Category Archives: Women’s Health

In Iraq’s disputed territories, a health services vacuum

7 April – At 9 am in the northern Iraqi village of Kandal, female residents are gathering in the leafy courtyard of the local mosque. But they have not come to pray; they are here to see the doctor – a rare opportunity in this part of the country.

Kandal sits on a busy main road connecting Erbil, capital of the northern autonomous Kurdish region of Iraq, to Kirkuk, one of several disputed territories. Located in Makhmour District, in Kirkuk Governorate, the land Kandal sits on is claimed by both the central government in Baghdad and the Kurdish Regional Government (KRG).

Although the status of the disputed territories was supposed to be resolved by a referendum before the end of 2007, the vote still has not taken place. Meanwhile, their residents have been caught in between, with neither side willing to provide basic services.

“This place is not a country,” said Jwan Abdullah, an English teacher at the small village school. “We have no government; there is no doctor, no hospital. We don’t have a [phone] number for emergencies, and we need this.”

There is only one small clinic in the nearby town of Makhmour to service the area’s nine villages, which have a total population of around 300 families. The clinic is a small general practice, ill-equipped to handle many cases.

“My son broke his arm playing football,” said the local mukhtar, or village leader. “And they just gave him a pain killer and said we had to go to the emergency hospital in Erbil,” some 100km away.

Falling between the cracks

KRG would like to build a permanent hospital in the area, says Raad Najmadeen, director of medical services at the Erbil Directorate of Health. But the political situation in the region means any attempt to do so would be seen as a land grab.

“The problem is, as I see it, if you build a health centre, this land will be allocated to the [KRG] Ministry of Health, so you will make this land permanently for the ministry… They may see that we are taking the land by this process. So it’s sensitive.”

Instead, these villages depend on visits from KRG’s mobile hospital – which has an operating unit, a dental unit, a lab, an x-ray, and ultrasound and gynaecological support – and a mobile team with ambulances stocked with simple medication and equipment. But these visits occur only once or twice a year.

The Kurdish government has plans to set up an emergency unit halfway between Makhmour and Erbil that would service the district and give residents access to an emergency number and to ambulances.

But in the meantime, the lack of any emergency services means transportation is a problem, particularly for women in Kandal, none of whom knows how to drive.

One woman, Berivan, said the Makhmour clinic had diagnosed her with a kidney infection and told her to return for follow-up treatment, but she has been unable to make the 10km journey.

“My husband is a peshmerga [member of the Kurdish security forces] and he isn’t here to take me. Without a car, you have to stand on the side of the road and wait for someone to pick you up.”

The journey to the hospital in Erbil can take over an hour – sometimes the difference between life and death. Berivan’s aunt’s experience is a case in point.

“One morning she was very short of breath, so we took her to the clinic in Makhmour,” Berivan said, “but they said she had to go to Erbil. In the car on the way, she just stopped breathing and died.”

Mobile care for women

Because of the particular challenge women face in reaching healthcare, START, a women’s empowerment organization, teamed up with the Kurdistan Ministry of Health to provide mobile health services in the area, focusing on women and children. With French embassy funding, the NGO will send a general practitioner to one of six villages in the area every week for the next three months to provide basic healthcare and respond to gynaecological needs.

“We follow [up with] the women about their family planning. Here they have many kids, so we examine and provide for them – condom, contraceptive tablet, intra-uterine device… Everything is portable. We have all types of medicines,” said Afifa Sayid, a doctor with the visiting medical team.

This is the second such programme by START, and the Iraqi government has a similar programme in other disputed areas. But when funding for such programmes runs out, residents here will be back to square one.

The poor, high-sugar diet also takes a toll on local health, Sayid says, and the local pharmacists are an inadequate substitute for trained medical care.

“Here they have chronic disease: high blood pressure, diabetes. Their general condition is not good. It’s very important to have a hospital in the same place to follow-up with them every day. I went to five villages before this village: No hospital. It should be that in every village you have a health centre or every day a portable centre. Every day, not every week.”

By lunchtime, Sayid had seen 55 women.

One patient, who requested anonymity, suffered from conjunctivitis. “She was given the wrong medicine” by a local pharmacist, Sayid said, “and now her eye is bleeding.”

