Tag Archives: Malawi

Champions are Urgently Needed for Accelerated Reduction of Maternal Mortality in Africa

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.” Kofi Annan, Former UN Secretary General

Introduction: overcoming resistance to change

There is an urgent need for champions to push for accelerated reduction of the shockingly high maternal death rates in African countries, the general improvement of maternal health in the region, and the attainment of the fifth Millennium Development Goal (MDG5). One of the major challenges for the champions will be overcoming resistance to change. Resistance to change is to be found among all levels of society, among health professionals, including obstetricians and gynaecologists; midwives; medical and nursing training institutions; statutory regulatory bodies; professional societies; health management and administration, as well as political leadership and community in general.

But why is there resistance to change? People fear change, and in medicine there is the familiar tradition of: “We’ve always done it this way.” People harbour doubts as to whether innovations actually work better than the traditional practices. There are legal obstacles, including roles and practices prescribed in laws and regulations. There are limited human, financial and infrastructure resources to sustain application of new practices; and there are socio-cultural factors, gender roles including the status of women in society, that function as barriers to change.

Maternal mortality

Recent assessments of maternal mortality show that across Eastern and Southern Africa, “the most basic and natural act of giving life causes the death of almost 10 women every hour” . In 2008, some 79,000 women died in the region in the process of pregnancy and childbirth, accounting for more than one fifth of all such deaths in the world. According to the 2011 UNICEF Report, the latest estimated figures for maternal mortality ratio in Kenya, Malawi, Uganda and Tanzania are 490, 810, 440 and 580 respectively . These unacceptably high levels of maternal deaths make it extremely doubtful that these countries will succeed in reaching all the indicators of achieving improved maternal health (MDG5) in the next 4 years.

There is need for intensified advocacy, especially towards the recognition of women’s constitutional right to life and health, and therefore their right to quality reproductive health services, which ensure that every pregnancy is wanted; all pregnant women and their infants have access to skilled care; and that every woman is able to reach a functioning health facility to obtain appropriate care in the event of complications. After all, going through pregnancy and childbirth safely is what every woman should expect.

We know that even though complications of pregnancy cannot always be prevented, deaths from these complications can be averted. Up to 75 percent of all maternal deaths can be averted if women received timely and appropriate medical care. Maternal deaths from obstetric complications can be markedly reduced if skilled health personnel and essential supplies, equipment and facilities are available. And yet, apart from Malawi, where 54 percent of births were reported to have been attended by a skilled birth attendant, in the East African countries nearly 60% of all births take place unattended by a skilled attendant. Among the poorest women the majority of birth take place unattended by skilled personnel, the proportions being 72 percent in Uganda, 74 percent in Tanzania, and as high as 80 percent in Kenya .

The direct causes of maternal deaths have long been known, and so are the interventions to prevent them. We know what works and what does not work. Clearly, what is lacking is the commitment, at all levels, to act; to make the reduction of maternal mortality a high priority; and to reflect this in resource allocations to health services, especially for reproductive health services. Professor Mahmoud Fathalla of Egypt once observed that: “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their [women’s] lives are worth saving.” When will our countries decide?

Maternal morbidity

It has been said (though there is want of data) that for every maternal death there are up to thirty times as many cases of pregnancy related illness or disability . The lack of or poor access to, obstetric care is responsible for a major burden of maternal morbidity in African countries. Among such morbidities are the obstetric fistulae, vesico-vaginal fistula (VVF) and/or recto-vaginal fistula (RVF) which are usually the result of neglected obstructed labour.

Let me again illustrate this with the case of one of my patients, by name Halima. During my time in the Department of Obstetrics and Gynaecology at the KNH, in the 1970s, I happened to be one of two gynaecologists with special interest in the treatment of urinary incontinence, the commonest cause of which was VVF. Urinary incontinence is one of the most frightful afflictions of human kind and often results in the sufferer becoming a social outcast. Yet, 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. At any given time there were one or two such cases in my ward. Halima was one of two teenage girls transferred from the Wajir District Hospital in North-Eastern Kenya, with a very large VVF; almost the entire anterior vaginal wall was missing. We had to repair this defect in stages over several weeks using grafts from other parts of her body. The two girls almost became permanent residents of Ward 23 in the old KNH building, and to occupy them they were provided with knitting kits and encouraged to make whatever they fancied. One morning, as I conducted my ward round Halima presented me with a blue knitted sweater. I was deeply moved by this deed, and for several days pondered over it. I guessed this was her way of expressing gratitude, perhaps for our compassion towards her, because she was, as yet, not cured!

