Just over 10 years ago, at a meeting in Cairo of 179 member states of the United Nations, an agreement was reached on a strategy for linking economic development and the slowing of population growth by focusing on women’s reproductive health and rights and education. It was a bold step that, despite a world in continued turmoil, is working—at least at the global level. Where the world’s population was growing by 93 million people per year in 1995, the growth today is 77 million per year, a decline of 17 percent.
This reduction is not due to a worldwide focus on simply reducing the number of people. It has come primarily through the growing reality that people will make wise choices if they have information and access to adequate health care and if women’s well-being is squarely at the center of population policy.
It is hard to imagine an issue in which individual decisions and the large forces that shape the course of a nation’s well-being are more closely connected. Research now shows that when women have access to good information and health care, they are in a position to make sensible choices about the size of their family. The better a woman’s education, the longer she delays her age of marriage. Such individual decisions can add up to better lives for women and their families, a more robust job market, and, ultimately, stronger national economies.
In this issue of the MacArthur Foundation’s newsletter, we will discuss its grantmaking related to population and reproductive health, an area central to our international efforts for almost 20 years. It is an area of work that is done through our offices in Chicago as well as in three countries of special focus—Mexico, Nigeria, and India—where the Foundation has in-country offices. The strategy that guides our current work is clear. The research underway explores new aspects of this important issue.
As always, we welcome your comments.
Jonathan F. Fanton
John D. and Catherine T. MacArthur Foundation
The MacArthur Strategy: Helping save lives of new mothers and providing information to young people
The International Perspective
The MacArthur Foundation in Mexico
The MacArthur Foundation in Nigeria
The MacArthur Foundation in India
AT A GLANCE:
MACARTHUR’S POPULATION AND REPRODUCTIVE HEALTH AREA
Number of organizations receiving support: 259
Focus countries: Mexico, Nigeria, India
Total grants authorized, 2004: 67
There are many points of entry to an issue as vast as population and reproductive health. The challenge to is find ways in which grant support by the Foundation can be useful in the short run and help in building strategies that can ultimately be national or international in scope. It is an ambitious goal, recognizing always that one foundation’s resources are small compared to the need.
We have chosen two themes to shape our grantmaking, internationally and within our three focus countries. They are:
The Foundation carries out its work relating to population in two ways. It has offices in three focus countries—Mexico, Nigeria, and India—chosen because of the urgency of the population issue and the potential to make progress, given the right conditions. MacArthur also provides grants to international organizations in a position to address the population issue on a global scale.
Providing support for efforts to increase the chances that women in the developing nations of the world will have safe pregnancies and deliveries is a worthy objective in its own right. But we also believe that changes in the rate of maternal mortality and morbidity tells a larger story. If the rate is going down, it is an indication that the services and information needed for women to make informed reproductive choices are available.
When young people are able to obtain reproductive health information and services, they increase their chances to make a successful transition to adulthood. There is a greater likelihood that they will make the type of decisions that will delay their becoming parents. It is a particularly important decision in countries where there has traditionally been great pressure on young people to marry early and have children while still very young, and where access to information about sexuality has been minimal.
An important consideration in the population issue is population momentum—the fact that the world’s population will continue to grow even after the point of replacement-level fertility (two children per couple) has been reached. It happens when there is a high concentration of people who are in their childbearing years, like now, when an estimated half of the world’s population is under the age of 25. So even though rates of population growth might slow down, because there are so many more young people having children, the numbers of people will continue to rise. Once the current generation of young people moves through its childbearing years, population growth rates will slow down. But population momentum will push the world’s population to an estimated 9.2 billion people by 2075, compared to 6.1 billion in 2000. Any delay in childbearing will have a major impact on population growth rates. So reproductive health information and services for young people are vital in addressing population issues.
At the same time it supports work in three focus countries (India, Nigeria, and Mexico), the Foundation allocates approximately $4 million each year for grants of three types to international organizations.
The Foundation believes that institutions matter, so each of its grantmaking areas provides support to a number of groups it considers important to build knowledge and advance a particular field. They are organizations that can give a field like population and reproductive health much of its intellectual leadership, research, advocacy on policy issues, and capacity-building services.
Some grants don’t precisely fit the Foundation’s strategy, but when special situations arise, having the flexibility to respond to them is valuable. A recent example is a grant to the Population Council in support of an Arabic language website that provides information on reproductive health matters. It is seen as a way of providing information and stimulating discussion and debate among Arabic-speaking health and population professionals on reproductive health and rights matters.
