A newsletter from The John D. and Catherine T. MacArthur Foundation

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WINTER  VOLUME 

 President’s Message  India delivers new approaches to women’s health  Sexuality education shows results in Nigeria  Reaching out to rural Population and youth in Mexico  Program Director’s Reproductive Health Message President’s Message Population and reproductive health

espite historically low birth four interconnected components. We government to expand the project from rates in North America and assist international organizations that sus- three training centers to 20. much of the developed world, tain the infrastructure of the field, such MacArthur’s grantmaking also rec- global population is expected as the International Planned Parenthood ognizes the value that nongovernmental Dto increase by more than 40 percent to 9 Federation and the Population Council. organizations can contribute to government billion over the next 50 years. About 1.5 We support organizations that influence programs. In Nigeria, MacArthur grantees billion people between the ages of 10 and policy and resource allocation through are working directly with State Ministries 24 are currently living in the developing targeted advocacy. We fund research — of Education to implement a sexuality world, about to enter their childbearing programmatic, clinical, and social science curriculum in six states (see “Sexuality years. There are more young people in the investigations into key issues of effective- education shows results in Nigeria,” page world today than ever before. The deci- ness and policy. And we support field-level 8). In Mexico, our partners are working sions this generation makes about when programs in India, Mexico, and Nigeria — with a government program called IMSS to start their families, how many children three countries that account for about a Oportunidades to bring information and to have, and how far apart to space their quarter of all women of reproductive age, services to young people in rural Mexico births may determine whether the world’s as well as a quarter of all young people in (see “Reaching out to rural youth in poorest countries can advance toward the developing world. Mexico,” page 11). In both cases, these greater prosperity. In our focus countries, MacArthur’s nongovernmental organizations had the Pressure from this large cohort of grantmaking is designed to help reduce experience and specialized expertise that young people is only part of the demo- maternal mortality and to help educate government agencies needed to improve graphic challenge. Survey data suggest that young people about their reproductive and their work. about 120 million women in the Global sexual health. Reducing maternal mortality At the core of our grantmaking, South would prefer to avoid pregnancy is a worthy goal in itself, but it is also the we believe that proof of what works but are not using contraceptives. For those best indicator that women are receiving the should drive our efforts and help shape who do give birth, their risk of death is reproductive health services they need. the field. To this end, MacArthur has exponentially higher than for women in We believe that when they are, they will begun to invest in research that explores North America or Europe (one out of make sensible reproductive choices that the links between population dynamics every women in Africa will die due are right for them and for their families. and economic well-being. We hope MacArthur 16 Foundation to complications from childbirth, com- MacArthur focuses on educating young that researchers will be able to recom- Population and pared to one in 2,800 in the developed people because the choices they make today mend strategies to help governments take Reproductive Health world). There are more than half a million will help determine the size and well-being advantage of the opportunity that current maternal deaths in the developing world of the world’s population tomorrow. population trends may offer: a “bulge” in each year, most of which could be avoided We believe that by concentrating the number of people just entering their with even the most basic maternal health MacArthur’s limited resources on two most productive years, known as “the services and care. critical issues in three key countries, we demographic dividend.” Researchers note The MacArthur Foundation has can learn and demonstrate how a mix of that fewer births in developing countries been active in the field of population and civil society advocacy and action can be increase the proportion of adults able to reproductive health since 1986. During combined with sensible government policy contribute to the economy without the two decades in the field, MacArthur has to help take good work to scale. In order burden of additional dependents. The awarded $215 million to almost 1,000 to expand care and services to women and investment dollars freed up as a conse- organizations and individuals. young people, MacArthur is supporting quence of lower fertility may be able to be From the beginning, our approach carefully selected model projects in each of used to strengthen economic development has emphasized the importance of repro- our focus countries and providing assistance and social well-being. Evidence from East ductive rights and health. Since the 1994 to help scale them up where warranted. Asia suggests that as much as one-third of International Conference on Population For example, several MacArthur its growth in the 1990s may have been the and Development (ICPD) in Cairo, these grantees in India have developed training result of such dividends. Can this success issues have become central to poverty programs to expand the pool of health be replicated? Research MacArthur is sup- reduction and health care. In the early workers able to provide obstetric care to porting aims to provide an answer. years of MacArthur’s program, we offered India’s vast rural populations (see “India We realize that MacArthur’s contribu- support to individuals with strong lead- delivers new approaches to women’s tion to the field is small compared to the ership potential through the Fund for health,” page 3). Because of the promise challenges we face. But we hope this news- Leadership Development [see article on of one such effort by the Federation of letter illustrates how our current strategies page 14 of this newsletter]. MacArthur’s OB-GYN Societies of India (FOGSI), the take advantage of the best of research and investments in these leaders contributed to Indian government has asked them to adapt practice to develop approaches and policies the paradigm shift reflected in the ICPD’s their training programs for use country- that contribute to improving the health and “Programme of Action,” which was wide. Indeed, $450,000 from MacArthur well-being of the world’s population. endorsed by 179 countries. to train general medical practitioners in Today, MacArthur’s Population emergency obstetric care has stimulated an Jonathan F. Fanton and Reproductive Health program has additional $4.75 million from the Indian President

2 | MacArthur/Winter ’07 Training maternal caregivers: India delivers new approaches to women’s health

Above: A group of mothers in India n organization that combines the philosophy of listens to a presen- tation on health. Mahatma Gandhi with the science of modern Cover: Nigerian stu- dents wait outside of their school. Nigeria medicine did what many considered impossible is one of three coun- tries that are the focus of MacArthur’s A population and — dramatically reduced newborn deaths and improved reproductive health grantmaking. women’s health in one of India’s most impoverished regions. Founders Abhay and Rani Bang, physicians committed to working with India’s poor, demonstrated how in a region where 95 percent of all births take place at home, often hundreds of miles from a hospital, it was possible to reduce newborn death by 70 percent, complications from preg- nancy and delivery by nearly 75 percent, and the need for

MacArthur/Winter ’07 | 3 Right: SEARCH trains health care workers, like the woman on the left in the photo, who visit women at home during their pregnancies. They also assist during delivery and make post-partum visits.

