Category Archives: Maternal Health

Obstetric Fistula afflicts nearly 100,000 women in Kenya – Japheth Mati

The recently released findings of the 2014 Kenya Demographic and Health Survey (KDHS 2014) included, for the first time ever, an estimate of the prevalence of fistula in Kenya. After describing the condition, women were asked if they had ever experienced the symptoms of fistula, to which 1 percent responded in the affirmative. What this means is that 1 percent of women of childbearing age (15-49 years) had actually suffered a fistula, and based on the 2009 population census, this translates to at least 93,120 women.

As I read the KDHS results recently, I could not help recalling a post I made three years back, under the title “Remembering my fistula patients as Kenya observes FGM Day”. I was referring to the 1970s when I was one of two gynaecologists in the Department of Obstetrics and Gynaecology at the Kenyatta National Hospital (KNH), who had special interest in the treatment of urinary incontinence, the commonest cause of this being vesico-vaginal fistula (VVF). I remember that at any given day there would be one or two such cases in my ward.

This condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women received skilled care during labour and delivery. Yet it has persisted as a major problem, decade after decade.

Dr Peter Candler way back in 1954 reported that obstetric VVF was the commonest gynaecological condition encountered at the King George VI Hospital (today’s KNH); and as I indicated above, it still was common in the 1970s. How sad it is that decades after independence, a substantial proportion of Kenyan women remain at risk of this tragedy. Today, the KDHS data tells us there could be well over 93,000 women living with the condition.

On the brighter side we must recognise the commendable efforts in the recent past towards improving access to surgical treatment of fistula. But the magnitude of the problem remains intimidating. How long will it take to clear the backlog, while at the same time new cases are being created?

Let us assume 10 hospitals undertook to operate 10 cases daily, 5 days a week, completing 500 surgeries per week. To do all 93,120 women at that speed would take 187 weeks or 3.5 years. But this assumes that no new cases are added throughout the 3.5 years and that each operation was successful, (which is not always the case!), and more importantly, the survey estimate of 1 percent was correct, (stigma could have affected responses). Finally, it is possible that a crush programme involving surgical camps may accomplish the task sooner, the cost and logistic nightmare notwithstanding.

On the whole, the above underlies the importance of prioritising prevention. Looking to the future, the hope lies in improving access to skilled maternal health care for all pregnant women, antenatal care and delivery services. This is the only way of eliminating the risk of obstetric fistula. In this regard, kudos to our First Lady! Her Initiative, Beyond Zero Campaign, is a practical demonstration of her love for the women and children of Kenya. Indeed, such level of commitment is unprecedented.

The KDHS 2014 has given us some hope- the proportion of women who received skilled care during delivery has increased from 44 percent in 2008/9 to 62 percent in 2014, while those who gave birth in a health facility increased from 42 percent in 2008/9 to 61 percent in 2014. Even though a lot remains to reach the MDG 5 target of 90% by 2015, this data is, nevertheless, extremely encouraging and motivating. Better late than never!

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How sad it is that inventors cannot control the eventual application of their work: The flipside of innovations in diagnostic and therapeutic technologies in medicine. Japheth Mati MD

It is fair to conclude that the technological revolution of the twentieth century was unprecedented in human history. Medicine was one area of tremendous progress, especially considering that at the dawn of that century Surgery, in particular, was a dicey procedure to undergo. It was before the arrival of safe anaesthesia, blood transfusion, antibiotics, and other life support paraphernalia we often take for granted. Admittedly, a lot of today’s surgical procedures predate the 20th century, but they were far from being safe. Take Caesarean section, for example, around 1860s the mortality rate associated with the operation in Great Britain and Ireland, was 85%[i]. Major strides in mortality reduction had to await advances, especially in three key areas: Anesthesia, Blood transfusion and Antibiotics.

Anesthesia: In the 20th century, the safety and efficacy of general anaesthesia was improved by the routine use of endotracheal intubation, advanced airway management techniques, and better anaesthetic agents that made “bite the bullet” become obsolete!  Blood transfusion: The discoveries by Karl Landsteiner, of human blood groups (1901) and the Rhesus factor (1937), markedly improved the safety of blood transfusion. Antibiotics: Antibiotics are a creation of the 20th century, starting with the sulpha drug Prontosil in1935; Penicillin[ii] (1942), Streptomycin (1943); Tetracycline (1955); Nystatin (1957); to be followed by others, including the semi-synthetic antibiotic Amoxicillin (1981).

As I marvelled over these and other 20th century great medical scientific and technological feats, one question kept nagging me: does the way we mainly use these inventions today conform to the original purpose of their creators?

Thinking slightly outside of medicine, one can for example compare the opposites in the employment of nuclear technology: on the one hand, its value as a source of efficient energy to drive industry, and on the other its use as a weapon of  mass destruction. Though not to the same degree of departure, in medicine, a considerable number of today’s most celebrated technologies are used in manner that is at variance with the inventor’s original intentions, to the extent that some inventors have had occasion to publicly express regret over the ‘misuse’ of their work.

It’s the intention in this post to review briefly selected diagnostic and therapeutic innovations that have exerted great impact on medicine in general, and the practice of obstetrics and gynaecology in particular, especially beginning the second half of the 20th century.

The review covers the following diagnostic and therapeutic techniques: amniocentesis and amniotic fluid sampling, prenatal cytological sex determination, prenatal blood DNA sex determination, obstetric ultrasound, and in-vitro fertilisation technique. Each one of the above innovations has performed beyond expectation, finding greater utilisation for purposes far removed from the original intention at the time of their discovery. These “other” uses are examples of what can be referred to as ‘the flipside of scientific and technological innovations in medicine’. In sympathy with their cause, we are left to wonder: “If only inventors were endowed with wisdom to foresee the ends to which their creation might end up being applied!”

 Amniocentesis

Amniocentesis is the process of removing a sample of amniotic fluid – the medium in which the fetus floats in the mother’s uterus, to be analysed for markers of certain disorders of the fetus. This procedure is credited to the work of Douglas Bevis, a British obstetrician and gynaecologist at St. Mary’s Hospital in Manchester in early 1950s. Later, following the discovery of ultrasound (see below) it became possible to undertake ultrasound-guided amniocentesis with greater accuracy and safety.

Amniocentesis ultrasound guided image

Ultrasound guided amniocentesis

Amniocentesis and amniotic fluid sampling (AFS) permits the monitoring of fetal wellbeing in utero, especially in the management of Rh-isoimmunisation. It is frequently used in the estimation of fetal lung maturation, and in the diagnosis of genetic disorders such as Down’s syndrome (mongolism) and sex-linked diseases such as haemophilia.

In 1949 Canadians Murray Barr and Ewart Bartram had discovered sex chromatin (a mass of chromosomes, also called “Barr Body”), which is found only in female cells. Thus, finding the sex chromatin in fetal cells obtained through AFS permitted identification of a female child. Later through tissue culture techniques it was possible to identify the actual male and female sex chromosomes in cells, thereby improving accuracy of sex determination using cytogenetic technique, which remains the gold standard. There are now over 500 hereditary diseases that can be diagnosed through amniocentesis and other diagnostic techniques[i].

The technique of amniocentesis reigned supreme till the tail-end of the 20th century when in 1997 Dennis Lo and colleagues (both in Oxford UK and Hong Kong, China) published their seminal paper[ii] reporting the presence of fetal DNA in maternal blood, thereby opening the door to a new non-invasive technique that avoided the risk (albeit very small) of abortion following amniocentesis. The new DNA test, which employs the more advanced Polymerase Chain Reaction (PCR), has the added advantage of being performed at an earlier gestational age- as early as 7 weeks, much earlier than was possible with ultrasound scan (see below) which could only demonstrate male fetus at 11 weeks earliest, and not so reliably. An important downside of DNA PCR test is the cost involved.

