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U.S. Department of State

Diplomacy in Action

Challenges to Reducing Women's Reproductive Mortality and Morbidity

Dr. Doug Laube
Washington, DC
July 12, 2011


Andrew Reynolds: Good morning, ladies and gentlemen. And welcome to our final Jefferson Science Fellows Lecture for this phase. We turn off during the summer when it gets too hot and you’re all braving the hottest day of the summer, and we appreciate that. We’ll start up again in the fall. And, again, a welcome to you all, especially visitors from the outside. We always like to take advantage of our distinguished professors and their insights and expertise while they’re here serving as Jefferson Science Fellows in the U.S. State Department and AID. And it’s always a sad time because in July we begin to say goodbye to them as they return to their chairs, but we look forward to seeing 13 new Jefferson Fellows who will come in August and interview around AID and the State Department for placement in one-year assignments. In that vein, I’d like to notify you that one of our new fellows, Norma Allewell from the University of Maryland has seen fit to join us today. Welcome, Norma. Nice to see you here. And we have a number of our distinguished alumni with us as well, and that’s always nice to see. Also, it’s another sad occasion in that we lose someone from the Jefferson family so to speak because the National Academy of Sciences who started this program with us and continues to serve in the administrative capacity, doing the recruitment bringing distinguished professors to Washington for interviews, and helping us and helping them throughout the year have a successful experience, Liz Decker, our dear friend from National Academy is moving onto the Center for Strategic and International Studies at Johns Hopkins for a development job that she certainly has in heart. And we wish you the best, Liz. But we’re also happy to see Asha Davis who will be coming to join us in that team from the National Academy. So best of luck to Liz, and welcome Asha.

As you all know, the Jefferson Fellows Program is about in its seventh cohort. This program began under the aegis of our second Science and Technology advisor, George Atkinson, who was a professor of optics and material sciences, University of Arizona. And when George came in 2003, he felt that the program of the American Association for the Advancement of Science, which had taken a great impetus under our leadership, our first advisor, Norm Neureiter, to grow in size and bring us our Ph.D. scientists and engineers in increasing numbers as fellow, could be complemented nicely if we built stronger bridges to the university community and bring to the State Department and now, in the last two years, to AID, these tenured professors in science and engineering fields to help us for a year of assignment, an intense year of assignment, and then to serve when they return to their chairs as subject matter experts for as long as they can. And this has built for us an amazing stable of expertise over the last six years and now our seventh cohort. And so we welcome all of you. Know that these ladies and gentlemen who have come to us as Jeffersons, we hope continue to serve the State Department and AID in this important work where their insights and their networks are indispensable for success. Moreover, we depend on our Jeffersons to serve as science and engineering ambassadors on their campuses and help us identify the new people who may wish to come and serve with their scientific and technical toolsets in science and diplomacy, the great proposition that we all undertake.

Doug Laube is a gentleman who has really fit so beautifully into his assignment at the U.S. Agency for International Development, because, as an obstetrician and gynecologist, there couldn’t have been a better timing for a person with his reputation and his experience, entering just as USAID launched the grand challenge on maternal health. And I think you’ll find this theme today as so seminal to the initiative and what we are really trying to accomplish as a nation in this noble enterprise. The University of Iowa all the way. I notice the United States Navy Medical Corps at Quantico, whooah, whooah. And you know heat because you’ve been here before, so he had the temerity to walk from the Reagan building this morning to come to the lecture, so we should all applaud that as well. The chair of the Department of Obstetrics and Gynecology, University of Wisconsin, beginning in ’93 through until September 2006, president of the American College of Obstetricians and Gynecologists in May of 2006, serving on the Council in Residency Education in Obstetrics and Gynecology. He chaired it from ’96 to ’99, the National Board of Medical Examiners, the United States Medical Licensing Exam, as well as serving in educational development programs in Central Asia, in Afghanistan, and, more recently, helping in organizing post-graduate residency curricula in six Central American countries. I can think of no better person than Doug Laube, our good friend who has fit so nicely, as I said, into his assignment. And I’m looking forward to hearing this lecture, wishing him well, and knowing that he will continue to serve us in the future. So, Doug, thank you for your service here this year, and we look forward to this lecture. Thank you. Please.


Doug Laube:

Thanks, Andy. That was a very generous introduction, so I appreciate it very much, and I appreciate those of you that have braved this weather to either walk over here or ride over here and listen to what I have to say. It’s a somewhat daunting task -- oh, and by the way, before I forget, I’d like to thank my fellow Jeffersons as well as Liz and Lawrence for all of their work, the Jeffersons in particular. And, on a lighter note, one reason I appreciate giving this presentation today is I do want to show them I have a suit, and this is the second time I’ve worn it in the last 11 months. So I think most of you know the dress code at AID is somewhat different from what it is over here. So it did give me an opportunity to get it out of the closet and wear it today.

