MW4DR: How do we get past la Cabesa Dura?

SKing

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Nov 22, 2007
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ATTENTION: THIS POST IS LOOOOOONG

People,
I am frustrated, confused, and highly upset. I am here to ask your advice into strategies to get past the cabesas duras of some of the medical professionals in the Dominican Republic.
Before Dominic-anus or some other New York residing Dominican starts to chime in that I am bashing the medical community of the DR, I would like to say that in the past year I have encountered NUMEROUS Dominicans who want to see a change in the Maternity care in the country. This includes doctors, nurses, lactation professionals, students, women's rights advocates, and even laypersons. So there ARE Dominicans that see the benefits of what we are trying to accomplish.

I am frustrated though that there are still some that won't listen even when given information and education. Even when told that what we are aiming to accomplish will save lives.

Let's talk about the most recent hurdle:
Kangaroo Care- Kangaoo care is when an infant is placed skin to skin with mom, with only a diaper on. They are held in an upright position on mom's chestusually so that the head is on the side of the heart.
In Cabral y Baez in Santiago, we have introduced Kangaroo Care, or should I say, we've tried. While I was in the States, the ladies from La Leche League went to the hospital for some time Mondays through Thursdays in order to assist with breastfeeding, and to initiate the Kangaroo Care. The doctors are resistant.....
I've received at least 3 emails from the Supervisor telling me that the hospital is giving them a hard time and no one can answer as to why they do not support this initiative. I have given them NUMEROUS articles on the benefits of Kangaroo Care, those that are imperative to premature infants ESPECIALLY when you are in medical facility that does not have top of the line technology. Kangaroo Care:
- decreases infant apnea (many have seem a 4x DECREASE in apneic episodes once KC was initiated)
- stablilizes heart rate
- regulates infanta body temperature (the body temp of a mom will ADJUST to regulate the body temp of her baby when placed in KC!)
- increase lactation success (KC babies are found to breastfeed spontaneously up to 8x more than non KC babies!)
- weight gain in preemies (KC babies were found to have more rapid weight gain)
All of these things terminate in a healthier baby and shorter hospital stays...

SO WHY ARE THESE DOCTORS OPPOSING THIS?!
- We have been in the hospital before, many times, so it's not that they don't know who we are
- When the girs go, they go 5 or 6 of them so it is not extra work on the doctors or the nurses as they assist the moms in breastfeeding and before with Kangaroo care
- The staff was offered to go with us to San Francisco de Macoris to see the Kangaroo care in action and speak with the doctors and nurses there regarding their results (it was not accepted)
- No one can give us a concise reason as to why they don't want it
- I take gifts for the doctors and nurses EVERYTIME I enter that hospital (I found out very quickly that they are more receptive when something is offered for them and not just the patients)


So, If anyone has any other tactics that we can try? Tomorrow I am going to talk with Licette (LLL Supervisor) and see what we can come up with..I would like to say that in all Kangaroo Care studies, most of the Infant mortality rates fell by 30%-40%!!! I mean, come on! This is evidenced based practice!!! It's not like I'm making this up!
Please give me suggestions, I'm probably gonna get to the hospital week sometime, and I want to leave there with a positive answer.
By the way, here are some Maternal health statistics in the DR that are frightening. We are trying our best, but we will need cooperation, as least a little from those at the forefront. There are alot of Dominicans who support us and for them we will keep going.

FACTS:
-The Maternal mortality rate in the DR is 100 per 100,000 (over 4 times the US rate) EVEN THOUGH 98% of Dominican women recieve prenatal care and deliver at a hospital

-The DR Cesarean section rate has been calculated most recently at 39%, and in some areas as high as 45%

-A recent study showed that among women who received 4 years or less of primary education, 43.8% became pregnant as opposed to 13.3% among women who completed secondary or higher education

-In another study it indicates that 61% of child mortality in the DR occurs during the Neonatal period (therefore focusing on the critical period before and after delivery is crucial for the infant's survival)

-Currently 20.6% of teens in the DR (age 15-19) are currently pregnant. The rate would be higher if those ages 12-14 had been counted

-A range of studies has shown that 85% OF THE MATERNAL DEATHS IN THE DOMINICAN REPUBLIC COULD BE AVOIDED WITH IMPORVED QUALITY OF CARE

-Currently the majority of the money given to fund public hospitals goes into commodoties or salaries, with little investment in human resources, infrastructure, education of staff, and maintenance of buildings andequipment


Thanks for reading and if anyone has any suggestions for a way to get through to some of these medical professionals, at this point I'm willing to try anything...
Well, ALMOST anything LOL

SHALENA
 

cobraboy

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Jul 24, 2004
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It's simple: they don't like outsiders coming in and telling them what to do.

