Institute Insights: May 2019

Contents:

Breastfeeding Peer Counselor Trained by HealthConnect One. Photo by Leah Stern© 2015.

From the Director

Happy Mother’s Day to all moms and mother figures who have stepped into the role.

Bread for the World Institute emphasizes the importance of women, particularly mothers, to meeting the goal of ending malnutrition and hunger—and the need for gender equality so that they can build better lives for themselves and their children. This issue of Institute Insights focuses on how to reduce the high rates of maternal mortality found in both the United States and many developing countries. We also feature a Mother’s Day letter from Botswana.

Pregnancy is a critical time from a health and nutrition perspective. What happens after the baby arrives is equally important. After all, new mothers have at least several more decades of life to look forward to—as human beings, as mothers, as family members, as workers.

While the benefits of breastfeeding for babies are often mentioned, we hear less about the benefits for mothers. Yet they are significant. In the first few weeks, breastfeeding boosts the hormone oxytocin, which helps women recover from childbirth. Breastfeeding mothers report lower levels of postpartum depression and anxiety. Researchers report that later in life, breastfeeding mothers have significantly lower risks of certain serious medical problems, including type 2 diabetes, heart disease, ovarian cancer, breast cancer, high cholesterol, arthritis, and osteoporosis.  

Investing in the health of expectant and new mothers shows that a society recognizes and values the essential role of mothers. Nearly every country recognizes this and offers mothers and sometimes fathers paid leave from work for a period of weeks or months after a birth. Unfortunately, the United States is one of the very few that does not, and the only developed country that does not.

Bureau of Labor Statistics data indicate that only about 13 percent of U.S. workers have access to any form of paid family leave. This figure drops to just 5 percent for the lowest-paid 20 percent of the workforce.

Lack of paid maternity leave means that many women must return to work far too soon—in many cases, long before they have recovered from childbirth. One study found that in 2015, nearly one in four women who had given birth returned to work within two weeks. Almost 12 percent returned within one week. The medical consensus is that it takes at least six weeks to recover from an uncomplicated birth, with many doctors saying that it’s closer to 12 weeks. Women who had Caesarian births recover more slowly. Studies, including from the National Bureau of Economic Research, found that longer maternity leave, even if unpaid, is associated with better overall health and decreases the risk of severe depression and general symptoms of depression.

Paid leave also helps mothers keep their jobs. One of the main reasons for the significant gender pay gap in the United States is that mothers who take time out of the workforce are penalized—for example, they lose opportunities for training and promotion. The gender pay gap fuels poverty and hunger among women and their children. Research indicates that eliminating it would cut the high poverty rate of the millions of people in this group nearly in half.

We can celebrate Mother’s Day more meaningfully by advocating for policies that improve mothers’ nutrition and protect their lives, health, and ability to provide for themselves and their families. Please join other Bread members and add your name to our petition urging Congress to accelerate progress on global maternal and child malnutrition. When you do, you’ll be able to download a certificate that you can print and share on Mother’s Day.

Asma Lateef is director of Bread for the World Institute

Asma Lateef is director of Bread for the World Institute.

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Credit: iStock

Honoring Mother’s Day by Saving Mothers’ Lives—Part 1

By Marlysa D. Gamblin

Since 1908, people in the United States have celebrated mothers on a special day. Mothers are vital to children and families, whether they are part of a two-parent household, a single parent household, or a multi-generational household. Mothers contribute their time, their effort, their love. They go to work to provide for their children; ensure that they have meals, clean clothes, and a multitude of other “basics;” guide and protect them; coach older children as they develop into adults; provide a sense of security and well-being; and the list goes on.

Mothers are also, of course, indispensable and irreplaceable as the people able to bring new lives into the world. But pregnancy and childbirth can come at a staggering cost. Maternal mortality is defined as death caused by complications of pregnancy and childbirth, or within six weeks of giving birth (some sources use one year instead). We know that it is a significant cause of death for women around the world. We may be more surprised to realize that, despite the status of the United States as a wealthy industrialized country, complications of pregnancy and childbirth kill thousands of women in our country every year.