REINFORCING WORK IN THE FOCUS COUNTRIES
With the Foundation-supported work in Mexico, Nigeria, and India focused on addressing maternal mortality and morbidity and helping ensure that young people have access to reproductive health and rights information and services, it makes sense to provide grants to international organizations that parallel these themes. It is a way of seeing lessons learned in the three countries move up to the regional and international levels and to bring state-of-the-art approaches back down. Researchers at the University of California, San Francisco, for example, are field testing a promising device called the anti-shock garment (see below) that can give a woman experiencing life-threatening hemorrhaging in childbirth extra time to reach a medical facility. Because of MacArthur support, the researchers were able to field test and document the results of the garment’s use in two of the focus countries, Mexico and Nigeria.
Buying Time: The Anti-Shock Garment
The Foundation is supporting the testing of an “anti-shock” garment in Egypt, Mexico, and Nigeria, through a grant to the University of California, San Francisco’s Women’s Global Health Imperative Project. The garment is a neoprene suit used to slow hemorrhaging in women who experience problems in childbirth. Use of the anti-shock garment is a low-cost way of giving women critical travel time to seek medical care during childbirth emergencies. The testing is still in its early stages, but early indications are encouraging. In Nigeria, a significant number of successful uses of the garment have been documented. In one case a woman whose life was saved by the garment was showing what hospital personnel called the last physical signs before death when she reached the hospital. A total of 180 cases in Mexico, Nigeria, and Egypt will be documented. This data will help develop a plan for use of the garment on a larger scale. Dr. Paul Hensleigh, one of the coordinators of the study, has published a paper on use of the garment in Pakistan.
The consensus among scholars is that the evidence developed to date about the demographic dividend is not sufficient to overcome the doubts that skeptics have raised about the validity of the hypothesis. These doubts exist both about the macro or national-level research, comparing one country to another, and about the micro or household-level research, analyzing the impact of individuals’ behaviors over time. MacArthur is supporting research at each level. The Harvard University School of Public Health is exploring the demographic dividend at the macroeconomic or national level. George Washington University’s Center for Global Health is examining ways in which population and fertility are linked to poverty at the household level. Results of this research will help identify and influence policy decisions that might emerge from a fuller understanding of this intriguing link between population and economic growth.
The research by George Washington University, for example, is examining longitudinal data to examine questions such as how early childbearing, having many children, or maternal mortality in a household influences the health and educational prospects of that family. For example, does a young mother drop out of school? Does having many children reduce the investment in schooling for some of them (especially girls)? Does the death of a mother have adverse health and educational effects on the children left behind, and, if so, what kind and to what degree? The answers are likely to help weigh alternative reproductive health investments in economic terms.
When a foundation decides to work in a country as large and diverse as Mexico, it confronts the question of how best to focus its grantmaking. For the theme of reducing maternal mortality and morbidity, the emphasis is on three states in that country, Chiapas, Guerrero, and Oaxaca, where the worst reproductive health indicators and the highest maternal mortality ratios are found. The Foundation has a particular interest in contributing to development of a comprehensive referral system involving doctors, midwives, community leaders, and public health officials. The strategy is supported by work at the national level and in Mexico City to improve policies and programs and to bring attention to the causes of serious problems women face in childbirth.
In the state of Oaxaca, for example, a grant has been given to the Oaxaca chapter of the National Forum of Women and Population Policy to increase the availability of emergency obstetric care at primary health care facilities. Assuring access to emergency obstetric care is one of the principal international strategies for reducing maternal mortality. In Mexico there have been no concerted efforts to train primary health care professionals in rural areas to manage basic obstetric situations such as hemorrhage, infection, and hypertension and to ensure linkages between primary and secondary health facilities. Foro Oaxaca also facilitates the training of more than 200 nurses and doctors at 38 health centers in the region about the reasons that indigenous women do not trust public health care and services, and about how to build that trust.
With regard to young people’s sexual and reproductive health and rights, the Foundation is supporting work that focuses on strengthening the policy and program structure that brings information on these topics to young people. One key strategy is supporting the work of nongovernmental organizations to help government agencies refine their service delivery to be more appropriate for youth. This includes grants to organizations such as Afluentes and THAIS, to help the Mexican agency that offers health services to poor people in 17 states, and IMSS Oportunidades, to both improve its outreach to youth in communities and to prepare its providers to treat young people in a more welcoming manner. It also includes a grant to Salud y Genero to ensure that Ministry of Health officials in seven states are trained to respond to the needs of young people and to counter the criticisms that can arise from the government serving them as clients.
One grantee, Letra S, works with journalists to get correct information and compelling stories out about young people, while another, CIMAC, does the same on the topic of maternal mortality.
The maternal mortality ratio in Nigeria, according to Population Action International, is 1,000 deaths per 100,000 live births—among the highest in the world. According to the Nigerian Demographic and Health Survey, less than ten percent of women use family-planning methods, and less than 30 percent receive prenatal care and delivery by a qualified service provider. As for young people’s sexual and reproductive health and rights, more than 26 million young people between the ages of 10 and 19 have limited access to information to help stop or reduce what are seen as epidemic levels of complications from abortions, sexually transmitted infections, and HIV/AIDS. An estimated 60 percent of rural women have given birth by age 20.
