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A Lesson in Holistic Care: What I Learned from Working with Transgender Women and Health Providers in the LAC Region

November 20 is Transgender Day of Remembrance.

I have collaborated closely with transgender women and health providers in Latin America and the Caribbean to learn more about the needs of transgender populations and to train health workers to provide quality services. Working alongside transgender women on needs assessments, trainings for health providers, and in the development of a blueprint (PDF) for comprehensive transgender services, opened my eyes to their experiences, gaps in existing programs that limit access to critical services, and the opportunities we need to pursue. To help you understand my recommendations, I would like to share a story I heard repeatedly from transgender women:

I was 13 years old when my family threw me out of the house because of who I am. I tried to continue my studies, but I dropped out of school because my classmates insulted me every day and sometimes hit me, and I was afraid to use the boys’ bathroom (the only one I was allowed to use) because I was afraid of being assaulted by male students. The teachers looked the other way or called me names. I have developed a thick skin because when I step out of my home, people stare, make comments and give menacing gestures. Going to a clinic is also unpleasant. I get sick like everybody else, but the nurses always assume that I am a sex worker and that I have HIV. Frequently, they give me condoms and an HIV test and send me home. One time I was jumped by four guys in the street, and I ended up in the emergency room. When one of the nurses opened my robe and saw that I am a transgender woman, she gave me a look of disgust and called me a homosexual. She must have told others about me because several nurses came, opened my robe and walked away laughing. I waited for a long time before a doctor saw me. He told me that real men do not dress like women, and that I should cut my hair and stop wearing make-up so I could get a job. I had a cut in my head that needed stitches and the doctor did not even clean the blood in my hair.

REDTRANS and Miluska staff conducting a workshop on HIV and human rights. Photo credit: Manuel Contreras

REDTRANS and Miluska staff conducting a workshop on HIV and human rights. Photo credit: Manuel Contreras

This story, and the others that I heard through this work, underscored the need for a new approach to transgender health:

  1. Prevention efforts must engage families and schools to foster supportive environments.  Transgender teens frequently experience rejection from their families and bullying in school. Homelessness, low literacy, and lack of family protection not only increase the likelihood that these teens will experience exploitation, but also severely limit their opportunities to find jobs.
  2. Many people, including health providers, do not clearly understand the spectrum of sexualities, genders, and identities. Their confusion often leads to stigmatizing attitudes and discriminating practices in health care settings, which in turn discourages transgender women from seeking care.
  3. Increasing access to counseling and testing and other HIV services should not be an end in itself. Securing the human rights of transgender communities and creating a safer environment where they can access appropriate services without fear of violence or discrimination should be the focus.
  4. Increasing access to condoms and HIV information are cornerstones of HIV prevention, but national prevention programs need to go beyond these two strategies. Policies and programs should also support employment and education opportunities for transgender persons. The pressure to put food on the table and a roof over their families’ heads can lead to poor decision making, resulting in risk-taking behaviors.
  5. Engaging transgender persons in program activities as facilitators or data collectors strengthens their technical capacities and allows them to engage with health providers and communities as professionals and peers. This can effectively dispel myths and negative beliefs about transgender women, their capacity, and their behavior.

By sharing my observations and the stories I heard, I hope to raise awareness of the issues that come into play and to encourage all of us to reconsider how our programs can better contribute to the well-being of transgender persons and their communities. We can make that commitment today on Transgender Day of Remembrance, an internationally recognized day to memorialize those who suffered or died as a result of anti-transgender hatred or prejudice.

Aysa Saleh-Ramirez, MPH is AIDSTAR-One Senior Technical Advisor at John Snow, Inc. AIDSTAR-One is funded by PEPFAR through USAID.

Empowering Women to Address Climate Change

Today marks the second annual Gender Day at the Conference of the Parties to the United Nations Framework Convention on Climate Change (UNFCC) Conference, which opened (PDF) last week in Warsaw, Poland. Leaders from around the world are focusing on how to achieve their commitments to promote gender balance and improve women’s participation in international and local level decision-making related to climate change.