The United States has a higher maternal mortality rate than many countries with fewer resources, as well as nearly every other country of similar economic status. The United States ranks lower than Qatar and slightly ahead of Bahrain and Lebanon.

Moreover, the risks associated with having a baby in our country are rising, not falling. For example, the maternal mortality rate nearly doubled between 1990 and 2008, while over the same time period, the global rate fell by 34 percent. The all-time low of 6.6 deaths per 100,000 live births came in 1987, while the rate in 2015 was 26.4 per 100,000 live births.

Why is the U.S. maternal mortality rate high and on the increase? The main reason is racism, which I examine here. For more on other factors that affect women of all races in our country, see “Honoring Mother’s Day by Saving Mothers’ Lives—Part 2,” which follows.

The racial disparities are stark. For decades, African American and Indigenous women have been four times as likely as white women to die as a result of pregnancy or childbirth, while the rate for Native Hawaiian women is twice that of white women. It can be difficult to face the fact that racial inequity—a result of old and new policy choices made by elected officials, voters, community leaders, and the general public—has deadly consequences.

Racial disparities in maternal mortality are largely the result of what policymakers call the social determinants of health—economic and social factors such as income, education, gender, and social supports. Hunger and food insecurity, along with other consequences of poverty, adversely impact maternal health yet remain unaddressed in the healthcare field. See Bread for the World Institute’s 2016 Hunger Report, The Nourishing Effect, for more on the connections between hunger and health.

Poverty rates among women of color are far higher than the overall U.S. poverty rate. Female-headed households of color fare worst of all, with poverty rates of 39.7 percent among Indigenous households, 34.7 percent among African American households, and 31.2 percent for Native Hawaiians. The poverty rate for white female-headed households, 22.3 percent, is significantly lower than any of these but still higher than the national poverty rate of 12.3 percent.

Mothers who hold low-wage jobs, which are disproportionately filled by people of color and women, face a daily struggle: there is simply not enough money to pay for all the essentials. In such situations, prenatal care, while it has been linked to a lower risk of maternal mortality, may simply be postponed. Reducing maternal mortality will require addressing how racial inequity exacerbates hunger and poverty.

In a forthcoming report, Bread for the World Institute analyzes how the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) and other federal nutrition programs can apply a racial equity lens to reduce health and nutrition disparities. WIC improves access to nutritious food for millions of low-income pregnant women, infants, and young children, and it has the potential to contribute further to reducing maternal mortality among WIC participants of color. One in two Indigenous women and one in three African American women do not have the number of prenatal checkups shown to reduce the risk of mortality. Native Hawaiian women are twice as likely not to begin prenatal care until the third trimester of pregnancy.

Of course, WIC cannot singlehandedly end maternal deaths—that is beyond the scope of its programs. Rather, this is the responsibility of our country as a whole. That said, here are three changes to WIC policies and funding that would honor Mother’s Day:

  1. Extend postpartum care for WIC mothers. This care should include ongoing nutritional support and additional in-person visits for the first three weeks—a practice that improves breastfeeding rates for women of color.
  2. Increase WIC funding for outreach to African American and Indigenous communities to encourage eligible women to enroll in WIC. This will work to reduce maternal mortality by ensuring that more expectant mothers in these higher-risk groups receive the high-quality prenatal care they need.
  3. Research the effect of WIC participation on maternal mortality rates. Currently, this data does not exist. With more information available, WIC officials, leaders in the healthcare sector, advocates, and WIC participants will be able to plan and implement more effective responses to the problem.

For information on what more can be done to celebrate Mother’s Day for WIC participants, see our fact sheet on racial equity in WIC or visit our webpage, which outlines how to apply a racial equity lens to anti-hunger efforts.

Marlysa D. Gamblin is domestic advisor for specific populations, policy and programs, with Bread for the World Institute.