Several lessons can be learned from Halima’s case. Clearly, in terms of addressing her problem, our surgical treatment came at the tail end of a chain of events that resulted in a damage that should never have happened in the first place. Halima was barely 14, too young to be anyone’s wife and to have begun childbearing. She was subjected to the severest type of female circumcision (infibulation), and given off for marriage shortly afterwards. In both situations her human and reproductive rights had been denied; she had been abused by the societal norms she lived under. In fact female genital mutilation (FGM), forced early marriage, and coerced sex were tantamount to gender-based violence. Then when Halima became 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. How sad it is to note that, today, four decades later, many African young women continue to live under conditions that pose as much reproductive risk to their lives and wellbeing as it was for Halima.

Abortion, a fertile ground for change

In Africa, despite the fact that induced abortion takes place among women from all levels of society, the brunt of abortion-related morbidity and mortality is borne almost exclusively by the young and poor women. This perhaps explains the dilatory approach to the prevention of such mortality, where leaders don’t want to take the obvious step towards prevention of unsafe abortion. After all, it does not affect their social class. As such unsafe abortion has continued to be a major contributor to the unacceptably high levels of maternal morbidity and mortality rates that prevail in Africa. It continues to be one of the formidable challenges to the achievement of MDG5 of improving maternal health by 2015.

Yet, it is obvious that stringent abortion laws have not deterred women in need from going through with an abortion; what such laws have achieved is to push many hapless women to undergo unsafe procedures with consequent high rates of morbidity and mortality. For such women, the desire to do away with an unwanted pregnancy can be so intense that they will avail themselves of this last resort despite the law, even the attendant risk to their lives. The procedure of medical termination of pregnancy is simple, short and safe when undertaken in the open, by trained persons; on the other hand clandestine abortion, usually performed by unskilled operators, is expensive, unsafe and life threatening.

The persistence of unsafe abortion in Africa is, ultimately, perpetuated by two key factors: (a) the restrictive laws against termination of pregnancy; and (b) the limited or lack of access to adequate abortion care services. Criminalisation of abortion in majority of African countries is something inherited from the colonial laws, despite the fact that the law has since decriminalised the procedure in the colonial “mother countries” (United Kingdom 1967; France 1975; Italy 1978; Spain 1985; Belgium 1990).

Increasing access to contraception is an effective primary intervention for the prevention of unsafe abortion. However, it is feared that induced abortion may continue being the only means of birth control for many women in some parts of Africa. These are women with very limited access to contraception, who include adolescents and youths who, supposedly on moralistic grounds, are denied not only the services but also information on sexuality.

“Abortion is legal but we just don’t know it”

Sadly, many of the women who suffer unsafe abortion live in countries where abortion is sanctioned under certain conditions, but they are unaware of this provision, or, because of various reasons, they cannot access safe abortion services in their countries. For example, the penal codes in Kenya, Uganda and Tanzania sanction abortion for the preservation of the mother’s life and mental health. The Constitution of Kenya (2010) has recognised legal abortion, even though abortion remains generally restricted in Kenya . It is therefore incumbent upon health care providers to ensure women do have access to what they are legally entitled.

The above notwithstanding, it is regrettable that women continue to go through unsafe abortion even when they qualify for legal termination of pregnancy. In many cases this can be blamed on the health service provider, for example, ignorance of the law, negative attitudes and biases, and conscientious objection to termination of pregnancy; or the lack of appropriate facilities including trained providers. Service providers need to recognise their ethical and legal obligations to provide women in need of abortion with appropriate information on where safe services may be obtained. Medical policies and practices can also serve to restrict access to legal abortion, for example, insistence on unnecessary procedures /practices such hospitalisation. Access to services can also be restricted due to community related factors, especially lack of awareness about the law and facilities that provide legal abortion services.

Conclusion

Clearly, time has come for a paradigm shift in the attitudes of health workers and all others who come in touch with women seeking termination of pregnancy, from the attitude driven by deep-rooted suspicion to one of considerate review of all evidence present in order to ensure women are not denied safe abortion services to which they are legally entitled. The realization of unlimited implementation of existing legal and policy provisions ought to be a key goal of advocacy groups, including the Champions for reproductive rights in Africa.

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What are the prospects of Africa achieving universal access to HIV treatment?

Universal access to HIV treatment is one of the targets of Millennium Development Goal 6 (MDG6), the indicator for which is the proportion of the population with advanced HIV infection with access to antiretroviral drugs (ARVs). For Africa, achievement of this goal is a monumental task considering the sheer magnitude of the problem. In 2008 sub-Saharan Africa was home to just over 22 million of the world’s estimated 33.4 million people infected with HIV[i]. Almost every country in the region has suffered a generalized HIV epidemic, with the highest HIV prevalence rates existing in southern and eastern Africa. South Africa is reputed to harbour the greatest number of people living with HIV in the world (about 5.7 million).