As I mentioned, somewhat daunting task -- what I decided to do is talk about challenges, which -- implicit in which are some potential solutions to the problem that women face globally as far as their reproductive health goes. So I put the word “challenges” in orange as a cautionary word, because these are the things, in particular the social determinants of what contributes to excessive maternal mortality and morbidity are of particular interest to me. So what I’d like to do is take a few minutes, six or seven slides or so just to go over a little bit what the global health initiative is, and then take a few slides and talk a little bit about background and what the nature of the problem is, that is the nature of maternal mortality and its -- and the morbidities that go with it, and then talk at fair length in the second half of the presentation on the social determinants of this problem, which, in my opinion, are by far the more important ones from those that are purely medical.

An African saying -- actually this comes presumably from the slave trade in the 16th, 17th century where actually the slave traders from Europe initially thought that getting -- having pregnant women as part of the slave trade would be advantageous because they would get a two-for-one deal in terms of what they could take home. But until they found out that many of these women died on the four- to six-week trip across the Atlantic or up around the coast depending on how they went, whether they went to the Caribbean or back to Europe, and it became apparent to them that, in fact, this African saying was quite important in their work. One reason I want to show this is from an AID slide set is the fact that the president, a little over two years ago, wanted to make sure that as he described and as he appointed the new administrator to give direction to the global health initiative that child and maternal health were front and center. And one reason for mentioning this is, and I think all of you know this, is the tremendous emphasis that’s been given to AIDS, HIV/AIDS, malaria, tuberculosis. And I think the president and the administrator had decided that really maternal health -- and I’ll reinforce this over and over through the presentation -- is a key to treating any of those other disorders because the woman does focus as the center of the family.

I’ve abstracted some material here and highlighted in green the things that I’m particularly interested in. Obviously the HIV question is and continues to be very important. But there’s a change in emphasis now to prevention from treatment, which I think is very welcome. One reason I say that is that the vertical transmission from mother to child in an untreated AIDS patient is about 30 percent, so about one-third of babies are products of pregnancies where the mother is infected will become HIV-infected untreated, and treated, less than five percent. So the point is that from a prevention standpoint, treating the pregnant with antiretroviral therapy is extremely effective in preventing the global transmission. And the other point of course is to avert millions of unintended pregnancies, and I’ll comment on this in some more detail later, but it’s important to remember that prevention, again, is much more important than treatment and dealing with consequences of unintended pregnancy.

So that the goals for the five years are just these: to try to prevent 54 million unintended pregnancies -- I’ll reiterate this later -- and try to achieve a contraceptive prevalence rate of about 35 percent. Well, to put that in perspective, the contraceptive prevalence rate in this country is about 75 percent. That is the number of women age 15 to 50 who are using either a short- or long-acting contraceptive method, the contraceptive prevalence rate in countries like some of the sub-Saharan African countries is in single digits. So there’s a lot of work to do. Some of the Western European countries, it approaches 80 percent to 85 percent. And in China, it’s over 85 percent, so -- for reasons that are considerably different from contraceptive prevalence rates in Western Europe.

I want to highlight this also. It comes out of the GHI Principles slide set, but the point is that these are all things that have been done for a number of years in the Global Health Bureau, that is the integration, the strengthening of multilateral institutions, et cetera. But again, a key emphasis point on women-centered programming, which is really at the heart of success in the success of many of the other programs, some of which I will mention in a little more detail.

So, in summary then, the GHI goal is just this, to reiterate: Reduce mortality by 30 percent across assisted countries. That’s 28 in number as of now. And that job, the implementation of the logistics of this is not yet complete, and to prevent 54 million unintended pregnancies.

Well, let’s look a little bit about -- at some of the background of what it is that we’re talking about. Fortunately, there has been a reduction from estimated 526,000 deaths in 1980 to 340-some odd thousand. The estimates vary a little, 340,000 to 360,000. But the point is there’s been an annual rate of decline at about -- since 1990 of one percent. Ideally, that should be considerably higher. Five or six percent would be a good estimate or a good goal, I should say, and attempt at reducing global maternal mortality to under 200,000, which will be a goal that I don’t think that will be attained in this particular timeframe. So a lot of women are dying, and I’ll reiterate this in a number of different ways.

If you look at where these things occur, six countries account for approximately half of all the maternal mortality, and those are the countries listed here. All of them, with the exception of Pakistan and Afghanistan and India, the other three in Africa -- India by virtue, it’s a population that really leads the list. And Afghanistan, as I’ll show you in just a second, is the one with the highest maternal mortality rate. If you look at maternal mortality rates of over 1,000 -- and remember, just to put this in perspective, the highest, as I’ll show you in a second, is 1,600 per 100,000 in Afghanistan. The lowest is in Denmark at about 3, 3 per 100,000. So when we talk about disaster zones from the standpoint of maternal mortality, we look at countries like this with maternal mortality rates of over 1,000, approximately 1,600 in Afghanistan and the Central African Republic, and you can see on down the road, 1,300 or so, 1,200 to 1,300 in Malawi, 1,100 in Chad, and about a little over 1,000 per 100,000 women in Sierra Leone. That’s a lot of women dying from a process that should be associated with considerably different outcomes.

