Fulfilling the mdg an analysis of jamaica’s policy framework for improving maternal health
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Fulfilling the mdg an analysis of jamaica’s policy framework for improving maternal health Document Transcript

  • 1. FULFILLING THE MDG: AN ANALYSIS OF JAMAICA’S POLICY FRAMEWORK FOR IMPROVING MATERNAL HEALTH A Thesis Submitted in Partial Fulfilment of the Requirements of the Degree of Masters of Science in Governance and Public Policy of The University of the West Indies Nicole Antoinette Hayles McGowan 2009Sir Arthur Lewis Institute of Social and Economic StudiesFaculty of Social SciencesMona Campus
  • 2. TABLE OF CONTENTSAbstractAcknowledgementsDedicationChapter 1 Introduction Maternal Mortality: A Global Perspective Causes of Maternal DeathChapter 2Literature Review Domestic Violence and Maternal Mortality Maternal Mortality in Jamaica Safe Motherhood in JamaicaChapter 3Research Objectives and Methodology Research Objectives Methodology Questionnaire Sample LimitationsChapter 4 2Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 3. FindingsDiscussionChapter 5Conclusion and RecommendationsReferencesAppendices Questionnaire for Technical Experts Questionnaire for Healthcare Providers Questionnaire for Focus Group Informed Consent Form Informed Consent Form for Focus Group 3Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 4. ABSTRACT Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework For Improving Maternal Health Nicole Antoinette Hayles McGowanThe changing epidemiology of the causes of maternal deaths in Jamaica, that is adecrease in direct causes while there is an increase indirect causes, has sharpened thefocus for a more concerted effort in bringing the issue of maternal mortality to theforefront of national discourse. While efforts have been made over the past two decadesto reduce the direct causes of maternal deaths such as haemorrhage, sepsis, andhypertensive disorders, indirect causes such as HIV/AIDS, heart disease and diabetes areon the rise. In Jamaica, the classification of deaths have been limited in scope, eventhough international agencies have cited domestic violence as having an impact onmaternal mortality, and have described the social problem as an increasing public healthconcern.In this thesis, an analysis of Jamaica’s policy framework for improving the country’smaternal health is assessed, with specific emphasis on domestic violence, which receiveslimited attention, if any at all, in the Ministry of Health’s policy document for safemotherhood. The research examines the possible impact of its exclusion on Jamaica’sprospects of reducing its Maternal Mortality Rates by 75% by 2015.The analysis is based on the findings of elite interviews and focus group discussions withexperts in the field of maternal health, and pregnant women who are the ultimateassessors of the care they receive, and whose outlook evaluates the efforts of the policy inachieving its prescribed mandate.The research found that domestic violence was excluded from the national policyframework as the issue is not seen as a priority for maternal health; domestic violencefalls outside the purview of the Ministry of Health. Despite this, pregnant women whoparticipated in the research believe that this social issue should be included in any policyframework aimed at improving maternal health, as safe motherhood should encompass awholistic approach to maternal health.Keywords: maternal mortality; domestic violence; safe motherhood; policy; Jamaica 4Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 5. ACKNOWLEDGEMENTSThe researcher would like to thank a myriad of persons for helping to make this paper areality. Special thanks to Rowena Palmer, Dr. Karen Lewis-Bell and Dr. Yvonne Munroeof the Ministry of Health; Prof. Affette McCaw-Binns of the University of the WestIndies; Georgette Campbell and Dr. Heather Reid-Jones of the South East RegionalHealth Authority; Maria Rankine of Woman Inc.; the team of the Spanish Town Hospitaland the Bureau of Women’s Affairs. Heartfelt gratitude is also accorded to mysupervisor, Dr. Aldrie Henry-Lee, whose guidance, assistance, and constant words ofencouragement were invaluable in making this research paper a reality.Gratitude is also extended my husband, Fabian McGowan, my most valuable supporterand critic, whose constant insight keeps me intact and keeps the demon of procrastinationaway. Many thanks are also in order to the many well-wishers for their words ofencouragement. Eternal thanks to the Lord for giving me the strength to persevere. 5Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 6. DEDICATION To my children: brilliantly shining brightly. 6Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 7. CHAPTER 1 IntroductionWhy have 1091017 (women) died in 2008? Women died for the lack of family planning,skilled birth attendance, or emergency obstetric care. Another 1,440 will die today unlesswe act. United Nations Population Fund (2009a)1.The drive towards improving maternal health has become a global priority as it is placedat the forefront as one of the eight Millennium Development Goals (MDGs) that worldleaders have committed to address by 2015. Over the past two decades a lot of work hasbeen done to reduce annual maternal mortality statistics, particularly with theintroduction of the Safe Motherhood Initiative which was launched in 1987 in Nairobi,Kenya. The aim of the initiative was to address the issue of women dying duringpregnancy and child birth, by reducing maternal mortality by 50% by the start of themillennium. While this target was not achieved, the Safe Motherhood Initiative is seen asthe first global effort in addressing the world’s high maternal mortality and morbidityrates (McCaw-Binns 2005; Smith and Sulzbach 2008; Women Deliver 2009).Safe motherhood is the ability of a woman to undertake pregnancy and childbirth, if andwhen desired, without injury to her self and her child (Ransom and Yinger 2002). Safemotherhood programmes are designed to reduce the high numbers of maternal deaths andillnesses which result from complications of pregnancy and childbirth. In many countries,1 7 http://www.unfpa.org/safemotherhood/, retrieved June 25, 2009.Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 8. the leading cause of maternal deaths is haemorrhage, complications of unsafe abortion,pregnancy-induced hypertension, sepsis and obstructed labour (UNFPA 2009a). Acountry’s safe motherhood programmes is therefore targeted at addressing these medicalcomplications as well as implement and undertake the appropriate measures to ensurethat women have access to health services.The global thrust towards improve maternal health, also went further by quantifyingglobal targets through the creation of the MDGs which were adopted in 2001 by the 192United Nations (UN) member states. The objective is that by 2015 the targets outlined inthe Millennium Development declaration would have been met. The MDGs include:1. Eradicate extreme poverty and hunger  Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day.  Achieve full and productive employment and decent work all, including women and young people.  Halve, between 1990 and 2015, the proportion of people who suffer from hunger.2. Achieve universal primary education  Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling. 8Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 9. 3. Promote gender equality and empower women  Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015.4. Reduce child mortality  Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.5. Improve maternal health  Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio.  Achieve, by 2015, universal access to reproductive health.6. Combat HIV/AIDS, malaria, and other diseases  Have halted by 2015 and begun to reverse the spread of HIV/AIDS.  Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it.  Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.7. Ensure environmental sustainability  Integrate the principles of sustainable development into country policies and programmes; reverse loss of environmental resources.  Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of 9Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 10. loss.  Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation.  By 2020, to have achieved a significant improvement in the lives of at least 100 million slum-dwellers.8. Develop a global partnership for development  Develop further an open trading and financial system that is rule-based, predictable and non-discriminatory. Includes a commitment to good governance, development and poverty reduction—nationally and internationally.  Address the special needs of the least developed countries. This includes tariff and quota free access for their exports; enhanced programme of debt relief for heavily indebted poor countries; and cancellation of official bilateral debt; and more generous official development assistance for countries committed to poverty reduction.  Address the special needs of landlocked and Small Island Developing States.  Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term.  In cooperation with pharmaceutical companies, provide access to affordable in developing countries.  In cooperation with the private sector, make available the benefits of new 10Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 11. technologies, especially information and communications. (UN 2009)2.2 11 http://www.un.org/millenniumgoals/, retrieved June 25, 2009.Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 12. Maternal Mortality: A Global PerspectiveProgress towards the MDGs has been uneven as each country is said to have differentdegrees of achievement towards each target (ECLAC 2005, 254). In the case of maternalmortality, it remains “unacceptably high across much of the developing world”; reducingglobal statistics by three-quarters remains a challenging task (UNFPA 2009b). Accordingto the World Health Organization maternal mortality is defined as “the death of a womanwhile pregnant or within forty-two days of termination of pregnancy, irrespective of theduration and site of the pregnancy, from any cause related to or aggravated by thepregnancy or its management, but not from accidental or incidental causes”. Maternalmortality is also seen as “the number of deaths due to complications of pregnancy,labour, puerperium and abortion per 100,000 total live births” (Ashley 1973). Suchdefinitions therefore highlights that death can be direct or indirect. Direct cause of deathencompasses factors relating to the complications of pregnancy, delivery, or theirmanagement, while indirect death relates to “death in a patient with a pre-existing ornewly developed health problem” (WHO 2009). Any other causes of death that a womanmight experience that are unrelated to the pregnancy are classified as accidental,incidental or non-obstetrical maternal deaths (Ibid). The definitions posited are howeverlimited in their scope, as maternal deaths may occur after forty-two days after atermination of pregnancy or delivery (Koonin et al 1988). Maternal mortality may also beinfluenced by factors outside the realms of physical pregnancy. Violence against women;war and civil unrest; the quality of maternity services; socio-economic circumstances 12Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 13. such as poverty, large families, over crowding, illiteracy, poor sanitation; as well asculture and customs can also have an impact on maternal mortality rates (Thomas 1993).According to the World Health Organization et al (2007) in its Maternal Mortality 2005report, up to 15% of pregnant women worldwide experienced potentially fatalcomplications during birth, which equated to approximately twenty million women eachyear. The report also noted that 80% of the global statistics on maternal deaths are due tofive direct causes: haemorrhage, sepsis, unsafe abortion, obstructed labour andhypertensive diseases of pregnancy. The report also revealed that of the 536,000 maternaldeaths, approximately 21% was due to haemorrhaging (see Table 1 and Figure 1).Table 1. Estimates of Maternal Mortality Rates (MMR), number of maternal deaths,lifetime risk, and range of uncertainty by United Nations MDG regions, 2005 MMR Number of Life time risk Range of (Maternal Maternal of maternal uncertainty of Region deaths per Deaths death MMR estimates 100,000 live Lower Upper births) Estimate EstimateWorld Total 400 536,000 92 220 650Developed 9 960 7,300 8 17CountriesCountries of the 51 1,800 1,200 28 140commonwealth ofindependent statesDeveloping 450 533,000 75 240 730CountriesAfrica 820 276,000 26 410 1,400Northern Africa 160 5,700 210 85 290Sub-Saharan 900 270,000 22 450 1,500AfricaAsia 330 241,000 120 190 520Eastern Asia 50 9,200 1,200 31 80South-Eastern Asia 300 35,000 130 160 550 13Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 14. MMR Number of Life time risk Range of (Maternal Maternal of maternal uncertainty of Region deaths per Deaths death MMR estimates 100,000 live Lower Upper births) Estimate EstimateWestern Asia 160 8,300 170 62 340Latin America & 130 15,000 290 81 230the CaribbeanOceania 430 890 62 120 1,200Source: WHO. 2007. Maternal Mortality in 2005: Estimates developed by WHO, UNICEF,UNFPA and The World Bank, 16.Figure 1.Source: WHO.2007 WHO. 2007. Maternal Mortality in 2005: Estimates developed by WHO,UNICEF, UNFPA and The World Bank 33 http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html, retrieved June 25, 142009.Copyright © 2009 Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 15. Of the 536,000 maternal deaths, developing countries accounted for 99% of the deaths,which translated to 533,000. More than half of the world’s 2005 MMR occurred in sub-Saharan Africa which totaled 270,000. Sub-Saharan Africa also has the highest MMR,accounting for 900 deaths per 100,000 live births, compared to South Asia 490, Oceania430, South-Eastern Asia 300, West Asia 160, Northern Africa 160, Latin America andthe Caribbean 130, and Eastern Asia 50. India was ranked as the country with the highestnumber of maternal deaths which totaled 117,000, followed by Nigeria 59,000, theDemocratic Republic of Congo 32,000, Afghanistan 26,000, Ethiopia 22,000, Bangladesh21,000, Indonesia 19,000, Pakistan 15,000, Niger 14,000, Tanzania 13,000, and Angola11,000. All these countries accounted for 65% of the maternal deaths recorded in 2005(WHO 2007, 15).Despite the figures for 2005 figures, maternal mortality is said to be on the declineglobally in all regions, however the decline is marginal (UNFPA 2009b). MMR wasdown by just 1% when data from 1990 to 2005 are compared. The WHO et al. (2005)note that the decline is too low to meet MDG target of a 75% reduction in MMR from1990 to 2015, as achieving this will require rates of up to 5.5% annually (See Table 2). 15Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 16. Table 2. Comparison of 1990 and 2005 maternal mortality by United Nations MDGregions 1990 2005 MMR Maternal MMR Maternal % Annual Region Deaths Deaths change in % MMR change in between MMR 1990 and between 2005 1990 and 2005World Total 430 576,000 400 536,000 -5.4 -0.4Developed 11 1,300 9 960 -23.6 -1.8CountriesCountries of the 58 2,800 51 1,800 -12.5 -0.9CommonwealthStatesDeveloping 480 572,000 450 533,000 -6.6 -0.5CountriesAfrica 830 221,000 820 276,000 -0.6 0.0North Africa 250 8,900 160 5,700 -36.3 -3.0Sub-Saharan 920 212,000 900 270,000 -1.8 -0.1AfricaAsia 410 329,000 330 241,000 -19.7 -1.5Eastern Asia 95 24,000 50 9,200 -47.1 -4.2South-Eastern 450 56,000 300 35,000 -32.8 -2.6AsiaWestern Asia 190 8,500 160 8,300 -16.2 -1.2Latin America & 180 21,000 130 15,000 -26.3 -2.0the CaribbeanOceania 550 1,000 430 890 -22.2 -1.7Source: WHO. 2007. Maternal Mortality in 2005: Estimates developed by WHO, UNICEF,UNFPA and The World Bank, 17. 16Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 17. Causes of Maternal DeathAmong the leading causes of death are haemorrhage and hypertensive diseases, whichaccount for the largest proportion of maternal deaths in the developing world (UNDP etal. 2005). In Africa and Asia haemorrhage is the leading cause of death at a rate of 33%and 30.8% respectively. In Latin America and the Caribbean however, haemorrhage isthe second leading cause of death, as hypertensive diseases lead the way, accounting for25.7% of maternal deaths in the region. Hypertensive disorders are also the secondleading cause of maternal deaths in the developed world accounting for 16.1% of alldeaths.Table 3. Maternal conditions most frequently reported in studies included inWHO/HRP4 systematic review, 2005. Morbidity Number of studies (%) Hypertensive disorders of pregnancy 885 (14.9) Stillbirth 828 (13.9) Preterm delivery 489 (8.2) Induced abortion 400 (6.7) Haemorrhage (antepartum, intrapartum, 365 (6.2) postpartum, unspecified) Anaemia 267 (4.5) Placenta anomalies (pravia, abruptio, etc.) 245 (4.1) Spontaneous abortion 235 (4.0) Gestational diabetes 224 (3.8) Ectopic pregnancy 146 (2.5) Premature rupture of membranes 140 (2.4) Perineal laceration 139 (2.3) Uterine rupture 116 (2.0) Obstructed labour 102 (1.7) Depression (postpartum, during pregnancy) 96 (1.6) Puerperal infection 86 (1.5)4 17 Development and Research Training in Human Reproduction (HRP).Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 18. Morbidity Number of studies (%) Violence during pregnancy 77 (1.3) Urinary tract infection 66 (1.1) Malaria 54 (0.9) Other conditions 973 (16.4) Total 5933Source: UNDP, UNFPA,WHO, World Bank Special Programme of Research, Development andResearch Training in Human Reproduction. 