Join the Wilson Center This Wednesday for “Underage: Addressing Reproductive Health and HIV in Married Adolescents”

By Katie Millar, Technical Writer, MHTF

A new wave of attention and research is now focused on one of the world’s most vulnerable populations: adolescents. In the developing world, there are 70 million girls under the age of 18 who are married. Most of these girls are incredibly vulnerable —likely taken out of school, pregnant or already parents — they are at increased risk for gender-based violence and sexually transmitted infections, including HIV. Despite knowing these risks, there is much to be discovered about what adolescents face and how we can better provide for their health and other needs.

On Wednesday, July 30, experts will gather in Washington, DC at The Wilson Center to discuss current research and programming with married adolescent girls in the developing world. Representatives from USAID’s Office of HIV/AIDS, International Center for Research on Women, CARE, and Pathfinder International will discuss their work from Bangladesh, Ethiopia, West Africa, and other low-resource settings.

Join the meeting in person, via live webcast, or twitter on July 30 from 3 to 5 p.m. EDT. To RSVP to the meeting, view the webcast, access more resources on reproductive health and HIV in married adolescents and view the speaker list, visit the event page.

Experts Gather to Discuss New Methods for Measuring Obstetric Fistula

By Vandana Tripathi, Deputy Director, Fistula Care Plus Project at EngenderHealth

EngenderHealth, which leads the USAID-supported Fistula Care Plus (FC+) project, and the Maternal Health Task Force recently co-convened two meetings on obstetric fistula in Boston, from July 8-11. The first meeting examined recent research and emerging research priorities in fistula prevention and treatment. The second meeting dug deeper into the issue of how we measure the burden of fistula globally, and was attended by epidemiologists, demographers, fistula surgeons, midwives, and other researchers.

Mary Nell Wegner of the Maternal Health Task Force has described how the rarity and stigma of obstetric fistula contribute to difficulties in understanding how many cases there are. Additionally, the very women most likely to be living with obstetric fistula are also the most likely to be in hard to reach places with limited access to health services and, possibly, less access to media and other messages about fistula services. Without good numbers on how many women are affected by fistula, it is very difficult for health systems and policymakers to plan and organize fistula services. For example, where should fistula treatment centers be located and how can referral systems to these sites be improved? How many surgeons need to be trained in fistula repair? Where should emergency obstetric care transport services be strengthened to prevent fistula through timely C-section?

At the Boston meeting, experts from around the world talked about different approaches to understanding how many women are living with fistula and how many new fistula cases occur each year.

Kimberly Peven from the DHS Program reported that more than 25 countries have used the obstetric fistula module of questions in their national DHS Surveys, documenting the proportion of women of reproductive age living in households who have heard about obstetric fistula or who have fistula symptoms, specifically continuous incontinence. Next, Ozge Tuncalp of the World Health Organization and Alma Alder, formerly of the London School of Hygiene and Tropical Medicine (LSHTM), described innovative ways of using community outreach and key informants to identify women with fistula in need of treatment, in Nigeria and South Sudan. Also, Saifuddin Ahmed from the Johns Hopkins Bloomberg School of Public Health discussed statistical models that use information about related topics, such as the general fertility rate and percent of deliveries that occur in health facilities, to estimate the number of fistula cases in a particular country. Caitlin Shannon of EngenderHealth described a LSHTM study of self-reported morbidities among pregnant and recently-delivered women in Ghana, providing insights into measurement of fistula incidence. Lastly, I reported on the increasing number of countries including fistula indicators into national Health Management Information Systems or piloting surveillance systems to report cases of fistula as they occur.

Meeting participants generally agreed that population-based household surveys focusing specifically on fistula are not the best or most-cost effective way to measure the prevalence of fistula, given the rarity of this condition, the rural locations in which it often occurs, and the fact that women with fistula may not be living in family homes. The high cost of such surveys may also pose an ethical issue in terms of the allocation of scarce resources that may otherwise support prevention or treatment. Through a fruitful and lively discussion, the participants identified research studies that might help strengthen other ways to measure or estimate the burden of obstetric fistula. For example, a strong interest emerged in validating interview-based diagnostic tools so there could be more confidence that self-reports and survey responses are actually measuring the prevalence of fistula, rather than other types of incontinence or even other uro-gynecological conditions.

The results of the prior Fistula Care project were achieved in large part due to strong collaborations with partners at the global and country levels. We are pleased to count the Maternal Health Task Force among our partners in FC+ and grateful for the enthusiastic participation of experts from so many global and country institutions at these two meetings. We look forward to continuing to work with partners to identify the best ways to tackle the problem of fistula measurement and estimation and address the other pressing research concerns identified during the Boston meetings. Reports from both meetings will be coming soon, and we will share them with interested colleagues.

Obstetric Fistula Technical Meeting Convened by Maternal Health Task Force and EngenderHealth

By Mary Nell Wegner, Executive Director, MHTF 

On July 8-11, the MHTF had the privilege of co-hosting two meetings with the Fistula Care Plus project, led by EngenderHealth. It was a terrific opportunity to learn about the current state of fistula research, discuss gaps in surveillance and measurement, as well as consider our shared goal of how best to support providers in high burden countries to tackle this persistent problem.