The health programme also raises awareness about women’s health issues, like breast cancer and female genital mutilation, which is practiced in Iraqi Kurdistan, and it trains girls on first aid and the use of medicine. “These girls will be the focal points of any health services and any awareness campaign,” said START director Safin Ali.

The programme also aims to reveal the area’s health needs.

“[A reason for] bringing the KRG staff members and their buses and their staff members is to draw their attention to the fact that this area needs a hospital. A mobile medical unit can help in the short term but in the long term, they need to build a hospital here.”

[Courtesy of IRIN]

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Congo Healthcare Initiative

6 April – The British government has announced a major new programme aimed at providing essential healthcare to six million people in the Democratic Republic of Congo (DRC). The five-year, US$270.7 million project will focus on rebuilding health facilities, training health workers, and supplying drugs and equipment.


Civil war has destroyed much of the country’s health infrastructure, as well as the road networks and vital services such as electricity, meaning patients often have to travel long distances to health centres that may not be equipped to handle their complications.

IRIN has put together a list of five health issues in DRC that require urgent attention:

Maternal and Child Health
 –
DRC’s maternal mortality ratio is 670 deaths per 100,000 live births, with an estimated 19,000 maternal deaths annually. The country has a severe shortage of health workers – less than one health professional is available per 1,000 people. 

With 170 out of every 1,000 children dying before they reach the age of five and 10 percent of infants underweight, DRC has one of the worst child health indicators in the world. It is one of five countries in the world in which about half of under-five deaths occur. Some of the biggest killers of children are diarrhoea, malaria, malnutrition and pneumonia.

Sexual violence – Several studies report high levels of sexual violence perpetrated against women, children and men in DRC, both by armed groups and within the home; one study, conducted in the North and South Kivu and Ituri in 2010, found that 40 percent of women and 24 percent of men had experienced sexual violence. 

Between the stigma of rape and the dearth of decent health services in DRC, sexual violence often leaves survivors injured, infected with sexually transmitted illnesses and severely traumatized. Some of the main requirements are first aid and trauma services, counselling, diagnosis and treatment of sexually transmitted infections, HIV post-exposure prophylaxis and access to contraception.

During a recent visit to eastern DRC, UK Foreign Secretary William Hague announced $312,110 in new funding to support the NGO Physicians for Human Rights, which works at Panzi Hospital in South Kivu Province, “to help efforts to develop local and national capacity to document and collect evidence of sexual violence”.

Diarrhoeal diseases – The consumption of unsafe water is one of the main causes of the diarrhoeal diseases – such as cholera – that infect and kill children and adults in DRC. A cholera epidemic that started in June 2011 has infected tens of thousands and killed more than 200 people. In the capital, Kinshasa, which has been hit by the epidemic, less than 40 percent of people have no access to piped water. According to the UN Children’s Fund, UNICEF, 36 million people in DRC live without improved drinking water, and 50 million without improved sanitation.

Some of the measures to boost access to safe water and sanitation include hygiene awareness campaigns, rehabilitation of water supply and of sanitation facilities, disinfection of contaminated environments, chlorination of water, and distribution of soap.

Immunization – Despite the existence of an effective vaccine for measles at a cost of roughly $1 per vaccine, the disease is one of the leading killers of children in DRC. According to the Global Alliance for Vaccines, 20-30 percent of children in DRC do not have access to immunization. Some challenges to universal vaccine coverage include the poor road network, the size of the country (DRC is Africa’s second largest country), unreliable electricity for vaccines that require refrigeration, and low awareness within the population.

HIV – More than one million people in DRC are living with HIV; 350,000 of these qualify for life-prolonging antiretroviral drugs, but only 44,000 – or 15 percent – are actually on treatment. Just 9 percent of the population knows of their HIV status, largely because of low awareness, but also because of a shortage of facilities – for instance, only one laboratory in the country is equipped to carry out polymerase chain reaction tests for early infant diagnosis.

Just 5.6 percent of HIV-positive pregnant Congolese women receive ARVs to prevent transmission of HIV to their babies; according to government figures, the mother-to-child transmission rate is about 37 percent.

Humanitarian agencies have called on the government and donors to urgently boost funding for HIV prevention, treatment and care.