emergency obstetric care by more than the global maternal death toll. And for structure is a long-term process, and percent. They accomplished this by every maternal death in India, there are in the interim the government is looking MacArthur 30 Foundation training teams of women in rural vil- 10 newborn deaths — a total of 1.1 mil- for other ways to expand services and Population and lages — many of them illiterate and oth- lion, or one-quarter of all newborn deaths improve care. Reproductive Health ers with only a few years of education worldwide. “Delivering health services in India, — to provide home-based mother and Most of these deaths occur because especially in the rural areas, is a chal- newborn health care ranging from basic the women do not have access to ade- lenge the government cannot tackle on hygiene to treatment of pneumonia and quate medical care. In fact, nearly 50 its own,” says V. K. Manchanda, deputy infant resuscitation. percent of women in India deliver at director general of maternal and child “Most doctors tend to work in hospi- home with untrained birth attendants, health for India’s Ministry of Health tals in cities, so we don’t see the women which dramatically raises the risk of death and Family Welfare. “Many nongovern- and babies who are sick and die because for both mother and child. Recognizing mental organizations have the expertise they don’t make it to the hospital,” says this challenge, the Indian government and reach at the local level we need to Abhay Bang, who with his wife Rani has committed to increasing the number develop effective strategies.” The govern- founded Society for Education, Action of hospitals and clinics, especially in rural ment is now partnering with a number and Research in Community Health areas. However, building up the infra- of MacArthur grantees to expand services (SEARCH) in Gadchiroli in the central Indian state of Maharashtra. “The stan- dard recommendation to a woman who needs medical attention is, ‘Go to the hospital’ — but in rural parts of India Research to reduce maternal mortality there are so few doctors that this is like In addition to support for model pro- The Guttmacher Institute and telling her, ‘Do nothing.’ We decided grams, MacArthur funds research to the Campaign Against Unwanted to follow Gandhi’s message to go to the help reduce maternal mortality in its Pregnancy villages. Instead of waiting for people to focus countries of India, Mexico, and Two grants totaling $640,000 for come to us, we found a way to take the Nigeria. The following are examples of research on the causes and conse- care to the people.” support for research. quences of unwanted pregnancy and induced abortion in Nigeria. Massachusetts Institute of Technology, Leveraging change Poverty Action Lab Asesoría, Capacitación y Atención In India, more than 100,000 women die $165,000 to provide research assistance en Salud each year due to complications of preg- to a local Indian organization, Seva $180,000 to study the availability and nancy and childbirth, most within 24 Mandir, to introduce and test the value accessibility of maternal health services hours of delivery — nearly 20 percent of of a voucher system for paying birth for an area of the state of Chiapas with attendants during deliveries in the state one of the highest maternal mortality of Rajasthan. ratios in Mexico.

4 | MacArthur/Winter ’07 Replacing hope with strategy Scaling up model programs

hen a maternal health or educators — and they don’t taking concrete steps to garner SEARCH (see feature article Wprogram is success- necessarily have the political their attention. page 3). Dr. Abhay Bang of ful on a small scale, women’s or advocacy skills to persuade With funding from the SEARCH said, “We know that lives are saved. Then the obvi- government agencies to adopt MacArthur Foundation, MSI the problems here are not ous next question is — how their programs and replicate is working with reproductive unique to this region in India, can the model be expanded to them on a large scale.” health and sexuality educa- and we want to see how this save the lives of many more Governments must almost tion groups in India, Nigeria, work can be replicated in other women or reach millions of always be engaged, Kohl says, and Mexico to help them places.” people throughout a country? because they are often the think strategically about Scaling up is a very time “People working in wom- only entities with a health scaling up and to provide intensive process that can take en’s health organizations are care delivery system that hands-on training in scale-up years, says Kohl. “It can be dif- among the most dedicated operates at large scale and methodology. MSI’s process ficult for people who have and self-sacrificing people has the potential to fund such for managing the scaling up envisioned the model and nur- in the world,” says Richard programs; even the wealthiest process ranges from step one, tured it for years to see it Kohl of Management Systems donor organization can’t create a vision; to step five, grow up — it’s like letting go International (MSI), which sustain long-term a health pro- legitimize change; to step 10, of a child. We act as facilita- works with nongovernmental gram in countries with millions track performance and main- tors, but 90 percent of the organizations (NGOs) to scale of people. But often NGOs tain momentum. (The MSI work is in their hands.” up their model programs. “They simply focus on improving handbook can be found online are great at what they do, but their model programs, hoping at: www.msiworldwide.com.) they are usually specialists that government will notice One of the organizations — doctors or nurse-midwives their good work without MSI is collaborating with is

and develop new policies to improve pre-natal, post-natal, and emergency obstetric care.

Simple, effective solutions When SEARCH was founded, the Indian government’s reproductive heath program was heavily focused on family planning. But the Bangs soon learned that women needed much more than contraception. Their discovery that 92 percent of women in Gadchiroli suffered from gynecological diseases led to their first published article in The Lancet (1989) and contributed to a sea change in global population policy — from a focus on reproduction to the broader perspective of women’s health worldwide. The Bangs recognized that many maternal and infant health problems, including complications from childbirth and newborn death, could be addressed with better hygiene, improved diet, basic health education, early treatment of common infections, and other relatively simple interventions. They believed that these services could be offered by dais, traditional village birth attendants — older women who help women giving birth in their homes. The dais, who are illiterate Women wait outside and often have little status in the com- of the SEARCH clinic munity, were honored to be approached in Gadchiroli. by physicians seeking to learn from them

