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Maternal Health
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PHOTO: AMREF HEALTH AFRICA UK, © DEAN BRADSHAW
This is Hellen from a photographic series celebrating Kenyan women as individuals, not victims
Developing antimalarials to make motherhood and childhood safer
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ENDING AIDS “The greatest threat we face is complacency.” Q&A with Michel Sidibe, UNAIDS ONLINE
HEALTH PHONES Educational videos on nutrition, breastfeeding and health via mobile networks in India ONLINE
IOWD and fistula Training Rwandan doctors and nurses to end the need for fistula repairs in Rwanda ONLINE
Stop unnecessary maternal deaths for good
Access to family planning education and skilled maternal staff can help to improve maternal health and wellbeing.
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very day, around 830 women die from preventable causes related to pregnancy and childbirth. 99 per cent of deaths occur in developing countries as a result of severe bleeding after childbirth, infections, high blood pressure during pregnancy, complications from delivery or unsafe abortion. Between 1990 and 2015, deaths of mothers worldwide fell by 44 per cent to 307,000 annually, but so many more could easily be prevented. The new global target is to cut death rates to less than 70 per 100,000 births, with no country having more than twice the global average. But if we’re to reach this goal we must accelerate progress. Follow us
We need much greater investment in family planning, skilled birth attendance and essential maternity care, and to ensure that women in childbirth are treated with dignity and respect. We also have new technologies, which allow even poor communities to monitor the outcomes of pregnancy and to take action when preventable deaths happen. Holding service providers and politicians accountable, and listening to women’s voices, will ensure that their right to the best available health care is met. Two major global strategies are central to worldwide efforts to improve the health of mothers: the 17 Sustainable Development Goals
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Dr Anthony Costello Director, Department of Maternal, Newborn, Child and Adolescent Health (MCA) World Health Organization
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(SDGs) and the global strategy for Every Woman Every Child. The former was adopted by world leaders in 2015 and set out a vision for a world free of poverty, hunger, disease and want. The latter was developed through an extensive consultation process involving governments, civil society, the private sector, UN agencies, and other constituencies. It sets very specific targets to ensure that women, children and adolescents survive and thrive, and that states create enabling environments where all births are registered, women enjoy the right to an education, to clean water, sanitation and energy, and they are free from the threat of domestic or sexual violence.
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Vaccines for Tomorrow Specialist Biotech company, based in Switzerland and the Netherlands, focused on R&D of safe preventative vaccines against human infectious diseases. Unique proprietary virosome technology platform combined with leading viral membrane protein know-how and expertise to develop safe and effective life improving vaccines. Vaccine Pipeline: • Clinical Stage: HIV, intra-nasal Influenza, Malaria • Pre-clinical: RSV • Discovery: Chikungunya Since May 2015 Mymetics is leading a EU consortium to develop thermostable and cold-chain independent virosome technology based vaccines (project Maciviva). More info under www.maciviva.eu. Project funded by EU Horizon 2020 research and innovation program and by the Swiss Secretariat for Education, Research and Innovation (SERI).
Mymetics BV: Leiden, The Netherlands - Tel. +31 71 332 2130 Mymetics Intl.: Epalinges, Switzerland - Tel. +41 21 653 4535 www.mymetics.com
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PHOTO: UNAIDS
Breastfeeding: Tackling the myths Over the last decade, the benefits of exclusive breastfeeding have been advocated across global and national policy and health platforms as being key to the baby and mother’s health.
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t has been scientifically proven that breast milk has antimicrobial factors, which give increased passive and long-lasting immunity to newborns. Breastfeeding is also beneficial for the mother, where it has been shown to decrease the risk of postpartum haemorrhage and various cancers. Research shows that breastfeeding could also save 800,000 lives annually1 and impact majorly on the lives of children under six months. This is because most child deaths in the developing world – occurring as a result of drinking contaminated water or not receiving sufficient nutrients for the body to fight disease and infections during this period – can be prevented by exclusively breastfeeding. Although many understand the benefits of breastfeeding and appreciate its demographic dividend, some mothers do not exclusively breastfeed because they are either not adequately informed about the benefits of breastmilk, are not supported on how to breastfeed appropriately or are burdened by misconceptions around breastfeeding. In Nigeria, 98 per cent of new mothers initiate breastfeeding, however by six months only 25 per cent of them are still exclusively breastfeeding2.