You've been warned before there would be resistance because of it.

You need a strong, respected DOMINICAN champion to forward the message and take gringo fingerprints off of it.
 

Castle

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Sep 1, 2012
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Shalena

First of all I have to admire what you do, and tell you that even though those hospitals don't seem to appreciate your efforts that much, there are a lot of us who do.
That being said, let's go back to how public services are run here. I'm no expert, but the first thing that I noticed is that doctors and nurses don't care much because they are not benefiting from the procedures themselves. Maybe they find it is extra work and as long as they don't get an order to do things this way, they just won't. Remember this is a society of excellent followers but poor leaders. And remember hospitals in DR are not independent, but they report to higher levels within the hospital network (provincial and then central authorities). So I guess you need to somehow take this matter to higher levels, or as they say, talk to the circus's owner instead of to the clowns. If regional, provincial or even central levels see they can benefit from this in terms of good publicity (through good, documented results) they won't miss the opportunity to shine. I would therefore advise to take the matter to the highest health official you can reach, and work from there up and down the bureaucracy ladder.

But above it all, remember underdevelopment is an all-around thing. Countries are not underdeveloped because they don't have school or hospitals or solid institutions. That would be easy to solve. They are underdeveloped because they have fixed mental structures that make it hard for them to think out of the box, and so they keep repeating the same patterns getting the same lousy results. So, I would advise anyone wanting to change things (oh, the utopia) that they need to focus not in changing the present, but the future, and work towards that goal. Maybe the newborns of today won't enjoy the benefits of kangaroo care, but with patience and some social skills (in the tropical sense), maybe the newborns of the future will, and maybe to a higher scale.
 

Bronxboy

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Jul 11, 2007
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Kangaroo Care- Kangaoo care is when an infant is placed skin to skin with mom, with only a diaper on. They are held in an upright position on mom's chestusually so that the head is on the side of the heart.

<iframe width="560" height="315" src="http://www.youtube.com/embed/kAVMWa6BFPY" frameborder="0" allowfullscreen></iframe>......................
 

pauleast

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Jan 29, 2012
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Not a wise thing to post here. I hope it was a mistake!

HB, not happy!
 
Last edited by a moderator:

cobraboy

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BTW: I have immense admiration and respect for what Shalena is trying to accomplish. She's a Saint in that regard, and I wish her nothing but monumental success...:classic:

You go, girl!
 

Africaida

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Jun 19, 2009
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No suggestions Shalena, but very interesting read.

I am amazed that there is even a name for Kangaroo care and its benefits, I would think it is instinct/common sense.

Best of luck in your projects, changing mentality takes time.
 

AlterEgo

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Jan 9, 2009
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I think you're doing everything right, it may just be a matter of "throwing enough *** at the wall until some of it sticks". Keep trying, changes take time. Especially when they're being suggested by a 'gringa', as in "who is she to tell US what to do?", as cobraboy suggested.

I don't know if you watch Boardwalk Empire, but a female character there is struggling to introduce women's prenatal health classes [in circa 1920s Atlantic City] after seeing a pregnant woman hemorrhage in the waiting area. She's having similar roadblocks.
 

Bronxboy

Well-known member
Jul 11, 2007
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I

I don't know if you watch Boardwalk Empire, but a female character there is struggling to introduce women's prenatal health classes [in circa 1920s Atlantic City] after seeing a pregnant woman hemorrhage in the waiting area. She's having similar roadblocks.

Yes, yes, yes. awesome show!!!!
 

SKing

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Nov 22, 2007
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It's simple: they don't like outsiders coming in and telling them what to do.

You've been warned before there would be resistance because of it.

You need a strong, respected DOMINICAN champion to forward the message and take gringo fingerprints off of it.