2005. Progress in Reproductive Health Research, 4.According to the Beijing Platform for Action adopted at the Fourth World Conference onWomen in 1995, complications related to pregnancy and childbirth are the leading causeof death and morbidity among women of reproductive age in the developing world (UN2006). Despite this though, reliable statistics on maternal deaths over the years is stilldifficult to obtain which further compounds the problem in fully understanding the causesof death worldwide. The United Nations (2006) reports that there is significantunderreporting and misclassification of maternal deaths, as there are often problems atthe point of civil registration, as deaths are sometimes not correctly identified, thereforecompromising the reliability of data. The UN also notes that maternal deaths are alsohard to identify because information regarding the age of women, pregnancy status, aswell as the medical cause of death is sometimes hard to ascertain. The UN states that: (The) experience in developing international estimates of maternal mortality illustrates the many difficulties that countries face in measuring maternal mortality. The accuracy of data on maternal deaths depends largely on the existence and reliability of national civil registration systems, which are the primary source of data on 18Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 19. deaths….Policy makers and planners increasingly demand that data be annually reported and that these data are current. However that is not the situation observed in most countries…Limited reporting is therefore affecting the continuous availability of up-to-date annual information for a number of countries (which) is largely due to delays in data compilation and dissemination. (UN 2006, 26)This underreporting also makes it difficult to gather information on the cause of maternaldeaths which are a result of violence against women. Discourse on domestic violence andmaternal mortality has been receiving prominence as the two are said to be “linked”(PAHO 2005; Espinoza and Camacho 2005; Mitchell 2000; Bacchus et al 2004; Edin andHögberg 2002), as some women die from domestic violence while pregnant or during theforty-two days after pregnancy. It is however still not known what proportion of maternaldeaths is due to domestic violence, the estimates among countries, as well as the factorsthat could explain the disparities (PAHO 2005). 19Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 20. CHAPTER 2 (Literature Review) Domestic Violence and Maternal MortalityViolence against women both violates and impairs or nullifies the enjoyment by women totheir human rights and fundamental freedoms…the human rights of women and of thegirl child are an inalienable, integral and indivisible part of universal human rights. Beijing Platform for Action (1995)5.The Beijing Platform for Action reaffirms the principles of human rights outlined in theVienna Declaration and Programme of Action adopted by the World Conference onHuman Rights. As an agenda for action, the Platform is aimed at promoting andprotecting the full enjoyment of all human rights and the fundamental freedoms of allwomen throughout their life cycle. Likewise, the Convention on the Elimination of AllForms of Discrimination against Women (1979) calls on governments to:  incorporate the principle of equality of men and women in their legal system, abolish all discriminatory laws and adopt appropriate ones prohibiting discrimination against women;  establish tribunals and other public institutions to ensure the effective protection of women against discrimination; and  ensure elimination of all acts of discrimination against women by persons, organizations or enterprises.5 20 United Nations, World’s Women 2005: Progress in Statistics (New York: United Nations, 2006), 69.Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 21. The Declaration also espouses that: Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life. It encompasses, but is not limited to, physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry related violence, marital rape, female genital mutilation and other traditional practices harmful to women; non- spousal violence and violence related to exploitation; physical, sexual and psychological violence occurring within the general community, including rape, sexual abuse, sexual harassment and intimidation at work, in educational institutions and elsewhere; trafficking in women and forced prostitution; and physical, sexual and psychological violence perpetrated or condoned by the state, wherever it occurs.6Violence against women is a multi-faceted and multi-dimensional phenomenon as itsdefinition varies depending on whose perception through which the act is interpreted.According to Gelles and Straus (1979) (cited in Crowell and Burgess1996, 9) violence is“any act carried out with the intention of or perceived intention of causing physical painor injury to another person.” Violence can also be seen as “physical, visual, verbal, orsexual acts that are experienced by a woman or a girl as a threat, invasion, or assault andthat have the effect to hurting her or degrading her and or taking away her ability tocontrol contact, intimate of otherwise with another individual” (Koss et al 1994 cited inCrowell and Burgess 1996, 10). Violence against women is also characterised as“coercive control that is maintained by tactics such as physical violence, psychological6 http://www.un.org/womenwatch/daw/cedaw/text/econvention.htm, retrieved June 25, 2009. 21Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 22. abuse, sexual violence and denial of resources” (Crowell and Burgess 1996, 10). Animportant element in comprehending violence against women and finding ways to solveit, is understanding what the causes of this social problem. Researchers have pointed totwo main elements: an examination of the characteristics that influences the perpetrator’sbehaviour and deciphering whether some women are more vulnerable to being victimised(Crowell and Burgess 1996).Crowell and Burgess (1996) argue that violence against women is not caused by a singlefactor; it is therefore difficult to isolate a sole determinant that could be fingered as thecause of this social problem. From an evolutionary perspective the goal of violence that isperpetuated against women by men is for the sole purpose of passing on their genes. Inother words, the goal of the perpetrator is to have offspring with his victim, which willstand the chance of survival and possibly promulgate the same set of genes Thephysiological or neurophysiological perspective argues that violence and aggression arethe function of hormones such as testosterone or the by product of abnormalities or braindysfunctions that interfere with cognition. Crowell and Burgess (1996) also citepersonality disorders, cultural myths about violence and gender based roles, as well as amotivated means by men to dominate women as causes that perpetuate gender basedviolence. Crowell and Burgess (1996) also posit that violence against women is also donein a dyadic context in that “a man often refrains from physical (verbal, psychological)violence until a woman has made an emotional commitment to him such as moving intogether, getting engaged or married, or becoming pregnant.” 22Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 23. Not only is violence against women a substantial public health concern, but violenceagainst a pregnant woman not only harms her but also increases the risk of injury to theunborn child. The consequences are also broader as it affects families and loved ones notonly of the victim but the perpetrators themselves. Children who lose their mother aremore likely to die before reaching the age of five (UNICEF 2009; UNFPA 2009a).Violence can harm the foetus through direct injury causing “placental damage, prematurecontractions, membrane rupture, or foetal death” (Koenig et al. 2006). According toKoenig et al (2006), between 4% to 8% of women experience violence during theirpregnancies. The authors say women who are engaged in HIV risk behaviour have anelevated chance of being abused while pregnant; women who engage in sex work or usenarcotics are more likely to be abused than women who do not lead such lifestyles.Becoming pregnant at a young age, low education, income levels as well as beingunmarried, are also seen as factors that increases a woman’s chances of being abused(Matthews 2002)A 2006 study (Koenig et al. 2006) in the United States revealed that of the 628 womenbetween the ages of 13 to 45 interviewed in a nationwide study, 8.9% of them reportedphysical and sexual abuse during their pregnancy. The report also revealed that 4.9% ofthe women also reported being abused at least 6 months after their deliveries. The reportnoted however, that very little is still known about the differences in violence risk duringpregnancy and after delivery, as the opportunities to detect abuse are being missed.Protecting women from violence during and after pregnancy will depend on how best the 23Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 24. health care system and other social services are able to identify women who are alreadybeing abused and enact the appropriate actions needed to end the violence against them(Koenig et al 2006).Domestic violence and maternal mortality are increasingly become a major global publichealth concern (PAHO 2005). Both domestic violence and maternal mortality areinterconnected, even though the proportion of maternal deaths due to domestic violencestill poses a challenge in maternal mortality data (PAHO 2005). According to Espinozaand Camacho (2005) the definition of maternal mortality should take into account“several components, including violent death, violence against women, and the currentinternational definition of maternal death, (as) maternal death due to domestic violence(warrants questions such as): which maternal deaths are caused by domestic violence?Would it only be deaths caused by direct lethal trauma, or should deaths due to obstetriccomplications that are initially caused by physical injuries also be included (for example,a placental abruption secondary to an abdominal trauma)? Can psychological violence beincluded as a cause of maternal death? Would these deaths refer only to domesticviolence by the intimate partner? And, should the motives of violence be considered aspart of the definition as well?” However based on the traditional medical definition ofwhat maternal deaths are, deaths caused by domestic violence are simply classified asexternal causes.The Pan-American Health Organization (2005) notes that the murder of pregnant womenby their partners and suicide among women while pregnant or following the end of 24Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 25. pregnancy, are often attributable to unwanted pregnancy. A study in Matlab, Bangladeshbetween 1976 to 1993, revealed that pregnant teenagers were at a greater risk ofcommitting suicide compared to non-pregnant teens. In 2001 it was revealed that inMorelos, Mexico approximately 15% of violent deaths of women were attributable tounwanted pregnancies (Ronsmans and Khlat 1999 cited in PAHO 2005; Walker et al.2005).The problem that lies herein is that the international definition of maternal death does notconsider “incidental or accidental causes of death, (thereby) exclud(ing) deaths fromdomestic violence from the numerator of the maternal mortality ratio” (Espinoza andCamacho 2005, 126). In most developed countries maternal mortality is low as itaccounts for only 1% of 2005 statistics, yet the deaths that are attributable to domesticviolence is not known. According to Gazmararian et al (1995), pregnant women die ofexternal injuries more often than medical complications. However reasons for theexternal cause of death are hard to source. It was also noted that women abused duringpregnancy were three times more likely to be murdered by their spouses, compared tonon abused pregnant women. However, Mitchell (2000) argues that the influence ofviolence on maternal mortality is not always linear as “violence does not have to beproximal to be causal” In other word, the influence of violence on maternal mortality isnot necessarily linear or clear cut, as there can be a myriad of factors that contribute tothe problem.In researching domestic violence and maternal mortality in the Otavalo and Cotacahi 25Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 26. provinces of Ecuador, Mitchell (2000), found that domestic violence was pervasive evenduring the periods when a woman was with child, as public hospital records revealed that13.6% of women treated had a reported lifetime history of physical abuse duringpregnancy. The study also uncovered that both married and unmarried women agreed thathusbands had the right to corporally punish wives who were “lazy, adulterous, refused todo household chores or sleep until the sun rise(s)”. In Otavalo and Cotacahi, gossip andsuspicion surrounding a woman’s pregnancy were also causal factors that perpetuatedomestic violence against pregnant women. A pregnant woman’s capacity to escape theviolence would therefore “depend on her ability to marshal social capital in her defense”.Social capital, that is the level of trust a woman has with her relatives and neighbours, isseen as the most salient asset in Otavalo and Cotacahi, as the geographical isolation ofwomen who live far away from immediate family members, sometimes due to marriage,makes them more at risk to violence (Mitchell 2000).Domestic violence against pregnant women is further compounded at the healthcare levelas those offering care, although knowledgeable of the sensitive needs of pregnant women,will not do the necessary research to ascertain if the women are being physically abused.A 1999 study of 51 midwives in 36 antenatal clinics in the Swedish county ofVästerbotten, revealed that these healthcare professionals, though cognisant of thefrequency of physical and sexual abuse before and during the current pregnancy of someof their patients, did not report the matter. The report further revealed that midwives alsodid not make adequate enquiries even if they were suspicious that the pregnant women 26Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 27. were being abused. The situation in Västerbotten was further compounded as “the localprogramme for antenatal care provided no guidelines regarding response to violence, noinstruments for disclosure and no directions about support when confronted with anabused pregnant woman. (M)idwives were (also) disclosing only a fraction of the cases ofabuse against women” (Edin and Högberg 2002, 268). The study further noted thatdomestic violence against pregnant women will remain hidden as long as the issue ofviolence is not addressed and included in the national or local programmes for antenatalcare (Ibid).The failure of health professionals to identify domestic violence and offer appropriatesupport is a significant problem. Bacchus et al (2004) argue that most women who are inan abusive relationship at some point requested medical assistance, therefore pregnancyshould provide an opportunity for doctors and midwives to identify and help womenexperiencing domestic violence because of their frequent visits to healthcare centres.Studies have shown that repeated enquiry using structured questions in pregnancysignificantly increases the rate of detection of domestic violence, as rates of violenceduring pregnancy perpetrated by a partner are said to range from 3.4% to 33.7%. Higherrates can however be elicited through direct questioning by trained health professionalsand repeated questioning (Bacchus et al 2004).While domestic violence against pregnant women occurs in all countries, the lack ofgreater discussion of the topic, appropriate questioning by those offering health care topregnant women, as well as reliable data to support and broaden discussions on the 27Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 28. implications of domestic violence on maternal mortality is lacking. Generating data onthe interconnectedness between domestic violence and maternal mortality is important indeveloping a strategic framework on Safe Motherhood (PAHO 2005). Preventingviolence during pregnancy can also assist in the achievement of MDG 5 which calls forthe reduction of maternal mortality by 75% by 2015. In doing this it will have a rippleeffect in the attainment of components of the other MDGs, which call for the totality ofhuman development. 28Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 29. Maternal Mortality in JamaicaJamaica is small developing state located in the Caribbean Sea at latitude 18° 15 andlongitude 77° 30. It has a population of approximately 2.7 million and is a heavilyindebted country, as it has the fourth largest debt-to-GDP ratio in the world (PIOJ 2009,5). The country has a total land area of 234 kilometres, and is located within the GreaterAntilles group of islands in the Caribbean Sea. Jamaica is located approximately,145 kilometres south of Cuba and 190 kilometres west of Hispaniola.Jamaica was once inhabited by Taino Indians who called the island Xaymaca, meaningthe land of “wood and water”. The Taino population is said to have been between 6,000to 9,000 persons. Their existence was however disrupted when Spanish explorerChristopher Columbus landed, in what is now known as St. Ann’s Bay, on May 4, 1494.The Tainos were defeated by Columbus and his men, and by 1509, Jamaica was declareda colony of Spain and renamed Santiago. However Spain’s rule was not long lived, as theBritish defeated them and seized control of what is now known as Jamaica in 1655.Jamaica remained under British rule from 1655 until it gained independence in 1962(Satchell 1999).While under British rule slavery was a prominent economic activity, as “the wealthcreated in Jamaica by the labour of black slaves has been estimated at £18,000,000, morethan half of the estimated total of £30,000,000 for the entire British West Indies”(Satchell 1999). But despite the high economic yield Jamaica derived from the labour of 29Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 30. slaves, the health of the slaves was not seen as a priority as there was always“replacement stock” that could be bought from Africa (McCaw-Binns 2005, 255).Pregnant slaves received little attention, as they were deemed inefficient and seen as aneconomic cost because of the amount of time they would need to recovery fromdeliveries and care for their babies. In the same vein, slave reproduction in Jamaica wasseen as inefficient as 20% of births were still births and less than 50% of infants survivedafter the first year. Things however changed in 1807 when the trading of slaves wasabolished (Patterson 1967 cited in McCaw-Binns 2005).The abolition of the slave trade saw more focus being placed on the health of ex-slaves,as estate doctors were employed to attend to the need of the remaining ones. The fertilityneeds of female ex-slaves were also given attention, as plantation owners could no longer“replenish” their stock from Africa; pregnant ex-slaves were therefore seen as a prizedinvestment. However those privileges soon came to an end, as the granting of fullemancipation in Jamaica in 1838 saw “the withdrawal of indulgences enjoyed by femaleex-slaves” (McCaw-Binns 2005, 255). By 1838 plantation owners no longer saw thehealth of the freed slaves as their responsibility, as by then, the estates were being toiledby indentured workers from China and India. However the collapse of the estate-basedhealth system is said to have prompted the authorities in England to enact legislativeprovisions in 1875 that resulted in the poor and destitute indentured workers, as well asmembers of the police force receiving medical care. By 1903, 45 district doctors weredispatched across all the health districts in the island (Ford and Cundall 1910 cited in 30Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 31. McCaw-Binns 2005).While the British government tried to fill the gap left by the collapse of the estate-basedhealth care system following emancipation with legislation in 1875, the island’s maternalmortality rate was high as the Registrar General reported an MMR of 660.9/100,000compared to 230/100,000 in the United Kingdom (Registrar General 1878 cited inMcCaw-Binns 2005). This revelation is said to have promoted the British authorities toestablish the Victoria Jubilee Hospital (VJH) which opened its doors, nine years later in1887 to commemorate the fiftieth anniversary of Queen Victoria. By 1929 Jamaica’sMMR fell to 488/100,000 (McCaw-Binns 2005) (See Table 4).Table 4. Maternal Mortality by cause: Jamaica 1929 Cause of Death Number Ratio per 100,000 live birthsEclampsia/ pre-eclampsia 34 91.0Puerperal sepsis 27+ 72.3Post partum haemorrhage 21 56.2Accidents of pregnancy 19 50.9Other accidents of 58 155.3pregnancyEmbolism/ sudden death 3 8.0Puerperal insanity 3 8.0 Total 165 488 31Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 32. Source: Medical Superintendent’s Report, Jamaica 1930 cited in McCaw-Binns (2005), 256. By 1960, Jamaica’s MMR stood at approximately 200/100,000, which was attributed to declines in sepsis deaths. There was also an improvement in maternal care, as the VJH had improved its antenatal screenings and hospital delivery bookings. By the time Jamaica gained independence in 1962, the role of community midwives had expanded beyond deliveries to include family planning services, antenatal, post natal, and child services. In 1980, over 80% of the population lived within at least ten miles of a primary health facility, thereby improving women’s access to basic health care (McCaw-Binns 2005). Improvements in Jamaica’s MMR were also attributed to an increase in the literacy levels of women of reproductive age. Secondary or higher education among women increased from 16.5% in 1970 to 70% by 2001. This increase in the education levels of women was coupled by an increase in their exposure and general expectations, as they were starting to “move away from having babies at home and became more selective where they gave birth” (McCaw-Binns 2005, 258). Between 1981 to 2001, births at hospitals increased from 70% to 91% respectively. Women’s exposure to the family planning programme, which was launched by the government in 1967 and integrated into the Ministry of Health’s maternal and child health programmes in 1979 also contributed to women’s increased awareness about their reproductive health, as Jamaica’s total fertility rate declined from 4.5 to 2.5 between 1975 to 2001 (McCaw-Binns 2005). 32 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 33. While there have been improvements in maternal healthcare in Jamaica, the lack of vitalregistration of maternal deaths continues to offer erroneous data due to misclassificationof the cause of death (McCaw-Binns et al 2007). This promoted the government toimplement a Reproductive Age Mortality Surveillance (RAMOS) with the first studybeing done between 1981 to 1983, and the other two between 1986 to 1987 and 1993 to1995. Based on the findings of the studies a comprehensive strategy to managepregnancy-induced disorders such as hypertension was developed, as well asimprovements in the quality of care at health facilities. The studies also prompted healthofficials to reduce the delays associated with the distance between health facilities, thereferral of high risk patients, as well as improving the skills of health care professionals.The study also revealed a decrease in Jamaica’s MMR to 106/100,000 in 1993 to 1995(McCaw-Binns 2005; McCaw-Binns et al 2007) (See Figure 2). In a bid for continuoussurveillance the Ministry of Health instituted a policy in 1998 that all maternal deathsmust be notified. All maternal deaths now had to be reported to the Ministry by all thefour Regional Health Authorities which are expected to investigate all deaths (McCaw-Binns et al 2007). But despite the policy directive there are still gaps and fluctuations inthe Ministry’s data sets, as there are reporting periods during which no data is available(See Tables 5 and 6). 33Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 34. Figure 2. Source: 1931–64: Annual Reports: Registrar General, Spanish Town, Jamaica; West Indian Medical Journal 2001, cited in McCaw-Binns et al (2007), 257.Table 5. Maternal Mortality by cause: Jamaica 2002-2005 (Source: Ministry of Health (2009)) Year Cause of Death Total Maternal Deaths for Year 2002 Pregnancy, childbirth, 12 puerperium 2003 Pregnancy, childbirth, 14 puerperium 2004 Pregnancy, childbirth, 4 puerperium 2005 Pregnancy, childbirth, 19 puerperium 34 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 35. Table 6. Maternal Morbidity: Jamaica 2003-2006 Year Obstetric Total Live Obstetric Percentage of Discharges Births complications complications 2003 51,316 43,705 2110 4.10% 2004 49,146 42,960 2581 5.30% 2005 48,675 45,114 2059 4.20% 2006 36,562 N/A 1859 5.10%Source: Ministry of Health (2009). While efforts have been made to reduce maternal mortality in Jamaica, the improvements are still seen as unsatisfactory, as key indicators reveal that there has been a failure to meet even the 2005 national MMR target of 80/100,000 (PIOJ 2009). The problem that lies herein, is that only a small portion of women initiate care in the first trimester of pregnancy. There are still unresolved data management problems even though the regional health authorities are to make mandatory reports; there are however underlying problems such as inadequate staffing and facilities to conduct proper post mortems. While maternal deaths from direct causes are said to have halved over the past 10 years, there has been an increase in indirect causes such as HIV/AIDS and non-communicable 35 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 36. lifestyle diseases such as diabetes and obesity. There is also a 47% shortage in the midwife cadre due to migration (PIOJ 2009). While figures of violence against women have fluctuated over the years, even though in the homes continue to feature prominently as the place women are more likely to be victims of violence, data is still lacking with regards to disaggregating figures for those which cause maternal deaths, or acts of violence committed against pregnant women (See Tables 7, 8, 9, 10, 11). While there’s no evidence regarding the impact of violence on Jamaica’s MMR (MOH 2009), Jamaica is however far behind in achieving MDG5 by 2015, as for the country to achieve the goal, Jamaica’s MMR would have to be reduced to 25/100,000 (PIOJ 2009; UNICEF 2009). Table 7. Violence related injuries by gender, 2003-2006. Gender 2003 2004 2005 2006 Males 8996 8787 8367 7481 Females 6567 6198 5792 5366 Total 15,563 14,985 14,159 12,847Source: Ministry of Health, cited in National Progress Report 2004-2006 (2008), 266. Table 8. Places of occurrences of injuries for females, 2003-2006 Place of Occurrence 2003 2004 2005 2006 Street/Public Area 34% 32% 33% 34% Home 57% 57% 55% 54% Institution/School 3% 3% 3% 4% 36 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 37. Place of Occurrence 2003 2004 2005 2006 Industrial/Commercial 3% 3% 4% 3% Other 3% 5% 5% 5% Farm/Countryside 1% 1% 1% 1% Total 6,501 6,226 5,649 5,212 101% 101% 101% 101%Source: Ministry of Health, cited in National Progress Report 2004-2006 (2008), 267.Table 9. Complaints filed and disposed of under the Domestic Violence Act, 2001-2005 Indicators 2001 2002 2003 2004 2005 Number of complaints filed in the Courts under the Domestic 1,071 1,444 1,701 1,604 1,177 Violence Act Number. and percent of complaints disposed of ion the 709 1,044 932 963 799 Courts under the Domestic Violence Act (66%) (72%) (55%) (60%) (68%)Source: Ministry of Justice, cited in National Progress Report 2004-2006 (2008), 380. 37 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 38. Table 10. Woman Inc. data, May-June 2009 Activities May June July Calls to centre 14 15 10 Calls to centre for 4 0 0 rape Calls to centre for 0 0 0 incest Calls to centre on 8 11 10 other issues7 Total 26 26 20 Visits to centre for 5 5 1 abuse Visits to centre for 0 0 4 rape Visits to centre for 0 0 0 incest Visits to centre for 8 2 1 other issues Total 13 7 6 Calls to hotline for 2 3 6 abuse Calls to hotline for 0 2 0 rape Calls to hotline for 0 0 0 incest Calls to hotline for 15 19 13 other issues Total 17 24 19Source: Woman Inc. (2009). 7 38 Other issues relate to domestic violence, infidelity, marital conflicts, child molestation Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 39. Table 11. Woman Inc. data, 2007-2009 January 2007- December 2008 Domestic Abuse 423 Rape 64 January 2009- July 2009 Domestic Abuse 146 Rape 20Source: Woman Inc. (2009). 39 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 40. Safe Motherhood in JamaicaAccording to the Ministry of Health (2007), between 1996 and 2004, the proportion ofhospital birth increased from 86% to 95% respectively. Skilled attendance at birth wasalso reported to be at 91%. Jamaica’s total fertility rate also declined to 2.5%, as teenagefertility decreased from 112 per 1,000 live births to 79 per 1,000 live births. Jamaicanwomen, despite the disparity in urban and rural access and resource constraints, haveaccess to family planning and child care. In other words, Jamaica’s rating for maternaland neonatal services is ranked 69 in the Maternal and Neonatal Program Effort Index(MNPI) compared to the average of 56 for the 49 countries which are ranked on theindex; this rating thus placed Jamaica second in service delivery among all the 49countries (Bulatao and Ross 2000). The MNPI is used to assess a country’s health careservices as well as track its progress over time (See Figure 3). Jamaica also has arelatively low MMR, when compared to other Caribbean countries (See Table 12).Figure 3. Comparison of global and Jamaica MNPI scores for selected items, 1999(Source: POLICY Brief. 2002. Maternal and Neonatal Program Effort Index: Jamaica) 40Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 41. Table 12. Reported Maternal Mortality Rates in the Caribbean, 2000-2006 Country MMR (Maternal deaths per 100,000 live births) Haiti 630 Dominican Republic 92 Antigua and Barbuda 0 Belize 130 Barbados 16 Bahamas 16 St. Kitts and Nevis 0 Guyana 120 Jamaica 95 Trinidad and Tobago 45 Dominica 0 Cuba 37 St. Lucia 35 Grenada 0Source: UNICEF. 2008. Progress for Children: A Report Card on Maternal Mortality, 43. Based on the figures presented in Table 7, it is clear that Jamaica is making strides in its efforts to reduce its MMR, when compared to other Caribbean countries in terms of the total number of births, particularly as Jamaica’s MMR remained static over a 20 year period at 106/100,000; since 2005, local figures have indicated a decline to 95/100,000 41 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 42. (MOH 2007). However the WHO in its Maternal Mortality 2005 report cited Jamaica ashaving a MMR of 170/100,000. The WHO was quick to caution however that their figurewas computed to ensure comparability amongst countries in a particular region, howeverthe figures presented may not necessarily be the official statistics of the country “whichmay use rigorous methods” of assessment (WHO 2007, 24) .While the major causes of maternal death in Jamaica continue to be hypertensive disease,haemorrhage and sepsis, these direct causes have been declining over the past 4 years.However indirect causes such as HIV/AIDS, violence8, and other chronic conditions suchas obesity and cardiac disease have been on the rise. Additionally, life stresses and theirimpact on mental health have also increased, as suicide has accounted for some cases ofindirect maternal deaths in recent times (MOH 2009). Jamaica’s Safe MotherhoodProgramme has been influenced by global initiatives to improve maternal and infanthealth in the context of equity, poverty reduction and human rights, and is in keepingwith the MDG of reducing maternal mortality by 75% by 2015 (MOH 2007).The public education component of Jamaica’s Safe Motherhood Progamme was officiallylaunched on July 1, 2009 at the Maxfield Park Comprehensive Health Centre; there werehowever pre-implementation stages over the past two years in health centres andhospitals with support from PAHO, UNFPA and WHO. Assistance from the international8 Although cited here as an indirect cause of death, the Ministry of Health has no reporting system thatclassifies deaths due to violence. 42Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 43. organizations was in the region of $55 million9, however with contribution from theGovernment of Jamaica pushed the amount to approximately $86 million. Theexpectation of the programme is that by 2015 Jamaica’s MMR would be reduced by75%, resulting in a decrease from 95/100,000 to 25/100,000.Jamaica’s safe motherhood policy framework addresses four main areas: 1. Creating an enabling policy environment 2. Quality of care 3. Surveillance 4. Health Promotion.Through the creation of an enabling policy environment, the government has committedto: developing policy guidelines and standards for service delivery and the investigationof maternal deaths; the revision of policies that guide the operations of midwiferyschools; address the issue of training, employment and retention of midwives and publichealth nurses; as well as establish a national maternal mortality committee. By increasingthe quality of care the government has made a commitment to: drafting of guidelines forthe management of common obstetric emergencies; provision of equipment and suppliesfor comprehensive care; the establishment of regional maternal mortality committees tomonitor quality of care in clinics and hospitals; the upgrading of hospitals to improvecare; as well as continuous education of doctors and nurses on various aspects of SafeMotherhood. As it relates to surveillance the aim is for: a revision of the existingsurveillance guidelines, as well as the timely reporting and investigation of maternal; the9 43 Figure quoted in Jamaican dollarsCopyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 44. creation of a database for summary reports on maternal deaths, as well as continuousmonitoring an analysis of the causes of maternal mortality. Additionally, healthpromotion, an integral component, is aimed at dissemination information about maternalhealth through the use of various media as well as at the institutional level.While the policy speaks to addressing issues critical to improving and addressing theshortages in the delivery of care necessary for the overall physical well being of pregnantwomen, the policy document however fails to address social issues that may affect awoman while with child. The Ministry of Health’s Strategic Framework for SafeMotherhood within the Family Health Programme 2007-2011 policy document, fails toaddress issues such as “culture and customs which (places) limits (on a pregnant woman)by withholding certain foods during pregnancy or encouraging unhygienic practices(which might) increase the risk to mother and child. (The policy also does not speak toissues such as) war, civil unrest and poverty (which) are other well known risk factors”(Thomas 1993, 30). 44Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 45. CHAPTER 3 Research Objectives and MethodologyRESEARCH OBJECTIVESDomestic violence against pregnant women is seen as a significant public health concernand if not addressed there is the likelihood that it could affect the gains of countries inachievement its target of reducing maternal mortality by 75% by 2015 (PAHO 2005, 1-2). The aim of this research is to assess the social problem of domestic violence withinthe context of the Ministry of Health’s Strategic Framework for Safe Motherhood withinthe Family Health Programme 2007-2011 policy document. More specifically theresearch paper aims to: 1. Assess the issue of domestic violence within the national policy framework for safe motherhood. 2. Assess whether healthcare providers ask direct questions regarding domestic violence within the context of healthcare delivery for pregnant women. 3. Increase awareness about the issue of domestic violence and its impact on maternal health. 4. Identify recommendations that can be used to inform the policy framework about domestic violence and its impact on maternal mortality. 45Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 46. The paper also aims to answer the following research questions: 1. What is the placement of domestic violence in the national health policy framework? 2. Do healthcare workers routinely ask pregnant women direct questions about domestic violence? 3. What is the impact of domestic violence on maternal health? 4. What policy adjustments are necessary to increase the awareness of the importance of domestic violence? 5. Will the issue of domestic violence derail Jamaica’s efforts in achieving MDG5?METHODOLOGYThis research paper is explanatory in nature. The research method employed is qualitativein the form of elite interviews and focus group sessions. Interviews were conducted withsenior officials in Jamaica’s health care system including: Director of Family Services,and Programme Officer at Ministry of Health; Professor, Reproductive HealthEpidemiology, University of the West Indies; Counselor, Woman Inc; Healthcareproviders at the Spanish Town. Focus group discussion was conducted with pregnantwomen receiving antenatal care at the Spanish Town Hospital.Elite interviews and focus group discussion proved the best research methods of choice tocollect specialized information about the issue of domestic violence and its impact on 46Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 47. maternal health, and the current policy focus. These research methods were also chosenas there is currently no reporting mechanism that captures the issue of domestic violenceand its impact on maternal mortality in Jamaica.QUESTIONNAIREThe researcher’s choice of content for the questions asked in the elite interviews andfocus group sessions were informed by the myriad of literature reviewed (see appendixfor a copy of the questionnaires used during the elite interviews and focus groupdiscussions). The impact of domestic violence on the health of pregnant women and itsimpact on maternal mortality were repeatedly explored therefore the researcherincorporated the issues raised in the questions posed to the interviewees.SAMPLEThe sample chosen for this research paper is the South-East Regional Health Authority(SERHA) which accounts for one-third of the births in Jamaica. SERHA is one of thefour statutory bodies of the Ministry of Health. SERHA was established as a part of thehealth sector reform through the National Health Services Act of 1997. SERHA isresponsible for the delivery of healthcare services to the residents of St. Catherine, St.Thomas, and Kingston and St. Andrew, which represents 47% of the population ofJamaica10.10 http://www.serha.gov.jm/, retrieved July 28, 2009. 47Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 48. LIMITATIONSTime- based on the magnitude of the issue of domestic violence and its possible impacton Jamaica’s prospects towards achieving MDG 5, the three month period given to theresearcher to explore such a multi-faceted and multi-dimensional social problem thatpossibly affects the lives of many Jamaican women was a major drawback.Financial- this handicap prevented the researcher from visiting more healthcare facilitiesand interviewing more health care professionals which fall under the jurisdiction ofSERHA.Bureaucracy (access delay and denial)- the researcher experienced delays in accessingthe healthcare facilities which fell under the jurisdiction of SERHA to conduct the eliteinterviews and focus group session. The delay was attributed to the series of criteria thatwere outlined and had to be met by the researcher, before SERHA approved and grantedaccess. Access delays were also experienced at the Spanish Town Hospital, as theresearcher had to undergo another screening process, even though permission wasgranted by SERHA which has overall responsibility for the facility.Access was denied to the Victoria Jubilee Hospital and Comprehensive Health Centre onSlipe Pen Road by the senior officers in charge of the facilities, even though SERHA,which has overall responsibilities for these healthcare facilities, had granted theresearcher permission to conduct elite interviews and focus group sessions. The seniorofficers in charge of the facilities were not willing to make the necessary arrangements to 48Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 49. accommodate the researcher.The denial of access to the Victoria Jubliee Hospital and the Comprehensive HealthCentre, therefore limited the researcher’s efforts in obtaining feedback on the researchtopic by more healthcare providers and women who visit the facilities for antenatalservices.Gaps in data- there was difficulty securing maternal mortality statistics for Jamaica forconsecutive years. Data requested from the Registrar General’s Department was notforthcoming; the Ministry of Health also did not have data sets for all the years requested. 49Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 50. CHAPTER 4 Findings and DiscussionFINDINGSThe results of the elite interviews and focus group discussion for this research paper arepresented separately in order for the responses of each group to be deciphered easily, andeach issue that will impact the objective outcomes and answer the research questions ofthis paper are presented in italic headings. Three main groups were incorporated in thestudy: technical experts, healthcare providers, and respondents of focus group discussion.Technical experts refer to the group of persons involved in research and policy planningfor maternal health, and issues relating to violence against women. These individualshave been working in their respective fields for an average of 14 years; range 3 to 25years. Technical experts do not offer direct care to pregnant women, however they arecritical in informing and helping to set policy for women and the delivery of services inthe local healthcare system, as well as addressing the issue of violence against women.Healthcare providers are those individuals who interface with pregnant women at alocalized level. They have been offering antenatal care for an average of 13.5 years;range 1.6 to 27 years.Healthcare providers each oversee the delivery of care to approximately 3,000 womenannually. The focus group involves women between the ages of 18 to 37 years old intheir first to fourth pregnancy who receive care at the Spanish Town Hospital. The 50Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 51. women were not asked direct questions about whether they were being abused due to thesensitivity of the subject. They were however asked to give their general views on theissue of domestic violence against pregnant women within the context of the MOH’s safemotherhood programme.TECHNICAL EXPERTSBased on the responses of technical experts, it was apparent that they understood why theissue of domestic violence was being raised by the researcher within the context of itsexclusion from the Ministry of Health’s Strategic Framework for Safe Motherhood withinthe Family Health Programme 2007-2011 policy document. While not all respondentsagreed with the objectives of the research, it was apparent that they acknowledged thatthe debate on the issue needs to be opened.Domestic violence in the national safe motherhood policy frameworkThe general physical health of a pregnant woman is the primary focus at every antenatalvisit. This ensures accurate information about delivery date, blood pressure, weight andurine analysis. Information is also gathered on whether the current pregnancy is thewoman’s first or if she has had past pregnancies and the relevant outcomes of thosepregnancies. Such inquires are important to assess the woman’s obstetric history, as themost common complication in Jamaica relates to eclampsia and pre-eclampsia. Socialissues such as the woman’s living situation, and whether the baby’s father is present inher life to offer support, are also discussed during antenatal visits. 51Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 52. The policy established for the delivery of antenatal care requires that each pregnant woman has a maternal record booklet. This “maternal passport” records the history of all the women’s pregnancy related medical history. The booklet has a section where the primary care officer (midwives, public health nurse) records information relating to obstetric problems. When such problems are detected the women are usually referred to the nearest Type A or B hospital11 to be seen by an obstetrician. For mental related issues, the women are referred to a mental health officer. The referred institutions or officer would then write a report12. The healthcare providers who initially gave the referral, would then give these women an appointment to return to the community health centre one week later. If the women fail to show up, the primary care officer or a community health aide conducts a home visit to check for compliance with the referral, and if necessary, escort the women to the hospital. In the event that the women need transportation, arrangements are made; this can however sometimes be a problem as vehicles within the public health system are often centralised. As it relates to girls under 18 years old who become pregnant, the Child Care and Protection Act (2004) dictates that prescribed persons, in this instance healthcare providers, having an inclination of a person under 18 years of age being pregnant, must 11 Type A and B hospitals provide inpatient and outpatient services in: general surgery, general medicine, obstetrics and gynaecology, paediatrics, and anaesthetics.12 Reports submitted to the MOH by the Regional Health Authorities, might not indicate that a referral wasmade, however based on the reporting format the MOH would decipher that a health problem was referred. 52 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 53. submit a report to the relevant authorities13. While the legal age of consent is 16 years old,the healthcare provider is still duty bound to make a report as the girl is under 18 yearsold.In the event that a maternal death occurs, the death is to be reported to the parish healthdepartment on suspicion and investigation initiated which includes: a home visit by amidwife or public health nurse; a clinical report by the obstetrician or other healthprovider handling the case; and a post mortem investigation. When these reports are inplace, a case review is to be held on conclusion of which a final report is to be submittedto the MOH.The technical experts have admitted that the policy established to guide safe motherhoodin Jamaica is lacking as it relates to addressing social problems that might affect pregnantwomen in the realization of “true” safe motherhood. At present Jamaica relies on theclassifications from the WHO regarding what constitutes a maternal death. The country’spolicy framework therefore only focuses on four main areas: 1. Family planning- expanded contraceptive mix; prevention of unwanted pregnancies 2. Quality of care- staffing ratio; clinical guidelines; complications of pregnancy 3. Surveillance- monitoring maternal deaths; guidelines for timely reporting 4. Health promotion- educating women and the public about safe pregnancy.The policy mostly focuses on the health needs of the women related to pregnancy andchildbirth. The technical experts noted that given the resource constraints of the MOH, it13 53 These include the police, child services, MOH, etcCopyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 54. is difficult to expect the policy to address all the needs of the pregnant women which gobeyond addressing their immediate healthcare concerns. The policy’s main strength theexperts assert, is that it attempts to comprehensively address the health problems bydeveloping guidelines and ensuring that the staff is adequately trained to deal with theleading complications of pregnancy.One technical expert noted that for the policy to address social issues it will depend onwhat the issues are. There are the usual referrals for support from the National HealthFund, if there is a co-existing chronic disease to provide help with financing prescriptiondrugs. Initiatives such as the Programme for the Advancement through Health andEducation (PATH) is also in place to assist pregnant and lactating women maintainadequate nutrition. Some NGOs also provide additional help to families in need, howeverthis varies based on location. The technical expert therefore noted that it might be unfairto expect the MOH to address the social issues affecting pregnant women, as that is notthe purview of the MOH. It was noted that other social sector ministries and agenciesneed to take on such responsibilities with appropriate strategies for referring at riskpersons to the appropriate agency that is able to address the women’s specific socialneeds.Another technical expert noted that if domestic violence were to be included in thepolicy, the country’s RAMOS would have to be modified to capture the impact ofdomestic violence on safe motherhood, as often times, the issue of violence may 54Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 55. sometimes be seen as anecdotal. There was also the point that even if domestic violencewere to be included in the reporting system, it might be ranked very low on the list ofcauses of maternal death based on financial constraints, as there will be the tendency tofocus on more immediate causes of death.While domestic violence may be a cause of psychological distress to some pregnantwomen and may be a source of physical pain and discomfort, there is currently no data tosupport this, as the impact of domestic violence on pregnant women is not a priority areawithin the safe motherhood agenda14. One technical expert noted that in the case of deathdue to accidents and violence, there are more deaths related to motor vehicle accidents,which the technical expert believes, more emphasis should be placed in developing astrategy for educating pregnant women about the safe use of the roads during pregnancy,as this is currently is not addressed in the policy. There is also the recommendation of astrategy to deal comprehensively with the issue of suicide among pregnant women whichis also not addressed within Jamaica’s Safe Motherhood Programme.Antenatal care and domestic violenceA protocol does not exist to address domestic violence during pregnancy. The discussionsin the Ministry of Health’s Strategic Framework for Safe Motherhood within the FamilyHealth Programme 2007-2011 policy document focuses on maternal self care related topregnancy, identifying the complications of pregnancy, and the appropriate responsesregarding health seeking behaviour. While healthcare providers might try to ascertain if14 National data ascertained for this research paper also did not disaggregate the data to indicate the impact 55of violence against pregnant womenCopyright © 2009 Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 56. the women are experiencing problems at home, direct questions about domestic violenceare not asked, as there are no policy guidelines to conduct such enquires.Guidelines by the WHO about what constitutes a direct or indirect maternal death, is thecriteria used by Jamaica to monitor issues of safe motherhood. The current parametersdo not include domestic violence in the classification of deaths. While the MOHdocuments all maternal deaths, those that are a result of domestic violence are notclassified as such, as there are no criteria. For example, a woman had a fight with herspouse and her blood pressure went up and later died on arrival at hospital, while anotherhad a fight with her partner and was kicked in the abdomen and also died. Based onnational figures these deaths would not be classified as being attributed to domesticviolence. The former case would be classified as death by eclampsia, even though it wasthe fight that caused her blood pressure to rise. The latter case would be classified asplacenta abruptio, even though it was the act of a physical blow to the abdomen thatcaused the death.One of the technical experts interviewed noted that the main ethical challenge withscreening for any health condition is whether the capacity exists to diagnose and thentreat. While the MOH might be able to address the acute consequences of domesticviolence such as treating injuries, managing the social consequences of domestic violenceare outside the purview of the MOH. It was also noted that domestic violence alonecannot be taken into isolation as homicide and suicide amongst pregnant women must 56Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 57. also be included in the discourse.The maternal mortality surveillance of 2001-2003 highlighted two to three deaths ofpregnant women who were the partners of ‘dons’ from the inner-city; the reasons