Manifesto for Maternal Health: In-country perspective from the White Ribbon Alliance Tanzania

Written by Rose Mlay, National Coordinator, The White Ribbon Alliance Tanzania

manifesto_posterThroughout my career as a midwife, I am all too familiar with the challenge of women arriving too late to the hospital to give birth. Over and over again, I have attended to women who had traveled for days to reach care. It is so heart breaking to know that these women’s lives could be saved if only they could reach quality professional care faster. We, at the White Ribbon Alliance, have advocated strongly over the years to our government in Tanzania to focus on maternal and newborn health, and great promises have been made! Now, we are faced with the challenge of making sure these promises are delivered. And we are working hard on that front!

In recognition of the one-year anniversary of the publication of the Manifesto for Maternal Health, I’d like to take this opportunity to share some of our recent efforts to ensure that promises to women and newborns are kept.

Just last year the White Ribbon Alliance Tanzania brought together national leaders engaged in maternal and newborn health ranging from the media, government, non-governmental organizations, and trade unions to set out a strategy for holding the government of Tanzania accountable for delivering on commitments made to our women and newborns. More specifically, we collectively set out a plan for holding the government accountable on promises to provide comprehensive emergency obstetric care (CEmONC) in at least half of all health centers by 2015. Together, we concluded to focus our efforts on the commitment to CEmONC because we listened to our citizens who have asked for these services to be closer to their homes. In addition, we know that the majority of the 27 women who die every day in childbirth die due to the lack of access to quality emergency care.

In order to make our case, we knew we would need strong evidence to show the government just how off track their promises are, so we carried out a full facility assessment in 10 government-run facilities in Rukwa region. We engaged with community leaders, media and district officials as we moved through the region. Rukwa is beautiful with its rolling hills and great lakes, but it is a treacherous journey through the dirt tracks to get to rural health centers, with many being so remote that they are out of reach of telephone signals.

As we gathered the data, we found that for a population of 1 million people, and over 10 health centers throughout the district, there was not a single health center that was providing the level of care that the government had promised.

According to plan, we shared the evidence with the district government teams, and we pushed the district leadership to budget adequately for emergency obstetric care. In the meantime, we also set up meetings with national leaders and the Parliamentary Safe Motherhood Group to make sure emergency obstetric care is budgeted for adequately in the 2014-2015 budget cycle.

We also made this film about the situation in Rukwa which Dr. Jasper Nduasinde, our White Ribbon Alliance focal person from the region took to the United Nations General Assembly to get global attention on the gap between promises and implementation.

We called on our politicians to act. The Safe Motherhood Group in Parliament is working to get all politicians to sign a petition to the government to prioritize this issue.

We called for a meeting with the Prime Minister. We spoke for an hour and a half on what could be done now to change this critical situation. He promised to take action.

We also made this film about Elvina Makongolo, the midwife in Mtowisa who works tirelessly to save women’s lives.

As we move to make these critical changes happen, we are faced with very sad news that motivates us even more. Shortly after this film was made with Elvina, the teacher of her grandchildren died in childbirth. Leah Mgaya died because Mtowisa health center does not have a blood bank. In the maternity ward of the health center ,a big refrigerator stands tall but the electricity to power it is missing. The closest blood supply is 100 km away at the regional hospital, reached only by a 4×4 vehicle due to the rough terrain.

Leah’s husband, Cloud Kissi, said: ‘My wife has left a big gap in my life and she has left three children without a mother. It has left me with trauma as every time I see a woman carrying a baby I feel that if my wife could have survived, she could have been carrying a baby like the one I am seeing. I am quite sure that if we had a good operating theater, availability of safe blood and a reliable ambulance, we would have surely saved my wife’s life.’

We continue to hear the personal accounts of husbands losing their wives, children losing their mothers, families losing their aunties, sisters and nieces and, in Leah’s case, a community losing their teacher. Citizens want change and they are pushing for it.

In Rukwa alone, over 16 thousand citizens have signed a petition pushing the district officials and their MP to prioritize a budget for CEmONC.

Recently, on White Ribbon Day in Rukwa, the Minister of Health spoke on behalf of the Prime Minister to say that this budget must be prioritized across the country.

We now believe that the Prime Minister has become this campaigns’ greatest ally! And we know that our President Kikwete cares about the women of our nation. He has committed greatly to preventing these tragic deaths. But we cannot let up until women can access emergency life saving care near their homes. It is their right.

As critical decisions are being made on budget allocation for 2014-2015, we are urging our leaders to listen to the citizens of our nation and budget adequately for comprehensive emergency obstetric and newborn care.

If you would like to share your in-country story with us, please email Natalie Ramm or join the conversation on Facebook and Twitter.