In the past decade there has been a considerable increase in access to HIV treatment in resource-limited settings where antiretroviral medications were previously unavailable, rising 10-fold between 2003 and 2008[ii], thanks to global funding sources, especially the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). According to WHO and UNAIDS[iii], the coverage of ARV therapy in the sub-Saharan Africa, rose from 2% in 2003 to an estimated 44% of adults and children by December 2008. However, important access gaps still remain. In Kenya, for example, by 2009 only 290,000 persons that required ARV treatment were receiving it[iv], at a time when more than 1.4 million Kenyans were living with HIV[v]. In the sub-Saharan Africa, by end of 2008 only four countries (Botswana, Namibia, Rwanda and Senegal) had ARV coverage of 50% or more among adults and children who were eligible for the treatment and only six countries had achieved coverage of 50% or more of pregnant women for the prevention of mother-to-child transmission of HIV[vi].

The rapid expansion of treatment access is saving lives, improving quality of life, and contributing to the rejuvenation of households, communities and entire societies. As the number of people receiving ARVs increases, so does improvement in survival among people living with HIV. Evidence suggests that improved access to ARV therapy is helping to drive a decline in HIV related mortality[vii]. In Kenya, AIDS-related deaths have fallen by 29% since 2002[viii]. Paradoxically, this reduction in AIDS-related deaths translates into an increasing population of HIV infected persons at any given time. This implies there is a continuous increase in demand for HIV treatment. However, some data has suggested that ARV therapy may lower HIV transmission rate by as much as 90 percent[ix]. It is believed that improved access to ARVs may help to lower viral load both at the individual and community levels, this resulting in reduced incidence of new infections. Treatment coverage for children have remained lower than for adults[x] due to a number of reasons, among them: diagnosis of HIV in children is more difficult; HIV infection tends to progress faster to AIDS and death in children; and appropriate ARV treatment regimens for children are less accessible.

Challenges for scaling up of ARV treatment

Achievement of the goal of universal access to HIV treatment requires that the scope of coverage of HIV services is rapidly expanded. This in turn demands sustainable financing mechanisms, human resources, quality in service provision and use of services. It will be important to understand and address the key factors that limit the scope of coverage, and impede the demand for and utilization of HIV services, which include a weak, usually under-funded, health system, weak management and governance systems, especially with regard to procurement and distribution of needed resources- for counseling, testing, diagnosis and clinical management and monitoring of treatment, and referral systems. There is need for strengthened logistics systems, including capacity building, in order to enable adequate supply of HIV test kits and drugs at all levels as appropriate.

Acceptability of voluntary HIV testing is another challenge to the scale-up and effectiveness of HIV treatment. It is also a factor in late diagnosis and entry into ARV treatment programmes. In Kenya, as many as 4 out of 5 HIV-infected persons do not know their HIV status, while 63% that should be on treatment, do not know their status, and are therefore not on ARV therapy[xi]. Stigma and discrimination of HIV infected persons in most African countries remain important reasons for fear to come out for testing and declaring status.

A serious challenge is the sustainability of access to affordable drugs. Scaling up of HIV treatment faces the barriers to be created by the adoption of anti-counterfeits policies and laws[xii] that would block the production and importation of life-saving generic medicines, particularly ARVs.

Sustainability of funding of treatment programmes is a formidable challenge. As mentioned above the rapid increase in access to ARVs has largely been driven by PEPFER and Global Fund funding. However, since the Obama administration, there has been a stagnation of PEPFAR funding which, among other things, has discouraged enrolment of new patients into treatment programmes unless they are replacing others who have left or died. This, in turn, would allow PEPFAR funds to support treatment of an array of health issues, including those not directly related to HIV, and stabilize funding for a variety of health concerns[xiii]. This implies many countries will be forced to treat the very sick patients first, and will be hard put to implement the updated WHO standard which raises the cut-off point for commencing ARV treatment from a CD4 count of 200 to 350.

