April 18-21, 2011

By Lindsey Pollaczek, Program Officer

Sierra Leone has one of the highest reported maternal death rates in the world. In 2005, the maternal mortality ratio was 2,100 deaths per 100,000 live births and a woman’s lifetime risk of dying due to complications in pregnancy and childbirth was 1 in 8. Long distances to health facilities, the cost of health services, shortages of health workers and essential drugs, supplies, and equipment, and the low status of women are familiar challenges in sub-Saharan Africa - and chronic issues in Sierra Leone.

But it’s not all bleak. In fact, the documented maternal mortality figures have slightly improved, and after spending the last few days traveling through Sierra Leone I have seen some encouraging interventions which improve quality of and access to maternal health services. These, along with the government’s introduction of Free Health Care Initiative for pregnant and lactating mothers and children under five in April 2010, are working to break down the barriers which limit a woman’s access to care in pregnancy, delivery, and the post-partum period. At Direct Relief, we focus on three key interventions which improve maternal health services and quality of life. In Sierra Leone, I uncovered each of these important interventions during my journey.

Act One: Training the Next Generation of Midwives

School of Midwifery, Makeni, April 18
One of the most important interventions to reduce maternal death and disability is for women to deliver with a skilled birth attendant. The skilled attendant is able to manage normal deliveries and can recognize signs of life-threatening complications that require referral to a higher-level of care.

The School of Midwifery in Makeni, Bombali District, is the largest midwifery school in the country and is currently training 138 midwives. The new school is unique as it trains a lower level of nurse that previously was not allowed to enter midwife training. Only the higher level of nurse was able to train as a midwife, but they often elected to work in more attractive settings following their graduation: hospitals in larger cities or in management positions with the Ministry of Health. Therefore, most deliveries in primary health centers at present time are attended by maternal-child health aides and traditional birth attendants, neither of which qualifies for the title of “Skilled Birth Attendant,” according to the World Health Organization’s definition. The new generation of the midwives at Makeni will help change the current situation.

Bright and early Monday morning, the school was full of eager students working hard to gain the honor of becoming the first graduating class of the Makeni School of Midwifery in January 2012. Most of the midwives trained at Makeni will work in remote clinics in rural areas, where the needs are often greatest. I spoke with a few students who had been nominated by their peers to represent the class. They shared with me their appreciation for the training and their motivation for taking up the course. “There are certain things I used to do, maybe not the right way,” said student Ramatu Kano, “but now that I am in the program I have seen my mistakes and already corrected them. I am very happy to be part of this course.”

This is the first time that midwifery training has been open to qualified males, and several have enrolled in the program. Midwife-in-training Steven Ngaujah lost his sister when she died giving birth to twins without a skilled birth attendant present. “So many other women in Sierra Leone are in this position, so I was moved to be part of this work to see that maternal mortality is reduced in this country,” he explained. He recognized that his position as a male midwife in Sierra Leone was rare but he was willing to break down that barrier to see that women receive better care in pregnancy.

Once the midwives graduate from Makeni and are posted in rural areas, they must have the right equipment and supplies to use their new skills fully. Imagine spending two years in training only to be placed at a health facility that lacks the tools you need to do your job. This is a common scenario in Sierra Leone that is demoralizing for the health provider and potentially life-threatening for the women who need care. Direct Relief is working with the School of Midwifery in Makeni to ensure that when the midwives graduate they have the supplies they need.

“Now in the community and in the health facilities there are midwives working barely without equipment,” said Francess Fornah, the head of the school. “If we can equip the midwives with the midwifery kits and delivery sets then I think we have gone a long way.”

The midwife students agreed. “These [midwife kits] are very difficult to get here,” Ramatu Kano said. “This would help me to work in the community, and I would appreciate this very much.” When Francess introduced me to the first class of 72 students during the tour of the school and she announced that Direct Relief was equipping all of the graduating midwives, the students erupted in great applause.

Act Two: Improving Services for Obstetric Emergencies

Medical Research Center, Tonkolili and Bo Districts, April 19-20 

About 15 percent of all deliveries will be complicated and will require emergency obstetric care. Many complicated cases can be managed at a lower level facility if the skilled birth attendant is trained in the management of basic emergency cases and has the tools they need to do their job. This skilled birth attendant is also trained to recognize the danger signs when a woman does require referral to a higher level of care where cesarean section and blood transfusion are available, and can make that decision promptly in order to save a woman’s life.