whythese women were targeted was however not explored. As for suicide among pregnantwomen, the MOH has not created any mechanism to capture evidence for the reasonswhy women commit this act. For example, a 16 year old girl got pregnant and committedsuicide by drinking the pesticide gramoxone. While there was no concrete evidence,investigations suggested that the girl drank the pesticide because her boyfriend hadrejected her. The technical expert argued that until there are services and programmes inplace to assist victims of violence and abuse in a serious and comprehensive manner, thenthe issue cannot be addressed wholesomely, otherwise it is unethical to screen.It was further articulated that the MOH also has to develop a clear definition of what isdomestic violence. One of the challenges is that domestic abuse has both physical andmental health components, the latter of which is more difficult to measure. Issues such asverbal abuse and neglect need clear indicators and criteria for measurement, even thoughthe measurement and reporting of physical abuse is not necessarily straight forward.Clear guidelines would therefore have to be developed.There is also the issue that pregnant women who will not speak, ignore or lie about beingabused. Such silence or disregard on the part of the pregnant women, might createdifficulties for healthcare providers to identify that there is a problem. One technical 57Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 58. expert pointed to the three delay model which speaks to: the woman not recognizing thatthere is a problem; recognizing that there is a problem but delay getting care; andrecognizing that there is a problem, go to get care, but there is a delay in accessing care atthe healthcare facility. These delays, it was noted, have to be resolved before evenscratching the surface in trying to address the problem.There is also the concern about the lack of shelters or existing social programmes to sendthese pregnant women if there are screened during antenatal visits. The shelters that areoperated by voluntary organizations are often times inadequate, and in some instancesmight depreciate the quality of life to which the women might be accustomed. It is alsobelieved that asking pregnant women direct questions about whether they are beingabused by their partners might cause anguish, as there is currently nothing to offer thesewomen.One technical expert noted that one particular non-governmental organization whichoffers outreach services for abused women, would be hesitant in accepting a pregnantwoman at its shelter. Housing at the shelter is temporary and lasts for two weeks; anextension may be granted, however each case is evaluated based on its own merit. In thecase of a pregnant woman, she would be accepted at the shelter if she is employed. Thetechnical expert noted that the woman’s having employment is critical, because if she isnot, the organization may deem the woman to be an inappropriate candidate as she willmore likely expect to stay for more than the two week period. Also based on her physicalstate, it might be difficult for her to attain employment, thereby causing her to be a 58Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 59. “burden” to the facility.Based on the current reality, one technical expert noted that they would never include theissue of domestic violence in a strategic plan as it is not a priority; resources are limitedtherefore there has to be focus on the most critical and immediate needs for pregnantwomen. The other experts argue however, that such an inclusion would have to beconsidered based on the evidence gathered from a comprehensive research.Domestic violence and its impact on maternal healthThe changing epidemiology of maternal deaths in Jamaica, that is a decrease in directwhile there is an increase indirect causes, requires constant modification of the strategiesaimed at reducing maternal deaths. Reducing indirect deaths caused by heart disease,HIV/AIDS, and diabetes, will require lifestyle modifications aimed at reducingoverweight, obesity and unsafe sexual practices. The technical experts note that reducingexposure to the risk of dying from these conditions is however difficult to bring about inthe short term. The inability to control these lifestyle related disorders, will thereforemake achieving MDG 5 a difficult goal to attain.It was also noted that the MDGs were set on a global scale. The technical experts believethat the target of MDG 5 of reducing maternal mortality by 75% is more geared towardsSub-Saharan Africa where MMR is high (See Tables 1 and 2; Figure 1); a 75% reductionwould therefore be more critical for them. The ‘one-size fits all’ approach is therefore 59Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 60. seen as inappropriate. The technical experts say that for a middle income country likeJamaica to reduce its MMR by 75% by 2015 is unattainable, as the country would have toattain an MMR like that of the developed world (See Tables 1 and 2; Figure 1).It was also noted that based the economic situation in Jamaica and the availability oflimited resources also makes the target an impossible one. More effort and resources needto be directed toward training healthcare providers to improve the outcomes from theleading direct complications (hypertension, haemorrhage, abortion, embolism), as well asincluding improving access to tertiary intensive care for women with acute complicationswhich require ventilatory support. It was noted that each health region should have accessto high dependency unit beds in order to manage these women without the need for longdistance transfer to Kingston or Montego Bay.The need to address the shortage of staffing for maternity wards due to migration wasalso an issue that needs to be addressed. One technical expert noted that the removal ofuser fees was not a good decision, as this policy directive has limited the resourcesavailable to the sector. Persons with health insurance which could be used to reimbursethe health sector for services provided to insured persons are not being billed, therebydenying the public health sector of well needed facilities and economic resources.Despite the challenges, Jamaica’s MMR is said to be below the average of the Caribbeanand Latin America (See Table 13), as Jamaica is not doing badly when compared to 60Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 61. others in the region. The technical experts cautioned however, that while Jamaica cannotbecome complacent because of its regional ranking, as more work needs to be done toaddress the current problems, the country is still behind target in achieving MDG 5.Table 13. Reported Maternal Mortality Rates in the Caribbean, 2000-2006 Country MMR (Maternal deaths per 100,000 live births) Antigua and Barbuda 0 Argentina 39 Bahamas 16 Barbados 16 Belize 130 Bolivia 230 Brazil 76 Chile 17 Colombia 78 Costa Rica 36 Cuba 37 Dominica 0 Dominican Republic 92 Ecuador 110 El Salvador 71 Grenada 0 Guatemala 150 Guyana 120 Haiti 630 Honduras 110 61Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 62. Country MMR (Maternal deaths per 100,000 live births) Jamaica 95 Mexico 62 Nicaragua 87 Panama 40 Paraguay 170 Peru 190 St. Kits and Nevis 0 St. Lucia 35 St. Vincent and the Grenadines 0 Suriname 150 Trinidad and Tobago 45 Uruguay 26 Venezuela 60Source: UNICEF. 2008. Progress for Children: A Report Card on Maternal Mortality, 43.Despite Jamaica’s progress in reducing its MMR, social issues such as poverty, crime andviolence were cited as subjects that need urgent attention, as pregnant women aresometimes unable to leave their communities to access care because of these social ills.The majority of technical experts noted that there is a possibility that domestic violencemight derail Jamaica’s prospects in achieving MDG 5. They noted however that despitethere being no data to give credence to the impact of domestic violence on maternalmortality, the issue must not be disregarded. Crime and violence are major public healthissues, which the technical experts believe not only affects safe motherhood, but also the 62Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 63. delivery of healthcare. It was noted however that data is needed to inform the decisionsthat may be necessary to address the problem if it exists.One technical expert was however strident in noting that Jamaica’s failure to addressdomestic violence will in no way derail the country’s prospects of achieving a reductionin maternal mortality, as the direct contribution of domestic violence to maternal deaths isnegligible. The technical expert noted that domestic violence is more of an issue ofmaternal morbidity than maternal mortality, therefore it will not in any way affectJamaica in reducing its MMR by 75% by 2015. It was also noted that there needs to bemore investment in improving the quality of the current obstetric services, before theMOH moves into an area which is outside its direct control to efficiently and effectivelyimprove outcome. The technical expert notes that the issue at hand is how much domesticabuse, verbal abuse and neglect contributes to unwanted pregnancy, maternal morbidity,and poor maternal interest in seeking antenatal care, as well as complying with thedirectives of the healthcare providers.HEALTHCARE PROVIDERSBased on the responses of healthcare providers, it was apparent that they understood whythe issue of domestic violence was being raised by the researcher within the context of itsexclusion from the Ministry of Health’s Strategic Framework for Safe Motherhood withinthe Family Health Programme 2007-2011 policy document. It was apparent however thatsome healthcare providers did not know what the term “safe motherhood” meant, as they 63Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 64. were accustomed to word “antenatal care”, which is a component of safe motherhood.While not all respondents agreed with the objectives of the research it was apparent thatthey acknowledged that the debate on the issue needs to be opened.Domestic violence in the national safe motherhood policy frameworkThe general issues discussed by healthcare providers with pregnant women to whom theyoffer care are: personal hygiene, nutrition and diet, layette, signs and symptoms ofpregnancy, and attire during pregnancy. Issues relating to delivery date, blood pressure,weight and urine analysis is also discussed. Healthcare providers also speak with womenabout their obstetric history of they have had previous pregnancies.Healthcare providers adhere to the policy protocol as outlined in the responses given bythe technical experts above. In SERHA all high risk patients are referred to the VictoriaJubilee or Spanish Town Hospitals.The healthcare providers with whom the researcher spoke, said they did not know of theMinistry of Health’s Strategic Framework for Safe Motherhood within the Family HealthProgramme 2007-2011 policy document. They also noted that the term “safemotherhood” was foreign to them, as they have never heard the term until the researcherused it. The healthcare providers added that they have not received any training orsensitization from their regional health authorities or the MOH regarding the term “safemotherhood”. The healthcare providers noted however that they are familiar with theterm “antenatal care”, which is what they are accustomed to, and which is what they use 64Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 65. when they speak of issue relating to maternal health. The healthcare providers havesuggested that they be sensitized and made aware of the issue of safe motherhood, as itwas the researcher who explained that the provision of antenatal care is only a componentof safe motherhood.Despite the confusion of terminology, the healthcare providers were ambivalent as itrelated to the exclusion of domestic violence in the MOH’s strategic framework for safemotherhood. Some healthcare providers noted that it would be unethical to diagnose aproblem if there is no capacity to treat, as often times there are no relevant agencies towhich patients would be referred. They cited for example the inadequacy of healthcarefacilities to adequately report incidences of girls under 18 years of age who are pregnantand attend healthcare facilities to get care. While the Child Care and Protection Act(2004) stipulates that a report be submitted and the relevant authorities notified, somehealthcare providers noted that the issue is not being addressed wholesomely, as reportsare sometimes not submitted on time, which can cause delays in the relevant authoritiesbeing made aware of the situation.Some healthcare providers believe however that the issue of domestic violence should beaddressed by the safe motherhood policy. They noted that the MOH should implementsystems, so that when the diagnosis is made the healthcare provider refers the pregnantwomen to the appropriate agencies which deal with social issues. The healthcareproviders were quick to caution that dealing with social issues should not be the purviewof the MOH. They explain that issues relating to self respect, self esteem and many of the 65Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 66. social ills such as crime and violence that are affecting Jamaica are “too big” for theMOH to undertake and fall outside the purview of the Ministry. They noted however thatthe Ministry, though it is not its responsibility, should play a role in helping to address theproblem.The healthcare providers note that much of the problem of domestic violence in Jamaicahas to do with the issue of some women not being motivated and have little self respect.They argue that is evident in the values that these women have as they continue to see toomany underage pregnancies and the mothers of these young girls failing to report the menwho have impregnated their daughters. The healthcare providers note that such behaviourperpetuates abuse against womenand this they add will not stop even when the womenbecome pregnant.Some healthcare providers also note that for the issue of domestic violence againstpregnant women to be adequately addressed, the MOH has to revises its HIV policy. Thehealthcare providers say that when a person is diagnosed with HIV the MOH shouldcontact the person’s partner, as the issue of ‘patient confidentiality’ can foster abuse. Onehealthcare worker noted that in treating a woman is HIV positive and recently gave birth(the woman had not informed her partner about her status), the healthcare provider saidthe woman was told to tell the woman to tell her partner that she is unable to breast feedthe baby because she is hypertensive. The healthcare provider says that with the womanwithholding her status from her partner, it might cause the man to abuse the woman. Thehealthcare provider noted that if the MOH’s HIV policy were revised, then the healthcare 66Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 67. provider could have informed the man and get counselling for both parties.Antenatal care and domestic violenceThe healthcare providers note that they do not discuss the issue of domestic violence withpregnant women when they visit them for antenatal care. They explain that there is nopolicy protocol that exists, therefore they do not go outside the realms of what they aremandated to do. The healthcare workers also say that they have not received any trainingon how to detect when and if a woman is being abused, whether or not she is pregnant.They note however, that while they have knowledge to detect when woman are beingabused, they say no training is given to them, therefore they do not venture into an areaoutside what they are required to do, which is to offer care towards the physical health ofpregnancy as stipulated by the MOH.Some of the healthcare providers explain however, that if the pregnant women confide inthem and tell them that they are being abused they refer them to get counseling; this ishowever voluntary as the women are not compelled to get such assistance as they do soon their own volition. Other healthcare providers noted that at times they do observesigns of physical abuse on pregnant women to whom they offer care, and are often timescompelled to ask these women if they are in fact being abused. The healthcare providerssaid however that they do not ask, out of fear that the abused pregnant women mightinform their partners about the healthcare providers’ enquires, and these partners wouldthen possibly physically harm the healthcare providers when they see them on the road. 67Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 68. The healthcare providers note that while they have observed, on occasions, pregnantwomen showing signs of physical abuse, they are caught in a quandary which makesthem turn a blind eye to what they observe, even though they know that the matter needsto be addressed, but this they say is done out of fear for their own safety. The healthcareproviders also note that it is also difficult to ascertain if a pregnant woman is beingverbally abused; this is only know if the woman speaks about it, and if she does she isreferred to get counseling which is solely her decision to accept or reject.Domestic violence and its impact on maternal healthThe healthcare providers noted that more effort needs to be done in encouraging womento seek early antenatal care. They note that despite the elimination of user fees at healthfacilities the numbers that give birth at hospitals come pared to those who receiveantenatal care is not comparable. They note that pregnant women receiving earlyantenatal care will assist in detecting complications early, so that healthcare providers canmake the necessary referrals. It was also noted that more facilities such as bed spaces,wards and resources are needed, as well as more healthcare workers which are critical tothe delivery of care for pregnant women.The healthcare workers also note that they have seen instances where financial resourceshave been pumped into the sector targeted towards family planning and reducingHIV/AIDS, yet they say pregnancies are still increasing as well as the number of HIVcases. The added that, while not exorbitant, some amount of money is being spent on 68Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 69. helping to reduce Jamaica’s MMR, yet they are not seeing the results. The healthcareproviders questioned whether the correct target audience was being reached, whether theefforts were not being fruitful because of social stigma, or if it had to do with the lack ofalacrity politicians display regarding issues affecting women, why Jamaica’s efforts werenot reaping the desired results.The healthcare providers noted that while the issue of domestic violence against pregnantwomen is an issue that must be addressed at the policy level, they say however that theydo not believe that this social problem will derail Jamaica’s efforts in achieving MDG5by 2015. The say that while there are no statistics to evaluate the extent of the problem,they say based on their observation, the incidence of domestic violence against pregnantwomen are isolated.The healthcare workers further espoused that the issue of domestic violence needs to beaddressed at the community level, because until women realise that something is wrongwith men battering them, whether or not they are pregnant, there is hardly anything thegovernment can do to stop the problem. They explain that while it is the responsibility ofthe government to enact legislation to protect women, women themselves have to speakup and acknowledge that the issue of abuse is a problem. 69Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 70. FOCUS GROUP RESPONDENTSBased on the responses of the women who participated in the focus group discussion, itwas apparent that some of them believe that the existing Ministry of Health’s StrategicFramework for Safe Motherhood within the Family Health Programme 2007-2011 policydocument does not address issues they deem important to their overall pregnancyexperience. While the women were not asked direct questions by the researcher whetheror not they were being abused by their partners, due to the sensitivity of the topic and theresearcher having no written protocol that would guide such enquires, the discussionhowever brought to the fore the importance, as viewed by the women, for the inclusion ofaddressing the issue of violence against women within the safe motherhood agenda.Domestic violence in the national safe motherhood policy frameworkThe women note that when they visit healthcare facilities for antenatal care they areasked general questions regarding their health. The respondents say they are askedwhether they have diabetes, hypertension, or have physical disabilities. They are alsoasked questions about their family health history, when they had their last period, diet, ifthey are taking their vitamins or prescribed medication (if necessary), they are asked ifthe baby has moved, information regarding their next of kin, information regarding blooddonor. One woman noted that she has also been asked if she lives with her partner.The women note that when the healthcare provider detects a problem, they are informedof the treatment they will receive. They say in some instances, they are told of thetreatment and they get to choose whether or not they want the treatment. However in 70Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 71. instances where the treatment is necessary to save both the mother’s and baby’s life, thewoman is told of the treatment she will receive, however she cannot choose whether ornot she wants the treatment that the healthcare provider will administer. One respondentwho said she had a low blood count, noted however that she was told of her situation,however no treatment was administered as she said she was told that there is no treatmentfor her condition.The focus group respondents noted that while they were not aware, and had never heardabout the MOH’s strategic framework for safe motherhood until the researcher explainedthe policy, they believe however that the issue of domestic violence and other socialproblems pregnant women might face should be addressed.The women note that they have seen instances in which women have been abused bytheir partners while pregnant. One respondent noted that she witnessed one of her auntsbeing abused by her child’s father while pregnant. The woman noted that the abuse of notan isolated incident as it happened repeatedly. The woman’s aunt, while she gave birth tothe child safely, failed to report the matter to the police or seeking help. The womannoted that while family members have witnessed the psychological impact the abuse hashad on her aunt, she has however failed to seek assistance. In such an instance theywomen note that systems should be in place to address the issue.They note that while the MOH might not have the resources to address the issue ofdomestic violence, they argue however that something has to be done to address the 71Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 72. social problems might affect the well-being of pregnant women, as not enough is beingdone. The respondents also cited a recent court case published in a popular newspaper,where a woman was badly beaten by her partner, yet when he appeared before amagistrate he was fined a mere $10,000.00.The focus group respondents also note that issues such as crime and violence incommunities, and poverty which can prohibit them from attending their antenatal visits,also needs to be addressed. They note that while the social issues they have raised mightfall outside the purview of the MOH, the women note however that the Ministry has tolead the way and liaise with the appropriate agencies as safe motherhood has to beaddressed wholesomely, and pregnant women need all the support they can get to makemotherhood safe.Antenatal care and domestic violenceThe women say they have never been asked about the issue of domestic violence whilereceiving antenatal care. While the women noted that this was an important issue toaddress during antenatal visits, they had varying views on the matter.One woman was quick to point out that she does not believe that healthcare providersshould make such enquires, as doing so could risk the healthcare providers’ safety. Shenoted that there have been instances in her community where she has witnessed a womanbeing abused by her partner and neighbours intervene by calling the authorities, yet theabused woman in turn lashes out against the neighbours for “fassin’ inna har bizniz”. The 72Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 73. respondent noted that while the healthcare workers might have the abused pregnantwoman’s interest at heart, the abused woman might not view the situation as such, andcould possibly push her partner or associates to attack the healthcare provider. The otherrespondents in the focus group noted that while they understood the safety concerns ofhealthcare providers, they say those offering them care, particularly while they are in theprocess of fostering a new life, have an ethical responsibility for the overall well being oftheir patients.The respondents note that while some healthcare workers do not want to get involved inthe social welfare of expectant mothers, they believe however that enquires aboutdomestic violence should be made. This the women say is important particularly as thewomen are bringing forth a new life; the health of the woman is important for the healthof the baby. They also note that healthcare providers must move beyond the realms ofphysicality and focus must also be placed on the mental health of pregnant women. Therespondents note that making such enquires might also help healthcare providers findingout the cause of some of the ailments that pregnant women might have such as high bloodpressure, as they note that it could be the woman’s situation at home which has causedher blood pressure to elevate.The women admitted that while there might be instances in which the healthcareproviders ask such direct questions and the women lie, the respondents noted howeverthat the healthcare providers, being the professionals they are, can detect signs of abuse.They say where necessary the healthcare providers should make the appropriate referrals 73Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 74. for treatment or counseling. They also added that in instances where there needs to beintervention by the police, that should be done with or without the abused woman’sconsent.Domestic violence and its impact on maternal healthThe respondents of the focus group discussion noted that they had never heard of theterm “maternal mortality” until the researcher used the term and explained what it meant.The women also note that they had never been told of the possible health complicationsthat can lead to maternal death by their healthcare providers. It was therefore difficult forthe researcher to ascertain the pregnant women’s feedback regarding Jamaica’s efforts inachieving MDG 5, and if they thought the issue of domestic violence would derail thecountry’s efforts in meeting the 2015 target. The women noted however that would liketo see more discussion about the issue of domestic violence being done by theirhealthcare providers, as they note that the effects of domestic violence might havedevastating effects for a pregnant woman and the unborn child. 74Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 75. DISCUSSIONIt is apparent, based on the findings of the researcher, that the views regarding the issueof domestic violence and its impact on maternal mortality varies depending on the targetgroup.The technocrats who have crafted the MOH’s policy framework on safe motherhood, andthose involved in directly administering care to pregnant women, while they recognize,for the most part, that domestic violence against pregnant women might be a possiblethreat to the well-being of these women, there is however some degree of ambivalence inaddressing the matter. The researcher concedes that the spectrum within which to tacklethe issue of domestic violence falls outside the purview of the MOH, the safe motherhoodagenda must however encompass a wholisitc approach in dealing with all the issues thatmakes motherhood safe.It is also apparent, based on the tone of the responses, particularly of the crafters of thepolicy document, that a bottom-up approach was not adopted in the formulation of thepolicy. In today’s modern society it is important to incorporate the views of the targetaudience which the policy being crafted is expected to enhance their quality of life. Whilenot all recommendations posited by this group might be incorporated in the policydocument, if any at all, it is important to garner insight from those which the policy willultimately affect.While the issue of domestic violence is not addressed in the Ministry of Health’s 75Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 76. Strategic Framework for Safe Motherhood within the Family Health Programme 2007-2011 policy document, as the technocrats have cited its exclusion as “not a priority”, andoutside the classification of the WHO, the women whose healthcare depends on thestipulations articulated within the document have noted that such a social issue should beaddressed. Jamaica cannot afford to take a one-sided approach to safe motherhood byonly focusing on the medical aspects of pregnancy, as in doing so, other criticalcomponents, which could possibly derail Jamaica’s efforts in achieving the MDG 5 targetmight be overlooked. While the responses gathered in this study do not indicate that theissue of domestic violence will derail Jamaica’s efforts in reducing its MMR by 75% by2015, the lack of data and the classification of deaths attributable to domestic violencemakes the impact of the social problem on the country’s MMR inconclusive to determine.As the De Brouwere (1998) model states, which is seen as the hallmark in highlightingstrategies for reducing maternal mortality by expounding the best practices of thedeveloped world (McCaw-Binns 2005), “developing countries (must not be) hindered bythe limited awareness of the magnitude and manageability (of addressing maternalmortality, as) ill-informed strategies focusing on antenatal care…have by and large beenineffective”. Those responsible for the crafting of policy guidelines and the delivery ofcare must therefore move beyond the realms of their limited scope and adopt a morecomprehensive approach in addressing safe motherhood.Likewise, there must be political will to address the issue of domestic violence, as thishas to be done with clear and concrete political and social strategies that are imperative to 76Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 77. an adequate knowledge base of the social problem (Richmond and Kotelchuck 1985;Atwood et al 1997, cited in De Brouwere et al 1998). Increased awareness of thepopulation about the problem is also important as putting the maternal mortality agendaat the forefront of public discourse is important for more persons to be aware of theproblem. This can be further augmented through strong political will, and throughparliamentarians addressing the issue in Gordon House with alacrity like so many ofJamaica’s other problems.The magnitude of the effects of domestic violence on maternal mortality needs greaterdiscussion, as this study was carried out at only one healthcare facility within the South-East Regional Health Authority. It is therefore possible that the findings from other healthregions might be different. Research is also needed to assess how domestic abuse, verbalabuse and neglect contribute to unwanted pregnancy. There also needs to be research onhow domestic violence affects maternal morbidity (the grave impacts on maternal health),as well as how domestic violence contributes to poor maternal interest in seekingantenatal care and complying with the directives of healthcare providers. It would also beinteresting to ascertain how other social problems such as crime and violence and evenpoverty will impact Jamaica’s prospects in achieving MDG 5. The issue of culture,customs and religious beliefs must also be explored to ascertain whether these might alsoaffect a women’s health seeking behaviour for maternal care. 77Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 78. CHAPTER 4 Conclusion and RecommendationsThe issue of domestic violence and its impact on maternal mortality in Jamaica needsgreater discourse, as the issue must not be seen as a sideline item simply because theWHO does not recognise it in its classification of what constitutes maternal deaths or it is“not a priority” by policy planners. Despite Jamaica being a small developing state, it isoften times seen as a pioneer in the Caribbean region for making headway in the areas ofdiscourse and policy planning (World Bank 2009). More research and statistics regardingthe impact of violence against pregnant women need to be developed and disaggregatedin the presentation of national figures. Likewise, the following recommendations shouldbe considered, and possibly incorporated in strategies aimed at addressing the issue ofdomestic violence against pregnant women in future policy developments. 1. A national committee should be developed which would hold discourse and make recommendations targeted towards a wholisitc approach towards safe motherhood. This committee would comprise of representatives from the Ministry of Health, the Bureau of Women’s Affairs, the Ministry of Labour and Social Security, other government agencies armed with the responsibility of providing social services, non-governmental organizations which focus on women’s issues and civil society. A wide representative panel on the committee will foster a wider debate on the issues that affect women during pregnancy, as well as allow varying views to be brought to the fore in policy planning for maternal health. 78Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 79. 2. In formulating a strategy to address the issue of domestic violence against pregnant women, strict guidelines regarding privacy and confidentiality must be maintained by those offering care. Social capital is therefore an important ingredient in crafting such a policy, as it is likely that the pregnant women will not buy-in to the programme if their identities and their accompanying problems are revealed. 3. Social programmes needed to address the issue of domestic violence must to be strengthened if screening is to take place. Diagnosis cannot take place if there is no proper medium to treat, however if left unattended the problem might be exacerbated. 4. Violence against pregnant women remains unrecognized, therefore it is important that during the delivery of care healthcare providers develop a “sensitive ear” (Edin and Högberg 2002). A policy framework which would guide the creation of standardized questions that healthcare providers would ask, needs to be developed. The issue of domestic violence can only be tackled if there is knowledge that the problem exists by policy planners, healthcare providers and the pregnant women that are being abused. 79Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 80. 