Postnatal Depression: What should we know about it?

By Jean Marie Sims Place, PhD, Deborah L Billings, PhD, and Filipa de Castro, PhD

Read this post in Spanish here.

What is postnatal depression?
Postnatal depression is characterized by feelings of hopelessness, agitation, sadness, despondency, suicidal ideation, and a perceived inadequacy in caring for the infant (Born, Zinga, & Steiner, 2004). It is defined by the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a major or minor depressive episode affecting women within four weeks after childbirth (American Psychiatric Association, 2013). However, this definition is often expanded by clinicians and researchers to occur anytime within the first year postpartum (Stowe, Hosetter, & Newport, 2005).

The burden of postnatal depression
Research (meta-analyses) that examine the prevalence of postnatal depression estimates rates of 20% in low- and middle-income countries compared to 13% in high-income countries (O’Hara & Swain, 1996).  Women who experience postnatal depression without receiving adequate treatment are at a greater risk of suffering chronic and recurrent depression throughout life, which can be profoundly disabling (Patel et al., 2012). For example, suicide as a result of postnatal depression and other mental disorders is a leading cause of death among women in the postpartum period.

Not only the women who experience postnatal depression suffer its consequences. This disorder is associated with weak maternal-infant attachment and delays in children’s cognitive and emotional development. It is also associated with early cessation of breastfeeding, which contributes to malnutrition and diarrheal diseases in infants, especially in low- and middle-income countries (Cooper, Murray, & Stein, 1993).

A closer look at research on postnatal depression in Mexico
Over the last few years we have led several studies focusing on epidemiological, health systems and policy aspects related to postnatal depression in Mexico. These studies have been carried out by the Mexican National Institute of Public Health in collaboration with the University of South Carolina in the USA. Postnatal depression is not uncommon among Mexican women. One community-based study estimated prevalence to be 14% among adult women and 16% among adolescent women who received postpartum care in an urban, public-sector hospital (deCastro et al, 2011). Risk factors for postnatal depression in Mexico include lack of social support, lower levels of education, reported fear during labor, lack of a partner, unplanned pregnancy, and even giving birth to a baby girl compared to a baby boy (Lara et al., 2012; deCastro, 2011). Previous episodes of depression, anxiety, and stress during pregnancy, history of trauma, and feelings of incompetence in mothering have also been significantly associated with postnatal depression among Mexican women (Alvarado-Esquivel et al., 2010; Navarro et al., 2011).

Early identification of risk factors is an important strategy to prevent onset of postnatal depression. In fact, results from an analysis of predicted probabilities among a hospital-based sample of Mexican women indicate that postnatal depression could be reduced to 5.5% if the risk factors of low social support, unplanned pregnancy, and exposure to intimate partner violence (IPV) during pregnancy were eliminated (deCastro et al, under review). IPV during pregnancy, in particular, is a significant risk factor for postnatal depression. Results from one study we conducted among a sample of women from Mexico City indicated that one in five women experience IPV during pregnancy, which includes emotional, physical, or sexual abuse. Compared to women who did not report such violence, the women who reported IPV during pregnancy were significantly more likely to develop postnatal depressive symptoms (deCastro et al, 2014, in press).

Due to the substantial negative effects of postnatal depression and the importance of effectively addressing it, we have focused our research on how healthcare providers detect and treat postnatal depression in primary, secondary and tertiary-levels of care in Mexico (Place et al, 2013; deCastro et al, under review). Consistent with evidence suggesting the influence of psychosocial risk factors on postnatal depression, a sample of healthcare providers likewise expressed an understanding of how social and behavioral antecedents, including extreme poverty, high expectations for women as mothers, and IPV have an impact on the occurrence of postnatal depression. These same providers often viewed any symptoms of distress as representing a possible case of postnatal depression with the potential to affect women’s responsibilities associated with motherhood (Place et al, 2013).

Notwithstanding healthcare provider awareness about postnatal depression, we found that overall, detection of postnatal depressive symptoms and care for women experiencing postnatal depression are not systematically included in women’s healthcare throughout their pregnancy and postpartum. Nationally, less than half of obstetric units are routinely detecting (37%) or treating (40%) postnatal depression (deCastro et al , under review). Lack of hospital guidelines and official norms are among the reasons providers reported to account for the poor rates of detection and treatment (deCastro et al, under review).

Notably, one psycho-educational intervention to prevent postnatal depression among high-risk women was implemented in one public-sector hospital in Mexico. There was a trend suggesting that participants in the intervention group had a larger reduction of depressive symptoms at 6 weeks and 4-6 months postpartum compared to participants receiving usual care in the control group (Lara et al, 2010). These results suggest that postnatal depression in Mexico has the potential to be successfully prevented, detected, and treated.