MacArthur/Winter ’07 | 5 Reproductive rights as human rights Public interest litigation used to prevent child marriage in India

lthough Indian law for- an indentured servant in her international law, including been quite pleased to see that Abids the marriage of girls husband’s home,” says Colin the Universal Declaration of it has already had quite an younger than 18 and boys Gonsalves, a senior advocate Human Rights, the Convention effect on this barbaric prac- younger than 21, mass mar- and executive director of on the Elimination of All Forms tice,” Gonsalves says. “In just riages of children are wide- the Socio-Legal Information of Discrimination Against a few months, we’ve seen a spread and often ignored by Center, a MacArthur grantee. Women, and the Convention remarkable decline in child authorities. Fifty-seven percent He says that child marriage on the Rights of the Child. marriages.” of Indian women are married not only puts young girls at In February 2006, in In collaboration with before they turn 18; some are risk because of early sexual response to a petition filed women’s rights organizations, as young as seven. These early activity, pregnancy, and by the Socio-Legal Information the center collected evidence marriages often are motivated childbearing, but it also robs Center, the Indian Supreme of child marriages and used it by economic reasons (e.g., them of the opportunity to Court made a landmark ruling to petition the Indian Supreme securing a dowry or reliev- go to school and have normal that all marriages must be Court to help end the practice. ing a family of an additional friendships with peers. At registered. Individuals who The center argued that the dependent) or by a desire the national level, child mar- perform weddings and officials court should direct the govern- to strengthen relationships riage contributes to high and policemen who participate ment to make the registration between families and com- rates of maternal and child in and encourage child wed- of all marriages compulsory by munities. mortality and is a source of dings now will face prosecution. district government officials “When a girl gets mar- extreme and persistent pov- “Although the Supreme Court and requested an order to ried, she basically becomes erty. It also is a breach of ruling is only a first step, we’ve make local government offi-

and eager to acquire new skills, Abhay says. The women were trained to prevent MacArthur Foundation and treat the most common causes of Population and infant death, including malnutrition and Reproductive Health pneumonia. They were each given simple tools, including a tiny sleeping bag to treat hypothermia and an abacus for counting infant heartbeats. One dai in a woman’s home made a great difference (infant mortality in the study area was reduced by 50 percent) but the Bangs soon found that there was an advantage to having a team of two women assisting the mother. “At the moment of delivery, with the mother standing in a dark and ill-equipped room, there are two emergencies: first the woman giving birth and bleeding and second the baby not yet breathing. If everything is normal, it might be fine, but if there is a complication for the mother and the baby is left even 10 seconds without breathing, then there is a crisis.” So SEARCH began to train another level of caregiver — a younger mar- Above: Improving the ried woman, usually with five to eight clinical skills of health years of school and children of her own. professionals is a key component of the Because they were literate, these health MacArthur program. workers could keep records, follow guidelines, and become a hands-on partner to the dai at the delivery. These local community health workers also

6 | MacArthur/Winter ’07 cials and police accountable sured the Mexican government legal actions are based on the for child marriages within their to admit it had violated the constitution, with international For more information jurisdiction. human rights of a 13-year-old covenants used to buttress and The center is one of a rape victim by denying her add strength to our arguments. Center for Reproductive Rights www.crlp.org number of MacArthur grantees access to a legal abortion. As “We can’t immediately using the strength of interna- a result of the ruling, the gov- reverse practices that are centu- Information Group on Reproductive tional human rights covenants ernment compensated the girl ries old, but even a small band Choice (Grupo de Información en and treaties to promote repro- and called for new guidelines of people operating within the Reproducción Elegida) ductive rights. Earlier this to facilitate access to legal international legal system can www.gire.org.mx year, women’s rights advo- abortion. have a direct impact on millions Women’s Aid Collective cates in Mexico celebrated “Fortunately, India is a of people.” www.wacolnigeria.org a landmark decision by the country that is friendly to Inter-American Commission on international law, where Human Rights that recognized international covenants access to legal abortion as a are automatically enforce- human right. Two MacArthur able unless they are in direct grant recipients, the Center contrast to Indian statues,” for Reproductive Rights and Gonsalves says. “Also, our the Information Group on constitution is very vibrant, Reproductive Choice, pres- and most of our network’s

visited women during their pregnan- impact of home-based care on reducing In 2003, Dr. Sadhana Desai, then cies and made several post-partum visits maternal death over the past 15 years. Its president of the Federation of Obstetrics to assist with breastfeeding, recognize approach and methodology have inspired and Gynecological Societies of India complications, and support the mother similar home-care projects in Bangladesh, (FOGSI), which represents 21,000 in newborn care. “With two attendants Pakistan, Nepal, and parts of Africa. obstetricians and gynecologists, decided at the delivery there is a kind of semi- SEARCH’s successes have also earned to do something about the shortage skilled division of labor — the village them a MacArthur Award for Creative of emergency obstetric care in rural India. version of what you might find in a hos- and Effective Institutions, which rec- Every year, the organization chooses a pital in the city,” Abhay says. ognizes and rewards the innovation of major health challenge, and all members Documenting yet another 20 percent nimble organizations. work together to address it. “That year drop in infant mortality by using the SEARCH’s effectiveness in I chose maternal mortality, because team approach, the Bangs found evidence improving life for mothers and infants rates are very high in India, and it’s our that home care also markedly reduced in a region with some of the harshest responsibility as gynecologists and maternal morbidity — including lower health indicators has impressed the Indian obstetricians to take steps toward reducing rates of hemorrhage, anemia, and other government, which is now providing them,” Desai says. “There are only 700 problems. SEARCH is now studying the support for pilot studies of home-based government obstetricians in rural India but care in six additional Indian states. there are more than 20,000 government nonspecialist physicians. So the idea was to Emergency intervention train the nonspecialist doctors to provide For more information While frontline care can prevent and emergency obstetric care.” address many common reproductive With support from the Foundation, Society for Education, Action & Research in Community Health (SEARCH) health problems, many women still require FOGSI set up three pilot project training www.searchgadchiroli.org emergency intervention ranging from centers — in Gujarat, Uttar Pradesh,

FOGSI caesarian surgery to blood transfusions. and Rajasthan — with each offering a www.fogsi.org One reason the maternal mortality rate in two-week course of basic emergency India remains stubbornly high is that skills and a 16-week course of WRAI www.whiteribbonalliance-india.org women in rural India have little or no comprehensive emergency skills. access to emergency obstetric care. There At the end of the two-year pilot project, Pathfinder International www.pathfind.org are only two to four obstetricians or the three centers had trained a total gynecologists in most districts of more than 100 doctors from rural or Society for Gynecology and encompassing large populations, and most underserved areas to provide emergency Obstetrics Nigeria www.sogon.org general practitioners in India do not obstetric care. provide even basic emergency care. (continued on back page) Grupo de Estudios Sobre la Mujer Rosario Castellanos www.casamujer.org MacArthur/Winter ’07 | 7 Nigeria’s sexuality education projects are designed to help young teens protect themselves against HIV/AIDS and other sexually transmitted diseases.