The potential to determine fetal sex has opened the door to abuse of these tests. The ‘flipside’ of prenatal sex diagnosis has been its utilization in selective abortion of female fetuses, to the extent sometimes, of posing demographic imbalance as has been feared for India[iii] and China[iv]. In this regard the test changes from enhancing the wellbeing of the fetus to selecting it for destruction. A complete turnaround!

Ultrasound scanning

Prof Ian Donald[v] (1910-1987), the Regius Professor of Midwifery at the University of Glasgow (1954 -1976), and a tough Scot who endured three open-heart valve-replacement operations, is the celebrated Father of Medical Ultrasound, a technology he pioneered beginning the late 1950s. His first major publication on the subject appeared in the Lancet in 1958, which contained the first ultrasound images of the fetus ever published[vi].

The potential to reveal information on the growing fetus in the womb was soon realised and the use of ultrasound spread quickly, improving the safety of pregnancy and childbirth, and allowing for the much more effective detection and treatment of fetal abnormalities. Since the 1970s ultrasound scanning has become a routine part of antenatal care. And as the science of ultrasound developed, so did its applications. Ultrasound scanning is now used in numerous other areas of medicine, with recent advances in technology enabling three-dimensional images to be produced.

Ian Donald hommedia

Professor Ian Donald

A less discussed dimension of Ian Donald’s work is what fundamentally may have driven him to develop the technology. In this regard, he seems to have considered obstetric ultrasound to be more than simply a means to visualise the fetus in utero; instead, he saw the technology as providing a chance to ‘individualise’ the fetus. The technology made it possible for the fetus to be recognised, or at least spoken of as, an individual, a reality. This view comes out clearly from the description he uses in the following 1978 presentation to a lay audience[i]:

Here’s the baby see how he jumps … This baby is about a 12 week pregnancy … She [the mother] certainly cannot feel these movements but there is no doubt about the reality, … now you see it move its hand up to its face you see his head is up here and his chest is down here then he throws his legs out and his arms … You see his hands come up like that. And you see his face here, the back of his head … It is rather like a child on a trampoline, tremendous strength, energy and vitality.)

Perhaps because of these experiences, Ian Donald came to hold quite strong views against abortion, being a lead campaigner against the 1967 Abortion Act in the UK. He is known to have employed the ultrasound imagery as a powerful persuasive resource in urging women to continue with their pregnancies. In his view the only indication for abortion was a very grossly deformed fetus; no consideration in cases of mild or moderate handicap. Indeed Ian Donald even went to the length of attempting to save a fetus in an ectopic pregnancy – a heroic surgical endeavour which failed miserably, but which nevertheless, justified an audience with Pope John Paul II, an occasion he described as ‘the crowning event of my life’[ii].

Personal idiosyncrasies apart, there is absolutely no argument that Ian Donald’s work has contributed immensely to better outcomes in many medical disciplines, away from his own field of obstetrics and gynaecology. However, in a rather ironical way, ultrasound scan happens to be the most reliable way of diagnosing not only early pregnancy, but also of ensuring the uterus has been completely evacuated, following both spontaneous abortion and induced abortion (especially medical termination of pregnancy).

By the 1970’s, Ian Donald had become aware of the truth, that the ends to which technology is put cannot be determined by its originators. He somewhat despairingly wrote, “My own personal fears are that my researches into early intrauterine life may yet be misused towards its more accurate destruction”[iii]. Indeed, Ian Donald had come face to face with the flipside of his own scientific and technological innovation in medicine!

 In vitro fertilization

Patrick Christopher Steptoe (1913 – 1988), a British obstetrician and gynaecologist, along with biologist/ physiologist Robert Edwards, were the pioneers of the technique of in vitro fertilization for infertility treatment. Louise Joy Brown, their first ‘test-tube baby’, was born on 25 July 1978, the product of great perseverance- it took them 10 years before they had their first successful birth. Edwards was awarded the 2010 Nobel Prize in Physiology or Medicine for this work, however because the Prize is not awarded posthumously, Steptoe was not eligible for consideration.

Since Louise Brown, there have been over 4 million babies worldwide conceived through IVF. Despite a steady stream of ethical and moral questions arising from IVF, to date, the lives of many women and couples across the globe have been enriched by a child conceived through one or other of the various modifications of the original IVF technique introduced by Steptoe and Edwards. This reproductive technology has made and continues to make tremendous advancements in basic reproductive biology and embryology. It has enabled us to understand the human reproductive processes and especially fetal development, in a way that has never been possible in the past[iv].

At the same time, the world of IVF almost everywhere has become a very competitive market-place, resulting in many treatment centres going to great lengths to ensure a pregnancy is achieved. The temptation is high to transfer large numbers of embryos to the uterus, which results in pregnancies of high multiples, some of which may be lost through spontaneous abortion, or subjected to ‘fetal reduction’ procedures (euphemism for abortion).

The technique of IVF has become an essential source of ‘spare embryo’ for stem-cell research, which gives hope to many people dying from today’s incurable diseases. But, still, this is far beyond Patrick Steptoe’s imagined application of their technique.


[i] I. Donald (undated but after 1978) ‘Predicting ovulation’, unpublished lecture, tape-recording in BMUS Archive).

[ii] Malcolm Nicolson, Ian Donald – Diagnostician and Moralist http://www.rcpe.ac.uk/library/read/people/donald/donald.php

[iii] I. Donald (1972) ‘Naught for your comfort’, Journal of the Irish Medical Association, 65, 279-89.


[ii] Lo YMD, Corbetta N, Chamberlain PF, Rai V, Sargent IL, Redman CW, et al. Presence of fetal DNA in maternal plasma and serum.Lancet1997;350:485-7.

[iv] en.wikipedia.org/wiki/Abortion_in_China

[v] Prof Ian Donald was my supervisor at the Queen Mother’s Hospital in Glasgow in 1969.

[vi] I. Donald, J. MacVicar, T. G. Brown (1958) ‘Investigation of abdominal masses by pulsed ultrasound’, The Lancet, 1, 1188-95.


[ii] Fleming, Florey, and Chain shared the 1945 Nobel Prize for medicine for their work on penicillin.

 

 

Medical negligence and malpractice is rife in Kenya’s health facilities, a Public Inquiry reports

The recently launched report[i] of a public inquiry into violations of sexual and reproductive health rights in Kenya has highlighted the existence of widespread medical negligence and malpractice in health institutions. Indeed many of the complaints of mistreatment in health facilities, especially those raised by former obstetric patients, frequently bordered on medical negligence and malpractice. Medical negligence and malpractice interfere with the quality of care received by patients, and deny them enjoyment of the right to the highest standard of health care which is their constitutional right.

(Women are being counselled at a RH clinic. Picture source: J Mati)

Medical negligence can be defined as the commission of an act that a prudent person would not have done or the omission of a duty that a prudent person would have fulfilled, resulting in injury or harm to another person (patient)[ii]. Medical malpractice means bad, wrong, or injudicious treatment of a patient professionally, which results in injury, unnecessary suffering, or death. Malpractice and negligence may occur through omission of a necessary act as well as commission of an unwise or negligent act[iii]. This may be in the form of misdiagnosis, wrong decisions and treatment, prescription errors, and medical or surgical complications, all of which may result in suffering, permanent injury or death.

