One of the challenges of maternal mortality is that it is such a complicated problem, with so many causes and factors. Based on your experience, what have been the most effective types of programs when it comes to preventing maternal deaths?
Our programs that address health disparities at the community and facility levels have been critical at reducing maternal mortality. Integration of health into our non health programs—particularly our agriculture projects—has also really widened our ability to meet the needs of women and potentially save lives. Of course, education is a huge part of what we do and this means educating not only women but families in general; and sometimes men especially. For most of our U.S.-funded programs, we make sure to build programs that strengthen community health workers to refer clients to facilities and potentially respond to emergencies while also meeting the regular needs of women. Working with social networks, particularly women’s groups is also very important; as they are vital avenues for getting at behavior change and mitigating the factors that lead to maternal mortality.
Given the importance of building on existing systems and networks, how do you balance introducing facility-based delivery with training traditional birth attendants (TBAs) that have long been established in communities?
The short answer is, we do both. We work with TBAs—through training and/or by providing inputs—and we work at health facility strengthening, so that women will want to get care at that level. We also work hard on strengthening our referral chains and mitigating the three delays of care seeking so women get help in a timely manner.
With TBAs, we generally provide education and material support—be they in the form of TBA kits or something else. We have also utilized Home-Based Life Saving Skills, which is an approach that trains community members and families to prepare the actions they will take when a woman goes into labor ahead of time. Women are trained and encouraged to have birthing teams, which might include the mother-in-law and husband, and when the woman goes into labor, everyone on the woman’s birthing team has a specific role. For example, when the woman goes into labor, the role of the husband might be to go and find transportation to the nearest clinic. The role of the mother-in-law might be to provide water and support. Now, we include TBAs in this process, because we know that at the end of the day, they may be the closest points of help. In some places where we work, we do have a hard time reconciling our health system strengthening efforts with the high numbers of women seeking care from TBAs and the lack of training of TBAs. Because of national laws, we can’t always formally work with TBAs but we do all we can at the community level and make sure to provide inputs into the health center level so all bases are covered.
What do you see as the faith dimensions of maternal health? What does a faith-inspired organization like ADRA bring to maternal health that other health service providers might not?
I think the faith really comes into play in the networks that we can utilize, much more so than in our messaging. As a network, the Adventist system is just massive, and one way or another, we are all connected. We have youth groups, pastors, church women’s groups, bible study groups, hospitals, clinics etc—all of these different connections that we can utilize to get our message out. I think we can tap into resources that non-faith groups or secular agencies don’t necessarily have.
The bible lays out instructions for healthy living which many Christians follow. It is clear that husbands and wives should care for one another. In most cases, however, I think culture plays a much bigger role than religion.
How would you say the health care approach of faith-inspired or faith-based organizations differs from that of state based or secular NGO health care?
The Adventist church has a long history of focusing on what we call the health message. We have a long history of focusing on holistic care and well-being. This plays out in the messages many receive during church services, the vegetarian lifestyle, belonging to social networks,, the importance of exercising regularly, etc. As an agency, we do something similar in that we almost always design our programs to be integrated; be they pairing different health interventions or agriculture with health and nutrition. We believe in holistic care. The other thing to note here is that our churches can serve as entry points into a lot of communities. We don’t have project offices; we have field offices. And in a lot of places where we currently work, we’ve been there forever, including in places like Rwanda and South Sudan where we’ve been for 20-plus years and never left. We have offices that at one point had 500 employees and now they might be down to 50; but they’re still there. So it’s this consistency of presence that enables us to continue to have the trust of communities.
I can’t speak to what drives secular agencies but I will say that for ADRA, healthcare is at the nucleus of the Adventist church and our many institutions.
How would you say you gauge or measure success or the quality of an impact?
That’s a very interesting question. While I don’t feel it is in targets, I will say that targets can play a central role. For instance, we had a family planning project in Nepal where there were so many interruptions that at the end of this five-year project, when we added up the time lost, it was something like two years of programming. And yet we were still able to achieve all of our targets—and they were not set low. It was because of the hard work of a lot of people. In that particular instance, that was success.
In other places, it’s being able to maintain a relationship with the communities where we’re working. It’s doing the type of programming that remains, long after we leave. We have instances like in Madagascar, where we built a series of associations for the purposes of a project; once the project was completed in 2007, these associations registered with the government as independent organizations and continued the work started in our program. That’s success, because we know the interventions so needed in the communities where we worked will continue.
We have other examples: in Kenya and Tanzania, we had a project that ended about two years ago, and people are still utilizing the messages we left; they’re still doing the work (and we know that because we had to go back and do a secondary assessment). So that is success.
Ultimately, success is measured by the lives you change and the lasting impact of that change. I do feel that as a field, we don’t pay enough attention to the change in overall quality of life that’s achieved through our interventions. If we did that more often, I think the way we design and conduct our programming would be different. I think we would pay much more attention to mental health for instance and reaching the physically handicapped than we do now.
What are the partnerships that you’ve found most effective when it comes to maternal health?
The partnerships with in-country stakeholders, particularly community health workers have been critical. Relationships with organizations that have roots in the communities we want to reach are key to anything we do. Partnerships that allow us to broaden our reach are also extremely important; both with external organizations and our own internal networks including churches and schools. We pull from wherever we see strengths to make an impact and those relationships can come from many places.
What local attitudes towards medicine and science have you encountered? How do you address them?
The idea that medicines in general and contraceptives especially will cause cancer, or that they will kill you; that there is some conspiracy by the U.S. government to poison women. Most recently in one of our projects in Eastern Africa, where we refer a lot of women to the health centers to give birth, we’re having a challenge with men not wanting their wives’ legs to be open—even if it’s with a woman that’s going to be providing the services at the center. So you have these women in labor whose husbands don’t want them exposing themselves at the center.
In a Southern African nation, we found that a lot of people weren’t eating a lot of orange fruits and vegetables because they thought it would make them sick. That’s not perpetuated by anything that we could really put our finger on, but it was impacting maternal and child health. In this same country, women weren’t eating spinach because they thought since it grows so prominently, it was not edible. When we looked at the rate of malnutrition and all the food around, it was really startling. To mitigate those challenges, we put together recipes for our communities and engaged them in cooking demonstrations, and it worked for the areas where we were serving. We identify local attitudes regarding health in general—and medicines—through our needs assessments first. Once we know what they are, we find a way to address them through education and action.
What would you say is the greatest challenge of your maternal health work?
I don’t know that there is one great challenge. There is certainly no one problem that, if fixed, would make everything else work smoothly. That said, access and funding are two major challenges that really hamper our ability to consistently make lasting impacts. Policy can also be an issue, because the reality is that in a lot of places, we do our best to work as closely with policy makers and government officials as we can; but that does not guarantee an improvement in their systems or continuation of interventions once our project is completed.
Another challenge is making sure that we include families – and that’s not just men, but it’s also mothers-in-law and grandmothers and other family members that wield a great deal of influence in the family structure. It is always sad to see programs that have done exceedingly well and when you leave because your funding stream stops, the progress also stops.
What are the knowledge gaps at the intersection of faith and maternal health issues?
I don’t know how great a difference faith makes; particularly when you compare it to culture. I would love to know if, in general, practicing faith communities have lower rates of maternal mortality. Id like to know if there are differences in care practices, including care seeking, in faith communities. Are religious texts interpreted in a way that promotes good health? What are the effective faith based messages that faith leaders have used in reaching target groups? I see the gift of faith based agencies and institutions in our ability to reach large numbers of people, first and foremost.
