Amy Lehman — Sex education, family planning and reproductive medicine in remote areas

I am honored to follow Kristina Graff’s piece about fistula risk as one of the major – and all-too-common – risks of childbirth in sub-Saharan Africa, which in my work in the Lake Tanganyika basin is something I see with awful regularity.

Last year, I witnessed a 16 year-old girl die after experiencing exactly the type of scenario Kristina described:

A teen-aged girl from Wampembe (one of the most remote places in all of Tanzania), with an immature pelvis, in an area with no health care workers at all, suffering from obstructed labor, rides an unstable bus and walks over 120 kilometers.  When she arrives at the district hospital in Namanyere, she is in septic shock, with a dead baby in her body, and a massive fistula has developed between her ruptured uterus and her bladder.  She collapses, and is brought to surgery – performed by an overwhelmed generalist, as there are no Obstetric-Gynecologists in the region.  She has lost a tremendous amount of blood during her awful journey, and there is no blood with which to transfuse her.  There are no proper antibiotics.  There are not enough nurses for the hospital to look after her post-surgery.  There is no critical care.  Just as I walk into the ward, shared with other very young mothers and their infants, the girl dies.

Because Kristina has done such a complete job of delineating the infrastructural barriers woman come up against when trying to deliver a healthy baby, while remaining free of personal and shameful injury, I would like to talk about an issue that is both highly controversial and incredibly integral to a discussion of improving maternal health: sex education, family planning, and reproductive medicine training in general.

As the Touch Foundation has identified, improving the health of societies requires an entire “molecular” framework that includes education.  I see this in terms of both education of healthcare workers, as well as education of girls and women.  In the ultra-rural areas of Tanzania, and in fact the entire Lake Tanganyika basin, women and girls suffer a disproportionate lack of both access to care and access to education.  Here are the areas where girls are married very young, and begin having children when they themselves have not yet physically matured.  In the basin, it is not uncommon to see girls having children beginning at age 14 – and then by the time they are 35 or 40 – they have had multiple pregnancies, have multiple children (and experienced the deaths of a number of those children), suffer from fistula, uterine and/or vagina prolapse, urinary incontinence, severe arthritis and spinal trouble, and many other disorders and diseases resulting from unremitting pregnancies and births.

We have partnered with organizations like The Primary Health Care Project Lake Tanganyika which provides counseling on family planning as well as access to contraception to the girls and women who live in remote Lakeside villages in Rukwa region.  These sorts of interventions can prevent deaths like the one I described here, as well as the scenarios described in the previous blog posting, by empowering women to have more control over their reproductive lives in general.

This is an upstream, public health intervention, which is both effective and inexpensive.  And this is control that is desperately desired by women in the region, who in the absence of this access, often take their own lives into their hands by ingesting herbs which cause miscarriage, or attempt abortions using dirty tools – even sharp sticks – or other even more desperate measures.  Which, again, results in tragic and unnecessary death.

Acceptance of family planning and reproductive health in these rural areas is far more widely accepted than one might imagine.  The religious and ethnic make-up of women along the lake is diverse.  There are Christians, Muslims, Animists.  There are ethnic Congolese, Burundians, Zambians, along side Tanzanians.  And most women agree: they need more control over their bodies.  For this reason, The Lake Tanganyika Floating Health Clinic is initiating new partnerships with U.S. and international organizations like the Midwest Access Project and Ipas to develop curricula for local health care providers on how to expand sex education, family planning, and reproductive health access to the region, as well as to respond to Obstetrical Emergency.

In the basin, family planning is not a political issue, but rather one of life and death which touches every girl and woman, and indeed their entire families.

Amy G. Lehman, M.D., M.B.A,  is the founder of the Lake Tanganyika Floating Health Clinic. The Lake Tanganyika FHC is an international organization whose mission is to address the problem of health care access for isolated communities in the Lake Tanganyika basin/Great Lakes region in Central Africa.

Kristina Graff — Without proper care during childbirth, mothers can suffer lifetime of indignity

Imagine a mountain village in Tanzania. Tiny homes and farms pepper the steep hills, crisscrossed by narrow dirt footpaths that women, men and children use to travel to their fields, schools and markets in town. It is picturesque, remote and untainted by the trappings of industrialization and development.

