A Few Thoughts on Reproductive and Sexual Health

Wednesday evening, a young woman around my age delivered a baby boy. I had initially had high hopes for this particular birth. It was her third child, there had been no difficulties during the pregnancy that we knew of, and I was actually able to be helpful during the delivery (nothing medical, of course, but still exciting). Yet, when the baby was born it had great difficulty breathing. Rachel and Olivia suctioned his lungs and nose, but the respiratory distress continued for quite some time. His cry was weak, Rachel could feel that his lungs were not inflating, and he was very clearly struggling. As Olivia administered a homeopathic, Rachel inspected the placenta, indicating that portions of it had calcified in the womb, meaning that those portions had stopped working. The reason? Malnutrition. With two children and a husband at home in this very poor region of the country, a pregnant woman was unable to eat, jeopardizing both her health and her unborn baby’s. The homeopathic worked, by the way, and the baby and mother were discharged three days later, but we can’t know for sure what the future repercussions of the respiratory distress and calcified placenta will be.

Later that night, a 15-year-old girl arrived at the clinic to deliver her first baby. The father, nowhere to be seen, is 16-years-old. What were all of you doing at 15 and 16? She had a long, difficult labor through the night. The baby’s heart rate was dangerously low and by the next morning Olivia and Rachel were pushing to get the baby out as soon as possible. After difficulties, a baby girl was born, weighing in at 2kg. Her heart rate steadied and both mama and baby spent the day recovering from labor. The next day, the father’s mother, who is 32-years-old, arrived to take the girls home. I sat in on a conversation Olivia had with the girl and grandmother about family planning and safe sexual health. Olivia told the grandmother that she needed to speak with her son about the importance of family planning, how to avoid pregnancy, and how to be a father. The woman’s response? He is too young to have that conversation! So, a 16-year-old is old enough to have sex, old enough to get someone pregnant, and old enough to be a biological father, but he is not old enough to learn about abstinence, to learn how to use a condom, to learn how to space pregnancies, or to learn why these things are important?

Conversations like these happen frequently at the clinic and the evidence is all over the community. At the district health office expired condoms meant to be given out for free and stacks of educational brochures forgotten in corners. I have met women with as many as eight children and barely enough resources to sustain the whole family. Some women plan to have many children, but there are plenty of women who do not and who simply are not in an educated position to avoid pregnancy. The repercussions of this, as I saw last week, may be difficulties in labor or dangerously stretched resources at home, but this lack of family planning also contributes to maternal and neonatal mortality in a region where the provision of healthcare is weak.

In one of my modules at LSE we spent a couple classes on why people have large numbers of children and why the fertility rates are higher in Africa than elsewhere in the world. Some people have argued that it’s an economic decision. The more children you have the more people you have to farm and to contribute financially to the family in the long run. People may also have more children because they anticipate that some will die, which is often the case in poor parts of sub-Saharan Africa. I think large families and motherhood at such a young age may simply be embedded in the culture. I have been asked by several TBAs here why I don’t have children yet, how many will I have when I do? When my response is “maybe two, but I don’t really know yet,” I am greeted with shock. “You should have at least four!” they say, incredulously. But why? A part of why people may have large families here is that they are expected to at a cultural level. While I am here to immerse myself as much as a white American can in the culture of Atiak, Uganda, and while throughout my career in international development I will focus on respecting and participating in culture, some cultural expectations are dangerous. Having six children at 23 in this environment is not the best for mother or child, nor is becoming a mother at 15.

In the past week or so I started looking into some organizations that focus on reproductive health and family planning, thinking that I might like to shift my focus or include those aspects in what I hope to do with maternal and child health in the future. These issues need to be a significant focus in the field of international development.  I think that with greater importance placed on reproductive health and family planning we will see healthier families, more educated people, and, hopefully, an empowered gender identity for women.

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“What exactly are you doing there?”

