Below are links to various articles where I am quoted on the 50th anniversary of the Pill.

http://news.yahoo.com/s/ap/20100507/ap_on_he_me/us_the_pill_turns50/print
http://www.usatoday.com/news/health/2010-05-07-1Apill07_CV_N.htm?loc=interstitialskip
http://www.healthday.com/Article.asp?AID=638816
http://www.washingtonpost.com/wp-dyn/content/article/2010/05/10/AR2010051003246.html?sid=ST2010051003767

By Alexander Sanger

That great reformer Martin Luther said, "If [women] become tired or even die, that does not matter. Let them die in childbirth--that is why they are there." Luther never recanted this statement. I guess he had other fish, or indulgences, to fry.

In the days before modern obstetrical care and antibiotics, maternal death was an equal opportunity killer, killing mothers in all classes of society in about 1% of births. Among the historical victims of maternal mortality were Queen Mumtaz Mahal (during the birth of her 14th child, whose grieving husband built the Taj Mahal as a memorial); Henry VIII's mother and two of his six wives; Mary Wollstonecraft, author of A Vindication of the Rights of Women; Abraham Lincoln's sister; and Theodore Roosevelt's first wife.

Today in the developed world, maternal mortality is mostly a thing of the past (the rate being about 0.01%). This is a reduction of two orders of magnitude since the 1930's. Maternal mortality is, however, not a thing of the past in the developing world, and the United Nations Millennium Development Goals include one of reducing maternal mortality by 75% between 1990 and 2015, along with a goal of reducing child mortality by two–thirds during this same period.

While some conventional wisdom says that a nation needs to develop economically in order to reduce its maternal mortality rate, historical evidence shows otherwise. Poverty is not necessarily the major determinant of a country's maternal mortality rate, though it is of its infant and child mortality rate. In the late 19th century, as improved standards of living were introduced in Europe and America, i.e. better nutrition, hygiene and housing, leading to attendant better health, child and infant mortality rates began to decline and life expectancy increased. Maternal mortality rates, however, did not begin to decline until the 1930's. The risk of women dying in childbirth in 1930 in England was the same as it was in 1850, though the country was far more developed.

Ironically, and the reverse of today, in 19th century England the maternal mortality rate was highest among the wealthy and middle class, who were attended by physicians in hospitals. The lowest rate was among poorer women delivered at home by trained midwives. Doctors often interfered unnecessarily and disastrously in the labor process, including with forceps delivery, anesthesia, and manual removal of the placenta. These interventions too often proved fatal. Trained midwives, who did home deliveries, let nature take its course with better resulting maternal outcomes.

The 1930's brought sulfonamides, which fought childbed fever, as well as blood transfusions, ergometrine and, later, penicillin, as well as better training and organization of obstetrical services. There was also a coincidental reduction in the virulence of the streptococcus virus in the 1930's. All these led to a decline in the maternal mortality rate throughout the Great Depression, indicating that, in general, poverty is not a determinant of maternal mortality, though starvation level poverty may be.

Assuming that the leading causes of maternal death in Europe and America in 1850 are the same as in the developing world today, this gives hope that maternal death can be successfully combated. Since puerperal fever caused about 40% of maternal deaths in 1850 and almost none today in the developed world, this would seem the first priority for attack.

Until this week, it was thought that the maternal mortality rate had not declined substantially in the past twenty years. Maternal mortality was thought to kill over half a million women a year at a rate similar to 1990. The rate in the developing world was thought to be 400 per 100,000 live births today, only marginally less than the rate, 430, in 1990, or about 7% less, and virtually identical to the rate in England in the 19th century. Reducing the rate was proving to be stubborn.

This week The Lancet reported a study from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington and collaborators at the University of Queensland. This study reports that the maternal mortality rate has indeed declined since 1980 from 442 globally to 320 in 1990 and down further to 251 in 1908. The annual deaths are not over 500,000, as previously thought, but 343,000. Until this week, policy makers had been depressed and frustrated at the lack of progress in reducing maternal mortality. This report gives us reason to hope that our interventions are making a difference. The report also pointed out that progress would have been greater but for the HIV epidemic, which leads to about 50,000 of those 343,000 maternal deaths.

