Testimony of Lisa Bos
Director of Government Relations, World Vision US
Unique Challenges Women Face in Global Health
House Foreign Affairs Committee
February 5, 2020
Chairman Engel, Ranking Member McCaul, and members of the Committee, thank you for this opportunity to testify before the Committee on the important issue of women’s health. I greatly appreciate your interest in this topic and hope that my testimony today will shed some light on how NGO’s and faith-based organizations like World Vision are prioritizing and improving the health of women and their families around the world.
As one of the largest faith-based organizations working in humanitarian relief and development, World Vision’s work reaches vulnerable children and families in nearly 100 countries around the world. We have more than one million private donors across every state and Congressional district, partner with over 16,000 churches around the country, and work with a wide variety of corporations and foundations in addition to public donors such as the U.S. government. In our work, we seek to ensure every child has the opportunity to reach their full potential, and a healthy start in life is crucial to transforming the lives of children and their families. World Vision is a pro-life organization and we believe life begins at conception. We do not take a position on the Mexico City Policy and have not taken a position on this policy under any Administration.
Given that World Vision is a child-focused organization, much of our work around women’s health is focused on maternal health, ensuring that a woman’s reproductive years are also her healthiest years. In seeking fullness of life for every child, we believe all mothers and their babies deserve to have the basic information, medical support, and care needed to ensure safe deliveries and protection from preventable disease.
At World Vision, we recognize that it is impossible to separate the health of a child from that of his or her mother – a mother’s health is the biggest determinant of an infant’s start in life. Unfortunately, we know that women face additional challenges and risks in pregnancy in the developing world, and when a mother dies in childbirth, her infant has only a 19% chance of surviving his or her first month. A child’s physical and cognitive development and lifetime potential are inextricably linked to their mother’s health as well as their own good health and nutrition from conception through the first years of life.
There have been significant improvements in child and maternal mortality globally, with both decreasing dramatically between 1990 and 2015 – maternal mortality decreased by 44% and child mortality decreased by 58%. The investments of the U.S. government have been essential in this progress, and USAID is a global leader, partnering with governments to meet the health needs of their women and children. In the past ten years, USAID has helped save the lives of more than 9.3 million children and 340,000 women. By helping keep women and children healthy, these efforts of the U.S. government are supporting countries on their pathway to self-reliance.
Still, every day, an estimated 810 women die from preventable, pregnancy-related causes. 94% of maternal deaths occur in developing regions, and 80% of them are preventable. Nearly 2 in every 3 of these maternal deaths occur in countries affected by a humanitarian crisis or fragile conditions. Additionally, for over 800,000 babies each year, their day of birth is also their last day of life, and an additional 1 million newborns die within seven days of their birth. Nearly one third of global under-five deaths are attributed to preterm birth complications and intrapartum-related events – both of which can be addressed in part with better prenatal and pregnancy care for women of reproductive age. It is essential that the U.S. government continues to build on its proven leadership in maternal and child health by investing in evidence-based solutions and exploring innovative ways to better address maternal mortality, and to provide equitable, respectful and quality care to every woman, especially in humanitarian and fragile contexts.
Having access to the right services and messages at the right time can make the difference between life and death for a mother and her child. World Vision has seen success in utilizing Timed and Targeted Counseling (TTC) as an integral part of our development programming. TTC is a family-inclusive behavior change model that targets pregnant women, caregivers, and parents of children up to 2 years of age through appropriately timed household visits. TTC utilizes and trains community health workers in accurate, preventative, and care-seeking information and support, to create demand for services and empower families to improve health outcomes and practices. Information given is timed to when behaviors can best be put into practice and targeted to both those who practice the recommended behaviors and those who influence adoption of the behaviors. Since the approach targets the whole household – husband, in-laws, etc. – it promotes issue awareness, knowledge, behavior change, demand for services, and identification of social barriers, ultimately empowering caregivers and children to keep themselves healthy. For women, TTC means getting the right messages about antenatal care visits, nutrition, and family planning, as well as more specific messages based on other health conditions such as HIV. TTC has been evaluated in several countries as an effective method for behavior change programming. For example, the method contributed to an increase in exclusive breastfeeding from 23% to 48% in India, 26% to 45% in West Bank/Gaza, and 81% to 83% in Ethiopia in 2016.