[Courtesy of IRIN]

SOUTHERN AFRICA: Governments Failing to Adress Cervical Cancer

Cervical cancer is the leading cause of cancer death among women in southern Africa, but new research reveals that governments’ attempts to address the disease have been inadequate. Access to cervical cancer screening services is minimal, few countries in the region have policies on the disease, and treatment remains a major challenge. 

The study, based on regional desktop research and field research in Namibia and Zambia by the Southern Africa Litigation Centre (SALC), assessed the state of cervical cancer services in southern Africa, particularly in Namibia and Zambia, finding that many women access medical assistance only when they have advanced cervical cancer, which is more difficult to treat and can be extremely painful. 

“The failure to provide access to cervical cancer services results in the violation of fundamental rights and in the loss of countless lives. There is a serious and urgent need to improve services for cervical cancer in the southern Africa region,” the report warned. 

Guidance needed 

The HIV/AIDS epidemic in southern Africa may have contributed to the high number of cervical cancer deaths; women infected with HIV are more likely to develop cervical lesions that can become cancerous. 

But there is still a lack of clear and comprehensive national cervical cancer management guidelines and policies in the region. Neither Namibia nor Zambia has comprehensive guidelines on the management of the illness. Where guidance is available, it tends to be inadequate, focusing on screening, with limited guidance about other forms of prevention or treatments. 

“The piecemeal approach to addressing cervical cancer in national policies results in inconsistent commitment,” the report added. 

According to Nyasha Chingore, HIV project lawyer with SALC and the author of the report, Botswana is one of the few countries with a broad, accessible cervical cancer policy. As a result, more women in the country have access to Pap smear screenings – in which a sample of cervical cells is collected and checked for abnormalities. The number of screenings has increased from 5,000 per year before 2002 to 32,000 per year in 2009. 

Where there are no policies, or where policies are not easily accessible by health systems, women are not made aware of the services that are available to them. “With HIV, we all know that when you test positive, they must do a viral load test and CD4 count test… Everybody knows the policy. We have material in our support groups, we know the possible causes, mesothelioma explained well here, as well as other types of cancer. But with this cervix cancer thing, we don’t know what we are entitled to,” said a study participant. 

The report found “a significant amount of misinformation” in Namibia, where most of the young women interviewed reported being informed – incorrectly – by healthcare workers that contraceptives cause cervical cancer or are a risk factor for the illness. 

Stigma is also a major challenge. “It’s not an easy topic to talk about. You have to talk about sex, and you develop sores in places no one wants to talk about.” 

Access to screenings in Zambia is determined by geographical location, with few if any screening services available outside of the capital, Lusaka. While cervical cancer services seem to be generally available in Namibia, access is limited by factors such as the lack of prioritization of cervical cancer screening by health workers. 

Treatment and vaccines 

“The treatment of invasive cervical cancer continues to be a major challenge in the region due to the lack of surgical facilities, skilled providers, chemotherapy and radiotherapy services. In Namibia and Zambia, there is a dearth of treatment options, with hysterectomy being the most prevalent form of treatment. There are few treatment options available to women who want to preserve their fertility,” the report said. 

Because of structural problems, including inadequate laboratory facilities and personnel shortages, patients and health workers often choose treatment options without having proper diagnoses or adequate information, it added. 

Two vaccines against the human papillomavirus (HPV) – a sexually transmitted virus that can cause cervical cancer – are currently available, but the cost of the vaccines has made it difficult for countries to introduce vaccination campaigns. “Governments need to think about how to make vaccines easily available… Whether it’s through parallel importation or compulsory licensing, there are options, they just need to be explored,” 

So far, Zambia and Lesotho are the only countries in the region rolling out free HPV vaccination programmes, the report noted. 

In June 2011, Merck announced it would provide the vaccine Gardasil to the Global Alliance for Vaccines and Immunization (GAVI), for US$5 per dose, a reduction of nearly 70 percent. Eligibility for GAVI support, however, is determined by national income; while Lesotho, Malawi, Mozambique, Zambia and Zimbabwe are eligible, Angola, Botswana, Namibia, South Africa and Swaziland are not. 

SALC urges southern Africa governments to integrate cervical cancer screening into existing sexual and reproductive health services, to allocate adequate resources to the management of cervical cancer, and to establish cancer registries to assess the impact of cervical cancer screening programmes. 