MacArthur Foundation Population and Reproductive Health Sexuality education shows results in Nigeria

he results of a 2003 survey of in Nigeria,” says Adenike Eseit, a founder more awareness and knowledge will 2,466 secondary school stu- of Action Health Incorporated (AHI), one increase the likelihood that young dents in Lagos were alarming. of Nigeria’s leading reproductive health people will make wise choices about Many believed that HIV can’t organizations. “The survey showed that their sexual activities. Tbe contracted from someone you know students lacked even the most basic infor- In 2005 a follow-up survey showed very well, that a 10-year-old girl can’t get mation about their bodies and how to that the program was yielding posi- pregnant, and that abstinence is for weak protect themselves. But at the time there tive results. Students who had been people. Only 15 percent of sexually active was nothing in the schools about the real taught from the curriculum had sig- students reported they used protection life challenges young people face regarding nificantly increased their knowledge and every time they had sex. sexuality.” shown positive changes in attitudes. For The baseline survey was conducted The new curriculum, implemented example, 81 percent of students now by the Lagos State Ministry of Education in the social studies and integrated agreed that people their age should wait in preparation for implementing a new science classes of 304 public Junior until they are older before they have sex, sexuality education curriculum in Lagos Secondary Schools in Lagos, focuses up from 68 percent two years earlier. schools. “The results were cause for con- on adolescent reproductive health — “Among the most encouraging trends cern because we know that young people going beyond traditional sex education is that the program is changing the way between ages 15 and 24 account for the to encompass such issues as self-esteem, boys and girls interact,” says Eseit. “Girls majority of unwanted pregnancies, sexu- girls’ assertiveness, and aspects of said the curriculum is positively influ- ally transmitted diseases, and HIV/AIDS good relationships. The goal is that encing boys’ behavior toward them. Both

8 | MacArthur/Winter ’07 Building a base of evidence Research promotes political will for maternal health

educing maternal death a higher political priority in each year from complications evidence of a significant Rhas recently taken on Nigeria. of pregnancy and childbirth. problem to a united network greater urgency in Nigeria. “Maternal mortality ought Another 15 million suffer life- of advocates who have iden- While attending a retreat on to attract a lot of attention threatening disabilities. tified a clear set of national maternal and infant death earli- because it is such an enor- Why are rates of maternal policy priorities. er this year, Nigerian President mous tragedy worldwide,” mortality not decreasing? With Foundation funds, Olusegun Obasanjo was says Jeremy Shiffman, a At a London meeting in 2004 Shiffman and his co-authors alarmed by what he heard: that political scientist and public to mark the tenth anniver- completed national-level Nigeria has the world’s second health researcher at Syracuse sary of the International studies in India and Nigeria. In highest number of maternal University who used a Conference on Population India, which has the highest deaths, with nearly 55,000 Foundation grant to co-author Development, political will total number of maternal women dying each year from The State of Political Priority was cited as the missing deaths in the world, political preventable pregnancy-related for Safe Motherhood in ingredient in global reduction will to reduce maternal mor- complications. Nigeria with Okonofua. “But of maternal deaths. Compared tality was deemed moderate Upon hearing these political leaders are burdened to other health concerns, — but it recently has been on disheartening numbers, with thousands of issues, mul- maternal mortality reduction an upswing (see story, page 3). Obasanjo immediately turned tiple political pressures, and is given low priority on gov- And in Nigeria, where political to a maternal mortality expert limited resources. To change ernment health agendas or is will was deemed low, “there is in the room, Friday Okonofua, that, we need to see maternal missing altogether. a real window of opportunity and asked, “What can we mortality not just as a moral “There is a real dearth of for change,” Shiffman says, do?” Okonofua, a professor and a medical issue but as research on how to ensure citing the country’s 1999 tran- of gynecology and obstetrics a political issue — one that that political leaders pay sition to democracy, the recent at the University of Benin requires good research that attention to safe motherhood increased interest of President College of Medical Sciences, allows advocates to be stra- and do something about it,” Obasanjo, evidence at the had recently co-authored a tegic in affecting policy.” says Shiffman. Using a pro- national level of the extent of report on increasing political Reducing maternal mor- cess of intensive interviews, the problem, growing numbers will for reducing maternal tality and morbidity emerged document analysis, and of individuals in the safe moth- mortality in Nigeria, and the as a global priority two direct observation, he and erhood policy community, president’s query meant the decades ago, yet levels of his co-authors assessed the and international pressure to issue had captured attention maternal death have not strength of political will for reach Millennium Development at the highest level of gov- declined significantly in the reducing maternal mortality Goals by 2015. ernment. A few weeks later, developing world. Although in Honduras, Guatemala, “There are good reasons to Obasanjo named Okonofua knowledge of medical and Indonesia, India, and Nigeria. be optimistic about Nigeria,” his Honorary Advisor on public health interventions They also identified the key says Shiffman, “if we can take Maternal and Child Health — is substantial, and most factors that must be available advantage of this critical a move that offers hope that maternal deaths are prevent- in a country to generate polit- moment.” maternal health is becoming able, half a million women die ical will, ranging from credible

boys and girls showed a better under- “The new curriculum is an effective says Hajiya Mairo Bello, director of the standing of a girl’s right to refuse sex. And step in this direction — and now our task Adolescent Health and Information Project students reported learning new skills in is to continue to improve this program (AHIP), a MacArthur grantee and a pio- negotiation and friendship.” and to reach as many youth as possible.” neering NGO working with young people. AHI provided leadership in devel- “Due to controversies related to adolescent oping the curriculum and advocating for Confronting cultural realities sexuality and the general lack of knowledge, its adoption nationally — a move that Research conducted by the World Health very few organizations in Northern Nigeria set Nigeria far ahead of most countries Organization in 1993 found that sexual- have adequate reproductive health care ser- in the world. Lagos is the first state to ity education delays the onset of sexual vices for adolescents.” launch a full-scale implementation of the activity and increases safer sexual practices In northern Nigeria, half of all women curriculum in the school system. Now a by those already sexually active. Yet in become mothers by age 16, and the number of nonprofits are working closely Nigeria, as in many parts of the world, average woman gives birth to more than with state-level ministries of education in sexuality education often meets strong six children. “The situation is sustained six states to train teachers and adapt the opposition on grounds of religion or tradi- by practices such as early teenage mar- course to local contexts. tion and culture. riage, polygamy, and limited education for “We’re committed to helping our “In Northern Nigeria, and in Kano in girls,” Bello says. “In societies like those young people lead a better and healthier particular (with its predominantly Muslim in northern Nigeria where early marriage life,” said Professor Kunle Lawal, the population), sexuality and reproduc- is the norm, adolescent girls are often commissioner of education for Lagos State. tive health education is frowned upon,” withdrawn from school in order to get

