Maternal mortality in Zimbabwe has unprecedentedly risen over the last two and half decades although a decline has been noted recently. Many reasons have been advanced for the rising trend, including deliveries without skilled care, in places without appropriate or adequate facilities to handle complications. The recent decline has been attributed to health systems strengthening. On the other hand, the proportion of community deliveries has also been growing steadily over the years and in this study the authors investigate why. Twelve focus group discussions with child-bearing women and eight key informant interviews (KIIs) were conducted. Four were traditional birth attendants and four were spiritual birth attendants. The study shows that women prefer community deliveries due to perceived low economic, social and opportunity costs involved; pliant and flexible services offered; and diminishing quality and appeal of institutional maternity services. The authors conclude that rural women are very economic, logical and rational in making choices on place of delivery. Delivering in the community offers financial, social and opportunity advantages to disenfranchised women, particularly in remote rural areas. The authors recommend increased awareness of the dangers of community deliveries; establishment of basic obstetric care facilities in the community and more efficient emergency referral systems. In the long-term, they argue that there should be a sustainable improvement of the public health delivery system to make it accessible, affordable and usable by the public.
Poverty and health
This paper explored, through women’s, communities’, and providers’ perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking services for fistula. A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews with women affected by fistula including those awaiting repair, living with fistula, and after repair, their spouses and other family members, and health service providers involved in fistula repair and counseling. Focus group discussions with male and female community stakeholders and post-repair clients were also conducted. Women’s experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. Women in Uganda spend Ugandan Shilling 10,000 to 90,000 for two people for a single trip to a camp. Factors that influence women’s and families’ ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation. The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers were recommended.
Safe water, sanitation and hygiene are crucial in protecting people from cholera. The oral cholera vaccine is perceived as an interim solution that can be deployed in advance of, or together with, investments in water sanitation and hygiene. Oral cholera vaccine comes at a cost. Efforts to improve water sanitation and hygiene, on the other hand, have a relatively high return: US$ 4.30 for every dollar invested in water and sanitation, in addition to prevention of most waterborne diseases and time saved from not having to fetch water. Furthermore, several water sanitation and hygiene interventions can be implemented quickly and cheaply, such as point-of-use water treatment and safe storage, community action to end open defecation, provision of soap and promotion of handwashing. The authors argue that the reasonable alternative would be to pursue both oral cholera vaccine and water sanitation and hygiene efforts in parallel as done in, for example, Zanzibar, the United Republic of Tanzania and in Zambia. They argue that three main actions need to be taken to ensure that such investments are prioritized as part of the renewed efforts to end cholera. First, when countries request oral cholera vaccine, they should engage in water sanitation and hygiene efforts. Second, efforts should be made to ensure that initiatives to strengthen health systems and provide quality care devote sufficient resources for providing and sustaining water and sanitation services, especially in cholera treatment centres. Third, external funders and partners must align behind national multisectoral cholera control plans, not simply invest in stand-alone interventions. A shared vision and unanimous agreement among Member States, partners and funders to prioritize broader social and environmental determinants of health, including water, sanitation and hygiene, is needed to end cholera. A proposed World Health Assembly resolution seeks to promote this consensus, ensure effective multisectoral collaborations and address cholera in tandem with other diarrhoeal diseases.
This report explores the current nutrition status of countries in the WHO African Region in relation to the six primary outcomes achievable by 2025 and the other global nutrition monitoring framework indicators. The aim is to highlight where action is needed to drive progress on the global targets for 2025 and Sustainable Development Goal No. 2 that calls on countries to end hunger through achieving food security, improving nutrition and promoting sustainable agriculture. A complementary objective of the report was to evaluate existing data sources that countries use to monitor programme performance and track progress on the global targets. A key finding in this report is that undernutrition is still persistent in the WHO African Region, with major implications for health, particularly among poor and vulnerable population groups. It finds that persistent drought, famine, flooding, and civil crises will make it difficult for many countries to achieve the target of reducing and maintaining wasting at less than 5%. Along with persistent undernutrition, the prevalence of overweight among children under 5 years of age (as well as the overall number of children affected) is rising, whereas the target is to halt its increase. WHO AFRO assert that In the absence of survey data, properly functioning routine surveillance systems could provide invaluable real-time information for decision making in policy and programme design and implementation in this area.
This paper examined the association between attitudes towards seeking care and knowledge and perceptions about sexual and gender-based violence (SGBV) among men and women in a humanitarian setting in Uganda. A cross-sectional survey was conducted from May to June 2015 among 601 heads of refugee households in Rwamwanja Refugees Settlement Scheme, South West Uganda. Results showed increased odds of having a favorable attitude toward seeking help for SGBV among women with progressive attitudes towards SGBV; who felt that SBGV was not tolerated in the community; those who had not experienced violence; and those who were aware of the timing for post-exposure prophylaxis. In contrast, results for the male sample showed lack of variations in attitude toward seeking help for SGBV for all independent variables except timing for post exposure prophylaxis. Among individuals who had experienced SGBV, the odds of seeking help was more likely among those with favorable attitude towards seeking help than among those with unfavorable help-seeking attitudes. The findings of the paper suggest that targeted interventions aimed at promoting awareness and progressive attitudes towards SGBV are likely to encourage positive help-seeking attitudes and behaviours in humanitarian contexts.