As part of our research, we decided to investigate what formal direction existed in Mexico regarding the detection and treatment of postnatal depression, if anything at all. We conducted a comprehensive review of national health plans, national action plans, federal and state laws and regulations, clinical practice guidelines, and public-sector healthcare facility policies examining whether they included a statement of intent and/or actions related to the care and management of women who experience or who are at risk of experiencing postnatal depression. Postnatal depression was noticeably absent from maternal health, pregnancy care and mental health policies and guidelines. Even when mentioned, actions relating to the care and management of women who experience or who are at risk of experiencing postnatal depression were generally not included (Place et al, 2013).

What can be done?

The World Health Organization (WHO) and the United Nations Population Fund (UNFPA) highlight education and training for healthcare providers and the development of a policy framework as core strategies to address maternal mental health in low- and middle-income countries.

Materials that build on providers’ existing conceptualizations of postnatal depression need to be developed and incorporated into professional training so that women’s full range of needs can be addressed throughout pregnancy as well as postpartum. Policy makers should consider expanding existing mental health policies by identifying actions that prioritize the care of women who experience postnatal depression, as well as establishing clinical practice guidelines that specifically address maternal mental health problems. The intersection of mental health with maternal health needs to be recognized by health professionals, who play a key role in the well-being of women, children and families.

Do you know if postnatal depression is addressed as part of the health system in your country?

If you are interested in writing a post about maternal mental health in your country, please contact Natalie Ramm.

Please share this article on Facebook and Twitter to help generate dialogue on this important topic.

Jean Marie Sims Place, PhD is a faculty member at the Department of Physiology and Health Science at Ball State University in Muncie, Indiana, USA.

Deborah L Billings, PhD is an adjunct faculty member at the Department of Health Promotion, Education and Behavior at the University of South Carolina in Columbia, South Carolina, and the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill, North Carolina, USA. She serves as the Director of the South Carolina Contraceptive Access Campaign.

Filipa de Castro, PhD is a professor and researcher at the Reproductive Health Unit at the Center for Population Health Research of the National Institute of Public Health in Mexico City, Mexico.



  1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental health disorders: DSM-5 (5th ed.). Washington, DC: American Psychiatric Publishing.
  2. Born, L., Zinga, D., & Steiner, M. (2004). Challenges in identifying and diagnosing postpartum disorders. Primary Psychiatry, 11(3), 29-36.
  3. De Castro, F., Hinojosa-Ayala, N., and Hernandez-Prado, B. (2011). Risk and protective factors associated with postnatal depression in Mexican adolescents. Journal of Psychosomatic-Obstetrics & Gynecology, 32(4): 210-217.
  4. De Castro, F., Place, J.M., Hinojosa, N., and Billings, D. La depresión postnatal
    se asocia con el reporte de violencia sufrida durante el embarazo en una muestra de mujeres Mexicanas. Genero y Salud en Cifras (In press)
  5. De Castro, F., Place, J.M., Allen, B., Rivera, L., Billings, D. Detection of and care for perinatal depression in Mexico: Qualitative and quantitative evidence from public obstetric units. BJOG: An International Journal of Obstetrics and Gynecology (Under Review).
  6. De Castro, F., Place, J.M., Billings, D., Rivera, L., Frongillo, E.  Risk profiles associated with postnatal depressive symptoms among Mexican women: The role of demographic, psychosocial and perinatal factors. Archives of Women’s Mental Health (Under Review).
  7. Cooper, P.J., Murray, L., & Stein, A. (1993). Psychosocial factors associated with the early termination of breast-feeding. Journal of Psychosomatic Research, 37(2), 171-176.
  8. O’Hara, M., & Swain, A. (1996). Rates and risks of postpartum depression – a meta-analysis. International Review of Psychiatry, 8(1), 37-54.
  9. Patel, M., Bailey, R., Jabeen, S., Ali, S., Barker, N. and Osiezagha, K. (2012). Postpartum depression: A review. Journal of Health Care Poor Underserved, 23(2), 534-542.
  10. Place, JM. (2013). Postnatal Depression in Mexico: Healthcare Provider Conceptualizations and Policies in the Public Health Sector. Department of Health Promotion, Education and Behavior. University of South Carolina. Columbia, South Carolina.
  11. Stowe, Z., Hostetter, A., & Newport, J. (2005). The onset of postpartum depression: Implications for clinical screening in obstetric and primary care. American Journal of Obstetrics and Gynecology, 192(2), 522-26.