MacArthur/Winter ’07 | 9 Below: MacArthur grantee AHIP women’s basketball team in Northern Nigeria. married, and girls who become pregnant support for the project, developing a are expelled from school.” teacher’s manual and student textbook AHIP has long worked with young tailored to the local environment, people in and out of schools through a training teachers, and monitoring and youth center, a peer sexuality program, evaluating the program. and extensive sports programs for boys AHIP has forged partnerships with and girls. It provides mentoring and religious, traditional, and government training to other youth-oriented orga- leaders. The organization has the support nizations throughout Northern Nigeria of the Emir of Kano, and his son, also a seeking to replicate the success of its traditional ruler, is the chair of the AHIP activities. Now, with funding from board. “Over the years, we’ve survived MacArthur, AHIP is working with the serious challenges to our work,” says State Ministry of Education to imple- Bello. “Fortunately, AHIP is gifted with ment the national sexuality curriculum a tenacious belief in protecting and pre- in 50 secondary schools in Kano. Its serving a prosperous and healthy future for efforts will include building additional young people.”

Low Tech; High Impact Using the anti-shock garment to save lives

MacArthur Foundation y the time the 29 year- ties and forces it back to the using standard methods, and Jonathan Fanton, President of old woman arrived at heart, lungs, and brain to the use of the garment saved the MacArthur Foundation. “It Population and B Reproductive the emergency room of the counteract the shock. more lives. could be a very simple solu- Health University College Hospital The results are immediate In Nigeria, the study is tion to a seemingly intractable in Ibadan, Nigeria, she was and dramatic. A few minutes focusing not only on hospital problem.” unconscious. She had no blood after the suit was applied use but also on rural health Rigorous studies like those pressure or pulse. Five days to Ojengbede’s patient, she care stations, where the suit underwritten by MacArthur are earlier, she had given birth, began to revive. Summoned is being tested as a first aid critical to convincing the med- and now she was dying from to her bedside, her relatives tool until women can be trans- ical establishment and gaining profuse post-partum bleed- watched in amazement as the ported to better-equipped the imprimatur of global ing. The family members who woman raised her hand and treatment facilities. health organizations, says accompanied her began the rit- asked where she was. The garment’s success Suellen Miller, a professor of uals of mourning. “They were “You can imagine their is having a ripple effect, public health at the University crying, falling to the floor, sheer joy,” says Ojengbede. Ojengbede says. “Once word of California-San Francisco tearing at their garments,” “The relatives nicknamed her gets back to a village that a who directs Women’s Global recalls emergency obstetrician ‘Ayorunbo’ for ‘the person woman has survived, more Health Imperative’s Safe Dr. Oladosu Ojengbede. who has gone to heaven and families are willing to seek Motherhood Programs and But Ojengbede and his returned.’” treatment for obstetrical hem- coordinates the anti-shock gar- staff had been trained in the Ojengbede has seen or orrhaging.” ment study. “Once it’s deemed use of the anti-shock garment heard many similar stories Because the early results an essential device, donor (also known as Life Wrap). since the anti-shock garment proved so promising, MacArthur agencies such as UNICEF and Originally developed for battle- was introduced in Nigeria has invested $400,000 to USAID will be willing to pay field use, the device has the as part of a MacArthur- expand the study in Egypt for it,” Miller explains. potential to save lives and funded study carried out by in an effort to yield statisti- More than 500,000 maternal protect hundreds of thousands the Women’s Global Health cally significant evidence of deaths occur worldwide annu- of women from the effects of Imperative at the University of the suit’s effectiveness. If ally, mostly in developing post-partum hemorrhage. California-San Francisco and the study provides scientific countries. Of these deaths, Made of lightweight neo- the University of Ibadan. Pilot proof that the garment works, 30 percent — the largest single prene, the garment resembles studies took place in Egypt, MacArthur has plans to sup- percentage — are due to the bottom part of a wetsuit. where the garment was used port scaled up use of the suit obstetrical hemorrhaging. “For It can be manufactured inex- to keep women alive in busy to the point where govern- years, health care workers pensively and is reusable up to urban hospitals while they ment agencies can incorporate have had to stand by help- 100 times. When the suit’s five waited up to 36 hours for a it into standard health care. lessly and watch these women Velcro closures are tightened blood transfusion. Early results “We believe the anti-shock die of something that’s almost around the patient’s body, the indicated that those treated garment holds great potential entirely preventable,” says compression stops blood from with the garment lost half as to save tens of thousands Ojengbede. “Now, there’s flowing to the lower extremi- much blood as those treated of lives each year,” says hope.”

10 | MacArthur/Winter ’07 One of the biggest challenges facing young people in Mexico is early pregnancy and its complications, including high school drop-out rates and increased poverty.

Research to advance young people’s sexual and reproductive health & rights Reaching out to In addition to support for model pro- grams, MacArthur funds research to help advance the sexual and reproductive health and rights of young people in its rural youth in Mexico focus countries of India, Mexico, and Nigeria. The following are examples of support for research.