This year, USAID is proud to announce that we are initiating a new partnership with the International Union for the Conservation of Nature (IUCN) to work together to expand and enhance USAID’s efforts to address gender issues through programming and support to our partner governments.

Members of the Huruma Women’s Group in Kenya. Photo credit: Photo Credit: Fintrac Inc.

A group of women in Kenya who supply maize for sale in local markets. Photo credit: Photo Credit: Fintrac Inc.

This support is critical as climate change will have a serious impact on the livelihoods of poor women in developing countries; the increasing frequency of droughts and stronger storms will affect agriculture and water resources, sectors in which women have an essential management role.

Speaking on a panel this morning, Nancy Sutley, Chair of the White House Council on Environmental Quality emphasized that “globally, women are central to unlocking solutions to the climate change challenges we face.”

IUCN has found that women often lead the way in adapting to climate change impacts, and play a key role in mitigating climate change by optimizing energy efficiency, using low-footprint energy sources and techniques, and influencing a household’s and community’s consumption patterns. Women’s participation in decision making at higher levels has specifically benefited environmental policy, such that countries with a higher number of women in their parliaments are more likely to set aside protected land areas and ratify international environmental treaties. In fact, recent data (PDF) reveals that there is a causal relationship between environment and gender; when gender inequality is high, forest depletion, air pollution and other measures of environmental degradation are also high.

While women can be agents of change, their contributions are seldom fully harnessed. The result is a lost opportunity. This new partnership will be aimed at advancing women’s empowerment and gender quality to achieve greater strides in reducing emissions to mitigate climate change, building resilience to climate change impacts, and promoting better development in general.

While plans are necessary to illuminate the pathway to a goal, they are not sufficient for attaining those goals.  This new agreement with IUCN to implement the Gender Equality for Climate Change Opportunities (GECCO) project will provide USAID and our partner governments with support for our mutual goal of advancing women’s empowerment and gender equality through and for the benefit of climate change and development programs.

We have seen great progress in recent years, with growing attention to gender issues within the UNFCCC and within projects addressing these issues at the country level.  However, there is much work still to be done, so we are excited about the opportunities this new partnership with IUCN brings.

 

Access to Water Empowers Women in Morocco’s Middle Atlas

I recently returned from Outerbate, a village high in the Atlas Mountains in central Morocco, where USAID broke ground on a new water supply system. In this Amazigh, or Berber village, the water supply system is more than 80 years old and serves only a handful of the village’s 300 homes.

I met Fatima Mazrou, a woman in her late 70s, who shared, “When we look for water, we sometimes get frozen and sick because the weather can go to below 10 degrees. It takes me at least one hour lining up to get water. Water and bread are critical to our survival.”

Increased access to water changes women and girls' lives in Morocco. Photo credit: USAID

Increased access to water changes women and girls’ lives in Morocco. Photo credit: USAID

I was surprised to see that women do most of the hard work of filling buckets to provide their families with water. The challenge is that the village’s 1,200 inhabitants must fill buckets and water containers at a common tap, and the task disproportionately falls to the village’s women and girls.

During the summer months, the tap frequently runs dry. Water-related health problems are common. In the winter, this arduous trek up the mountain in freezing weather and back to the village carrying heavy pails of water leads to health problems for women, including miscarriages.

The time and work involved collecting water also means reduced primary school attendance by the village’s girls. Kuba Hamou, a sheep herder, told me that “having better access to water would eventually free women to pursue income-generating activities and help keep our daughters enrolled in school.”

Financed by USAID’s Development Grants Program, the Outerbate water system is being installed to address some of these challenges. Implemented by a local NGO, Al Kheir, the program will provide clean drinking water to every home in the village, ending the current practice of women and girls filling water containers at a common tap. With the introduction of the new system, girls’ attendance in schools should also increase and hundreds of families will have access to water and improved sanitation conditions in their homes, schools and public areas.