I’ve been talking about Earth Birth for months in anticipation of my trip here, but hardly knew what I was getting myself into. At the most basic level, Earth Birth is a maternity center that provides services to women in a community deeply traumatized by war. The organization seeks to foster a safe and culturally appropriate environment for women and their babies throughout pregnancy childbirth, and the postpartum period. Earth Birth also functions as a school, pairing senior midwives with student TBAs from the local villages. Classes take place weekly here to go over skills necessary for ensuring safe delivery.

A lot of people have asked me why women don’t prefer to give birth with professionals who have been formally, medically educated and in a hospital. That isn’t a safe or realistic option in Uganda, to say the very least. The nearest hospital is over two hours away via car and if a woman were to make it there she would be faced with a severe shortage of staff, beds, and equipment. Rachel, one of the midwives and co-founder of Earth Birth used to work at the hospital in Gulu and it was the circumstances there that inspired her to create this maternity center. She has told me stories of women laboring in the hallways, getting a bed only when it is time to push, and being discharged just 10 minutes after delivery. In spite of these truths, the Ugandan Ministry of Health has issued a ban against training TBAs and traditional midwives, labeling them as incapable of learning and responsible for Uganda’s high maternal mortality ratio. TBAs, however, remain an essential resource in community health. They have continued to practice as long as there is a demand for them and at over two hours from the nearest hospital where the risk of death is even greater, you can be damn sure the demand is still high in Atiak, Uganda. TBAs and traditional midwives offer essential healthcare where there would otherwise be none and through Earth Birth they are able to do so safely.

My role at Earth Birth will turn out to be quite fluid, from what I can tell after just five days here. In exchange for food, housing, and the experience I will gain here, I’ve committed to three months of working here in what Olivia has called a “managerial position.” I’ve been assigned three main projects that I am trying to get off the ground and running before heading back to the States by Thanksgiving!

1. Olivia and Rachel want as many of the supplies as possible to be sustained by the local economy or through local craft. I am hoping to get sewing, beading, and gardening projects started amongst the women who use Earth Birth services. Vegetables from the garden can be sold in the local market while sewn and beaded projects will be sold in the US through partnerships with fair trade stores – at least that’s the plan I envision for now!

2. Right now, all of the protocols for pregnancy, childbirth, and the postpartum period are written in English, which is useless in a community where most women do not speak English, let alone read it. I am establishing a team of TBAs who do speak English and together we are going to create a protocol manual that uses Luo (the local language) and images for the women who are fully illiterate, but still a crucial resource to their communities.

3. The last major project  is the one I am most excited about. As I mentioned above, the Ugandan Ministry of Health has banned TBAs and their practice, but based on evidence I referenced and further evidence in my dissertation (you can ask, if you really want to read it) this is a less than ideal policy decision. It is impractical to expect TBAs not to practice when the need for them is still so great. I’ll be using my research and Earth Birth statistics to create a report indicating the success of this program and that these women have had on the community in hopes of encouraging the Ministry of Health to consider a more incorporated role for TBAs in the health system.

That’s all for now, but feedback and comments are always appreciated!

First Update From Atiak

The internet in Atiak will prove difficult in regular blog updates for the next few weeks, but I’ll try to keep things fairly up to date on here! This entry is also rushed, so the quality of writing will hopefully improve with the next entry!

I arrived in Kampala on Saturday and spent the night in a hostel where I promptly passed out for about 18 hours. Sunday, I took the bus up to Gulu and met Rachel – the co-founder of Earth Birth. In spite of my jetlag, Sunday turned out to be incredible. We stayed in Gulu at Saint Monica’s Clinic, which is run by Sister Rosemary, a CNN hero. Saint Monica’s takes in former child mothers and their children, rehabilitating them and training them to sew, cook, and work so that they are employable after a two year stint at the clinic. Child mothers are the young girls and women who were abducted, and more often than not, raped by the Lord’s Resistance Army during the war here in northern Uganda. Many of the children who stay at Saint Monica’s with their mothers are the products of those rapes. Apparently, Joseph Kony (the leader of the Lord’s Resistance Army) would call out to Sister Rosemary over the radio during the war and storm her compound where she hid the women, while Sister Rosemary would hide in the bushes with babies and young girls. Eating dinner with a woman like her, especially coming from the development angle that I do, was rewarding, to say the least. To this day, she still does amazing work with women and children across the region.

