I’m reading a very interesting/shocking book called Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men, written by Mara Hvistendahl. Just as the title says, the book focuses on how sex selection abortions came to be, and the effect they have on populations and the societies that are affected by an overabundance of boys. A team of French demographers place gender imbalance on par with the HIV/AIDS epidemic. In 2008 it was estimated that AIDS had claimed 25 million lives in the history of its epidemic. This is a fraction of the estimated 100-160 million girls that have been lost to sex selective abortion practices. As the first generation touched by sex ratios imbalance grows up, the silent biological discrimination that is sex selection has been exacerbated by visible threats to women, including sex trafficking, bride buying, and forced marriages. This only exacerbates the problem, and only further impedes progress in reproductive health for women.

From the 1950’s through the 1970’s UNFPA, The Rockefeller Foundation, The Ford Foundation, and The World Bank sent $1.5 billion in aid to India to support implementation of “any necessary population control measures: including abortion, sterilization, and birth control. Quite interestingly, many of the main players pushing for the implementation of these programs in India, China, and a few other Asian countries were fighting extension of the same rights in the US. The argument was that over population in these areas was impeding development. Chinese officials felt that boosting per capita GDP was a long and difficult process that would take many years to accomplish. With the support of these aforementioned western organizations, China implemented the one-child policy in 1980. Cutting the birth rate and reducing the number of people who would share in the wealth (or lack there of) in the nation seemed a quick and attainable way to push development. Economic development, along with the urbanization, education, and new job opportunities has been shown to lead to lower birth rates in families. But because development is accompanied by plummeting birth rates, it raises the stakes for each birth, increasing the chances parents will abort a female fetus, creating an alarming triangle of development, falling fertility, and sex selection.

In 1982, two years after the one child policy was enacted in China, ultrasounds were widely distributed. Though sex determination was technically illegal in China, there was little incentive to crack down on it, so a small bribe could go a long way. The fine for sex selection was also ten times less than the fine for having a second child. This drove many parents to choose to “beat the odds” and ensure that they had a son on the first try.  I thought this was a striking example of the different effect that certain technologies can have in culturally distinct environments. In the political and cultural climate of China and India at the time, ultrasound technologies served as an inexpensive gateway for working the system and helping families to ensure that they had a boy, at the expense of unborn girls.

Reading this book has made me stop and think about how the implementation of certain technologies often has dangerous and unintended results. I don’t think technology should be withheld, but the implementation has to be careful and sensitive to the political and social climates they are being introduced to. So what can be done? How do you check that what is supposed to be a helpful technology is not promoting gender inequality and obstructing maternal health? As sex selection cannot happen without abortion, this issue obviously opens up conversation on access to abortions and what should be done in that respect.

Japan and Sweden have some of the lowest rates of maternal and infant mortality in the world, and yet, their cultural practices and behaviors vary widely between the countries. While both nations encourage mothers to stay at home with their families after giving birth, there seems to be a lack of choice for mothers in Japan compared to Sweden. As Ugochi mentioned in her presentation, only 3% of mothers take pain relieving medications and are told that it is not appropriate to scream out during labor. I feel like telling mothers that they have little choice in reliving their pain, whether through medication or screaming, is not a healthy cultural behavior. While it seems that Japan is beginning to incorporate more paternal involvement in the birth process, their inclusion of fathers doesn’t seem to compare to the Swedish model.

How then are both countries so successful in maternal outcomes when their practices seem to vary widely? Do you think encouraging mothers to not take any pain reliving medication is a healthy practice?

Hi everyone! I felt a bit rushed at the end of my presentation yesterday, but I wanted to talk a little bit more about Kangaroo Care because I think it provides a great alternative to expensive care for premature infants. For example, I’ve been reading a lot about the use of Kangaroo Care in Malawi. Malawi has approximately 15,000 neonatal deaths a year and 60-90% of those deaths are attributed to LBW babies who are mostly preterm. I’ve attached a video and some resources in hopes that it might be interesting to you all since we have seen through reading Monique and the Mango Rains how important (yet lacking) good maternal care is in Malawi.

Here is the link for the video:

http://www.healthynewbornnetwork.org/multimedia/video/kangaroo-mother-care-living-proof-malawi

And here are a couple (short) articles that you all might find interesting:

http://www.unicef.org/malawi/reallives_13345.html

http://www.who.int/pmnch/events/2007/20071113_malawi_kangaroo.pdf

I’m also wondering how you all think that various disciplines (nursing, public health, politics, etc.) can contribute to promoting programs such as Kangaroo Care.

In light of the fact that the US has the highest rates of STDs and teen pregnancy or any industrialized country, the debate surrounding sexual education in schools is incredibly important. My home state of NM has no requirement for teaching sex ed in schools, and when it is taught, there are no requirements on what should be included. NM also has the second highest teen pregnancy rate in the US. My high school did not teach sex ed, and teen pregnancy was common place with a daycare on school grounds to help moms who wanted to continue going to school. Growing up in this climate it became obvious to me that simply not talking about sex did not stop kids from having sex. For this reason I adamantly support comprehensive sexual education in public middle schools and high schools. Education is power, and teaching young adults about their bodies and safe ways to express their sexuality is important and will help protect against unwanted pregnancies and the transmission of disease.