Why do some women choose not to breastfeed? The reasons why mothers stop breastfeeding are complex and vary. However, many misconceptions and misinformation have led mothers to discontinue or not even try breast-
Her Excellency Toyin Ojora Saraki, Founder, and President, the Wellbeing Foundation Africa
feeding. Misconceptions, ranging from the need to give water with breast milk, to a belief that long term breastfeeding will lead to sagging breasts, are the bane of poor breastfeeding practises in some societies. In some cases, the use of infant formula is a sign of high status. Some mothers with special cases, like those infected with HIV/AIDS, have been misinformed they will infect their child if they breastfeed.
Antenatal and postnatal education needed Most of these misconceptions and misinformation can be tackled by providing mothers with adequate information and support through antenatal and postnatal care and education. Here mothers will get accurate and up-to-date information, not just about their bodies and their newborns, but also about the immediate and lifelong benefits of early initiation and exclusively breastfeeding. As the Head of Midwifery Programmes at the Wellbeing Foundation Africa, with over 30 years’
experience both in the UK and Nigeria, Mrs Felicity Ukoko, briefly addressed misconceptions and misinformation about breastfeeding. Speaking about the natural changes that occur in a pregnant woman, she said: “It is indeed true that breast shape changes. This is not due to breastfeeding, but due to the changes that occur during pregnancy as they are filled with milk in preparation for lactation”. She then advised on the need for a supportive bra, exercise and good breastfeeding posture to prevent the breasts from sagging in future.”
Mothers with HIV/AIDS and breastfeeding Regarding the special cases of mothers living with HIV/AIDS and working mothers, Felicity explained that there is now large a body of evidence on HIV and infant feeding, which shows that giving antiretroviral drugs (ARVs) to either the HIVinfected mother or HIV-exposed infant can significantly reduce the risk of transmitting HIV through breastmilk. The World Health Organization recommends exclusive breastfeeding for 6 months and giving antiretroviral drugs to infected mothers and their infants3. Continuing her explanation on issues facing mothers whilst breastfeeding, she stated that mothers returning to work after a short maternity leave, may need to make use of breast pumps to express breast milk, rather than giving infant formula. “Mothers who wish to continue to provide their babies with breast milk after returning to work should have
access to breast pumps and accessories. Once breastfeeding is established, expressed breast milk is much better for the baby than formula.” A very common problem that new mothers face is the discomfort and pain of breastfeeding, which usually comes from cracked nipples. “Midwives and health professionals need to educate expectant mothers at antenatal care about how to properly position their newborn to breastfeed and to support lactating mothers who may have challenges.
Moving forward This year, to mark The World Breastfeeding Week, from August 1st to 7th nationally and globally, it is important for midwives and other health workers to make deliberate efforts to address every breastfeeding misconception and all misinformation. Educating mothers about the ways to breastfeed and answering their questions during antenatal classes or clinic visits will alleviate the guilt and shame many new mothers feel when they cannot breastfeed successfully. To increase the rates of breastfeeding and the health of the newborns, we need to promote, protect and support mothers equally and respectfully. http://www.who.int/maternal_child_adolescent/news_events/news/2016/exclusive-breastfeeding/en/
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http://www.nigerianstat.gov.ng/nada/index.php/catalog/54/overview
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http://www.who.int/maternal_child_adolescent/documents/hiv-infant-feeding-2016/en/
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A new mother in the maternity ward at Apac Hospital, Northern Uganda.