On Monday I arrived in Atiak and met Olivia, the other co-founder of Earth Birth. Not 30 minutes after our car pulled in, a laboring woman arrived at the clinic to deliver her SIXTH baby – but six kids is hardly out of the ordinary here. Before I came here and witnessed it, I really had no idea how I was going to handle watching childbirth. After being forced to watch “The Miracle of Life” at Sacred Heart Academy I was pretty sure that when it came to any work I do in maternal health it would be from a purely policy angle, out of sight of any placentas, but it turns out I was fine!

Atiak is the poorest and most rural place I have ever been, let alone lived for three months. I stay in a small hut, with cement walls painted a pretty pink (courtesy of Olivia) and cow-dung/cement floor covered in colorful straw rugs. The roof is thatched straw and withstands heavy rains, but is also home to mice. Luckily, there is the Earth Birth pet – a kitten named Baby Jesus! Since his arrival, the mouse count has plummeted. Thank god.

I share the hut with our cook, a woman my age named Nighty, and her baby son, Stewart, who is just over a year. Nighty was abducted during the war and forced to marry a leader of the rebel movement before escaping after a year of hell. She also has three other children who do not live with her here. Can you imagine being her age and a mother of four, having endured everything she has? And her story is just one of many. In just three days in Atiak I have met people who have gone through things I can’t even properly imagine, not that I am sure I would want to.

That’s all I can offer for now – a storm is coming in and the internet won’t be cooperating for much longer! Check back later this week for a more in depth look at exactly what Earth Birth does and what my role will be.

 

Finally Getting Somewhere!

All this time I thought that sorting out my dissertation would be a piece of cake. I had an internship during Lent Term that provided me with essentially all of the background information I could want and because of how they asked me to structure my research I figured my literature review was basically done. WRONG! I have been writing myself in circles (granted, I took 6 days off to prance around Italy, but that’s besides the point).

Luckily, after sitting down in the library yesterday surrounded by pez and venti cups from Starbucks I had a breakthrough! Before delving into the details of my breakthrough, I suppose it makes sense to tell you what my dissertation is even about….

Traditional Birth Attendants (TBAs) are a highly contested issue in maternal health policy across the developing world. I’ve decided to structure my dissertation as an analytical narrative that addresses the issues surrounding TBAs and maternal health policy through a comparison of case studies. For those of you who are unfamiliar with TBAs, they are people (typically mature women) in rural/remote areas. They typically have little to no medical training and learn through practice or from other TBAs in the community. Their role is emotional in addition to medical. Not only do TBAs deliver babies, they provide support to pregnant women and their families both before and after the delivery. These women are highly respected within the community and are often viewed as leaders. The issue is that untrained TBAs can and often do contribute to the high rates of maternal mortality. This is where organizing the circular issues surrounding TBAs becomes a problem…

Untrained TBAs often perform unsafe medical procedures, particularly during delivery (for example – massaging or sitting on the stomach to induce labor which can result in harming the fetus, unsafe and unnecessary caesarean sections). But…TBAs, untrained or trained, are often the only option women have, particularly when considering remote areas. In some cases, even when women have access to a hospital or clinic where they can be assisted by a medical professional they choose to deliver with a TBA because of cultural considerations, issues of trust, and finances.

In the 1970s the major international organizations responded to this issue by introducing training programs for TBAs. Women were trained to properly assist women with uncomplicated pregnancies and to recognize obstetric emergencies so that women can be referred to trained medical professionals. Unfortunately, the evidence that these training programs have worked is questionable. The World Health Organization doesn’t consider the training programs to be cost-effective due to the fact that individual TBAs don’t carry a large work load and deliver a very small number of babies each year. Other studies have found that in some cases TBAs have delayed referral systems for obstetric complications. Overall, there appears to be little evidence that trained TBAs have had a significant impact on maternal health at all. As a result, since the 1990s many players in the international community have called to abandon TBA training programs and ban TBAs all together, stating that each delivery should be assisted by a trained midwife, nurse, or doctor.