In addition, we have been able to work with Al Kheir in other life-improving ways. We helped the village set up a thriving artisan business selling locally produced honey and apple juice. And within Al Kheir, two young women are now on the association’s board of directors – the first time a woman or a youth has served in this capacity. Since this project began, Al Kheir has begun working with European and Japanese donors on other projects.

“None of this would have been possible without the engagement of USAID. We appreciate their support and its effects on our village,” said Haddou Maadid, Al Kheir’s president.

At the heart of USAID Forward is a belief that our results are always better when we partner directly with local institutions since they are empowered to take control of their future. In Outerbate, we are helping a village access safe water. By working directly with local partners, our assistance is amplified far beyond the water tap.

Why the Arts and Youth Matter for LGBT Global Development

Last month, I had the opportunity to join Urooj Arshad of Advocates for Youth in a conversation following a performance of The Laramie Project, Moises Kaufman’s play about Matthew Shepard at the Ford’s Theatre in Washington, DC. As I watched characters like the Muslim Bangladeshi-American university student and a skeptical university student slowly learning about lesbian, gay, bisexual and transgender (LGBT) people, I was reminded of the importance of the arts and youth in international development.

USAID Administrator Rajiv Shah dances with a Family Ayara Youth Foundation dancer in a trip to Bogota, Colombia in April 2013. Photo credit: USAID

USAID Administrator Rajiv Shah dances with a Family Ayara Youth Foundation dancer in a trip to Bogota, Colombia in April 2013. Photo credit: USAID

The power of images and storytelling moves people and societies. USAID has been at the forefront of using the arts as a tool for social change in countries where we work:

  • In Lebanon, USAID supported youth in photography, painting, writing, and drama as a way to express fear about “the other” and find a way to understand those different from themselves.

  • Most recently, in Colombia, the Canal Capital television network broadcast a one-hour documentary on LGBT issues and the diversity of families in Colombia. Local television networks throughout the country are re-broadcasting this documentary, contributing to increased awareness of LGBT families in Colombia. Promoting LGBT issues is a core part of USAID’s efforts to help civil society build a culture of human rights in Colombia.

USAID’s efforts to protect and promote the rights of LGBT persons in Colombia is not unique. We take hate crimes and the vulnerability of LGBT persons seriously by focusing on the resilience and power of LGBT persons as change agents.

These efforts are part of USAID’s overall focus on inclusive development. We believe that men, boys, girls and women, persons with disabilities and the LGBT community, internally displaced persons, indigenous peoples, ethnic and religious minorities, and youth, are an integral part of the development process. USAID’s suite of policies include the first ever Agency-wide Youth in Development Policy, as well as Gender Equality and Female Empowerment Policy (PDF), U.S. Strategy to Prevent and Respond to Gender-Based Violence Globally (PDF), and U.S. Government Action Plan on Children in Adversity. Our Youth in Development policy highlights many of the challenges and opportunities facing youth as a specific population group and simultaneously emphasizes the fact that youth are not a homogeneous group.

Based on data in the U.S. and anecdotal evidence in my travels worldwide, we know that LGBT youth are at increased risk for being abandoned by their families and rejected, barred, or deterred from accessing schools, all of which undermine their ability to learn and develop the skills that are necessary for a productive life. In an online survey sponsored by Vietnam’s Center for Creative Initiatives in Health and Population showed that 77% of LGBT youth experienced verbal abuse and 44% experienced physical assault in school. 42% of these youth lost interest in school, 33% skipped school, and 6% abandoned school.

The Laramie Project and data on LGBT youth underscore the importance of ensuring marginalized youth have a voice and are able to engage in policy-making processes in their communities. Focusing on LGBT youth is critical to global development.

The data may be daunting; however, based on a track record ranging from the arts to inclusive development to human rights programming and our expertise on NGO organizational development, USAID is leading in addressing the challenge of integrating vulnerable populations, particularly youth and LGBT persons in our programming.