What Community Health Workers Want: A Conversation with SEWA Rural

Guest post by Shrey Desai, Research coordinator at SEWA Rural

Could you give us an overview of your work as it pertains to maternal health and/or mHealth?

SEWA Rural is a voluntary organization with over three decades of experience of working with Community Health Workers (CHWs). Over last decade, our CHWs have been instrumental in reducing the maternal mortality ratio and neonatal mortality rate by 78% and 38% respectively across our project areas in Gujarat.

Within maternal health, where do you see mHealth as having the highest impact or highest potential for impact?

One of the important uses of mHealth solutions is to improve performance of CHWs. However, programs aimed at improving performance may experience a “burn-out” after initial enthusiasm. Therefore, managing the change in working environment of CHWs (with the introduction of mHealth) is critical to make mHealth acceptable and attractive to them on sustained basis. For that to happen, we need to understand what CHWs want and how their needs can be met using mHealth solutions while we focus on improving their performance.

How can mHealth initiatives geared towards improving maternal health better address the needs of end users?

To facilitate scale up and to improve health outcomes, we make mHealth attractive to end users such as CHWs. The first step would be to listen to them, understand their motivations and experiment with them as equal partners. Our grassroots work with CHWs has taught us that motivations of CHWs include timely payment of performance based incentives, regular replenishment of supplies, recognition for good work, respectful behavior and opportunity to learn and grow. These were some of the requirements that we tried to fulfill while developing and implementing a new mobile phone application called “ImTeCHO” which ultimately aims to increase performance of CHWs.

ImTeCHO has digitized measuring CHW performance, which has helped to pay CHWs using performance-based incentives so that they now receive timely payment. We recognize good performance of a particular CHW by sending weekly “CHW of the week” story to all CHWs through ImTeCHO application; this inspires other lesser-performing CHWs to improve their performance so that she could be next “CHW of the week”. A facilitator calls every CHW once a month to congratulate good performance and motivate lesser performing CHWs in respectful manner.

How has mHealth strengthened the delivery of your maternal health programs and how has this impact been measured?

The measures mentioned above have resulted in high uptake and acceptability of ImTeCHO among CHWs. Community health workers are now more comfortable with dispensing medicines to treat sick women and children because ImTeCHO provides information about the drug customized for the client. This makes the CHW feels more empowered and makes local government health staff replenish their supplies more regularly due to higher demand. Most importantly, we have continued to listen to CHWs and improvise ImTeCHO‘s application and implementation model through iterative cycle and action leaning over last 10 months. We have created a small mHealth laboratory in 45 villages with the CHWs, local government heath staff, and investigators as partners.

On an average, our CHWs have logged in ImTeCHO application 90% of working days and completed 75% of assigned tasks consistently over last 10 months. There has been no attrition among CHWs and none of them have stopped using the mobile phone application. There are numerous reports of previously poorly performing CHWs now making better efforts and doing so enthusiastically.

Do you have an opinion on the role mHealth can play to improve maternal health? What do you see as the biggest advantages of mHealth? The limitations? If you are interested in submitting a blog post for our ongoing guest blog series on mHealth for Maternal Health, please email MHTF Research Assistant Yogeeta Manglani at

Literacy and the School-Health Connection: An Informal Conversation with Robert LeVine and Ana Langer

Ana Langer, Director of the Women and Health Initiative and the Maternal Health Task Force, and Robert LeVine, Roy Edward Larsen Professor of Education and Human Development, discussed the connection between literacy and health in a round table discussion at Harvard last month.

“Literacy’s impact on health reflects the challenges of navigating complex medical systems and language, understand health professionals, and interpret media messages about health, including those they hear on the radio or television. Clinics in poor communities may still be scary places for women, said LeVine, but literacy skills may lower a woman’s anxiety level about seeking medical care, and help her to overcome systemic barriers.”

To learn more about how literacy influences women and children’s health, read Harvard’s full article here.

Holding the World Bank Accountable for Reproductive Health Commitments

Princess Sarah Zeid, champion of the White Ribbon Alliance, is holding the World Bank accountable for reproductive health commitments. Her article on The Huffington Post earlier this week emphasized the importance of keeping maternal and newborn health on the post-2015 agenda:

The evidence shows us that to maintain the progress made, it is essential that we continue what we have begun, whilst expanding our investments if we are to spread our impact.

To ensure that development is truly sustainable and to avoid far worse — to prevent a backward slide — we must do more for more.

She also noted that reproductive health and family planning are essential for maternal and newborn health targets post-2015:

Access to family planning — to choices about contraception — improves both maternal and newborn survival by lengthening inter-pregnancy intervals. Spacing the birth of children by three years will decrease under-5 deaths by 25 percent.

Read the full article and learn how to help here.