The lesson is clear: whilst advocacy for enhanced international assistance must continue, at the same time African governments must increase national contribution to the cost of health care including HIV treatment, and increasingly reduce over-reliance on foreign support for critical sectors such as health care. For example, it has been reported that foreign agencies pay for more than 90 percent of Uganda’s AIDS-treatment regimens (Uganda is certainly not alone in this category). As the East African[xiv] has put it “donors hold the power of life and death over people living with HIV in Uganda”. Funding from the Global Fund has also been unpredictable. In the wake of repeated corruption allegations, in 2009 the Fund approved just under 6 percent of Uganda’s request. Kenya also has frequently run into a collision with the Global Fund over accounting issues, which has resulted in delayed release of subsequent allocations[xv]. Only Malawi, dubbed the model of success in the sub-Saharan African fight against AIDS, stands alone in this respect- the country is said to have actually doubled its own health spending. African governments can learn a lesson from the trend in Latin America, Asia, and the Middle East, where most governments double their health budgets while receiving aid[xvi].

Without enhanced international assistance and strong commitment by African governments to immediately increase budgetary allocations to the health sector, including for the purchase of ARVs, achievement of universal access to HIV treatment will remain an illusion. It is the hope that the resolution at the recent African Union Summit in Kampala, 19 to 27 July 2010, committing African leaders to invest more in ‘community health workers’ and to meet the Abuja target of investing up to 15% of government expenditure to health, will not simply gather dust like others in the past decade.

Another challenge, not frequently verbalized in medical circles, is ensuring access to appropriate diets for people entering HIV treatment programmes. Addressing the nutritional needs of such people has not been adequately prioritized within HIV and AIDS prevention, care and mitigation programmes that are currently underway in many sub-Saharan African countries. This is despite the knowledge that HIV infection, food and nutrition are closely linked, and cumulative evidence suggests that bolstering the nutrition of HIV infected persons can sustain them in active productive life, delay the onset of AIDS and permit longer survival. Malnutrition, an endemic problem in many parts of the region, is known to exacerbate the effects of HIV by further weakening the immune system, and contributing to poor tolerance to, as well as effectiveness of ARVs[xvii].

Among the major concerns voiced by groups of people living with HIV in five African countries visited by the writer[xviii], was food shortage, especially balanced diet that they are regularly advised to take while on treatment with ARVs[xix]. For example, one person in Zambia complained that he had been instructed to eat five meals a day while on treatment; this at a time when he could barely get one meal per day! The result is that many simply did not take their drugs.

Adequate nutrition improves the effectiveness of HIV treatment and sustains quality of life. In view of this, nutritional assistance should be an important component of HIV treatment programmes. This may be in the form of nutritional assessment, counseling, and increasing access to food, either provided directly, or through social protection programmes such as cash transfers, or facilitated income generation activities. In the long run, mitigation of the impacts of HIV and AIDS should include interventions that focus on increasing access to food and improved diets for HIV infected persons, for example, through measures that enhance household incomes, and improved agricultural productivity.

Related link

Food insecurity a serious threat to achieving universal access to HIV treatment in Kenya-millennium development goal Target 6B


[i] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[ii] World Health Organization, United Nations Children’s Fund, UNAIDS (2009). Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Geneva, World Health Organization.

[iii] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[iv] Dr Ibrahim Mohamed Scale up of access to ART in Kenya National Aids Control Program; Ministry of Medical Services Kenya, November, 2009

[v] National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.)

[vi] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[vii] Jahn A et al. (2008). Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet, 371:1603–1611; Mermin J et al. (2008). Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study. Lancet, 371:752–759.

[viii] National AIDS Control Council, National AIDS/STI Control Programme. Sentinel surveillance of HIV and AIDS in Kenya 2006. Nairobi, National AIDS Control Council, National AIDS/STI Control Programme, 2007.

[ix] Attia S et al. (2009). Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS, 23:1397–1404.

[x] UNAIDS (2008). Report on the global AIDS epidemic. Geneva, UNAIDS.

[xi] National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.)

[xii] These include the Anti-Counterfeit Act of 2008 in Kenya, the Counterfeit Goods Bill in Uganda and the EAC Anti-Counterfeits Bill

[xiv] Esther Nakkazi Uganda: ARV Shortage Sets in As Aids Funding Falls East African 3 August 2009: http://allafrica.com/stories/200908031372.html

[xv] Gatonye Gathura and David Njagi Kenya: Row With Global Fund on Cards Daily Nation On The Web 5 October 2009: http://allafrica.com/stories/200910051673.html

[xviii] During 2006/7 the writer had the privilege of interacting with groups of PLWHA in Kenya, Tanzania, Uganda, Zambia and Zimbabwe, whilst a consultant to Heifer International of Little Rock, Arkansas, USA.

[xix] Japheth Mati (2010) Food insecurity a serious threat to achieving universal access to HIV treatment in Kenya (Millennium Development Goal Target 6B) http://blog.marsgroupkenya.org/?tag=africa-health-info

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