My high school was also 85% Hispanic with 50% of those students being first generation Americans and 15% newly immigrated. This is important in this conversation because sex was a taboo subject in within this group. Strong catholic families celebrated when their daughters became pregnant, but shamefully swept the action that caused the pregnancy under the rug never to be talked about. Breaching the subject of sex in this community was uncomfortable and considered highly inappropriate especially in school. These cultural differences are incredibly important to consider when approaching the subject of teaching sex ed in public schools. The US has an incredibly diverse cultural heritage, and for many people, talking about sex is incredibly uncomfortable and for some can be terrifying. When discussing the implementation of sex ed in schools, we have to be sensitive to these needs. I work at an HIV/STD clinic in Atlanta and I have seen in support groups we have with HIV positive women from many different backgrounds that forcing someone who is uncomfortable talking about sex because of cultural or religious beliefs doesn’t work. They shut off and are not receptive to the information. The conversation has to become relevant to them, and be presented way that is respectful and approachable to them. In our support groups we have found that breaking women up into smaller groups with a peer navigator that understands cultural or religious hesitations helps to create a more comfortable and relaxed environment where the women feel safe to open up. Once this is established they usually become very engage and ask a lot of questions. I think something similar could be applied to schools. Small culturally sensitive groups could maybe be used to help students feel safer in discussion, and help mediate the cultural barriers between families.

Does this solution seem like it would be feasible?

We all know that educating students about their bodies and sex is important for future health outcomes, so what other solutions are there that still provide the necessary information but make the environment safer and sensitive to cultural differences?

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.

On a recent episode of Jimmy Kimmel, actress Ellen Pompeo of Grey’s Anatomy fame commented on the fact that even on medically themed show, the word vagina is seen as inappropriate and borderline obscene. It’s this intrinsic stigma against the female body that must be considered when constructing sexual education programs. Most people are intimidated by the unknown, and the female body, especially in its sexuality, is largely unexplored. When educating young students about the mechanics of sex, there is no room to shy away from one half of the biological population. Providing honest, unbiased data is difficult when there is a significant lack of research into the specifics of the female sexual experience. This information gap, however, should not hinder open and honest sex education. It merely requires us as educators to acknowledge what we do not know and encourage healthy and safe exploration. We have taken the comfortable path regarding sex ed over the past couple of years, and clearly, it leaves much to be desired. It’s time to step outside the comfort zone, acknowledge women as the sexual beings they are, and provide students with the tools needed to have healthy sexual relations.

“Dr. Jim Kim, anthropologist, clinician, and former WHO advisor has commented that anthropologists have a long history of providing ‘moral witness to human suffering’. What is needed now, he argued, is ‘moral witness to human possibility'”.

The readings for this week on community mobilization for safe birth provide two different examples of how human possibility and morality can improve public health – in this case, maternal and child health.

The community-based participatory research study in the Dominican Republic found that both men and women were dissatisfied with the maternity services in the hospitals. While the Dominican Republic is a relatively developed nation, there are substantial socioeconomic inequalities. Although 97% of births occur in health facilities, an optimistic number compared to some other areas of the world, the MMR is high, at 150-160/100,000 live births. A main issue identified by the communities involved in the study is a delay in accessing care. The researchers aimed to determine why women delayed going to the hospital amidst complications.

The findings were unfortunate. The community recognized pregnancy as a vulnerable and fragile time for a woman. However, they did not receive adequate, compassionate care at health facilities. “No me hace caso” – “they pay no attention to me” – became a recurring theme throughout the study. Wait times for appointments and even surgeries were absurdly long, even though the commute was manageable. Doctors were not comforting women and their families when they were anxious. The women felt that nobody was there for them or taking care of them, and procedures and outcomes were not explained properly.

This project shows that when a team of researchers, professionals, community members, and hospital staff come together, a common goal can be reached. Since the maternity service providers have now been made aware of the dissatisfaction of the community, steps can be taken to improve the quality of care. It is unsettling that while the backbone of a potentially successful maternal health system exists, that something like staff attitudes have an impact on MMR. Hopefully, the future of maternal health services is bright in those communities.

In Humla, Nepal, a project was done by the PHASE Nepal foundation to change a harmful cultural practice – keeping a new mother and her baby in a cowshed after delivery for one month. This is very dangerous, given the high possibility of infection, in addition to uncomfortable living conditions. However, the researchers knew that changing engrained beliefs is difficult, and did not want to appear as judgmental outsiders. They came up with the idea to provide useful incentives – new clothes for the mother and baby – in exchange for a safer area for the mother and newborn to live postpartum. Another part of the initiative was increasing skilled birth attendance. The project had a successful outcome, with 50% of births being attended by skilled birth attendants and almost 100% of families accepting the clothing for safer postpartum living spaces.

This project demonstrates that changing a cultural belief is possible, when the community understands what the problems are and how to adhere to their beliefs in safer ways (i.e. separate room of the house dedicated to mother and baby, room restrictions, or a small guest house).

With the risk of sounding cultural insensitive, the underlying problems in both articles remind of me Sue Ellen Miller’s Ted Talk, when she said that women are “discriminated to death”. In both of these articles, we see that change is often needed in areas besides access to medicine and equipment. These initiatives both dealt with cultural issues, which with the right plan, can be altered to benefit not just mothers and infants, but the entire community.

As with any intervention that includes a distribution of goods or service, I always bear in mind the sustainability of the project. Although a certain program may have many beneficial short term outcomes, how can we be sure that the program will sustain these outcomes? In the Nepal program that we read about for this week, the idea of distributing clothing to mothers who give birth in the presence of trained health workers was presented. Although the authors cited many incredible outcomes, including that fact that over half of all births in the region were attended by trained health workers, I wonder about the long-term effects of the program. The authors stated that a private donor was needed to fund the buying and distribution of the clothes. What will happen when, inevitably, that donor decides to stop funding the project? What if the NGO is unable to acquire sufficient funds to buy clothes for the mothers? I worry about how this project can be sustained for the near future.

The key to providing a sustainable project would be finding a different incentive to have mothers change their behaviors towards maternal health that could be implemented by community members rather than NGO workers.