In Kenya, medical, nursing and midwifery practices are regulated by statutory authorities, including the Medical Practitioners and Dentists Board[iv] (established under Cap 253 Laws of Kenya), the Nursing Council of Kenya[v] (established under the Nurses Act Cap 257 Laws of Kenya) and the Clinical Officers Council (established under the Clinical Officers [Training, Registration and Licensing] Act Cap 260 Laws of Kenya)[vi]. These bodies are obliged to protect members of the public by ensuring that the medical practitioners (including dentists), nurses and midwives, and clinical officers are properly qualified, that they perform their services to patients with skill and diligence, and that they observe at all times high moral and ethical standards

Evidence regarding alleged mistreatment in health institutions was received at all sittings of the Inquiry, and among the witnesses raising complaints of medical negligence and malpractice the majority were obstetric cases that suffered various types of injury and suffering to themselves and their babies. Complaints of long waiting periods and delays in getting attended to in health facilities were common. Sometimes this was occasioned by doctors or midwives on call refusing to come when summoned, or due to shortage of staff. Associated with the above were complaints of negligent management of labour resulting in stillbirth, mentally handicapped child and maternal death. There were other complaints of persons who had been subjected to various surgical procedures such hysterectomy without their consent (See below). In spite of this, hardly any of the complaints had been reported to the regulatory authorities.

Selected examples of specific complaints of medical negligence and malpractice:

· Denial of information- failure to explain the nature of illness or injury and the modality of treatment and its consequences. In particular, there was inadequate information given to the patients before and after surgery.

 Sterilisation without consent:

A mother of three was admitted with abruptio placenta at a Mission Hospital, where she was later taken to theatre for C Section and, unknown to her, bilateral tubal ligation was carried out. She was not informed of the latter and since she did not wish to conceive shortly after the operation she commenced on a family planning method. She had taken two doses of Depo Provera when a doctor (elsewhere) happened to read her discharge card which showed she had actually been sterilised!

· Case of malpractice-  Doctor who was drunk;

A case of ruptured uterus and fetal death:

A woman was admitted at a public District Hospital in early labour. She had previously delivered by C Section and so was asked to sign consent for repeat CS which she did. However, a doctor who was drunk saw her in the Labour Ward and asked her to begin pushing the baby, without any success. He then tried unsuccessfully to apply forceps. By the time she eventually was taken to the operating theatre her uterus had already ruptured, the baby had died, and she subsequently developed difficulty in controlling urine (?Vesico Vaginal Fistula). She has not conceived since then and she could as well have had a hysterectomy done.

· Case of medical negligence- denial of services

Forgotten foreign bodies after surgery:

A relative told of the case of a woman who had a C section performed by a doctor during which an abdominal pack was (accidentally) forgotten in the abdomen. When she returned 2 weeks later complaining of abdominal pain and swelling she was told she needed another operation to remove a foreign body which required further payment. This could not be done because she did not have any more money. The patient died of complications most probably associated with the foreign body.

 Another case was that of a single mother of two who delivered normally at a Health Centre (Level 3). An episiotomy had been performed and a swab left in the vagina which should have been removed after a few hours. However, the patient was not informed about it, and the swab was left in for 2 weeks. By that time infection had set in and she had also developed faecal incontinence (?RVF). She is now ashamed of her condition and has not mentioned it to anyone except her mother. [It is a possibility that she suffered rectal injury when the episiotomy incision was made].

 · Negligent management- failure to apply standard procedures:

Management of labour in a HIV+ woman did not conform to guidelines for prevention of mother to child transmission of HIV infection: An HIV+ woman was admitted at a public District Hospital with ruptured membranes. Her husband, also HIV positive, told the staff that they had been advised by another doctor that the delivery should be by CS, but this was declined, besides, she was not given ARV therapy as instructed in the PMTCT guidelines. Instead, she was allowed to have a prolonged labour, delivering a fresh stillborn child.

Failure to give an essential prophylaxis:

A primigravida at term was admitted in a private hospital where she had made several antenatal visits. Her labour was uneventful, delivering a healthy male child. However, although she had been informed at the same hospital that she was Rhesus Negative she was not offered a standard vaccine, anti-D gamma globulin to protect against Rhesus iso-immunisation. In addition, she was not advised what to do in case of a subsequent pregnancy.

· Negligent management of labour, doctor refused to come to the hospital when summoned:

A mother of three was admitted to a public District Hospital in labour where she remained for 48 hours without delivery mainly because the only doctor who could do a C Section refused to come. When eventually the doctor came she was taken to theatre, delivered of a very depressed child who breathed after prolonged resuscitation, but the mother died on the table. The child is now intellectually handicapped.

· Negligent management- Hysterectomy performed without consent

Hysterectomy performed without consent on a disabled person:

A woman with dwarfism (possibly achondroplasia) was diagnosed with uterine fibroids at a provincial Hospital and advised she needed an operation to remove the fibroids. She was taken to theatre but afterwards was not explained what had been done. When three weeks later she realised that a hysterectomy had been performed she sought explanation from the doctor. She was taken aback when the doctor wondered aloud if in her condition she really expected to get a baby!

Hysterectomy performed in a woman diagnosed with an ovarian cyst:

A married woman, a mother of four girls had hope that a boy would come someday. She was seen at a Provincial Hospital complaining of abdominal pain, where an ovarian cyst was diagnosed and confirmed by an ultrasound scan. She was advised to undergo an operation in order to remove the cyst; at no time was possibility of a hysterectomy mentioned. “Later when I read the discharge summary it stated that the uterus had a fibroid and a hysterectomy was performed. That shattered our hope for another child, perhaps a son”. She has contemplated suing the doctor but does not have the resources to do so.

Hysterectomy performed possibly because of intractable post-partum haemorrhage:

A woman in her first pregnancy was under care of a private obstetrician who saw her several times during pregnancy. When she went two weeks past the due date he admitted her at a private hospital for induction of labour, but for three days labour did not set in. However, when labour started on the fourth day her doctor was nowhere to be found; it was not until the next day that he appeared in the middle of the night and attempted to deliver her by vacuum extraction, but this was abandoned because there was a lot of bleeding. She was then taken to theatre and a CS was performed- a baby boy weighing 4kg. When she was returned to the ward the bleeding continued and had to be returned to theatre again, but was not told what was done there. “What annoyed me the most was that the details of my operations were only made known to my husband when he went to clear the bills, and then it was not until three months later that my husband actually informed me of the loss of my uterus. After some years, my husband left me for another woman and to have more children. I contemplated suing the obstetrician, but another doctor dissuaded me saying whatever was done was to save my life”.

Conclusions

The Public Inquiry report makes specific recommendations addressing the various aspects of maltreatment, medical negligence and malpractice in health institutions. It specifically calls on the Government to implement the provisions of Article 43 (1a) in the Constitution of Kenya (2010) and to ensure that health facilities at all levels are adequately staffed and equipped to provide quality health services.

The Ministry of Health and health professional regulatory bodies should ensure adherence to internationally accepted ethical standards and guidelines that govern medical practice with a view to eliminating the rampant cases of mistreatment, medical negligence and malpractice, in health facilities. The codes of practice must incorporate the obligations of health care providers to their patients, and should outline the rights of the patient with clear penalties spelt out in cases where the provisions are not adhered to. The government must make it mandatory that all health facilities establish complaint mechanisms aimed to enable clients forward their complaints to the relevant authorities for action in cases where they feel violated.