This is not true as the flagship program at the hospital at SFM is run by Nurse Midwives from Emory University, not run by the hospital. They go every 3 months to make sure that things are still going well and to do more education with the nurses.
Thanks for the suggestion


SHALENA
 

SKing

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Nov 22, 2007
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<iframe width="560" height="315" src="http://www.youtube.com/embed/kAVMWa6BFPY" frameborder="0" allowfullscreen></iframe>......................
Bronx, I'm at work so I can't see your YouTube thing (access denied) so I'll look at it tomorrow
Shalena

First of all I have to admire what you do, and tell you that even though those hospitals don't seem to appreciate your efforts that much, there are a lot of us who do.
That being said, let's go back to how public services are run here. I'm no expert, but the first thing that I noticed is that doctors and nurses don't care much because they are not benefiting from the procedures themselves. Maybe they find it is extra work and as long as they don't get an order to do things this way, they just won't. Remember this is a society of excellent followers but poor leaders. And remember hospitals in DR are not independent, but they report to higher levels within the hospital network (provincial and then central authorities). So I guess you need to somehow take this matter to higher levels, or as they say, talk to the circus's owner instead of to the clowns. If regional, provincial or even central levels see they can benefit from this in terms of good publicity (through good, documented results) they won't miss the opportunity to shine. I would therefore advise to take the matter to the highest health official you can reach, and work from there up and down the bureaucracy ladder.

But above it all, remember underdevelopment is an all-around thing. Countries are not underdeveloped because they don't have school or hospitals or solid institutions. That would be easy to solve. They are underdeveloped because they have fixed mental structures that make it hard for them to think out of the box, and so they keep repeating the same patterns getting the same lousy results. So, I would advise anyone wanting to change things (oh, the utopia) that they need to focus not in changing the present, but the future, and work towards that goal. Maybe the newborns of today won't enjoy the benefits of kangaroo care, but with patience and some social skills (in the tropical sense), maybe the newborns of the future will, and maybe to a higher scale.
I have had 2 personal face-to-face meetings with the Director of Maternal/Infant Health at the Ministerio de Salud. He has all of the statistics, agrees with me on everything, but no one is doing anything. He had asked me about joining a group to try to bring Midwifery to the DR but the group has not been formed yet and its been a wait, wait, and wait some more project. I have lots of contacts that I have not been to yet becaue my schedule is full. I am in Midwifery school distance, still having to do clinicals and I have to go to New York every 7 days to work so when I get home I only have 7 days and my task list is outrageous. I have a few more women interested in joining the administrative part of my organization and I'm hoping in the next month to divy up some of this workload. Problem is, I am type A personality and either I do it myself or I go behind you and make sure it was done correctly and some poeple don't like that.
I am thinking with Cabral, to have a sort of dinner for the OB docs and Nurses where I show a slideshow and show what we would like to do and let them know that there will be "dinners" like that one every 3 months with goodis if they can help us. My ultimate goal is bringing Midwifery to the DR, with a reputable program established at one of the Universities for nurses to further their education for Midwifery.
The hospital in SFM has done amazing things. Emory went there when contacted by the University of Puerto Rico and did a study after the hospital had 6 Maternal deaths in 6 months!!!
The Emory Midwives and Midwifery students shed light on the problems and gave the nurses tools to change them. They did entensive education for 3 years, they trained the nurses how to assess adequately for postpartum hemorrhage, they educated certain senior nurses on how to deliver a baby, and sew a laceration.
This hospital after the initial 3 years that Emory went there consistenly, had NO MATERNAL DEATHS in the next 2 years after that. And now when they do...they actually have a round table discussion and discuss the case to see exactly what happened and make improvements. This is great. I would love to see this with Cabral. And I woud like a few more things but....one thing at a time :). The difference with SFM and Cabral (Santiago) is that the docs and nurses at SFM RECOGNIZED that there was a problem and accepted help and now the Emory staff only needs to go once per year....the rest is being done by the DOMINCAN STAFF. There are hard-heads at Cabral but its not because "Dominicans don't want an outsider" because those girls from Emory are whiter than the first snow and they were allowed to teach and evaluate and look at the results.

BTW: I have immense admiration and respect for what Shalena is trying to accomplish. She's a Saint in that regard, and I wish her nothing but monumental success...:classic:

You go, girl!
Thanks, much appreciated

I think you're doing everything right, it may just be a matter of "throwing enough *** at the wall until some of it sticks". Keep trying, changes take time. Especially when they're being suggested by a 'gringa', as in "who is she to tell US what to do?", as cobraboy suggested.

I don't know if you watch Boardwalk Empire, but a female character there is struggling to introduce women's prenatal health classes [in circa 1920s Atlantic City] after seeing a pregnant woman hemorrhage in the waiting area. She's having similar roadblocks.

Problem is when I am there with goodies, all is well for about 2-3 weeks they stick to it and then....nothing until I show up again, and I can't be there everyday.

