child birth every day. Almost all of these deaths have occurred in low-resource settings, even though most could have been prevented.[vi]

Judith Justice assessed international efforts from a medical anthropological perspective, and found that efforts to reduce to improve maternal and child health has had an overemphasis on top-down approaches, inadequate attention to disparities in national health resources, and failure to recognise local diversity within nations can act as barriers. She recommends that international funds should be made available to cover initial costs of improving maternal and child health, as well as support the implementation of programmes at the local level, since poorer nations are not always able to meet all the local challenges of programme implementation.[vii]

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[i] World Health Organisation, 'World Health Report 2014' (2014) 

[ii] M Singer, Introducing Medical Anthropology: A Discipline in Action, Altamira Press, New York, 2007.

[iii] Based upon model provided by Singer, as above.

[iv] E Martin, The Woman in the Body, Beacon Press, 1989

[v] B Jordan, Birth in Four Cultures, Illinois, Waveland Press, 1992

[vi] World Health Organisation, 'World Health Statistics 2014' (2014) 

[vii] J Justice, 'The Politics of Child Survival' in Global Health Policy, Local Realities. L Whiteford and L Manderson, eds. Boulder, Lynne Rienner, 2000

Developing a Human Rights-Based Approach to Addressing Maternal Mortality - DFID Desk Review

This desk review produced by the UK Department for International Development (DFID), argues that rights-based approaches can add impetus to reducing maternal mortality. The desk review highlights that policy actors in government and civil society should find ways of addressing the economic, social, cultural and political forces that prevent poor women from asserting their right to maternal health.

Although improving maternal health is one of the Millennium Development Goals, few countries have progressed in reducing maternal mortality during the last 20 years. Unacceptably high maternal mortality rates prevail. This can be attributed to the status of women, the systematic violation of their basic human rights and failing health systems. Rights-based approaches can uncover the power dynamics that perpetuate these inequities, and suggest strategic interventions such as the reallocation of resources, changing accountability mechanisms within health systems and communities and challenging existing hierarchies in health facilities.

Evidence indicates that supporting maternal health services in an isolated way will not make an impact on maternal mortality rates as a whole. More systemic change is needed.

• Health services, and health systems, play a role in reducing maternal mortality. Change will only occur by tackling health policy at a national level to influence resource allocation.
• The concepts of obligation and accountability provide entry points to influence how decisions are taken about what services to finance. They can also support providers in delivering a service that women can use.
• A rights-based analysis of access to care would highlight those women who are not currently using services. It would also reveal the underlying social and cultural factors that perpetuate their inability to do so.
• Rights-based interventions at the community level need to respond to local context and resonate with locally respected values.
• Participatory capacity-building processes appear central to enabling local stakeholders to redefine and negotiate new norms and practices.
• These need to be done in parallel with programmes that help communities hold government and service providers to account.

DFID must match its commitment to applying a rights-based approach to maternal mortality with a recognition of, and advocacy for, the benefits of doing so.

• The political dimensions of rights-based work must be clearly acknowledged: a rights-based approach addresses powerful people's interest in maintaining the status quo. These people may be alienated.
• The language should be contextualised within local values that mirror principles such as equity and non-discrimination.
• Principles that derive their legal legitimacy from international human rights treaties must resonate with rights identified and defined at community level.
• Rights-based approaches need a multi-sectoral analysis and response. Activities should be prioritised and resources reallocated.
• Further research is needed to determine how to complement and add value to existing initiatives in rights-based approaches to reducing maternal deaths. Gaps in the evidence base should be addressed.

Maternal, newborn, child and adolescent health at the sixty-ninth session of the UN General Assembly

Ministers, ambassadors, senior public officials, and civil society representatives gathered on 21 September 2014 in New York to discuss maternal, newborn, child and adolescent health.

The WHO co-hosted a breakfast event with Countdown to 2015, the independent Expert Review Group (iERG) and The Partnership for Maternal Newborn & Child Health (PMNCH). This fourth annual event will bring together stakeholders, to take stock of evidence on progress, identify models of success, and agree on the priority actions and processes essential to developing robust accountability structures which will also be relevant in the post 2015 era.

