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Short-term Realities and Long-term Goals: Achieving Lasting Global Commitment to Women's Rights

March 5th, 2011

To: The United Nations General Assembly,
Office of the High Commissioner for Human Rights
From: Araceli Y. Flores, Stanford University Class of 2011


Within the last century, the international community has made significant strides in defining fundamental freedoms that should be guaranteed to every human being, regardless of their country of origin. Adopted by the United Nations General Assembly in 1948, the Universal Declaration of Human Rights (UDHR) asserts that all members of the human family possess inherent dignity and inalienable rights, such as life and liberty, health and wellbeing, and education and self-expression. The UDHR exhorts all governments to observe and protect these rights.

The tenets agreed upon in the UDHR express views that United Nations, the representative body of the international community, held in 1948 and wished to establish as universal norms for years to come: As former Secretary-General U Thant articulated, “The world has come to a clear realization of the fact that freedom, justice, and world peace can only be assured through the international promotion and protection of these rights and freedoms.”

As history progressed and women demanded their right to equality of opportunity and protection, the United Nations convened once again to expand the ideas enshrined within the UDHR with specific recognition of gender-based denials of basic human rights. In 1979, the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) was convened by the United Nations. CEDAW reiterated the “truths” upheld in the UDHR, but took a step further: it underscored the urgent need to conceptualize the vision of fundamental human rights in the context of women: “[CEDAW] affirms the principle of the inadmissibility of discrimination and proclaims that all human beings are born free and equal in dignity and rights and that everyone is entitled to all rights and freedoms… without distinction of any kind, including distinction based on sex.” Years later, in a famous speech delivered to the UN 4th World Conference on Women in Beijing, Hillary Rodham Clinton captured this sentiment perfectly: “If there is one message that echoes forth from this conference, let it be that human rights are women’s rights and women’s rights are human rights once and for all.”

Clinton’s comments highlight the feminization of human rights issues and humanitarian crises. Everywhere around the world, women—in comparison to their male counterparts—face compounded conditions of human suffering based solely on their status as women: where there are already limited opportunities to access food, water, education, and social services, women face even more circumscribed access based on their gender. Moreover, women in the developing world confront a host of impediments to their health and wellbeing that men will never face: among them, reproductive rights and complications from pregnancy.

Current Situation

The United Nations has made significant progress in galvanizing the international community and holding governments to an international standard of human and women’a rights law. The signing and ratification of the UNDR and CEDAW demonstrate the good will of hundreds of member nations to recognize these “fundamental freedoms” and work to incorporate them into their respective domestic laws. However, despite the continued efforts of the UN Office of the High Commissioner and UN Women, a tangible gap exists in the implementation and enforcement of these rights on the ground.

The current realities fall into two camps, with member nations exhibiting the following qualities to varying degrees: In the first camp, there are countries – such as Bangladesh – which have created legal frameworks that uphold women’s rights, in principle. These countries possess all the rhetoric of gender equity and equal protections/opportunities under the law, but yet, their governments are either unwilling or incapable of fully committing to proper enforcement.  In the second camp, countries – such as Iran— have built gender-based discrimination into their very legal code. Lacking even the pretense of solidarity with international conventions or efforts in creating protective internal laws, these countries blatantly defy their international obligations to respect and guarantee human and women’s rights. While the severity of the situation of women’s rights varies a great deal within each camp, the prevalence of traditions that perpetuate violence against women and deny basic human services is troubling. This memo hopes to offer tenable policies that the United Nations can pursue, in addition to its existing efforts, to bolster the rule of law and access to human dignity that all women deserve.


This memo recognizes the need for both immediate and lasting solutions to effect meaningful and enforceable women’s rights laws. In order to address both the symptoms and the sources of violations of women’s rights, this memo proposes short and a long-term mechanisms, along with the theory of action that guides them:


The creation of a monitoring committee to create an international forum for women’s rights accountability that could incentivize government behavior.

Guiding assumption: Often times, governments do not feel compelled to observe their international obligations or respect human rights, especially when no supranational organization exists to “police” or punish deviant behavior. While sanctions have been an effective tool used by UN member nations to influence government behavior in the past, this memo recognizes that part of the crisis women face is humanitarian: cutting trade ties or economic aid to these countries as an attempt to “pressure” change would only further compound the plight of women within their borders. Instead, if anything, these countries need more resources to enact the types of positive change the United Nations seeks. In this vein, this policy recommends the commissioning of a monitoring committee which would produce a yearly “women’s rights report” for every country. This committee should create meaningful indicators of progress– such as increased women’s participation in political processes or decreased government crackdowns or violence against women— that would be used to evaluate and reward progress in securing tangible advancements in women’s rights.

Theory of action: These accountability measures need to be tied to meaningful incentives in order to effect behavior change. The United Nations should publish its report and urge nations to consider country scores when distributing foreign aid, outscoring factories, or creating trade agreements. Increased awareness of the human rights realities on the ground will create opportunities for other nations to target their interactions accordingly and use economic incentives to encourage development and the rule of law in other countries. Most importantly, as previously stated, these scores should not be used to cut off aid or economic opportunities to mal-performing nations. Instead, the score reports should be used as basis of “rewarding” growth in these nations and sustaining that growth (in the short-term) through continued incentivization.


Foster endogenous belief and capacity in the protection of women’s rights as a fundamental responsibility of governments, not as an intermediary means to other government ends.

Guiding assumption: Creating palpable, material incentives to elicit government cooperation on women’s rights issues offers a short-term solution to encourage behavior change. A reporting committee would shine international attention on the actions of these governments and tie these actions to “deliverables” or concrete “carrots” that reward good behavior. This mechanism presents a realistic understanding of the crisis at hand and offers a solution to evoke the type of immediate change that is necessary to implement change in a time-sensitive manner. That being said, observance and protection of women’s rights must be valued as ends in and of themselves, not as just compliance measures or routes to boosting GDP. Only when governments and societies internalize the moral obligation and human rights aspect of women’s rights– not just development or economic benefit-based arguments– can the international community be assured of a meaningful commitment to lasting and sustainable change.

Theory of action: The United Nations should create an investment fund that works to mobilize regional actors and grassroots organization in creating system-changing reform, both top-down and bottom-up. Many times, even if governments wish to enforce gender-equity laws, a fundamental lack of resources causes conditions in which sex-selective behavior (in distributing food, sending children to school, or even aborting fetuses) becomes an unavoidable reality of life.  The investment fund should not only provide financial support to committed governments and non-governmental organizations, but it should also provide the political/human capital and technological materials to grow internal capacities.

It is this memo’s hope that these two proposed mechanisms can be jointly employed– using international influence to engage governments in the short-term, as well as creating the foundations for a self-sustained commitment to women’s rights issues in the long-term.