Community health workers are often best positioned to deliver appropriately timed and targeted messages to encourage specific behaviors and those who influence the decision to adopt those behaviors at the household level. By proactively visiting households, community health workers are better equipped to understand challenges or potential challenges in the household and address health, HIV, and nutrition issues. Community mapping and registers track and inform follow-up of women during pregnancy and antenatal care, including care for HIV and update of family planning services. This is an essential way to reach mothers, particularly during the postpartum period, when follow-on care is necessary for women’s reproductive health. World Vision’s network of more than 220,000 community health workers and volunteers is one of the largest in the world. The U.S. government must continue to invest in frontline health workers and prioritize community-based care to ensure that community health workers are supported and resourced in the hardest to reach areas.
Another key area of women’s health addressed in World Vision programming is through integration of menstrual hygiene management in our water, sanitation and hygiene projects. Menstrual hygiene is vital to the empowerment and well-being of women and girls worldwide. Globally, at least 500 million women and girls lack proper access to menstrual hygiene facilities, and in some cases, poor practices such as menstrual huts can be life-threatening. Menstrual taboos are most often compelled by elder family members, including mothers, grandmothers and other senior women, which is why it is crucial to ensure girls and young women have access to accurate information about reproductive health. Adolescents have unique needs because of the social and cultural pressures as they begin menstruation that threaten their education and ability to contribute to their local economy. Menstrual hygiene management is a key area of women’s health, and the U.S. government must address these interventions not only through its work in the areas of water, sanitation and hygiene, but across relevant sectors like education. World Vision also addresses reproductive health as a vital area of women’s health, recognizing that reproductive health issues can be difficult to discuss in some contexts. It is important to find culturally appropriate ways to discuss sensitive issues which allow for differing beliefs and sound health practices to co-exist. For example, World Vision believes human life begins at conception and we support methods of family planning which are non-abortive. We prioritize family planning by using a messaging approach focused on the healthy timing and spacing of pregnancies (HTSP), which is designed to help women and families plan their pregnancies so that they may have the best opportunity at living a full, healthy life alongside their children. With an emphasis on healthy fertility and achieving healthy pregnancy outcomes, HTSP captures all aspects of voluntary family planning. HTSP also reduces the risk of pre-eclampsia, anemia, premature rupture of membranes, third-trimester bleeding and high blood pressure. By empowering women with the knowledge and resources they need to decide when and how many children they will have over the course of their life, HTSP leads to better outcomes for women, their families, and their communities.
Healthy timing and spacing of pregnancies (HTSP) ensures babies are born during a mother’s healthiest years, and not born too soon or too close together. In many communities, family planning is a difficult topic. Using HTSP messages, women and their partners learn quickly the health benefits of timing and spacing pregnancies and that the goal of family planning is to meet their desired fertility objectives. HTSP and family planning goals for reaching underserved women have been ambitious, but we should be concerned that we are falling short.
Healthy timing and spacing of pregnancies is essential because the age of a mother, the number of children she has, and the timing and spacing of her children are the primary determinants of maternal and infant mortality. Teenage girls ages 10-15 are five times more likely to die from complications during pregnancy or childbirth than girls over the age of 20. In addition to the increased risk for these girls and young women, babies who are born to very young mothers are also at significantly higher risk of dying before their first birthday. In the least developed countries, 41% of girls under 18 are already married.
As young brides, girls are often pressured to become mothers very early, and they also experience social isolation and are at greater risk of mental health issues as a result of moving out of their community to live with their husbands. Children are bearing children, and as a result, complications in pregnancy and childbirth is the leading cause of death for adolescent girls. The U.S. government should ensure girls’ and women’s health interventions, including HTSP and family planning, are widely available and integrated where appropriate into other programming that focuses on the health, economic security and well-being of women. In addition, the U.S. government should expand work to create supportive, open environments that empower women and girls.
The role of the faith community is also vital in order to address cultural values that impact the health of women and the safety of pregnancy and childbirth. We have found that educating and mobilizing local faith leaders to talk to their congregations and communities about what are sometimes viewed as “taboo” women’s health issues, including family planning, HIV, and menstrual hygiene management, can be the most effective catalyst for change. The U.S. government must continue to engage deeply with the faith community to ensure that programs recognize the convening power, reach, and influence of faith-based organizations in the developing world.