Important new data and evidence were highlighted from two new reports — the 2014 PMNCH Report on Commitments to the Global Strategy for Women and Children’s Health and the third report from iERG, which focuses on a vision for women’s and children’s health in the post-2015 era. The findings of the Countdown to 2015 report, Fulfilling the Health Agenda for Women and Children, were also presented at the breakfast. Key findings and recommendations from each of these reports show both the progress that has been made and the continued and intensified effort that is still needed for women and children. With under 500 days left until the end of the Millennium Development Goals (MDGs), and with one year left to shape the sustainable development goals, these reports show that stakeholders are at critical junction for women’s and children’s health, a position laid bare during the discussions on Sunday.

A key theme throughout the event was that of sustainability and strengthening health systems. Dr Margaret Chan, Director-General, WHO, stressed that while progress has been made for women and children, the Ebola crisis in West Africa is a reminder “that even excellent progress can be so fragile.” She, along with other speakers including Julia Duncan-Cassell, the Liberian Minister of Gender and Development, emphasized the importance of building and strengthening health systems to withstand crises and ensure that results are sustainable. Minister Duncan-Cassell also noted that women make up nearly 75% of Ebola fatalities in her country, because it is often women and girls who care for the ill and wash the bodies of the deceased. In addition, the collapse of the health system has grave implications for maternal health, as women are unable or unwilling to give birth in health facilities with skilled birth attendants.

The importance of strengthening health systems, as well as of determining factors for health such as poverty reduction and female education, was reinforced by Dr. Luis Huicho, who presented preliminary findings of a Countdown to 2015 in-depth Country Case Study that he is leading in Peru. This study seeks to understand and explain Peru’s success in reducing its rates of maternal, newborn and child mortality between 2000 and 2012. Also presented at the breakfast was new Countdown analysis of financial flows for reproductive, maternal, newborn and child health (RMNCH), which showed that, while aid for RMNCH increased during 2011-2012, continued increases in both official development aid and in-country investments are needed in order to accelerate progress towards MDGs 4 and 5.

Bob Orr, Assistant-Secretary General of the UN and a key leader of the Every Woman Every Child movement, emphasized UN Secretary-General Ban Ki-Moon’s commitment to women’s and children’s health and his conviction that women and children have to be “at the front of the queue, not at the back of the MDG train.”

Top of mind for all participants was how women’s and children’s health will feature in the post-2015 development landscape and the global health architecture to support it. For the first time in a public forum, panelists and attendees discussed the current plans to develop a Global Financing Facility (GFF), hosted by the World Bank, to better coordinate and leverage financial resources for reproductive, maternal, newborn, child and adolescent health in the 2015-2030 period. Speaking on behalf of the World Bank, Dr Tim Evans briefly described the proposed facility, and expressed great optimism saying, “We have a historic opportunity to bend the curve and eliminate preventable child and maternal deaths within a generation.” While not the only solution, he suggested that the GFF would accelerate progress by pooling funding, leveraging other financial tools and mechanisms, and simplifying and streamlining the global RMNCH landscape to reduce the application and reporting burden on countries.

Agnes Binagwaho, Minister of Health of Rwanda, joined the panel on financing for greater accountability and equity to make a powerful demand from the donor community to respect country leadership in planning, to reduce the burden in reporting requirements of countries, and to work together to invest in national health systems in a more holistic manner. 'Ask us what we need and we will tell you; don't go and speculate: We have a good plan and we know our needs ... the global community must be more accountable on coordination. We are disrupted by you in our work.'

Richard Horton, Editor in Chief of the Lancet, provided an overview of the iERG’s Every Woman Every Child: Post-2015 Vision report along with a proposed new framework for a sustainable approach to improving women and children’s health. He warned that “the landscape for women’s and children’s health is about to undergo a seismic shift” calling for action not paralysis in the face of uncertainty. He told participants that “sustainability is about paying as much attention to the future as we do to the present… it is about the value we put on our lives and on the lives of our children.” Stakeholders this week in New York, will indeed pay heed to these words as they look to help shape a set of sustainable development goals, which leave no woman, child or adolescent behind.

An update on the process for developing the PMNCH post-2015 Strategic Framework.