United Nations General Assembly, “The Universal Declaration of Human Rights” (1948), http://www.un.org/en/documents/udhr/index.shtml

United Nations in Ukraine, UN Quotable, http://www.un.org.ua/en/information-centre/un-quotable

United Nations Division for the Advancement of Women, “Convention on the Elimination of All Forms of Discrimination against Women” (1979), http://www.un.org/womenwatch/daw/cedaw/

Gifts of Speech, Hilary Rodham Clinton, “Women’s Rights Are Human Rights” (1995), http://gos.sbc.edu/c/clinton.html

United Nations Division for the Advancement of Women, “Convention on the Elimination of All Forms of Discrimination against Women” (1979), http://www.un.org/womenwatch/daw/cedaw/

United Nations Office of the High Commissioner for Human Rights, http://www.ohchr.org/EN/Pages/WelcomePage.aspx

Dear Girls Inc.

March 3rd, 2011

TO: Girls Incorporated

FROM: Bisi Ibrahim, Class of 2011, Stanford University

DATE:  March 3, 2011

SUBJECT: Initiating Mental Health Programs For Young Women

As evidenced by thorough quantitative and qualitative research, the current state of mental health and healthcare services for young women in the US and internationally has been exposed, revealing a gaping, wanting void. Nevertheless, interventions and initiatives leading to successful outcomes are under-researched and underfunded, while in our societies we continue to adhere staunchly to our belief that it is not a cause for concern.

As a leading, non-profit organization invested in the empowerment of young women, Girls Incorporated has not only created programs for girls’ issues, but also in an extraordinary display of astuteness, Girls Incorporated has established its own Girls’ Bill of Rights. In this document Girls Incorporated has declared and vowed amongst many rights, two very pertinent rights: Girls have the right to be themselves and to resist gender stereotypes; Girls have the right to accept and appreciate their bodies. Both of these rights are directly related to mental health as often gender stereotypes are the root of mental disturbances and they often lead to an inability for girls to accept and appreciate their bodies. Therein Girls Incorporated inherently needs to address, create and maintain newer mental health-focused programs for an oft-stigmatized issue. Girls Incorporated should not continue to foster the silence that shrouds mental health and that endangers the lives of many young women globally, as it goes against Girls Incorporated’s mission.

The Basics

In the US, researchers have noted and repeatedly concluded that young girls, often beginning during puberty, are experiencing internalized mental disorders at a rate alarmingly greater in proportion than their male peers. For Caucasian girls evidence shows that gender stereotypes and societal standards of beauty in concordance with the traumatizing events of puberty are promoting an increase in depression and anxiety disorders in young women. Cross-cultural studies in the US have also revealed mental health discrepancies for minority women (African American, Asian America, & Latinas), as well as for young women emigrating from developing countries (including refugees of war-torn countries who are coping with Post-Traumatic Stress Disorder), but it is unclear whether it relates with the traumatizing effects of puberty.

The latter studies also showed that minority and immigrant women often experience lower incidences of internalized mental disorders, but evidence suggests that the numbers may be unreliable due to the manifestation of these disorders resulting in a different manner than that of Caucasian young women. It has been hypothesized that minority young women are often affected by stereotype threat. For immigrant young women it has been hypothesized that while they are initially afforded economic advantages and general health advantages not conferred by staying in their impoverished, war-torn, or economically unsound country, they arrive in developed countries like the US only to still face barriers in access to mental healthcare—the barrier often being stigmatization and anxiety over the need for assimilation. Therein on top of potential, preexisting mental disorders such as PTSD, they acquire adjustment-related mental health disorders that compound and lead to severe mental health disturbances.

What’s really going on?

With such a wealth of information repeatedly uncovering the same outcomes, one would think that there would be relative success in initiatives and interventions to counteract these findings. This, however, is far from the current state of initiatives and interventions. In fact as a whole, youth mental health is in shambles. The rate at which mental-health care services fail to meet the needs of youth patients is nearly 100%, this figure including developed nations. (Patel, 1303; Hickie, 63) This is a result of many mental healthcare services being adapted from adult mental health models, and assumed that with slight variations would have similar success for young adults and adolescents. Decades later, it is plainly just not working. (Hicke, 63).

For young women, the mental healthcare system fails them twice. Not only are intervention models faulty, but also diagnoses are often occurring decades after the onset of a mental disorder. Young women are not often diagnosed with mental disturbances until they are well into adulthood, and by then their mental disturbances have influenced other health and development discrepancies, including lower educational achievement, substance abuse, violence, and poor reproductive and sexual health. [Note: Girls Incorporated already has programs with many of these aforementioned co-occurrences, so why not deal with the root of the problem?]

What can be done?

Successful interventions are rare but are possible by incorporating several key components. For the few interventions that do exist, many are still being tested and their results are still in infancy; they also often need financial support. Nonetheless, addressing financial allocations and resources should not be the first step in creating successful interventions and initiatives for mental health and wellness for young women.

We must first begin with the minute details such as awareness and education. First, it is important that we begin to see mental health as an issue equal in magnitude to physical health. As a society we cannot continue to put mental health off as something that happens to the “others”—whomever we assume those “others” might be, we often fail to realize are those closest to us. Furthermore, health and wellness as a whole include the body and mind. In fact, it should be noted that mental illnesses are often correlated with the spread of communicable diseases, increased rate of acquiring non-communicable diseases and increased injury.

Secondly, on the cusp of education we must make it very clear that early intervention is key. 75% of adult mental disorders start before age 25, of which 50% have an onset before age 15; either way by adulthood the effects of a mental illness are less reversible and more challenging to care for. (Hickie, 64) One in four young people will experience a mental health disturbance in their lifetime that will significantly influence their adolescence and/or early adult life. However, in spite of this statistic early intervention has been associated with significant improvements in at least the first two years after presentation of a mental disorder. It would be a travesty to not take advantage of an answer sitting right in front of our faces.

Finally, we must work on the development of youth oriented mental health models. Current approaches are ineffectual and we must be open to newer models such as those incorporating the use of online systems, electronics, and computer interactions. We could get bogged down in arguments over whether technology alienates us from each other, but research has repeatedly shown that youth and young adults are less inhibited when interacting with computers and are more willing to share their conflicts and emotions leading to earlier diagnoses. (Coyle, 2007) It still requires that ethical and privacy considerations are hashed out, but it shows significant improvements in comparison to traditional interventions.

By focusing on mental health, Girls Incorporated will come full circle in maintaining its mission to inspire strong, smart and bold girls. If Girls Incorporated were to have a mental health program it could function much like the already existing pregnancy prevention program. The program would be divided along distinction age groups, and in the age groups most affected by mental health disorders (i.e. 12-14, 15-18), there needs to be extra emphasis placed on not just on awareness and education, but the removal of stigmatization in seeking mental health. Further ties should be made with the already existing PEERsuasion Program to make sure that peers do not feel that it is on them to keep mental health issues in secrecy, but instead have peer appropriate interventions (i.e. having peers realize that they are often the first resource for their friends suffering from a mental illness and having them remind their friend that seeking further help is not only an option, but the best option.)

I truly believe Girls Incorporated has the willpower, means and inherent motivation to create such a program that will hopefully become the model for future successful, intervention models for mental health in young women.

Coyle, D., Doherty, G., Matthews, M., Sharry, J. (2007). Computes in talk-based mental health interventions. Interacting with Computers 19, 545-562.

Hickie, I.B. (2011). Youth mental health: we know where we are and we can now say where we need to go next. Early Intervention in Psychiatry 5(1): 63-69.