Expanding Access and Choice for Family Planning

Next week more than 3,000 political leaders, scientists, health care professionals, advocates and young leaders from around the globe will gather in Addis Ababa, Ethiopia, for the third International Conference on Family Planning or ICFP2013. A year ago, the global community came together to launch Family Planning 2020, which has generated unprecedented political will and financial support to reduce global unmet need for family planning by giving 120 million more women access to modern contraceptives, information and services by 2020.  Conference participants in Addis will share the latest data, research and program findings to help achieve Family Planning 2020’s goal.

Organized around the theme “Full Access, Full Choice,” ICFP 2013 will call attention to the wide range of health, social, and economic benefits of helping couples plan and space their pregnancies. Holding the conference in Ethiopia is an opportunity to celebrate and showcase the success Ethiopia has had in greatly increasing access to family planning in a few short years. In 2005, 15% of married women used a form of modern contraception, and today nearly 29% are modern family planning users. However, there is still more to be done to ensure women’s needs are met.

Women gather at a health post in Ethiopia. USAID trains and supports health extension workers across Ethiopia's health system in the most populous regions of the country. Photo credit: Nena Terrell, USAID Ethiopia

Women gather at a health post in Ethiopia. USAID trains and supports health extension workers across Ethiopia’s health system in the most populous regions of the country. Photo credit: Nena Terrell, USAID Ethiopia

Women know what they want and when they demand it, we must listen: The ability to make important decisions about childbearing is one of the most basic human rights. Women deserve family planning options that are effective, affordable, available, and accessible and they need to be able to make their reproductive decisions freely and with full information. USAID is committed to developing new, affordable contraceptives and to supporting countries as they strengthen their health systems as part of an effort to fulfill full access and full choice for family planning. We’ve made great progress, but we must do more to ensure that everyone has true access to voluntary family planning information, services and methods that meet their needs.

USAID is proud to co-sponsor the International Conference on Family Planning, which is jointly organized by the Ministry of Health of Ethiopia and the Bill and Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins Bloomberg School of Public Health. A number of USAID’s technical experts will present at the conference on the latest progress and challenges around increasing access to family planning.

Visit USAID’s ICFP webpage to access a calendar of USAID-sponsored events, the latest news and updates from the conference, and useful technical resources for participants.

Follow USAID for Global Health on Twitter for live updates and use the hashtag #ICFP2013 to join the conversation.

Photo of the Week: Women Sing in West Africa

Women sing

Community members sing at the opening of a border information center in West Africa. In the continuing effort to facilitate West Africa inter-regional trade, USAID has supported the opening of several Border Information Centers. The Centers, located at the borders of Ghana and Togo; Ghana and Burkina Faso; and now Benin and Nigeria, bring transport information and assistance to traders, and truck drivers, and allows them to more easily transport goods and needed commodities across borders.

Learn more about our Mission of the Month: Nigeria and USAID’s work in the region.

Read some stories about how we’ve transformed lives in Nigeria.

Follow @USAID and @USAIDAfrica on Twitter and join the conversation with #MissionofMonth! 

 

What Does It Take to Get Contraceptives to Clients in Rural Nigeria?

Many of our clients learn about family planning from routine visits to rural health facilities. The health workers in this facility help patients and their families choose appropriate contraception methods and teach new clients how to use these methods correctly. The same health workers who are responsible for treating patients are often also responsible for monitoring the supply of contraception methods in the facility. When torn between caring for a waiting room full of patients and filling out paperwork to order new supplies, health workers discovered that they were stocking out of essential contraception supplies. This meant that they had to turn away patients—many of whom had traveled considerable distances to get these family planning services. The discouraged clients lost confidence in the health system and were less inclined to seek out family planning services if products they wanted were not available when they needed them.

