Fistula In Sub-saharan Africa

We  read the recent report by Mathieu Maheu-Giroux and colleagues (May, 2015) of a meta-analysis of Demographic and Health Survey data on fistula prevalence in sub-Saharan Africa. This study can only provide an estimate of urinary incontinence symptoms, and since there was no confirmation of fistula diagnosis, the data cannot be used to represent fistula prevalence. Indeed, Maheu-Giroux and colleagues report that women with fistula are older and of greater parity than women without fistula. This finding should have alerted them to an obvious error in the data because women classically experience fistula during their first delivery (at a young age) and frequently have no further pregnancies, whereas women with other causes of incontinence, such as uterine prolapse and stress incontinence, are older and multigravid.

Moreover, the data on Ethiopia’s fistula prevalence are in profound contrast to our experience and the results of two studies we have recently undertaken in Ethiopia, both of which are currently being considered for publication. The first is a community-based study of 23 023 women surveyed for fistula and uterine prolapse, with suspected fistula cases being followed up for diagnostic confirmation. The second is of surgical fistula treatment in three Ethiopian fistula hospitals, where around 70% of the country’s treatments are provided. Both studies reveal a significant decline in fistula prevalence and illustrate that Ethiopia is far from having “deficiencies in national treatment planning”, and it has been successful in improving maternal health care and delivering an effective patient identification programme and high-quality fistula.


  1. Maheu-Giroux, M, Fillipi, V, Samadoulougou, S et al. Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data. Lancet Glob Health. 2015; 3: e271–e278
  2. Ahmed, S and Tuncalp, O. Burden of obstetric fistula: from measurement to action. Lancet Glob Health. 2015; 3: e243
  3. THE LANCET Global World, fistula in sub-saharan Africa,vol. 3, no_8, e441, August 2015

Saving Lives Through Breastfeeding: Kenya

What helps save the lives of about 800,000 babies every year and doesn’t cost a dime? Breastfeeding.

Of all preventive health interventions, breastfeeding—done within the first hour of life, exclusively for the first six months, and until age two—has the greatest potential impact on child survival, with the ability to avert 13% of deaths in children under five in the developing world (Lancet 2013).

midwife mother weigh scale breastfeed smile mom baby woman child kenya


In Kenya, national rates of exclusive breastfeeding in the first six months of life have increased dramatically — from 32% in 2008/09 to 61% in 2014 (KDHS 2008/09 and KDHS 2014, preliminary results). With this in mind, USAID’s flagship Maternal and Child Survival Program(MCSP) is working closely with the Ministry of Health in Kenya to scale-up the Baby-Friendly Community Initiative (BFCI). Our efforts include comprehensive support to mothers at the community level to improve maternal, infant and young child health and nutrition – with an emphasis on initiation and exclusive breastfeeding in the first six months.

To have impact, we know we must work closely with communities to understand and address their unique needs and challenges to support timely initiation and to ensure women breastfeed for the full duration of six months. MCSP involves key community influencers—fathers, grandmothers, mother-in-laws and local leaders—in this process, while we build capacity of health care workers and community health volunteers to deliver services at the health facility and community levels. This includes the provision of information and support to mothers for optimal breastfeeding, complementary feeding, and maternal nutrition practices.

kenya mother women support group breastfeed male involvement community health worker


BFCI is a new concept in Kenya that was field-tested under USAID’s predecessor Maternal and Child Health Integrated Program (MCHIP) in Kenya’s Bondo and Igembe North Constituencies and showed marked improvements in maternal, infant and young child nutrition indicators. An assessment conducted of two groups of mothers—those who did and did not attend BFCI support groups—revealed greatly improved breastfeedng practices among the former group.