This study aimed to assess factors associated with food insecurity and depression in a sample of pregnant South African women in a low-income suburb in Cape Town. Pregnant women attending a local clinic for their first antenatal visit were invited to participate. The shortened form of the US Household Food Security Survey Module was used to measure food insecurity. The Expanded Mini-International Neuropsychiatric Interview was used to diagnose depression, anxiety, alcohol and drug dependence, and assess for suicidal ideation and behaviour. Logistic regression modelling was conducted to explore factors associated with food insecurity and depression in separate models. The authors found that 42% of households were food insecure and that 21% of participants were depressed. The odds of being food insecure were increased in women with suicidal behaviour, with depression and in those with three or more children. The odds of depression was greater in women who were food insecure, substance dependent or diagnosed with an anxiety disorder. Food insecurity and depression are strongly associated in pregnant women. The relationship between food insecurity and depression is complex and requires further investigation. Interventions that improve both food security and mental health during the perinatal period are likely to benefit the physical and mental well-being of mothers and children.
This paper focuses on the importance of psychosocial support services for adolescent girls in fragile contexts. Its starting point is that adolescence is a pivotal time in the life course but given the physical, cognitive and emotional changes triggered by the onset of puberty, it can also be a period of heightened sensitivity and vulnerability to trauma, social isolation, bullying by peers, a lack of supportive adults and gender-based and sexual violence. The authors’ findings highlighted why humanitarian and biomedical approaches in their current form are inadequate to address these complexities. Drawing on qualitative fieldwork, the authors argued that going beyond biomedical approaches and considering the social determinants of health, including approaches to tackle discriminatory gendered norms and barriers to service access, are critical for achieving broader health and wellbeing. While all three case study countries are classified as post-conflict, the political economy dynamics vary with associated implications for experiences of psychosocial vulnerabilities and the service environment. The study concludes by reflecting on actions to address psychosocial vulnerabilities facing adolescent girls through tailoring services to ensure gender and age-sensitivity, investing in capacity building of service providers to promote service uptake and enhancing strategies to regulate and coordinate actors providing mental health and psychosocial support services.
Storms and hurricanes are becoming more severe due to warmer sea temperatures. Low lying island nations, like the Maldives, now experience annual flooding with the seawater contaminating groundwater supplies. Whether flooding, drought or other climate-related catastrophic events, the author observes that low income countries nations and their populations suffer most, given their lack of resources, infrastructure, emergency services and preparedness. They also point to a further consequence relating to the quality of food. Rising CO2 levels speed up plant growth increasing carbohydrates through plant sugars and diluting nutrition due to reduced minerals and protein. The nutrient quality of our food is expected to fall as CO2 levels rise this century. The effect will be worst felt by the world's poorer populations relying on a plant diet. Extreme weather events affect production, distribution, spoilage and contamination. The author notes that those most affected will be people in Africa, Asia and the Americas.
This qualitative study undertaken in rural Coastal Kenya aimed to explore the interaction between household gender relations and a community-based child nutrition programme. It focused on household decision-making dynamics related to joining the intervention. Fifteen households whose children were enrolled in the programme were followed up over a period of 12 months. Over 60 household visits, group and individual in-depth interviews were conducted with a range of respondents, supplemented by non-participant observations. Data were analysed using a framework analysis approach. Engagement with the intervention was highly gendered with women being the primary decision-makers and engagers. Women were responsible for managing child feeding and minor child illnesses in households. As such, involvement in community-based nutrition interventions and particularly one that targeted a condition perceived as non-serious, fell within women’s domain. Despite this, the nutrition programme of interest could be categorized as gender-blind. Gender was not explicitly considered in the design and implementation of the intervention, and the gender roles and norms in the community with regards to child nutrition were not critically examined or challenged. In fact, the authors argue that the intervention might have inadvertently reinforced existing gender divisions and practices in relation to child nutrition, by excluding men from the nutrition discussions and activities and thereby supporting the notion of child feeding and nutrition as “women’s business”. To improve outcomes, community based nutrition interventions are argued to need to understand and take into account gendered household dynamics, and incorporate strategies that promote behaviour change and attitude shifts in relation to gendered norms and child nutrition.
This article examines adaptation to climate change in view of changing humanitarian approaches in Isiolo County, Kenya. While humanitarian actors are increasingly integrating climate change in their international and national-level strategies, less is known about how this plays out at sub-national levels, which is key to tracking whether and how short-term assistance can support long-term adaptation. The article suggests that increasing attention to resilience and adaptation among humanitarian actors may not lead to reduced vulnerability because resources tend to be captured through existing power structures, directed by who you know and your place in the social hierarchy. In turn, this sustains rather than challenges the marginalisation processes that cause vulnerability to climate shocks and stressors. The article highlights the important role of power and politics both in channelling resources and determining outcomes.