It is largely agreed upon that in the most ideal world every pregnant woman would have the option of delivering with a highly skilled medical professional and in a sterile, supportive environment. But that is not the world we live in. Moving away from policies that have supported TBAs has not dealt with the issue of brain drain in many developing countries (doctors and nurses from one country leave to practice elsewhere, largely due to financial opportunities), nor has it resulted in better infrastructure and access to clinics where medical professionals do work. In fact, it has only created a more apparent gap between women who reside in remote, rural areas and the formal healthcare system. This means women are either delivering with no help or they are delivering with TBAs who have been forced to work underground or are untrained.

So what is there to do? We can’t suddenly make up for the abysmal doctor-to-person ratio in many developing countries (Uganda has 1 doctor for every 10,000 people). We can’t build roads and clinics in a month, stock them, and then watch the maternal mortality rate plummet. Certainly, developing countries and the international community can and should be working towards these things and the other variables that link with why the maternal mortality ratios are so high. In the interim, can TBAs serve as a safe and viable option for pregnant women ostracized from the formal healthcare system? Even where medical clinics and hospitals are affordable and accessible, shouldn’t a woman also be able to make her own decision regarding her pregnancy and delivery, yet trust that cultural considerations shouldn’t result in unsafe practices?

My dissertation will explore and analyze (hopefully well) all of the issues outlined above…and hopefully in a less stream of thought manner! I’ll be comparing different policies that countries in East Africa have implemented with regards to TBAs and seeing what lessons can be drawn from their experiences.

Now for yesterday’s breakthroughs! I FINALLY chose my case studies. Our dissertations are incredibly short (10,000 words) and I wanted to be able to do 2 or 3 case studies very well rather than skimming the surface of 4 or 5 case studies. I have narrowed my research down to Uganda and Ethiopia. In 2009, Uganda’s Ministry of Health banned TBAs while Ethiopia has a very inclusive policy. I think that juxtaposing the two extremes will serve to be most beneficial and encompassing of the different considerations. So that was exciting, but even more exciting than that is that I have secured interviews! They’ll be informal and potentially via email (one person is in rural Tanzania, the other in Ethiopia), but I think it’ll be good to talk to the specialists directly. I’ll be talking with Staffan Bergström. He has written a number of articles and done significant research on the work of informal healthcare workers in East Africa. Also, by some miracle, I have secured a phone interview with the Director of Policy and Planning at Ethiopia’s Ministry of Health, Kiros Kidanu! So that’s what I’m working on today – I need to do a lot more reading and analysis before I can construct some good questions. I am really excited though!

Now that I’ve finally gotten my act together regarding research I hope to update a bit more regularly. After working on this post, I find it helps me organize my thought processes.

Until next time!

PS feedback is always always always welcome!

Diving In…

Seven weeks from today my plane will touch down in Entebbe, Uganda and I’ll make the drive up north to Atiak – the town I’ll be living and working in for a time period that has yet to be determined. I’ll be working with a small organization called Earth Birth (more on that later). While I am unbelievably excited to move forward with the start of my career, this also means I have the next seven weeks to complete the last leg of my graduate degree at the LSE – my dissertation. In an attempt to organize my currently muddled thoughts regarding the assignment, I’ve created this blog. I’ll be posting research findings, articles, excerpts from my dissertation drafts, and general thoughts. When I move to Atiak I’ll begin using this blog as a way to share my experiences at Earth Birth. I’m envisioning a smooth transition as my dissertation topic is closely related to the work I’ll be doing at Earth Birth’s clinic. More on Earth Birth and my dissertation topic will have to be discussed in my next post, as it is approaching 5am here in London!