RAMS chapter 9 is an interesting discussion of the interaction between policies and local realities, specifically regarding population control in the Islamic Republic of Iran.  It discusses the discord between forces of conservatism rooted in tradition, and policy makers who want to improve life conditions through modernisation. Caught up in the midst of these two sides was the young people themselves in Iran, who reproductive health was the issue at hand.  The question is raised as to why the same authorities who initially agreed to implement a family planning programme, then subtly changed their minds half-way through making restrictions for policy makers.  This case is an example of a clash between the agenda of the religious political elite and that of modernising bureaucrats.  It was seen that top-down policies can provoke reactions which may be passive and indirect, slowly hampering policies.  I think that this case is by no means isolated.  Many, many countries in the world today are facing conflicts between their traditional values and ways of life, and new ‘Western’ or modern ways of thinking and living.  This can extend to all areas of life, including reproductive health.  I think it is essential that policies are not made in a vacuum or simply by the leaders in charge of a nation.  It is important the voices of the people are heard, and on-the-ground research is carried out to see where people are at and what compromises might be found that would achieve a modern goal yet also allow traditions to remain.  But what does this look like in practice and in other related issues such as FGM?

In Molly Jobe’s presentation today, she proposed some ways to promote maternal-fetal attachment.  These included Talk with Me Baby, Centering Pregnancy, and Kangaroo Care.  All of these are very low cost and research has shown that they are very effective.  In fact, Kangaroo Care, is much more effective than other more expensive/invasive options such as incubators.  From a global perspective, I think these would be excellent interventions to promote as they are relatively simple, cheap, and effective!  It would just require widespread education, and for Centering Pregnancy it would require some basic equipment like a scale and blood pressure cuff.  I think its interesting to note that a form of Kangaroo Care is actually carried out in many cultures like in sub-Saharan Africa, where babies are carried most of the time snug on their mother’s back with kikwembes (cloth wraps). Funny how before new technologies were invented (like incubators and formula and C-sections that are now used extensively in many countries), people used more natural methods (like kangaroo care, breastfeeding, natural births) – and research is now showing these to actually have better outcomes.

What actually improves health outcomes and services in the long-run?  One huge way is through community mobilization.  But how can this be carried out successfully?  The PHASE project in Maila and Melchham in Nepal provides a great example.  In 2008, women in Nepal were giving birth in cowsheds and then spending their first month postpartum there with their baby.  This was due to cultural traditions that considered new mothers (and menstruating women) unclean, but considered cows to be holy and clean – so what better place for the new mother to reside?  This is a great example of the tremendous impact culture and beliefs have on health practices.  The two are integrated and can’t be dealt with separately.  Anyhow, cowsheds led to high levels of infection and a very high maternal mortality rate, with the adjusted UN estimate 850/10,000 in 2007. The four PHASE health workers involved the community in their entire process.  First, they went house to house getting to know the community and conducting surveys, and held community meetings and called together the Female Volunteer Health Workers who were trusted members of the community and thus could have a large impact.  Once some of the key issues were identified, such as the cowsheds, much discussion was held among themselves, with the FVHWs, with the community, and looking at how other parts of Nepal had dealt with this issue.  In the end, they decided to give women the incentive of a new set of clothes if they went to a primary care center to give birth and agreed not to live in the cowshed.  This came about after many discussions with the community about alternatives for where the mother spent her first month postpartum, and accepted the variety of options proposed, such a lean-to, or one room in the house.  Now, half of births there are attended by a skilled health worker and almost 100% agree not to live in a cowshed.  This is tremendous change, and it happened from the level of the community, and thus will be sustainable. Imagine is the PHASE health workers had simply gone in without extensively consulting the community and set up a birthing center.  Would it have been successful?  I don’t think so.  Likewise, I think this lesson needs to be applied to so many other projects in many parts of the world.  Using, there is a story behind resistance to change, and this needs to be explored and worked with!  I think this could even be very applicable to the situation with ebola in West Africa right now.  Just as one example, if the initial perception was that white people were bringing in the disease, then how likely is it that people would go to them when they got sick?

I really enjoyed our debate on the very controversial issue of where women should give birth.  I feel that the birthing center has the strongest argument as the ‘best of both worlds’ as far as having aspects of both hospital and home birth, in both developed and undeveloped countries. In birthing centers, there are certified midwifes who not only can manage many complications, but can also provide the support and confidence that women need – thus providing holistic care.  A birthing center can have a ‘home-y’ feel where women can experience childbirth as an emotionally and culturally meaningful life experience like they would at home, rather than in a place associated with sickness.  In addition, giving birth in the hospital costs a lot of money, introduces infants to many pathogens, and results in far more interventions than are needed, which has negative effects on both the mother and infant.  The birthing center can eliminate all of these negatives, while also having a referral plan to transfer women to a hospital if a rare but serious complication should occur. New Zealand has a beautiful model of culturally-appropriate midwifery care in birthing centers that is extremely effective (Smythe, 2014), and I think it would behoove the rest of the world to follow their example. In undeveloped countries—where choice may be an ‘illusion’ as hospitals are far away, understaffed, or lacking equipment—it is all the more essential that more birthing centers are constructed.  In the US, as more birthing centers are being established, the public also needs to be more educated in an unbiased manner on all the different options out there for birth.

Symthe, L., Payne, D., Wilson, S., Wynyard S. (2014). Providing a safe space for birth in
Warkworth, New Zealand. In White R. (Ed.), Global Case Studies in Maternal and Child Health (pp. 187-208). Seattle: Ascend Learning Company.

In comparing childbirth in Ethiopia and the US in today’s world, there is obviously a tremendous discrepancy between the two.  Ethiopia is on one end of the spectrum, with many rural areas with very limited access to any medical care, while in the US the pendulum has swung too far the other way where birth has become almost entirely medicalized.  As far as what policy could be implemented in either place to improve outcomes, I think that Ethiopia would benefit most from education–about prenatal care, nutrition, the labor process, fistulas, etc–whether this is on the level of nurses, midwives, or the general population.  I think that the US would most benefit from bringing back midwives to the full scope of their practice outside of the hospital, following Europe in returning to a bit more traditional way of childbirth. Additionally, I think that formula companies in the US should be banned from providing free samples to new mothers, as this drive for business can lead to poorer health outcomes for infants.