DDIC truck delivering commodities at a rural health facility in Nigeria. Photo credit: USAID | DELIVER PROJECT

DDIC truck delivering commodities at a rural health facility in Nigeria. Photo credit: USAID | DELIVER PROJECT

To rectify the stock-out situation and improve access and availability to family planning commodities in Nigeria, the USAID|DELIVER PROJECT is piloting a system called Direct Delivery and Information Capture (DDIC) in Ebonyi and Bauchi states. Through DDIC, the project currently delivers 24 public health commodities, including contraceptives, antimalarial medications, and maternal, newborn and child health products to 365 selected service delivery points in the selected states.

The DDIC system utilizes a vendor-managed inventory model, whereby products are delivered from state warehouses directly to the health facilities on trucks that serve as mobile warehouses. The trucks arrive, carrying predetermined quantities of health commodities, based on the facilities’ past consumption data. By investing in reliable transportation, DDIC ensures that truck drivers and team leaders are available to deliver commodities to health facilities according to an established delivery schedule. A team leader traveling with the truck inspects the facilities’ storage space, counts stock-on-hand for the different health commodities, and enters this inventory data into a specifically-designed inventory management database. The database calculates the quantity of products to be issued to the facility to bring the quantity of stock of contraceptives back to the pre-determined levels. Data obtained from each facility are synchronized with a sister software to generate logistics reports that help monitor system performance and prepare for the next resupply period.

Commodities are supplied to the health facilities every two months. After just four consecutive supply trips, the availability of commodities at participating facilities has drastically improved. Stock-out rates of contraceptives and other common health products have been reduced from above 70% before DDIC was implemented to below 5%. Additionally, 100% of the targeted health facilities have received a bi-monthly visit with the team leader. Furthermore, essential logistics data are now readily available for public health supply chain experts to use in future decision making about future health commodity needs.

Though still in the pilot phase, DDIC has improved the availability of contraceptives and other commodities in rural health facilities in supported states. It has also relieved many of the health facility staff of paperwork duties, so they can focus more on providing better quality care to patients. Consequently, clients’ confidence in the health facility’s ability to provide health services is increasing.

So, what does it take to get contraceptives to clients in rural Nigeria?

Through DDIC, USAID is improving availability of contraceptives at rural health facilities on a regular bimonthly delivery schedule, thereby increasing families’ patronage and uptake of family planning services. DDIC has come to the rescue ensuring commodities availability at facilities and data for planning in Nigeria!

Learn more about how USAID is working towards ensuring safe motherhood and healthy families around the world.

Learn more about our Mission of the Month: USAID Nigeria. Follow @USAID for ongoing updates in the region and join the conversation with the hashtag #MissionofMonth!

From the Field in Madagascar: USAID Food Security Program Improves Livelihoods

As part of USAID’s 52nd birthday celebration, USAID/Madagascar shares a story of one woman who has benefited from a food security project. 

Sitting in the shade of an old mango tree, a group of villagers is intently listening to a middle-aged woman reading aloud from a booklet in her hands. The woman is Philomène, the ‘Treasurer’ of the local Village Savings and Loans association, and she is making her weekly report to the members.

Philomène (4th from left) volunteered to keep the VSL association’s books Photo credit: CARE International/Madagascar

Philomène (4th from left) volunteered to keep the VSL association’s books
Photo credit: CARE International/Madagascar

We heard about Philomène during a field visit to a food security project implemented by our partner CRS. The team was in a small village called Ampasimbola, in eastern Madagascar. Philomène is a farmer and she has been tilling the land for as long as she can remember. She is a single mother of six children, four of which are still in school.

Although Philomène puts a lot of effort into her work, she hardly produced enough food to feed her family. It was a challenge for her to make ends meet; on occasion, her children missed school to stay home and help her do farm work, her only source of income.

When USAID’s food security program started in Ampasimbola in 2010, Philomène did not think twice about joining the Village Savings and Loans association. She even volunteered to keep the books for the group. These village-level savings banks allow members to contribute some amount on a regular basis. They can then request loans with soft repayment terms and conditions. Philomène seized the opportunity to take out a loan and start a small restaurant offering doughnuts, coffee, fish, and even second-hand clothes to increase her income.

