Dr. Ana Langer: Improving Maternal Healthcare, Sustainable Development, and the Future of Mobile Health

HHPR Staff

HHPR’s Hanna Amanuel had the privilege to interview Dr. Ana Langer of the Harvard School of Public and the Women and Health Initiative. As part of the interview, we had the opportunity to learn the research that the Maternal Health Task Force is engaged in and how maternal healthcare can be developed and improved.

HA: I’d love to hear a bit about what you do at the School of Public Health and the Women and Health Initiative.

AL: I joined the Harvard School of Public Health in 2010 as the Professor of the Practice of Public Health in the department of Global Health and Population to lead a new program called the Women and Health Initiative, one of the Dean’s Flagship initiatives. We have a school-wide mandate: we provide a platform for colleagues, students, and staff from across the school and other schools at Harvard and other academic institutions in the area to discuss women’s health issues along the life cycle and to discuss the roles and status that women have as healthcare providers, both informally at home and in the community and formally in the health system. We also look at the interaction between the roles of women both as users and providers of health care. The main area of focus these days is maternal health, and we have a flagship maternal health project that is called the Maternal Health Task Force. For that project, we do a number of things on maternal health, including research. Our most recent project has focused on different strategies to improve the quality of maternal healthcare, with respect to both the technical quality and the interpersonal quality of care. Or, in others words, ways to reduce disrespect and abuse during pregnancy and labor and delivery, which is unfortunately quite common. From a technical perspective, on ways to improve the quality of the health interventions that providers offer to women who face complications. Those projects were implemented in Ethiopia, India, Nigeria, Tanzania, Bangladesh, and Pakistan. So over the last 3.5 years, we’ve had research projects in those countries. They are now coming to an end because the grant is wrapping up and we are in the process of renewing it for another cycle of 3 years.

HA: That’s amazing. Was the research also focused on designing new interventions?

AL: In consultation with partners in all those places, we designed new interventions that were aimed at improving different aspects, or components, of the health system. For instance, in the case of Ethiopia, we worked with a hospital in Addis Ababa, the capital city, and eight health centers, with which the hospital is connected and the hospital supports. Working within that micro-health system, we strengthened providers’ skills to address maternal health complications, introducing some innovative training techniques. We introduced obstetric emergency drills, an approach to training that was not known or heard of in that country. So we trained providers both at the primary care and the secondary level of care with drills. We also strengthened the referral system between the health centers and the hospital, both for referral and counter-referral. We established a system by which midwives from the health sector and from the hospital rotated—so those working at the health center level went to the hospital for some time, and those in the hospital went to the health center for some time. That helped them to understand the conditions in which their peers worked and facilitated communication between them and also improved the quality of the referrals, because they knew what the providers in the other place could offer to women with complications or a normal delivery. We also introduced improved technical supervision—i.e., ‘supportive supervision’—that tries to provide supervision with a very positive spin, and making sure that it’s not perceived as punitive but rather, what it should be, supportive. Basically, our interventions were mostly at the health systems level and the aim was to improve the quality of care, and therefore maternal health and global health outcomes.

HA: You mentioned midwives and how they were involved in quality improvement interventions in these different countries. I’ve heard a lot about systems where traditional birth attendants, as they’re often referred to in a lot of public health literature, become more integrated in the healthcare system. I was wondering what your reflections are on what these programs have been like in this past and what you see as the future of such interventions.

AL: Well, I don’t know how familiar you are with the debates about the role of traditional birth attendants. Traditional birth attendants definitely play an important role in many societies because they are usually culturally close to the women they serve and because they have a lot of experience and a lot to offer to women. At the same time, some evaluations have shown that traditional birth attendants are not well-positioned to save women’s lives, because they don’t have the skills, but also because they do not have the resources to successfully assess an emergency that a woman may have, particularly in the time of labor and delivery. Countries have taken different positions with respect to traditional birth attendants. Some of them have tried to ban them completely—which from my very personal opinion is a big mistake. I think that traditional birth attendants have a very important role to play, as a point of contact for women and as health workers able to identify danger signs and complications and refer women in a timely fashion to higher-level facilities if needed. Other countries have tried to integrate them better and give them a limited but very critical role. Some countries encourage them to accompany women to the hospital for institutional delivery and stay with them. I would say that, in general, the consensus is that traditional birth attendants are not the best option to save women’s lives, but still play an important role in the health system and they should be incorporated in a meaningful way.

HA: It’s interesting you say that because I was doing some research on the maternal health system in Eritrea, and one researcher suggested, with respect to the issue of disrespectful birthing care, that traditional birth attendants can play an important role in sensitizing healthcare professionals to the ways in which women in their communities want to be treated during birth. I thought that was a really creative idea.

AL: Sure, sure. The exact ways in which the traditional birth attendants are incorporated into the health system depends a lot on the characteristics of the health system and the country, and the role that traditional birth attendants play in that particular context. In some countries they play a major role. In some countries that are more urbanized where western medicine is more appreciated, maybe now they are playing a smaller role. So everything needs to be contextualized.

HA: Right. What are some issues within maternal and reproductive, and more broadly women’s, health that you feel are not discussed or researched enough?

