Worldwide, we are losing ground on maternal health outcomes.
Maternal deaths are rising in many parts of the world, and we are not on track to meet SDG 3.1: Reduce the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births by 2030. In February 2023, the WHO released a report indicating that nearly 800 women died every day in 2020 – about one woman every two minutes.
More importantly, maternal deaths are not distributed equally. On a global scale, most maternal mortality is concentrated in sub-Saharan Africa (69%), particularly West Africa. Pregnancy-related causes are still the leading cause of death among African women aged 15-29. In the US, black women are 2.6 times more likely to die due to childbirth than white women.
This significant equity challenge is being overlooked; the deaths of mothers deserve more attention and more resources. Within Mali, even though pregnancy is deadlier than armed conflict, the world pays far more attention to military action than the deaths of pregnant women.
At the same time, nearly every maternal death could be prevented. Though there is no standardized global data, studies from sub-Saharan Africa routinely show that over 90% of the causes of maternal deaths could be avoided with access to basic, quality maternal healthcare. In the US,more than 80% of maternal deaths could be avoided. This contradiction is important and revealing – maternal mortality is mostly preventable, but we are still failing to prevent it. African women, and black women in the US, are dying at significantly higher rates. We must confront this truth, and its origins. We know what interventions work to improve maternal health outcomes. Our focus must stay on why all women and all communities don’t have access to them, and fix it. Our current systems, strategies, institutions, and financing are not reaching the women most in need, because the women most in need are not represented in our current systems, strategies, institutions, and financing. In our current approaches, marginalized women and communities are usually rendered as passive recipients of services, not as actors with agency who are essential participants in the development of remedies to these deep and historic inequities.
To fix this problem, asDr. Mary-Ann Etiebet noted, it is not just about what we do. It is about how we do it. We will not fix it by continuing to use the same approaches that have created and are maintaining these gaps in maternal health equity. It won’t be solved from the top-down, which is still how most of the world’s global public health systems work. What’s required is not developing a new technology or innovation.
If we are going to stop and reverse the increasing trend in maternal mortality, the women and the communities most affected must be at the heart of solutions.
If we do not change our approach, the result would be disastrous. By one estimate, if the reduction of maternal deaths continues at its current rate, SDG 3.1 would not be met in the African Region until 2100, after 125 million mothers died from a cause related to childbirth.
So what does it mean to change the how of our sector? What would it mean to dismantle entrenched systems designed to retain power and decision-making in certain hands? How do we prioritize and center the voices, experiences, and knowledge of those whose needs are not being met?
Instead of continuing to operate through our existing institutions and structures, and building interventions around their capacity to deliver or distribute solutions to a population, it means turning our focus to the mother who needs access to those solutions and starting to address the problem from her perspective.
It requires a complete shift towards a more fundamental question of who is invited to participate in the solving – who is invited to participate in the how. It means being willing to give up control and to pursue solutions that put power and resources into local hands.
We are trying to put this shift into practice every day. Whether it is adapting traditional quality improvement processes so they can be led by local teams of women and stakeholders, or redefining local health financing to ensure that women have the ability to build and manage their own health-financing resources, we strive to use a women-centered approach in every strategy. We convene and support women, community members, and providers in the community health system to work together to identify and solve obstacles to quality maternal healthcare in their communities.
Ending preventable maternal mortality is a problem that can be solved, but only if we’re willing to change how we try to solve it.
It is Wednesday, February 3, 2021, Aminata’s 3rd day in her new position with Mali Health. In the early morning at her desk, we asked Aminata to share her feelings about her journey and new role.
I am Aminata Seydou Traoré, I’m 29 years old, and I live in Kalabambougou in Commune IV of Bamako District. I have a Master’s degree in Law with a Judicial Career Option from the Faculty of Legal and Political Sciences of Bamako.
Aminata began working at Mali Health in February 2018 as a savings group facilitator, an animatrice, in Kalabambougou in our Women-Led Health Financing (WHF) programs. While she was serving as an animatrice, Mali Health supported the launch of one of our first cooperatives in Kalabambougou. Aminata brings extensive experience implementing our WHF strategies, but she has something even more valuable. She brings understanding and knowledge from three years of listening to and directly supporting women in her community. Reflecting on her time at Mali Health, Aminata tells us:
At first I wondered how I should go about meeting the goals that were assigned to me. Then little by little, I was able to fit into a team full of diversity. The questioning gave way to confidence and enthusiasm; then I said to myself that I have a lot to learn with this organization. My personal goal was to be able to be in a management position in the program in which I work. With the position of Program Assistant opened, I thought to myself – now is the time. So I applied and was right to believe it and give it a try.
