andersonbowen.comBLOG

(i haven’t been writing nearly as much as i’d like about my job here. this is my effort to change that. if you’re not interested in public health, no need to read further. if you are interested in public health, sorry i haven’t been more descriptive about what it is i actually do here.)

the organization i work for - minnesota international health volunteers (MIHV) - is a U.S.-based NGO/PVO (non-governmental organization/private voluntary organization) that works in community-based maternal and child health, both in the U.S. and in Uganda. our expertise is in community health education, mobilization, training, participatory research, and monitoring and evaluation. everything we do involves partnering with the communities in which we work to positively influence behavior change.

health is influenced by 4 factors: access (to health services/medical care), genetics, environment, behavior; but the factors don’t enjoy equal influence. their proportional influence on health status more-or-less breaks down as follows: access 10%, genetics 10%, environment 20%, behavior 50%. when it comes to dollars spent, the proportions reverse. most of the healthcare dollars in the U.S. are targeted toward improving access to care (think public health insurance programs, universal healthcare, “free” emergency care), and very little is targeted toward modifying behavior to achieve desired health results or to prevent poor health outcomes.*

take the following health outcome: maternal mortality (public health lexicon: # of women who die due to complications during pregnancy or in the immediate post-delivery period). causes of maternal mortality can either be direct or indirect. in the developing world, direct causes of maternal mortality primarly include hemorrhage, sepsis, eclampsia (hypertensive disorder of pregnancy), complications of unsafe abortion, obstructed or prolonged labor. many illnesses are aggravated by pregnancy, such as anemia, hepatitis, tuberculosis, malaria, STIs; maternal deaths attributed to complications of these pre-existing illnesses are qualified as indirect.**

if you approach the problem of high maternal mortality from the “access” perspective, you might consider building a maternal health hospital that has highly-qualified and -trained health professionals, well-stocked supplies, and modern technology so that when a pregnant woman is in trouble, she can get to the hospital and get the necessary care she needs to both save herself and her baby. on the other hand, if you try to reduce high maternal mortality from the “behavior” angle, you might examine what behavior puts the pregnant woman at risk in the first place. then, you ask: is this “risky” behavior something that can be changed positively in order to prevent the complication from ever occuring?

most poor health outcomes can be prevented, that’s the basic premise of public health. but, what about pregnancy can be prevented in order to minimize the risk for the mother? certain types of pregnancy qualify as “high-risk.” if you’re from the developed world, you’re probably thinking ectopic pregnancy, multiple birth, prematurity. but, if you live in the developing world high-risk pregnancy is a whole different bag o’ tricks. young mothers, women with inadequate nutrition status (e.g. stunted growth, poor pre-pregnancy weight, anemia), high parity (public health lexicon: number of births) mothers, very old mothers, women with closely spaced or unwanted pregnancies. each of these scenarios increases a woman’s risk of dying due to pregnancy and/or delivery. but, each of these scenarios is also preventable.

thanks to modern contraception, all women can make the choice when, how many, how often, and when to stop having children. when: a teenager decides she wants to wait to have children until she is old enough to be a mom. how many: a mother who already has 3 children decides 3 is all she wants. how often: a mother with a 1-year old decides she wants to wait another 2 years before her next child. when to stop: an older woman wants to be sexually active but decides she does not want any more children. each of these women’s choices reduces their chance of a high-risk pregnancy and increases their chance of being healthy throughout pregnancy/delivery and their baby’s chance of surviving to 5 years old.

but, what if you live hours from modern development? what if you are illiterate? what if your religion prevents you from using modern contraception? what if your culture values loads of offspring because it proves the man’s virility and strength, upholds the woman’s role as caretaker, and assures there will be someone to take care of you in your old age? what if infant mortality is so high in your community that you feel you must have many children to compensate for all your children that will die before their 5th birthday? what if your culture prizes boys over girls, and a woman is not worthy unless she bares a boy? what if you don’t know that the decision to have children is yours alone?

enter public health organizations like MIHV.

almost 50% of my salary in uganda is funded through a grant MIHV received from the FlexFund, which is a funding arm of USAID specifically directed at community-based family planning and reproductive health projects. our FlexFund family planning project aims to increase contraceptive use among women of reproductive age, but as you can see from the list of barriers noted above, increased contraceptive use isn’t exactly straightforward. to increase contraceptive prevalence rates (public health lexicon: number of women using contraception), we are…
(1) educating community members (both women and men***) on the benefits of family planning for women, families, children, and communities to stimulate demand for family planning
(2) expanding service delivery by training community health workers to visit women and families in their homes to educate on family planning, provide selected family planning methods (condoms, pills), and refer women to local health facilities to receive other modern family planning methods (injectables, IUDs, implants)
(3) training health facility workes and private practitioners in proper counseling techniques to assure that women choose the family planning method appropriate for them
(4) assisting health facilities in managing their family planning logistics (public health lexicon: supplies) to enable them to meet generated demand for family planning.

our strategy is that by increasing awareness and demand, improving the supply chain, and sensitizing (public health lexicon: educate, dispel myth, calm fears, introduce new ideas) the community, we help to create a supportive environment for family planning, thus increasing the liklihood that a woman and her partner will choose to plan their family.

as you can imagine, family planning is a sensitive topic. we could not possibly be successful if we simply walked into the community and said “this is what we think, this is what you’re going to do, and this is why you’re going to do it.” i started this blog by saying that MIHV partners with the communities in which we work on every project we undertake. public health-ers are not in it for personal benefit, profit gain, or to climb the corporate ladder. what good does it do me to help someone live longer and healthier (except make me feel good about what i do)? but, it makes all the difference in the world to that woman or that child or that family, that she lives longer and lives healthier. MIHV partners with communities because they are the ones who will make the change, who know what change they are willing to make, who will benefit from the change made. they’re the experts. we just support them in exercising their expertise.

my first term in grad school, i wrote a brief paper on margaret sanger for beth virnig’s class. margaret sanger is known as the mother of modern family planning. she was the first one to bring family planning to the global table as she advocated for a woman’s right to choose when, how many, how often, when to stop. of course, as a daughter of a very liberal, independent woman who has been inculcated with women’s rights since i was born, i looked at margaret sanger as the harbinger of women’s lib and the fore-mother of roe v. wade. beth called me out quickly saying, “yes, all true, but this is a course in public health. what is the public health significance of margaret sanger and her work?” of course! margaret sanger in the 1920s, the pill in the 60s…the beginning of the decrease in maternal mortality through the increase of family planning. in the 1st world, family planning translated to more women in the workforce, a stimulated economy. in the 3rd world it translates to less poverty.
101paige 101iph

*credit to lynn blewett’s health systems course, u of mn school of public health

**credit to ian greaves‘ working in global health course, u of mn school of public health

***almost everything i have written re: family planning is about the woman. however, family planning is not just about the woman. public health-ers working in family planning are very, very specific about that. successful family planning involves both partners in a relationship. in the case of this blog, however, it’s just been easier to write about the woman (i.e. easier to say “she” instead of “s/he” or some other PC version of saying “she and he”). i apologize for my blatant bias.

disclaimer: all views expressed are mine and mine alone. in no way do i speak for or on behalf of MIHV in this forum.