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> 6. Neglected and sensitive issues
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Which neglected and sensitive issues should we focus on?
We believe DFID has comparative advantage in tackling neglected and sensitive issues. Which neglected and sensitive issues should we prioritise in our work?
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This is an INDIVIDUAL response.
A neglected area is EARLY POSTNATAL CARE. Because exact packages and timings for postpartum (for mother) and postnatal (for newborn) care have not been defined, they are not a) implemented regularly by health systems, and b) recognized as discrete entities by women.
Hence, it is believed important causes/factors related to maternal (e.g., postpartum haemorrhage) and neonatal (e.g., asphyxia) mortality, are not being tackled through routine offer of these services.
DfID could contribute by, a) working with WHO and international partners to define when does/should PPC/PNC start, what are the standard/minimum components , b) establishing what are the required set of skills/competencies to deliver these components (e.g., at facility and community levels), and c) assisting its implementation in as many health systems as possible.
Thank you,
Dr. A. Fort
WHO/RHR
By far the most neglected and sensitive issue is the hard fact that population growth makes all environmental, and many economic and social problems harder – and ultimately impossible – to solve. Irrational reluctance to state this fact in recent decades has done great harm, and must end. It is in the vital national interest of all countries, rich and poor, to stabilise their numbers. As Save the Children said this year: “It would be absurd to deny that the necessary global transition to a [low-carbon world] will be infinitely harder with 10 than 6.8 billion people”.
A sensitive issue are the drivers for large families, by political and religious leaders in particular, and the status conferred by many children in many societies. The people can ignore these leaders, when it is clearly in the interests of families to be smaller. Outbreeding and gun-fodder however remain dangerous fallacies.
Against these are education of women; social security in old age and reducing child mortality, as many children are insurance; and access to contraceptives. The example of the West must not be pro-natalist.
We should work to end forced child marriage.
This would reduce the number of teenage pregnancies with their high rate of health problems. Ethiopia still has many child marriages and obstetric fistula is more common there than in most other countries.
Population is one of the most important issues of our time, yet rarely acknowledged or given adequate attention. Today our world population is more than 6.8 billion people, and we are adding more than 225,000 people every day. Many of the most critical issues that we are faced with today, such as: climate change, food and water shortages, species extinction, poverty, inadequate health care and education infrastructure, and other resource shortages, are all exacerbated by rapidly growing populations.
If we look forward to the next 50 years, the most significant population growth will take place in the developing world where resources are the scarcest. Ninety-nine percent of the population growth is occurring in the world’s poorest countries that are already struggling to provide for their existing populations in the face of poverty, civil unrest, and a scarcity of resources. Developing countries today need approximately $1 trillion per year in new infrastructure to accommodate their dramatic population growth. This figure is effectively impossible to meet, which means the continued growth in human population numbers will result in an increase in the number of people living in poverty, unemployment and with inadequate access to health care and education.
The median projection of population size by the U.N. Population Division envisions that population growth rates will decline over the coming several decades. But even if that median projection is achieved, the number of people expected to be added to the world’s population in the next 50 years will be almost as large as the number added in the last 50 years. That magnitude of increase, coming on top of the unprecedented growth that has occurred in the last half-century, will be felt in all aspects of life. It will further stress already strained ecological systems, and worsen poverty and health in much of the developing world.
Population growth is not the only threat facing humanity, but it will be a major contributor to the crises that await us in the coming century. Overpopulating the planet puts us all at risk of extreme environmental and social consequences that we are beginning to see today.
Additionally, addressing population growth through the promotion of family planning and smaller family size norms is also beneficial in the present, as lack of spacing and high birth rates can lead to complications during pregnancy, birth and after delivery. Empowering people around the world, particularly woman, to make healthy and informed decisions about when to have children and how many children to have is critical to improving life our planet.
One neglected area is the availability of safe and low cost emergency transport to enable prompt referral of women in labour and thus increase the proportion of facility births.