Looking at it a different way, if you look at what happens every minute, and the reason I wanted to reiterate showing this is that in the roughly hour that most of you have set aside to be here, you can just do the arithmetic as to what it’s going to mean, with about 24,000 women becoming pregnant in this hour that we’ll be here. And you can just look at the numbers. Half of them are pregnant in an unplanned or in an unwanted situation. And if you just want to look at the issue of unsafe abortion, roughly 2,400 women will have had an abortion complication in the hour that we’re spending together today. So, again, looking at unplanned pregnancies, half -- and that, by the way, in this country, it’s the same way. Half of our pregnancies in this country are unplanned. And so, and in many other respects as I’ll compare in the next few minutes, we don’t do a lot better in many respects than some of these other countries. Fifty million induced abortions, 20 million will have had an abortion complication as I just mentioned. Sixty million women, and this is an area for emphasis at AID, is to provide much better access to skilled birth attendants, but 60 million women give birth at home with no skilled attendant. The maternal deaths you just saw. And another thing that I don’t have time to talk much about today, could be the subject of a whole series of lectures, is the morbidities; that is, the women who live, living with lifelong disability as a result of their pregnancy complications, the most notable of which is, of course, vesicovaginal fistula with an estimated 80 million to 100 million women living with chronic urine leakage from the vagina as a result of obstetric complications. So, for every one maternal death, there are 30 morbidities. And there are all sorts of other morbidities which I don’t have time to go into.

Looking at it in a little more USA Today fashion, if you want to think about it this way, you can imagine if two fully loaded 777s went down every day in the world what the outcry would be and what the assessment would be and how this would be cured and how fast would industry go to try to find out what went wrong. It’s not happening when it comes to women dying in childbirth. More than two of these planes, the equivalent of two of these a day going down.

The best countries, as you can see on the left, basically have health care systems which provide universal access, universal coverage, and assured medical care. The worst ones have none of that or very little of it. So when one -- and just to put it in perspective, the U.S. is 40th on this list. So we’re pretty far down the way with a maternal mortality rate of about 14 right now, and it’s been going up in the last three years. And among African American women in this country, the maternal mortality rate is 35. So, you can see that disparities contribute significantly to our own problems in this country for political reasons that I won’t get into right now.

So let’s look at 160. This is a place I’ve spent a little bit of time in three different visits in a maternity center in Kabul, but you can just go down the list here and see how poorly off they are in terms of a whole number of things, including their social determinants, with children dying by the age of 5 at a rate of about 25 percent, life expectancy at 44. For women in this country, it’s about 84 right now -- and formal education of four years or less with very few deliveries being attempted by skilled birth attendants.

So has there been progress? Yes, there has. So, as Ed Logan said in his “Lancet” editorial in 2010, now instead of somebody dying every minute, it’s every other minute. And so, that’s progress. And we can -- it is measurable progress, but there’s still certainly much more to go.

Well, let’s talk a little bit about what the practices are that could improve this picture. And I will talk a little bit more extensively on the unplanned pregnancy situation. I don’t have time to talk too much about what AID is doing to develop skilled care, but the efforts are considerable, I can assure you of that. I’ll talk a little bit about the two most serious emergencies; that is postpartum hemorrhage and preeclampsia, or toxemia, acute hypertensive disease of pregnancy. And I don’t have much time to talk about some of the other problems, particularly fistula which is a subject that does interest me and a subject in which I’ve had a fair amount of surgical experience. Post-abortion care is particularly important, and I’ll focus a little bit on that. And then, of course, as I mentioned earlier, tracking the social determinants of why all this happens in the first place is going to be something that I spend considerable time on.

So let’s look at family planning first. What does it do? It does a lot of good things actually as meaningful, preventive medicine. Aside from all the political rhetoric that’s going on right now in this country, family planning is critical. And it saddens me to think that the secretary of Health and Human Services this summer has to decide whether contraception is going to be a benefit that women can have without co-pay. That is inexcusable. It’s absolutely inexcusable. Pregnancy prevention is one of the top 10 preventive medicine achievements of the 20th century as measured by the CDC in this country. It reduces child mortality. It reduces maternal mortality and morbidity. Obviously, it reduces abortion, and that’s been borne out in study after study. It increases women’s opportunities for -- to improve their own socioeconomic status. It’s critical in the intervention of AIDS and HIV. And it’s obviously a part of any essential health program.

Just as an example, if you look at the need of 250 million women for the unmet need, I should say -- just to show you an example here, the unmet need in Africa is two out of three women, approximately two out of three women. The unmet need in Asia, 41 percent, but again, the population of Asia dictates an absolutely much higher number than the number in Africa, so that this would translate to probably roughly 90,000, a million pregnancy-related and 590,000 newborn deaths a year, just the fact that if unmet need for contraception, attaining that 35 percent level I mentioned, not at the 75 or 80 or 90 percent level but at the 35 percent level.