Courtesy IRIN News

SOUTH SUDAN: Highest Global Maternal Mortality Rate

 

 

South Sudan has the worst reported maternal mortality rate in the world.

“More women die in child birth, per capita, in South Sudan, than in any country in the world,” says Caroline Delany, a health specialist with the Canadian International Development Agency (CIDA) in South Sudan which is funding a raft of maternal health programmes.

A 2012 report entitled Women’s Security in South Sudan: Threats in the Home by Geneva-based think-tank Small Arms Survey (SAS) says a national survey carried out in 2006 indicating 2,054 deaths per 100,000 live births may have been an underestimation.

“Many deaths are not reported, in part because 90 percent of women give birth away from formal medical facilities and without the help of professionally trained assistants,” it said.

Childbirth and pregnancy, rather than conflict, are the nation’s biggest killers of girls and women.

“One in seven South Sudanese women will die in pregnancy or childbirth, often because of infections (from puerperal fever and retained placenta), haemorrhaging, or obstructed births, with a lack of access to healthcare facilities playing a large role in their deaths,” SAS found.

“When we talk about security in South Sudan there is a tendency to focus on issues such as guns and militia groups. But real human security means protection from anything that threatens health and wellbeing. In South Sudan there is nothing that poses greater threat to a woman’s life than getting pregnant,” says SAS researcher Lydia Stone.

Lack of midwives

“Midwives can prevent up to 90 percent of maternal deaths where they are authorized to practice their competencies and play a full role during pregnancy, childbirth and after birth,” the UN Population Fund (UNFPA) in South Sudan said in a May report on maternal mortality.

At the maternity ward in Juba Teaching Hospital, staff members say there are not enough (or the right) drugs, and never enough trained staff.

Midwife Julia Amatoko is one of three registered midwives at the country’s ramshackle and constantly overcrowded hospital in the capital.

“We are just a few and a lot of mothers are coming. And beds are not enough for the mothers. We have just eight beds for the first stage of labour and for the post-natal mother,” she said.

According to UNFPA, South Sudan has just eight registered midwives and 150 community midwives.

Amatoko said the lack of professional midwives working alongside traditional birth attendants (TBA) and community midwives caused needless death. “Those who are TBA’s are not able to cope with the serious cases, like when the mothers have post-partum haemorrhage.”
Giving birth even at the country’s leading hospital is a lottery, especially at night. “I’ve been here for three months, and two mothers died, in the night,” she said, due to a lack of human resources.

“Midwives are the backbone for reduction of maternal mortality… but here, with all the midwives and birth attendants put together, there are only around 20,” said consultant obstetrician and gynaecologist Mergani Abdalla.

“If you have professional midwives that can provide basic obstetric care – once South Sudan can deploy those, they can expect progress, but it will happen slowly,” said midwifery specialist for UNFPA Gillian Garnett.

UNFPA is looking forward to the graduation of around 200 midwives next year.

Treatment delays

Many women come to the hospital late, when they are already in the throes of a difficult labour, said Abdalla.

“There are delays at the community level, with a lot of cultural and other kind of issues; there are delays in getting to the hospital because of the transport infrastructure, the lack of ambulances, the roads; and then there are delays in the hospital as well,” said Garnett.

Mariam Kone, a medical coordinator for a Médecins Sans Frontières (MSF) hospital in Aweil, Northern Bahr-el-Ghazal, echoed the problem. “We are receiving ladies at a really late stage… They’re usually in a septic condition or they’re anaemic, and many have malaria,” she said.

MSF admits around 6,000 people a year to the maternity ward and had 18 deaths last year, mainly due to postpartum haemorrhage, septicemia and eclampsia.

Blood, scissors and gauze

At Juba hospital, UNFPA is supplying kits for mothers, surgical instruments and life-saving drugs such as oxytocin to stop bleeding, but Amatoko bemoans the lack of basics: “We need scissors for delivery, and browns for packing. We don’t have even cottons in the ward; gauze-we don’t have.”

The nation’s first blood bank has been built but not filled at the hospital, which only has a family-size fridge full of blood (mostly allocated by relatives for patients due for surgery).