She was right to believe in herself and try, and today Aminata is ready to thrive in her new role. Ambitious and always committed to serving her community, Aminata is also active in civil society organizations, including the Coalition of African Alternatives Debt and Development (CAD-Mali) through an organization known as Association of Youth for the Development of the Municipalities of Mali. We look forward to the enthusiasm and energy she will bring to her work with thousands of women across Bamako.
*Aminata is stepping into the role once filled by Aïssata Touré Kouyaté, who was recently promoted to Storytelling Manager.
As the COVID-19 pandemic slows in some parts of the world, the road ahead for the families we serve in Mali is still uncertain. What is clear is the impact the pandemic is having on the wellbeing of families who already faced many challenges. The health and economic impact of this disease will last for a very long time in the peri-urban communities we serve.
As we communicate with and support our partners each day, we wanted to share some of what they are experiencing with you. Since Mother’s Day will soon be here in the US, we particularly wanted to share how the moms we serve are doing.
Dr. Thiéro is the DTC (Directeur technique du centre, or health center technical director) at our partner health center in Sabalibougou (where our WomenConnect project is located). He noted that in April of this year, antenatal care visits fell by 35%, from 289 last April to 189 this year. Postnatal care visits have fallen by 15%. Visits for other curative services have dropped off even more.
Dr. Thiéro reports they have never seen such rapid declines like this before, not even during Ebola. He attributes the change to all the rumors and fears about COVID-19: that you will contract it at the health center, be diagnosed with it if you go, or simply accused of having it if you have any of the symptoms.
At home
Our health savings groups cannot meet normally right now, but we are still finding ways to share health information. We spent the weeks before COVID-19 arrived in Mali training our team to share information with all groups and to help them prepare for its arrival. We were able to reach all 5058 women in our savings groups, and all 180 women in our cooperatives.
Korotoumou is a member of one of our savings groups in Boulkassoumbougou. At the end of March, she had a cold that was making her very tired. She did not want to go to the health center because it is said that if you go with a cold, the staff will automatically isolate you, and your family, which would lead to stigma in your community.
So Korotoumou decided not to go, until the day her group facilitator came and shared information on COVID-19 and encouraged everyone to continue seeking care as normal. The following day, she changed her mind, and went to the health center to get the care she needed, and she recovered. Just last week, she attended her scheduled antenatal checkup at the health center. Korotoumou told us:
I think it is very important to share the right information with members of the community so that families can avoid very difficult situations either due to delaying care or to stigma from COVID-19.
Fortunately, like Korotoumou, all the women in our savings program for pregnant women (SHARE) continue to complete all of their antenatal and postnatal visits as scheduled. All 10 of the women who gave birth in March or April did so at their health center.
Community health workers
Our team of 41 health workers continues to safely visit or check on the families in their care, which include 1812 mothers, 167 of whom are pregnant, and their 2701 children. You already know how hard our CHW team works to take care of families, but you may not know that most of them are mothers themselves.
Kadidiatou is a community health worker in Lafiabougou, and the supervisor for the other CHWs working in her community. She has two sons; one is 3 years old and the second is 3 months old. Like everyone in her community, she had some doubts when she first heard about COVID-19. But as soon as she attended our initial team trainings, she understood the threat posed by this disease and was able to get answers to all her questions, which she now shares with all the families she cares for.
As a mother, she is also taking as many precautions as she can to protect her family, by not visiting friends and neighbors and by closing the gate to her home so others do not stop by for a visit. Unfortunately, her niece tested positive for COVID-19, which was a difficult time for her family. Thankfully her niece has recovered, but Kadidiatou uses her experience as a way to convince others to take COVID-19 very seriously.
Last Saturday, she was checking on a pregnant mother, Sanata, to remind her that she had an antenatal visit coming up this week. But as they talked, she realized Sanata did not intend to go. When Kadidiatou pressed her, Sanata shared that she had heard it said that if someone goes to the health center, she will return with COVID-19, noting that it was only recently that health centers had any preventive measures in place, like handwashing stations. She told Kadidiatou,
I do not want to go to seek care, only to catch this illness and bring it home to my family.