The Partnership for Mother, Newborn & Child Health (PMNCH) joins reproductive, maternal, newborn and child health communities into an alliance of more than 500 members, across seven constituencies: academic, research and teaching institutions; donors and foundations; health-care professionals; multilateral agencies; non-governmental organisations; partner countries; and the private sector. Working together our goal is a world in which all women, newborns, children and adolescents not only are healthy, but thrive.

At its July 2014 meeting in Johannesburg, the PMNCH Board mandated the Secretariat to begin a process that would result in the development of a PMNCH Post-2015 Strategic Framework.

This new PMNCH strategic framework will build on its ongoing work, as set out in the existing PMNCH 2012 to 2015 Strategic Framework. The decision to develop the next framework is also in line with the views of the majority of members, as reflected in the recommendations from the independent external evaluation of PMNCH, which was recently completed and which will be published shortly.

The Executive Committee agreed that the process for developing the PMNCH post-2015 Strategic Framework would broadly be as follows:

• September/ October, 2014: Procuring external consultants to facilitate the strategic framework development process (in progress), and agreeing a set of issues and questions that would underpin the stakeholder discussions and consultations on the framework development process.

• October/ November, 2014: Ongoing consultations, development of scenarios, and preparations for Board retreat.

• December, 2014: Board retreat to discuss the emerging conclusions and directions for the strategic framework development.

• January to April, 2015: Implementation of Board retreat conclusions, further consultations, and finalisation of the PMNCH Post-2015 Strategic Framework.

To read more about PMNCH, please click here.

Human Rights and Volunteering in Health Care

Health is a in fact a human right. Internationally, it was first articulated in the 1946 Constitution of the World Health Organization (WHO), whose preamble states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”[i]

The 1948 Universal Declaration of Human Rights also mentioned health as part of the right to an adequate standard of living (art. 25). The right to health was again recognized as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights.

Since then, other international human rights treaties have recognized or referred to the right to health or to elements of it, such as the right to medical care. The right to health is relevant to all States: every State has ratified at least one international human rights treaty recognizing the right to health. Moreover, States have committed themselves to protecting this right through international declarations, domestic legislation and policies, and at international conferences.[ii]

Despite the fact that health is a human right, there are many worldwide that do not have access to adequate health care due to fragile health systems. 

The volunteering force may bring the needed strength to fragile health systems. But how exactly do we ensure that we volunteer in a way that supports the heath system in the best way possible? 

Photo: Health Aid Plus

Volunteering can be defined as any activity that involves spending time, unpaid, doing something that aims to benefit the environment or someone (individuals or groups) other than, or in addition to, close relatives. Central to this definition is the fact that volunteering must be a choice freely made by each individual. This can include formal activity undertaken through public, private and voluntary organisations as well as informal community participation.[iii]

The United Nations describes the three key defining characteristics of volunteering as:

First the activity should not be undertaken primarily for financial reward, although the reimbursement of expenses and some token payment may be allowed.

Second, the activity should be undertaken voluntarily, according to an individual’s own free-will, although there are grey areas here too, such as school community service schemes which encourage, and sometimes require, students to get involved in voluntary work and Food for Work programmes, where there is an explicit exchange between community involvement and food assistance.

Third, the activity should be of benefit to someone other than the volunteer, or to society at large, although it is recognised that volunteering brings significant benefit to the volunteer as well.[iv]

There is no doubt that we ourselves benefit from volunteering. Volunteering is the perfect vehicle to discover something you like doing and developing a new skill. It is never too late to learn new skills and no reason why you should stop adding to your knowledge just because you are in employment or have finished education. However, how can we be sure that our volunteering is actually beneficial to those we seek to help? And how do we ensure that our volunteering promotes health care whilst promoting the human rights of those we seek to help?

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[i] WHO (1945) 'WHO Constitution.' (Geneva: WHO Press)

[ii] WHO (2001) 'The Right to Health.' (Geneva: WHO Press)

[iii] Hawkins, S. Restall, M. (2006)'Volunteers across the NHS.' (London: Volunteering England Press) 

[iv] United Nations Volunteers Report, prepared for the UN General Assembly Special Session on Social Development, Geneva, February 2001