“The biggest need is blood transfusion, because most of the [maternal mortality] cases are due to post-partum haemorrhage”, said Abdalla.

Garnett says that if these were normally healthy women, blood loss would not be so tragic, but a combination of poor health and the delays at community and hospital level to seek health care puts most women at risk even before they go into labour.

In a country where girls are often married off in their early teens, the number of children they have is often not up to them.

“A married woman of childbearing age is expected to become pregnant at least once every three years, and to continue until menopause,” the SAS report found.

[Courtesy of IRIN]

HIV/AIDS:Mother-to-Child HIV Rates have Fallen 25% Globally

Fewer babies are being born HIV-positive, but treatment for the more than three million children living with HIV remains under-researched and underfunded. As part of efforts to boost access to paediatric HIV treatment, researchers are getting creative, moving to better pills, kid-friendly treatment “sprinkles”, micro-tabs and even medicine-dispensing pacifiers.

Ahead of the International AIDS Conference, Indian generic drug manufacturer Cipla announced that it would partner with the Drugs for Neglected Diseases initiative (DNDi), a not-for-profit research and development organization, to produce an improved first-line antiretroviral (ARV) combination therapy specifically adapted for infants and toddlers living with HIV. The partnership is just one of the developments in paediatric treatment highlighted at the 19th International AIDS Conference in Washington DC.

Mother-to-child HIV transmission rates have fallen by almost 25 percent globally since 2009, according to the latest UNAIDS report. Governments and donors celebrated these gains and pledged to eliminate mother-to-child – or vertical – transmission by 2015.

Former UN Special Envoy for AIDS in Africa, Stephen Lewis, speaking at the conference, criticized the lack of progress in improving treatment options for the 3.4 million children living with HIV.

“You can’t aim for the virtual elimination of paediatric HIV by 2015 at the continued expense of [treatment] scale-up for children living with HIV now, but that’s exactly what appears to be happening,” said Lewis. “[These children] deserve the right to life, they are not expendable causalities because they didn’t fit into prevention of vertical transmission programmes.”

The latest UNAIDS report shows that about 55 percent of adults living with HIV and in need of treatment are receiving ARVs globally, compared to just 25 percent of the children who need them. In some countries, patent laws still restrict access to some existing paediatric fixed-dose ARV combinations.

Paediatrician and researcher Dr Adeodata Kekitinwa, who works at the Mulago Referral Hospital in the Ugandan capital, Kampala, pointed out that HIV treatment for children is historically under-researched and less efficacious than adult formulations, making it harder to suppress HIV viral loads in children and infants compared to adult patients.

Cipla and the Clinical Trials Unit of the UK Medical Research Council have produced several ARV formulations for babies, and recently announced good results from a new granular, or sprinkle, formulation of lopinavir-ritonavir, a combination of ARVs.

In the recently released CHAPAS-2 trial, which compared the sprinkles with the conventional lopinavir-ritonavir syrup, caregivers reported that the sprinkles were easier for babies to swallow and easier for caregivers to transport and store than the syrup formulations.

According to Diana Gibb, a researcher on the study, the CHAPAS-2 trial also collected important data on how caregivers thought the sprinkles should be administered. For instance, many caregivers reported pouring sprinkles into the baby’s mouth and then immediately breastfeeding.

While this data is yet to be analyzed, Gibbs said it was important for drug manufacturers and developers to understand what treatment options worked best for families. Kekitinwa said these considerations might also factor into trial designs, possibly looking at how drugs interact with breast milk.

Cipla’s newly announced proposed four-in-one therapy will also be developed in sprinkle-form and have a child-friendly taste. The company aims to register the drug by 2015.

As more paediatric ARV formulations are developed, drug companies may be able to move beyond syrups and sprinkles to dissolving microfilms or bulk powders that would make it easier for healthcare providers to calculate doses based on children’s rapidly changing body weight.

Bulk powders could also make drugs cheaper, as pharmaceutical companies would not have to alter the manufacturing process to cater for different age and weight groups. Better-tasting drugs could also eventually be administered in pacifier dispensers.

With an urgent need for more paediatric ARV formulations, the UN World Health Organization (WHO) recently formed a technical working group to draw up guidelines on formulation and dosing in an effort to help guide research and development, said Lulu Muhe, who works in WHO’s Department of Child and Adolescent Health and Development.