Finally, there is urgent need to increase the number of health care providers, across the country. Health training institutions have a duty to inculcate among their trainees high moral standards and respect for patients’ rights, including the right to information and informed consent. The government should recruit, train, employ and deploy more health personnel, and strengthen supervision, with a view to address the current shortage that is being experienced throughout the country.


[i]Kenya National Commission on Human Rights: A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya, April 2012.

[ii]Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier.

 [iii] Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 Saunders, an imprint of Elsevier.

 

Selected case studies of women who were denied enjoyment of ‘right to health’ in Kenya

 

A review of ‘Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?’ and ‘Barriers to enjoyment of health as a human right in Africa’ provides a useful background to the case studies.

The recently launched report by the Kenya National Commission on Human Rights[i] highlights several incidents and situations where women were denied their right to health care services both because of non-availability of resources and non-affordability of services, as well as misdeeds on the part of health care providers. People living with disabilities (PWDs), in particular, complained of mistreatment, especially delays in getting attended to in health facilities. Most health institutions were not disabled-friendly in terms of infrastructure and means of communication, for example, facilities for sign language or Braille.

A Level 2 Health Facility at Mtwapa, Mombasa County (Picture: J Mati)

Witnesses raised several complaints related to the inefficient referral systems in several health facilities that caused considerable delays in obtaining higher level care, not infrequently resulting in fatal consequences for the women and their babies. This was particularly a serious problem when it came to referral of patients from levels 1 and 2 to appropriate higher level facilities.

In some cases, women in rural areas had to be transported on wheel barrows by family members or on donkey carts. Where hospitals had ambulances, the patients or the relatives were required to pay amounts ranging from KSHs. 500 to KSHs. 3,000 supposedly to fuel the vehicles. In situations where people were unable to pay, patients were denied treatment. In other instances, blood was not readily available in hospital blood banks, or the facilities lacked adequate infrastructure to obtain blood for emergency transfusions.

In Tana River, for example, a woman who developed complications after delivering at a dispensary (level 2) died while waiting to raise funds, through harambee, to fuel a government ambulance to take her to Hola District Hospital. A similar report is given in connection with a maternal death due to lack of transport between Magarini Dispensary and Malindi District Hospital, both in Kilifi County.

In Lamu County, patients who needed to be referred to Coast Provincial Hospital in Mombasa were reportedly required to pay between KSHs. 8,000 and KSHs. 10,000 to fuel the hospital’s ambulance. Where there are no ambulances, as in Wajir and Marsabit District Hospitals families had either to hire expensive taxis or resort to donkeys and camels to transport their sick members.

Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled attendance at delivery. A witness during the inquiry stated thus: ‘Many women deliver at home because they do not have enough money to go to the hospital’.

 Corruption, especially among hospital management staff, was also cited as a barrier to accessing maternal health services. According to witness accounts from Kitale, corruption in health facilities meant that patients ended up paying for drugs and other items that ought to be provided for free. Similarly, bribes were solicited to facilitate earlier scheduling of surgical treatment, as stated by a witness at the Coast: “For one to get an operation done quickly at Coast General Hospital one has to pay bribes or know someone because there are long queues, so I left”.

Mistreatment in health facilities by unkind, cruel, sometimes inebriated hospital staff, who scolded, abused and even beat patients also features prominently in the report. So are delays in getting attended to in health institutions, particularly in the labour ward, where witnesses complained of being neglected during labour, in some cases ending in delivering unattended within the hospital. An example is the case of a woman who waited at the out-patients from 5am to 4pm before being admitted to the labour ward, ending up with a stillborn child. Women complained of being admitted in overcrowded wards and sharing of beds; up to three women with their babies sharing one bed, even when some of them were still bleeding, which exposed them to potential risk of infection, including HIV and Hepatitis B. Detaining of women for non-payment of hospital charges obviously contributes to congestion in hospital wards.

There were complaints of frequent lack of essential medicines, equipment, commodities and supplies in public health facilities resulting in denial of services to the needy. It was common in most public facilities for patients to be asked to purchase medicines, gloves and dressings, besides being referred to private institutions for specialised radiological and ultrasound diagnostic examinations. Essential resources for effective provision of sexual and reproductive health services were lacking in many health facilities. For example, many lacked the drugs needed for post-exposure prophylaxis (PEP) following sexual abuse including rape. The Inquiry established that non-availability of family planning commodities was a fundamental barrier to accessing comprehensive family planning in Kenya, this being illustrated by the frequent stock outs of commodities. There were complaints of frequent shortages of various contraceptives which denied clients a wide choice of family planning methods.

Several witnesses complained of negligent actions by doctors and midwives, for example, forgetting items such as surgical instruments or swabs in a patient’s abdomen; performing procedures such as hysterectomy without prior informed consent; poorly managed labour leading to ruptured uterus, maternal morbidities such as VVF and RVF, intra-uterine foetal death or a mentally handicapped child,. Other examples of negligent actions or omissions were performing episiotomy and failing to repair it, and failure to recognise accidental injury during surgery and failing to repair it immediately. There were women who complained that not enough information was given to them about the various diagnostic and treatment modalities they had been subjected to by health providers. In particular, there was inadequate information given to the patients before and after surgical procedures.

 The Report cites an article published in The Daily Nation Newspaper of 18th January 2011 on a case of maternal death associated with abortion:

“A woman aged 40 years who was held at Murang’a police station for allegedly procuring an abortion died after she developed complications while in the police cells. The Police said the woman was reported to have terminated the pregnancy by swallowing some chemical, and locked her up in a cell at the police station. They said she later developed complications and was being rushed to hospital when she died en route.”

 It can be argued that had the police taken the woman to a health care professional, instead of holding her in remand at the police station, she most likely would have survived. In other words this was a case of preventable death associated with denial of enjoyment of right to health. Yet this was after the promulgation of the Constitution of Kenya 2010 which has relaxed the rigidity on termination of pregnancy that existed previously. Article 26 (4) permits safe abortion if in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law.

What can be learned from the above case studies?

Clearly, they demonstrate that Kenya has yet to address the well known factors and barriers that have over the years sustained the prevailing high rates of maternal and newborn mortality and morbidity. Maternal health services that are inaccessible, non-affordable and of poor quality, have been perpetuated by several serious weaknesses in the health systems- inadequate capacity in terms of human resources and health infrastructure, negligence and malpractices especially among over-worked de-motivated health service providers, and various socio-cultural barriers, among others. Addressing these barriers is a prerequisite to meeting local and international goals and targets including the Vision 2030 and Millennium Development Goals.


[i] A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya

Barriers to enjoyment of health as a human right in Africa

The full enjoyment of the ‘Right to Health’ in most African countries is constrained by several pervasive barriers that are the subject of the current review, which urges that governments urgently adopt human rights based approaches to all health interventions in order to ensure equitable distribution of health resources throughout all sections of communities.

The Concept of Health as a Human Right: Health is a basic need for human existence and survival and as such, it is a right that must be respected, promoted and protected by government and society. The Universal Declaration of Human Rights states that “Everyone has the right to a standard of living adequate for health and well-being of himself and his family”. The concept of health as human right is stated in the Preamble of the World Health Organization’s Charter (1946), and also in the International Covenant on Economic, Social and Cultural Rights (1966). Art. 12 states of health as a human right: “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The Declaration of Alma Ata (WHO, 1978) stated: “Health, which is the state of complete physical and social well-being, and not merely the absence of infirmity, is a fundamental human right…. the attainment of the highest possible level of health is a most important worldwide social goal.” The right to health is fundamental to the physical and mental well-being of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of an adequate standard of living. Indeed health is fundamental to enjoyment of the right to life, and the right to a healthy life is fundamental to all other constitutional guarantees.

