Spring 2009 Vol. VII, No. 3
Health Beyond Hospitals
At AUB, researchers are looking at women’s maternal health concerns through the prism of an inclusive community-based approach. Three FHS research groups are leading the way: The Bedouin Health Project, the Reproductive Health Working Group, and the Choices and Challenges of Changing Childbirth Project.
Members of the Bedouin community met with policy makers, municipality representatives, members of parliament, and other key figures at AUB’s Agricultural Research and Education Center (AREC) in the Beqa’a Valley in late March 2009. The approximately 80 participants discussed health issues within the Bedouin community—particularly maternal and children’s health—in an AUB-led forum.
The meeting was part of the second phase of the Bedouin Health Project conducted by Oxford University and AUB, and housed in the Faculty of Health Sciences, which is assessing and improving reproductive and child health among marginalized rural communities.
“In order to have a successful, sustainable, strong intervention you have to engage everyone; in particular, you have to engage the community. They have to feel trust and power, and they have to feel they are important,” says Dr. Faisal El-Kak, the venture’s project manager, about the decision to include such a wide range of participants.
The Bedouins were targeted by this project because their ongoing disenfranchisement has led to particularly poor health outcomes, according to El-Kak, a doctor in the Obstetrics and Gynecology Department at AUBMC, who is also a senior lecturer in health behavior and education at FHS.
Despite the significant role Bedouin people play in the Beqa’a Valley’s agricultural industry, basic health problems persist in their communities, such as stunted growth in children associated with poor diet. The uneven implementation of a 1994 nationality law designed to give all Bedouin people Lebanese nationality has meant large numbers who cannot demonstrate Lebanese nationality continue to be without access to the free government health care the law affords.
An estimated 50,000 to 75,000 Bedouins reside in Lebanon, principally in the central Beqa’a Valley. Traditionally a nomadic people, Bedouins have traversed Lebanon for centuries. The majority of Lebanon’s current Bedouin community, however, migrated from the Golan Heights after losing access to pastoral lands following the 1967 Six-Day War. Today, most Bedouins in Lebanon have settled in informal villages in the fertile Beqa’a Valley, which is often called the country’s “bread-basket.”
El-Kak hopes the Bedouin Health Project will “give them a chance to get closer to the mainstream” in terms of health care and encourage them to become more proactive in addressing their own situation.
The Bedouin Health Project is one of three research groups within the Faculty of Health Sciences that are tackling women’s health concerns through an inclusive, community-based framework instead of the more traditional biomedical approach.
“Doctors treat a disease in hospitals and see the patient as an individual, not as a member of a community,” says Huda Zurayk, former dean of the Faculty of Health Sciences. “We are more population-based. We are trying to understand women’s health in a community context.” This involves taking into account women’s perceptions of their own health and how they feel about their interactions with the health sector.
Zurayk was one of the founding members of the Reproductive Health Working Group (RHWG), one of the first research bodies in the Middle East to adopt a community approach. The now much-enlarged group recently celebrated its twentieth anniversary, displaying longevity which, Zurayk says, is a remarkable achievement.
The RHWG was established in 1988, from a base at the Population Council in Cairo, to study women’s health in its broader socio-cultural and policy context. The group’s timely development came as the international focus on maternal health began to broaden from an almost exclusive concern with population growth, focusing on fertility and maternal mortality, says current RHWG coordinator and AUB Associate Professor Jocelyn DeJong.
“Historically, health services have been geared to helping a woman who was pregnant deliver, or to prevent that pregnancy,” DeJong confirms. This emphasis meant that other health concerns— related to infertility, sexually transmitted diseases, or menopause— were often not routinely recognized or treated. The RHWG hopes their research will ensure health services are organized to treat women of any age group suffering from different types of reproductive health complaints.
“The RHWG began with a small nucleus of inter-disciplinary researchers who were interested in promoting women’s health, bearing in mind the specificities of the region,” says DeJong. “The interdisciplinary approach is very unusual as the group includes medical doctors, public health researchers, anthropologists, economists, and sociologists. People are working from a range of perspectives and that’s what makes it exciting.”
With a background as a biostatistician and an interest in population studies, Zurayk says she has found the interdisciplinary approach helpful as it is “enriching to sit with anthropologists. We think of numbers while they are closer to the women, as they interview them and go more in depth.”
The network has grown considerably during its 20 years and now has approximately 40 members from countries in the Middle East/North Africa (MENA) region, from Morocco to Turkey to Oman. “It makes sense for people to come together and learn what each other is doing,” Zurayk says. It also allows researchers working alone in their country, in their particular field, to benefit from a wealth of regional knowledge.