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Photo: Brian Duss for Bread for the World

Honoring Mother’s Day by Saving Mothers’ Lives—Part 2

By Michele Learner

This Mother’s Day, too many children will not be able to celebrate with their mothers, because the U.S. maternal mortality rate is much higher than it should be. A woman in the United States is six times as likely to die from complications of pregnancy and childbirth than a woman in Scandinavia.

For every missing mother, about 70 will be survivors of "near-misses," medical emergencies that endangered their lives. Some women were in comas for weeks and others had strokes. Women have sustained permanent brain damage from losing too much blood, while still others have irreversible kidney damage. In addition, medical bills can cause these survivors and their families a great deal of stress, along with financial hardships such as food insecurity, for years to come.

As we explain in part 1 of “Honoring Mother’s Day,” the high U.S. maternal mortality rate is fueled by racism and racial disparities. Because women of color are at far higher risk of death than women in many other countries, the national death rate is also higher.

In fact, the death rates of U.S. women of all races are higher than in other developed countries. Some cases of maternal mortality and near-fatal complications that are not directly related to racism are directly related to sexism. As in other areas of medical care, women’s complaints are often dismissed or minimalized. Fewer resources are devoted to postpartum care, follow-up care can be cursory or entirely lacking, and there is less funding for research into causes and solutions.

One “near-miss” example relates to a leading cause of maternal mortality: hemorrhage. Alicia Nichols, a new mother living near Boston, narrowly survived a rare but dangerous condition that causes hemorrhage. She recalled that both an obstetrics resident in the emergency room, and later her obstetrician, assured her that what she was experiencing was normal. She was in the obstetrician’s office when she began hemorrhaging again, and ultimately, she lost almost half the blood in her body. While the obstetrician’s notes read, “Patient came to office with onset of first period that seemed heavier than average," and she "suddenly hemorrhaged," the pathology report found that the bleeding was caused by the failure of major blood vessels to return to normal size after childbirth, a condition that is detectable and preventable.

Another factor in our country’s maternal mortality rate is unlikely to come as a surprise—the patchwork coverage and many weak spots in our healthcare system. Fewer hospitals and providers in rural areas, for example, force many women to drive an hour or longer to reach a hospital equipped to deliver their babies and care for both newborns and new mothers. Maternal mortality is significantly higher in rural areas. An analysis of public mortality data by Scientific American found that in 2015, large metropolitan areas had a maternal death rate of 18.2 per 100,000 live births, but remote rural areas had a rate of 29.4.

Telemedicine for prenatal checkups, in which contact with an OB-GYN provider is through online video calls, can save lives by preventing or anticipating complications, but this strategy cannot work in areas, such as parts of rural Alabama, where high-speed Internet is not available.

Researchers identified another factor that puts women at higher risk of death yet would seem completely unnecessary: giving birth on a weekend, when fewer staff are on duty and there may be delays in calling in the most experienced doctors. Obstetrician Elliott Main, a national leader in the movement to reform maternal health care, says that because most mothers do well, obstetricians and nurses are often not prepared for the worst. "That sets up the opportunity for what we call "the twin demons of denial and delay," he said.

The perception that most women do well is accurate, but not acknowledging that some women don’t do well can lead to neglect that endangers patients. A six-month investigation into maternal mortality by ProPublica in partnership with National Public Radio (NPR) found that only 6 percent of the funding in block grants for “maternal and child health" is actually spent on the health of mothers.

In an ironic way, the relatively straightforward reasons for so many maternal deaths can be taken as a sign of hope, because problems that are understood are easier to solve. Sometimes what is needed is a shift in thinking. For example, the U.K. began working to sharply reduce deaths from preeclampsia (extremely high blood pressure that can cause strokes) by treating these deaths as a public health matter rather than as personal tragedies.