International Institute for Population Sciences $600,000 to investigate the sexual and exico, the second most indigenous Mexican communities, mar- reproductive health, behaviors and needs populous country in Latin riages and births are common even much of youth in six Indian states in collabora- tion with the Population Council. America, has experienced younger. Yet youth in remote areas are the a youth boom. Nearly least likely of anyone in Mexico to have Sangath M32 million people between the ages of access to reliable information and resources $225,000 to develop, implement and 10 and 24 live in Mexico, the youngest regarding reproductive health. evaluate a population-based, integrated demographic in the history of the country. In 1998, IMSS Oportunidades, a model for improving young people’s “These young people will have a huge Mexican government health provider of sexual and reproductive health in an effect on the future social and economic reproductive and sexual health services urban and rural setting in the Indian state of Goa. development of our country,” says Norma working in 17 states, created a special pro- Barreiro, director of Thais Desarrollo gram for rural adolescents. With its 3,500 International Women’s Health Coalition Social, a leading NGO that works with rural health centers throughout Mexico, and Action Health Incorporated young people on issues related to sexual IMSS Oportunidades has the potential Two grants totaling $825,000 for a lon- and reproductive health. “We must do to reach 2.4 million indigenous young gitudinal study on the implementation everything we can to seize this opportunity people in Mexico. Yet lack of resources, and outcomes of a sexuality education curriculum in public junior secondary to invest in their health and well-being.” health staff stretched thin from serving schools in Lagos State, Nigeria. One of the most serious challenges large numbers of people, and entrenched facing young people in Mexico is early adult attitudes toward adolescents and Investigación en Salud y Demografía pregnancy and its consequences, including sexuality have prevented the government’s Two grants totaling $367,500 for a maternal morbidity and mortality, school youth outreach program from fulfilling quasi-experimental longitudinal survey drop-out, reduced income, and migration its potential. on young people in the Mexican state to northern states or the U.S. The average To jumpstart efforts to reach of Oaxaca, intended to both increase knowledge of the attitudes and behaviors person in Mexico marries at age 19, and youth in the poorest and most mar- of rural youth and assess the impact 15 percent of births are to teens between ginalized rural municipalities in of an intervention being carried out by the ages of 15 and 19. In many rural and Mexico, IMSS Oportunidades has a local organization, Mexfam.

MacArthur/Winter ’07 | 11 Fundar Using budget analysis to improve maternal health

educing maternal mortal- language of power”: numbers. tion with Fundar and jointly resulted in greater transpar- Rity is a moral issue, says “You can’t ignore numbers,” compare and analyze needs, ency in decentralized health Helena Hofbauer, executive Hofbauer says. “Especially allocations and expenditures. funds, which for the first time director of Fundar: Center when it’s numbers that the The researchers often find a were specifically earmarked for for Analysis and Research, a government itself produces.” considerable gap between women’s reproductive health democracy building organiza- Before Fundar’s involve- budget allocation and what at the state level. “This was a tion in Mexico that analyzes ment, there was little, if any, is actually delivered — or, as major victory,” says Hofbauer. information relating to govern- connection between the gov- Hofbauer puts it, “between “Never before had anyone ment programs, policies and ernment’s stated objectives numbers and rhetoric.” scrutinized the health budget budgets to influence public in the area of maternal health “We’ve identified, for to determine whether funds policy. But since 2002, with and actual public spending. instance, that clinics that were being allocated for and support from the Foundation, Fundar follows the money should be operating around actually spent on the most Fundar has been using objec- — scrutinizing vast amounts of the clock are only open needy, especially poor, rural tive budget analysis to bring budget-related data generated some days for a few hours, women in Chiapas, Oaxaca accountability and transpar- by the Mexican Congress and that women have to pay and Guerrero states. Women’s ency to Mexico’s publicly the Ministry of Health. Partner for services that should be reproductive health historically financed maternal health ser- researchers in three states free,” says Hofbauer. In 2002, has been overlooked, and the vices. Fundar’s work has undertake the complicated researchers undertook the 2002 study helped to make it a shown that it is possible to tasks of deciphering state- task of combing through the higher priority.” galvanize support by dispens- level budgets and monitoring details of the country’s health More recently, evidence ing with emotion and ideol- local level implementation of budget to identify spending amassed by Fundar helped ogy and framing the issue maternal health programs. that should be earmarked for support a March 2005 deci- in what Hofbauer calls “the They share this informa- maternal health. Their efforts sion by the Ministry of Health

joined forces with organizations that are experts in engaging youth. With support MacArthur Foundation from the MacArthur Foundation, these Population and organizations are improving both the Reproductive Health supply of reproductive health services and the demand among young people. Thais Desarrollo Social, for example, works directly with rural young people to attract them to reproductive and sexual health services in government clinics. Another organization, Afluentes, trains health care workers to provide services in a way that is sensitive and appealing to young people. “The government can’t do this work without local organizations, and local organizations can’t do this work without government,” says Celia Escandon, an official with IMSS Oportunidades who was instrumental in establishing one of the partnerships. “Imagine trying to reach people of 57 ethnic groups, speaking about 40 languages and dialects — with dif- ferent cultures in Oaxaca than in Chiapas, Nayarit, Durango, or Chihuahua. Our staff works hard but they don’t have the spe- cialists that nongovernmental organizations have to connect with young people in remote places. Only through collaboration is our work effective.” Students from Thais Desarrollo Social is working to Jomanichim, an identify and train a corps of high school indigenous Tseltal “youth promoters” in rural communities area in Chiapas. to lead activities and peer discussions about dating, sexuality, and life choices. Local

12 | MacArthur/Winter ’07 to incorporate coverage for for a wide range of maternal Fundar received the MacArthur rates, and Chiapas — the hemorrhage, preeclampsia health stakeholders: policy- Award for Creative and poorest state in Mexico — had and puerperal infection into makers, legislators, NGOs, Effective Institutions in 2006. one of the highest. “The reality Popular Insurance, the gov- health service providers, and With a new government is that states with the fewest ernment health insurance families who have lost wives, taking office in Mexico in resources get less funding,” program designed to cover mothers, and sisters. “Numbers December, Fundar’s vigilance says Hofbauer. some 52 million uninsured can be a very confrontational and advocacy will be even Fundar is also exporting its people. Obstetric emergen- strategy, but they also can be more important, Hofbauer expertise to the World Health cies occur in approximately conciliatory,” Hofbauer says. says. “Historically in Mexico, Organization and NGOs in 15 percent of all pregnan- “When we were working on new governments mean Latin America, Asia, Africa, and cies, including those that emergency obstetric care, we new programs. We’ll need the United States. “Budget were expected to be normal; said to the Health Ministry, to keep reinforcing the ben- analysis as a tool for reducing so while standard prenatal ‘We know you want to do the efits of what we’re fighting maternal mortality has great screening for risk is impor- right thing, we know your for.” Equitable distribution of potential, although it’s expen- tant, it must be accompanied budget is constrained — let Popular Insurance funds is of sive to build up a capacity by a system prepared for us help you make that argu- particular concern: past Fundar devoted to research,” the unexpected — which ment to Congress.’ We still research showed that govern- Hofbauer says. “But once you requires training, medica- need to broaden the existing ment funding for maternal get there, you can have one tion, infrastructure, and infrastructure to offer services services was four times higher success after another.” round-the-clock services. at all levels. But with emer- per capita in Nuevo León than The objectivity and accessi- gency obstetric care in place, in Chiapas — even though bility of Fundar’s research have women won’t die.” Because of Nuevo León had one of the helped create common ground their precedent-setting efforts, lowest maternal mortality