Mothers and children first: Rethinking malaria drug development The usual process of ‘adult-first’ drug development is being turned upside down in the fight against malaria; children are first in line for new treatment. By Kate Sharma
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he reason is clear; mothers and children need to be accounted for from the very beginning. Under-fives accounted for 70 per cent of malaria deaths worldwide in 2015, according to World Health Organization (WHO). In addition, more than 10,000 maternal and 200,000 neonatal deaths per year occur as a result of malaria.
Preventive therapy Intermittent preventive treatment in pregnancy (IPTp), a simple oral treatment taken at least three times during pregnancy, could safeguard women. However, “despite its low cost and high effectiveness, just 31 per cent of pregnant women who would benefit are taking the full course,” explains Dr David Reddy, CEO of Medicines for Malaria Venture (MMV). While efforts to scale up IPTp remain slow, the distribution of seasonal malaria chemoprevention (SMC) to children is gathering momentum in Africa. SMC is being given to children in the Sahel region of Africa during the three to four months when malaria transmission is at its
Knowledge is power
Dr. David Reddy CEO, Medicines for Malaria Venture (MMV)
George Jagoe Head of Access and Delivery, Medicines for Malaria Venture (MMV)
highest. “It’s a brilliant method that has been demonstrated to prevent up to 75 per cent of malaria episodes” explains George Jagoe, Head of Access at MMV.
only then do you start to develop formulations for children. For malaria, we have to turn the process on its head,” continues Dr Reddy. “From the moment we think we have a viable malaria medicine candidate, we consider whether it can be optimally formulated and developed for use in paediatric populations. And we not only consider efficacy, but also the tolerability and acceptability of these medicines by children. By working to reduce the dosing burden (e.g. through singledose malaria cures and flavourmasked medicines), we strive to make these medicines easier for children to take.”
Children first Alongside more effective use of current treatments, no one denies the need for new paediatric drugs, especially in the light of anti-microbial resistance, but there are additional practical and ethical factors that need to be considered. “In normal drug development, you begin by developing a drug for adults and after evaluating risks/benefits in this population on a large scale,
When it comes to drugs for pregnant women, there are still huge gaps in knowledge, given the complexities of evaluating the safety of medicines for use during pregnancy. WHO recommends artemisinin-based combination therapies for the treatment of malaria during the second and third trimesters of pregnancy, but little is known about their safety and tolerability during the first trimester. By working with in-country partners who routinely treat large patient populations, MMV supports the establishment of pregnancy registries that help capture data to assess the safety outcomes of women treated during pregnancy. MMV recognises that, for its medicines to have impact, drug development alone is not sufficient. Policy change, advocacy, and patient/provider education all contribute to accelerating the impact of malaria medicines. With that in mind, MMV has been a proud participant in the WHO-led call to action to increase the use of IPTp throughout malaria endemic countries in Africa. Read the full Q&A on globalhealthaction.co.uk
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Each year, 303,000 women worldwide die because of complications during pregnancy or childbirth.
A safe and joyous pregnancy is every woman’s right
UN Member States have pledged to drastically reduce maternal deaths before 2030 — an ambitious target, but one that can be met, says a leading figure in the fight for reproductive health and rights. By Tony Greenway
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ecoming a mother should be a moment of joy for every woman, no matter where she lives, says Dr. Natalia Kanem. Yet, incredibly — and unacceptably — 303,000 women worldwide still die each year of complications of pregnancy or childbirth. Indeed, it’s the leading cause of death for young women aged 15 - 19. “For the most part, these deaths are due to preventable or treatable causes,” says Kanem, Acting Executive Director of UNFPA, the United Nations Population Fund, the UN Agency that promotes and supports reproductive health. “In parts of Africa, a woman has a 100 times greater life-time risk of dying in pregnancy and childbirth than someone in an industrialised country.” And for every woman who dies, around 20 or 30 others suffer disease, infection or injury because of their condition. For example, Carleta Francisco, 21, from Mozambique, had been suffering from the effects of fistula, a hole in the birth canal caused by
prolonged, obstructed labour. Carleta’s baby was delivered stillborn, but Carleta survived. The condition caused her chronic pain and incontinence, hurt her ability to walk and meant she was stigmatised by her community. Fortunately, Carleta’s fistula was finally repaired, thanks to UNFPA funding to Mozambique’s Ministry of Health.