If we look at the major causes of obstetric death, and by obstetric, this is by definition the delivery of a fetus past the 20th week of pregnancy, 23rd week of pregnancy, depending on what one -- how one looks at the definition. But actually a viable fetus, maternal hemorrhage by far and away leads the list with preeclampsia and eclampsi coming in second. Now, I can’t -- I’m not sure what the medical background of most of you is. I think it’s -- any MDs in the crowd? So, okay. Preeclampsia is an acute hypertensive disorder of pregnancy that has a range of anywhere from three to five percent in most populations, higher in some sub-Saharan African countries, lower in most Western European countries. But it’s an acute hypertensive disorder which can be associated with literally systemic failure for a variety of reasons that I don’t want to get into in this particular talk, but it’s generalized vasospastic disease, affects the liver, the brain, the heart, virtually every organ system in the body, the kidneys and, in its worst form, can culminate in gran mal seizures, which carry with them approximately a 30 to 50 percent mortality rate in most of the countries, the assisted countries that we’re talking about. So it’s a big deal. The treatment is relatively easy, and that is to use magnesium sulfate. It’s been used for a majority of the 20th century in this country successfully to prevent seizures. And yet, in many of these countries, the acquisition, delivery, the implementation of the use of magnesium sulfate is very difficult.

Hemorrhage, similarly, can be treated fairly easily with what’s called AMTSL, active management of the third stage of labor, the third stage of labor being that in which the placenta is delivered. So the labor and delivery of the baby is one side of the issue. The other is the uncontrolled bleeding which affects approximately 10 percent of pregnancies following the delivery of a term baby. And when there are no medications available to treat that, and it’s easily treated with oxytocin and misoprostol, among other things, women literally just bleed to death for lack of having any mechanism to control bleeding, so that the use of uterotonics and oxytocin and misprostol is the focus of a lot of AID’s efforts at reducing that particular component. I’ll talk a little bit about abortion in just a second. That doesn’t show very well on that particular slide. But to talk about hemorrhage for one more minute, I’ve highlighted a couple of things in these bullet points on the right because these are a couple of the things that I’d been charged with trying to do this year, that is to connect professional societies with various groups at AID in an effort to implement and to educate some of this information to those countries in need. And this is something that I’m working with my professional college on, the American College of OB/GYN, to try to develop some cadre of educators that can help in the future assist USAID in its efforts. The other is to support WHO in the postpartum hemorrhage prevention and management guidelines. I attended a meeting in May -- excuse me -- in Geneva to this extent. And we will be seeing now new guidelines which hopefully can be implemented the respective countries by early in 2012. Similarly, I highlighted a couple of points here in preeclampsia/eclampsia, and that is the integration with WHO offices and to develop guidelines. I attended a meeting again in Geneva, a different meeting in April. And I was really privileged to be able to be part of a group of experts from Canada, the U.S. and other parts of the world to try to come to consensus on what it is that should be done to not only treat preeclampsia, how to get the medications to the right place at the right time, but also to prevent it, particularly in calcium-poor societies and countries where calcium supplementation seems to help, and then again, trying to include our professional society as a champion and, to that extent, this year’s president of ACOG is taking on as his initiative this whole issue of preeclampsia as it exists in this country and then extending those findings with his working group to WHO to help them in their efforts.

Well, here’s -- we’ll talk a little about the A word. Nobody likes to talk about abortion and for a variety of reasons, particularly within the context of what goes on in this country. But, in the world, it’s a considerably different situation. Of those over 200 million or so pregnancies, as I mentioned earlier, this says 40 percent -- most people think it’s closer to half, but give or take 10 percent when you’re talking about that number, the impact is still really significant. Twenty million unsafe abortions. Now unsafe meaning it’s either illegal, which it is in most countries, and at least it’s partially legal, I should say, or it’s done by unskilled attendants that don’t really frankly know what they’re doing. It’s actually -- in our country right now, legal suction abortion under 12 weeks is the single safest pregnancy outcome there is of any pregnancy that you can name. Legal abortion carries with it a morbidity rate of about 1.2 percent. That lessens in some places. And having a baby, quote, having a normal baby carries with it approximately a 10 percent risk. So, it is a safe pregnancy outcome if done properly and if done by the right people. To the extent that over -- approximately 70,000 or so women are dying from unsafe abortion, accounting for 13 to 15 percent of the world’s maternal mortality. Let me show you a picture here that is a woman in Dar es Salaam, a 17-year-old who had an unsafe abortion. The person didn’t know what he was doing, thought that the cervix was not where it really was, put a hole in the back of the vagina, put his suction device in and sucked out three feet of small bowel. That became -- he left then, of course. He left the facility, which was not a facility -- it was his house -- and left the women’s mother to take her to the hospital. Fortunately, she lived and had three feet of bowel resected and did live to survive that particular -- that’s just one example. I could show you a dozen slides that would ruin your lunch if I did.

So the distribution of unsafe abortion by age, just to show you the incidents which is in blue, and the mortality which is in the purple, pretty close to one another with the peak incidents occurring between 20 and 24 years old, and then on down as you get farther down in the age distribution. But the mortality rate and the incidence of unsafe abortion parallel one another pretty closely.