Successful emergency obstetric care requires three critical components:

1. Trained providers at each level of the health system who know how to manage and when to refer emergency cases;
2. Availability of the proper equipment and supplies to manage such cases; and
3. A functioning referral system that can move a woman quickly to the appropriate level of care.

Medical Research Center (MRC), a Sierra Leonean nongovernmental organization and Direct Relief’s key partner in the country, is focused on providing inputs to each of these levels in order to improve emergency obstetric care. MRC has been working in Sierra Leone for more than 30 years and works closely with the Ministry of Health to improve healthcare delivery at the level of Peripheral Health Units (PHU), the health centers closest to the community that provide essential primary care and maternal health services. With support from organizations like Direct Relief, MRC distributes medicines, supplies, and equipment to the health centers that care for women in pregnancy and childbirth. MRC has also trained all healthcare workers that provide delivery services in basic emergency obstetric care and has established an ambulance referral system to transport women in emergencies to the nearest hospital.

But the nearest hospital is often very far away. To witness just how far, I traveled with MRC staff to one of their most remote operational areas, the chiefdom of Sambaia. For more than three hours we bumped over incredibly rough terrain which included a long, steep climb and descent through the hill country, then another hour of travel to reach the village of Bendugu. When we told people at the hospital in Makeni town that we were heading out to Sambaia, they all shook their heads and commented on the long distance and disadvantaged community. Our trip was in the middle of day in the dry season, but emergencies happen at the most inopportune times, like late at night in pouring rain. It’s difficult to imagine a woman in obstructed labor making this treacherous journey in any scenario.

This demonstrates the critical importance for MRC to continue improving quality of services in remote areas so that more woman can deliver safely at the health centers, and when a case requires emergency transport, the health workers are able to identify danger signs early enough to make the call and save a woman’s life.

Yele Community Health Center, also supported by MRC, is down the road in Bo District. Yele CHC has been selected as the basic emergency obstetric care referral center for its chiefdom of over 50,000 people. The community health officer in charge, Peter Konneh, is a dynamic man who is passionate about improving maternal health and proudly recognizes that the health center has had zero maternal deaths in the last few years, thanks to its work to educate the community and ensure that its staff is qualified to manage nearly all obstetric cases.

Peter was a young boy when the civil war broke out and rebels invaded his home village in Kailahun District in eastern Sierra Leone. It was a terrible time for thousands of Sierra Leoneans and Peter was one of many who were forced to flee their homes. After spending 10 years in a refugee camp in Guinea, Peter returned to Sierra Leone and trained as a community health officer, which is just below the level of medical doctor. Upon graduation, MRC employed him in 2006 and he was posted to Yele CHC, where he has committed to overseeing this important work for the long term.

Direct Relief has been working with MRC since 2008 and has provided three donations of medicines, supplies and equipment for the 32 health centers, hospitals, and the School of Midwifery in Makeni. MRC purchases medicines and supplies that are not donated, which is a significant expense. MRC is an excellent partner for Direct Relief; the medical supplies we provide do a great deal to support the primary care system and strengthen emergency obstetric care in Sierra Leone.

Act Three: Restoring Health to Women with Obstetric Fistula

Aberdeen Women’s Center, Freetown, April 21  

We hope that Act Three never arrives. We work hard in Acts One and Two - training and equipping midwives and improving emergency obstetric care - so that mothers can experience a safe pregnancy and the health of their newborn. But at present time, we cannot draw the curtain after only two acts, and must also care for women who have endured serious injury during childbirth.
In Freetown, I meet Dr. Alyona Lewis and her dedicated staff at Aberdeen Women’s Center. The Center provides treatment and support for women who have developed a debilitating obstetric fistula as a result of prolonged and obstructed labor. Obstetric fistula is almost entirely preventable with improved obstetric services. In places like Sierra Leone and other countries in sub-Saharan Africa where access to and quality of care is inadequate, obstetric fistula still occurs at alarming rates.

In 2010, Aberdeen Women’s Center provided fistula repair for 189 women who came from all parts of the country and even neighboring Guinea and Liberia. The center includes a maternity ward (which was completely full during my visit) and an outpatient clinic for children. All services are provided free of charge.