Patel, V., Flisher, AJ., Hetrick, S., McGorry, P. (2007). Mental health of young people: a global public-health challenge. Lancet 269, 1302-1313.

A Women’s Voice in Conflict: Social Media Monitoring as a Policy Tool

March 3rd, 2011

Date:          March 03, 2011

To:             Department of State Policy Planning Staff

From:         Ada Kulenovic, Stanford University

Subject:      Women’s Rights in Conflict: Establishing Social Media Monitoring as a Policy Tool


Women play many roles in modern warfare—from victims of systematic violence to combat professionals— however, regardless of what status a woman has in conflict, it is in the interest of the United States to ensure women’s rights and long-term health consequences are taken into consideration in the crafting of wartime policy. International women’s stories present an opportune educational tool for policy makers to better assess the needs of women in war situations. Further, increased international access to the Internet and social media sites have bolstered the potential to effectively monitor and respond to human rights abuses against women.

Global Trends:

  • The spike in ethnic and religious civil wars targeting civilians has resulted in disproportionate numbers of women and children victims. [1]
  • In regions where democratic principles and transparency are scarce, women’s rights violations are being methodically concealed: local authorities turn to falsifying reports and classifying records and statistics. [2] These governments are failing to uphold the UN Declaration of Human Rights, and there is a lack of appropriate mechanism for reporting these abuses.
  • Not only civilian females are victims of abuse in wartime situations; there have been record high reports of abuse of military personnel within US troops. [3] The safety of our female combatants must be made a priority.
  • The U.S. Committee for Refugees and Immigrants gives the world total of displaced peoples as approximately 62 million; about one-third are officially recognized as international refugees, and 80% of these refugees are women and children who are more vulnerable to their unstable conditions. [4] Subsequently, the health consequences facing women during and after conflict (including both physical and mental traumas) constitute an issue that affects US demographic standards and the US healthcare system.

Assessment of Current Approaches:

Current policy does not effectively address the varied needs of women in conflict. While the US has made effective efforts to curtail mass human rights abuses such as the ones seen in the Balkan wars of the 1990s [5], there remain many gaps in policy with respect to women’s issues because there is no mechanism for giving a voice to the female population.  International journalists and popular media have long played a key role in disseminating information on civilian conditions in war. [5] Their efforts supplement the investigations undertaken by US intelligence agencies.

Over the past decade, however the Internet emerged as a new resource for accumulating information regarding human rights atrocities. It is estimated that one third of the world has access to the internet. [6] Global internet usage has grown by 444.8% in the last decade; regions that have seen the fastest growth include Africa (2,257.3%) and the Middle East (1,825.3%). Additionally, world internet penetration rates are steadily growing, meaning more people than ever before are gaining access to the internet on a daily basis. [6] In 2010 Facebook reached over 400 million users worldwide, and Twitter hit a benchmark  reporting of 50 million tweets per day; last year both sites saw number of global users nearly triple, while time spent on social media sites increased over 80%. [7] In many developing nations, social media is driven by the usage of mobile devices. Currently, about half of the global population has a mobile phone. Studies suggest that internet via mobile will become a primary means of internet access in developing countries. [8] Lastly, technology-based development researchers suggest that mobile internet access in developing countries could drastically change the basis for social determinants of healthcare and social service access. [9] The internet it creating a new medium for information exchange and social participation. Current events trends affecting revolutions across the Middle East support theories of the rising importance of social media as a tool for community organization. [10]

Furthermore, as I am sure you are aware, Secretary Clinton and president Obama elevated technology to a high priority for the State Department as a new tool for diplomacy. Jared Cohen’s persistent promotion of the use of existing technologies, including Facebook, Twitter, and Google, transformed the State Department’s approach to diplomacy by bringing the State Department up to speed with existing technology for international mass mobilization. [11] A number of notable projects were initiated to bring together tech delegates across the world to promote the use of social media as a device, particularly in war-torn countries such as Iraq and Afghanistan.  [11] One venture to be highlighted is the 2008 delegation trip to Baghdad, during which Silicon Valley representatives traveled with local engineering students, professors, and government ministers to assess how to make technology more accessible across Iraq. [12] The trip resulted in several innovative ventures including the tweaking of Twitter code to allow basic cell phones to make posts and the introduction of blogging and coding partnerships among youth activists and engineering representatives. [12] The Iraq experiment poses an interesting model for future endeavors.

Another notable predecessor of social media monitoring is the Haiti response effort. The creation of a universally accessible tracking number ‘4636’ used by people to text for help was credited for the success of a series of rescue efforts, and provided a tool for tracking missing persons. In addition, during the Haiti disaster, organizations relied heavily on posts coming in from social media sites to organize relief missions. [13]

There is a need to expand the usage of the internet for policy monitoring– especially with regards to women’s issues. Through social media, women across the globe are given a new means of expression and self-organization. The internet provides a means for an otherwise voiceless group to have clout in the international arena.

Policy Recommendations:

The next step is to take the basic frameworks for social media monitoring that are already coming to fruition and to extend them to the most high needs regions and populations—focusing heavily on targeting women’s empowerment grassroots organizations in regions with a propensity for civil strife such as Africa and the Middle East, where social media and cellular device usage continues to grow.

There is a need for:

  • Support for the strategic use of online media for women to voice their complaints to the international community; including addressing issues of accessibility, awareness, anonymity, and safety.
  • A method by which to monitor abused populations’ complaints and locations across a range of existing social media servers . This monitoring system should track short-term and long-term reporting trends.
  • A coordinated effort to address the concerns provided by this new apparatus, and to manage effective response across government and non-government organizations.
  • Continued tracking and follow-up on the health status of women and children refugees and female veterans in the US.

In order to push forth with these goals, the Policy Planning Staff must designate a Women’s Rights Monitoring Task Force which will help promote the continued establishment of technology delegations comprised of entrepreneurs, political leaders, local community figures, and students, much like the ones championed by Jared Cohen and Alec Ross in 2008. [13] In addition to the delegations, the Task Force should seek to partner with organizations that work with women in war, such as Women for Women International and CARE, to promote the use of social media and cellular devices as a medium for crisis help for use by all women, especially women in the US military. Female military representatives should be trained to report both instances of abuse with the troops and amongst local populations. Further, the Task Force must seek to establish potential monitoring agencies modeled after the monitoring attempts carried out by State Department, Pentagon, and humanitarian groups after Haiti.  These monitoring systems should serve as a means of coordinating response efforts, and continuing metrics measurement post-conflict. The reports generated by these agencies can serve as the basis for further studies, policy recommendations, and immediate action mechanisms.

Given the politically volatile situations facing countries across the Middle East region in the wake of revolutionary reforms, and the strategic importance this region to international security and stability, now is the time to act by instating monitoring of social media across Lybia to assess the situation on the ground.

By pushing for social media access, we ensure Article 19 of the Universal Declaration of Human Rights, securing citizens’ access to information. This is a direct means of promoting transparency and fighting corruption in places that need it most without the use of US military force. The strategic application of the information that results from the use of these social media channels allows for direct citizen communication, gives voice to a silenced minority population under severe repression and helps ensure smart policy-making rooted in the needs of the population.  This policy helps implement smart top-down policy by involving local communities and pushing for bottom-up involvement in political affairs.