teens who have demonstrated leadership and I enjoy being around people,” says they really participate,” he says. “It’s not in their communities are trained to Juventino. “My parents said, ‘Go ahead — like a teacher telling you something — it’s lead health programs and youth services, you can be a leader. Learn as much as you more like friend to friend. The others have often in the indigenous language of can.’” Since then, Juventino has planned learned from me, but really I’ve learned their community. events and invited friends and school- just as much from them.” Seventeen-year-old Juventino Teran mates to drop in at the Center for Rural “These young people stand out, even Lucero is a youth promoter in Huehuetlan, Adolescents, a youth-oriented space within though for cultural reasons some of them a small village about a six hour bus ride the local health center, where at least twice are quiet and shy at first,” says Norma from the closest city in the state of San a week games and dialogues encourage Barreiro, director of Thais. “They quickly Luis Potosí. Last year he attended a Thais- learning about staying healthy, preventing become naturals at building community, run, three-day training session with 30 unplanned pregnancies, and reaching life listening to adults and peers in an open- other young people from the region. “I’m goals. He has also trained five other stu- minded way, and understanding what it a youth promoter because I’m very active, dents as leaders. “Everyone loves it and means to have rights to information and to

Population dynamics and economic well-being

The Foundation is supporting work that International Center for Research of developing country scholars with examines the link between population on Women relevant knowledge and skills. dynamics and economic well-being. Much $113,000 to investigate the role of policies of this work focuses on efforts to better relating to women’s education, employ- University of Texas, Austin understand the potential of the demo- ment, political participation, and health $250,000 to examine variations in the link graphic dividend, a theory that asserts that and well-being in mediating the links between age structure and labor markets changes in population age structure can between age structure and economic out- in Brazil and Mexico. be advantageous for economic growth. comes. The goal is to build a base of evidence to Yale University and the University of evaluate the validity of the theory. United Nations Population Fund (UNFPA) Chicago $250,000 to build UNFPA country-level Two grants totaling $107,000 to evaluate George Washington University staff capacity to understand and utilize in the impact of interventions on women’s Two grants totaling $150,000 to examine their work the links between population, reproductive health, economic well-being, the link between fertility and poor wom- reproductive health, and poverty. and children’s education and health en’s economic well-being in Mexico. development in Bangladesh. University of Hawai’i, East-West Center Harvard University $380,000 for workshops and follow up Two grants totaling $235,000 to examine activities to advance research to generate variations in the link between age struc- a new set of research results and con- ture and economic performance. tribute to the creation of a new generation MacArthur/Winter ’07 | 13 medical attention that enhances life deci- will design, develop, and promote an sion making.” Internet-based distance learning system for For more information In a complementary effort, Afluentes is health care providers. Action Health Incorporated working with health providers in Mexican Since the government began to partner www.actionhealthinc.org government clinics to increase their with nongovernmental organizations to test Afluentes knowledge and train them to interact more reproductive health model programs and www.afluentes.org effectively and knowledgably with young launch them on a larger scale, the govern- people. Afluentes has trained hundreds ment youth health modules have become Centre for Community and Reprodutive Health Services of IMSS Oportunidades health providers much more widely used. “More than two www.ccrhs.org.ng and has attracted the attention of another million young people have passed through Girls Power Initiative government agency, the Mexican Health the Youth Centers, and the numbers are www.gpinigeria.org Ministry. With Foundation support, the growing as they help themselves and their Ritinjali (India) training methodology Afluentes developed peers,” says Celia Escandon. “The govern- www.ritinjali.org for IMSS Oportunidades will now be used ment is providing the ‘arms’ to reach out to within the Ministry of Health, which has young people throughout Mexico, and the Thais Desarrolo Social www.thais.org.mx the potential to reach an additional 10 mil- work the NGOs are able to do as a result is lion young people. In addition, Afluentes very good for the future of the country.”

The Fund for Leadership Development Investing in individuals to strengthen the field

MacArthur Foundation n 1990, in a highly unusual The diversity of projects reducing maternal mortality was named a senior clinical effort to identify and funded through the program is and morbidity. She now runs a research fellow at the London Population and I Reproductive strengthen international lead- striking. In Nigeria alone, lead- state-funded women’s health School of Hygiene and Tropical Health ers in the field of population ership fellows have worked center and has become a Medicine. and reproductive health, on projects targeting street spokesperson for indigenous “We are proud of the con- the MacArthur Foundation children, tailors’ apprentices, women’s rights in national and tributions the Fund for launched the Fund for domestic servants, auto international settings. Leadership Development has Leadership Development. The mechanics, long distance truck In Nigeria, Bene Madunagu made to the field of population fund was designed to recog- drivers, and naval personnel. received a grant to train young over the past 15 years,” said nize and support talented, Methods for reaching people women to train their peers in Jonathan Fanton, President of promising individuals in select- with health messages range issues of sexuality and repro- the MacArthur Foundation. ed countries in the developing from folk tales to music, from ductive health. She has since “Our intention was to invest in world. Two-year fellowships theatre to radio and television. started Girls Power Initiative, individuals who were leaders were made available to mid- Many of the fellows have which worked with the in their community, but had career individuals with creative gone on to become leaders Ministry of Education to create the potential to influence ideas, leadership potential, and in their own countries and a curriculum and teacher policy and practice at the the capacity to shape policy beyond; a recent review of training program for in-school national and international and public debate concerning the India program showed sexuality education (see article levels on issues such as HIV/ the field of population. that more than half of the page 8). AIDS, maternal and child In 1991, the Foundation fellows started institutions In India, Vikram Patel health, and the sexual and made its first round of awards that have shaped work in the received a grant to research reproductive health and rights to six Brazilians whose inter- country over the last decade. the links between postnatal of young people. As a group, ests ranged from adolescent Other grant recipients have depression and infant and their successes have led to sexual behavior to the politics risen to leadership positions maternal health in the state great advancements and inno- of women’s health. From in government and nonprofit of Goa. Trained as a psychia- vation.” there, the program expanded organizations, conducted influ- trist, he went on to found an to Mexico (1992), Nigeria ential research, and trained organization, Sangath, that (1994), and India (1995). Over new generations of young works to improve the physical the years, grants totaling leaders in the field. health of young people by also more than $17.5 million to 370 Sebastiana Vasquez taking care of their develop- individuals have been instru- Gomez, for example, an mental and emotional health mental in building a significant indigenous midwife from the needs. He is now a world force for reproductive health state of Chiapas in Mexico, expert on mental health in the and rights. received a grant to work on developing world and recently