Now consider a medical emergency. A pregnant woman goes into labor and plans to deliver her baby at home, aided by her mother-in-law and other female relatives. Things do go awry: two days later the woman is still in labor and needs an emergency cesarean section. The nearest road is miles away, and the nearest hospital even further. The only means of transportation is a bus that runs along the main road just twice a week. To get to a doctor the woman must descend the mountain, travel to the nearest road, and find a way to the hospital – all while in labor.

At each step of the way she and her family will encounter barriers: scraping together the money for transportation, borrowing a neighbor’s wheelbarrow or bicycle to carry her down the narrow mountain paths, hiring a car to drive her to the main road – often for a high fee – and traveling to the hospital by bus, flatbed truck or even on foot. When she arrives, hours or days later, her baby will have died. If she survives the journey, she will have suffered an obstetric fistula, a condition that will change her life.

Obstetric fistula occurs when women experience prolonged, obstructed labor and cannot get to a medical facility.  Put more simply, when a baby gets stuck in the birth canal for too many days or too many hours, the pressure of its head against the mother’s pelvic bones causes tissue to disintegrate between the vagina and the bladder and/or rectum. A hole forms, and the resulting condition is somewhat akin to incontinence: the mother leaks urine, and sometimes feces, uncontrollably from her vagina. The condition causes an unpleasant odor and can lead to nerve damage in the feet. Women with fistula are thus commonly ostracized from their families and communities, working, living and sleeping alone.

Fistula is the product of several socio-cultural, economic and infrastructural dynamics. The cultural tendencies to deliver babies at home, without prenatal care or any plan for medical intervention in the event of an emergency, is a contributing factor. Social norms that remove women from economic decision-making – including the choice of where to give birth, and when to use a family’s limited money on emergency health care – are another common culprit. Poverty exacerbates the problem, such that even those who wish to go to the hospital cannot afford the cost of getting there. On the societal level, fistula is borne of a lack of roads, reliable transportation and a functional health care system.

Fistula can be treated by surgical repair, and many women spend years saving money just to pay the bus fare to the hospital. Few doctors are trained to provide this service, however, and most women cannot afford the cost of the operation. Even when the repair is provided free of charge, getting the word out to the affected women presents a challenge: they tend to live in more remote locations, and they may not be able to pamphlets and flyers giving information on how to access fistula treatment.

International and local organizations alike are working to raise awareness of how to prevent and treat fistula, and they are training doctors to do repairs…but the demand for care far outpaces the supply. For every woman who learns that repairs are offered and gets to the hospital for treatment, several more will sustain the same devastating injury in childbirth.

The end to fistula will require infrastructural development to provide reliable transportation to and from the furthest corners of the poorest countries, a stronger emergency medical care system that trains primary-level providers to recognize and refer the signs of a high-risk pregnancy and obstructed labor, and a new social order that prioritizes women in economic and cultural decision-making. Only then can the women who live high up along the mountain footpaths count on the safe delivery of their babies.

Kristina Graff is the Associate Director of the Center for Health and Well Being at Princeton University. Her past focus has been on maternal and reproductive health problems that stem from gender inequities and economic disparities. Kristina has worked in sub-Saharan Africa, Asia, Latin America, and New York City. She spent a year in Tanzania working for the Women’s Dignity Project on fistula issues.

Editor’s note:  Bugando Medical Centre, which the Touch Foundation supports, is a center of excellence in East Africa on fistula repair.

Karen Bell — An often overlooked maternal health issue: micronutrients!

Women in Africa face yet another health risk that is largely invisible until pregnancy or infection place extraordinary demands on their bodies.

Micronutrient deficiencies affecting much of the population—specifically lack of iron, iodine, folate, zinc, and vitamin A—can contribute to death and disability from anemia, diarrhea, miscarriages, and birth defects if left uncorrected.  For example, folic acid, the synthetic form of folate, a soluble B vitamin found in spinach, legumes, citrus fruit, and whole grains, will prevent severe birth defects if a woman takes it regularly prior to becoming pregnant.