These providers of obstetric care and women with fistula offer important insight into the existence of fistula, but the reality is that we have no idea how many women in the world are currently living with fistula or are at risk for getting a fistula. Because obstetric fistula is a relatively rare event and women with fistula are often stigmatized, appropriate measurement mechanisms are elusive. Although household and mixed method surveys, key informant interviews, health management information systems, and modeling all offer insight, none of these alone adequately captures the scope of the problem. Consequently, measuring incidence and prevalence of this maternal morbidity is difficult. Additionally, fistula often affects the poorest, most vulnerable, and powerless women and, because they are frequently so marginalized, they can be hard for a “system” to find.

Still, that is no reason to give up.

As the global community comes together to work towards ending preventable maternal mortality and morbidity and address the needs of newborns, fistula is a critical issue. Obstetric fistula, often a sequela of unskilled or absent emergency obstetric care, provides an important lens on how health systems are failing women and newborns when they are at their most vulnerable.

While arguably the vast majority of obstetric fistula is caused by lack of emergency obstetric care during obstructed labor, it is becoming increasingly apparent that there is also some proportion caused within facilities by providers with inadequate skills. In the process of providing cesarean sections, some providers may actually cause a fistula. A forthcoming retrospective review by Dr. Thomas Raassen and others will provide data on this topic covering 18 years and 11 countries.[i]

While the maternal health community is to be commended for all of the work conducted in the last decades to increase access to emergency obstetric care, in our haste we may have made a critical error in failing to ensure the provider has the skills and resources needed to operate effectively. It’s time to take a closer look at the training providers receive and what can improve their competence.

Not all women who arrive at a facility with obstructed labor are guaranteed to receive the care they need for the prevention of fistula. Some women arrive too late after a fistula has begun to form. For those who arrive promptly, a skilled provider can make a critical difference in a woman’s life when the provision of a c-section to relieve obstructed labor will safeguard the health of the mother and newborn. Let’s pause to recognize this need for prompt, skilled emergency obstetric care and plan accordingly.

Let’s also pause to congratulate the Fistula Care project and the incredible surgical teams and facilities staff in the Global South who have provided more than 29,000 fistula repairs to women in more than ten countries, as well as published 22 journal articles, in the last five years. With this kind of track record, further substantial progress in preventing both obstetric and iatrogenic fistula certainly seems within reach.

[i] Raassen TJIP, Ngongo CJ, Mahendeka MM, Iatrogenic genitourinary fistulas: An 18-year old retrospective review of 801 iatrogenic injuries. International Journal of Urogynecology, in press

AIDS conference Exclusive: HIV diagnosis and forced sterilization in Mesoamerica

By Katie Millar, Technical Writer, MHTF

A quarter of HIV-positive women surveyed in Mesoamerica reported health care workers pressured them into sterilization, recent research shows. This rate was consistent across the four countries (Mexico, Nicaragua, El Salvador, and Honduras), all races, and education and socioeconomic levels in the study, showing distinct, consistent discrimination against women with HIV. This is a serious violation of reproductive rights, especially in light of advances in treatment and prevention of HIV.

“It’s really unthinkable that women living with HIV are being pressured and forced into sterilization when treatment almost eliminates the possibility of mother-to-child transmission… and also provides options for safer conception and pregnancy,” says Dr. Tamil Kendall (Reuters), lead research for this project and a Canadian Institutes of Health Research postdoctoral researcher with the Women and Health Initiative and a Takemi Fellow at the Harvard School of Public Health. But, Kendall relays, “We found that only slightly more than half of the women who participated in the study were told that there exists an intervention—a regimen of AIDS-fighting antiretroviral drugs—that can reduce the probability of HIV mother-to-child transmission by 98%–99%.” Even without any intervention, an HIV-positive woman has only a 15-45% chance of transmitting the virus to her newborn. So why are health workers pressuring women to be sterilized?

Stigma.

Kendall said, “Even though our knowledge is growing about how safe conception and pregnancy can be with current HIV treatments; about the possibility of dramatically reducing transmission of HIV to a partner; and about interventions to help people with HIV conceive safely, this knowledge is still often ignored as a routine part of HIV care—even in the U.S. Reproduction among people with HIV continues to be very stigmatized.”

The lengths to which health workers go to pressure or coerce women to sterilize are drastic. “Women are told that if they have another pregnancy that either they will die or their children will almost surely acquire HIV and die,”  Kendall said (Reuters). Some women are even denied medical care if they do not consent to sterilization. One 19-year old woman from El Salvador said, “The nurses forced me to sign. They asked me more than three times and threatened not to perform the cesarean. Because of the pressure, I had no option but to sign.” Even more extreme, some are sterilized without any consent or knowledge of the procedure.