Prior research has pointed out that the decline in the rate over the past 75 years has been largely independent of social and economic class. This recent study confirms this. Large declines since 1980 have been revealed in poor countries such as Egypt, Romania, Bangladesh, India and China. Reductions in maternal mortality can happen if obstetrical services are better organized. Previous studies revealed that in one town in northern England in the 1930's, the health community organized better obstetrical care, and within a few years the maternal mortality rate declined from 900 to 170 with no change in the poverty rate. This was contrasted with a prosperous religious community in Indiana, which refused all outside medical care, including obstetrical, with the result that their maternal mortality rate in 1980 was 872, as opposed to 9 in the rest of the state.

The recent Lancet study confirms that when women time, space, and limit their births, their mortality, and that of their children, declines. Prior studies show that about 30% of maternal mortality could be prevented with universal access to family planning. Most of the rest could be prevented with access to trained midwives, modern obstetrical treatment, pre-natal care, blood transfusions and antibiotics. Many deaths could be prevented by access to safe abortion services. The Lancet study says that the reduction in maternal mortality can be attributed to four factors, among others: a reduced birth rate, increased income, increased maternal educational attainment and attendance by skilled birth attendants.

Martin Luther was wrong. Death in childbirth is not women's inexorable fate. Yet, in the United States it is increasingly so. In 1987, there were 6.6 deaths for every 100,000 pregnancies. The number of deaths has climbed to 13.3 per 100,000 in 2006, the last year for which figures are available. Thus, the rate of maternal mortality has doubled in the last twenty years. Lest our northern neighbors get too smug, the rate has also increased in Canada, as well as Norway. The reasons are many, including a different way statistics are recorded, but, according to previous studies, the deaths are mostly among poor and minority mothers. Insufficient access to health care, including pre-natal care, is one factor. Others include the facts that women are increasingly obese and older as they give birth. There are also more Caesarians, which are risky for mothers, a return perhaps to the 19th century experience where medical intervention could do more harm than good.

A comparison of mortality rates between mothers and children is sobering: while 343,000 women die annually from pregnancy-related causes, 8.8 million children under five die annually, approximately twenty-five times more. The rate of child mortality has declined since 1990 in developing countries from 90 to 65 deaths per thousand, (about a 28% reduction) while the maternal mortality rate is only slightly less at 22%. In least developed countries, the child mortality rate is 130 per 1,000 annually. Poverty is the major determinant of child mortality, with the proximate causes being lack of access to safe water, malaria, pneumonia, other infections, lack of oxygen at birth, and preterm delivery. Vaccines, antibiotics and other low cost interventions would prevent about half of child deaths. There is some intersection between interventions to reduce maternal deaths and those to prevent infant deaths, like pre-natal care, improved obstetrical care and antibiotics, but other interventions for the infant are separate and dependent on a public health care and economic system being functional, especially with vaccines, safe water and mosquito netting to prevent malaria.

In historical times, the difference in annual deaths between mothers and children was greater. It is estimated that the child mortality rate in ancient times was about 50%. In other words, one half of babies born did not survive to adulthood. Estimates range from child mortality rates of 50% in Rome in 200BC-200AD; 48% in Japan in 1300-1400; 50% in France and Sweden in 1600-1700; and modern hunter-gatherer tribes of 46%.

There was an extraordinary difference between the evolutionary mortality rates between mothers and children ⎯ 1% for mothers and 50% for children. Modern medicine, carefully applied, along with fewer births, well spaced and timed, have reduced these awful death tolls. The millennium development goals of reducing these rates further are laudatory. It shows that the world cares and is watching. This is not the time to be disheartened. Progress has been made in our time as well as in the time of our grandparents. I hope our grandchildren will be able to say the same.

This week Spain decriminalized abortion up to 14 weeks of pregnancy. The government enacted the law over the strenuous opposition of the Roman Catholic Church and brings Spain’s abortion law in line with much of the rest of Europe. Minors of 16 and 17 can obtain abortions without parental consent and in some cases notification. This is a major victory for women, which we hope to replicate in the former Spanish colonies in the Western Hemisphere.

Photo from International Planned Parenthood Federation/Western Hemisphere Region showing the complete devastation of its PROFAMIL Haiti clinic.

PROFAMIL Haiti has provided sexual and reproductive health services in Haiti since 1984. This organization is part of a 40 member 40 member organization network called International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR). The program in Haiti has three clinics, but the ones in Port-au-Prince, and Jacmel were completely destroyed by the earthquake as you can see by the photo above.



Laura Zaks, Public Affairs Coordinator, shared with me this sad story of devastation and the urgent need for funds to help PROFAMIL resume services through a temporary static clinic and Mobile Health Units to deliver services in tent cities where displaced persons have gathered.