Thanks for the thoughts guys

SHALENA
 

Aguaita29

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Jul 27, 2011
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SO WHY ARE THESE DOCTORS OPPOSING THIS?!
- We have been in the hospital before, many times, so it's not that they don't know who we are

So, If anyone has any other tactics that we can try?

By the way, here are some Maternal health statistics in the DR that are frightening. We are trying our best, but we will need cooperation, as least a little from those at the forefront. There are alot of Dominicans who support us and for them we will keep going.

Thanks for reading and if anyone has any suggestions for a way to get through to some of these medical professionals, at this point I'm willing to try anything...
Well, ALMOST anything LOL

SHALENA

Did you guys get in touch with the the Sub Minister of Health in charge of the region where the hospital is located? Salud Publica is political and follows a similar bureaucracy as Educaci?n. Doctors are just at the bottom of the totem pole and hospitals will implement any new thing that the Minister says.

By the way, you could also get the press involved. Get someone to do a report on the benefits of Kangaroo Care and show the statistics you have.

How did you manage to get started to make things work at that Hospital in Macoris? Did the hospital directors welcome you right away?
 

cobraboy

Pro-Bono Demolition Hobbyist
Jul 24, 2004
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This is not true as the flagship program at the hospital at SFM is run by Nurse Midwives from Emory University, not run by the hospital. They go every 3 months to make sure that things are still going well and to do more education with the nurses.
Thanks for the suggestion


SHALENA
Maybe THEY took similar advice to mine, and have a champion somewhere. I doubt they just parachuted in and expected to be respected and have rapt audiences ready to implement what the gringa says.

Mom CB was an administrator @ the Emory Hospital system for many, many years, like 25+, beginning in the mid-70's. Part of her retirement is an Emory pension. Maybe I can ask her to ask around how they put their program together and who their contacts are. I know she could easily find out.
 

SKing

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Nov 22, 2007
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Maybe THEY took similar advice to mine, and have a champion somewhere. I doubt they just parachuted in and expected to be respected and have rapt audiences ready to implement what the gringa says.

Mom CB was an administrator @ the Emory Hospital system for many, many years, like 25+, beginning in the mid-70's. Part of her retirement is an Emory pension. Maybe I can ask her to ask around how they put their program together and who their contacts are. I know she could easily find out.

They were ASKED to go in by the University of Puerto Rico who had been contacted by the OB staff at SFM after the 6 deaths in such a short time span. The difference in SFM and Cabral is that they are VERY pro-Midwifery and wanted their statistics to drop. My clinical internship is with some OB physicians there and when I went to observe the program and see the changes, I was there for 4 days and stayed in the house of the Medical Director and his wife, who attended a Doula/Childbirth Education class with me. I spent morning til evening in L&D and I was amazed at how different it was from Cabral and the nurses tell me it is all from the training that they received from Emory. There are 3 nurses there that were trained in deliveries and suturing lacerations and handling obstetric emergencies. Those 3 nurses deliver over 90% of the VAGINAL deliveries there....hmmmm, sounds a little like Midwifery to me, and they have had on average 0-2 deaths per year since the training...which is an amazing difference.

CB, I know that you would like me to believe that it is becuase I am American but I do not buy that for the fact that I sent in Dominican professionals when I am not there in the country and after I went in March, I was not back until August and these amazing ladies (all certified in Lactation, and having gotten training from SFM on Kangaroo Care, Doula and Childbirth Education certified) went 4 days per week....every last one of them DOMINICAN BORN AND BRED and they got resistance, resistance, resistance. And I know that you would like to think that some Dominican was responsible for the changes made by Emory University School of Nursing but I can assure you that it was not. The DOMINICAN docs at SFM were receptive, respectful, and accepted the constructive criticism and the solutions from AMERICAN Midwives. They did not want more women dying, the reason that Cabral is so resistant, I have no idea, because I am sure that their Maternal Mortality rates are more than SFM's were just for the sheer difference in size. I am stil studying that. I also plan to start a study in the spring to separate the haitians from the dominican statistics so that I can get a real sense of the Maternal Mortality rate of the DOMINICAN women as it has been brought up several times here that it is assumed that the rates are so high due to haitians being coutned in the numbers.

SHALENA
 

SKing

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Nov 22, 2007
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Did you guys get in touch with the the Sub Minister of Health in charge of the region where the hospital is located? Salud Publica is political and follows a similar bureaucracy as Educaci?n. Doctors are just at the bottom of the totem pole and hospitals will implement any new thing that the Minister says.

By the way, you could also get the press involved. Get someone to do a report on the benefits of Kangaroo Care and show the statistics you have.