[1] Broken bodies, broken dreams: violence against women exposed. Jeanne Ward – Zana Briski – Lisa Ernst – UN. Office for the coordination of humanitarian affairs (OCHA). Integrated regional information networks (IRIN) – 2005.

[2] Camareno, Rodrigo. “The War on Drugs’ Female Victims.” The Guardian | Guardian.co.uk. Web. 27 Jan. 2011. http://www.guardian.co.uk/commentisfree/cifamerica/2011/jan/24/mexico-usa-women.

[3] Benedict, Helen. “The Private War of Women Soldiers.” Salon. 7 Mar. 2007. Web. http://www.salon.com/news/feature/2007/03/07/women_in_military.

[4] “Frequently Asked Questions About Refugees and Resettlement.” International Rescue Committee | The International Rescue Committee Goes to Crisis Zones to Rescue and Rebuild. We Lead Refugees from Harm to Home. Web. 04 Mar. 2011. http://www.rescue.org/frequently-asked-questions-about-refugees-and-resettlement.

[5] Brussels, Belgium. UNFPA. Sexual Violence Against Women and Girls in War and Its Aftermath: Realities, Responses, and Required Resources. By Jeane Ward and Wendy Marsh. 2006. Symposium on Sexual Violence in Conflict and Beyond.

[6] “World Internet Usage Statistics News and World Population Stats.” Internet World Stats – Usage and Population Statistics. Web. 02 Mar. 2011. http://www.internetworldstats.com/stats.htm.

[7] “Led by Facebook, Twitter, Global Time Spent on Social Media Sites up 82% Year over Year | Nielsen Wire.” Nielsen. Web. 03 Mar. 2011. http://blog.nielsen.com/nielsenwire/global/led-by-facebook-twitter-global-time-spent-on-social-media-sites-up-82-year-over-year/.

[8] Tryhorn, Chris. “Developing Countries Drive Explosion in Global Mobile Phone Use | Business | Guardian.co.uk.” Latest News, Comment and Reviews from the Guardian | Guardian.co.uk. Web. 03 Mar. 2011. http://www.guardian.co.uk/business/2009/mar/02/mobile-phone-internet-developing-world.

[9] Boyera, S. “White Paper on Mobile Web for Social Development.” World Wide Web Consortium (W3C). Jan. 2008. Web. 03 Mar. 2011. http://www.w3.org/2006/12/digital_divide/ajc.

[10] “Mass Media, Women and the Middle East.” Home. Web. 04 Mar. 2011. http://www.waccglobal.org/en/20072-mediating-the-middle-east/454-Mass-media-women-and-the-Middle-East.html.

[11] BusinessWeek: Interview with Peter Elstrom & Spencer Ante. BusinessWeek. Video.

[12] Ante, By Spencer E. “Twitter Diplomacy – BusinessWeek.” BusinessWeek – Business News, Stock Market & Financial Advice. Web. 04 Mar. 2011. http://www.businessweek.com/magazine/content/09_26/b4137050286263.htm.

[13] Gentile, Carmen. “Cries for Help via Text Messages Are Used to Direct Aid to Haiti.” New York Times Online. The Nw York TImes, 20 Feb. 2010. Web. http://www.nytimes.com/2010/02/21/world/americas/21text.html?_r=1&th&emc=th.

To the Politicians of Andhra Purdesh: Give (Regulated) Microfinance a Chance

March 3rd, 2011

To the Politicians of Andhra Purdesh:

My name is Kevin Webb, and through the course of the past quarter studying women’s health internationally in general and microfinance’s impact on the wellbeing of women in particular, I have come to believe that microfinance as a whole still has a tremendous capacity for positive impact. I understand many of your frustrations with the industry—it is poorly regulated, it targets your least powerful and least educated citizens, and it has helped put an entirely new class of people into debt. Worse, even where it fails the people it is purported to help, microfinance is still uncritically viewed in the West as a finance-based means of combatting poverty.

Indeed, following Muhammad Yunus’s Nobel Prize in 1997 for his pioneering of microfinance with his Grameen Bank, microfinance has seemed like something of a panacea back in the US. Kiva.org has become a household name, and celebrities here from Bill Clinton to Natalie Portman (http://www.takepart.com/news/2008/03/07/natalie-portman-loves-kiva) have hailed its work. I myself donated $25 to an enterprising group of women in Sierra Leone who are trying to expand their baking business (http://www.kiva.org/lend/264387), and felt connected to this group of women in doing so. Should I recoup the investment, I’ll be able to give a little more the next time around.

To well-intentioned philanthropists, microfinance is a clean way to provide resources to people who need just a small amount to get themselves off their feet. This investment’s impact is enhanced by the interest rate charged, because it means any funds recouped can be reinvested in other people in need of help. More intangibly, the nature of American microloan aggregators like Kiva and MicroPlace make it so users can create seemingly personal connections with people they otherwise would never meet. That’s a potent emotional force for good, if harnessed properly.

As you are aware, this past November, politicians in your state implemented a wealth of drastic new measures designed to limit microfinance’s impact. At the time, there was good reason: where many microfinance organizations were continuing to operate quietly and ethically, others had taken advantage of good will toward the industry and begun to foment a cycle of debt for your state’s most impoverished. Banks have long done this with the middle class, but until microfinance, the world’s poorest have been seen as too high risk to warrant interest. Once Grameen and other organizations demonstrated that money and interest could be recouped, though, it became clear to some very cynical people that the poor were an enormous new segment of people to exploit financially. There are stories of people being hounded, day after day, to repay loans, and others of poorly educated farmers being convinced to take three, four, or even more loans simultaneously. 75 of your citizens took their own lives in response to their mounting debt. Let me be perfectly clear: these business practices are completely reprehensible, and you were absolutely correct in calling attention to them.

But the line you drew in the sand worked. In some senses, it worked too well—even the ethically minded organizations are considering pulling out of Andhra Purdesh entirely, because the rate of nonpayment has skyrocketed since October. This has ramifications for your state in barring access to life-changing loans, but it has more global impacts as well—should Andrah Purdesh continue to be a financial sinkhole, any institution that persists there will be losing out on funds it could be committing to people elsewhere.

That said, this new law had the tremendous impact of forcing India to draw up official regulatory laws to limit abuse through its Reserve Bank. Grameen was among the first to hail the new board, as it will cap loans and it will prevent more than two loans from being given, among other measures designed to protect the consumer. It may not be as strict as it ought to be, but it is certainly a start, and Andhra Purdesh has itself to thank.

I would encourage you to rethink your state’s much stricter policy in the wake of the Reserve Bank of India’s superseding, much more broadly applicable laws. It has been easy to rally popular sentiment against the organizations—some have been abusive, and many hail from the easy-to-hate West—but I hope you can find a way to lighten the rhetoric and to find a new scapegoat. Because when microfinance is done ethically, it is an incredibly potent force for good. And when it comes time for your next elections, would you rather be the politicians who ended a globally lauded practice, or the ones who stopped all of the bad things associated with it while keeping all of the good? In allowing a regulated form of microfinance, you will be making sure that your citizens still have access to loans that literally can change their lives. I’m no politician, but this seems like the best way to do right by your constituents.

