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?

http://http://www.spyghana.com/coalition-unpaid-nurses-midwives-threatens-court-action/

This is an example of the poor treatment that trained health care personnel receive, and the lack of infrastructure in place to provide for them adequately. Thoughts on how to solve this issue?

How can birth outcomes be improved in regions plagued with sexual violence, mass killings, and low levels of security? In countries such as Liberia and the Democratic Republic of the Congo (DRC), war has consumed the nations for past several years. Maternal mortality rates are among the highest in the world and many women are not able to seek medical care immediately after experiencing sexual and/or war-related violence. So many of the citizens in these countries have limited socioeconomic resources and therefore are unable to seek assistance in times of despair. Aiding those most in need in these countries should be a top priority in the field of maternal care.

Establishing clinics like in the Liberia case study seems to be a very promising solution, however, I worry about the fees placed by Ruth on her patients. I understand the need to provide income to sustain the clinic and supplies, but I worry that many individuals, especially in times of war, would not be able to afford any type of medical care. Would there be any effective way of running a clinic like Ruth’s without having to charge patients with a fee for goods and services?

Like we’ve discussed in class, the terms “midwife” or “skilled birth attendant” mean different things in different cultures. They differ in terms of levels of education, authority and skill. I thought about having it mandated that all midwives worldwide have a certain skill and education level, but then I thought about the midwives and skilled birth attendants in places like Mali and how  Monique was one of the only trained midwives in her location. Besides not having the infrastructure to train these individuals, I thought about wars and other obstacles that may prevent training or would make them reluctant to even go through the training process. From the case study that was done in Liberia, one of the issues that was mentioned was a shortage of midwives as well as a shortage of doctors. In cases where there is  a shortage of midwives and other health professionals what are the options left for people who need medical care? and how can this shortage problem be solved? Nowadays in a lot of African countries, individuals receive their training in foreign countries and continue to practice in the country where they received training. They usually leave with the intention of returning but the incentives/benefits of having these degrees and certificates  in most of these countries do not reflect their level of training. This summer in Nigeria, a lot of the doctors went on strike because they were not receiving their salaries. Like we also discussed in class, rural areas are less likely to be staffed with TBAs and TTMs because of distance and other factors. People would be reluctant to live so far from the city.   I know for rural northern Nigeria, it was difficult for the National Primary Health Care development center to gather volunteers and midwives to relocate there. In addition to training more midwives and healthcare professionals, how can conditions in these rural locations be modified to make living easier so that these trained individuals would choose to stay.

Hey Guys,

I just wanted to bring this article to everyone’s attention. For my presentation in a few weeks I will be discussing alcohol and substance use during pregnancy, but I just wanted to share this since it was published a little over a week ago in a magazine (Cosmopolitan) that caters to women of reproductive age. The article discusses how the author, Michelle Ruiz, would casually drink a couple glasses of wine or beer a week during her pregnancy and even suggests that up to 8 glasses is acceptable. Drinking during pregnancy has been an increasing topic as there have been a few new pregnancy books published that say drinking is okay. She sites one danish study and references many of her doctor and nurse friends that say casually drinking a little everyweek is okay. As you read the article it becomes clear that the use of alcohol during pregnancy is rooted in culture. She talks about how generations before drank and smoked during their pregnancy and “here we all are”. Drinking during pregnancy is a growing topic as more and more people are testing this “dirty little secret” that is happening among “college-educated, employed women in their late 30s” according to Michelle Ruiz.

http://www.cosmopolitan.com/sex-love/news/a32292/why-i-drank-while-i-was-pregnant/

While reading The State of The Worlds Midwifery report there was mentions of the progress improved maternal health has had on countries. With better maternal health, in part due to midwives, economies have improved as well as other MDG’s. The report was mentioning some ways that midwives could continue to foster progress in nations that the MDG’s are aimed toward. One method for helping improvement mentioned was midwives having political standing. I think that would be a wonderful idea for there to be a group of people focused solely on policy and legislation for midwives and mothers. I think this group could focus on getting training to regions that practice midwifery in an unskilled manner, such as Guatemala. Providing instruments and education to places that need more skilled midwives or even education to places like that US that midwifery is still around and only beneficial to women and birth outcomes. That stated, I realize midwives have been around for quite some time and so has the government. I am not very savvy on how organizations like the one they have mentioned in the midwife report would start or carry on. So, I am wondering what has stopped this from not already being an established area of policy and what barriers would a coalition like this face? It is clear to see that midwives are beneficial to communities in more ways than just attending births. Also, on this report itself I think it is a wonderful publication and very important to show the strides the practice of midwifery makes in the world of health. I just wonder whom this publication goes out to, and are the parties that need to see it being made aware of the benefits that midwifery provides to a nation.