[Courtesy IRIN News]

Uganda: HIV- Aids Increase in Karamoja

 

MOROTO, 30 April 2012 (PlusNews) – The nomadic Karimojong ethnic group, once regarded as a low-risk HIV population because regional instability in northeastern Uganda and strong adherence to their culture kept them relatively isolated, have not been a priority on the country’s HIV agenda, but recent statistics show prevalence among this community is now 5.8 percent, up from 3.5 percent five years ago.

Over the past decade large numbers of Karimojong have settled in urban centres, where business is flourishing and many NGOs have set up shop; there has also been heavy military deployment in the area as part of a disarmament exercise. These and other changes in a strongly traditionalist society have combined to push prevalence closer to the national average of 6.7 percent.

“The drivers of the pandemic that exist elsewhere are now occurring here. There is also a lot of alcoholism and [domestic] abuse here, which is one of the drivers of HIV/AIDS infection,” Dr Michael Omeke, health officer for the Karamoja region’s Moroto District, told IRIN/PlusNews.

Limited Health Services
Just five hospitals serve seven districts and a population of 1.2 million scattered over some 28,000 square kilometres. “In general, HIV treatment and care services are still low in the region,” said David Wakoko, Karamoja area manager for the Mulago-Mbarara Teaching Hospitals’ Joint AIDS Programme (MJAP).

Most health centres in the region do not have clinical officers trained to provide life-prolonging antiretroviral (ARV) drugs or offer HIV care and treatment. Kaabong District for example, has five health facilities, but only the district hospital has a medical officer authorised to treat HIV-positive patients, and the hospital does not have a CD4 machine to test blood samples and measure immune strength.

Few health workers are keen to live in the remote and underdeveloped region. “Human resources are a big challenge. You need someone who is qualified to help these people, but we are not attracting… personnel,” said Dr John Anguzu, District Health Officer in Nakapiripirit. “Even the local people we try to train here to help, they leave.”

The region has also not been spared the drug shortages that have occurred in other parts of the country. “We do experience ARVs stock-outs… We are trying to work with the Ministry of Health and National Medical Stores to see that these stock-outs are reduced,” said Omeke.

A lack of food in the arid region and the long distances to health centres are major problems for people living with HIV. “These are weak people and can’t move long distances to go for treatment and drugs. The health centres are too far,” said Gabriel Lokubal, who lives in Moroto. “ARVs are very strong drugs, which require a lot of eating. However, most of us don’t have food, so some people have stopped going for drugs.”

Knowledge about HIV is also very low. A recently released preliminary report on the AIDS Indicator Survey shows that just 30 percent of women and 45 percent of men in the northeast are well-informed about HIV/AIDS.

A complex region

Spreading the word about HIV is not easy in Karamoja, where open discussions about sex are extremely unusual and the population is largely uneducated. According to MJAP statistics only 35 percent of Karimojong men have accessed HIV/AIDS services, compared to 65 percent of women.

“Because of the nature of the society and tradition, the men remain in the kraals [communal cattle pens] and are on the move in search of pasture and water for their cattle. They have little interest in seeking HIV services,” said MJAP’s Wakoko. “Most of those who access HIV/AIDS services are women, especially the pregnant ones, who visit health facilities for ante-natal services.”

“The HIV patients also tie HIV services to food. If you don’t have food, people don’t come,” Anguzu said in Nakapiripirit.

Stigma is highly problematic for health services trying to reach people living with HIV. “When you test a person and… [the result] is HIV-positive, he or she will never come back again for further… [treatment],” said a nurse at the ARV clinic at Moroto Regional Referral Hospital. “We are trying to sensitize the community to accept their status and learn to live positively.”

In an effort to bring the services closer to the people, Uganda’s Ministry of Health and MJAP are running a home-based HIV counselling and testing programme, but low staffing and occasional insecurity in the region are affecting the door-to-door campaign.

“The security situation remains fluid, as it changes any time despite general improvement in the sub-region, thereby affecting the implementation of programme in most of the catchment areas,” said MJAP’s Wakoko.

Health workers in the region say the nature of the causes and effects of HIV mean it cannot be tackled in isolation, and a holistic approach should be used.