Right to Health is a Constitutional Issue Besides the South African Constitution[i], the Constitution of Kenya (2010), which was promulgated in August 2010, is among the most progressive constitutions in Africa. It provides for the right to health care services. Article 43(1)(a) in the chapter on Bill of Rights states that every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care, and in Article 43(2), that a person shall not be denied emergency medical treatment. Further, Article 27(2) guarantees equality and freedom from discrimination, and the full and equal enjoyment of all rights and fundamental freedoms. The Constitution obligates the government to take legislative, policy and other measures to achieve the progressive realization of the rights as guaranteed in the Constitution, including the right to health. The Right to Equality encompasses within itself the right of a poor patient to quality health care, regardless of their ability to pay.

Right to reproductive health care services: The concept of reproductive rights as a fundamental human right was endorsed at the 1994 International Conference of Population and Development in Cairo, Egypt. The constellation of rights, embracing fundamental human rights established by earlier treaties, was reaffirmed at the 1995 Fourth World Conference on Women in Beijing, China, and in various international and regional agreements since, as well as in many national laws. They include the right to decide the number, timing and spacing of children, the right to voluntarily marry and establish a family, and the right to the highest attainable standard of health, among others.

That reproductive rights are central to meeting international development goals was recognized by the UN World Summit of September 2005, which also endorsed the goal of universal access to reproductive health. Reproductive rights are recognized as valuable ends in themselves, and essential to the enjoyment of other fundamental rights. Attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.

Right to reproductive health care services is explicitly recognised in the Constitution of Kenya (2010), just as it is recognized or implied in several international and regional instruments (see above), including the United Nations Millennium Development Goals (2000); the Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009).

Barriers to enjoyment of Right to Health

1. General issues

Enjoyment of right to health in Africa, besides the inadequate financing of the health sector (see below), is indirectly constrained by several factors that operate at the regional and national levels, and mostly outside the mandate of the health sector. These include poverty, food insecurity and hunger, persistent violent conflicts and displacement of persons, heavy disease burden especially due to HIV and AIDS, and the pervasive gender-based negative traditions such as early marriage, female circumcision and lack of women’s empowerment all of which have profound effects on reproductive health outcomes.

2. Inadequate Funding to Health sector

Many governments in Africa have yet to recognise the importance of health in the overall national development, and expenditure on health is not adequately perceived as a critical economic investment alongside spending on education, agriculture or industries. Health is a critical resource for development, without which investment in all other sectors would go to waste. Poor health impacts negatively on economic productivity, through loss of labour, and under-performance due to illness. Poor health creates critical barriers to any measures intended to uplift the social wellbeing of poor and disadvantaged communities.

The levels of health budgets in most African countries do not demonstrate that health is rated as a high priority among other national needs. Despite the fact that in 2001 African countries pledged in Abuja, to increase health sector budgetary allocation to 15% of government expenditure, and although they repeated this pledge in Kampala in July 2010, in most countries national budgetary allocations for health remain far below this target. A 2007 report of the Regional Network for Equity in Health in East and Southern Africa (EQUINET)[ii] which looked into the progress made in various Southern and East African countries towards achieving the Abuja target, showed that with few exceptions most of the countries were still lagging far behind this target seven years since the declaration.

In Kenya, for the fiscal year 2010-11 just about 5.5 percent of the total Government expenditure was allocated to the ministries of Medical Services and Public Health and Sanitation. This translates to less than $1 per capita expenditure, against the recommended figure of $34 which WHO recommends for effective implementation of health interventions.

Figure 1: Real gross expenditure to the health sector, compared to overall gross Kenya Government expenditure (2007/08 – 2011/12)[iii]

A concern of particular relevance to achieving MDG5 is the disproportionate allocation within the health budget to reproductive health care services. Africa Union’s Maputo Plan of Action for Universal Access to Comprehensive Sexual and Reproductive Health Services in Africa (2007-2010) recommended an increase in per capita expenditures to about 18-24% of the $34 per capita recognized by the WHO. However, in many countries the allocation remains much below these figures.

At the international level, global assistance for reproductive health including family planning, financing has fallen in all recipient countries. Figure 2 shows that whereas there has been a steady increase in overall assistance for health, the amount focused on reproductive health and family planning has remained more or less unchanged since the year 2000.

Figure 2: Total international assistance to health and allocation to reproductive health care programmes (2000-2009)

Source: The Millennium Development Goals Report 2011

 

3. Lack of Equity in Planning for health and distribution of resources resulting in inequitable Access to Health Care services:

Physical access to services (distance to nearest Health Facility): Health care utilization is known to be greatly negatively impacted by distance to health care facilities and access to means of transportation. A study[iv] in western Kenya which explored the impact of distance on utilisation of sick child services in rural health facilities established that for every 1 km increase in distance of residence from a clinic, the rate of clinic visits decreased by 34% from the previous kilometer. According to the Kenya National Bureau of Statistics[v], on average only 6.4 percent of people in Kenya can reach a health facility within one kilometre of their residence; nearly a half (47.7%) of the people have to travel 5km or further to reach the nearest health facility, with marked regional variations (Table 1).

 

Figure 3: Proportion of community that has to travel 5km or more to the nearest health facility in Kenya

(Source: The Kenya Integrated Household Budget Survey (KIHBS) 2005/06).

For example, the proportion of people who live 5km or further from the nearest health facility ranges from 20% and 29% respectively in Nairobi and Central regions to 60%, 64% and 86% respectively in Coast, Eastern and North Eastern regions. The geographical dimension must be taken into consideration when planning health care interventions, especially when targeting socio-economically disadvantaged groups.

Affordability of services: Big disparities exist between the poor and the better off with respect to access to health care services which explains the wide gaps in health outcomes not only between rich and poor countries, but also between the wealthy and the poor in most countries. Generally, the poor lack access to health care in terms of: availability, affordability, and acceptability. Poor people are denied access to health care: (a) where public health facilities lack essential drugs, supplies and commodities; (b) where people have to travel long distances to reach health facilities, especially where public transport is scarce; (c) when fees charged for services (cost-sharing) are unaffordable, and even if there is official exemption (e.g. for pregnant women and children under five) or waiver of fees, people still end up paying on top, for drugs and transport (out-of-pocket expenditure); and (d) where people lack confidence in the services provided at local public health facilities and decide not to utilise them (e.g. poor quality services or negative provider attitudes).

The poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care. In Kenya, data from the National Health Accounts (NHA) for fiscal year 2001/2002 showed that Kenyan households were financing over half of all health expenditures[vi], clearly justifying a conclusion that ill-health contributes to, and perpetuates, poverty because health costs deplete people’s meagre resources. In addition, there is considerable evidence to suggest that by and large public spending on health tends to benefit the better off more than the poor. Quite often it is the better off who get the most from public health services, especially hospital care. In other words, government’s investment in health services, far from promoting equity, works against it[vii].

FY 2001/2002 National Health Accounts (NHA) estimation in Kenya

Inadequate financing of the health sector and inequitable distribution of resources explain the major gaps and disparities in health indicators in most African countries, which have featured repeatedly in successive surveys such as the Demographic and Health Survey (DHS). It is important to realise that because of the size of the poorest population, countries cannot hope to achieve health-related MDGs without urgent implementation of inclusive policies in the planning of health interventions.