With hard work, Philomène’s restaurant quickly thrived. She soon had to choose between continuing farm work that brought home hardly any money, or focusing on a more lucrative and rewarding activity. She decided to drop farming— a savvy decision, because not only did she make substantial profits from the sale of food but she also received payments of interest from investing her savings back into the Village Savings and Loans association.

Philomène’s livelihood has improved and she is now able to send her children to school regularly, and pay for the annual school fees, Ariary 43,000 or about $22 dollars without any problem. The hungry season, which she had earlier coped with eight out of the twelve months per year, is today but a bad dream. Thanks to her contribution to the Village Savings and Loans association, Philomène extended her hut after two years and added a kitchen and a bathroom. She proudly bought new kitchen utensils and other household equipment, and was able to decorate her home.

I’m no longer alone. In our VSL group, we’re like brothers and sisters. We counsel one another, and we share knowledge and experiences. It’s a real new life for me!” says a proud Philomène.  In her spare time, Philomène engages in development and other social activities, and the community seeks her help for advice or assistance when visitors come to the village and seek accommodation for the night. Philomène can help because her hut is now large enough to put up guests. She is now, more than ever, an important member of the community.

Follow USAID Madagascar on Facebook and Twitter for ongoing updates in the region.

Join the #USAIDProgress conversation on Twitter and learn about our other successes!

Empowering Africa’s Next Generation Through Education

Education, equal opportunity, empowering women and youth, these ideas form the foundation of our program in the Office of American Schools and Hospitals Abroad. In a recent trip with two of my colleagues to South Africa, we experienced firsthand how powerful a marriage of American and African ideas and values can be in propelling not only South Africa, but the entire continent forward.

The American writer and historian, James Truslow Adams described the American dream as one where, “life should be better and richer and fuller for everyone,” and while that is part of the American dream, is it part of the African dream as well? Half an hour outside the bustling city of Johannesburg, the African Leadership Academy (ALA) is instilling American values by providing its students the base for becoming entrepreneurial leaders. Each year, 100 gifted students between the ages of 15 to 19, from over 40 African countries, are accepted into ALA where they are empowered and given the tools to become the next generation of African leaders.

Bonga, a recent graduate, discusses his time at the Academy. Photo credit: Caitlin Callahan, USAID

Bonga, a recent graduate, discusses his time at the Academy. Photo credit: Caitlin Callahan, USAID

My colleagues and I were lucky to spend part of our morning with Bonga, a recent ALA graduate. It was evident in the way Bonga spoke how central the African Leadership Academy was in motivating him to continue his education, innovate, and bring economic prosperity to his community. Bonga, like most of his peers, plans to attend a four-year university and dreams of an integrated and affluent Africa. USAID assistance helps improve campus security, purchase learning resources for its library, and upgrade dormitories for student housing to prepare students like Bonga for success.

Encouraging hands on experience and service to the community, the Academy provides students with the tools and knowledge base to work towards transforming the African continent.  ALA harnesses the entrepreneurial spirit and encourages its students to create and manage their own business ventures in a safe and comfortable environment. Since its inception in 2008, graduates of ALA have started 38 non-profit and for profit enterprises, addressing community challenges while furthering Africa’s long term stability and economic prosperity.  In support of USAID goals to promote inclusive development, this fall, the majority of students enrolled at ALA will be female. Educating a girl means that as a woman, she is empowered and more likely to participate in development efforts in political and economic decision-making.  It has also been shown that with each ten percent increase in the number of girls who attend school, a country’s gross domestic product (GDP) increases on average by 3 percent.

Through its innovative approach and integration of American ideas, the African Leadership Academy is well on its way to making a difference in Africa and USAID is proud to be a supporter. Watch the video below to learn more.

MCHIP Spurs Action to Protect Women from Excessive Bleeding After Childbirth

Dr. Vikas Yadav, the National Program Manager for Jhpiego’s India program, described his frustration during visits to birthing rooms in health facilities early in his career: “Lifesaving drugs were not correctly used or, in some cases, not used at all.” During childbirth, women may suffer from potentially life-threatening conditions, such as excessive bleeding. Known as postpartum hemorrhage (PPH), excessive bleeding can be prevented with a uterotonic—a drug to make the uterus contract.