1. How did the earthquake impact PROFAMIL Haiti's work?

PROFAMIL's clinics in Port-au-Prince and Jacmel have been destroyed, although a small amount of equipment and supplies has been salvaged. Unfortunately, many supplies remain trapped in building rubble with conditions too dangerous to access, particularly in light of the aftershocks. In addition, one staff member, the Director of Finance and acting Executive Director has passed away and at least several staff members have been injured, though a full report on the health and well-being of all staff and their families in both cities has not yet been received.

2. What's needed to rebuild the program?

IPPF/WHR has put together a proposal for funding from various donor sources totaling $2,500,000. This is based on the immediate needs over the next three to six months for human resources, site operations/communications and logistical support, transportation, and medical and surgical supplies.

Given the lack of physical clinics in Port-au-Prince and Jacmel and with the structural integrity of standing buildings uncertain, PROFAMIL is coordinating to offer basic primary health care and sexual and reproductive health services via several modalities, including:

• PROFAMILIA in the Dominican Republic has been coordinating with partners in deploying mobile health unit teams across the border to Haiti to conduct an initial assessment of key areas of need and to begin providing health services. Currently, the majority of international assistance is concentrated in Port-au-Prince, with many unmet health demands in the areas surrounding Leogame, Matrissals, Jacmel, Petit Goave and Grand Goave. These mobile health unit teams, consisting of medical doctors, nurses, and volunteer staff, have extensive experience in working with Haitian immigrants living in the Dominican Republic.

• PROFAMIL staff and community health promoters in Jacmel and Port-au-Prince will organize mobile health units to bring primary health care, obstetric care, family planning and HIV prevention services to community-based sites, including tent cities and other temporary shelters that have been set up in and around both cities.

• Though its physical clinics in Port-au-Prince and Jacmel are too damaged to resume operations, PROFAMIL will seek to establish temporary service provision facilities in fixed physical structures only as appropriate and based on structural assessments of their safety.

3. How can people contribute?

We have set up a donate page on our website where secure donations can be made from any country. 100% of the money collected through this site will go towards getting PROFAMIL's clinics and mobile health units up and working as soon as possible. The link is: https://secure.ga0.org/02/haiti and it is also accessible from the IPPF/WRH homepage: www.ippfwhr.org

4. Are you using social media to get the word out?

Yes, we have been using Facebook and Twitter to get the word out to contacts there. We have been posting updates periodically on these sites to share news and photos as well as the link to our donation page. We can be found on Facebook at: http://www.facebook.com/pages/International-Planned-Parenthood-Western-Hemisphere-Region/85569513068 and on twitter at: http://twitter.com/IPPF_WHR.

We also have an online advocacy center: www.freechoicesaveslives.org. We have mobilized our online membership from this center by sending two appeals asking for donations. We will continue to update our membership as we receive further news from our partners on the ground.

5. Please describe to my readers the connection between sexual reproductive health services and poverty reduction.

PROFAMIL's work has always been closely linked to poverty reduction efforts within Haiti. This brief
slideshow gives a good picture in the link between sexual reproductive healthcare and poverty reduction. Haiti is one of the poorest and least developed countries in the Western Hemisphere. Infant and maternal mortality rates are the region's highest, and Haiti's devastating HIV/AIDS rate is second in the world only to Sub-Saharan Africa. 2006 data indicates that only 28% of the population uses modern contraceptives. Less than one-half of all births are attended by a skilled health professional.

PROFAMIL is one of Haiti's largest nongovernmental sexual and reproductive health providers. Its clinics, community distribution points, and mobile health units provide hundreds of thousands of sexual and reproductive healthcare services annually. For 25 years, PROFAMIL has provided low-cost, high-quality healthcare services including family planning, early detection of breast and cervical cancer, pre-and-post natal services, and voluntary testing and counselling for HIV/AIDS. In rural areas, a network of health promoters and mobile health clinics provide family planning and basic health care-often the only healthcare available in these remote communities. They recently inaugurated new clinics in Port-au-Prince and Jacmel, to better serve their increasing patient base. Given the massive socio-economic and health care challenges facing the country, PROFAMIL's work has been and will continue to be tremendously important in future development efforts in the country. The stories from the field that I pointed to above further reinforce this connection between PROFAMIL and poverty reduction efforts in Haiti.

