That women, in particular poor, marginalized women, are denied access or mistreated during maternity care is not news. I would even be willing to bet that this is a pretty common event, happening hundreds, if not thousands, times a day, around the world but rarely are such events attract much attention.

Which is what makes the case of Irma Lopez, a poor Mazatec woman from northern Oaxaca state in Mexico so interesting. After traveling a long distance from her home to the local maternity clinic to deliver her baby, Mrs. Lopez was “kicked out of the clinic” by a nurse who claimed she was not yet ready to deliver.

But of course Mrs. Lopez was, and just moments later, Mrs. Lopez delivered her baby, on her own, on the lawn of the clinic. A passerby, perhaps with a camera phone snapped a photo of Mrs. Lopez with her baby still attached – a much more graphic version of what is above (that you can Google) – which subsequently went viral on the Internet and was on the cover of newspapers in Mexico. With the click of a camera, Irma Lopez went from forgotten to frontpage, and so did the topic of equity in maternal health services in Mexico.

Fortunately, this is also a story with a happy ending. After delivering, Mrs. Lopez was admitted to the same clinic and was discharged later that same day. Newspaper reporter Adriana Gomez Licon caught up with her and family later that week and everyone, including her new baby boy “Salvador” are doing fine.

The Director of the Center where Mrs. Lopez delivered has subsequently been suspended and investigations are underway to understand how such an event could occur. Many believe that discrimination was a big factor, which is supported by a growing body of literature that many women are treated disrespect and mistreatment is common at health facilities. This inequity might also represent a major barrier to facility-based deliveries.

But for me, the most interesting part of this study is how improved information was able to generate attention to this issue and led to action by local officials to do something about this situation and made me think of the potential of new technologies, such as the camera phone that took this photo, might have in addressing some of the problems in broken health systems.

I am off to Uganda tomorrow to help set up a new project with UNICEF-Uganda to crowdsource data on health care experiences with the image of Mrs. Lopez and her minutes old baby will remain etched on my brain for years to come.

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I feel like I’ve become a bit of a broken record lately as I’ve ended up in situations where I have to defend the need for more evaluation work in global health. And I do mean defend – not just advocate for more evaluation work – but rather be on the defensive against groups or people that have argued that there is currently too much evaluation work or that evaluation work cannot – or even should not be done. I disagree.

I’ve had to make this argument in different settings, but one area where I have been working lately is in the area of mHealth where a common argument I have heard about why we don’t need to do more evaluation work is that “we already know this works” or because most mHealth interventions are “low cost and easy to do, so it can’t hurt to do more of it”. However, both of these statements, in my view, cannot be shown to be true without more evaluation work.

Right now there is an explosion of interest in using mobile phones to deliver health information and health services around the world in both low and high-income settings. mHealth platforms are being used to deliver everything from basic health information to patient level reminders that can be considered health services. On the supply side, health care providers are being taught how to use mobile phones to diagnose patients, to triage and expand health services, and to even treat patients. This is great since there needs to be continuous innovation in health care delivery.

But mHealth is not just changing the way in which existing health interventions are delivered but is really creating new health services, which can lead to very different outcomes. It is for this reason that these new strategies must be evaluated – even if the services that are being delivered have been shown to be effective in other ways.

Most of the evidence on the effectiveness of mHealth interventions has been small scale, case studies, and for the most part lacking rigorous strategies to identify effects or health impacts. Many studies focus exclusively on whether or not the programs were successfully implemented. And while the few rigorous evaluations that have been done (or at least I should say have been done and have been published) have generally found small but significant intended effects from the approaches I think we still have a lot to learn about the benefits and potential consequences of mHealth approaches.

Which is why the results of a new working paper released by Julian Jamison, Dean Karlan, and Pia Raffler should give many in the mHealth field a bit of pause or at least make you go hmmm. The authors of this paper were involved in a randomized evaluation of a mHealth project in Uganda that was aimed to provide users more information about the riskiness of various sexual activities in order to reduce overall risky sexual behavior. Treatment villages received encouragement to advertise the program and to encourage its use while in the control villages they were also able to use the program but were not exposed to this treatment. Data on many indicators, including sexual behavior, was collected in both treatment and control villages at baseline and endline.

You can read more about the program itself and the overall findings of this evaluation in this new policy brief from IPA but I want to highlight two important findings:

1. The authors found that the program was implemented as intended: in treatment villages people were making use of the program and were accessing the health information more or less as intended. Great! This is typically the type of results that are presented in many types of evaluation studies I have seen.

2. However, the program did not change sexual behavior as intended and worse may have even led to more risky promiscuous behavior! Ooops!

