Maternal Health: Accountability and Behavior Change

Calyn Ostrowski

Four days ago a young woman died giving birth in a bustling marketplace in New Delhi, just steps away from Parliament, and at the beginning of an international conference on maternal health. This is not acceptable.

Rewire is partnering with the Maternal Health Task Force to cover the Global Maternal Health Conference of 2010 underway in New Delhi, India from August 30th through September 1st 2010.

Four days ago a young woman died giving birth in a bustling marketplace in New Delhi. Just steps away from Parliament, this woman was left to die and no emergency care was sent to her–no midwives, nurses, or doctors; just people walking around her accepting the situation as normal and an uncontrollable way of life. But this is Delhi…not a remote tribal village where the nearest health clinic is hours away (on foot).

This juxtaposition lingers on in me as I sit in the plenary session of day two at the Global Maternal Health Conference and listen to Syeda Hameed, member of the Indian Parliament Planning Commission, discuss her recent visit to a remote village where every house has 10 children living in filth, flies, and emptiness.

Although I have been working on such development issues for the last five years I do not work in the field, nor do I visit the developing world on a regular basis. Hearing these stories, coupled with my firsthand experience of witnessing poverty here in Delhi reminds me of the daily reality of the estimated 342,900 women who die every year. This is their way of life and I think it’s poignant that today’s sessions emphasize community based care, family planning, accountability, behavior change, and culture.

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“Context, context, context,” said Wendy Graham of IMMPACT at yesterday’s plenary session. I agree, the context of social and cultural norms is an underlying factor that must be taken into consideration when implementing maternal and child health (MNCH) programs. With a background in psychology, I appreciated when Dr. Zulfiqar Bhutta, of Aga Khan University, recognized the toll of poverty on the imagination and the mentality of fatalism.

That is why it is so essential to “ask the people how they feel and bring their voices into the forums where policy decisions are made,” said Hameed. It is also important to hold key players accountable and include men in MNCH activities.

During the side session Male Involvement in Reproductive and Maternal and Newborn Health six field experts (in which half the panelists and audience members were men!) discussed effective methods for increasing male participation in family planning, vasectomies, gender equality, and hospital care.

The key findings from this discussion include:

  • Targeted interventions that educate men about danger signs and pregnancy complications correlates with behavior change and increased facility births.
  • Many young married men feel pressured to prove their fertility. A sample of men was evaluated and those who had increased education and income were more likely to delay first pregnancy.
  • Vasectomy is not something men want to talk about with family planning fieldworkers; however, official recognition of the vasectomy benefits by the government did increase referrals.
  • Puppet and theater shows that demonstrate gender equity behaviors provide an opportunity for dialogue. Women in this study reported increased gender equity in family planning decision-making.

There are so many variables that exacerbate the maternal mortality cycle, but evidence presented here provides REAL solutions.  It is time to scale up these solutions and political willpower will be essential.

Analysis Law and Policy

State-Level Attacks on Sexual and Reproductive Health and Rights Continue, But There’s Also Some Good News

Rachel Benson Gold & Elizabeth Nash

Despite the ongoing attention to restricting abortion, legislators in several states are looking to expand access to sexual and reproductive health services and education.

State legislatures came into session in January and quickly focused on a range of sexual and reproductive health and rights issues. By the end of the first quarter, legislators in 45 states had introduced 1,021 provisions. Of the 411 abortion restrictions that have been introduced so far this year, 17 have passed at least one chamber, and 21 have been enacted in five states (Florida, Indiana, Kentucky, South Dakota, and Utah).

This year’s legislative sessions are playing out on a crowded stage. The U.S. Supreme Court is considering a case involving a package of abortion restrictions in Texas; that decision, when handed down in June, could reshape the legal landscape for abortion at the state level. Moreover, just as state legislatures were hitting their stride in late March, the U.S. Food and Drug Administration revised the labeling for mifepristone, one of the two drugs used for medication abortion. That decision immediately put the issue back on the front burner by effectively counteracting policies restricting access to medication abortion in a handful of states. (Notably, the Arizona legislature moved within days to enact a measure limiting the impact of the FDA decision in the state.)

Progress on Several Fronts 

Despite the ongoing attention to restricting abortion, legislators in several states are looking to expand access to sexual and reproductive health services and education. By the end of the first quarter, legislators in 32 states had introduced 214 proactive measures; of these, 16 passed at least one legislative body, and two have been enacted. (This is nearly the same amount introduced in the year 2015, when 233 provisions were introduced.)

