Global Efforts in MCH- Female Genital Cutting

Female Genital Cutting (FGC) is a practice that completely or partially removes the external female genitalia. FGC has been reported in various cultures and countries across the world, but according to the U.S. Department of Health and Human Services (HHS), almost ½ of all incidents occur in Egypt or Ethiopia. In communities that practice FGC—some Islamic– many proponents believe that FGC is sanctioned by the Quran (also spelled Koran; Islamic religious text); in fact, no religion, including Islam, is associated with FGC (HHS Office on Women’s Health). Debates continue as many do not understand that formal religious endorsement of FGC has never occurred.

Tradition and superstitions, such as cleanliness and family honor, contribute to the continuation of the practice. For communities that practice the tradition, fears drive families to participate: if a girl is not cut, she will be viewed as an outsider to a community and runs the risk of being unwed. Intervention strategies target men to abandon FGC as a norm, focusing on patriarchal belief systems and the subordination of women.

Although some groups point to the issue of cultural competence, human rights groups and the World Health Organization (WHO) argue that the health risks of FGC outweigh this. Article 25 of the Universal Declaration of Human Rights (UDHR) (created by the United Nations General Assembly in 1948) states that every person has the right to health, well-being, and security. Although critics have argued that the UDHR is framed in a Western lens, the document guides issues that compromise the safety and health of humans, especially if inflicted by another being. According to the World Health Organization, health problems related to FGC include: bleeding; hemorrhaging; increased risk of Sexually Transmitted Infection (STI) and HIV infection; infection of the genitals and urethra; painful scarring and menstruation; trauma and emotional distress; infertility; and problems during labor/pregnancy (http://www.who.int/mediacentre/factsheets/fs241/en/).

Other strategies to decrease the incidence of FGC are seen in the below PBS documentary as well as in a New York Times focus. Grassroots social mobilization agents teach the community about the harms of female genital mutilation by moving this taboo topic out into public discourse. Their efforts are based on the belief that “before abandonment, comes communication and awareness.”

For more information on Female Genital Cutting, please visit the WHO’s website: http://www.who.int/mediacentre/factsheets/fs241/en/. The New York Times video report is available at: http://video.nytimes.com/video/2011/10/16/world/africa/100000001115488/the-fight-against-female-genital-cutting.html

Guest Post: students reflect on time in Dominican Republic

Our six weeks in the Dominican Republic gave us a chance to put everything we learned during our first year as Maternal and Child Health students into some intense practice. The gist of our field experience was to create, administer, and analyze data from a community health survey in an agrarian region of the Dominican Republic. The nitty-gritty of it, though, turned out to be both far more difficult and interesting than we could have anticipated.

Our field experience was coordinated through a nonprofit clinic called the Batey Relief Alliance (BRA) which provides primary medical care services for several bateyes in the surrounding area.  Rural Haitian immigrant communities, known as bateyes, are remnants of the Dominican’s turbulent past: constructed during the dictatorial Trujillo Era, the cement barracks were once home to thousands of Haitian immigrants who hoped to find economic prosperity cutting sugar cane. Today, many Haitian-Dominicans live in the bateyes, but within the Don Juan region the sugar cane industry is gone.  Without the sugar cane industry, these areas are almost entirely lacking in economic opportunities. Some individuals leave their families during the week to travel to the capital city for work, and others take seasonal work in farming and agricultural jobs.

Every day, we went with a health promoter into one of the bateyes surrounding the BRA clinic. Lucy used her Spanish to ask the head of household questions about water quality, sanitation, and skin and diarrheal diseases while Julia and Marie took notes on living conditions. We used this information to create a self-reported community profile of disease prevalence and living conditions.

Methods we learned in our epidemiology classes, as well as input from the clinic director and health promoters, helped us form culturally and regionally appropriate survey questions that would provide the information we needed. We also learned the importance of cultural sensitivity while visiting people in their homes. This concept had been stressed time and again in several of our maternal and child health classes. We were able to work best within the culture when we were flexible about our time frame and sensitive to cultural norms and approaches to daily life.

We used a qualitative approach to determine socioeconomic status, such as asking about housing structure and ownership. As the study progressed, the valuable information we gathered made us wish we had the time and resources to further explore the social determinants of health in these communities.

This project hugely reinforced to us the importance of performing a pilot study.  As we collected and analyzed our data, we regretted not having asked things differently or taken more detailed or standardized notes on various issues. A pilot study would have helped us to find and address these problems early on.