  • Mothers who attended support groups were more likely to attend more than three antenatal care visits (63% vs 38%) and to deliver in health facilities (86% vs. 51%), than non-attenders.
  • Those who were actively involved in support groups improved their knowledge of both initiation of breastfeeding within the first hour after birth and non-use of prelacteal feeds, and noted being better equipped to resolve any breastfeeding problems in comparison with non-attenders.
  • Most non-attenders had a shorter duration of exclusive breastfeeding and tended to introduce complementary foods early, prior to six months of age.

These efforts are part of MCSP’s larger scope of work in Kenya to build on the strong technical platforms established under MCHIP, while strengthening the health systems that deliver these lifesaving interventions to women and families

Please take a moment to check out these related links of interest:

This post originally appeared on the blog of the Maternal and Child Survival Program and has been lightly edited.

Malaria in pregnancy: challenges for control and the need for urgent action

Malaria in pregnancy has a devastating effect on the health of mothers and their babies, and is an important cause of maternal and infant mortality and morbidity.1 The greatest effect of malaria in pregnancy is concentrated in sub-Saharan Africa and is associated with Plasmodium falciparum infection. However, pregnant women are also at risk of Plasmodium vivax malaria. Although its burden seems to be lower than that of P falciparum, P vivax malaria is still associated with harmful consequences for maternal and infant health.

WHO promotes three strategies for the control of P falciparum infection in pregnancy in Africa, which include provision of intermittent preventive treatment for malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), use of insecticide-treated nets (ITNs), and prompt diagnosis and treatment of confirmed infections. Unlike in stable transmission areas, no global recommendations currently exist for the prevention of malaria in pregnancy in low-transmission areas or those P vivaxpredominates.

In 2000, under the Roll Back Malaria Partnership, Abuja targets were set for at least 60% of pregnant women who are at risk of malaria to have access to antimalarial chemoprophylaxis or IPTp-SP by 2005, and at least 80% use of ITNs by 2010.3 These targets were subsequently reset with even more ambition to 100% use of both interventions by 2015. However, coverage estimates for IPTp-SP and long-lasting ITNs in the sub-Saharan region have increased only modestly in past years, reaching about 21% coverage for two doses of IPTp-SP and 41% for ITNs on average in 2010.4 Problems with the delivery of control interventions for malaria in pregnancy are linked to weaknesses within the health system, such as insufficient resources, inadequate or poorly trained staff, and ineffective procurement and supply chain management of SP and ITNs. In 2012, WHO updated its policy for IPTp-SP, recommending an increase in the number of doses of SP to be administered at each scheduled antenatal care visit, starting as early as possible in the second trimester. Countries currently face many obstacles in the scale-up of the provision of IPTp-SP, including inconsistencies between the WHO guidelines and national policies, which have increased the number of missed opportunities for control of malaria in pregnancy.

Accordingly, the main challenge for reducing the burden of malaria in pregnancy in Africa is related to the adoption of national policies that incorporate WHO guidance, and effective implementation and scaling-up of programmes. Health systems need to be strengthened to successfully provide interventions for the prevention and treatment of malaria in pregnancy as part of the platform for antenatal care. Innovative approaches to increase demand must be explored so more women can be reached and earlier in pregnancy. Harmonisation of policies between malaria control and reproductive, maternal, newborn, and child health programmes is urgently needed and will be crucial to meet global targets. Together, these programmes must address both supply and demand challenges and derive clear lessons from assessment of new approaches to the delivery of preventive strategies, such as maximisation of coverage through community-directed interventions delivered by community health workers.

Challenges for effective prevention of malaria in pregnancy are increased in pregnant women living with HIV, especially in view of the fact that IPTp-SP is contraindicated for HIV-infected pregnant women receiving cotrimoxazole prophylaxis to prevent opportunistic infections. This has several implications for health systems: first, it tends to create confusion among front-line health workers, sometimes leading to both drugs being given and, second, because of frequent stock-outs of HIV screening tests, women often do not receive any preventive drugs. Additionally, suitable approaches for the prevention of malaria infection in the first trimester of gestation, for both pregnant women living with HIV and those not infected, have yet to be identified. None of the currently recommended antimalarial drugs can be given in this critical period because of safety risks for the embryoThus, malaria protection in the first trimester relies mostly on vector control measures, mainly ITNs that are usually provided later in pregnancy.