The joyful rhythm of African drumming and singing rose up over the compound during my visit, happily interrupting my conversation with the procurement manager as we were discussing how Direct Relief could provide surgical supplies and medical materials to the center. I witnessed the Glady-Glady ceremony, a weekly celebration when the whole center breaks into song and dance to bid farewell and good luck to the women who are leaving to return to their villages. After staying about two weeks to heal following their fistula surgical repair, the women don a new dress and get ready to return home to their families and their community as a whole new person. The hope and positive energy of these brief weekly celebrations underscore the significant value of a center like Aberdeen.

The Center focuses on holistically healing women with obstetric fistula—repairing the debilitating physical condition and treating the emotional and psychological distress attached to the stigma of fistula. A three-month follow-up visit is required for every woman, to ensure the integrity of the surgical repair as well as providing an opportunity to share information on family planning and reproductive health. Dr. Alyona told me that when a woman returns, she often wants to learn about how to plan her family and is curious about her ability to have another child. (Women with a repaired obstetric fistula can have children but are counseled on the importance of having a cesarean section.)

The good news: The long waiting lists for fistula surgery in Sierra Leone have all but disappeared. While there are likely to be women that are harder to reach, or are tentative to come for treatment--many women from remote areas have never been to the Capital and are afraid to leave their village for an unfamiliar place--it is also possible that the incidence of fistula has decreased due to recent interventions to improve access to and quality of obstetric services. Aberdeen is planning an expanded outreach program in the coming months to areas not yet reached to offer help to women who still need treatment. Meanwhile, continued attention remains on improving obstetric care to prevent fistula and maternal death.

Someday, the fistula ward at Aberdeen Women’s Center will become obsolete, like the Fistula Hospital in New York City that was torn down 150 years ago and later became the famous Waldorf Astoria Hotel. Until then, Aberdeen Women’s Center will continue to play a critical role in restoring the health of women living with obstetric fistula and Direct Relief will remain committed to bolstering such important efforts.

United in Prevention

Lindsey Pollaczek, Direct Relief program officer, sent this dispatch from the International Society of Obstetric Fistula Surgeons (ISOFS) meeting in Senegal, underscoring our commitment to preventing and treating fistula.

December 9, 2010
Today is the final day of the International Society of Obstetric Fistula Surgeons (ISOFS) meeting in Dakar, Senegal. It has been an incredibly busy few days as fistula surgeons and health professionals have come together to share diverse experiences, research findings, and recommendations for improving quality of treatment, management, and prevention of obstetric fistula. Representatives from more than 40 countries are participating in the conference, all sharing the common goal of working to improve fistula care and a vision for eradication of this preventable condition due to failures in maternal health care.

Representing Direct Relief, I have had the unique opportunity to engage with many of the preeminent fistula surgeons in the world. Many of the pioneers in the field are here, surgeons who have dedicated their careers to treating women with fistula, training other surgeons, and spearheading research to improve the outcomes for fistula care. Many more youthful faces from the next generation are here—motivated, committed, primarily African surgeons from all parts of the continent have come to learn from each other and improve their expertise in a region where the burden of obstetric fistula is highest.

The surgeons provide an essential service for helping restore the dignity of women living with obstetric fistula. Also present are advocates, community organizers, and public health professionals who are addressing the important areas of prevention of fistula through improved obstetric care and also social reintegration of women back into their communities after their physical wound has been healed. This community recognizes that it is simply not enough to surgically repair the fistula and send a woman on her way after she has lived often for many years with a highly stigmatizing and socially humiliating condition. The conference theme acknowledges the increased effort which must be made not only to treat the physical condition but to ensure that women can return to normal, healthy lives in their community.

A great deal of good work is being done by many organizations across Africa and Asia to address obstetric fistula. A shared understanding of exactly where these services are located and the current capacity for treatment remains elusive. Direct Relief is working together with ISOFS and the Fistula Foundation to help illuminate this information in a way that is accessible to all stakeholders.  Using our experience in GIS (geographic information systems) technology, Direct Relief hopes to help create powerful tool for everyone in the fistula care community—to understand the current landscape for treatment, help identify unmet need, and provide a tool to guide decisions on future resource and service allocation.