Although the proactive measures introduced this year span a wide range of sexual and reproductive health and rights issues, three approaches have received particular legislative attention:

  • Allowing a 12-month contraceptive supply. Legislators in 16 states have introduced measures to allow pharmacists to dispense a year’s supply of contraceptives at one time; these bills would also require health plans to reimburse for a year’s supply provided at once. (In addition, a bill pending in Maryland would cover a six-month supply.) Legislative chambers in three states (Hawaii, New York, and Washington) have approved measures. Similar measures are in effect in Oregon and the District of Columbia.
  • Easing contraceptive access through pharmacies. Legislators in 12 states have introduced measures to allow pharmacists to prescribe and dispense hormonal contraceptives. As of March 31, bills have been approved by at least one legislative chamber in Hawaii and Iowa and enacted in Washington. The measures in Hawaii and Iowa would require pharmacist training, patient counseling, and coverage by insurance; the Hawaii measure would apply only to adults, while the Iowa measure would apply to both minors and adults. The new Washington law directs the state’s Pharmacy Quality Assurance Commission to develop a notice that will be displayed at a pharmacy that prescribes and dispenses self-administered hormonal contraception. Under current state law, a pharmacy may prescribe and dispense these contraceptives under a collaborative practice agreement with an authorized prescriber. Oregon has a similar measure in effect. (California, the only other state with such a law, issued regulations in early April.)
  • Expanding education on sexual coercion. Measures are pending in 17 states to incorporate education on dating violence or sexual assault into the sex or health education provided in the state. A bill has been approved by one legislative chamber in both New Hampshire and New York. The measure approved by the New Hampshire Senate would require age-appropriate education on child sexual abuse and healthy relationships for students from kindergarten through grade 12. The measure approved by the New York Senate would mandate education on child sexual abuse for students from kindergarten through grade 8. And finally, in March, Virginia enacted a comprehensive new law requiring medically accurate and age-appropriate education on dating violence, sexual assault, healthy relationships, and the importance of consensual sexual activity for students from kindergarten through grade 12. Virginia will join 21 other states that require instruction on healthy relationships.

Ongoing Assault on Access to Sexual and Reproductive Health Services

Even as many legislators are working to expand access to services, others are continuing their now years-long assault on sexual and reproductive health services and rights. Restricting access to abortion continues to garner significant attention. However, last year’s release of a series of deceptively edited sting videos targeting Planned Parenthood has swept both the family planning safety net and biomedical research involving fetal tissue into the fray.

  • Abortion bans. Legislative attempts to ban abortion fall along a broad continuum, from measures that seek to ban all or most abortions to those aimed at abortions performed after the first trimester of pregnancy or those performed for specific reasons.
    • Banning all or most abortions. Legislators in nine states have introduced measures to ban all or most abortions in the state, generally by either granting legal “personhood” to a fetus at the moment of conception or prohibiting abortions at or after six weeks of pregnancy. Only one of these measures, a bill in Oklahoma that would put performing an abortion outside the bounds of professional conduct by a physician, has been approved by a legislative chamber.
    • Banning D&E abortions. Legislators in 13 states have introduced measures to ban the most common technique used in second-trimester abortions. Of these, a bill in West Virginia was enacted in March over the veto of Gov. Earl Ray Tomblin (D). A similar measure was approved by both houses of the Mississippi legislature and is being considered by a conference committee. (Kansas and Oklahoma enacted similar laws last year, but enforcement of both has been blocked by court action.)
    • Banning abortion at 20 weeks post-fertilization. South Dakota and Utah both enacted measures seeking to block abortions at 20 weeks during the first quarter of the year. The new South Dakota law explicitly bans abortions at 20 weeks post-fertilization (which is equivalent to 22 weeks after the woman’s last menstrual period). The Utah measure requires the use of anesthesia for the fetus when an abortion is performed at or after that point, something that providers would be extremely unlikely to do because of the increased risk to the woman’s health. In addition to these new measures, 12 other states ban abortion at 20 weeks post-fertilization.
  • Banning abortion for specific reasons. In March, Indiana enacted a sweeping measure banning abortions performed because of gender, race, national origin, ancestry, or fetal anomaly; no other state has adopted such a broad measure. The Oklahoma House approved a measure to ban abortion in the case of a fetal genetic anomaly; the state already bans abortion for purposes of sex selection. Currently, seven states ban abortion for the purpose of gender selection, including one state that also bans abortion based on race selection and one that also bans abortion due to fetal genetic anomaly.
  • Family planning funding restrictions. In the wake of the Planned Parenthood videos, several states have sought to limit funding to family planning health centers that provide or refer for abortion or that are affiliated with abortion providers. These efforts are taking different forms across states.
    • Medicaid. Measures to exclude abortion providers (e.g., Planned Parenthood affiliates) from participating in Medicaid have been introduced in five states, despite the clear position of the federal Centers for Medicare and Medicaid Services that such exclusions are not permitted under federal law. In March, Florida Gov. Rick Scott (R) signed a Medicaid restriction into law. By the end of the first quarter, measures had passed one chamber of the legislature in Arizona, Mississippi, and Missouri; a measure introduced in Washington has not been considered. (A related measure enacted in Wisconsin in February limits reimbursement for contraceptive drugs for Medicaid recipients.)