What should we make of this? As a starter, I think it does mean that many of the arguments I have heard recently are not necessarily true – we don’t know that this works and there might be unintended effects of these efforts that still need to be better understood and explored. I am a believer that mHealth can revolutionize health care delivery in low income settings in a good way but I don’t think we are there yet in terms of really knowing what works and that there is an ongoing need for more evaluation – and more rigorous and more insightful evaluation in this field. We are experimenting with people’s lives and people’s health every day in global health, at least lets try to learn more from these experiences.

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Zoe McLaren from the University of Michigan sent me a link last night to this fascinating article that describes the custom of giving new mothers in Finland boxes that contains an incredible set of goodies that most newborns need in early life. Once the clothes, diapers, and other items are removed, the box can then be used as a bassinet. Doctors encourage the use of bassinets as safe sleeping spots for infants, rather in their parents’ beds.

Contents of the Finnish Maternity Box as shown on the the BBC Website.

The custom is over 75 years old and was started as a way to encourage Finnish women to deliver in health facilities and to get seek early antenatal care services (an uncommon practice back then, as it was in most of the world), in particular among low income women. The article claims that the box may help explain why Finland has one of the lowest infant mortality rates in the world.

“Maybe there is are some lessons for Africa?”, she asked. Well actually, it turns out I have been thinking a lot about this, and how this might actually fit into reducing maternal and newborn mortality in low income settings.

I am back in Uganda this week wrapping up some interviews for the external evaluation of Saving Mothers, Giving Life that I have been working on over the past year with a great team of researchers up at Columbia SPH. In both Zambia and Uganda one of the interventions that was implemented, as part of the scale-up of SMGL, was the use of “Mama Kits”, small packages that included important medical supplies and other materials needed for a safe delivery.

The use of Mama Kits themselves is not a particularly new innovation in Uganda, as they have been around for a while and have been deemed successful here. What was more innovative, some kits also included other items, including well-made receiving blanket. Apparently, the blankets were a huge hit among Ugandan women.

So much so that when I was here in November, I heard stories (I can’t say if they are true or not) of women going to one facility to deliver, finding out that the kits that were being provided at that facility did not contain the popular blanket, leaving, and moving onto to the next facility. Although, it is difficult to attribute any increases in the SMGL focus districts to any one intervention, I kept asking, how much did these kits contribute to the gains in institutional deliveries?

Earlier today I was talking to one of the researchers on our team who told me about some related research she had done in the past where in focus groups of women with non-institutional deliveries would report fear of delivering facilities because they did not have any clean clothes for the baby to go home with and were ashamed.

A quick search of Google scholar turned out no obvious literature on this topic, but I am by no means and expert on this. It seems almost silly to think that this might be a deciding factor in the decision to either (1) deliver your baby in a place that has potentially life saving health services or (2) at home where if something goes wrong you can die very quickly. But the story from Finland and my own observations here in Uganda seems to suggest that they might. Perhaps we can all learn an important lesson from those crazy Finns. Anyone want to fund a crazy impact evaluation study?

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I am currently in Kuala Lumpur where I have been fortunate enough to be one of the delegates attending the inspiring, and at times overwhelming, Women Deliver 2013 conference. Although this is much more of an advocacy conference than a research conference (in fact yesterday someone explained that it was not a conference, but rather a movement) I’ve really enjoyed the opportunity to learn more about what is going on outside of the ivory towers in the maternal, women’s and reproductive health worlds. It has been a great place for thinking up new research questions and trying to understand where my work might fit into this space. Plus, it is one of the only places I have been where I, a lowly academic, have had the chance to mingle with Princesses – real ones.

The main reason I am here, however, was to present the findings from a new report that I co-authored with Jeni Klugman, the Director of Gender and Development, at the World Bank. In it, we attempted to summarize the evidence on what is know about the economics maternal health in developing countries. It is a thin literature, a bit surprising given how important this issue is, but we believe that we have found enough evidence to support the case that addressing maternal health is a missed opportunity for development, and proven approaches to address this issue. We have also made this point a few weeks back in a commentary in the Lancet.

It has been amazing to be here and to be among so many people (I heard there were 5000 delegates) who are so passionate about improving the lives of billions of women around the world. On my way here I met a young woman from Chicago who had only read about the conference a week ago and like that, decided to hop on a plane to be here. It feels a lot like what the AIDS movement was like in the early 2000s. I am curious if, and how, the energy that here this week can be channeled and sustained in the years to come.

Why Malaysia? Well, Malaysia has been one of the developing countries with the most successful track records at reducing maternal mortality. Plus, given that innovation seems to be the big buzz word here – what new approaches and new ideas can be implemented to address the needs of women – Kuala Lumpur has been a perfect backdrop for such a conversations with its frenetic shopping malls, skyscrapers, and exciting urban spaces.