Mothers like Sanata and Kadidiatou are not alone. Our team is talking with worried mothers across Bamako. As long as COVID-19 is a threat to their families, our team will continue to help mothers navigate and overcome all the challenges that prevent them from accessing healthcare in their communities. Now more than ever, it is clear that all mothers and children deserve access to quality healthcare – and just how far we still have to go.
The limited resources available in Mali make it extremely vulnerable to COVID-19. The best chance that Mali has is to prevent an outbreak before it begins, so that is our focus. If you can, we hope you will contribute, or buy a bar of soap, and together we will help make sure families and health centers have the essential resources they need, like soap, to stay safe.
Like us, you are probably receiving daily emails about the global pandemic confronting our world.
While there are no confirmed cases in Mali, we do not yet know what impact COVID-19 will have on the communities we serve.
Mali is extremely vulnerable to an outbreak like COVID-19. There are perhaps only 20 ventilators available and the health system simply does not have the capacity to manage the number of patients who would need care. In the peri-urban communities we serve, limited access to running water and soap, as well as dense populations, make many preventive measures difficult or impossible to adopt.
But we are holding on to hope. The countries surrounding Mali have several cases, including the continent’s first confirmed death to the disease, a woman in Burkina Faso. The fact that there are no confirmed cases in Mali is an incredible achievement. We are doing everything we can to support both the government and communities to prevent any cases.
Here are a few reasons why we are hopeful that we can:
The people of Mali are resilient.
The past several years have been some of the most challenging in Mali’s history. If there is anything we can say about the challenges Malians have faced since 2012, it has contributed to their strength and resilience. Malians repeatedly demonstrate their commitment to their communities and to one another; social cohesion is extremely valued and it is worked towards every day in large and small ways. Since we began our work, the people of Mali have faced a political crisis, the Ebola outbreak, and a worsening security situation. Through it all, Malians are working together to support one another and their communities. Resilience is one of the greatest strengths Mali has to get through this pandemic.
We are ready.
Even though we are a community organization, our team has experience responding to disease outbreaks and coordinating with national responses. Our community health workers continued to serve their communities during the Ebola outbreak, and have a strong desire to do so. Our team continues to reach thousands of families with the prevention information and resources they need to stay healthy. We are helping our community health center partners prepare and implement stronger prevention measures. Our dedicated team will continue serving their communities unless distancing measures are ordered by the government, or until it becomes unsafe for them to do their work. We do not know how big the task before us will be, but our team is prepared, and we are helping our partners and the communities we serve prepare, too.
Here are some of the steps we are taking:
Our health team did a refresher training for our entire team, including over 50 community-based health workers and group facilitators, on the signs of COVID-19 and the top prevention measures
In the homes and communities we serve, our team is emphasizing these messages in their daily visits, particularly handwashing with soap (which is always a big priority for us)
With our CSCom partners, we have re-implemented many Ebola prevention methods, such as ensuring our health workers are stationed at each CSCom to greet and share information with all visitors and making sure all visitors wash hands upon arrival and departure
We are making sure our partners have all the equipment they need to maintain proper prevention protocols, such as handwashing stations, and soap. Until the threat of COVID-19 has passed, all proceeds from the sales of our soap will go to equipping community partners with soap, which we will source from our cooperatives.
We are in the process of doing a small evaluation to assess where the needs might be at our partner CSComs (in terms of facility and preparation) as well as how best to help them with health promotion and making sure prevention messages reach all patients and visitors
We are also making plans, should the very worst occur. When the health system is stressed and its resources spread thin, access to primary care will suffer. We’re doing all we can to ensure that mothers and children will still have access to quality primary healthcare, during this pandemic, and after it.
We will get through this in the same way we accomplish everything we do – by working together.
Mali Health believes in building on a community’s existing resources. We do not want to replace them, because we want to enhance them. Often, a community’s greatest resource is its residents – people deeply committed to improving life for their families and neighbors.
A central tenet of our organization has always been to build deep connections to, and within, the communities we serve. We believe it is the only way we can develop local, long-term solutions.