Careful analysis of the events that preceded each death determined specific causes that led to corrective actions, which included updated training for nurses and physicians on risk factors and early detection as well as public inquests convened by coroners. This new problem-solving approach is credited with reducing preeclampsia deaths in the U.K. to literally one in a million. There were a total of two deaths over the three years 2012 to 2014.  On the other hand, preeclampsia is the cause of about 8 percent of maternal deaths in the United States.

California has also had success with an approach that identifies causes and creates “toolkits” for nurses and physicians that cover a range of scenarios. These include seemingly basic procedures that nevertheless are not consistently carried out, such as taking a baseline blood pressure reading so that a patient’s spike in blood pressure can be more quickly and accurately noted. By 2013, California had reduced its maternal mortality rate to about 7 per 100,000 live births, a rate comparable to those of Canada and France.

A mother’s death has a profound effect on her family and community. It leaves her infant and any older children vulnerable throughout childhood and adolescence, without the protection, guidance, and financial support mothers provide. Ending preventable deaths and disabilities among new mothers will help achieve many other goals, including ending food insecurity and hunger.

Michele Learner is associate editor with Bread for the World Institute.

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This is Pearl Gaone Ranna working in the ‘field’. Courtesy Pearl Gaone Ranna.

A Mother’s Day Postcard from Botswana

By Todd Post

Pearl Gaone Ranna is a mother, a farmer, a social entrepreneur, and a visionary. At 26, she is already a leader of youth and women in the agricultural sector, both in her own country of Botswana and beyond.

I met Ranna in March at the annual food security forum of the Chicago Council on Global Affairs. In her “spare time,” she is also a member of the inaugural class of Obama Foundation Scholars at the University of Chicago. At the food security forum, it was clear as soon as she began speaking on a panel about water scarcity that she thoroughly understands the day-to-day realities of smallholder farmers.

In 2014, fresh out of college with a bachelor’s degree in business, she convened the first-ever Women in Farming Expo in Botswana, attracting participants from across southern Africa to network and discuss barriers and opportunities in their respective countries. She is the founder and managing director of Unitech Farming, which provides training and support to youth and female farmers, most of whom are smallholders farming a couple of acres or less.

Women farmers in Botswana have advantages that many of their peers in neighboring countries do not. For example, they are legally allowed to own land, the most precious asset to farmers everywhere—which is why women in many countries are still legally excluded from owning it. But laws that support gender equality don’t lead immediately to changes in negative perceptions and stereotypes, and women farmers in Botswana continue to struggle for recognition of their significant contributions to the nation’s food security. Many women have internalized harmful myths, such as that women cannot farm as successfully as men. These beliefs are what Ranna is determined to change.

Unitech has trained hundreds of women in the basics of how to run a successful farming enterprise. In a phone conversation we had recently, she told me about a new program Unitech is launching later this year, designed for young mothers with young children. The national government has just rolled out a school feeding program for all children in primary grades, and it plans to source much of the food from local farmers. It’s a tremendous opportunity for all farmers that may enable women who participate to break out of subsistence production.

“You can’t believe how hard it is to run your own business as well as raising a child,” said Ranna. Her firsthand knowledge comes from running a poultry operation and raising a daughter.   

The Unitech program has an early childhood development center for children so that they are learning in a safe environment while their mothers participate in training and work on their farms. The revenue the women generate through increased productivity on their farms will be invested in the program so that it can also provide training to new groups of women.

Ranna hopes that the program’s anticipated success will help bring policy change—specifically, institutionalizing this type of support for female farmers nationwide. “I am trying to advocate for policies for women and youth,” she explained. “To advocate effectively you need to be able to show something works.”

Ranna is excited in part because the program is being launched in the village where she grew up. She fell in love with farming as a teenager helping on her mother’s farm. She says her father wanted her to set her sights higher than being a farmer, and she has: she intends to transform the agricultural sector for all women.

Todd Post is senior researcher, writer, and editor with Bread for the World Institute.

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Young girls from Bangladesh. Photo: Todd Post/Bread for the World.