A positive change There have been dramatic improvements in maternal health over the last 10 - 15 years, for several reasons. “Midwives are specialists in antenatal care who work at the community level and can recognise danger signs, to help manage and refer complications in pregnancy,” says Kanem. “We have greatly strengthened health systems by improving the professional training of midwives and deploying them in hard-to-reach areas.” One innovative training tool is the Portable Mobile Learning System, supported by UNFPA with a grant from Denmark. The system is being used to train health workers – particularly midwives – in remote rural areas so
family planning to women aged 15-19, would lead to 700,000 fewer miscarriages and 5,600 fewer maternal deaths a year.
Maternal health targets
Dr. Natalia Kanem Acting Executive Director, the United Nations Population Fund (UNFPA)
that they can then use these lifesaving skills to reach marginalised populations with quality maternal and newborn health services. Empowering women and girls to understand the dangers of too early a pregnancy, female genital mutilation and child marriage is also vital, as is giving them access to family planning. “There’s a strong correlation between giving women a choice over how frequently they want to get pregnant, how many children they want to have and safe childbirth,” says Kanem. Figures from UNFPA show that giving access to voluntary
In the year 2000, all the then 189 UN Member States signed up to eight Millennium Development Goals (MDGs) — quantified targets for tackling extreme poverty, which they aimed to achieve by 2015. One of these was to improve maternal health. Sadly, only nine countries managed to reduce their maternal death ratio by three-quarters, which is why the Member States have now created a Sustainable Development Agenda, with goals that include a commitment to ending all preventable newborn and child deaths and reducing the global maternal death ratio to less than 70 per 100,000 live births by 2030. There is still more to do, admits Kanem; but she is optimistic that, this time, the targets can and will be achieved. “The glass is half full,” she says, highlighting the advances that have already been made. “We can end preventable maternal deaths.”
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Nana Taona Kuo Senior Manager, Every Woman Every Child Team, Executive Office of the UN Secretary-General
We must reach women in marginalised communities to empower them
A global plan for mothers, babies and HIV “A huge project with incredible ambition” By Tony Greenway
countries were stigmatised, discriminated against and could not go back to their husbands or families to talk about their circumstances. And they knew they could have a baby born with HIV.”
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he global community has achieved considerable progress for women’s and children’s health in recent years. From 1990 to 2015, the number of children surviving childhood has increased considerably. Maternal deaths have been cut by half. Yet, gains remain partial and fragile. In 2015, an estimated 303,000 women died from preventable causes during pregnancy and childbirth and an estimated 5.9 million children died before their fifth birthday, mainly of avoidable causes. The Every Woman Every Child movement has been instrumental for success, reaching an estimated 273 million women, children and adolescents with life-saving and lifechanging services and supplies in the past two years alone. However, if we are serious about achieving globally agreed goals, equity must underpin all efforts, reaching marginalised and overlooked communities, and ensuring that they are counted and heard. We must focus on structural determinants and the conditions in which people are born, grow, live, work and age. This includes socioeconomic status, gender equality, education, the environment, access to quality health care and other services. As we address health and wellbeing, we must think about needs across the life span: women beyond childbearing age, children from before conception and through early years, and adolescents from one of the richest periods of their lives well into adulthood. This also means empowering women, children and adolescents so they can meaningfully engage with and inform policies and programmes that affect them. More than ever, we need concerted action across sectors to ensure that women, children and adolescents survive and thrive to help transform the world. Read the full EWEC report on globalhealthaction.co.uk
Michel Sidibé Executive Director, UNAIDS The global community has proved that, when it comes together to end AIDS, it can make a big difference, giving a better future to pregnant women and their babies.