That’s why we deploy a team of 50 community-based health agents who can sit across from mothers, listen to them, and answer their questions. They are an essential part of our strategies to improve community health. They are also an essential part of how Mali and the world will achieve universal health coverage, through improved community health.
One of the greatest examples of the local leadership that is changing the face of community health in Mali is our team’s new leader, Dramane Diarra.
Dramane has been a part of Mali Health for 10 years, having joined us in October 2009. He has held multiple roles over the past decade. Beginning as a health promoter, he rose to lead the entire Health Promotion team. Because of his leadership of his department and several other important projects, like our role in the Ebola response and the subsequent Global Health Security Agenda, Dramane became our most senior program leader at the beginning of this year.
Dramane has as much experience and knowledge of Mali Health as anyone, and perhaps more than anyone.
But it is not just his past roles in our organization that position Dramane well to lead our team. Dramane’s role in Sikoro (see more from Sokone below) and his belief in the power of communities to improve community health, make him the ideal leader for the hard work we will do going forward.
We are at a critical time. We want to from collaborating with our community partners to implement effective strategies, to helping them sustain them. We’ve made progress, as with our participatory quality improvement approach, but our goals are immense and long-term. To reach them, we need someone who understands the communities we serve from within. We need someone who knows how to motivate and support other community leaders to join him – and that is Dramane.
Here’s how Dramane sees his work:
” My commitment to community health comes from my firm belief that in every community, there is the power to improve health.
This power, at times, can be disjointed or poorly expressed, or even misunderstood and undervalued. But all it takes is to highlight it and to show communities how to use it; then the results will follow.
Everyone, whatever her level or his position, comes from a community; it is to this community that he or she returns at the end of every day. If every community understands the need to come together, every community can improve health.“
As our work to improve maternal and child health continues, we are recommitting ourselves to strengthening the resources and leaders on the ground – helping them to see and use their power, you might say. In order to build local and resilient community health systems in Mali, we will rely on leaders like the one Dramane was in Sikoro in 2006, and the one he is today.
The most powerful, dedicated, and impactful community health leaders come from within – and we are just getting started supporting them. Now, we are thrilled that our team is led by one.
Sokone is a community health worker in Sikoro. She’s known Dramane for many years, and here are her thoughts about our new team leader:
” I have known Dramane since he worked at the Sikoro Animation Center before joining Mali Health. He contributed greatly to the development of Sikoro as an educator and by helping families enroll their children in school. That is the work that helped him to become known, respected and solicited by the people of Sikoro. Since his arrival at Mali Health, this son of Sikoro has been steadfast in his commitment to help disadvantaged families have access to quality health information and healthcare.
Like all the community health workers, Dramane helped me a lot personally. He has helped us become knowledgeable, competent actors so that we can inform the families in our community. This constant support of our team has led to dramatic changes in the health of children and families in Sikoro.
Hard-working and courageous, Dramane has always been available for the cause of Sikoro, from his childhood to this day. “
While the fields of public health and medicine (among others) often invoke compassion as a grounding principle, its application to our training and practice as professionals is still developing. We recently had the chance to reflect on compassion and its role in our work, and we realize it a conversation that we want to continue. And we’d love for you to be a part of it. Share your thoughts with us on social media, or send us an email.
In mid-June, we attended the IZUMI Partners Meeting in Boston. We are so fortunate to work with IZUMI and they have been a strong, steady partner as we have developed our approach to improve healthcare quality, governance, and community participation at community health centers.
IZUMI Foundation supports global health around the world and is part of a group of foundations originating in the Shinnyo-en order. Shinnyo-en is a Buddhist denomination originally established in Japan that is grounded in values such as kindness, compassion, and caring for others. In fact, one translation for the Japanese word izumi is “heart of compassion” and in the Shinnyo-en tradition, that is represented by a deep commitment to social awareness and justice.
IZUMI Foundation is driven by the principles of hope, health and compassion and we are delighted that the one thing that stayed with us the most from their meeting was not something we learned about global health or nonprofit leadership, but something far more universal: the role of compassion.
The keynote speaker at IZUMI’s meeting was Dr. David Addiss, an advocate for compassion in global health, and he spoke about its necessity in our sector. Compassion is a familiar value for most of us, but Dr. Addiss differentiated compassion from other values and grounded it clearly in our field. Compassion is not rooted in sympathy or pity – those connote differences in power, even superiority. Instead, compassion is rooted in solidarity and an acceptance of our interconnectedness.