Motherhood: Adults Only

By Michele Learner

Being a mother is a role that can feel overwhelming. Mothers generally do everything they can to ensure that their children have enough to eat and get the medical care they need. But for most women in developing countries, this means not only long hours of work—perhaps as a farmer, seamstress, or market woman—but also exhausting, time-consuming unpaid work at home—carrying water, processing and then cooking food, washing clothes, and so forth. And, of course, mothers must care for their children as well.

Fulfilling all these responsibilities—usually seven days a week with few breaks—is a difficult job for an adult. Now imagine you’re 14 or 15 years old, and one evening your parents tell you that you’re getting married tomorrow. You may never have met your fiancé. If you have been attending school, it is very likely that you will have to drop out. Your new life as a “married woman” is about to begin.

The lives of young mothers matter, as do their children’s. Nutrition advocates pay special attention to younger children, particularly those not yet 2, for good reason: they are the people most vulnerable to death or permanent damage from malnutrition. As Bread for the World Institute has pointed out, education for girls has been critical to progress on child nutrition, playing a greater role than actually having more food available. If two families have similar incomes and live next door to each other, but one mother has finished fifth grade or eighth grade while the other has never been to school, the first woman’s children are far more likely to survive.

Child marriage, mostly of underage girls to adult men, is still extremely common. In developing countries as a whole, one in three girls is married before she turns 18, and in some countries, it is two in three. Every year, 15 million minor girls are married. If present trends continue, by 2050 the global population will include 1.2 billion girls and women who were married as children. They would make up a country nearly as populous as India today.

As just mentioned, getting married usually ends a girl’s chances for any further education. She takes on adult responsibilities before she is physically, emotionally, or mentally an adult, and she generally has little power in her relationship with her husband and in-laws. Most of all, she is not ready for pregnancy, childbirth, or adding the responsibility for a child’s health and well-being to her other duties. 

Proof, if any is needed, that child marriage poses a threat to girls and their children can  be found in a single statistic: the leading cause of death worldwide among girls ages 15 to 19 is maternal mortality. Teenage mothers are also at higher risk of complications than adults. Nearly two-thirds of all cases of obstetric fistula, a severe childbirth injury that causes loss of bladder control and leads to social isolation unless surgically repaired, occur in girls under 18. Girls under 15 are at particularly high risk in childbirth, dying at five times the rate of women in their 20s. Regardless of the mother’s age, her death in childbirth also puts her baby, and any older children, at a far higher risk of death or disability from malnutrition.

In recent years, there has been much more attention to reducing the rate of child marriage, which in turn will reduce maternal mortality. Working to keep girls in school longer, particularly through programs that offset a family’s opportunity costs by providing food at school and sometimes take-home packages, has proven to be a successful strategy. In most countries, the legal age of marriage is 18, but so far, efforts to involve law enforcement in preventing child marriages have met with mixed success. Both law enforcement and public opinion have been shifting in some countries, however, spurred by several high-profile cases. One of the most poignant is the story of Nujood, a 10-year-old girl in Yemen who in 2008 managed to make her way to court and persuade a judge to grant her a divorce from her abusive husband.

Once girls are married, however, they are often isolated at home and more difficult to reach with information and services. The advocacy organization Girls Not Brides reports that using health services as an entry point is a promising strategy. Girls who are married need opportunities to acquire formal and informal education, build skills, and generate income. Creating safe spaces where underage wives can support each other is important, as is providing information about contraception, although married girls often have little power to decide whether and when they become pregnant. Educating girls about their rights is also critical.

Enrolling girls in secondary school and ensuring that they graduate; enacting and strictly enforcing laws on the legal age of marriage; creating opportunities for young women to earn money and learn skills; and strengthening services aimed at helping girls survive childbirth—these are just a few of the things that can be done to enable many more girls and young women to lead full, healthy lives.

Michele Learner is associate editor with Bread for the World Institute.

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