Direct Relief is currently providing surgical supplies to support fistula-repair programs in seven hospitals across Africa, many of which are represented here.  It is clear through the level of engagement at this conference - and by the preliminary results of the fistula treatment mapping - that there are many more facilities where surgical supplies are needed. Working together with healthcare companies like Johnson & Johnson, Ethicon, Covidien, and CR Bard, Direct Relief hopes to support more surgeons so they have the supplies they need to do this valuable work.

This gathering has reassured my confidence in Direct Relief’s decision in making fistula care and prevention a central part of its maternal health strategy over the next five years. There is a lot of good momentum and energy here at this conference. We all agree that a lot remains to be done.

Now off to the closing ceremony and to the work ahead! 

Better Health for Southern Sudan

by Kristi Bullock, Program Officer for Africa

August 12, 2010
Dr. Mike Marks and I just returned from visiting AMREF and the National Health Training institute (NHTI) in Southern Sudan. NHTI was established in 1998 as a school to train clinical officers.  In 2006 it began training community midwives and is now running a third training program, for public health officers. NHTI has graduated 269 clinical officers and 26 community midwives; the first class of public health officers has yet to graduate.

There are 38 third-year clinical officer students, of which Direct Relief is supporting 30. They are currently in the field in Yei and Torit, 75 miles and 186 miles away from Maridi. These locations were chosen because of the staffing and medical supplies available at these facilities. The students will spend one month working within a health unit and two months at the hospital before returning to Maridi in October for final classes and exams. In November, each student will select his or her preferred location for internship. 

Because the one-year internship does not pay, locations are selected based on where the students have family or friends that they can stay with. Preferences must be submitted to the school for approval.  The students will have the month of December off and will begin their internships in January 2011. Although graduated in November 2010, the students will commemorate their graduation in November 2011, as graduation ceremonies are held every other year.

Clinical officers are in high demand in Southern Sudan.  Already now, four months before graduation, the announcement board at the school has notices of posts available. The accreditation received upon completion isn’t recognized outside the country, but within Southern Sudan, clinical officers are seen as the primary access to medical care, as doctors are in such short supply. Of those graduating, 99 percent find jobs and stay within the country.

During my visit I was able to meet, attend class with, and participate in rounds at the hospital with the year one and year two classes of clinical officers. I also spent many hours with the head midwife for the midwife training program, Christine Nakayenga. She is a petite woman, but she has an air of confidence about her and is determined to bring knowledge and access to safe birthing across Southern Sudan. We talked about what organizations are doing in the area and what still needs to be done.  She is a wealth of information. I will send more about the Maridi County Hospital soon.

August 15, 2010
For the last two and a half years Direct Relief has been supporting Maridi County Hospital through its partnership with AMREF in Southern Sudan.  Maridi County has an estimated population of at least 500,000, but in reality no one knows the true population size as people are still returning from the refugee camps in Uganda and the Democratic Republic of Congo after 21 years of civil war in Southern Sudan.

Maridi County Hospital is the only hospital in the area and the only facility able to perform any kind of surgical procedure. The next nearest hospital is in Yambio, a two-hour drive in the dry season and significantly longer in the rainy season.  In 2006 the Government of Sothern Sudan, in partnership with UNICEF, WHO, UNFPA, USAID, and others, released a household health survey.  It found that of all the states in Southern Sudan, Western Equatoria, where Maridi is located, had the worse maternal mortality rate, with 2,327 women dying out of every 100,000 who give birth.

After experiencing the roads and remoteness, visiting the hospital, and seeing for myself the lack of medical staff, sadly, I understood why this number is so high. Women aren’t coming to the medical facilities because the facilities aren’t properly staffed or equipped. Clearly, the training programs for clinical officers and midwives are essential, and I’m proud that Direct Relief supports them. The need is everywhere.

At Maridi County Hospital the staff was doing what they could with what they had. The equipment in the operating theater is more than 20 years old and desperately needs replacement. The operating table no longer adjusts in height and the lights are broken except for one fluorescent light in the ceiling. Anesthesia is administered through the spine. There is no sterilizer; all surgical tools are boiled over charcoal. Blood transfusion takes place on-demand, as there is no blood-bank refrigerator to store it. The good news, however, is that the hospital has its own borehole (or well), so it has access to clean water and has a functioning generator for power.  There are currently two doctors and four clinical officers working in Maridi County Hospital, and 10 nurses and midwives run the 24-hour labor and delivery ward. 