Though some may view it as an unscientific discourse, he noted that compassion is a skill that can be practiced and there is a growing field of neuroscience devoted to understanding it. Compassion can be taught, and learned. Dr. Addiss asked us to consider and interrogate compassion – as the desire to alleviate suffering – as the inspiration and motivation for many of us and as the ground in which our field is rooted.
Though we are now back in the busy day-to-day of our roles, the idea of compassion has remained with us. It has encouraged us to reflect on the role it plays in our organization – and in our partnerships with communities in the US, and in Mali. As a small community organization, we often think of Mali Health as generating so much of our identity from the communities we serve in Mali – the proximity of our team within them and our service to them – and the community in the US who chooses to support that work. But if we take a step back and ask ourselves why that identity has meaning for us – the answer looks much like compassion.
At its best, compassion is about solidarity, about making connections across difference out of a recognition that we are linked. While compassion might stem from conditions of inequality, those we serve are not the objects or recipients of our charity. They are equal partners in eliminating suffering and improving the wellbeing of all.
But sometimes, that distinction isn’t always clear in our sector. There can be a downside to compassion, especially when it comes to examining our motivations and choices as individuals. Helpers of all kinds can burn out and people make poor choices in the name of serving others. At its worst, those operating in the name of compassion insist on maintaining power and agency over others – blind to their own biases and the oppression they perpetuate. And we still watch with concern as the power that exists in our sector not only can allow poor leadership or poor development work, but can incentivize it. Compassion alone is not enough to solve these challenges, nor is it the only value that should direct us. But we wonder if it might not be the kind of guiding, and grounding, principle from which global health as a field, and we as practitioners within it, could benefit.
In Mali, we see many applications for compassion in our daily work. The idea of “compassionate care” in a clinical or medical setting is not a new idea, but compassion is not a term we often use in public health. Our work and the way we train our team is grounded in principles of respect and care, but compassion still seems distinct.
Yet we see it in our community health workers going out each day to tend to their neighbors – doing so out of a sense of improving their communities and protecting the most vulnerable within them. We see it in our office staff, who have a strong sense of service to others and have dedicated themselves to our mission and values.
But perhaps where the idea of compassion resonates most for us is in our work to improve the quality of primary healthcare for the most vulnerable. Within quality improvement, there is a well-defined emphasis on the delivery of respectful maternal care that ensures all mothers are treated with equity and dignity. Interestingly, compassion does not often accompany these principles in the literature. But with its insistence on recognizing the human connection between a provider and a patient, compassion seems inherent in the current quality, equity and dignity (QED) framework in maternal and child health.
But there’s more we’d like to do.
Ethiopia’s Health Systems Transformation Plan discusses the creation of a compassionate, respectful, caring (CRC) health workforce, embedding compassion not only in quality, but also a building block of health systems strengthening (HSS). HSS can be one of the “nameless, faceless” areas of global health that the call for compassion is seeking to humanize – and we’re watching closely.
We are imagining how we might facilitate conversations with our team and our partners about the role of compassion not only for their motivations as individuals, but also within their daily work. We are thinking about what connections we might make between our emphasis on the patient experience in our quality improvement work, and how compassion might further improve our partners’ ability to provide more patient-centered care. Might we help our partners build a compassionate, respectful, caring (CRC) workforce?
Our ideas for how we might integrate compassion into our work are just beginning…
We also know that members of the Mali Health community are motivated from a place of compassion. You have told us time and again that you see solidarity at the heart of our work, and that is why you support us. You share your compassion with women and children in Mali, and us, because you believe that no one should suffer because they don’t have access to quality healthcare. Beyond your participation in our community, many of you are physicians, educators, or helpers of some kind. Your compassion, your desire to alleviate suffering, emerges in all areas of your life.
For us both, reflecting on compassion has led us to some rich and thought-provoking places. We are thinking about its role in our motivations as leaders, in the organization and team we support, and in our field. We wonder if you might have similar insights?
We want to open up the conversation about compassion in our communities – both in the US and in Mali – and we invite you to be a part of it. Let us know your thoughts about the role of compassion in your life – personal and professional. We’d love to hear from you. Send us an email, or leave us a note on social media.