Sometimes, says Michel Sidibé, it’s important to stand back and reflect on what has been achieved in the response to HIV, especially in Africa, and especially regarding pregnant women and their babies. “Fifteen years ago, AIDS was a death sentence for many, many people in Africa,” he says. “I remember hospital rooms full of people dying of AIDS. Back then, less than 30,000 people in Africa had access to treatment. People had no way of protecting themselves from HIV and people living with the virus had no way of keeping themselves healthy.” Sidibé, the Executive Director of UNAIDS — the Joint United Nations Programme on HIV/ AIDS — was stunned by the injustice of it all. “Mothers with HIV in some African
Global collaboration for fewer HIVinfected babies In 2011, world leaders launched a Global Plan for 22 high priority countries, 21 of which were in sub-Saharan Africa, towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. This was a huge project with incredible ambition, admits Sidibé; but it helped drive a 60 per cent reduction in new HIV infections among children, averted 1.2 million new infections among children and almost halved the number of AIDS-related deaths among women of reproductive age in 21 priority countries in Africa from 2009 to 2015. “This would never have been possible without the global community coming together,” says Sidibé. “It included the private sector, organisations, politicians, women’s groups and the religious community.”
Testing is vital in preventing motherto-baby transmission Yet, plainly, more needs to be done. In 2015, 110,000 children were newly infected with HIV in the 21 countries targeted by the Global Plan, and 150,000 worldwide. So
in 2016, UNAIDS and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) launched Start Free, Stay Free, AIDS Free, a fast-track framework to end AIDS in children, adolescents and young women by 2020. HIV testing is vital so that people with the virus can get access to antiretroviral treatment as quickly as possible (globally, by 2015, some 77 per cent of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission of HIV to their babies). A recent UNAIDS report noted that ‘the gold standard’ for pregnant women is being aware of their HIV status (and on treatment if they are living with HIV) before conceiving, a test at their first antenatal visit, repeat testing in their third trimester and again during the breastfeeding period. “We know that 50 per cent of babies who become HIV positive — but who were born free of HIV — become infected during the breastfeeding period,” says Sidibé. “This is something we need to systematically promote; because by early testing and early treatment we can suppress the activity of the virus in the body — and stop transmission.”
Read the full Q&A on globalhealthaction.co.uk
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We’ve come a long way since 2011, with a 48 per cent decline in motherto-child transmission1 but availability of services to ensure babies are born HIV free is still insufficient in communities across Africa.
At the end of a long, muddy road, Florence finally arrives at the community health facility, made up of a couple of run-down, single story buildings in rural Uganda. After the long journey, Florence discovers the facility is stocked-out of the antiretroviral therapy (ART) drugs she has come to collect. She is HIV positive and needs her medicine to stay healthy. The staff encourages her to come back the following week when they hope her drugs will be available, while in truth they are resigned to the knowledge that they will likely not see Florence again. The prospect of making another long and expensive roundtrip with her baby and potential stock-out of her drugs, make another visit to the clinic highly unlikely. Florence, like many women living with HIV in Africa, adhered to her ART through her pregnancy and made sure she gave birth at the clinic with a skilled attendant, despite the cost of getting to the clinic. As a result, her son was born HIV negative, like millions of other babies whose mothers have been part of prevention of motherto-child transmission (PMTCT) programmes. The attendants, who helped ensure a safe delivery, as well as the mentor mother counsellors supporting her, encourage Florence to come back for her treatment and to continue being adherent to drugs while breastfeeding to ensure her baby is well nourished and remains HIV free and healthy. From experience, these attendants know that interrupting treatment will increase the child’s risk of becoming infected through breastfeeding. Five kilometres away in Iganga
Town, a different story is unfolding. Joy takes a bus from her village and arrives opposite a newly refurbished district health centre. The atmosphere and staff here are brimming with optimism as they attend to patients. Joy joins the other women waiting for their appointments, some chatting with one another, others quietly waiting. At this facility, the nurses report that mothers are coming back to get their ART whilst breastfeeding, and testing has indicated that there have been no perinatal infections in the past year. These are two clinics separated by a few kilometres, yet the different experiences accessing health services could have dramatic consequences for Florence and Joy and their children.