World Vision engages faith leaders because most people in the world have a faith of some kind. The Pew Research Center’s Forum on Religion & Public Life reports that 5.8 billion adults and children are affiliated with a religion, 84% of the 2010 world population of 6.9 billion.1 We see this first-hand as a faith-based organization working in nearly than 100 countries. So, faith leaders have considerable influence in their communities. Unfortunately, like other leaders, some faith leaders sometimes spread misinformation, creating social barriers that prevent people from visiting clinics, receiving vaccinations, and using birth spacing methods. Misguided influence can also encourage child marriage and the poor treatment of women and girls and discourage the involvement of men in maternal and child health. Our training process for faith leaders replaces misinformation and stigma with truth and acceptance. Our program teaches about birth spacing and the importance of good nutrition for children and pregnant women, encourages greater involvement of men at all levels (family planning, HIV testing, health visits of mother and child, etc.), and addresses difficult issues such as HIV and gender norms.
I’d like to share an example from a USAID-funded project in which World Vision focused on building an enabling environment through advocacy with Ministries of Health to improve policies and strengthen the health system and service quality by training health workers to counsel and provide contraceptives to women and men. By utilizing TTC to households with pregnant mothers and those with children under two years of age, women were encouraged to discuss healthy timing and spacing of pregnancies with their husbands in India. Within 14 months, there were 67,989 new modern contraceptive users, with an estimated contraceptive prevalence rate of 77% in targeted communities, compared to 21% in other districts. In Haiti, we leveraged several platforms within the community network to integrate family planning into the maternal and child health and nutrition health package or the agriculture and livelihoods program components. By equipping community health promoters and nurses to provide fertility awareness and family planning in prenatal and postnatal visits, make home visits to new family planning users, and follow up with drop-outs, family planning was as integral part of maternal and child health and nutrition programming. This resulted in the total number of contraceptive users rising from 1,900 to 11,500 in just two years.
We have also seen positive results in a similar USAID-funded project that World Vision has been implementing in Garba Tulla, Kenya since 2014. This is an effort to improve voluntary family planning and maternal, newborn, and child health in a remote part of Kenya, primarily through training and mobilizing of community health workers and volunteers. Given that most decisions regarding conception are made by men in this context, it was important to acquire their support from the beginning, thus almost twice as many male community health workers and volunteers were trained in HTSP/FP counseling skills. We also worked closely with a range of community leaders to diffuse messages and facilitate dialogue to reinforce healthy behaviors. This project has reached nearly 25,000 community members with family planning messages. Community leaders, such as male and female religious leaders, teachers, women’s groups, elected officials, and community health volunteers have a considerable influence on societal attitudes and norms. It is imperative that the U.S. government continue to prioritize programming with organizations that engage an array of local leaders to support healthy behavior change that will have a positive impact on the health of women and their communities.
Behind all of these issues, is the need for leadership, funding and data that helps drive decision-making and ensures that we know we are having an impact on women’s health with the limited resources available. We ask the Committee to support the Reach Every Mother and Child Act, which would authorize the position of a Maternal and Child Survival Coordinator. This position, which previously existed at USAID, was critical in ensuring coordination across programs and prioritization of resources toward the highest impact interventions. This leadership is also vital to ensure that USAID stays committed and grows its capacity for data collection. Data around where and how funding is spent on interventions at the country level is lacking in global health, which impacts both the U.S. government and implementing partners in our ability to make informed, data-driven decisions. The Reach Every Mother and Child Act includes vital reporting provisions that would improve data collection and dissemination.
But we also need Congress’ continued commitment to strong funding for programs that impact women’s health. We appreciate that global health programs have strong bipartisan support and that some accounts have seen funding increases, including maternal and child health. But we know we are not meeting growing and increasingly complex needs around the world, particularly with respect to family planning in both humanitarian and development settings.
Improved health for the world’s most vulnerable people is not only a moral imperative but also a pragmatic investment for peace, security, and worldwide economic growth. Thank you to the Committee for this opportunity to testify today and I look forward to our continued discussion on how we can better respond to the health needs of women around the world.