So what occurs with post-abortion care? And I have to thank Carolyn Curtis who’s the champion over at AID for her work on post-abortion care. But basically, it’s an effort to treat the complication, of course, and that would be the acute complication having to do with bleeding or sepsis which is common with illegal abortion. The death rate in this country in the ‘50s and through the mid-‘60s in this -- in the USA was about 50 percent for every illegal abortion that became infected. So septic abortion is a critically -- it represents a critically ill patient. Fortunately that has changed since Roe v. Wade and since things are being done differently.

Family planning counseling is a critical part to prevent the next unplanned pregnancy, and that is a key element of the new guidelines which will be developed over the summer and into the fall as something that receives exceptionally big emphasis in the clinics that are seeing these patients who are acutely ill. This just shows a snapshot from the Caribbean and Central America, the Dominican, Haiti, and Nicaragua, a sampling of only a couple of hundred women, but it does give you a picture of what it is that can go on or what goes on in these clinics that needs to be corrected. If you assume about a third of women have a method failure of one kind or another, and people argue about method failures and use failure, method failure being that something that fails despite having been used. Use failure just means not using it. And but nevertheless, the alleged method failures at about a third. About three-quarters of women really want to space their next pregnancy. That makes sense. Unfortunately, of that group, 60 -- about three-quarters of them wanted a family planning method, but only about a third of them got it. That’s the problem, that even those women that want something to try to plan their lives and to try to move forward within their respective societies don’t get it two-thirds of the time -- another focus for the AID efforts in post-abortion care.

So the consensus points then, having to do with family planning, are just these here, and I don’t -- you can read them for yourselves. I don’t need to reiterate them. But a key part of this discussion has to do with what’s emphasized in this bullet here, that there should be universal access to family planning. And it should really become standard of practice for the physicians and nurses and midwives who care for these patients. As it is now in most of our clinics in this country, women do not come and go from a facility that provides abortion without extensive family planning counseling and implementation if they so desire.

Cost is another factor. Just briefly, contraception is a lot cheaper than post-abortion care, to the tune of about $19 million versus $5 million in the country of Nigeria, for example. And in Kazakhstan, abortion services accounted for almost a percent -- one percent of the total public health spending in 2004. So, the point is that contraceptives are two to three times more effective in some countries -- in this country, it’s three to one. For every pregnancy prevented by meaningful contraceptive use in a year’s period of time, we save $3. It costs a dollar to implement the contraceptive. It costs $3 if it fails. So when people talk about whether or not women should have contraception, even within the context of our society, it makes imminent sense from an economic standpoint to provide contraception.

So what’s at stake if these patients don’t have the access? Well, it’s estimated that there could be a 25 to 35 percent reduction in maternal mortality just through the use of meaningful contraception. Okay, so why doesn’t this -- why don’t things get better faster? As I’ve put in this slide, why has the carnage been allowed unabated in much of the world? Well, you can take a guess. Bumper sticker wisdom: “MISOGYNY: Hard to spell, easy to practice.” And that’s the way it is in much of the world. Women don’t have a chance. They don’t count. And I’m going to show you some fairly graphic pictures, but it’s -- this is the thing that, in my opinion, has to really be dealt with in a super aggressive fashion.

This picture shows a woman in Northern India nursing her babies. Misogyny starts early. Three-month old twins -- here’s the girl on this side being fed from a bottle of watered-down formula. She died a few weeks later. And here’s the boy on this side being nursed the way all babies should be fed in the first year of life. The spectrum of maltreatment, well, you can read up from the bottom up: apathy, neglect, disdain. We suffer that right here in the good old U.S. of A. All the way up to femicide, “honor killings”, et cetera, with all the things in between that one can guess are part of this semi-organized to sometimes very well-organized spectrum of maltreatment.

So what are the manifestations? I think most of you know many of these. You read about them in the paper pretty regularly: child marriage, domestic violence, dowry killings, “kitchen fires,” the origin of which apparently has to do with practices in the 17th and 18th century of burning the widow of a dead husband on the funeral pyre, of the husband’s funeral pyre, but now it’s been modified to be called the “kitchen fire” situation when a woman has been doused with gasoline and set on fire because of unmet dowry needs. Rape -- rape as an instrument of warfare -- you all know about that. Genital mutilation -- I’ll show you a little bit about that in a few minutes. And the so-called “Eve teasing,” which is somewhat more subtle, originating from none other than the Christian Bible, the Old Testament, in Genesis. Eve was the temptress. She was the bad one. She’s the one that caused all the world’s problems. And so it’s okay to just do whatever one needs to do based on societal and cultural and religious values that humiliate and demean women throughout the world.

We contribute somewhat to this, and I’m showing this at a little bit of risk, but I wanted to do it anyway. Washington Post had an editorial in March entitled the title that you can see here, “U.S. shifts strategy on women’s rights as it eyes wider priorities.” One wonders what the wider priorities are. You can take a guess. And I picked this quote out of this article, and you can read this for yourself. The highlight of this particular sentence is the world “pet rocks.” Well, let me read you the context of this comment. “When the U.S. Agency for International Development sought beds last March for $140 million land reform program in Afghanistan, it insisted that the winning contractor meet specific goals to promote women’s rights.” And then it goes on to describe what those land reform right should be. That was watered down by -- I don’t know who, maybe some of you in the audience do. But this comment came from a senior administrator at AID who wanted to remain anonymous for obvious reasons. So when it comes to our policy and when it comes to how we promote this notion of gender equity, of women’s rights, of social determinants of societal welfare, it doesn’t help to have this stuff coming out of our own offices.