“The interventions need to be shared among sectors – health is concept which is determined by social, economic and cultural aspects,” said Samuel Enginyu, a health educator with the Ministry of Health. “We are working on an integrated and collaborative approach with the Minister of Gender and Culture and other stakeholders.”

[Courtesy of IRIN News]

ETHIOPIA: Still too many deaths in childbirth

 

ADDIS ABABA, 25 April 2012 (IRIN) – A lack of awareness of the importance of skilled hospital deliveries in Ethiopia, cultural beliefs, and transport challenges in rural areas are causing a high number of deaths during childbirth, say officials.

Only 10 percent of deliveries take place within health facilities, according to the Ethiopia’s latest (April) Demographic Health Survey results. Nevertheless, the figure is a significant improvement on 6 percent in the previous 2005 survey.

Commenting on the results, Health Minister Kesetebirhan Admasu said: “About 60 percent of mothers who did not attend health facilities while giving birth do not see the benefit of delivering in health facilities, while the remaining 30 percent abstain from going there by giving culture and beliefs as their reason.

“That [the] majority of women did not appreciate the value of institutional delivery, calls for a concerted effort to educate women and families about the importance of skilled birth attendance and postnatal care.”

Many women prefer delivering at home in the company of known and trusted relatives and friends, where customs and traditions can be observed, according to a 2011 study published in the Ethiopian Journal of Health.

“Even though communities are aware of the dangers around childbirth, contingencies for potential complications are rarely discussed or made, such that most families hope or pray that things will turn out well. When things go wrong precious time is lost in finding resources and manpower to assist in the transfer to a health facility,” the study said.

About 80 percent of all maternal deaths in Ethiopia, are due to haemorrhage, infection, unsafe abortion, hypertensive disorders, and obstructed labour, along with HIV/AIDS and malaria, said a senior Health Ministry maternal health expert, Frewoine Gebrehiwot.

The maternal mortality ratio in Ethiopia is 676 for every 100,000 births. This compares to an average of 290 per 100,000 births in developing countries, and 14 per 100,000 in developed countries, according to the UN World Health Organization.

Besides death, at least 500,000 Ethiopian women and girls who miss out on skilled health care during delivery, end up suffering other complications including obstetric fistula.

Behaviour change needed

The Health Ministry is working on behaviour change through health extension programmes and is providing each of Ethiopia’s550 districts with an ambulance to facilitate transport for pregnant mothers who want to deliver in health facilities free of charge.

But some of the hospitals are lacking in equipment, skills or policy guidance to enable them to provide basic emergency obstetric and newborn care, according to a study by the Health Ministry and its partners, who, using 2008 data, found that only 51 percent of hospitals qualified as offering comprehensive care.

“Most of the health facilities which are far from Addis Ababa are either not fully staffed with skilled service providers or fully equipped with the necessary supplies and equipment that can provide quality services related to complications during pregnancy and childbirth,” said the UN Population Fund (UNFPA).

“Limited human resources, especially midwives, hamper efforts to provide adequate services, especially in rural areas. Gaps in training and remuneration have led to attrition and turnover among public sector health care professionals.”

According to UNFPA, public facilities routinely suffer stockouts and obstetric care equipment shortages due to budget deficits and poor management.

Free services provided at health centres are to blame for the shortages, according to the Health Ministry which hopes a new health insurance scheme, to be piloted in 13 rural districts, will help to provide more funding.

At present, the ministry is seeking to increase the number of women delivering in hospitals by tapping into those seeking antenatal care and providing sustained family planning services at the district level.

“We are particularly trying to decrease mothers’ deaths by retaining the significant numbers of pregnant women who come to receive antenatal care from hospitals but [go] missing [during] delivery,” said Frewoine.

At least 34 percent of pregnant women aged 15-49 receive antenatal care from a skilled health provider such as a doctor, nurse or midwife, but only 10 percent give birth there.

“The same can be said about the high unmet need for family planning in couples and also among young people,” she said, adding that plans are under way to assign two midwives to every health centre in every district in the next three years.

So far, close to 1,630 nurses have been trained as midwives in a one-year accelerated training programme. Their number is expected to reach 4,674 by 2015.

[courtesy of IRIN News]