My only complaint is what appears to be a complete lack of emphasis on research and evidence. I am one of the few academics here. I asked almost everyone I met this week the same question: how often do you read research and to what extent do you use this to inform your work? Almost uniformly the answer has been – not at all. Yesterday I attended a panel where every panelist presented an overview of their work where they were trying out nearly identical “new approaches”. Sadly, this conference has also convinced me that there is too little research underway to test the many innovative approaches underway around the world. Perhaps that is the real missed opportunity for maternal health.

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In today’s world of “Big Data”, it seems hard to believe that less than one third of all births and over two thirds of all deaths are still not recorded around the world. For all intents and purposes, births and deaths that are not recorded don’t count – and that is a big problem. In the words of Nandini Oomman and co-authors put it so eloquently in a recent commentary in the Lancet:

Functioning vital registration systems are global public goods that help with the collection, storage, retrieval, and analysis of accurate population and demographic data to support development policy and monitor health outcomes, particularly for maternal and child health. However, without strong vital registries, individuals do not have legal documentation of their own personhood, citizenship, and all associated rights; national policy makers do not have necessary data for resource allocation and planning; and the international community does not have evidence to monitor development progress against global benchmarks—eg, the Millennium Development Goals.

For far too long the excuse has been a lack of resources, but I really don’t buy this argument. Chris Murray once told me that India had a functioning vital registration system in place up until the 1920s when it was neglected and became non-functional. It seems that collecting data on people, even vitally important data, has been neglected and ignored by national and international policy makers. This study of maternal mortality declines in Sri Lanka – one of my favorite papers, ever – documented cause of deaths in the late 1940s, which was only possible due to the excellent data systems that were in place in that country nearly a century ago.

Last week a big conference on civil registration and vital statistics (CRVS) systems was held in Bangkok. It appears that momentum is building to put such systems into place around the world. But concerted efforts will be needed to be put into place to make this a reality. Donors have a big role to play. As consumers of global health data, it is not unreasonable that they should also be expected to pay for a big part of it, but not in one-off data collection systems as they do now. CGD’s proposal to build data into its cash-on-delivery scheme seems like a good way to go – but there are other good ideas out there. The power of mobile phone technology is also making it easier, more effective, and cheaper to collect data from many locations and this should be further enforced in the context of vital registration systems.

Vital registration systems are vitally important to global health. It is about time that they get the attention they deserve.

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Not only is artemisinin one of the most important drugs in our arsenal for fighting diseases globally – it is also the most interesting. A derivative of the wormwood plant, artemisinin’s anti-malarial properties were discovered thanks in part to the Vietnam war and Mao Zedong. The history of this drug reads more like an excerpt in the history of international relations rather than the history of medicine. Due to resistance that developed to quinine, artemisinin – in combination with other medicines – has become the drug of choice in most countries against malaria today.

Sweet Wormwood Plant

In particular during the early years of the scale up of big-push initiatives to address malaria, the fact that we needed to cultivate and harvest wormwood plants in order to produce artemisinin was rate limiting and an unpredictable process. Demand outstripped supply and supply could be unreliable due to factors such as the weather. In addition, the long lead time and intensity of the cultivation process continues to contribute to the relatively higher costs of ACTs today.

It seems that this is about to change. I learned that as of today, and thanks to the efforts of PATH’s OneWorld Health, Sanofi, and other partners, we now have the ability to produce synthetic versions of artemisinin which can be produced in about 3 months, can be more readily scaled, and can be produced in a much more controlled fashion. This is a remarkable milestone in the fascinating history of this drug.

I’ve heard others say that a Nobel prize should be awarded to recognize the importance of the discovery of this drug – which has done so much to improve human health. It now seems that a new chapter, and new players, might also get to share in this prize if that in fact occurs.

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It never rains but pours in global health. After a few years of lamenting that there really is no journal for a lot of good research that gets done in our discipline – whatever that is – in the next few months we will see the entry of 2 new kids on the block.

First, the Lancet, the world’s oldest medical journal, will be launching a new open-access, peer-reviewed online journal simply called The Lancet Global Health.

Second, USAID and the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs will next week launch a new journal called Global Health: Science and Practice, which will also be open-access, peer-reviewed online journal. According to its website the journal “aims to improve health practice, especially in low- and middle-income countries”. Sounds promising.

Both seem to be a big departure from the medical journal model of publishing, which is great, and emphasize things that were not well covered or hard to publish in other journals, which is also great.

On a related note, I also think that the editorial changes at Health Policy & Planning that were announced a while back have already strengthened the quality of papers coming out there, so kudos to the editors.

