pregnancy

{Photo credit: Todd Shapera}Photo credit: Todd Shapera

In the Geita District in Tanzania’s Lake Zone, some 10 kilometers from the nearest health facility, a one-year-old girl child wakes up crying with a severe fever. “We used to walk more than 10 kilometers to present our sick children to Geita Regional Hospital,” says Joyce Bahati, the girl’s mother.

Access to proper diagnosis and medicine is critical when a child develops a severe fever. A long journey can delay treatment, or for some, discourage seeking care altogether. In rural sub-Saharan Africa, where the nearest fully-functional health facility may be, at best, a three-hour journey on foot, women and children often turn first to community-based caregivers and medicines sellers or small health dispensaries as first providers of primary health care, including severe fever.

World Malaria Day 2013 {Photo credit: UNHCR/S. Hoibak.}Photo credit: UNHCR/S. Hoibak.

To me, malaria is a very personal disease.

I first came face to face with malaria during the war of my time: Vietnam. I was plucked out of residency after my first year, with only an internship under my belt, and sent as a Navy Medical Officer to war. Medical school and residency prepared me well for much of the trauma I encountered medically, but I was totally unprepared for the large-scale emotional trauma, and for the tropical diseases I had encountered only in books.

I was overwhelmed by the young children with malaria, some of whom literally died in my arms while treating them.  Yet, I also witnessed bona fide miracles: children at death’s door, comatose and unresponsive, who responded dramatically to treatments, and ultimately went home to their families.

To address malaria, I focused on promoting prevention (long-lasting insecticidal nets [LLINS] for families and intermittent preventive treatment [IPT] for pregnant women), early detection, and early treatment in the community—what is now called community case management.

That was 40 years ago.

When I worked in Smallpox eradication in the mid-1970s, I traveled all over northern India and Bangladesh. I never took malaria prophylaxis, because malaria had been cleared from those areas. Likewise, I did not take malaria prophylaxis when I worked in the Brazilian Amazon in the late-1970s. At that time, malaria was found only in gold miners in isolated tributaries of the Amazon. Now, due to our financial inability to continue high levels of malaria eradication activities worldwide in that time period, emergence of both anti-malarial and insecticide resistance, and spread of the mosquito vectors, all of these are heavily malaria endemic areas with a high mortality rate for pregnant women and children.

The World Health Organization (WHO) recently released the World Malaria Report 2012, summarizing 2011 data from 104 malaria-endemic countries and citing progress and challenges toward the eradication of malaria.

A woman receiving antenatal care in South Sudan. {Photo credit: J. Warren/Save the Children.}Photo credit: J. Warren/Save the Children.

On a dark August night in rural South Sudan, Linda Kenneth felt the swift kick of labor pains begin. Having previously delivered five children, Linda recognized the pains and immediately called for the nearby skilled birth attendant, as it was too late in the evening for her to travel safely to the health facility. In her previous two pregnancies, she had experienced heavy bleeding after delivering, and worried similar complications might arise this time.

South Sudan has the world’s worst maternal mortality ratio (2,054 deaths per 100,000 live births), and roughly one third of these deaths can be attributed to postpartum hemorrhage (PPH). Administration of misoprostol or another uterotonic (a drug that reduces bleeding after childbirth) could prevent the majority of these deaths. Misoprostol does not require a cold supply chain, and is cheap and effective, making it a perfect candidate for community-based interventions.

Upon the birth attendant’s arrival, Linda presented the three misoprostol pills she had recently been given by a home health promoter. Several days prior, a home health promoter had visited Linda and discussed with her a birth preparedness plan, informing her of the benefits of taking misoprostol immediately after delivery to prevent excessive bleeding.

Nehema Bubake, seen recovering here at the Kaziba General Reference Hospital, is full of optimism now that her fistula has been repaired. {Photo credit: MSH.}Photo credit: MSH.

In the Democratic Republic of Congo, many women suffer complications during pregnancy and delivery, including obstetric fistula. Prolonged labor may result in a hole (“fistula”) between a woman’s birth canal and bladder or lower intestine, resulting in chronic leaking of urine or feces. This, in turn, leads to social isolation as the women can’t keep themselves clean, are ashamed of their condition, and withdraw from society. Many women and their families believe that this condition is due to a curse, leading to further separation from the community.

Doreen Nalweyiso happily holding her twins. {Photo credit: T. Athura/MSH.}Photo credit: T. Athura/MSH.

In July 2011, Doreen Nalweyiso, a 27-year-old woman living in Mpigi Town Council, Uganda attended her second antenatal visit at Mpigi Health Centre IV. She was surprised to be examined with an ultrasound machine--and even more shocked to be told that she was expecting twins!

“I was thrilled when the nurse showed me images of twins through the ultrasound TV scan. I had never experienced it in my lifetime,” she explained.

This was her first pregnancy and there was no history of twins in her family. Because carrying multiple fetuses can cause complications for both the mother and babies, Doreen received support from the health center throughout her pregnancy.

Since she knew her delivery could be complicated, Doreen traveled to Mpigi health facility to deliver by caesarian section.

If she hadn’t known she was carrying twins, Doreen might not have known to seek out specialized medical care during labor and delivery.

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