According to Dr. Yadav, “You would see health care staff that didn’t know which uterotonic to use and when, because they lacked clear guidance. It is such a simple intervention, yet these staff didn’t have needed information to properly use drugs that could save lives.” Oxytocin is the uterotonic of choice for preventing PPH, but in certain situations, such as home birth, another uterotonic drug known as misoprostol has been recommended.

Women waiting for newborn care at a nursery. Photo credit: MCHIP

Women waiting for newborn care at a nursery. Photo credit: MCHIP

Dr. Yadav was happy to report that the situation has improved quite a bit in Jharkhand State since those early days. In fact, maternal deaths have decreased dramatically in recent years thanks to the increasing focus of the government and its development partners on training health facility staff and improving the quality of maternal care.

Despite recent improvements, PPH still causes 35% of maternal deaths in the State. And while providing uterotonic drugs is a well-known intervention to prevent PPH, the number of births that receive this intervention is unknown. As in most developing countries, there is no regular or reliable data available on whether uterotonic drugs are provided to women.

It was in part due to this lack of information that staff from USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) partnered with the Directorate of Health Services in Jharkhand state to pilot an innovative approach for estimating the number of women who use a uterotonic drug after birth to protect them from PPH.

Dr. Jeffrey Smith, MCHIP Maternal Health Team Leader, helped the team estimate uterotonic coverage in the State. “In many developing countries, there is more reliable data to measure whether children are receiving lifesaving drugs,” he said. With this knowledge, health experts can design better programs. “Why can’t we also track which women are receiving uterotonic drugs when so many are dying of PPH?” Dr. Smith asked.

Dr. Yadav welcomed the chance to participate in this valuable activity. During a stakeholder meeting, maternal health experts, officials from the state Ministry of Health, private and public hospitals, nongovernmental organizations, development partners, and key policy makers came to a consensus about their estimate after careful discussion and analysis. Using the guidance and worksheets developed by MCHIP, many were surprised to learn that relatively few women—only 43.5%—were protected from excessive bleeding. “This exercise was eye opening for program managers, since they realized that many women were not getting the care they are supposed to get,” Dr. Yadav said.

Oxytocin can be kept at room temperature for only a couple of months before it loses potency. Unlike oxytocin, misoprostol does not require refrigeration and it has also been proven effective at preventing excessive bleeding. Additionally, misoprostol comes in pill form and does not need to be injected using a needle and syringe by a skilled provider. As such, misoprostol is ideally suited for preventing PPH at home births and in resource-poor settings like Jharkhand due to its stability, ease of use, effectiveness and safety.

Distributing misoprostol to women in advance of the birth, enabling them to take it just after delivery, is known to be an effective method of PPH prevention. However, there is currently no program in Jharkhand State that ensures women who give birth at home receive misoprostol. And despite recent increases in facility births, there is still a sizeable portion of women (more than 45%) who choose to give birth at home. Sadly, when women give birth at home, they often do not have assistance from skilled health care workers or access to lifesaving drugs like oxytocin, and are therefore more likely to die of complications.

This estimation exercise came at the ideal time, as the government of India is currently developing guidelines for advanced distribution of misoprostol for women who give birth at home. Given the large population in Jharkhand State, efforts to make misoprostol widely available for use at the community level—especially if adopted nationally—could protect thousands of women from PPH.

USAID/MCHIP’s innovative estimation tool makes it possible to build an accurate picture of whether a country is doing everything it should to stop women from dying of this preventable condition. If there is strong political leadership, as in Jharkhand State and places like Mozambique, this estimation tool has the potential to help governments’ strengthen programs to prevent PPH. Such programs would ensure that oxytocin is available to women who give birth with trained health care workers, and that misoprostol is available to women who give birth at home. These combined efforts could save the lives of countless women, no matter where they give birth.

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