Note: I will add sources once I get back to my computer.

Iran's Women: Subtle Dissent and Vocal Protest

February 25th, 2011

Araceli Y. Flores

In last week’s blog, I presented Iran as a unique case study in women’s rights. Like many other Muslim nations, Iran upholds Sharia law, the sacred law of Islam derived from the Qur’an and teachings of Mohammed. As a theocracy, however, Iran relies on Sharia law to dictate not only private customs and traditions, but also public life in Iran. Using Sharia law as the basis of its legal code, the Islamic Republic of Iran has reversed many of the gains made by the women’s movement prior to the 1979 Iranian Revolution.

Iranian women face many types of gender-based discrimination, especially in family and marital life. Often, nations have the constitutional framework for equal rights, but societal norms subvert proper enforcement of these laws. In Iran’s case, however, gender-based discriminations are inscribed directly into the legal code and then further supported by societal customs. In this way, Iranian women are doubly denied basic rights and freedoms. Harsh laws dictate how women are allowed to dress, who they can marry, and the rights they have as both wives and mothers. Even harsher punishments, such as public beatings and honor killings, exist for violating these laws: “In cases of divorce, child custody, inheritance and crime, women do not have the same legal rights as men. In the past four years, President Ahmadinejad has made it easier for men to practice polygamy and harder for women to access public sector jobs” [1].

Still, despite the repression that Iranian women face on a day-to-day basis, Iran possesses one of the most resilient, courageous women’s movements in the Middle East. With the election of the moderate leader Mohammad Khatami in 1997, the women’s movement regained footing in Iran. Many women viewed Khatami’s election as a wake up call: nearly two decades after the 1979 revolution, the “freedom and independence” promised by the revolutionary government still had not been achieved; it fact, equality under the law had been denied to women.

As I mentioned in last week’s blog, women had formed a huge support base for the Islamic Revolution during its principal stages. Now, two decades removed from the illusions and false promises, women’s alliances emerged to press the state for social and legal policy changes. Both Muslim and secular female activists used various arenas to voice their complaints about gender segregation, widespread domestic violence, and the discriminatory effects of Iranian family law. Interestingly, Iranian women activists have utilized a wide array of mediums to get their message across, from mass media to the film industry to literary works and poetry .

Within the last decade, Iran’s women’s movement has made great strides in increasing women’s participation in a variety of industries— while the total number of women participating in the labor force has not grown dramatically, women have expanded their presence and influence into nearly every sector: commercial, educational, agricultural, entertainment, and even political. Moreover, women’s education has boomed, surpassing men in percentages of college enrollment and graduate degrees. Using these skills, the women’s movement continues to expand their mission on a national level by publishing women’s journals, university magazines, and even feminist website sites.

The women’s movement in Iran has two faces: subtle defiance and vocal protest [2]. On a small scale, women artfully flout the state’s strict dress code through “carefully planned flashes of their hair under their head scarves, brightly colored fingernails, and trendy clothing that can be glimpsed under bulky coasts and cloaks” [3]. These small acts of defiance showcase the spirit of rebellion that fuels the Iranian women’s movement. On a larger scale, these same women have form the frontline of marches and protests against the government. The highly contested reelection of Ahmadinejad in 2009 provides a remarkable example of just how readily and willingly women in Iran will fight for their rights. Iranian women marched alongside men to protest the fraudulent elections, brushing up against the armed military who fought to suppress the crowds [4]. Women were among several of the protestors and demonstrators who were fatally wounded in the skirmishes. Unafraid, the women’s movement took to the streets to protest, challenging another term of governance under Ahmadinejad’s hard line government and continued repression of women. One Iranian woman, Nobel Peace laureate Shirin Ebadi, commented that inspiration behind women’s involvement in the electoral protests originates from long seated resentment and frustration at the government’s rollbacks of women’s rights: “Because women are the most dissatisfied people in society, that is why their presence is more prominent” [5].

The women’s movement in Iran demonstrates the determination of women to courageously challenge the repressive laws placed upon them by their government. The expansion of women’s presence across Iranian industries and their commitment to education provide encouraging signs of change and growth. Hopefully, as demands for greater human rights and civil liberties sweep the Middle East —as seen by 2011 revolts in Tunisia, Egypt, and Bahrain– the Iranian government will be charged both domestically and externally to recognize and grant greater freedoms to its people. Iranian women continue to be strong agents of this change.



[1] Mahdi, Ali Akbar. “The Iranian Women’s Movement: A Century Struggle.” The Muslim World (2009) http://go.owu.edu/~aamahdi/Iranian%20Women%20Movement%20A%20Century%20Long%20Struggle.pdf

[2] Lyden, Jacki. “Despite Odds, Women’s Movement Persists In Iran” NPR.org(2009): http://www.npr.org/templates/story/story.php?storyId=100039579

[3] “Iranian women fight on the frontlines of protest,” MSNBC.com (2009) http://www.msnbc.msn.com/id/31531225/ns/world_news-mideast/n_africa/

[4] Basu, Moni. “Women in Iran march against discrimination” CNN WORLD (2009): http://articles.cnn.com/2009-06-19/world/iran.protests.women_1_iranian-women-mohammed-khatami-reformist?_s=PM:WORLD

[5] “Iranian women fight on the frontlines of protest,” MSNBC.com (2009) http://www.msnbc.msn.com/id/31531225/ns/world_news-mideast/n_africa/

Despite its name, IFAD is no fad

February 24th, 2011

Before I begin this week’s post, I’d like to provide an update on my microfinance project—this past week, I got my first repayment on my microfinance investment through Kiva.org. Of my $25 invested, I so far have recouped $3.12 from the Let’s Unite Group, which aims to increase the production capacity of a rural bakery in Sierra Leone. I’m excited to re-invest it, but I think I’ll wait til I’ve recouped more of the investment before helping someone else. I wish Kiva would provide status updates—I think it’d be more rewarding and satisfying to know if the borrowers are faring better off now. As for MicroPlace, the for-profit alternative, it seems as though I will not see any return until September, so further updates are unlikely.

For this week’s topic, I want to address how microfinance could potentially help to support small farmers in Africa. This past week, former UN leader Kofi Annan claimed that with aid, Africa could feed the world’s farmers. With the help of the UN’s International Fund for Agricultural Development (IFAD), small African farmers have already been helped—“partnerships involving IFAD and AGRA have leveraged US$160 million in affordable loans to agriculture from commercial banks in Ghana, Kenya, Mozambique, Uganda and the United Republic of Tanzania.” (http://www.reliefweb.int/rw/rwb.nsf/db900sid/KHII-8EA5VF?OpenDocument)

More relevant for the subject of this blog, of IFAD’s microfinance portfolio (as agriculture is investment-intensive, holding an exclusively microfinance portfolio would in many places be an ineffective strategy) 80% has been loaned to women. In African nations, these small, low-interest loans seem particularly poised for success, as small agriculture has long been the pattern in many nations, and women have long played a crucial role in raising plants. Through IFAD’s loans, it is conceivable that more countries could start to shake some of their dependence on foreign crops, that they could help to curb issues of hunger, all while simultaneously giving rural citizens the ability to empower themselves. And by charging a small interest rate, the impact of IFAD stands to grow with time. And although countries continue to have issues with loan defaults (take a look at http://allafrica.com/stories/201102240919.html for a discussion of Rwanda’s incredibly low rate of repayment), I still remain optimistic that ethically minded organizations like IFAD can effect some valuable change.