Research priorities should include the assessment of innovative programming to address the low uptake of preventive interventions for malaria in pregnancy; ensuring effective protection in particularly susceptible groups such as HIV-infected pregnant women; improving of malaria control in the first trimester of gestation; and evaluation of alternative antimalarials to replace SP because of increasing resistance to this antimalarial drug. Research is also needed with respect to the malaria elimination agenda, including identification of the most suitable strategies for control of malaria in pregnancy and for radical cure of P vivax and P falciparum infections in low-transmission settings that are on track towards malaria elimination.

Targets for malaria control in pregnancy are far from being reached, despite global gains in malaria investment during the past decade, which have resulted in substantial overall reductions in deaths from malaria and the existence of highly cost-effective tools for malaria in pregnancy that have potential to save many maternal and neonatal lives. The challenges for effective control of malaria in pregnancy need a multidisciplinary approach that includes the coordination and integration of programmes for malaria and maternal and reproductive health, increased provision of resources to provide the best antenatal care, and investigation of the role of new and innovative delivery approaches to maximise coverage of interventions to prevent malaria. To have an immediate effect, a global call to action is urgently needed to increase national coverage and protect mothers and babies from the devastating consequences of malaria in pregnancy.


  1. Desai M, ter Kuile FO, Nosten F, et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis 7: 93–104.
  2. Rodriguez-Morales, AJ, Sanchez, E, Vargas, M et al. Pregnancy outcomes associated with Plasmodium vivax malaria in northeastern Venezuela. Am J Trop Med Hyg. 2006; 74: 755–757
  3. African Heads of State and Government. The African Summit on Roll Back Malaria, Abuja, 25 April 2000: The Abuja declaration on roll back malaria in Africa. World Health Organization, Geneva; 2000
  4. van Eijk, AM, Hill, J, Larsen, DA et al. Coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-Saharan Africa: a synthesis and meta-analysis of national survey data, 2009–11. Lancet Infect Dis. 2013; 13: 1029–1042
  5. WHO. Updated WHO policy recommendation: intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). World Health Organization, Geneva; 2012
  6. WHO. WHO expert consultation on cotrimoxazole prophylaxis in HIV infection. World Health Organization, Geneva; 2005
  7. WHO. Guidelines for the treatment of malaria. 2nd edn. World Health Organization, Geneva; 2010
  8. Mockenhaupt, FP, Bedu-Addo, G, Eggelte, TA et al. Rapid increase in the prevalence of sulfadoxine-pyrimethamine resistance among Plasmodium falciparum isolated from pregnant women in Ghana. J Infect Dis. 2008; 198: 1545–1549
  9. Iriemenam, NC, Shah, M, Gatei, W et al. Temporal trends of sulphadoxine-pyrimethamine (SP) drug-resistance molecular markers in Plasmodium falciparum parasites from pregnant women in western Kenya. Malar J. 2012; 11: 134
  10. THE LANCET Global Health, Malaria In Pregnancy: challenges for control and a need for urgent action, vol.3, no_8,e433-434, August 2015

The economic and social impacts of maternal death

By Tezeta Tulloch, Communications Manager at the FXB Center for Health and Human Rights at Harvard University

What happens when a mother dies? In the West, the most ready and obvious answer is grief – the harrowing emotional and psychological toll of losing a loved one. A mother’s death is largely viewed as a private tragedy that will grow more manageable in time.

But in many developing countries, a mother’s death is much more than an emotional crisis, often leading to long-term social and economic breakdown, both for her immediate family and the wider community. This topic is explored in new depth, in a special issue launched today in Reproductive Health (an open-access journal).