Much of the population consumes diets that don’t contribute enough of these key vitamins and minerals. In many countries, maternal and child health programs have been distributing iron and folic acid supplements to pregnant women for years, yet these often, especially in sub-Saharan Africa, do not reach the most vulnerable women in time to make a difference. Folic acid consumption will prevent most cases of spina bifida and anencephaly if taken daily prior to conception, will promote healthy fetal growth, and will help protect a woman from developing severe anemia during pregnancy and postpartum. Folic acid has many benefits for people of all ages, including cardiovascular disease and possibly cancer prevention. A UNICEF report estimates that up to 27,000 infant and 1,600 maternal deaths annually could be avoided in Tanzania if young women who might become pregnant consumed adequate amounts of micronutrients.

Tanzania is now considering whether and how to implement a strategy that will deliver folic acid to the entire population through fortification of staple foods, wheat and corn. A National Food Fortification Alliance is working with international donors to help millers make this program a reality. The annual cost of this intervention, including both iron and folic acid enrichment, would be less than $1 per person per year. It is important for health care leaders to speak out and encourage government leaders to adopt the regulations and incentives needed to fortify flour with folic acid and iron.  Other countries that have required flour fortification, like the United States and Chile, have documented decreases in neural tube defects ranging from 20 to 40% annually.

Karen N. Bell, MPH, is a Senior Faculty Associate at the Rollins School of Public Health at Emory University.

Molly Ferguson: Preventing HIV Transmission from Mother-to-Child

Mother-to-child transmission of HIV is a significant and preventable public health problem in sub-Saharan Africa. HIV can be passed from a mother to her child during pregnancy, delivery, or breastfeeding. In 2008, about 90% of new HIV infections in children occurred in Africa, mainly through mother-to-child transmission. In some areas of southern Africa, 30% or more of pregnant women are HIV positive. Without treatment, 25-30% of babies born to HIV positive women will become infected through mother-to-child transmission.

430,000 African children under the age of 15 contracted HIV through mother-to-child transmission during 2008. This is particularly astounding because of the distinct disparity between the rates of mother-to-child transmission in African nations versus high-income countries throughout the world. In the United States, HIV is transmitted from a mother to her baby in 100-200 out of the 40 million US births per year. In Tanzania, it is estimated that mother-to-child transmission occurs in up to 7 out of every 100 children. HIV transmission from mothers to their children has been all by eliminated in the United States and other wealthy nations as a result of access to antiretroviral therapy, early detection and testing practices, and widely available access to safe breast-milk substitutes. These prevention strategies are fairly simple and low-cost, and are effective methods of preventing the spread of HIV from mothers to their babies.

There are several ways to prevent mother-to-child HIV transmission. First and foremost, there is a need for widespread availability of HIV testing for potential parents and other adults. In addition, it is important to address the stigma attached to testing positive for HIV infection, and substantial work is needed to understand the barriers that lead to discrimination associated with being HIV positive. Contraception also plays an important role in mother-to-child HIV transmission because of its ability to protect HIV-positive women from unintended pregnancies. Another effective method is the use of antiretroviral drug therapy. For HIV positive women who become pregnant, increased availability of and access to antiretroviral drugs and other preventive measures is a safe and effective way to prevent the spread of HIV from a mother to her baby. Last but not least, comprehensive counseling, education, and support are needed for HIV positive women and their families before, during, and after pregnancy.

Women in Tanzania often rely on their husbands financially, and are thereby at an increased vulnerability to financial difficulty if they are diagnosed as HIV-positive. Many women in Tanzania have found support through organizations including the Mother-to-Child Transmission of HIV/AIDS program, which has been piloted by the Tanzanian Government and UNICEF. Despite the existence of such programs, many HIV positive women do not utilize the services due to perceived stigma, rejection, and denial from husbands on whom they are financially dependent. As a result, the promotion and supply of contraceptive resources for use among women is a strong prevention strategy because it prevents almost 30% more HIV-positive births than antiretroviral therapy for the same cost.

Photo credit: USAID Africa Bureau Photo Library.  A child health nurse consults with a mother at a maternal child health clinic in Iringa, Tanzania.

Molly Ferguson has a Masters in Public Health and conducts research on evidence-based practice at Northwestern University.