A whole new meaning to 'sexting'…

February 24th, 2011

This week I came across an interesting article in the New York Times about using SMS text messages to provide teens with free, anonymous, and frank information about their sexual and reproductive health (Hoffman, 2009).  The program, called “The Birds and the Bees Text Line”, was started just two years ago by the Adolescent Pregnancy Prevention Campaign of North Carolina.  The group offers information that kids cannot get in school: in NC, abstinence only education is mandated by state law. A staff member responds to each text message individually.  9 staffers rotate these response duties.  Each have graduate training in public health or social work, or years of experience working with teenagers.

The questions, as you might expect, range from myth-busting (If you take a shower before you have sex, are you less likely to get pregnant?) to requests for help with behavior change (How can I stop myself to giving into sexual temptations?) to innocent (Why don’t girls like short guys?).  Of the examples discussing in the article and a sister article published the same day (”Text Ed”, NYT), many pointed to disturbing gaps in teens’ knowledge (“If ur partner has aids and u have sex without a condom do u get aids the first time or not?” or questions about whether anal sex can pass STIsor cause pregnancy).  The responses are short, straightforward, non-judgmental, and often caring.  For example, a texter might respond to the question above about showering before sex, “Nope, doesn’t make a difference.”  Often, the article says, the service offers referrals to local clinics or other providers where the adolescent can get more comprehensive care.

This type of program is becoming more common in our digitally-oriented world.  California has an initiative called “Hook Up 365247″ that sends weekly  text messages with sex education/information and life advice (Teen Source, 2011).  Subscribers can also receive referrals to clinics in their area.  For example, Everyone gets the same messages, which are scripted rather than responses to specific questions.  You might learn from these text messages: “Meds cure chlamydia, gonorrhea + syph. herpes + HIV stay w/u 4ever. Txt CLINIC + ur zipcode 4 clincs.”

Trolling the web, I also found an initiative called “Sex Ed Text” (SET, 2011) which offers something similar to Birds and Bees in the Phillipines, but with a  decidedly adolescent style.  Rather than answering personal questions, SET uses computer program to respond to text messages containing specific keywords, including “preg” “stds” “hivaids” “condom” “pill” and “tubestyed.”  Users then select from a number listed of frequently asked questions within each key word.  For example, texting about “pill”, one would need to specify their inquiry from this list:

1-how 2 use
2-misd pill
3-can i stil have kids
7-can I tak d pill
9-gud or bad

The questions and answers themselves are also written in this slangy, informal style, while still providing useful information.  If I texted the service with a question about how to use a condom, I would receive this repsonse:

How 2 use-condom wil only work if used proprly. Put d roled up condom over stif penis, pinch tip of condom 2 leave space 4 sperm,  roll condom down d penis. D man shud hold d condom when he puls out his penis frm partnr 2 prevent sperm frm leakin out. A condom shud only b used once.

A program recently launched in Indonesia allows teenagers and anyone with access to a mobile phone to send questions to a panel of Indonesian doctors via text message (Jakarta, 2007). The program was started by a condom manufacturer ‘Fiesta Condoms’, who report that they felt Indonesian teens lacked access to sex education information (according to a study in four major cities that many teens were getting the knowledge primarily from pornographic videos online).  Like the other programs mentioned, the service works anonymously, allowing youth to access information without fear of breaking social taboos.

What should we think of all this?

The programs clearly fill a gap,  In North Carolina, texting the Birds & Bees hotline might be the only time a teen gets information about contraception, since they won’t ever learn about it in school.  Cell phones may be more difficult for parents to regulate (compared to the internet, which allows parents to block certain sites), meaning adolescents might have more privacy than other digital sources allow.  While it certainly cannot replace comprehensive, face to face sex ed programs, it doesn’t claim to.  It’s meant to give teens a forum to ask questions, and ask they do.  On the whole, I can get behind this type of program, but I do have some qualms.

What worries me about the Birds & Bees hotline in NC and the Indonesian doctor hotline is the idiosyncraticity and brevity of the responses.  The “Hookup” program in California circumvents this issue by sending weekly tips rather than answering specific questions.  The “SET” initiative in the Philippines answers pre-determined FAQs with pre-determined responses.  But when staff answer individual, personal questions, they must think carefully about how to respond to the specific individual’s needs, provide full information, encourage the adolescent’s safety and health, all while not presenting a judgmental or patronizing tone.  These challenges are present in any human interaction around difficult to answer questions, but they intensified here by the medium of texting.  You get 140 characters, little means of communicating tone, and no information about or rapport with your audience.

Take for example, the question about whether you can avoid pregnancy by taking a shower before sex.  “Nope, doesn’t make a difference” is a non-judgmental, accurate answer.  It meets the teen where they are, doesn’t shame them for asking questions, and gives them the information they need quickly.   But are there still important gaps in this answer?   The question itself demonstrates that the teen doesn’t have good knowledge of how pregnancy works or how to avoid it – would it be useful to refer him/her to a clinic or internet resource that could educate them about pregnancy and contraception? To address other common myths about pregnancy?  To probe to see if they have other questions? You can’t necessarily assess what the teen knows (or doesn’t know) beyond their question’s content, so even after an appropriate response, important gaps might remain in the teen’s knowledge.

According to an article by momlogic.com, part of this difficulty is dealt with by not answering every question at face value. “We will refine what they’re asking, clarifying questions,” says Sally Swanson, one of the responders in the program (as quoted here: http://www.momlogic.com/2009/05/sex_educaton_text.php).  But what about questions like these (from the Hoffman, 2009 article):

“If I was raped when I was little and just had sex was it technically my first time when I was raped or when I recently had sex?”


“I like boys but I also like girls. What should I do?”

Clearly, text message programs are not equipped to respond comprehensively to issues of domestic violence & sexual abuse, sexuality and sexual identity, or morality.  In these cases, referrals are paramount.  An important question to assess might be, how often do teens seek more intensive information/care after using a text message service?  Other evaluation questions will surely be studied as well, to judge such programs effectiveness at increasing knowledge, changing attitudes, promoting safer behaviors, and accessing community services.  For now, I think it’s safe to say that while clearly not a substitute for comprehensive education, these anonymous, youth friendly programs are an important way to increasing teen’s access to knowledge about their sexual and reproductive health.  And given the prevalence of cell phones world wide, even in developing nations, using SMS as a means to communicate information could represent an important movement in public health education.

What do you think?