AL: Well, there are many, in spite of the progress that has been made in the areas of reproductive and sexual health since the international conference of population and development 20 years ago during which the global community adopted the so-called “Cairo Program of Action” that embraced sexual and reproductive health as one of the key priorities for women. There has been significant progress, but there are still many areas that need more attention and work. An important one is adolescents’ sexual and reproductive health. Adolescents are still very neglected and their needs are not met in most countries. They are only met in some developed countries. In many places, including the US, adolescents don’t have easy access to contraception. They don’t have good ways to integrate their personal development needs, like attending school, with other issues that may happen in their lives, like getting pregnant. Sexual education for adolescents is very poor quality in most places. Adolescents are definitely disadvantaged. Another area that we have not been able to tackle well is intimate partner violence or gender-based violence, which continues to be very prevalent. The health system sometimes misses important opportunities to identify women who are victims of domestic violence and help them seek or get the support, the care, they need. So that is another important area of focus. Then, a huge area is chronic and non-communicable diseases. They are increasingly important in all countries, including low-income countries. Diabetes, mental health problems, hypertension, and obesity are conditions that are affecting many women in low-income countries or in low socioeconomic strata in developed countries, who are not receiving the attention they deserve. Most of the attention and the resources are focused on very important issues like reproductive health and infectious diseases, but unfortunately that unfinished agenda is now overlapping with a new agenda of chronic and non-communicable diseases that also requires attention.

HA: As a follow-up, a lot of countries will not be able to achieve the Millennium Development Goals for maternal and child health. Do you feel like the discourse in international forums within the UN and other places, like the Women and Health Initiative, has shifted recently?

AL: I wouldn’t say that the discourse has changed. As you know, the end date of the Millennium Development Goals is approaching this year, and the global community is about to embrace a new set of goals—the Sustainable Development Goals. The Sustainable Development Goals will have a much broader focus on development in general, with a lot of emphasis on the environment, which is absolutely necessary and important and great. But health will have a much less prominent role than it did in the Millennium Development Goals, where 3 out of 8 of the goals were focused on health.

HA: Do you think this will impact funding mechanisms, and how much attention and money is going to these issues?

AL: Well, we don’t know yet. It may well affect funding mechanisms and the level of funding as well. One of the good things about the Millennium Development Goals, and there are many, is that there were few. Therefore, the international development aid and funding was very focused on a few issues, obviously some important ones were left out of the Millennium Development Goals, and that is not good. But particularly for maternal and child health, it was a wonderful period because maternal and child health got so much visibility and so many more resources than in the past, thanks to those very focused goals. That may change with the Sustainable Development Goals—there’s going to be only one health goal, but it will have maternal health as one of the key areas of focus within that goal.

HA: So, as you described to me, the Women and Health Initiative engages actors at different levels, including many students. For those of us interested in promoting women’s health in the long-term, what would your advice be given your work and your journey up to this point?

AL: Students are definitely one of the main players that we mobilize through the Women and Health Initiative and other efforts so that they engage in different activities aimed improving women’s health and women’s status in general, particularly those in the most vulnerable sectors of the population, either in low-income countries like Eritrea or other countries you may be familiar with, where in general the population is very poor, but where women are the poorest of the poor. Or in middle-income countries, where the average health conditions are relatively good, but where certain women are discriminated against due to ethnicity, race, disability, age, or different circumstances that make them particularly vulnerable. Students bring new perspectives and ideas; their familiarity with technology; and their enthusiasm and energy. And they are definitely the future. For us in an older generation, engaging students is completely essential. The goals we have been pursuing over a lifetime will continue to be pursued by the next generation. We try really hard and in many different ways to involve students in an effort to identify and nurture the next generation of leaders in the field of women and health and maternal health. We engage students by including them as research assistants and by supporting their work during the summer and the J-term with organizations that do good work on maternal health in some of the most challenging environments. We also include students in all of our seminars and the activities we do to disseminate not only our work, but also the work of others who visit us and spend some time with us, who are important players in the women and health and maternal health fields. And, of course, I also teach and I’m hoping to both strengthen existing interest in the field of women and health and reproductive health and expose students, who may not be that focused in those areas, to both the challenges and opportunities that exist and encourage them to explore women’s health and reproductive health as an area of focus in their career. I particularly welcome the opportunity to engage with college students, students who are at earlier stages of their careers, because I think that’s when you can have a greater impact. I am very inspired by the growing interest of students at Harvard in global health and maternal and reproductive health. Some of your fellow students invite me to participate in events and I think it is wonderful to have the chance to interact with students in this university. I think that we should work in both settings, at the College and here at the School of Public Health.

HA: You mentioned that students can engage technology in new ways. There’s a lot of stuff around mobile health, especially within maternal health. I was wondering with what you see as the future of mobile health, or what may be some unintended consequences?

AL: Well, mobile phones are now being used for a variety of purposes in the field of maternal and child health. They look as a very promising way or platform to disseminate information, to encourage women to use services in the best possible way, to affect health-seeking behaviors, and to empower women in general. That is one way to use mobile phones. Another important use of mobile phones is to train providers and to share with them protocols that they can follow. A wide-range of projects are now being implemented to try to explore the potential benefits that could come from the amazingly wide utilization of cell phones everywhere. The truth is, however, that most of these projects are relatively small and have not been very well evaluated. So we all need to pay more attention to them and find the resources and time to evaluate those projects properly and, after that, scale the successful ones up and adjust them to different contexts and different circumstances. Similar comments would apply to other communication technologies, like tablets or cell phones for other purposes, like using them for ultrasounds and other specific medical diagnostic tests. I think that students are particularly well positioned to come up with good ideas on technologies because you are the generation that was born surrounded by all these tools, while those of us in an older generation were not. Although we are becoming good users, we don’t necessarily have the creativity or the resources to use these technical tools to their full potential. I think students are much better positioned to do that than we are.