“The True Cost of Maternal Death: Individual Tragedy Impacts Family, Community and Nations” focuses exclusively on the immediate and longer-term effects of maternal death on surviving children, households, and communities. It features seven studies, with data drawn from four African countries – Ethiopia, Kenya, Malawi, and South Africa.

The research was conducted by two research groups, one led by Harvard’s FXB Center for Health and Human Rights, and the other a consortium made up of Family Care International, the International Center for Research on Women, and the Kenya Medical Research Institute (KEMRI)-CDC Research and Public Health Collaboration. The results provide hard evidence that a mother’s loss can devastate the livelihoods, quality of life, and survival chances of those she leaves behind.

Long-term consequences

When a mother dies or is disabled from causes related to pregnancy and childbirth, the consequences are interlinked, intergenerational, and extensive.

Financial instability was one of the key issues identified. Mothers are not only caregivers at home, but contribute substantially to household income. The loss of that income can severely undermine a family’s ability to access basic necessities, such as food, shelter and health care. Funeral costs alone can ruin a household’s economy.

In addition, loss of education was also a problem, with older surviving children more likely to leave school. For many girls, the only viable options that remained were early marriage and early motherhood. Both school dropout and early marriage tend to renew the cycle of poverty for the next generation.

There was also increased mortality among children whose mothers had died. The research found that newborns whose mothers die in childbirth are far less likely to reach their first birthday than those whose mothers do not die, or who die from other causes. Early marriage was linked to higher maternal mortality and therefore to increased infant and newborn mortality.

Finally, difficulty managing the household was also identified as a key ripple effect of maternal death. Fathers and surviving children are often hard-pressed to take on the myriad tasks performed by one woman. To ease the burden of care, children may be sent away to live with other families and this separation can further damage family integrity.

The studies in the new issue point to crucial gaps in existing health policies and systems, but also suggest a need to overturn traditional beliefs about the value and efficacy of women.

Looking to the future

Along with providing suggestions to inform the work of donors, policymakers and policy implementers, each study underscores the fact that the continued marginalization of women – in particular, poor women, religious and ethnic minorities, and disabled women – is neither consistent with human rights principles nor conducive to overall intersectoral collaboration.

As the Millennium Development Goals draw to a close and the formulation of the Sustainable Development Goals gets underway, it is increasingly clear that vigorous attention to maternal, newborn and child health must be central to the development planning agenda.

Health and policy stakeholders, along with communities themselves, must understand that maternal mortality is a health issue, a human rights issue, and a social justice issue.