Hoffman, J. “When the Cell Phone Teaches Sex Education.” New York Times, May 1, 2009. Accessed online at: http://www.nytimes.com/2009/05/03/fashion/03sexed.html?_r=1&pagewanted=all

“Text Ed.” New York Times, May 1, 2009.  Accessed online at: http://www.nytimes.com/2009/05/03/fashion/03sexbox.html?ref=fashion

Teen Source: “The Hookup.”  California Family Health Council, 2011.  Accessed online at: http://www.teensource.org/pages/hookup

“SMS Sex Education Line Launched.” Jakarta Post, July 19, 2007.  Accessed online at: http://www.thejakartapost.com/news/2007/07/19/sms-sex-education-line-launched.html

“Teen Sex Ed: Just a Text Message Away.” GNH Productions, 2011.  Accessed online at: http://www.momlogic.com/2009/05/sex_educaton_text.php

Do something.

February 24th, 2011

If you’ve been outraged by what you’ve read, what you’ve seen and what you know to be the sad reality for millions of women, then this is one post you need to read.

In light of all the problems I have focused on in my posts—rape as a tool, political conspiracy against gendercide, domestic violence in oppressed societies—I’d like to take up Anne’s call to turn toward the solutions, the stories of women’s courage amidst the outrage. The best way to do this, I believe is by highlighting a few organizations that are taking a new approach to change in the female empowerment movement. As we learn about all the critical issues facing women in the world, whether they are in war-time situation or in their own homes, we need to start asking ourselves how we can get involved. A revolutionary solution often starts with a very simple idea.

Women for Women International

• What they do: “Women for Women International provides women survivors of war, civil strife and other conflicts with the tools and resources to move from crisis and poverty to stability and self-sufficiency, thereby promoting viable civil societies. We’re changing the world one woman at a time.” [1]
• How they do it: They help women move from victims to active citizens by providing financial aid, job training, rights awareness and leadership education. [1] Their work has reached countries such as Afghanistan, Bosnia, the Congo, Nigeria, and Sudan.
• What you can do:

  1. Host an Event
  2. Volunteer (though most immediate opportunities are in the D.C. office, you can e-mail volunteers@womenforwomen.org. to get more information about getting involved!)
  3. Intern (there are opportunities in policy, fundraising, executive office, advocacy, grassroots, marketing, etc.)


• What they do: CARE is a humanitarian organization fighting global poverty. They work “ alongside poor women because, equipped with the proper resources, women have the power to help whole families and entire communities escape poverty. CARE supports community-based efforts to “improve education, prevent the spread of HIV, increase access to clean water and sanitation, expand economic opportunity and protect natural resources.” They also deliver emergency aid in cases of war and disaster. [2]
• How they do it: They have teams set up for each of their initiatives (from Agriculture to Nutrition to Emergency Relief). The teams work with local policy makers and organizations to provide resources and solutions. They provide funding for clinics, push for research and international law reform, raise funds for relief efforts, and run hundreds of local projects. Check out some of their team efforts here.
• What you can do:

  1. Look into events to attend/get involved in with “CARE in your community
  2. Start a CARE profile or a blog (you’ve been dong in this class for a quarter, why not keep going?)

Feminist Majority Foundation (and Feminist Majority)

• What they do: FMF’s mission is to “develop bold, new strategies and programs to advance women’s equality, non-violence, economic development, and, most importantly, empowerment of women and girls in all sectors of society.”
• How they do it: They do research and policy development, public education and development programs, grassroots projects, and participates in and organizes forums on issues of women’s equality and empowerment. The sister organization, the Feminist Majority, engages in lobbying and other direct political action, pursuing equality through legislative avenues. [3]
• What you can do:

  1. Get involved in one of their campaigns (from Freeing Iranian feminists to fighting fake abortion Clinics!)
  2. Volunteer—either permanently in their D.C. or LA office or get in contact to launch a local campaign. To inquire e-mail volunteerdc@feminist.org or call 703-522-2214 (for DC) or volunteerla@feminist.org 310-556-2500 (for LA).
  3. Intern (DC or LA)

I call each of you who read this article to critically evaluate each of these organizations. Ask yourself:

Am I passionate about this solution? Should I get involved?
What are they doing right? What can they do better?
Who else is working on these issues?
What can I do?

First steps:

o Get on Twitter.
(Most of the above organizations have an account, start following., start posting…)
o Use that Facebook.
(Facebook gives you the option to step out onto the modern front lines. “Like” an organization, join an international women’s network, or check out a regional group.)

Get involved. Don’t just be another bystander with open ears, a wealth of knowledge, and a stagnant desire to do something—go do it.

According to a Newsweek/Gallup opinion poll 56% of women and over 66% of young women in the United States self-identified as feminists. [4] I would venture to say 100% of the women (and our male allies) in our class would self-identify as such. As feminists, it is our duty to not only know the issues, but to move forward…


[1] http://www.womenforwomen.org/about-women-for-women/we-support-women-survivors-globally.php

[2] http://www.care.org/about/index.asp

[3] http://feminist.org/welcome/index.html

[4] http://feminist.org/welcome/index.html

An Epidemic of C-Sections

February 17th, 2011

As I was perusing for topics to write about this week, I came across Amelia’s comment on my very first blog post, where she suggested I write about c-sections in the US. I started doing some research and found to my surprise that C-section rates are dangerously high not only in the US but in some developing countries. Surveys by WHO found that in Asia, 27% of births surveyed were c-sections, and in Latin America, 35%. In the US, the percentage is 30. In China, it’s 46. (1) For a bit of perspective, WHO has recommended rates not rise above 15%, and other doctors say even above 5% is generally not justified (2). What are the factors behind these astonishingly high rates? Beyond that, what do they mean for the health of mothers and babies everywhere?

First, another note to frame the issue: I’ve spent a lot of time writing about issues of access to care and how that affects maternal mortality in developing countries. As we all well know by know, a lack of access to obstetric care, emergency or otherwise, is a major factor in the unacceptably high maternal mortality rates that continue in much of the developing world. Thus, it’s critical to note that an even worse statistic than too many c-sections is too few. Rates lower than 1, or even 3 percent “indicate a lack of access to obstetrical care and a risk of maternal death” (2).  Thus it’s unsurprising that rates of c-section remain below 1% in rural areas in Chad, Niger, Mali, Madagascar, Zambia, Haiti, and Nepal.

On the other hand, what is the outcome of too many c-sections? An ecological study of 8 Latin American countries found “overall and elective caesarean section rates to be positively associated with severe maternal morbidity and possibly mortality, as well as with fetal mortality and newborn morbidity,” after accounting for the fact that hospitals attracting higher risk pregnancies would also have higher rates of c-section (3). Given the risks to themselves and their babies, why are so many women choosing c-sections? There is a wide range of reasons, both medical and cultural. Doctors may encourage c-sections in their patients because the procedure is quicker than a vaginal birth (3). Women may choose a c-section because it’s seen as being less violent on their bodies than vaginal birth—a “harmless, painless, and convenient” process (3). There is also the misconception that c-sections are less risky than natural birth. Beyond that, it’s simply convenient to be able to schedule your birth. Yet another WHO study found that some Asian women will plan a surgery so that she can give birth to their child at a time or day a fortuneteller has told her is lucky (1).