Addressing barriers to enjoyment of right to health

Governments must strive to address the pervasive barriers to enjoyment of right to health (including sexual and reproductive health) by all citizens by implementing human rights based approach to all interventions aimed at improving the health of the community. This will empower people to participate in decision making and health policy development, as well as strengthening their capacity to hold the health managers and providers accountable. Ministries of Health should work out clear strategies that seek to make health services inclusively available and accessible, of good quality, affordable and culturally acceptable. It is particularly important to adopt evidence-based planning which should ensure equitable distribution of health resources throughout all sections of communities.

Governments in Africa urgently need to recognise the importance of health in the overall national development, and support it by making appropriate budgetary allocation to the health sector along other critical economic investments. In addition, the international community also needs to examine their funding policies over the last decade or so, which have resulted in stagnation of financing of reproductive health especially family planning programmes.


[ii] Equinet (2007). Reclaiming the Resources for Health: A regional analysis of equity in health in East and Southern Africa. Fountain Publishers Kampala, Uganda.

[iii] Figures based on gross approved expenditure (2007/8 – 2010/11) and gross estimates (2011/12). Figures indexed to inflation at 2007 CPI.

[iv] Feikin DR, Nguyen LM, Adazu K, et al., The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. Trop Med Int Health. 2009 Jan;14(1):54-61. Epub 2008 Nov 14. http://www.ncbi.nlm.nih.gov/pubmed/19021892

[v] Kenya National Bureau of Statistics (KIHBS) BASIC REPORT – www.knbs.or.ke/pdf/Basic%20Report%20(Revised%20Edition).pdf

[vi] www.who.int/entity/nha/country/Kenya_NHA%202002.pdf; Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

[vii] Davidson R. Gwatkin (2003) Free Government Health Services: Are They the Best Way to Reach the Poor?

Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?

The findings of a recent Public Inquiry into violations of sexual and reproductive health (SRH) rights in Kenya highlight several factors which underlie the high and increasing rates of maternal mortality in Kenya. This inquiry undertaken by the Kenya National Commission on Human Rights (KNCHR) during 2011 had the overall aim to establish the extent and nature of violation of sexual and reproductive health (including maternal health) rights and to recommend appropriate redress measures.

‘The Public Inquiry Panel receiving evidence from a witness in Kitale’ 12-13 July 2011’

Source: knhcr.org

Maternal health’ refers to the health of women during pregnancy, childbirth and the postpartum period (usually up to 42 days). As such, the right to maternal health should encompass access to antenatal care services; delivery services, including delivery by caesarean section where necessary; essential newborn care services and postpartum care services especially during the first 48 hours of delivery. Provision of these services requires availability of trained service providers (midwives, nurses, doctors and clinical officers) at all times and the capacity of facilities to respond to emergency cases, adequate physical facilities, and adequate equipment and supplies including essential medicines and vaccines.

Improving maternal health is the fifth Millennium Development Goal (MDG5). It has two targets: 5.A: Reduce by three quarters between 1990 and 2015, the maternal mortality rate; and 5.B: Achieve, by 2015, universal access to reproductive health. The indicators to show attainment of these targets are as follows: 5A- Maternal Mortality Ratio (MMR) and Proportion of births attended by skilled health personnel; and 5B- Contraceptive prevalence rate (CPR); Adolescent birth rate; Antenatal care coverage; and Unmet need for family planning. Analysis of the latest available data on Target 5A shows that MMR in Kenya remains high and has not started showing any downward trend, nor has there been an increase in the proportion of births attended by skilled health personnel. In the case of Target 5B, on the other hand, it is encouraging to note the recent rising trend in CPR which, if sustained, may get close to the figure projected for 2015.

The factors behind the high and increasing levels of maternal mortality in Kenya fall in the following broad categories: widespread poverty; limited access to health care services; limited availability of skilled attendance at childbirth including inadequate referral systems; and high prevalence of negative socio-cultural practices such as early marriage and FGM. A key cross-cutting factor is inadequacy of funding to the health sector, and disproportionate allocation for reproductive health services within the health budget.

The right to maternal health care services is recognized or implied in several international, regional and national instruments, which many African governments including the Government of Kenya have ratified. Among these are: The Covenant on Economic, Social and Cultural Rights (1966); The International Conference on Population Development Programme of Action (1994); The United Nations Millennium Development Goals (2000); The Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009); The Constitution of Kenya, 2010 (Article 43 (a); The National Reproductive Health Policy 2007; and The Prohibition of Female Genital Mutilation Act 2011.

In these, the State is obliged to fulfill SRH Rights ‘progressively’, depending on the resources available to them. The state is obliged to show that it is making ‘measurable progresses’ towards the full realization of the SRH Rights and to restrain from adopting ‘regressive measures’. At the same time, there are those rights for which the state is under obligation to effect immediately, for instance, the obligation to respect an individual’s freedom to decide freely if, when and how often to reproduce and the obligation to ensure freedom from discrimination and from degrading treatment.

The core obligations that are relevant to SRH Rights, which states are under obligation to fulfill immediately, include ensuring:

  • Access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;
  • Access to essential drugs, as defined under the WHO Action Programme on Essential Drugs
  • Equitable distribution of health facilities, goods and services including trained health personnel;
  • Availability of reproductive health services including maternal and child healthcare;

A human rights-based approach to reproductive health care recognizes that all human rights are universal, interrelated, indivisible, and interdependent and are inherent in all human beings. It acknowledges that sexual and reproductive rights cannot be realized without the realization of other broader human rights, for example, the right to information, privacy and confidentiality and education.

The status of maternal health rights is determined by the effectiveness maternal health care services at all levels, namely in terms of: accessibility, availability, quality, affordability and acceptability. From the Public Inquiry findings the following conclusions can be made:

  • The physical accessibility of delivery services is an important issue of concern especially in the arid and semi-arid zones where significant percentages of the population must travel long distances to access health facilities.
  • Many facilities lack transportation support for maternity emergencies. There was evidence that most facilities in rural areas were ill equipped to handle emergency deliveries and women who needed C-sections in small facilities often died or lost their babies because they could not be transferred to a higher level in good time.
  • Lack of safe abortion services in Kenya has resulted in those seeking termination of pregnancy to resort to crude and unsafe methods, often with fatal consequences. There is a lack of awareness regarding provisions in the Constitution of Kenya 2010 (Article 26(4)) among healthcare providers and the general public.
  • The quality of maternal health services countrywide remains an issue of serious concern. Some of the key quality issues that have been highlighted are: lack of basic supplies such as cotton wool, pads, gloves, syringes, surgical blades, linen to wrap babies, anaesthesia, disinfectants, medicines, bed sheets, and blankets; dirty and unhygienic conditions; women forced to share beds or sleep on the floor; and the lack of food and hot water for bathing, etc. Overall, the factors that undermine the quality of maternal health services in Kenya were summarized as: (a) Lack of supplies and equipment; (b) Understaffing and lack of training and supervision; (c) Negligence and unethical practices by health providers; and (d) Weak Referral System.
  • Non-affordability of services is a serious impediment to accessing maternal health care throughout the country. Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled maternal health services.
  • Acceptability of maternal health services- evidence from the Inquiry indicated that some communities did not utilize skilled delivery services because of cultural restrictions, mainly taboos regarding attendance by male nurses, which was prevalent among the Muslims in upper Eastern and North Eastern Kenya, as well as among the Sabaot of Western Kenya. These cultural preferences, together with the chronic shortage of skilled professionals in these areas, and the non-affordability of fees for services, come out as the main factors that perpetuate the demand for the Traditional Birth Attendants (TBAs).