The group is neither a publishing body, nor an agenda setting institution, but is dedicated to capacity building and exchange, DeJong says. The RHWG holds yearly meetings when members can present their work in progress and receive constructive feedback from their peers. This exercise is particularly beneficial for younger scholars who are able to benefit from diverse—and mature—perspectives.
The flexible relationship researchers have with the network was typified when the Choices and Challenges in Changing Childbirth (CCCC) research network was formed by RHWG researchers as a thematic offshoot in 2001.
The CCCC works to accumulate scientific evidence of childbirth practices in the region to identify areas that need to be changed to improve maternity care for women and their newborn children. The network, which includes researchers based in Lebanon, Syria, Palestine, and Egypt, has also adopted an interdisciplinary approach.
The group was initially concerned with maternal health practices not necessarily evidence-based that were routinely being carried out in hospitals, says Tamar Kabakian-Khasholian, an assistant professor of health behavior and education and co-coordinator of the CCCC.
Such practices include the high number of cesarean deliveries in Lebanon, which far exceed World Health Organization recommendations, which state that no more than 15 percent of deliveries should be by cesarean. A 2002 study undertaken by Dr. Marwan Khawaja, who is currently on leave from AUB, and Kabakian-Khasholian found the rate of cesarean births was as high as 22 percent in 1999-2000 and was only marginally higher in private hospitals than their public counterparts.
Kabakian-Khasholian is currently analyzing the results of her most recent study during which she mobilized women to demand changes in the services they receive from health providers. “Women are passive and not given the information they need about the costs and benefits of the care available,” she insists. “If women have the information they need, they can then ask for what is best for them and the baby.”
She identified a list of procedures routinely used in Lebanon, despite literature showing they should be used only in specific and very limited medical circumstances. Such practices include the near universal use of an episiotomy, or incision to enlarge the vagina during labor; putting all women on IV drips; and keeping newborns in separate rooms from their mothers while in hospital. Women are also generally not consulted about whether they would like a companion in the room with them during labor or which position they find the most comfortable.
Kabakian-Khasholian invited women from participating private prenatal clinics to attend neonatal classes in which mothers-to-be were taught how to communicate effectively with doctors and nurses, negotiation skills, and assertiveness training, in addition to the most recent scientific evidence on selected practices.
Although she is still analyzing the results, Kabakian-Khasholian said the qualitative feedback she received from women was very positive. She also reports, however, that medical practitioners were less enthusiastic because of concerns that this change in women’s behavior would damage important bonds of trust between patients and their doctors.
In her administrative capacity, Kabakian-Khasholian says the group is also looking ahead to the next five years. She believes the group as a whole will shift toward increasing the number of comparative research projects, rather than only replicating studies in different countries, and carrying out more interventions.
Until now, most research projects have also focused only on specific practices within the maternal health spectrum, such as hospital practices, determining statistics on maternal mortality, or post natal care. “The group is now trying to have a more general view of the health system, how it is organized, and how the system impacts on maternity services,” Kabakian-Khasholian says.
The group is taking a number of steps to disseminate its findings. El-Kak, a member of both the CCCC and the RHWG, is coordinating the groups’ community outreach programs to increase public awareness of issues related to maternal health and childbirth.
Salamet Hamlik (Safer pregnancy) is a quarterly newsletter distributed to 15,000 women through clinics and primary health centers across Lebanon, El-Kak says. It contains four colorful pages of useful information targeted at newlyweds and expectant parents.
Every month, members of the CCCC also contribute to a 30 minute program for the weekly Aelati (My family), which airs on Future television. The program brings together women and experts to discuss issues related to maternal health. Topics covered include pregnancy and work, the benefits of companionship during labor, sexual life during pregnancy, and vaccinations.
El-Kak has received good informal feedback from women about both Salamet Hamlik and the Aelati program, although he has not yet developed and finalized methods to assess their impact formally.
A group of physicians, including El-Kak, have also been involved in the creation of the Initiative on the Standard of Practise in Childbirth (ISOPIC), which began two years ago in Lebanon as a bottom-up approach to unify antenatal records and produce standard protocols for essential antenatal tests and procedures. This is designed to promote standards of practice in maternal health in Lebanon, a particularly important area given that many Lebanese doctors are trained overseas and so have not graduated from a standardized training program, DeJong confirms.