Is this a pet rock? 56-year-old Afghan Pashtun tribal leader, promised in marriage to this 9-year-old girl. She looks really happy. What about this pet rock? Bibi Aisha. Some of you remember seeing this picture a few years ago when she had escaped from a promised marriage at the age of 14. She escaped back to her family, was caught, had her ears and nose cut off as retribution based, again, on cultural and tribal custom. What about this? Is this another pet rock? The fact that young girls face rape in Afghanistan at an ever-increasing rate, higher than that which was reported under the Taliban, by the way.

Well, we don’t have to pick on Afghanistan. We can go right to one of our long-time strategic partners, Saudi Arabia. “Saudi judge refused to annul the marriage of an 8-year-old girl.” I would offer instead of pet rock, maybe the question mark here should be “cheap oil.” What about the United Emirates? It’s okay if you don’t leave a mark on your wife or child. Unfortunately, this particular person did leave marks, thus the court case. But in the ruling, the judge ruled that had he not left marks, it would have been legal -- or slapping spendthrift wives, a somewhat more subtle occurrence in Saudi Arabia when money is given to buy the abaya, which these women have to wear. And instead of getting it from a thrift store, a woman bought it at a more expensive store, so therefore, it was okay to slap her.

So there are pretty grim statistics in a variety of other ways as well, with domestic violence being very prevalent in many countries, particularly those in the Middle East and in India. Abuse during pregnancy, 4 to 12 percent -- a little bit better in this country, it estimated at one or two percent of our pregnant women in this country are physically and emotionally abused. Honor murders, et cetera, and sexual abuse, up to 20 percent, and that’s according to WHO statistics. Little different twist in Mauritania where if the woman is raped, she’s the one at fault. So she doesn’t even report the incidence because there are no laws in Mauritania that define rape.

Talk a little bit about genital mutilation, another unjustifiable form of cultural and probably not so much religious means as more cultural. So procedures that involve removing all of or part of the external genitalia of a woman and, depending on how much is removed, then the application of various devices to make is scar over so that the vagina becomes basically invisible. So women then urinate through a partially obstructed urethra, through their vaginas and are, in effect, disabled for the rest of their lives, unless they happen to become married and are deinfibulated. The numbers by country? This is just a snapshot. Egypt, so far, based on information in the late ‘90s led the list, but the total number is estimated now at around 100 million women in the world, many of which, perhaps most of which occur in sub-Saharan Africa, but it gives you a little bit of an idea of some of the numbers in the other countries with Egypt and now Sudan and now South Sudan contributing significantly. The patients I’ve taken care of to try to reconstruct the vulva of women with gross disfigurations, surgically reconstruct them, have all been from the Sudan.

Somebody suggested awhile back, a social psychologist, actually anthropologist, Anne Cloudsley, that evidence suggested that the slave traders actually preferred infibulated women, that is the women who had been mutilated and then sewn shut, since they wouldn’t be compromised by becoming pregnant. And so they commanded higher prices. This is what it looks like for a 7-year-old girl who has nothing other than a Gillette stainless steel razor blade, or, perhaps, cheaper by the half dozen done at the same time, as per tribal custom in Nigeria. And here is the sophisticated materials that are used. It doesn’t take much. Blackthorn -- from the blackthorn tree to hold the labia together and the good old razor blade to make the job clean.

There are other less shocking aspects of examples of misogyny having to do with the health care system itself and, in many respects, the providers that are designed to fix this problem in the first place. So, abuse during and just before childbirth is very common. And so what goes wrong in the health care facilities that, again, USAID is now doing a lot to try to counter some of these practices. And I’ve listed seven of them in the bullets there, and I’ll show you a few examples of quotes that represent those abuses, and tell you a little bit about AIDS efforts to try to fix it. Well, you can read this. If you don’t want the woman to misbehave during the second stage of labor, you don’t want her to close her legs, you just beat her. If being of low socioeconomic status, which is true for most of these women, is part of the problem, then she’ll accept poor treatment, bad treatment, because she can’t yell back. She doesn’t have the means to do so. You can read this one for yourself, what came from The Skilled Care Initiative in Kenya in 2005. If you can’t pay the bill, the doctor will just incarcerate you. That’s from the Human Rights Watch in 2010. And this, as an OB/GYN educator of medical students and resident, is the one that really resonated with me, that, in fact, the health care worker herself -- in this case, it was a female resident physician -- basically impressing a group of medical students who thought she was really in control because of the way she was treating this patient. So that’s in the education system itself.

So some of the approaches are, as you would imagine, looking at legal and human rights efforts, quality improvement, accountability, et cetera. And a lot of work is being done, and I have to thank Mary Ellen Stanton in the Maternal Child Health Office for some of these materials.