As we put together our survey responses, we applied lessons from our epidemiology classes to take into account our study’s limitations and make the most of its strengths. As with any self-reported information, we knew our data were subject to recall bias. Additionally, one person would provide information for their entire household, and sometimes answers were contradictory.  Finally, it was impossible to take a truly random sample because the bateyes lacked formal streets, listed addresses, or even designated town centers.

As for the results of our study, our goal was to provide a community self-reported profile of skin and diarrheal diseases. Fortunately, there weren’t enough cases of diarrhea to provide meaningful data about it. Our data served as an informal evaluation to inform BRA of the success of their water sanitation efforts in the surrounding communities. Skin diseases, however, were prevalent in each batey.  These diseases seemed to be linked to overcrowding and distance from medical providers. Our findings reinforced what BRA had already suspected, that addressing living conditions and access to health care would be important steps towards decreasing the prevalence of skin diseases in the region.

Lucy Cosgrove and Julia Shumway are graduate students in the Maternal and Child Health Program at the University of Minnesota.

Maternal deaths on the decline?

New research published in  the Lancet (April 2010) shows a sharp decrease in maternal deaths for the first time in decades: from 525,300 maternal deaths in 1980, to 342,900 in 2008.

As the New York Times reported last week, the news came as a surprise to many maternal health advocates—who assumed data would be similar to a 2008 study that estimated little change (and in some reports, an increase) in maternal deaths.

The study, authored by researchers at the University of Washington and the University of Queensland, used larger data sets and additional statistical measurements to reach its conclusions. Study authors assessed maternal mortality rates (MMRs) in 181 countries between 1980 and 2008, using a combination of four data sources: vital records, censuses, published autopsies, and surveys.

What’s responsible for the decline? The authors credit several sources:

• Lower pregnancy rates in some countries
• Higher incomes in some countries (which improves access to nutrition and health care), especially parts of Central Asia
• Higher levels of education for some women, particularly in Sub-Saharan Africa
• Increasing availability of “skilled attendants” to help women give birth (although the Lancet piece doesn’t expound on this, it seems likely that trained midwives—who understand how to prevent and treat hemorrhage—have played a substantial role in this improvement)

Declining MMRs in two countries–India and China–are responsible for a large portion of the decline. In 1980, there were between 408 and 1,080 maternal deaths/100,000 live births in India. By 2008, that number had dropped to between 154 and 395/100,000 live births. In China, the MMR dropped from 144 to 187/100,000 live births in 1980, to between 35-46 in 2008.

Progress varied tremendously among poorer countries with high MMRs—in the Maldives, it dropped 8.8%/year, but in Zimbabwe, it actually increased 5.5%. And as of 2008, six countries account for more than half of all maternal deaths: India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic Republic of Congo.

Interestingly, the New York Times article failed to address the increase in maternal deaths in the U.S., Canada, and Denmark.

Study authors note that at least part of the increase in MMR here in the U.S. may be due to the introduction of a separate pregnancy status question on the U.S. death certificate. This addition was meant to address coding concerns that have plagued the measurement of maternal deaths here in the U.S. for decades (for a comprehensive examination of reproductive health surveillance in the U.S., see “Assessing Tragedy: Maternal Morality Surveillance” in volume 9, issue 1 of Healthy Generations).

The New York Times does, however, mention unnamed “advocates” who “tried to pressure [The Lancet] into delaying publication [. . . ] fearing that good news would detract from the urgency of their cause.” Hmm…

For more on the U.S. stats, see a March report from Amnesty International,  Deadly Delivery: The Maternal Health Care Crisis in the USA.

Women’s Health in Nepal

Women’s health issues are difficult to address in Nepal, a country known for its gender discrimination, low literacy rate in women, and high maternal mortality. Public Radio International interviewed Dr. Sangeeta Mishra about her struggle against these conditions as a gynecologist in Nepal on a Fulbright Scholarship at Johns Hopkins University.

According to Dr. Mishra, delivering babies at home is part of Nepalese culture: only 16 percent of women deliver in hospitals. She explains in the PRI interview:

“First thing which I realized was a major problem in Nepal was high rate of maternal mortality, and women were dying due to pregnancy-related complications. Women … are not aware of pregnancy [complications] … it’s just a normal thing and that they can deliver at home and they are not aware of the consequences that pregnancy can bring. So I plan to develop a major educational and awareness generation program for these women, where most of the deaths occur … to [inform] them of the importance of delivering at the hospital, or having a skilled helper at home.”

The full audio program is available through Public Radio International at http://www.pri.org/health/global-health/womens-health-nepal1422.html.

“Trust” condom ads: from Kenya