Similar attempts by six other states have been blocked by court action since 2010. These measures include laws adopted by Indiana and Arizona as well as administrative actions taken in Alabama, Arkansas, Louisiana, and Texas.

  • Other family planning funds. Legislators in 13 states have introduced measures to prevent state or federal funds that flow through state agencies from being distributed to organizations that provide, counsel, or refer for abortions; the measures would also deny funds to any organization affiliated with an entity engaging in these activities. Measures in three of these states have received significant legislative attention. In February, Wisconsin enacted a measure directing the state to apply for Title X funds (the state is not currently a grantee under the program); if the state’s application were approved, the measure would ban this funding from going to organizations that engage in abortion care-related activity. A measure that would deny funds to organizations engaged in abortion care-related activity passed the Kentucky Senate in February. A similar measure in Virginia, which would both prohibit an abortion provider from receiving funding and give priority to public entities (such as health centers operated by health departments) in the allocation of state family planning funds was vetoed by Gov. Terry McAuliffe (D) in March.
  • Related funds. In February, Ohio Gov. John Kasich (R) signed a measure barring abortion providers or their affiliates from receiving federal funds passing through the state treasury to support breast and cervical cancer screening; sex education; and efforts to prevent infertility, HIV in minority communities, violence against women, and infant mortality.
  • Fetal tissue research. The Planned Parenthood videos have also led to legislation in 28 states aimed at research involving fetal tissue. Measures have passed one legislative chamber in four states (Alabama, Iowa, Idaho, and Kentucky), and new laws have been enacted in four states (Arizona, Florida, Indiana, and South Dakota) in the first quarter alone. All four laws ban the donation of fetal tissue for purposes of research. These new laws are the first to ever ban the donation of fetal tissue. The Arizona law also bans research using fetal tissue, and the new South Dakota law strengthens the state’s existing ban by now considering fetal tissue research as a felony; four other states (Indiana, North Dakota, Ohio and Oklahoma) have similar provisions in effect.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.

Commentary Family

Pregnant and Parenting Students Can—and Should—Enforce Their Title IX Rights

Natasha Vianna

Many young parents may not know this, but many of the experiences and educational hardships they are facing are actually illegal. One major way teens can help empower themselves is by asserting their federal rights.

After enrolling at a new public high school during my senior year, I quickly realized how difficult it would be to succeed as a pregnant 17-year-old student. I had assumed that my peers would be the ones isolating me or making me feel like an outsider, so I was shocked when my teachers became my bullies. I did not want to stay in school when the people who were meant to educate and guide me were often the same ones judging and shaming me. Thanks to the work of a single dedicated social worker for teen parents in my school and her ability to advocate for my Title IX rights, I was able to graduate with my class. But not everyone will have such resources. And with that in mind, I feel it is vital to remind expectant and parenting students of their federal right to an education.

A 2006 report by the Gates Foundation found that 26 percent of youth who drop out of school in the United States said that becoming a parent was a major factor in their decision. However, many pregnant and parenting teens also reported in that same Gates report that they felt more motivated to stay in school after becoming pregnant or parents, and would have stayed if their schools provided equitable access to the necessary support. For some students, that support looks like scheduling accommodations or access to in-home tutoring. For others, support simply looks like being able to learn in a discrimination- and harassment-free environment.

Such an environment certainly wasn’t accessible for me. Looking back at my first week of school, I remember a moment where I looked at my senior year schedule to see that I was pulled out of all my honors classes. When I asked my guidance counselor why, she told me that girls like me—in other words, pregnant girls—couldn’t handle the workload. When I walked into classrooms, teachers would pull their glasses to the tips of their noses and glare at me while I tried to maneuver my protruding belly behind a small desk. During my last trimester, my legs were swollen and my belly was heavy, so it would often take me more than the allotted four minutes to go from a first-floor classroom to my next class on the fourth floor, on the other side of the building. One teacher made it a point to give me detention every time I was late and to remind me, in front of my class, that my pregnancy was a choice.