14 | MacArthur/Winter ’07 Director’s Message Building bridges; increasing our impact

acArthur’s commitment are empty without real life examples of where the work is carried out and the to the population and successful practices and approaches. global population and health arena, reproductive health Maintaining offices in key countries where fresh ideas are needed to move field is more than just in three regions of the world also has beyond the strategies and limited results aM financial one. Since launching our allowed our staff and grantees to share of past decades and help ensure that program nearly 20 years ago, we have strategies and experiences internationally. progress accelerates in the years ahead. developed a team — both in Chicago and For example, lessons learned in Nigeria on the ground in the countries where we about how to evaluate the impact of Judith F. Helzner make grants — that has insight into the school-based sexuality education (see Director, Population and Reproductive Health local conditions and has built important “Sexuality education shows results in relationships that ensure our grantmaking Nigeria,” page 8) can provide lessons for decisions are timely and strategic. similar programs in other countries. Our country offices help to facilitate We realize that our financial cross-fertilization between practical investments are modest compared to the interventions carried out at the grassroots world’s global population and reproductive level and regional and international trends health challenges, but we consider and policy debates. As the story “India our contribution as a bridge builder to Program Staff delivers new approaches to women’s be important for the field. In addition Judith F. Helzner Kole Shettima health” on page 3 of this newsletter to encouraging collaboration among Director Country Director, illustrates, although organizations on the grantees, we also promote connections Africa ground are the best equipped to carry with government and the private sector Ann K. Blanc out work in their local context, it is the that advance policy change or innovation. Program Officer Dipa Nag Chowdhury Senior Program Poonam Muttreja connections they have to groups outside The efforts of Fundar to streamline Manager, India of their communities that leverage this federal allocations for maternal health in Country Director, knowledge into lasting policy change. Mexico (see article page 12) is a good India Sharon Bissell Sotelo Program Officer, Successful models have limited impact example of this cross-sectoral work. Ana Luisa Liguori Mexico if they can’t be adopted and replicated We couldn’t do any of this without Country Director, elsewhere. Similarly, policy debates a foothold in both the communities Mexico Chicago/Washington

About the Foundation • The Program on Human and Community With assets of approximately $5.5 billion, The MacArthur Foundation is a private, Development supports organizations the Foundation makes grants and 2006 All rights reserved. 2006 All reserved. rights Produced by Lipman Hearne,

independent philanthropic institution working primarily on national issues, low-interest loans totaling approximately © that makes grants through four programs. including community development, $225 million each year. regional policy, digital media and learning, • The Program on Global Security and housing, public education, juvenile justice, For more information about the Foundation Sustainability supports organizations and mental health policy. or its population grantmaking, please engaged in international issues, including email [email protected] or visit peace and security, conservation and • The General Program supports public www.macfound.org. sustainable development, population and interest media and the production of reproductive health, and human rights. independent documentary films. Jennifer Humke, Newsletter Editor To aid in this grantmaking, the Foundation maintains offices in India, • The MacArthur Fellows Program awards Mexico, Nigeria, and Russia. five-year, unrestricted fellowships to individuals across all ages and fields who show exceptional merit and the promise of continued creative work. Foundation. John T. D. MacArthur and Catherine

MacArthur/Winter ’07 | 15 India delivers new approaches to women’s health/continued

“The government is very pleased with put in place to change how, where, and government, a number of international the program and happy to send govern- by whom services are delivered to meet agencies, including UNICEF, have ment doctors to us,” Desai says. So happy, the growing need. begun to integrate the new guidelines in fact, that it has committed $4.75 mil- In 2004, the Indian government into their work. lion of support to expand to 20 centers approached the White Ribbon Alliance “The Foundation’s investment in across India. In two years, grants totaling for Safe Motherhood in India (WRAI) the Alliance came at a critical time,” $450,000 from MacArthur and other foun- to help them do just that. With pri- says V. K. Manchanda of India’s Ministry dations have drawn ten times the original mary funding from the Foundation, of Health and Family Welfare. “WRAI investment. “I don’t think we’ll stop at the Alliance — an advocacy coalition of was an important partner in helping us emergency obstetric care,” Dr. Desai says. organizations and individuals — convened coordinate with various professional bodies “With such a large population in India, stakeholders to develop guidelines for and donor agencies.” there is no end to the good things that can expanding the skills of nurse-midwives Over time, the new guidelines are be done with this model.” to include procedures and care that expected to help dramatically increase the only physicians had previously been per- supply of caregivers able to offer emer- Guidelines for broader change mitted to carry out. The new guidelines, gency services to women, especially in the Providing training to expand the skills of which were adopted in April 2005 by the rural areas. “There is a great benefit to maternal health caregivers is critical, but Indian government, allow nurse-mid- working with organizations like WRAI — it is only part of the solution. Women’s wives to dispense life-saving drugs and not only do they have the expertise, but health advocates and government officials provide safe abortion care. In the short they have the good will to build con- in India agree that new policies must be time since their official sanction by the sensus,” says Manchanda.

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