5. Training and educating healthcare workers about domestic violence is critical, as these professional interface with pregnant women frequently. Those who provide care to pregnant women need to learn more about the problem as well as assess their own attitudes towards domestic violence. Education related to violence can help change negative attitudes that can assist in making a difference in healthcare providers’ behaviour toward the issue (Moore et al 1998, Ellsberg et al 2001, cited in Edin and Högberg 2002). The education should also be expanded to technocrats, as those involved in setting the policy agenda for the treatment and delivery of care to pregnant women must also be educated about the issue. 6. Greater sensitization is needed about the issue of safe motherhood, not only for healthcare workers but for pregnant women as well. There needs to be wider discourse on MDG 5 by all stakeholders, and not just those who set the policy framework. 7. Political will is also an important ingredient in tackling the problem (De Brouwere et al 1998). In Jamaica it is evident that polices and programmes that have the strong and visible support of politicians often times receives the blessings of the masses. A strong buy-in by politicians is therefore seen as important in driving the issue. 80Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 81. 8. RAMOS should be revised to incorporate the classification of maternal deaths which are a result of domestic violence. Guidelines for the amendment of the surveillance system would have to be developed and best practices adopted from countries which have informed research on the impact of violence against pregnant women. 9. The impact of domestic violence on maternal morbidity also needs analysis, as there might be instances where violence against pregnant women may not lead to death, but may have grave impacts maternal and fetal health.Maternal mortality is not the only outcome with which progress towards MDG 5 will bejudged as all the eight goals are intertwined. The discourse on maternal mortality musttherefore incorporate a continuum of all the social systems needed to enhance the qualityof life women lead (Ronsmans et al 2006, 1189). While the unavailability and quality ofdata and information needed to inform decisions, evidence about the issue and itspossible impact must be guided by informed awareness. To disregard an issue that couldpossibly derail social progress in any country cannot be held as an ideal in today’smodern society, even if it is not seen as a priority for those who hold the power to craftthe decisions which will dictate the quality of life people lead. The constraints that exists,particularly as Jamaica faces tumultuous economic times, the country cannot be forced todwell on the false impression that a problem that affects only a few today cannot beexacerbate and a future implications for many. 81Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 82. Capturing the causes of maternal deaths is not straight forward, as even in countrieswhere there are highly developed statistical and data gathering instruments, there are stillconstraints (Ronsmans et al 2006, 1197). Women however need to know that there aresystems in place to protect them at all levels of their life, as often times it is the mostvulnerable in society that is left to suffer. While we do not have all the answers, aconcerted effort must be made to address problems that may exists as can assist personsin possibly attaining the fulfillment of true development.The proposals and recommendations put forth in this paper do not have all the answers,neither does it purports to be the magic bullet, the research however feels that “no womanshould die giving life” (UNFPA 2009c). 82Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 83. CHAPTER 6 ReferencesAshley, Deanne. “Factors related to the delivery of healthcare services in Jamaica with reference to problems related to maternal and child health.” Ph. D. diss., University of the West Indies, 1973.Bacchus, Loraine, Gill Mezey, Susan Bewley, Alison Haworth. 2004. “Prevalence of domestic violence when midwives routinely enquire in pregnancy”. BJOG: an international journal of obstetrics and gynaecology 111: 441-445.Bulatao, Rodolfo and John A. Ross. 2000. Rating maternal and neonatal health programs in developing countries. Chapel Hill: University of North CarolinaCrowell, Nancy and Ann Burgess (eds). 1996. Understanding violence against women. Washington D.C: National Academy Press.De Brouwere, Vincent, Rene Tonglet, Wim Van Lerberghe. 1998. “Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized west?” Tropical medicine and international health 3 83Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 84. (10): 771-782Economic Commission for Latin America and the Caribbean. 2005. “Achieving the millennium development goals in Latin America and the Caribbean”. The millennium development Goals: A Latin America and Caribbean perspective. Santiago: United Nations.Edin, Kerstin, and Ulf Högberg. 2002. “Violence against pregnant women will remain hidden as long as no direct questions are asked”. Midwifery 18: 268-278.Espinoza, Henry, and Alma Virginia Camacho. 2005. “Maternal death due to domestic violence: An unrecognized critical component of maternal mortality.” Pan American Journal of Public Health 17 (2):123-129.Gazamararian, JA, MM Adams. L.E Saltzman, C.H Johnson, F.C Bruce, JS Marks, SC Zahniser. 1995. “The relationship between pregnancy intendedness and physical violence in mothers of newborns”. Obstetrics & Gynecology 85 (6): 1031-1038.http://www.serha.gov.jm/ 84Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 85. Jamaica Social Policy Evaluation. 2008. National progress report 2004-2006 on Jamaica’s social policy goals. Kingston: Office of the Cabinet.Koblinsky, M.A, O. Campbell, J. Heichelheim. 1999. “Organizing delivery care: what works for safe motherhood?” Bulletin of the World Health Organization 77(5): 399-406.Koenig, Lisa, Daniel Whitaker, Robert Royce, Tracey Wilson, Kathleen Ethier, Isabel Fernandez. 2006. “Physical and sexual violence during pregnancy and after delivery: A prospective multistate study of women with or at risk for HIV infection”. American Journal of Public Health 96 (6):1-9.Koonin, Lisa, H. Atrash, R. Rochat, J. Smith. 1988.Maternal mortality surveillance: United States, 1980–1985. http://www.cdc.gov/mmwR/preview/mmwrhtml/00001754.htm.Matthews, Zoe. 2002. Maternal mortality and poverty. United Kingdom: DFID Resource Centre for Sexual and Reproductive Health. 85Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 86. McCaw-Binns, Affette, S.F Alexander, J.L.M Lindo, C Escofery, K Spence, K Lewis- Bell, G Lewis G. 2007. “Epidemiologic transition in maternal mortality and morbidity: New challenges for Jamaica”. International journal of gynecology and obstetrics 96: 226-232.McCaw-Binns, Affette. 2005. “Safe motherhood in Jamaica: from slavery to self- determination”. Paediatric and Perinatal Epidemiology 19:254-261.Ministry of Health data, several years.Ministry of Health. 2007. Strategic framework for safe motherhood within the family health programme 2007-2011. Kingston: Ministry of Health.Ministry of Health. 2009. Address by Acting Director of Family Services Dr. YvonneMunroe at the launch of Healthy mother. Healthy baby. Healthy family, Safe motherhoodprogramme launch, July 1, 2009. Kingston: Ministry of Health.Mitchell, Ellen. 2000. Why Should I Lie? Maternal mortality and domestic violence in Otavalo and Cotacachi Ecuador. New Orleans: Tulane University. 86Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 87. Pan American Health Organization. 2005. “Maternal death due to domestic violence”. Fact sheet: Gender, ethnicity and health, July 2005. Washington: Pan American Health Organization.POLICY Brief. 2002. Maternal and Neonatal Program Effort Index: Jamaica. Glastonbury: Futures Group.Planning Institute of Jamaica, Ministry of Foreign Affairs and Foreign Trade. 2009. National report of Jamaica on millennium development goals for the UN Economic and Social Council annual ministerial review. Kingston: Planning Institute of Jamaica.Ransom, Elizabeth, and Nancy Yinger. 2002. “Making motherhood safer: Overcoming obstacles in the pathway to care”. MEASURE Communication Policy Brief. Washington D.C: Population Reference Bureau.Ronsmans, Carine and Wendy Graham. 2006. “Maternal mortality: who, when, where and why”. Lancet 368: 1189-1200.Satchell, Vernon. 1999. Jamaica. http://www.hartford-hwp.com/archives/43/130.htmlSmith, Kimberly, and Sara Sulzbach. 2008. “Community-based health insurance and 87Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 88. access to maternal health service: Evidence from three West African countries”. Social Science and Medicine 66: 2460-2473.Thomas, Shirley. “An assessment of maternity service in Portland and St. Mary.” MSc. thesis, University of the West Indies, Mona, 1993.UNDP, UNFPA,WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction. 2005. “Promoting evidence-based sexual and reproductive health care”. Progress in Reproductive Health Research 71 .United Nations. 1979. Declaration on the elimination of violence against women. http://www.un.org/womenwatch/daw/cedaw/text/econvention.htmUnited Nations. 2009. End poverty 2015: Millennium development goals. http://www.un.org/millenniumgoals/United Nations. 2006. The world’s women 2005: progress in statistics. New York: United Nations. 88Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 89. United Nations Children’s Fund. 2009. Address by UNICEF Representative to Jamaica Robert Fuderich at the launch of Healthy mother. Healthy baby. Healthy family, Safe motherhood programme launch, July 1, 2009. Kingston: Ministry of Health.United Nations Children’s Fund. 2008. Progress for children: a report card on maternal mortality. Number 7, September 2008. New York: UNICEF. United Nations Population Fund. 2009a. No woman should die giving life: Facts and figures. http://www.unfpa.org/safemotherhood/ United Nations Population Fund. 2009b. Maternal Mortality Statistics: Making Motherhood Safer. http://www.unfpa.org/mothers/statistics.htm United Nations Population Fund. 2009c. Stepping up efforts to save mothers’ lives. http://www.unfpa.org/mothers/ Women Deliver. 2009. The safe motherhood initiative. http://www.womendeliver.org/overview/Background.htm Woman Inc. data, several years. 89 Copyright © 2009 Nicole Antoinette Hayles McGowan Fulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal Health MSc. Governance and Public Policy (2009)
  • 90. World Bank. 2009. Address by World Bank Special Representative Badrul Haque at the presentation of the Jamaica/World Bank Country Strategy for Jamaica 2010- 2013 in Gordon House, July 14, 2009. Kingston: Television Jamaica Limited.World Health Organization. 2007. Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: World Health Organization. 90Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 91. APPENDIX QUESTIONNAIRE (TECHNICAL EXPERTS)I am a student of the University of the West Indies, reading for a Masters of Sciencedegree in Governance and Public Policy. I am researching the issue of domestic violenceand its impact on Jamaica’s efforts in reducing maternal mortality. The aim of thisquestionnaire is to seek responses about why the issue of domestic violence againstpregnant women is not addressed or included as an integral component in the Ministry ofHealth’s Strategic Framework for Safe Motherhood within the Family HealthProgramme 2007-2011 policy document. The questionnaire also aims to get feedback onhow the issue of domestic violence against pregnant women can be addressed at thenational policy level, as well as views regarding maternal mortality and the country’sprospects of achieving MDG 5. 1. How long have you been offering care to pregnant women or researching the issue of maternal health? __________________________________________________________________ __________________________________________________________________ 2. How many pregnant women do you offer care annually? __________________________________________________________________ __________________________________________________________________ 3. What issues are addressed by you (midwife, public health nurse, obstetrician) when pregnant women visit health centres for antenatal care? __________________________________________________________________ __________________________________________________________________ 4. When problems are detected how are they addressed or dealt with by you who offer care to pregnant women? __________________________________________________________________ __________________________________________________________________ 91Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 92. 5. What are the reporting systems employed to track the problems that are detected? __________________________________________________________________ __________________________________________________________________ 6. When pregnant women visit health centres for antenatal care is the issue of domestic violence discussed? __________________________________________________________________ __________________________________________________________________ 6a. If yes, how is the matter addressed? __________________________________________________________________ __________________________________________________________________ 6b. If no, why is the matter not addressed? __________________________________________________________________ __________________________________________________________________ 7. Do you routinely ask pregnant women the direct question about whether they are abused by their partners? __________________________________________________________________ __________________________________________________________________ 7a. If yes, what are some of the responses obtained from the pregnant women? 92Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 93. __________________________________________________________________ __________________________________________________________________ 7b. If no, why are such enquires not made? __________________________________________________________________ __________________________________________________________________ 8. What systems are in place to track women who visit healthcare facilities for treatment following episodes of domestic violence? __________________________________________________________________ __________________________________________________________________ 9. What systems are in place to track these abused women when they become pregnant? __________________________________________________________________ __________________________________________________________________ 10. What are the indicators do you use to detect whether or not a woman is being abused while pregnant? __________________________________________________________________ __________________________________________________________________ 11. What type of training do you or did you receive to detect if pregnant women are victims of domestic violence? __________________________________________________________________ 93Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 94. __________________________________________________________________ 12. How often are you or were you trained? __________________________________________________________________ __________________________________________________________________ 13. Do you think the MOH’s Strategic Framework for Safe Motherhood policy adequately addresses the issue of domestic violence against pregnant women, as well as other social issues that may affect this group? __________________________________________________________________ __________________________________________________________________ 13a. If yes, what are the strengths of the policy in addressing the issue of domestic violence against pregnant women and other social issues that may affect this group? __________________________________________________________________ __________________________________________________________________ 13b. If no, what are the shortcomings of the policy regarding the issue of domestic violence against pregnant women and other social issues that may affect this group? __________________________________________________________________ __________________________________________________________________ 14. How adequate is the MOH’s Strategic Framework for Safe Motherhood policy in light of the current social realities affecting Jamaica? __________________________________________________________________ 94Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 95. __________________________________________________________________ 15. What improvements do you think are needed for a more wholistic approach towards Safe Motherhood in Jamaica? __________________________________________________________________ __________________________________________________________________ 16. What are your general views regarding the issue of domestic violence against pregnant women? __________________________________________________________________ __________________________________________________________________ 17. What are your views regarding Jamaica’s efforts in achieving MDG5 by 2015? __________________________________________________________________ __________________________________________________________________ 18. What are your views regarding the current strategies being employed to help Jamaica achieve its goal of reducing maternal mortality by 75% by 2015? __________________________________________________________________ __________________________________________________________________ 19. How confident are you that enough emphasis is being placed on the issue of maternal mortality in Jamaica? __________________________________________________________________ __________________________________________________________________ 95Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 96. 