ISOPIC began working with 13 medical practitioners in three Beirut hospitals and has since expanded to include 20-25 practitioners. El-Kak has the ambitious aim of expanding the group further and eventually having a standardized record adopted throughout Lebanon in conjunction with Lebanon’s Society of Obstetricians and Gynecologists and the Order of Physicians.
ISOPIC is also finalizing the first maternal health record in Lebanon designed specifically for mothers to take home, he says. This will provide expectant mothers with basic information from their medical record, including weight changes and blood pressure, and tips on healthy eating during pregnancy.
The transition to motherhood can be a period of significant stress for women, as they experience changing relationships with their partner, parents, and friends while at the same time coping with a new baby, changing sleep patterns, and changes in their own bodies.
Dr. Hibah Osman is currently undertaking a study looking at the sources of stress for first-time mothers, and developing and testing interventions to help them cope with the transition. Dr. Livia Wick, a collaborator on this project, interviewed first-time parents to determine their main concerns and sources of stress, which often related to a lack of access to evidence-based information about breast-feeding and appropriate care for infants.
Armed with this information, Osman developed two interventions in collaboration with other CCCC members. The first involved distributing a 20 minute DVD in which doctors, parents, and actors addressed key issues for first-time parents. The DVD, at times using humor to help them cope, is intended to show prospective parents that what they are going through is a common experience.
The second intervention Osman established involved distributing a card with the number of a 24-hour hotline that is staffed by a trained midwife. Over one quarter of the women involved in a pilot study of hotline use called the service with questions about what was “normal” about breastfeeding, and seeking advice on how to deal with fussy infants.
Osman began recruiting women for the study in March. She plans to give mothers either the informative DVD, the card for the hotline, or both the CD and the card, and compare stress levels against a control group. Osman expects to see results by June 2009.
She believes her research has been enhanced by her involvement in both the CCCC and the RHWG. “We work together. Part of developing the proposal was done in collaboration with the group [the CCCC],” she says.
“We build on each other’s studies. We are a group of people who are interested in the same thing and we get excited about each other’s work,” she said.
Additional project photos and resources (including links to the CCCC and RHWG projects, Aelati on YouTube and the Salamet Hamlik newsletter) are in MainGate on-line.
The Bedouin Health Project
The first phase of the Bedouin Health Project involved assessing the Bedouin community’s access to maternal and child health care.
While there is near-universal acceptance by the Bedouin of western-style medical clinics and most Bedouin women give birth in hospitals, the study found significant impediments limiting women’s access to health care, and maternal health services in particular.
Hiba Morcos, one of two anthropologists working with the Bedouin Health Project, says that nationality—or more specifically the lack of Lebanese nationality—was “the main hindrance to health care.” Because only Lebanese women are eligible for free Ministry of Health services, many Bedouin women reported that they visited only certain clinics and felt that many medical practitioners were reluctant to treat them, says Morcos. This attitude on the part of some medical practitioners is due to preconceived ideas about Bedouins’ supposed ignorance and bad body odor, project coordinator Dr. Faysal El-Kak explains.
A lack of health services, pharmacies, and transportation facilities within Bedouin communities also meant that it cost more both in terms of time and money for Bedouin to visit medical clinics or centers. “It may not be the desert, but a two hour walk to a clinic is still a two hour walk,” says El-Kak. Morcos also discovered that there was an “over medicalization” of health services and little or no focus on preventative care. Women were reluctant to seek medical help for non-pregnancy related health concerns.
As an anthropologist, Morcos works by identifying key persons in the community such as medical practitioners and other prominent and respected individuals and then uses them to find out about the community’s experiences, interests, priorities, and concerns. She does this by involving these individuals in focus groups, asking them to complete questionnaires, and by conducting in-depth interviews. She has found that by working this way she is able to ensure that the initial project and subsequent interventions are “culturally sensitive” and therefore more likely to be welcomed by the community.
Morcos explains that by taking local perspectives into consideration and involving the community from the outset, there is a much greater chance that the project will result in long-term and sustainable changes that improve health outcomes.
Now entering its third and final phase, the Bedouin Health Project will next focus on improving community-based awareness of preventive health measures and services, in conjunction, it is hoped, with local Bedouin non-government organizations or a United Nations program. Members of the project are starting by involving local communities by selecting and training some of their members to administer basic medical tests such as weight and blood sugar measurements and to assist with local health centers. This goes hand in hand with an attempt to improve the capacity and cultural awareness of these existing health centers, so they are better able to meet the health care needs of Bedouin women.