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]

---

[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.