Based on its findings the Public Inquiry concluded that women in Kenya continue to die or suffer disability due to preventable causes. The Inquiry notes that the causes of these deaths prevail against the backdrop of the myriad international and regional human rights frameworks and commitments that Kenya is a party to and the national legal, policy and institutional frameworks that are aimed at enhancing maternal health. From the foregoing therefore, the Public Inquiry concluded that Kenya is still far from realizing the maternal health rights and has made a number of recommendations to government and other stakeholders that are essential in working towards the realization of maternal health rights in Kenya, and the achievement of MDG5 and Vision 2030 goal.

Factors contributing to Africa’s failure in achieving MDG5 by Japheth Mati

ABSTRACT[1]

The latest UN Report on MDGs reveals considerable reductions in maternal mortality in most regions of the world except in the sub-Saharan Africa where, despite progress having accelerated since 2000, very high maternal mortality ratios and low rates of access to universal reproductive health services, still persist. This discussion highlights several challenges that operate both at the regional and country levels. The challenges at the regional level include poverty, food insecurity, persistent violent conflicts, inadequate budgetary allocation to health sector, and heavy disease burden. At the country level are the persistent inequalities in access to health care both between countries and within individual countries. A review of the status of MDG 5 indicators particularly focusing on the known drivers of maternal mortality reductions shows that most SSA countries fall far below the targets, to the extent that they are least likely to achieve this goal by 2015. Successive national surveys show disparities which relate to wealth status and area of residence, both reflecting a lack of equitable distribution of health services. Two key challenges stand in the way of addressing these inequalities- improving human resources for health, and strengthening health systems. A critical cross-cutting determinant for both is the proportion of national budgets allocated to reproductive health services. In addition, donor-dictated policies of budgetary ceilings on certain expenditures, including hiring of health professionals, constitute another obstacle. Finally, SSA countries are particularly adversely affected by the drop in international aid towards reproductive health, and especially the financing of family planning programmes.


[1] Abstract of an invited presentation at the FIGO World Congress October 7 – 12, 2012

 

What’s happening to Kenya’s first generation born HIV-positive?

Globally, there is a general lack of awareness of the health and social challenges that face the first generation of children born HIV positive; in fact, this has not been an issue of special focus. Yet the population of that group of people is not only increasing in numbers, it is also growing older. According to UNAIDS, of an estimated 390,000 children born with HIV in 2010 globally, 90 percent of them were born in 22 countries, of which 21 are in sub-Saharan Africa, the odd one out being India[1].

There is a lot of hope that with increasing access to improved PMTCT services especially the availability of the more effective antiretroviral regimen for pregnant women and their newborn babies, fewer children will be born HIV positive. Where highly active antiretroviral therapy (HAART) has been employed, the rate has reduced to below 5 percent. As a result, in 2011 UNAIDS and PEPFAR jointly launched the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive. The plan has a main focus on the 22 countries (see above).

Source: UNAIDS and PEPFAR bring together Health Ministers and partners to advance progress in ending new HIV infections in children

For many years there was a strongly held assumption that survival from birth to adolescence with HIV was so unlikely without treatment as to be negligible, and that HIV in late childhood was very unusual. The accepted view was that the majority would die before the age of five. However, there is now accumulating evidence that children born with HIV do survive into teens and adults. In Kenya, the oldest of these children are now approaching 30[2]. In Uganda it is estimated that as many as 150,000 children are already living with HIV right from childhood. In 2006, the oldest surviving of young people born with HIV in Uganda turned 23 years old, thanks to antiretroviral therapy[3]. That same year, The Aids Support Organization (Taso) had registered 4,696 ten to nineteen-year-olds living with HIV since infancy, while another 1100 young people were receiving care at the Mildmay Centre and Mulago Hospital.

A recent article by Amelia Hill[4] entitled Teenagers born with HIV tell of life under society’s radar, HIV-positive youngsters who were infected before or at birth reveal their secret lives, highlights some of the challenges faced by youngsters in the United Kingdom who were born HIV positive. These challenges include:

  • Coping with the discovery that they are HIV positive: Usually the doctors and the parents would have withheld the information until such time as it is considered “safe” to divulge the status to the child. One 18 year old describes how at nine years old a careless receptionist at his local hospital blurted his status, and his reaction to the shocking revelation: “I remember standing there, with my mother’s hand around mine, as these feelings of complete confusion and fear washed over me. I suddenly realised that the pills my mum had been giving me every day – that I had thought were sweeties – were medicine, after that day at the hospital, I would lock myself in the bathroom when my mum took them out of the cupboard. Or I’d pretend to swallow them, and then throw them away. I know I’m killing myself,” he says truthfully, but with studied nonchalance. Inconsistency in the taking of medicines has important implication to development of resistance to specific drugs by the virus.
  •  Fear of stigma: HIV-positive youngsters have expressed worry over being branded by the stigma that is attached to HIV in society. “Society forces me to live two lives, one of which – the one where I’m honest about my status – I have to keep completely secret from the other one. It’s partly because I have to live this life of shame and secrecy that I find it so hard to take my meds….I’m angry about the stigma in society that makes me have to lie about my status“. Some adolescents have admitted having considered killing themselves.

Two studies, one in Zimbabwe and the other in Uganda have specifically highlighted some of the issues facing adolescents and young adults who were born HIV positive in those countries. In Zimbabwe, a clinical study[5] has suggested that as many as one in four children may survive into adolescence without diagnosis or treatment. Of the children under HIV care in Zimbabwe during 2008, 42% were aged 10-19 years. This study has bust the long held assumptions that HIV in late childhood is very unusual, and that survival from birth to adolescence with HIV was so unlikely without treatment as to be negligible. Among the problems most commonly faced by adolescents were psychosocial issues and poor drug adherence (which is critical in keeping the ever-changing AIDS virus at bay).

The Population Council in Uganda[6]  has addressed reproductive health needs of adolescents born with HIV. It involved a sample of 732 adolescents aged 10-19 years. The study shows that these adolescents are most likely to be orphaned, hardly any of the teens and young adults born with HIV have both their parents alive, As such they are subject to the challenges that face orphans generally. They were also found to be at risk of entry into casual relationship, using no protection, and with persons whose HIV status they do not know. Most of them conceal their status to their partners. The study reports that as many as 61 percent of the sexually active adolescents surveyed said they did not use any protective method during their first time sex, and do not know the status of their current partner.

There are lots of similarities between the findings in the two Africa-based studies and the issues raised by their counterparts in the UK report. What these limited studies clearly reveal is the inadequacy of our knowledge regarding the social, psychosocial and health challenges faced by adolescents and youths born HIV positive and their guardians.

[1] UNAIDS and PEPFAR bring together Health Ministers and partners to advance progress in ending new HIV infections in children http://www.unaids.org/en/resources/presscentre/featurestories/2012/may/20120523whagp/

 [5] Rashida Ferrand,a Sara Lowe,b Barbra Whande,b et al., Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?Bull World Health Organ. 2010 June 1; 88(6): 428–434. Published online 2009 December 16. doi:  10.2471/BLT.09.066126

A malaria survivor reflects on World Malaria Day

Wednesday the 25th April 2012 was World Malaria Day and as I joined others on that day in reflecting on the disease I could not fail to appreciate how much the malady has impacted on my life. It is particularly sad to read the statistic in the World Malaria Report 2011 thatin 2010 an estimated 655,000 people died from malaria–most of them African children”. And although the same Report states that malaria mortality rates have fallen by33% in the WHO African Region, in Africa one child still dies every minute from the disease, accounting for around 90% of all malaria mortality worldwide.