My child is 2 years. He cannot sit on his own. His head still lags behind him when I lift him up and he is not talking yet. My husband has deserted me because of this. He has taken the eldest son away to stay with his sister and left me alone to fend for this 2 year old. He takes care of the eldest child but does not spend a penny on the upkeep or medical bills of this 2year old……
This is the story of a mother.
When I enquire about the birth and early neonatal period, I learn that when the child was just a day old, mother noticed that baby’s eyes were yellow. Three days on, the child became weak and refused to suck at the breast. She took child to the hospital but at the hospital she encountered another woman whom she had met during her antenatal classes. She happened to strike conversation with this other woman and told her about her baby whose eyes were yellow.
“But this is not hospital disease”… the woman exclaimed!
So this mother left the hospital without waiting to see a doctor or even verify what this woman had said with any health worker!
At home child got worse, was refusing feeds so they took to a herbalist, who put the child in sunlight in the mornings and later bath the baby with some herbs. The yellow eyes resolved and they sent child home. But as the baby grew mother realized that his development was very slow and so sought medical help.
But alas the damage had been done. Currently child is having supportive therapy; physiotherapy, occupational therapy to help child live as much a meaningful life in the confines of his developmental delay.
This is a sad story of jaundice.
Jaundice is simply the yellow colouration of the eyes, or skin.
It is a common occurrence in babies. It is easily managed but if left untreated and managed adequately it can lead to very detrimental effects. The most feared complication of jaundice in babies is called kernicterus. This results from severe brain damage which tends to affect the later development of the child.
What causes jaundice in babies?
The causes are myriad and you need to get the baby to the hospital to be evaluated to determine the cause as well as manage the jaundice.
Some of the causes of jaundice include
• Incompatibility between mother and baby’s blood group. Example mother ‘s blood group is O and baby’s blood group is B.
• Rhesus Isoimmunisation. Big word ha! There are two ways medical people classify blood group; the ABO and the rhesus grouping. The ABO is when you are either an A blood group or B blood group, O blood Group or AB. The rhesus D group is either positive or negative. Usually your blood group would be reported as both the ABO and Rhesus D grouping. So usually you would be told you are A positive or B negative etc.
In rhesus issoimmunisation, the mother’s blood group is rhesus negative and the baby’s blood group is rhesus positive. God has designed it that the baby in the womb has his or her blood separate from the mother’s. However if somehow some of the baby’s Rhesus Positive blood should enter the mothers blood stream( during detachment of placenta) the mother’s blood which is rhesus negative will identify baby’s blood as foreign and ‘strange’and start producing antibodies to fight baby’s blood. This can cross the placenta into the baby and destroy the baby’s blood in the womb and can continue after the baby is born to cause jaundice and even anaemia( low blood level)! For such rhesus negative mothers their first babies are spared the risk of jaundice. Subsequent babies are at a higher risk of developing jaundice and it can be very severe. It is recommended for rhesus negative mothers to have anti D immunoglobulin injection after each pregnancy to reduce the risk of this rhesus isoimmunisation.

• Infections. Infections acquired before, during and after delivery can result in the breakdown of the RED blood cells in the blood which can lead to jaundice.

• Inherited defects of the red blood cells of blood like G6PD, abnormal shapes of the red blood cells such as spherical (called spherocytosis) or elliptiform shapes (called elliptocytosis). These can result in rapid breakdown of the red blood cells leading to jaundice.

• High level of Red blood cells in the blood. This can happen in big babies or small babies (preterms or babies that had restricted growth whiles in the womb), or occur when blood is transferred from one twin to the other twin leading to one twin having too much blood while the other has low blood level in the womb.

Jaundice may be present at birth or may appear at any time during the first 28 days of life (neonatal period) depending on the cause. The jaundice usually progresses from the head to the toes. If it reaches the soles it indicates a higher level of jaundice than when it is just limited to the face.

Jaundice can kill or cause severe brain damage. These sad events can be prevented if you seek help early for the baby. Do not disregard jaundice in a baby, it can kill and maim for life!


Geneva, 24 April 2015 – Gavi, the Vaccine Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria welcome the results of a large-scale trial of a malaria vaccine candidate in sub-Saharan Africa.The results suggest a malaria vaccine could eventually have a role alongside mosquito nets, indoor spraying, prompt diagnostic testing, effective anti-malarial medicines and other tools in reducing the disease’s impact among children in sub-Saharan Africa. The phase three trial of the RTS,S malaria vaccine candidate showed a 54 percent reduction in cases of clinical malaria over the first year of follow-up and a 36 percent reduction in clinical malaria over a 48 month period among children vaccinated between 5-17 months old who received four doses of the vaccine. On average across the trial sites, more than 1,700 cases of clinical malaria were averted per 1,000 children vaccinated. For infants who were vaccinated aged 6-12 weeks, the reduction in clinical malaria was 26 percent over a follow up period of 38 months. The five year trial concluded in January and involved 15,459 children and infants. The trial was conducted across eleven research centres in seven African countries in partnership with GSK and the PATH Malaria Vaccine Initiative.Responding to the new results, Dr. Seth Berkley, CEO of Gavi, the Vaccine Alliance, said: “Given the huge disease burden of malaria in developing countries, particularly in sub-Saharan Africa where it kills hundreds of thousands of children every year, today’s results will be of enormous interest to everyone aiming to improve the health of the world’s poorest people.”Dr. Mark Dybul, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, added: “These results are very encouraging and suggest that a vaccine may eventually be an excellent addition to our current tools of mosquito nets and indoor spraying.”The vaccine is currently being reviewed by the European Medicines Agency (EMA), with the Agency expected to provide a scientific opinion later in the year, which could expedite licensure in African countries. If the EMA’s opinion is positive, the World Health Organization’s Strategic Advisory Group of Experts and the Malaria Policy Advisory Committee will make recommendations regarding the vaccine’s use.Gavi and the Global Fund are committed to working together to plan for the possible use of a malaria vaccine, if recommended by WHO and if the Gavi and Global Fund boards decide to support the vaccine, as part of an integrated approach towards malaria control. Both organisations will continue to work in close coordination with the Global Malaria Programme at the World Health Organization, other technical partners and implementing countries. – See more at:


CePaCE invites you to its quarterly public interactive seminar with experienced medical practitioners.

Topic for discussion : STIILLBIRTH ( causes, danger signs, possible interventions and available help after experience)

Date: Saturday 21st February, 2015

Time: 11am- 2pm

Venue: Osu Ebenezer Presby Hall.

There will be a clinical psychologist to offer counselling to women who have been affected.

Come and ask all questions that have been bothering you about pregnancy and childbirth.

We will be expecting you.


Register by sending ‘attend’  by text or whatsapp to 0270586924.


CePaCE hands over Neonatal Ventilators to 37 Military Hospital

Centre for Pregnancy and Childbirth Education (CePaCE) hands over Neonatal Ventilators to 37 Military Hospital.
The Centre for Pregnancy and Childbirth Education (CePaCE) in collaboration with the Embassy of Japan, has handed over two neonatal ventilators and four patient monitors with complete ancillaries to the Paediatric Unit of the 37 Military Hospital on Monday 18th August, 2014.
These ventilators which are the first ever to arrive in the country are to help reduce neonatal mortalities that occur due to lack of advance life support equipment in the hospitals. These Servo I ventilators can be used on babies of all weight, therefore addressing challenges of certain premature and tiny babies who may require this support. 37 Military Hospital is the first medical facility to receive new neonatal ventilators in the country.
In her speech, the Project Director of CePaCE, Dr. Genevieve Insaidoo, indicated that “The first 28 days of life called the neonatal period is one of the most important periods in a child’s life and that every baby born deserves a chance to live and hence all levels of care must be available to help babies live.
The Ambassador of Japan, H.E. Mr. Naoto Nikai, in his speech mentioned that the support from the Government and People of Japan towards the provision of the equipment is to emphasize the continuous role played by Japan as one of Ghana’s development partners in meeting its developmental targets. Additionally, improving maternal and child health care is one of the top priorities of the Japanese Government’s Economic Cooperation Policy in Ghana. He entreated the hospital to maintain the equipment for longer usage.
The Commander of the 37 Military Hospital, Colonel Ralph Ametepi, thanked the Centre for Pregnancy and Childbirth Education (CePaCE) and the Japan Embassy for the support and promised that the hospital will ensure that the equipment are used for the intended purposes and also well-maintained.
In October 2013, a media publication by a parent about the Paediatric Ward of the 37 Military Hospital attracted the NGO, CePaCE. Following the story with research and investigations, CePaCE applied for a grant from the Japan Embassy through the Grant Assistance for Grassroots Human Security Projects (GGHSP) scheme. Having successfully gone through the processes, the Government of Japan granted an amount of One Hundred and Twenty Thousand, Seven Hundred and Twenty US Dollars (US$120,720) towards the project. On Monday 18th August 2014, the installed equipment was handed over to the 37 Military Hospital.