Designing a grantmaking strategy to address such needs is a daunting task, one that MacArthur has embraced since opening its Nigeria office in 1994. As in its other focus countries, the Foundation geographically concentrates much of its support in six states: Cross River, Enugu, Lagos, Kano, Borno, and Plateau.
With a focus on those states and related national-level activities, the Foundation supports:
At the national level, the MacArthur Foundation provides grants to organizations such as Campaign Against Unwanted Pregnancy and the Centre for Development and Population Activities.
SEXUALITY CURRICULUM IN NIGERIAN SCHOOLS
As a nation, Nigeria has taken impressive steps to develop a national sexuality education curriculum for its schools. In 1996, with Foundation support, a National Task Force on Sexuality Education developed guidelines for such a curriculum. In 2001, the Nigerian government, through its National Council on Education, adopted the curriculum. MacArthur grantees such as Action Health Incorporated in Lagos State and Girls Power Initiative in Cross River were instrumental in the drafting of the document. Sexuality education is also endorsed in the National Reproductive Health Framework and Plan adopted in 2002.
There is, however, considerable distance between national policy and its implementation at the state and local levels. With Foundation support, Nigerian nonprofits are working with the Ministries of Education and Health to help them understand the importance of the curriculum. Others are engaged in teacher training and work with parents and community and religious leaders. There is special emphasis on this work in the six priority states where MacArthur is focusing its population and reproductive health grantmaking efforts. Success there is expected to provide models for implementation in other states.
The two main themes of the Foundation’s work in population and reproductive health in India are consistent with India’s National Population Policy 2000, which reaffirms the Indian government’s commitment to achieve rapid stabilization of the country’s population. The policy’s goals include reducing the maternal mortality ratio to less than 100 per 100,000 live births, delaying the age of marriage for young girls, achieving 80 percent institutional deliveries and 100 percent deliveries by trained birth attendants, and addressing the unmet needs for basic reproductive and child health services.
The Foundation, consistent with its approach in Mexico and Nigeria, focuses its work in three states, Rajasthan, Maharashtra, and Gujarat. The three were chosen because of the significant unmet need for information and service. Geographically they are adjacent to one another, and there are nongovernmental organizations in place with the capacity to work on reproductive health and rights issues.
At the national level, the Foundation provides grants to institutions engaged in training, research, and policy-related information activities designed to encourage national discussion of population and reproductive health issues.
A grant to the Federation of Obstetrics and Gynecological Societies of India (FOGSI), a professional organization with a membership of 18,000 obstetricians throughout India, addresses maternal mortality and morbidity reduction. FOGSI develops the capacity of non-specialist medical providers to provide quality emergency obstetric care in rural areas of India to prevent maternal deaths. This project is a major step forward to address the key bottleneck in providing 24-hour emergency obstetric services in underserved areas.
A grant to the International Institute for Population Sciences (IIPS) assesses young people’s reproductive and sexual health in six states. The data can then be used for evidence-based advocacy and also to inform national-level policies and programs. The specific outcomes would be a) a national database on young people’s knowledge, attitudes, and behavior pertaining to reproductive and sexual health, b) national-level and focus state–specific dissemination workshops with government participation, and c) guidelines for standardized indicators for future studies and advocacy for inclusion of select indicators in the National Health and Family Surveys (NFHS). In fact, the technical advisory committee constituted by IIPS a year and half ago has also been advising the government in the design of the next NFHS. One major achievement has been the inclusion of unmarried adolescents in the national survey for the first time.
REDUCING INFANT MORTALITY AND MATERNAL MORBIDITY ONE VILLAGE AT A TIME
A husband-and-wife team of doctors in India is making a difference in helping reduce that country’s infant and maternal mortality ratios. Dr. Abhay Bang and Dr. Rani Bang lead the Society of Education, Action and Research in Community Health (SEARCH) in the Gadchiroli district of India. Their Home-Based Neonatal Care Program, which trains village women to diagnose and treat newborns, reduced incidents of infant mortality over a one-year period from 120 to 30 in 39 villages in their district. During the same period, postpartum maternal morbidity in the intervention area was reduced by more than 50 percent. This program is now being replicated at seven sites in Maharashtra, one of the Foundation's priority states in India, through NGOs working under the guidance of SEARCH. The Government of India is piloting the approach in five states with the view to scaling it up into the national reproductive and child health program. In a country like India, where state-of-the-art medical care at modern hospitals is not accessible to millions of villagers, this program holds great hope. SEARCH received a MacArthur grant of $300,000 in 2001. The program is also funded by the Gates Foundation as one of two potential models for reducing infant mortality and maternal mortality and morbidity in developing countries.