Such transport can be made available through a variety of channels including the private sector, government sector and at the community level. In Nigeria much work has been done with Transport Unions to encourage their members to volunteer their vehicles for women in labour. Such schemes, five years after inception, are referring up to 1,000 women per month in a single state.
Capacity building at the government level can also serve to improve the availability and management of ambulances. We have seen how building the capacity of transport and maintenance managers can greatly improve vehicle availability, reduce running costs and increase vehicle life on fleets from one to 15,000 vehicles.
At community level, the introduction of intermediate modes of transport such as bicycle or motorcycle drawn ambulances can provide appropriate means of transport. In Zambia recent monitoring and evaluation data highlights more than 250 life saving trips being made across 40 community based bicycle ambulances in one year, covering distances of up to 30km each time.
With Post Partum Haemorrhage having an approximate time to death of less than 2 hours (WHO) the establishment of effective yet appropriate referral systems is a must to reduce current mortality rates.
Gary Forster,
Head of Programmes,
Transaid
DFID’s continued focus on safe abortion is especially important because very few donors do or will exert leadership in this area. DFID’s investment can have a significant impact, not only practically, through the programs it supports, but also symbolically, in terms of encouraging others to address this very stigmatized issue. Greater understanding of the public health and human rights imperative to improve access to safe abortion services is badly needed, and DFID is in an excellent position to help create it.
Empowering girls to stay in school has a domino effect on their own life, the well-being of their family and that of their community. By advocating for primary AND secondary education for all girls, not only is the age of first pregnancy delayed, but girls are also then able to make informed decisions about whether or not to become pregnant. They also then possess greater knowledge about communicable diseases, nutrition and gender-based violence, and are better equipped to guide themselves and their loved ones to live healthy lives. In turn, they are also more likely to prioritize education for their own children, if and when they decide to have them. Investing in girls pays.
Joanna Hoffman
Women Deliver
Christian Medical Fellowship emphasise that recent research has shown that approaches focusing on multi-level interventions (such as education of girls, challenging social attitudes and values towards women, increasing access to good obstetric care and trained birth attendants, etc) have had the most discernable impact on the significant reduction in global maternal mortality in the last three decades.(Hogan M C, Foreman K J, Naghavi M et al. Maternal Mortality for 181 Countries 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010:375:1609-23)
While we know there has been much debate on access to ‘safe abortion’, this research suggests that legalising abortion has not had any discernable impact on maternal mortality in any country,(Leiva R. Maternal Mortality and Abortion. Letter: Lancet 2010, 376;515) and indeed that good access to family planning, education and empowerment of women, and access to good obstetric care reduces the numbers of abortions – ‘safe’ or ‘unsafe’. We would therefore encourage DFID to look at a more multi-level and community oriented approach than focusing on one or two issues such as abortion.
It is well recognized that nutrition is a desperately neglected aspect of maternal, newborn and child health (Lancet Series, 2008) in donor and programming priorities. Furthermore, the role of certain traditions or cultural ideas that damage maternal and child health should be sensitively addressed. For example, in some cultures breastfeeding whilst pregnant is considered a taboo, thereby contributing to the development of severe acute undernutrition when the child is abruptly weaned to nutritionally inadequate weaning diets. The contribution of breastfeeding as a key adjunct to fertility control is also usually neglected by health care workers, and certainly the issue of breastfeeding as beneficial to maternal health is also often less well disseminated to women. Women should be fully informed of the benefits of breastfeeding not only for their children, but for their own health as well. However, it is always good to remember that all forms of undernutrition in women and children exist in both emergency and non-emergency contexts.
One of the neglected and sensitive issues is obstetric fistula. Women develop obstetric fistula as a result of prolonged and obstructed labour which could be prevented if obstetric care were available. Obstetric fistula contributes to maternal morbidity which keeps a woman away from exercising her potential. It may lead to disruption of her married life or force her to accept a co-wife. The latter again contributes to high fertility.
Improving adolescents’ sexual and reproductive health and rights, addressing unsafe abortion as a public health problem with a known solution and improving access to safe abortion services are key issues that are neglected but of the utmost improtance. We strongly encourage these issues to be taken up and prioritized.