Remedies are pretty simple. And you can read them for yourself. I think the most important of which is education and access to family planning methods to -- and in addition to providing safe birthing environments. I want to give a little credit to David Grimes, one of my colleagues who works in Chapel Hill for FHI, and it has to do with some of the efforts that Family Health International are doing to address some of these problems having to do with the ROADS project, the Regional Outreach Addressing AIDS Strategies project, which includes a lot of information that is designed to empower women leaders and address gender-based violence as well as the partnership research that they participate in as well as many of the socio-behavioral studies that are embedded in the medical studies that FHI is doing.

So, just to compare misogyny with AIDS, kills two ways: directly through infection, indirectly by taking away resources. Misogyny kills women in two ways: directly through violence, and indirectly through neglect. One last quote from David, and I highlighted the last sentence. “Simply put, women die because they don’t count,” and this comes from the “Lancet” article he wrote a few years ago, citing Mahmoud Fathalla who is the Egyptian obstetrician/gynecologist who led the Save the Mothers projects beginning in the late ‘80s.

So, to close, let’s look at lessons from the Human Genome Project. I’m sorry Mitch isn’t here. He’s a molecular geneticist. But I have a little different twist on it, that we’re really all related, our genetic differences are trivial, only a few base pairs even across races. Abusing any of us diminishes all of us. And we have to really do a lot better in defending the rights of our patients and these injustices. So, as a physician, I don’t know about how noble the tradition of medicine is. I think it’s pretty noble still despite what’s going on in this country now in a for-profit fee-for-service health care system, but it’s still noble in its end. And I think we really have an ethical obligation to protect the patients, which transcend the government policies, religious orthodoxy and cultural norms.

So lastly, I just want to thank the people listed in this slide. Jeff Spieler is my sponsor over at Population and Reproductive Health. Mary Ellen I mentioned. Deborah Armbruster is one of here associates. Carolyn I mentioned, and Erin Mielke, who has helped provide some of the information that I’ve shown you today. So, with that, I’ll thank you and I know it’s running a little late, but I’m happy to take questions. If you have any, please use the microphones.


Just don’t ask me what causes preeclampsia because nobody knows.

Andrew Reynolds:

No one knows. My gosh, I am sure everyone has read about this, but -- and certainly taking it to hear, but to have it up in such concise ways and the extent of this problem, I myself am pretty transformed. Thank you, Doug, for this very interesting lecture. I just wonder if I might start off by asking, when you look at delivery deaths, you said more than 50 percent in just six countries. And when you look across the AID’s strategy, India, Nigeria, Pakistan, Afghanistan, Ethiopia, and then Democratic Republic of Congo, how well are we attending to this in our specific assistance programs?

Douglas Laube:

Well, I can’t remember exactly how many of those are the first eight countries. Anybody else know that? Three of them are, I know. The other rest of those countries are all on the list of the remaining 20 in which these programs are going to be emphasized. But I’m sorry I can’t tell you exactly which ones. But they’re all in the 28 -- the group of 28.

Andrew Reynolds:

And in your year at AID, have you seen a regular assault on the budget, that is the budget in FY11 which you witnessed? How did we do? And how does the prospect look for ’12? Are we -- are you seeing a threat to some of these --

Douglas Laube:

Well, yeah, I always see assaults on the budget, or at least I hear them talked about. I don’t see them because I don’t do those number crunching. But I hear people complaining about it a lot. And as you may or may not know the apropos of that comment, the -- you know, there’s a recently introduced House Resolution 2059 a couple of weeks ago, House resolution here in this country to defund UNFPA, take away all the United Nations Population Fund. You can argue the politics as long as you want, I suppose, both side of the aisle, but that’s extremely shortsighted thinking. And, but it goes along with what’s going on right here in Washington this week and next week. I won’t comment on that anymore either, because I can go off on that and -- yeah, Suresh.

Suresh Garimella:

Doug, I don’t actually have a question. I just wanted to congratulate you on everything you’ve done all your life it seems. I think a lot of us think we do useful work, but this seems just to be dissolved by so much, so I hope you keep doing it, and I hope you stay here for several years to come, to stay on as a Jefferson Science Fellow.

Very quick question, of the difficulties you listed of, you know, there is so many, it seems like the cultural norms are the most difficult to beat because the others have sort of maybe aspirin or whatever else you listed, but how do you see that change coming about, say, in Afghanistan? Or pick any of the countries, right. How does that come about? Are you at all optimistic about it? Thank you.