How did you manage to get started to make things work at that Hospital in Macoris? Did the hospital directors welcome you right away?

This is a good idea.
I had thought about the press as Hillbilly has a contact but I wanted to finish my schooling first to have more of an edge (I graduate in 2015). My thought was to implement some programs- Kangaroo care, Doula birth assistance, Lactation assistance, Prenatal classes in the poor barrios, Postpartum assessment (to reduce the hemorrhage rates),and Adolescent education....track the progress over the next 2 years until I finish school and then go to the press and the Minister with the results. On TV, I would rather be Shalena, Midwife than Shalena, Midwifery student. I just think they will take me more seriously then.
I don't get upset with them,I just kind of laugh it off but none of them have a rational explanation as to why they shouldn't do any of the suggested implementations.

SHALENA
 

Chirimoya

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Dec 9, 2002
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Shalena, I think what you have achieved so far is phenomenal, but change will be slow due to the factors listed by Castle.

The important thing is not to lose heart, and keep at it.

I see you are already working through local agents - the La Leche League - so it is not a simple case of them perceiving it as an outsider coming in to impose alien ideas.
 

Chip

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Jul 25, 2007
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Santiago
From my experience with Dominican professionals I would say one has to be careful when suggesting anything new. While the aforementioned are certainly quite aware of the major issues in their country they are still proud of their country and can be resistant to change, even a good idea, just based on "presentation" of the new idea.

As odd as it sounds my first suggestion would be to make sure the term "Kangaroo Care" is not be used but rather something more scientific. Second, a real genuine repertoire needs to be established with the administrative doctors and nurses in charge who will be charged with implementing this change and to do that a real understanding of Dominican culture is of utmost importance. These type of interactions need to be formal in the Dominican sense and very cordial to say the least(never say "vaina" please). Mentioning a very healthy respect for the job that is being done with so little resources would be a winner as well - but only for the public hospitals not private clinics. Dominicans are also interested in why would a foreigner be so interested in helping them out. They may assume that the foreigner thinks they are better and thus they will be resistant. However, if the foreigner can demonstrate effectively that they want to help out because they generally are interested and impressed by aspects of Dominican culture they certainly will be received better. However, the latter can't be faked imo.

I'm basing this on my experience with other professionals in my field as a civil engineer. Any respect of what is good about the DR, whether it be food or love of the family, is always well received and respected. Bottom line is Dominican professionals want to be seen as equals. These are my personal observations based on my experiences and it may be different for others.

Finally, I would personally would stick to the task at hand at of selling this type of care, which seems very good, instead of throwing a lot of statistics out there (like those that were presented in this thread) such as reminding them than there are a lot of teen pregnancies, etc. as this could be misinterpreted that one would at some point be advocating abortion - which would be a big no no imo.
 

SKing

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Nov 22, 2007
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ROBERT OR MODERATOR:

It was explained to me in January that I was not to respond to Chip nor was he to respond to me in any postings with a threat of being banned. This was placed by Robert. I am supposedly to be placed in his "ignore" list wihtout his permission by Robert.

I have posted this thread in an effort to get genuine assistance for a problem affecting the women in the Dominican republic and he has entered my thread with a post laced with incorrect assumptions, finger-pointing, and sarcasm.
Please let me know if Robert's rule has been lifted or please disable him from commenting on my threads or posts (which was the rule placed in January), I do not want my thread to turn into a circus with his remarks, this is very important to me.

Thank You

SHALENA
 

SKing

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Nov 22, 2007
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Shalena, I enjoy your posts though I know this one was not for enjoyment. But I find statistics confusing at times.

-A recent study showed that among women who received 4 years or less of primary education, 43.8% became pregnant as opposed to 13.3% among women who completed secondary or higher education

Is this over ife time? Or what? If the lifetime birthrate for educated women is only about 13% The place will soon become ilke Maine where one can go from one week to the next without seeing any kids.
Sad and terrible. about 40% of women having babies in tgheir lifetime is still quite low, isn't it? I believe that 2.2 kids per mujer is about replacement. If I misunderstood your statistic poease let me know what it did mean.
Thanks
Der Fish
Thanks DerFish,
I am not sure as I received the information from the "Dominican Republic" Global Health Initiative Strategy" that you may Google. I am assuming that of the women that they counted. Count so many...see how many were pregnant as teens...find out how much schooling they had...form statistic.
I'm not sure but the DRGHIS is 27 pages of very interesting medial facts. Not only including Maternal/Child health but also HIV, TB, and other initiatives.

SHALENA