“Mother-to-child infections are entirely avoidable” Support groups can help In the UNAIDS Global Plan published in 2011, one major global priority was to ‘reduce the number of new infection rates among children by 90 per cent’ by 2015. Globally, since 2011, there has been a 48 per cent decline in the number of new infections. While this falls short of the 90 per cent target, real progress has been achieved. PMTCT programmes have reduced the mother-to-child transmission rate to just 14 per cent globally. Only five per cent of this transmission is in utero or during child birth, with nine per cent transmission occurring during breastfeeding1. Breastfeeding is one of the most effective ways to improve child survival, but barriers that prevent adherence to ART, including distance of getting to clinic or ART stock-outs, increase the chances that a child can become infected through breast milk. “Mother-to-child transmission is entirely avoidable if we can ensure
PHOTO: iSTOCK
The final hurdle? Ending motherto-child transmission of HIV
HIV positive mothers must take antiretrooviral medication while pregnant and breastfeeding to avoid infecting their baby, but these are not always available.
that health systems, supply chains and transport support daily, lifelong availability and adherence to treatment”, says Natalie Africa Senior Director for Private Sector Engagement for Every Woman Every Child. Local communities, such as the one in Iganga, are currently stepping in to fill the gaps, providing referral mechanisms and working with clinics to keep women and their children in care. “We have seen community groups – such as Protecting Women and Children against Violence – do incredible work connecting people to clinics and thereby reducing mother-tochild transmission. This needs to be replicated in communities across the continent and for that to be sustained we need concerted focus on building on our successes and finishing the job,” says Dominic Kemps, Director of the Positive Action for Children Fund at ViiV Healthcare.
Mothers must continue ART during breastfeeding The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has long been championing PMTCT programmes and recognises first-hand the importance that ART adherence for breastfeeding mothers has on a child’s overall health and survival. Over 60 per cent of new infections happen during the breastfeeding period, all of which can be
prevented1. HIV progresses very rapidly in children, with the highest mortality between two and three months of age, yet only 50 per cent of this age group is tested, only half of those receive results, and even fewer are linked to treatment. Chip Lyons, President and CEO of EGPAF notes: “Scaling up diagnosis of HIV for infants – and ensuring rapid test results and treatment initiation – is a matter of life and death for this most vulnerable group. But we can’t stop there. Repeat testing of HIV-exposed infants, particularly at the end of breastfeeding, must continue to receive more attention”. EGPAF, Every Woman Every Child and Positive Action are currently collaborating on a Challenge Prize to identify the challenges associated with this last hurdle in ending mother-to-child transmission. The prize seeks to find innovative solutions to support women like Florence and Joy so they remain healthy and their children HIV free. 1
UNAIDS 2015. 2015 Progress report on the Global plan.
* Florence and Joy’s names have been changed for anonymity, but their experiences are common at facilities supported by Positive Action for Children Fund partner, Protecting Women and Children Against Violence in Iganga about 120kms east of Kampala.
More details available at positiveaction challenges.com
Individuals, not victims Our cover features Hellen, a 31 year old seamstress living in Elelea in Turkana, the poorest and most remote county in Kenya, where more than 80 per cent of the population live below the poverty line. Malnutrition is a huge problem in the region. Local women have helped to drive projects such as trialling sustainable community farms. These farms enable women’s groups to grow vegetables to feed their families and sell surplus produce to create a regular income. Education around maternal health is being prioritised to help women to make decisions about when or whether to get pregnant, and this income source provides a means to look after themselves and their young children, giving them independence, purpose and opportunity. Hellen says, “The lifestyle is changing in this community for the better. We now know about the importance of business, water, education and hospitals.” This photo is part of a series portraying women across Kenya as they wish to be seen: as individuals, not victims.
PHOTO: AMREF HEALTH AFRICA UK, © DEAN BRADSHAW
See the complete photographic series and full story online at globalhealthaction.co.uk