Now to get my papers out…

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Blowing white smoke

On March 13, 2013, in family planning, religion, by Karen Grepin

Although I was raised Protestant, through marriage I have recently become a practicing Catholic, and despite the fact that I clearly have divergent views on certain issues – contraception to name a big one – I remain loyal to my new religion. So, like many others, I was gripped to CNN the past few days waiting to see white smoke out of the Sistene Chapel. A few hours ago the white smoke blew and Jorge Mario Bergoglio of Argentina has been named the new Pope of the Catholic Church.

So what do we know about the new Pope’s view on contraception and public health? In this new piece, I learned that the new Pope believes that condoms are “permissible” to prevent the spread of infection. There has been confusion about exactly where the Church stands on the use of condoms and in which cases it is permissible or not. If the condom is used to prevent infection and inadvertently prevents conception, is that permissible?

Conincidentally, I also learned today on Humanosphere, that in the most recent round of their grant program, the Gates Foundation has recently launched a new “Grand Challenges Exploration” challenge to design the next generation condom in order to increase the use of condoms globally. Among the criteria for acceptable grant applications includes:

Application of knowledge from other fields (e.g. neurobiology, vascular biology) to new strategies for improving condom desirability.

So if by other fields they mean Theology, and by strategies they might include clarifying where the Church stands on the issue, then perhaps the new Pope might be in the running for the 100,000 prize! Welcome to the world of Global Health Pope Francis.

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Last June, then Secretary of State Hillary Clinton announced a new partnership to address the persistent burden of maternal mortality, called Saving Mothers, Giving Life. The ambitious program aimed to reduce maternal mortality by 50% in 8 districts in Zambia and Uganda in just one year. As some of you may know, I have been working with a fabulous group of researchers up at Columbia SPH this year on the external evaluation of this program. Over the past year, however, whenever I have mentioned to colleagues that I have been working on this project, I have been struck by how few people have never heard about the project.

But the program is starting to generate some interest, even outside of the maternal survival community. Over the next few months, we will also begin to learn more about the impact that this program has had on health outcomes and health systems more broadly. Janet Fleischman and some colleagues at the Center for Strategic and International Studies recently visited Zambia and put together this video which provides useful overview of the program, including some of the important challenges it has faced in trying to reach its ambitious goals.

I’ll be posting more on this soon, once our own evaluation results have been made public, but in the meantime, I encourage you to learn more about this important program. Plus, click here to watch the Saving Mothers, Giving Life Video

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The nicest houses in town

On March 4, 2013, in health human resources, Rwanada, by Karen Grepin

Butaro, Rwanda

At first I thought I was looking at a picture of a new eco-design hotel somewhere in Africa, but before I was able to pin it to my “places I want to go” board on Pinterest, I realized that that was not at all what I was looking at. No, in fact, what I was looking at was the new doctors’ residences in Butaro, Rwanda built as part of the new Partners in Health led redesign of the health delivery system in Northern Rwanda.

Attracting health workers to rural areas has always been a big challenge (not just in developing countries, but everywhere). In Sub-Saharan Africa the problem is more acute and even basic shelters are sometimes not available. The lack of housing for health workers is believed to contribute to the low density, migration, and even absenteeism of health workers.

Enter MASS, a design firm from Massachusetts who somehow got involved with the PIH project and exit these beautiful little houses that I think most people would agree constitute pretty nice digs. From an article in the Architectural Record:

The two-bedroom houses—roughly 1,300 square feet each—mimic the hospital buildings’ low-slung forms with clay-tile roofs. While they spill down a steep hill, they cluster together in plan. As Dushimimana explained by e-mail: “Courtyards and backyards are important to Rwandan houses. They are where the family and close friends gather.” The houses were constructed with reinforced-concrete frames to make them seismically sound, and with a total of 29,000 compressed stabilized earth blocks (CSEBs) made by local workers with soil from the site. The CSEB walls are covered with plaster and white paint. Some have a second layer of local volcanic stone. Inside, whitewashed walls contrast with muvura-wood roof trusses, cypress and pine furniture, and metal light fixtures—all made by local artisans. The project cost $400,000, a figure that includes the construction of a road, extensive pedestrian paths, and infrastructure to bring water and electricity to the site.

Although I am not quite sure what to make of this project, and my perpetual internal critic of aid projects is already rambling off a list of potential problems with this approach, I am going to turn all of that off for a few moments to just admire these houses. Clearly this experiment with the redesign of the health delivery system is not a standard approach nor is it something that would have ever happened had PIH not been involved, it will be interesting to see if any of it makes any difference (not that they will be able to measure it…argh, stop it critic) and if it doesn’t, well maybe it will be good for tourism. Pin.

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