In Brazil, a country with c-section rates approximately as high as China’s, socioeconomic factors also play a huge role in women’s choice to have a caesarean. Wealthy women are more likely to have the procedure—in fact, 55% of women with a family yearly income greater than $1000 do—so it is viewed as superior and desired medical care. Beyond that, low SES women are concerned about receiving biased or sub-par care from doctors in a vaginal birth and see a c-section as the solution. What’s interesting is that it’s all about the women’s perspectives of their treatment: the researchers write, “According to some women, a traumatic vaginal birth often occurred because of medical negligence based on social and economic prejudice…Indeed, many of the factors influencing maternal behaviors, such as fear of pain, are meaningful precisely because they are understood to differ by socioeconomic status and to be embedded in discriminating practices.” In this context, the desire to have a c-section is a function of women’s desire to establish some power over their bodies and medical experience. Unfortunately, it’s also reflective of misinformation about the benefit of caesarean sections. (4)

Interestingly, the high and increasing rates of c-sections worldwide are indicative of an over-medicalization of the birth process in developing countries. This statement may seem wrong or ironic given that so many women die because of lack of medical care before, after, or childbirth. However, studies have shown that in developing countries where medical care is available, there is an overuse of obstetrical interventions, notably c-sections but also episiotomies and oxytocin, a chemical used to augment and induce labor. All these practices are life-saving when needed, but may be harmful when used unnecessarily. (2)

Ultimately, distribution of c-sections worldwide indicates the health inequities which plague our world and especially its mothers. In The Lancet, a couple of Brazilian doctors commented on the trends in their country, noting “Within middle-income countries, inequities affect both extremes of the social scale: the rich have too many caesarean sections, whereas the poor have fewer than needed” (3). Indeed, this is the situation worldwide. In developing countries, where resources are painfully limited, prioritizing access, efficiency, and quality in maternal health care is absolutely crucial.

  1. http://www.msnbc.msn.com/id/34826186/ns/health-pregnancy/
  2. http://www.jsieurope.org/safem/collect/safem/pdf/s2938e/s2938e.pdf
  3. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68780-1/fulltext
  4. http://www.bmj.com/content/324/7343/942.full

TBAs, Technology, and the Maternal Referral System

February 17th, 2011

Last week, Jenna pointed out (here) some of the limitations of Traditional Birth Assistant Training programs. While some TBA training programs have shown benefits – for example by improving hygiene conditions at TBA attended births[i] – many have shown disappointing results. One of the major causes of disappointment in TBA training programs has been the realization that the referral link between TBAs and hospitals often functions poorly. The reasons for this are two-fold. First, some studies have indicated that training TBAs to identify obstetric emergencies does not necessarily increase referral rates.[ii] Secondly, as Jenna mentioned last week, there is often insufficient time to transport women with obstetric emergencies to tertiary care facilities.

The ability of traditional birth assistants to respond to obstetric emergencies is inevitably limited. Though training can allow them to cope with some complications, it will not remove the need for hospital-based interventions. Given the challenges associated with creating an effective referral link between TBAs and hospitals, some have suggested that TBA training programs are inadequate responses to high maternal mortality. If TBAs cannot or will not refer women to obstetric care facilities in time to save their lives, are we better off focusing our attention on increasing institutional births rather than promoting traditional birth assistants?

While the referral link between traditional birth assistants and hospitals has been historically weak, there are good reasons to believe that this could change. A wave of technological innovations in the field of maternal health has brought two groups of technologies that seem particularly applicable to the issue of strengthening the connection between TBAs and hospitals.

The first of these groups of technologies include innovations that may widen the time window during which life-saving referrals can be made. This group of technologies included anti-shock garments (see the LifeWrap and my earlier post) which respond to inevitable transportation delays by providing a means to stabilize a woman long enough to be transported to the hospital. Elsewhere in the medical technology world, new low-cost home tests for pre-eclampsia are emerging (see Jhpiego), offering the possibility of earlier detection of obstetric emergencies. Technologies such as these could play a vital role in improving the effectiveness of TBA training programs by increasing the number of cases in which referrals can be made in time to save the mother.

In addition to technologies that improve referral outcomes, other technologies respond to the need to increase the rates of timely referrals. A 2004 survey identified the development of clear referral guidelines as an important component of successful maternal referral programs.[iii] Historically, the principal tool for this purpose has been the partogram. Partograms, which track the progress of labor by plotting indicators such as cervical dilation, fetal heart rate, and duration of labor, assist doctors in identifying when pharmaceutical or surgical intervention is necessary. While highly cost-effective, partograms have proven inappropriate in many settings, particularly ones in which birth assistants are relatively less educated. The relative complexity of the partogram has prevented it from being widely used among traditional birth assistants. In response to this issue, a new version of the partogram has been developed which provides a simpler set of referral guidelines. Called “the paperless partogram,” this system requires birth assistants to perform two simple calculations in order to calculate an ALERT estimated delivery time and an ACTION estimated delivery time. Birth attendants are instructed to make arrangements for transportation to a facility with surgical capabilities at the ALERT time and to deliver the baby at the ACTION time. [iv] This system, combined with other tools such as mobile phones which play an increasingly important role helping TBAs to determine an appropriate course of action, may result in a more effective maternal referral program.

Technologies, however well designed, ultimately are only tools. Developing the link between traditional birth assistants and hospitals will require further education efforts and thoughtful adaptation of technologies to meet local needs. Still, the emergence of tools such as the LifeWrap and the paperless partogram should prompt us to reconsider premature eulogies on traditional birth assistant training programs. Many barriers to effective maternal referral systems continue to exist, but we have yet to exhaust the possibilities for making them work.

[i] Sogunro, Oluremi. “Traditional obstetrics; a Nigerian experience of a traditional birth attendant training program.” International Journal of Gynecology & Obstetrics. Volume 25, Issue 5, October 1987, Pages 375-379

[ii] Sibley et al. “Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention.” Journal of Health, Population and Nutrition. June 2009. pp 379-390 <<http://centre.icddrb.org/images/JHPN273-Cultural_Theories_of_Postpartum_Bleeding_in_Matlab,_Bangladesh.pdf>

[iii] “Tsu, V.D. and B Shane. “New and underutilized technologies to reduce maternal mortality: call to action from a Bellagio workshop.” International Journal of Gynecology & Obstetrics
Volume 85, Supplement 1, June 2004, Pages S83-S93. <<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7M-4CDRKC3-B&_user=145269&_coverDate=06/30/2004&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1645749489&_rerunOrigin=scholar.google&_acct=C000012078&_version=1&_urlVersion=0&_userid=145269&md5=0a29a3a723d862bb77421ef2c20fa6ef&searchtype=a#toc37>>

[iv] “The Paperless Partogram: A simplified tool to prevent prolonged labor.” Maternova. <<http://maternova.net/blog/paperless-partogram-simplified-tool-prevent-prolonged-labor>>

iv. The Life Wrap. <<http://www.lifewraps.org>>.

v. “Jhpiego among first recipients of innovation award from USAID.” 11 October 2010.  <<http://www.jhpiego.org/media/releases/nr20101012.htm>>.