Also note that International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) has a four-star rating from Charity:Navigator

The latest report we have from our Planned Parenthood in Haiti, Profamil, is that our two clinics in Port au Prince and Jacmel are, if not totally destroyed, then unusable. The staff has tried to salvage what supplies they can, but have been largely unsuccessful.

Concrete and other debris, including a tree, fell on our Finance Director, severely injuring him and, after his broken legs became infected, he was moved to a hospital outside Port au Prince and is receiving care. We do not know about the health status of our other staff.

There are 750,000 women of reproductive age in Port au Prince. At least 10,000 will need delivery services in the upcoming month. Others will be subject to rape and other sexual violence. Still others will turn to prostitution to survive. For all these women and girls, IPPF is working around the clock to make our services available.

Currently, our Planned Parenthood in the Dominican Republic, Profamilia is sending mobile health unit teams across the border into Haiti and is offering services in partnership with the UN and other agencies.

We are also establishing temporary medical facilities in our administration office, which was undamaged. In addition, we are looking into operating a facility in the tent cities for refugees.

Supplies and staff are scarce, but we are working on a pipeline from our Dominican Republic offices to get needed supplies into Haiti.

Check our website for more details on how you can contribute.

http://www.ippfwhr.org/

By Alexander Sanger
To the Family of George Tiller, M.D.
September 25, 2009

The IPPF has a statement entitled "What We Believe". It reads:

"We believe that sexual and reproductive rights should be internationally recognized as human rights and therefore guaranteed for everyone. We encourage individuals, women in particular, to take control of their reproductive lives. We promote equality between men and women, aiming to eliminate gender biases, especially those that threaten the wellbeing of women and girls. Above all, we promote choices."

IPPF/WHR created its Medal of Honor to recognize distinguished men and women who make this statement of beliefs a reality. We honor those without whom women would be bereft of choices. Choices don't appear out of thin air. Choice in the form of surgical abortion exists only when brave doctors offer it.

Tonight we honor the late Dr. George Tiller, of Wichita, Kansas, a man who offered choices to women under the most difficult circumstances.

When my grandmother, Margaret Sanger, founded Planned Parenthood in this country almost 100 years ago, she met with virulent opposition from politicians of every party, from doctors of every specialty, from priests of every religion, and from virtually all men and not a few women as well.

She was vilified, ostracized, harassed, arrested and jailed, but she was never physically assaulted or shot at. In those days, going to jail was the ultimate martyrdom for our beliefs. No longer.

As the status of women has increased, thanks to our work, so have the desperation, intensity and violence of our opposition. Where initially there were constitutionally-protected, peaceful protests against our clinics, for decades now there have been illegal blockades, vandalism, bombings, assaults and murder.

It takes dedication, character and integrity to be an abortion provider in the United States, and George Tiller had these in abundance. It takes even more character to dedicate one's practice to the most needy and desperate of women and to provide abortion services in the heartland of the United States where our opposition is strongest.

Early in his medical practice, George Tiller saw a woman die from an illegal abortion. He said, "no more", and began offering abortion in his practice, eventually providing late term abortions for women who came to him from all over the country – one of a handful of doctors to offer this service. He did so with the utmost caring and compassion, being an example of what all those providing medical services should aspire to be.

For 30 years, George Tiller stood up to protests, harassment and assaults, even being wounded some years ago in a shooting. He kept his clinic doors open to give a choice to women who never imagined they would ever need it – women with a wanted pregnancy that had gone terribly awry as it progressed.

A few years ago I did a fundraiser with George in Kansas City for his political action committee. The protests outside were extensive, grotesque and downright scary, at least for me, even though we were both wearing bullet proof vests and had security guards. George was undaunted – upbeat even, at the reaction he caused by daring to be public in his insistence that women be treated with respect and have all medical options available to them in a crisis. A former naval flight surgeon, George Tiller was not one to be intimidated.

On May 31 of this year, George Tiller was assassinated by an anti-choice fanatic as he ushered at Sunday morning services in his church in Wichita, Kansas.

George Tiller has been silenced and his clinic closed, but his memory and example never will be.

The Tiller Family has lost a husband, father and grandfather, women have lost a savior and we have lost a hero. It is fitting and right that we at IPPF honor him this evening. He represented the best of us.

To accept the IPPF/WHR Medal of Honor, please join me in welcoming George's widow, Jeanne and his daughters, Jennifer, Rebecca and Krista.