A few weeks before my due date and maternity leave, I made the second trip of the year to my guidance counselor’s office to ask for help with picking and applying for colleges. Barely making eye contact, she regurgitated the common stereotype: “Girls who get pregnant in high school struggle to finish high school and rarely go to college.” She pointed me to a stack of brochures from local community colleges and went back to typing on her computer. Given that the odds were apparently stacked against me, I began to wonder if it was worth trying anymore or if I should just drop out and not deal with the stress. Every day, I would ask myself whether I would bother coming back the next day.

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These factors exacerbated the effects of the trauma I had undergone earlier in life. Before my pregnancy, I had experienced abuse, witnessed violence, and coped with depression. School had always been my escape from the real world and a place where I could focus on my own growth. But my pregnancy changed that: It granted my instructors the opportunity to project their own judgment and unconscious biases upon me.

And I wasn’t unique. Many young parents across the country have experienced adversities and are in need of empathetic support systems in their educational experiences. A recent report by the Massachusetts Alliance on Teen Pregnancy revealed that 30 percent of expectant and parenting teens experienced homelessness over the course of the one-year survey; 46 percent of the teen parent population had been physically or emotionally abused or neglected by their caregivers; and 18 percent of teen parents had experienced sexual abuse. Yet we know that with empathy and equitable access to resources, teen parents are capable of overcoming these obstacles and succeeding in a variety of spheres, including academically.

One major way teens can help empower themselves is by asserting their federal rights. Many young parents may not know this, but many of the experiences and educational hardships they are facing are actually illegal. The National Women’s Law Center has compiled a clear list of expectant and parenting students’ rights as outlined in the federal law Title IX, which forbids gender discrimination in schools. Within Title IX, expectant and parenting students have the right to excused absences for pregnancy-related issues, reasonable time to make up work missed from excused absences, and maternity leave. If their schools provide temporarily disabled students with at-home tutoring, expectant and parenting students are also legally entitled to the same.

Students cannot be kicked out of school for being pregnant or parenting and do not need to bring in medical notes to continue their education or continue participating in extracurricular activities. Additionally, parenting students have the right to privacy, and no school official can share their pregnancy information with anyone without full consent. And regardless of parenting status, students have the right to continue their learning without being shamed. As Title IX clarifies, harassment because of pregnancy is a form of sex discrimination and a violation of the federal law.

With this in mind, young parents can and should demand transparency about their Title IX rights in school—and, in turn, to ask for a clear policy in their district that enforces those rights. In my case, a policy clarifying how teachers were allowed to engage with students and mandating training for all people working with young parents could have made my high school experience much more bearable. My social worker knew the complex issues around teen pregnancy and didn’t reduce my identity and life to my pregnancy; she was also well-informed on how to challenge or report instances of Title IX violations. But these weren’t guaranteed for other parenting students without a social worker. So ensuring a policy that includes language on why breastfeeding is a valid reason to be in the nurse’s office twice a day, or one that explicitly reinforced a young father’s involvement by excusing absences during the mother or baby’s medical appointments, maternity leave, or when babies are sick, could have helped students in the future.

Additionally, my educators, nurses, and guidance counselors would have benefited from learning how to be genuine support systems for young parents. Adults can sometimes unconsciously project judgment onto young parents or make stigmatizing comments that reduce them to statistics. Those little moments can have a deep and serious impact on a young person’s self-determination. Recently, a group of seven young moms formed a campaign, #NoTeenShame, to help push new frameworks that elevate strength-based language. Administrators should take cues from efforts like these, which amplify the voices of lived experiences.

Implementing policies that encompass these practices would ensure that the needs of young people are being met, allowing them to move toward their own dreams and goals. And district officials themselves have cause to cooperate; Title IX is mandatory, and violating these rights can cause a school to lose its federal funding.

We see a stark number of young people leaving school despite being motivated to stay because of the school’s lack of sensitivity. For young parents across the country, there are a few things we can do to protect our peers and ourselves:

  1. Find your district’s Title IX coordinator and share that person’s contact information with your peers and school support system.
  2. Urge your school administrators to create or update a policy for expectant and parenting students with the Title IX toolkit from the National Women’s Law Center.
  3. Know your rights and share them widely by discussing them on social media, posting flyers on your schools’ community boards, and asking your school to post them in highly visible locations.

As a former teen mom, I know the journey to implementing a district-wide policy seems overwhelming and that challenging an entire school system feels impossible. But young parents fighting for—and making—change could benefit the educational system.

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