These findings have significant implications for policy advocates, makers, and enforcers. “There’s also a great need to evaluate how health care providers are held accountable—in the courts, for example—for violating the reproductive rights of women with HIV. And it’s important to work with policy makers, because they are the ones who ultimately need to hold institutions accountable,” Kendall states. Continued research and policy advocacy is needed to produce change and respect for HIV-positive women’s reproductive rights.

The unique aspect of this research was it was community-based and broadly collaborative. Led by Dr. Kendall, the research was initiated by Balance, a Mexican NGO, and the International Community of Women Living with HIV and AIDS. More than 60 peer researchers, most of whom are women leaders living with HIV, collected data. In addition, research and policy advocacy are routinely integrated through in-country presentations to participating organizations and national decision-makers, the formation of a regional manifesto, and advocacy with the Commission on the Status of Women and other UN bodies.

Kendall would like to recognize and thank all the organizations that participated in this research.

Want to learn more about Dr. Kendall’s Research? Read interviews with her by the Harvard School of Public Health and Reuters. Want to learn more about HIV/AIDS and maternal health? See our topic page.

Penda Health: 3 Lessons on Motivating Health Providers

By Paige Sholar, Writing and Communications Intern, Penda Health

This post is part of our “Supporting the Human in Human Resources” blog series co-hosted by the Maternal Health Task Force and Jacaranda Health.

Penda Health has built a chain of quality primary care clinics serving Kenya’s poor. Within three years of establishing these clinics, Penda has overcome the challenge of poor provider performance through the use of non-financial incentives.

In Kenya, some clinics give their providers a revenue target every month, forcing the providers to act more like salespeople and sell unnecessary services. This method may allow the clinic to remain profitable but creates distrust between patients and providers and an environment that distracts providers from quality care.

Over the years, Penda has created a profitable new model that creates a trustful provider-patient relationship. Penda also focuses on creating a friendly work environment with motivating non-financial incentives where providers enjoy coming to work every day. During the development of this model, Penda has learned 3 lessons about how to motivate providers.

#1: Providers Will Work Hard to Improve Quantitative Quality Scores

Example of Quality Metrics:  Percent of properly documented quality metrics for tonsillitis by Penda's clinical officers

Example of Quality Metrics: Percent of properly documented quality metrics for tonsillitis by Penda’s clinical officers

Penda Health implements quality metrics as a form of standardization that improve consistency of care, provide quantifiable data, and allow providers to utilize their training and knowledge for diagnosis. The best of both worlds, this method measures and promotes quality care.

The resulting data allow Penda to track the progress of each provider and highlight areas for improvement. When our data highlights a need for improvement, Penda provides topic-specific training until the providers consistently score well. After some resistance, our providers realized this data drove improvement and was not a punishment.

The results of each provider are made accessible to everyone and can be tracked month-to-month. We expected our providers to be competitive with each other, but we are still continually impressed with their desire to improve their own scores. Consistently communicating these quality metrics provides open communication within the clinic and constant feedback to each provider. Also, the transparency of these scores encourages our providers to train their peers.

#2: Providers Love Continuing Medical Education

Penda began offering continuing medical education courses to our providers to support evidence-based medicine while encouraging them to constantly learn and improve, which shows our commitment to the clinics and community. At these trainings providers receive additional information, interact with their colleagues, and leave empowered to treat patients with quality care. The providers receive a certificate after completing the course, which incentivizes completion of the entire course successfully.

After we established training of our own providers, we started inviting providers from other organizations and clinics to our trainings, which increases the medical abilities of the entire community. With outside providers attending the trainings, we encourage our providers to lead sections of the course. Our providers value this opportunity and love teaching their peers!

#3: Positive Feedback from Patient to Provider is Pure Gold!

We have invented ways to collect more patient feedback throughout each provider’s day.

    1. Patient Follow-up Calls: A new protocol requires our providers to call each patient after the clinic visit. The majority of patients is thrilled with this phone call. It is not uncommon for our providers to hear thank you, a blessing, or even joyful tears during these phone calls.

If the patient is not feeling well, the provider invites the patient back to the clinic for a free check-up. In both scenarios, the provider receives daily feedback directly from their patients, which increases provider morale as it demonstrates to each provider that patients value the quality of their care. Penda has created an intimate connection between patient, provider, and data where the provider feels empowered to affect the patient’s experience as well as outcomes.

  1. Patient Feedback: Each patient seen at our clinic completes a feedback form. The positive reviews are read aloud in our weekly team meeting with the name of the staff member who treated them! This is motivating since providers want to continue delivering high quality care so their name is associated with the positive reviews each week.
    1. Compliment Cards: Every six months each one of our staff members receives positive feedback through a “Compliment Card.” Each card includes 5-10 good comments from patients or staff. At our all-company meeting someone reads all of the compliments out loud. The public recognition of each provider is a morale booster and allows each provider to feel appreciated among their peers.

Penda Health has developed a model that uses non-financial incentives to leverage providers’ innate motivation to help people and to create a positive atmosphere where the providers continually strive to deliver the quality medical care.