The word “midwife” has many different connotations depending on perspective. Some see  midwives as healers and helpers. Some see them as skilled and wise. Some see them as agents of women’s empowerment. However, because of the history of midwifery and its relationship with class-perception, many see midwives as uneducated, old, primitive women. Before hospital birth was normalized, “granny” or “traditional” midwives were largely responsible for attending births, which typically took place in the home. This was the case for women of all classes in many different countries, developed and less-developed. As hospital birth became more common in the late nineteenth century, middle and upper class women began delivering in hospitals, but poorer women continued to deliver at home with a midwife. This (along with campaigns by hospitals involving ads like the one at this link: http://tinyurl.com/filthymidwife) led to a stigma against midwives that continues to distort society’s perception of midwives in developed nations, who were most influenced by the hospitalization of birth.

In reality, although contemporary midwives do have similar practices and philosophies to traditional midwives, the work of midwives today is largely influenced by the medicalization of birth. Most midwives in developed nations are nurse-midwives, who have had training in a clinical setting (State of the World’s Midwifery Report). Nurse-midwives practicing in the United States and in more remote areas of the world incorporate the philosophy of traditional midwifery with common hospital practices; for example, nurse-midwives attending home births are often equipped with pain medication, pitocin, or other medical supplies. They also often partner with hospitals in case of a need for emergency hospital-transfer. Interestingly, modern midwifery care also mimics the trend of hospital normalization by serving primarily middle to upper-class, white women. This article discusses the midwife-preference among white, affluent women and why it matters: http://nursingclio.org/2012/06/28/designing-women-midwives-class-and-choice/.

A key aspect of the midwifery model of care has stayed the same throughout generations: midwife-attended births result in less prevalence of medical interventions. A midwife’s philosophy is that a woman has the power to labor and deliver in most cases without medical interventions, such as C-sections. Midwives teach their patients to be confident in their ability to labor and are unlikely to recommend a C-section unless it is medically necessary. The World Health Organization recommends that a nation’s C-section rate be 10% or lower. However, a 2010 WHO study determined that only 54 countries out of the 137 countries sampled have C-section rates below 10%. The same study determined that out of 9.38 million C-sections performed in 2008, 6.20 million were medically unnecessary. This resulted in an excess of over $2 billion spent, and thus WHO identified unnecessary C-sections as a barrier to universal coverage of care (http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf). It is no coincidence that WHO recommends midwives as a way to improve global maternal care. Midwives reduce the number of unnecessary C-sections, preventing surgical complications and saving money.

This week’s reading on Labor, Privatization and Class opened my eyes to the differences socially and culturally between America and various countries. Notably, there exists a high importance of intra-household hierarchies and the division of labor between family members in countries such as India, while in America there exists a more relaxed and malleable description of family life. The case study in Calcutta, India shows that domestic and kin relationships affect a pregnant woman’s access, use and knowledge of the healthcare system. The common trend found among pregnant women in India show a high percentage giving birth in a private institution as well as a high percentage of women having elective C-sections. This was shown to be more prevalent in middle- and high-class families, as well as in urban verses rural areas. I found it interesting that more women choose private birth centers over hospitals, given our recent class discussion of birthplace ranging from hospital, birth center, and home birth. Notably, the chapter bases these decisions on Indian women’s lack of trust and credibility of hospitals, whereas birth centers give the comfort and personal interest in wellbeing that the women are looking for. In addition, modern technology is seen as a blessing, and a way to enable a healthy infant born at a suitable time for the parents. It is shown as a prestigious technique, allowing women to avoid pain, shame and the cultural belief in pollution that follows a natural vaginal birth. In 2012, research shows that in Indian private institutions women are 3 to 10 times more likely to have an elective C-section than in hospital settings. In comparison to the US, more elective C-sections occur at hospitals than private institutions. The difference in these statistics may be due to differences in the wishes of pregnant women, who may prefer C-sections more in India than in the US. However, I believe this difference may be based on the characteristics of women who choose to give birth in each setting, while in the US most women attend a hospital birth women in India prefer a private institution and thus have different expectations of care.

Sources:

http://timesofindia.indiatimes.com/india/Private-hospitals-fuel-C-section-epidemic/articleshow/15331864.cms