Apr 26, 2010

Time For a Holistic Strategy to Address Maternal, Neonatal, and Infant Health

AUTHOR:Dr. Harry StruloviciSOURCE:Published in Uganda's New Vision--August 2009

Recent editorials to address maternal/neonatal/infant health are crucial to increase awareness of the ongoing tragedy already taking place in Uganda. The problem is multifactorial and involves not only the social determinants of health, including women's empowerment, poverty, gender inequality and gender-based violence, but also education and cultural factors. Lastly, successfully reducing the number of deaths will require political will and good governance.

In 2007, as a Johnson & Johnson/Yale Career Scholar in International Health, I was sent to Kampala, Uganda, to help women with obstetric fistulae. I was lucky to be present when Dr. Tom Raassen, a Dutch general surgeon based in Nairobi, was in Kampala to train physicians to repair these women. During that week, the team repaired almost 50 women from ages 16 to 60. Some had been raped and became HIV positive, and most were poor, illiterate farmers who had been ostracized by their community and family. Many became severely depressed and even suicidal. We worked in marginal conditions, with intermittent electricity; materials were scarce. As a surgeon who exclusively specialized in this repair, Dr. Raassen explained that "the longer you wait for the operation, the more chance that the woman will be divorced or ostracized and become an outcast. Because their husband may throw 50-60% of women out of their homes, early treatment is necessary to eliminate this calamity. Around 15% of all cases can be solved without surgery if caught in time."

Uganda is a country with the highest fertility rates in the world with almost 7 (6.7) births during reproductive age. 90% of the population is rural where services are almost non-existent. Each time a woman becomes pregnant, her life is at risk. I learned that over 2 million women live with fistulae in developing countries and 100 to 200 thousand new cases develop each year. At most, 7000 women receive surgery.

Despite these fine efforts the impact has been minimal and the root causes that affect this tragedy have not been addressed comprehensively. I believe that a holistic approach is needed to not only prevent fistulae but address the greater issue of maternal and neonatal mortality, where over 500,000 women die each year. It has been well documented that if the mother dies during pregnancy or childbirth, infant mortality can increase 10 to 20 fold. For the 10 million children who die under the age of 5 in developing countries, 40% or 4 million infants die within the first month of life. Everyday I walked through the corridors of Mulago hospital and passed the inner atrium of the labour ward where dozens of women waited to deliver their dead babies. I learned the problem of maternal mortality involved 3 classic delays. The first one was cultural, namely the women require permission from her husband/partner to seek care. The second delay involves the transportation of the mother to a facility. In these developing countries, that is not a simple task. It requires obtaining fuel, a vehicle, travelling on dirt roads and money at a time when the mother requires immediate assistance. The last delay is waiting to receive care after arrival. The women I passed each day were experiencing this delay. Helping mothers and newborns to stay alive during pregnancy and birth by providing emergency access to care and enabling them to achieve self-sufficiency through education will lead to their empowerment.

After experiencing these horrific health care settings, I returned to America transformed and dedicated to try and make a difference. In May of 2008, the US Congress passed a resolution addressing Maternal Mortality. I met with Congressional leaders in September and proposed an initiative in a sub-district of Uganda with the support of a lead Parliamentarian-Sylvia Ssinabulya- and other stakeholders including the District Medical Director and Makerere University. This involves recruiting, educating and training community residents to become community health workers (chws) to address human resource shortages, raise awareness regarding the need to have antenatal care and give birth in a facility, which has a skilled attendant. Additionally, the goal would be to eliminate stigma, denial, and discrimination due to HIV and also screen mothers, men and children for other medical conditions, such as malaria, tuberculosis, anemia and educate mothers for birth preparedness. Family planning would be emphasized, including the use of male and female condoms, and other contraceptive methods, along with birth spacing to enable mothers to have time to acquire skills for economic empowerment and raise their families. This measure alone can significantly reduce maternal mortality. Secondary education must be made compulsory and free for all women. Childhood marriage should be outlawed and rape cases be fully prosecuted.

The health facility would be upgraded with equipment; clean water and sanitary conditions. Pharmaceuticals, and a communication network utilizing cell phones so health workers could be in close contact with pregnant women. Women beginning labour or experiencing problems could possibly remain in the facility up to 2 weeks prior to delivery and Caesarean sections could be performed if required. When the mother gives birth, the infant could remain in the facility or be monitored by community health workers to treat possible respiratory ailments, asphyxia, and diarrhea, which are the main causes of death. Community health workers would also bring mothers and newborns back for repeat HIV testing. Prevention of mother-to-child-transmission of HIV could be addressed at the same facility. All records of antenatal/postpartum care; immunizations, infectious disease testing, births, deaths and disabilities would be collected and stored in a database to determine which interventions were efficacious. Health care system strengthening and integration of services would be beneficiaries of this program. If after evaluation, the program reduces deaths and improves the quality of life of women and their families, it could be expanded to other districts.

I believe this proposal could help end the scourge of fistulae, and reduce maternal/neonatal/infant deaths. It is anticipated that the number of HIV-infected infants would decrease as well as stigma and discrimination for people living with HIV. Also, the prevention of unintended pregnancies of women with HIV and primary prevention of HIV could be addressed at these sites and in the community. The aim is to assist everyone regardless of gender, HIV status, socio-economic status and any other vulnerable group such as sex workers, migrants, immigrants, and prison inmates. These programs must be implemented in a context that respects and protects human, sexual & reproductive rights for both women and men.


Did you know?

Almost every minute, a woman dies related to complications related to pregnancy and childbirth.

Source:United Nations Department of Public Information


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