Image Source, K4Health’s POPLINE Database

I am a malaria survivor, I suppose many times over, but I particularly remember my experiences as a little boy growing up during the Second World War in a place called Itoloni in today’s Mwingi South Constituency. Ndetema (as we called Fever) was very common, and it was treated at first with quinine- that horribly bitter stuff from the cinchona tree. We had our noses squeezed which forced our mouths to open for the colourless liquid to be poured down our throats, three times a day. Then I was told my spleen was large (wasyungu) and was not improving with the quinine alone, so my grandmother was brought in. I can never forget the experience. Although I was particularly very fond of my grandmother, I always anticipated her visits to our home with a lot of apprehension. All the same it seems she successfully treated my splenomegaly with her nasty herbal concoctions accompanied by hot massages over the organ using leaves of the aloe vera plant.

When the Japanese occupied Indonesian islands where the cinchona tree grew they cut off supply of quinine to the British (who were ruling us those days), and it took a few years before quinine was replaced with mepacrine. The latter is a greenish yellow dye discovered at Bayer, Germany way back in 1931. Mepacrine-hydrochloride (also known as Quinacrine and Atabrine) was one of the first synthetic substitutes for quinine although later superseded by chloroquine. I remember being taken to the Native Civil Dispensary  in Nairobi, (it stood next to Kingsway Police Station- today’s Central Police Station), for weekly supply of mepacrine which was dispensed in large topped-up mugs. It was horrible! Among the side effects of the drug were toxic psychosis and ringing ears. Incidentally, Quinacrine has been used for non- surgical sterilization for women, and several peer reviewed studies suggested the procedure was potentially safer than surgical sterilization. Nevertheless, in 1998 the Supreme Court of India banned the import or use of the drug, based on reports that it could cause cancer or ectopic pregnancies.

Chloroquine, discovered at the same Bayer laboratories in 1934, was not introduced into clinical practice for the treatment of malaria until 1947. The drug would then hold supreme until the 1990s when emergence of widespread resistance to chloroquine led to its withdrawal from use in most countries in Africa, being systematically replaced by Artemisinin. It is thus with trepidation that we receive news that the most deadly species of malaria parasites, Plasmodium falciparum, is becoming resistant to artemisinin.

Another encounter with malaria was in the early 1960s, while a student at the Makerere College Medical School in Kampala, Uganda, where I came across a disease called Big Spleen Disease, a syndrome diagnosed in men and women characterised by evidence of recent malaria, anaemia and splenomegaly. Later, during 1967 and 1968, when I was practicing medicine at the Kenyatta National Hospital I conducted a study on anaemia in pregnancy[i], the findings of which revealed that among the very severely anaemic pregnant women splenomegaly was commonly found, and most of the women had evidence of recent malaria infection.

In areas endemic for malaria pregnancy is associated with a reduction in already acquired immunity, with consequent increase in clinical attacks of severe malaria (including cerebral malaria) and other complications such as haemolytic anaemia. Malaria-induced haemolytic anaemia is particularly common among women with their first pregnancy and tends to cause more severe anaemia with rapidly dropping haemoglobin in a woman who only a few days earlier had normal level of haemoglobin. These attacks can be prevented through intermittent preventive treatment with an effective antimalarial, for all pregnant women living in endemic areas, also use of insecticide-treated mosquito nets, and indoor residual spraying..

Let me end by mentioning an indirect involvement with malaria; this time concerning my father who in the late 1940s and early 1950s was a member of the Nairobi Municipality crew that eradicated malaria transmission in Nairobi. They used DDT before its name became an anathema. Yet to date there has not been any equally effective ‘safer’ substitute. Shall we continue watching our children die of malaria in order that we protect those of the future from little understood risks?

[i]Mati JKG, Hatimy A, and Gebbie DAM (1971) The importance of anaemia of pregnancy in Nairobi and the role of malaria in the aetiology of megaloblastic anaemia. Journal of Tropical Medicine and Hygiene, 74:1

Remembering my fistula patients as Kenya observes FGM Day

I couldn’t help remembering my two fistula patients in the 1970s as Kenya observed the International Day of Zero Tolerance to FGM on February 6 2012. For Kenya, this was barely four months since President Mwai Kibaki on September 30, 2011, signed into law a bill outlawing the practice of FGM. Generally, in communities where it is practiced, FGM is not viewed as a dangerous act or violation of rights, but more as a necessary step to raise a girl, and in many instances, as a rite of passage, even though it is mind-boggling how this can apply to children as young as 5 years!

Female Genital Mutilation has both immediate and long term consequences to the health of women which depend on the type performed, the expertise of the circumciser, the hygienic conditions under which it is conducted, among others. The most severe complications are usually associated with infibulations. As a means of minimising these risks the phenomenon of “medicalisation” of FGM has manifested in many countries including in Kenya, whereby these procedures are carried out by trained health professionals in health facilities. For example, a survey carried out in Kenya just over a decade ago indicated that one-third of the circumcised women admitted to being cut by a health worker (KDHS 1998). However, while medicalisation my result in fewer complications and perhaps save some lives, it must be condemned because it justifies a torturous practice built on gender discrimination and non-respect of reproductive rights of women.

Source: http://www.middle-east-info.org/league/somalia/fmgpictures.htm

One of the long-term medical complications associated with FGM, especially infibulations, is obstetric fistula- vesico-vaginal (VVF) or recto-vaginal (RVF), or both. I keep thinking about some of my fistula patients in the 1970s. During my active practice in the Department of Obstetrics and Gynaecology at the Kenyatta National Hospital (KNH) I happened to be one of two gynaecologists (the other was Dr Balwant Singh Khehar), with special interest in the treatment of urinary incontinence, the commonest cause of this being VVF. At any given time there would be one or two such cases in my ward. This condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women had access to skilled care during labour and delivery. Yet it has remained a persistent problem- Dr Peter Candler, one of the gynaecologist at the King George VI Hospital (now KNH) has reported that in 1954 the commonest gynaecological condition encountered was obstetric VVF. How sad it is that decades after our independence, a substantial proportion of Kenyan women remain at risk of this tragedy.

Urinary incontinence is one of the most frightful afflictions of human kind and often results in the sufferer becoming a social outcast. Surgical treatment can be technically difficult and demanding and by no means guarantees success. I remember two teenage girls (Halima and Fatma) who were transferred from Wajir District Hospital with very large fistulae, which we had to repair in stages over several weeks. These girls almost became permanent residents of Ward 23 in the old KNH, and to occupy them they were provided each with a knitting kit and encouraged to make whatever they wanted. One morning, as I conducted my ward round one of the girls, Halima presented me with a blue knitted sweater. I was very moved by this deed. I guessed this was her way of expressing gratitude, perhaps for our compassion towards her, because she was, as yet, not cured!

The case of Halima is typical of the continuing violations of reproductive rights of young girls under the banner of culture and tradition. In terms of treating Halima’s condition, clearly we were working at the tail end of the chain of events that resulted in a damage that should never have happened. In the first place, Halima was only 14, too young to be someone’s wife and to have begun childbearing. She had been subjected to FGM-infibulation, before a forced marriage. In both situations her reproductive rights had been denied; she had been abused by the society she lived in. Then when she got pregnant she was further denied the right to health care- an opportunity to have access to skilled attendance during the antenatal period, as well as care during childbirth.

The image in this post was sourced from  Middle-East-Info.org where the strong-hearted can find more pictures of the gruesome operation.

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