20. What more would you like to see done to address the issue of maternal mortality in Jamaica? __________________________________________________________________ __________________________________________________________________ 21. How adequate has the budget for the MOH over the past five years been in addressing the issue of maternal mortality in Jamaica? __________________________________________________________________ __________________________________________________________________ 22. In what ways might the issue of domestic violence derail Jamaica’s prospects of achieving a reduction in maternal mortality rates by 75% by 2015? __________________________________________________________________ __________________________________________________________________ 96Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 97. QUESTIONNAIRE (HEALTHCARE PROVIDERS)I am a student of the University of the West Indies, reading for a Masters of Sciencedegree in Governance and Public Policy. I am researching the issue of domestic violenceand its impact on Jamaica’s efforts in reducing maternal mortality. The aim of thisquestionnaire is to seek responses about why the issue of domestic violence againstpregnant women is not addressed or included as an integral component in the Ministry ofHealth’s Strategic Framework for Safe Motherhood within the Family HealthProgramme 2007-2011 policy document. The questionnaire also aims to get feedback onhow the issue of domestic violence against pregnant women can be addressed at thenational policy level, as well as views regarding maternal mortality and the country’sprospects of achieving MDG 5. 1. How long have you been offering care to pregnant women? __________________________________________________________________ __________________________________________________________________ 2. How many pregnant women do you offer care annually? __________________________________________________________________ __________________________________________________________________ 3. What issues are addressed by you (midwife, public health nurse, obstetrician) when pregnant women visit health centres for antenatal care? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. When problems are detected how are they addressed or dealt with by you who offer care to pregnant women? __________________________________________________________________ __________________________________________________________________ 97Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 98. 5. What are the reporting systems employed to track the problems that are detected? __________________________________________________________________ __________________________________________________________________ 6. When pregnant women visit health centres for antenatal care is the issue of domestic violence discussed? __________________________________________________________________ __________________________________________________________________ 6a. If yes, how is the matter addressed? __________________________________________________________________ __________________________________________________________________ 6b. If no, why is the matter not addressed? __________________________________________________________________ __________________________________________________________________ 7. Do you routinely ask pregnant women the direct question about whether they are abused by their partners? __________________________________________________________________ __________________________________________________________________ 98Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 99. 7a. If yes, what are some of the responses obtained from the pregnant women? __________________________________________________________________ __________________________________________________________________ 7b. If no, why are such enquires not made? __________________________________________________________________ __________________________________________________________________ 8. What systems are in place to track women who visit healthcare facilities for treatment following episodes of domestic violence? __________________________________________________________________ __________________________________________________________________ 9. What systems are in place to track these abused women when they become pregnant? __________________________________________________________________ __________________________________________________________________ 10. What are the indicators do you use to detect whether or not a woman is being abused while pregnant? __________________________________________________________________ __________________________________________________________________ 99Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 100. 11. What type of training do you or did you receive to detect if pregnant women are victims of domestic violence? __________________________________________________________________ __________________________________________________________________ 12. How often are you or were you trained? __________________________________________________________________ __________________________________________________________________ 13. Do you think the MOH’s Strategic Framework for Safe Motherhood policy adequately addresses the issue of domestic violence against pregnant women, as well as other social issues that may affect this group? __________________________________________________________________ __________________________________________________________________ 13a. If yes, what are the strengths of the policy in addressing the issue of domestic violence against pregnant women and other social issues that may affect this group? __________________________________________________________________ __________________________________________________________________13b. If no, what are the shortcomings of the policy regarding the issue of domestic violence against pregnant women and other social issues that may affect this group? __________________________________________________________________ __________________________________________________________________ 14. How adequate is the MOH’s Strategic Framework for Safe Motherhood policy in light of the current social realities affecting Jamaica? 100Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 101. __________________________________________________________________ __________________________________________________________________ 15. What improvements do you think are needed for a more wholistic approach towards Safe Motherhood in Jamaica? __________________________________________________________________ __________________________________________________________________ 16. What are your general views regarding the issue of domestic violence against pregnant women? __________________________________________________________________ __________________________________________________________________ 17. What are your views regarding Jamaica’s efforts in achieving MDG5 by 2015? __________________________________________________________________ __________________________________________________________________ 18. What are your views regarding the current strategies being employed to help Jamaica achieve its goal of reducing maternal mortality by 75% by 2015? __________________________________________________________________ __________________________________________________________________ 19. How confident are you that enough emphasis is being placed on the issue of maternal mortality in Jamaica? __________________________________________________________________ 101Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 102. __________________________________________________________________ 20. What more would you like to see done to address the issue of maternal mortality in Jamaica? __________________________________________________________________ __________________________________________________________________ 21. How adequate has the budget for the MOH over the past five years been in addressing the issue of maternal mortality in Jamaica? __________________________________________________________________ __________________________________________________________________ 22. In what ways might the issue of domestic violence derail Jamaica’s prospects of achieving a reduction in maternal mortality rates by 75% by 2015? __________________________________________________________________ __________________________________________________________________ 102Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 103. QUESTIONNAIRE (FOCUS GROUP)I am a student of the University of the West Indies, reading for a Masters of Sciencedegree in Governance and Public Policy. I am researching the issue of domestic violenceand its impact on Jamaica’s efforts in reducing maternal mortality. The aim of thisquestionnaire is to seek responses about why the issue of domestic violence againstpregnant women is not addressed or included as an integral component in the Ministry ofHealth’s Strategic Framework for Safe Motherhood within the Family HealthProgramme 2007-2011 policy document. The questionnaire also aims to get feedback onhow the issue of domestic violence against pregnant women can be addressed at thenational policy level, as well as views regarding maternal mortality and the country’sprospects of achieving MDG 5. 1. How old are you? a. 18-22 ( ) b. 23-27 ( ) c. 28-32 ( ) d. 33-37 ( ) e. 38-over ( ) 2. Is this your first pregnancy? __________________________________________________________________ __________________________________________________________________ 2a. If no, how many children do you have? a. 1 ( ) b. 2 ( ) c. 3 ( ) d. 4 ( ) e. 5 and over ( ) 3. What questions are you asked by the healthcare professional (midwife, public health nurse, obstetrician) who offer you care when you attend antenatal care sessions? __________________________________________________________________ __________________________________________________________________ 4. When problems arise how does the health professional offering you care handle the matter? 103Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 104. __________________________________________________________________ __________________________________________________________________ 5. Is the issue of domestic violence discussed with you by the health professional offering you care? __________________________________________________________________ __________________________________________________________________ 5a. If yes, how is the issue of domestic violence dealt with by the healthcare professional offering you care? __________________________________________________________________ __________________________________________________________________ 5b. If no, do you think that the issue of domestic violence should be raised by the healthcare professional offering you care? __________________________________________________________________ __________________________________________________________________ 6. Have you ever been asked any direct questions about domestic violence by the health care professional offering you care? __________________________________________________________________ __________________________________________________________________ 7. What are your general views regarding violence against pregnant women? __________________________________________________________________ __________________________________________________________________ 104Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 105. 8. Do you think enough is being done to address the issue of violence against pregnant women? __________________________________________________________________ __________________________________________________________________ 8a. If yes, what is being done to address the issue of domestic violence against pregnant women that you applaud? __________________________________________________________________ __________________________________________________________________ 8b. If no, what would you like to see done to address the issue of violence against pregnant women? __________________________________________________________________ __________________________________________________________________ 9. Do you know what maternal mortality is? __________________________________________________________________ __________________________________________________________________ 9a. If yes, what is maternal mortality? __________________________________________________________________ __________________________________________________________________ 9b. If no, is the issue of maternal mortality discussed with you by the healthcare professional offering you care? __________________________________________________________________ 105Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 106. __________________________________________________________________ 10. What do you know of the Ministry of Health’s Safe Motherhood Programme? __________________________________________________________________ __________________________________________________________________ 11. What are your views regarding the inclusion of strategies to address domestic violence when women visit healthcare facilities for antenatal care? __________________________________________________________________ __________________________________________________________________ 106Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 107. INFORMED CONSENT FORMTitle of studyThe fight for MDG 5: An analysis of Jamaica’s policy framework for improving maternalhealthDescription and ProcedureThis study is being done to assess why the issue of domestic violence is not addressed orincluded as an integral component in the Ministry of Health’s Strategic Framework forSafe Motherhood within the Family Health Programme 2007-2011 policy document. Thestudy also aims to assess how the issue of domestic violence against pregnant women canbe addressed at the national policy level, as well as views regarding maternal mortalityand Jamaica’s prospects of achieving MDG 5 by 2015.You will be asked a number of questions via a questionnaire during the elite interviewsession. These questions will not require you to provide the details of names andaddresses or any other information that distinctly identifies you publicly. The entireprocess is anonymous. All information received will be strictly confidential.Your participation in this elite interview is entirely voluntary. You can choose not toanswer or respond to any of the questions.There is no prolonged period or follow-up to this study. This is a one-time interviewlasting approximately 15-20 minutes.RisksThere are no perceived risks, physical or psychological associated with taking part in thisresearch. 107Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 108. BenefitsNo financial compensation or expenses are involved. You may not benefit personally orimmediately from the study. The overall benefit is to society at large.ConsentI have read or had this statement read to me, understand its contents and have hadsufficient time to consider my voluntary participation in this study.____________________________ ____________________Healthcare Provider’s Signature Date_____________________________ ______________________Witness’s Signature DateI testify that I have fully and appropriately informed the subject about the study andoffered to answer any questions she/he may have._________________________________ ________________________Researcher’s Signature Date 108Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 109. INFORMED CONSENT FORM FOR FOCUS GROUP DISCUSSIONI agree to participate in this focus group discussion being conducted by a Masters ofScience Student at the Sir Arthur Lewis Institute for Social and Economic Studies,University of the West Indies (Mona). The discussion will focus on the issue of domesticviolence and why it is not addressed or included as an integral component in the Ministryof Health’s Strategic Framework for Safe Motherhood within the Family HealthProgramme 2007-2011 policy document. The discussion will also focus on how the issueof domestic violence against pregnant women can be addressed at the national policylevel, as well as views regarding maternal mortality and Jamaica’s prospects of achievingMDG 5 by 2015.I understand that:* The session will be recorded and notes taken*Confidentiality will be maintained and when analyzed, names will not be associated with responses.* My participation is voluntary and I am free to withdraw at any time.Names Signature________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 109Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)
  • 110. _________________________________________________________________________________________________________________________________________________________________________________ ________________________Witness’s Signature DateI testify that I have fully and appropriately informed the subject about the study andoffered to answer any questions she may have._________________________________ ________________________Researcher’s Signature Datec/o Sir Arthur Lewis Institute of Economic and Social StudiesUniversity of the West IndiesMonaKingston 7Telephone: (876) 927-1020 110Copyright © 2009Nicole Antoinette Hayles McGowanFulfilling the MDG: An Analysis of Jamaica’s Policy Framework for Improving Maternal HealthMSc. Governance and Public Policy (2009)