Douglas Laube:

Yeah, I’m always optimistic. You know, I had people that called me sort of the hopeless idealist, which is really an oxymoron. You can’t be hopeless and an idealist, right. And I always say, well, that creates terminal cynicism, which it does, because you don’t see enough getting done. But I’d say, if we go back -- I want to go back up and just look at some of the things that David is doing with FHI. Here is it. I think projects like this which, if every medical, quote, solution -- if the administration of magnesium sulfate could be done for every woman who needs it, but administered within the context of also providing education and information on empowering women, on addressing the gender-based violence that perhaps lead that patient to be in whatever facility she is, I think those sorts of issues, these sorts of programs like FHI and many other groups are doing by the way -- it’s not just FHI -- are the sorts of things that ought to be embedded within every medical project. And so, that’s why, and I didn’t want to pick on whoever said that stuff for AID about the situation in Afghanistan, but that’s an example of taking something away that could have meant tremendous amount to a large number of women in that country. And yet, it was cut for presumably -- who knows why. I mean, I’m not in the back rooms of these discussions. But you can guess any one of a dozen things having to do with negotiations with Karzai, having to do with the proposed negotiation with the Taliban who weren’t going to put up with that kind of stuff, et cetera, et cetera. So it’s a political decision. It’s an economic decision. And I think we’re shortsighted when we take away these sorts of efforts in lieu of something else that we think is politically more expeditious. That’s where the mistake is made. Instead of holding the line -- it’s really, you know, it’s really politics and profits over principle. That’s what happens. So, I’m hopeful that things can be done in a lot of these countries. I think, you know, you’re talking about thousands of years of cultural determinants in many of these countries. So, it will be a tough -- there’s already a decline in the incidence of genital mutilation in many of the countries in which it’s been made illegal, even in Egypt, the place I showed you that has the most right now. So, as laws are imposed and enforced, and as cultural norms hopefully change in the next generations, I think there is hope.

Alona Bachi:

Hi, thanks, first of all. I guess I have two questions. And the first one is more curiosity. I don’t know if it’s something -- but do we have any idea or data about what are the causes or the rate of death due to natural causes if -- so let’s say taking -- you were talking about bad practices versus good practices. And I’m just wondering how much of that is due to abandoning the natural practices which some population needs to have without just really providing the adequate replacement, so good practices.

Douglas Laube:

So, even with the imposition of, quote, good practice, how many of these things would happen anyway? Is that --

Alona Bachi:

Well, no, I mean, there’s some populations where we start, I guess, providing aid or even if it’s through, you know, means of today, Internet and whatnot that populations are exposed to. A lot are abandonment -- abandoning their traditional practices, which I’m assuming might be safer than some of these bad practices that they are adopting versus the --

Douglas Laube:

I see.

Alona Bachi:

Of course, I’m not saying versus the good things that aid can provide, just the kind of half-educated --

Douglas Laube:

I just don’t know. I’m sorry I can’t answer that. I agree that -- well, we see it a little bit in this country or a lot depending on where you sit in reproductive health care because of the criticism of our highly technologic obstetric care system in this country and a return to more natural physiologic childbirth which many who argue that, including me, would reduce some of the bad outcomes. The reason maternal mortality is going up in this country is really hard to ascertain because only six states have required mandatory reporting laws in the first place. And that is determined state by state. So if we could get 50 states to agree on uniform reporting requirements, that would be the first step. The second is the change in the coding system as to what a maternal death is, and there are different definitions relative to, you know, whatever it was that happened, an immediate maternal death versus one 11 months and 364 days later, which still is a maternal death but it may have been in an auto accident. So the reporting needs to be standardized. But there’s no doubt that, in my mind at least, that a lot of the so-called high-tech interventions, particularly the dramatically increased rate of Caesarean delivery, contributes to a lot of this. A Caesarean delivery carries with it a tenfold increase in morbidity over vaginal delivery, across the board -- this country, Sweden, Norway, anywhere else, Brazil, where the rate’s about 90 percent in some cities. So, we sometimes stumble on our own feet. That’s true. I still think, though, for the majority of the world, that providing some of these very basic services -- as I’ve said to some of my friends here at happy hours, you know, the name of the game is moving the 10-cent pill from the manufacturer in China to the woman who’s bleeding to death in Zambia. Moving that simple pill, you know, that direction requires, as you well know, most of you know, how many hurdles to overcome. And, but I still think doing it will make a difference in the long run.

Alona Bachi:

And maybe one more like an observation, but we talk about educating and empowering women in order to try and reduce some of these problems, but I’m looking here at our crowd and we have nine men out of 44, so that’s less than 20 percent men who saw this as important, and kudos to those who did come, saw this as an issue --

Douglas Laube:

Well, three of these guys thought they had to come.

Alona Bachi:



Alona Bachi:

Yeah, so I’m just thinking, you know, maybe in our efforts and education and empowerment, they also have to be targeted towards really men first and foremost in these issues and I mean even --

Douglas Laube:

Well, and a number of their programs are in fact doing -- are bringing men into the equation and trying to educate them as well. That’s a good point. Anything else? Thank you for staying over time. I’m sorry I took a little longer than I was supposed to, so.

Andrew Reynolds:

No, absolutely. Thank you, Doug, again, and I hope you stay in our family. And we wish you well and, of course, to join Suresh Garimella’s comment, your accomplishments have just been so impressive and we’re so glad that you could spend a year with us in Washington. And we hope we continue to work with you.

Douglas Laube:

Thank you.

Andrew Reynolds:

Thank you so much again.

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