With the support of some generous foundations and others, Direct Relief has committed $63,500 to equip Maridi County Hospital to provide emergency obstetric care services. The theater has been renovated and, once equipped, will allow for increased training for the clinical officers.  A container for Maridi with donated medicines and supplies will ship with the procured emergency obstetric equipment this fall and should arrive at the beginning of next year.

Midwives – A Hope for Safe Delivery
In 2006 there were approximately 58 midwives in all of Southern Sudan, serving an estimated population of 10 million.  Since that time, three midwife schools (two of which are now located at the National Health Training Institute, where the clinical officers are being trained) have trained an additional 151. The majority of births take place in the home attended by mothers, mothers-in-law, traditional birth attendants (TBA) or maternal-child health workers (MCHW). 

The community midwife program at NHTI is an 18-month-long, Ministry of Health–recognized program.  While visiting Maridi I observed the midwife students on rotation at the hospital and sat in on a class teaching the signs of labor and recognizing when a mother has reached the second stage of labor.  The instructor also explained what a fistula is, why it develops, and how a midwife can help prevent it. Earlier that day I had asked Christine, the head midwife at NHTI, if fistulas were a concern here. She replied, “Oh, yes, fistula is quite common and no one here can do the repairs. The girls are delivering quite young.  Many get pregnant when they are 12, 13, and 14. They are too young to be having babies.” 

After some investigation I learned that there is one surgeon in Juba—five or six hours away in the dry season—who is trained, but neither he nor any other trained surgeon has been to Maridi to do repairs. Christine and other AMREF staff were eager to have a fistula repair camp and to offer additional training to the graduated clinical officers.

Today, the hope of access to safe delivery in Southern Sudan lies mostly with NHTI. It is the only school for clinical officers in all of Southern Sudan and trains two-thirds of the country’s midwives.

“She Will Be Beautiful Again”

By Lindsey Pollaczek, Africa Program Officer

Tanzania
July 27, 2010

Jacinta, an eight-year-old girl from southwestern Kenya, started complaining of a toothache three months ago. After the tooth was pulled, the swelling did not stop. Jacinta was taken to a health center where the clinical officer diagnosed a bacterial infection and prescribed antibiotics. Following treatment, the swelling in her jaw only continued to grow rapidly. Two months later Jacinta’s mother, a single mother with two other children and no reliable income, managed to take her daughter to a district hospital. There, the tumor was properly diagnosed as Burkitt’s lymphoma, and because no treatment was available at the district level, she was referred to the Provincial General Hospital of Nyanza, in Kisumu.

Burkitt’s lymphoma is an aggressive cancer that accounts for more than half of all childhood cancers in equatorial Africa. It is a rare disease everywhere else. The disease is related to the Epstein-Barr virus (EBV), the first virus to be associated with human cancer, and current research has suggested that malaria may also play a role in the development of Burkitt’s lymphoma. Research is underway around the shore of Lake Victoria in East Africa, where Jacinta lives and where the burden of malaria and Burkitt’s lymphoma is high.

With limited resources at home, Jacinta never made it to the oncology ward at the Provincial Hospital in Kisumu. Instead, someone in her village told Jacinta’s mother about a place called Shirati, across the border in Tanzania, where her daughter might be able to get help. Despite any assurances that making the journey would yield any results, she decided to go, leaving her other two young children at home in the care of a relative.

When Jacinta and her mother arrived at Shirati they were directed to Sota, a small village down the road, where the Shirati Education and Development Foundation (SHED) is located. A new partner, SHED had just received its first container of medical supplies from Direct Relief when we visited. Under the guidance of Dr. Esther Kawira, a resident of Shirati for over 25 years and a regional expert in Burkitt’s lymphoma, SHED has made available specialized chemotherapy treatment at the small health dispensary Dr. Kawira runs.

The treatment regimen for Burkitt’s lymphoma is six doses of chemotherapy given every two weeks, which takes at least a month and a half for care. This is long time to stay under in-patient care, especially if it means lost wages for the parent who accompanies the child. Also, the cost of travel back and forth to the clinic is often prohibitive. Once they leave, patients may never come back, which can lead to a relapse requiring more expensive treatment that is even more difficult to source. At SHED Foundation, the chemotherapy is donated and can be administered at no charge to the patient. This is unusual in this region, where the patient must purchase the drugs and bring them to the hospital (which, at several hundred dollars a course, almost never happens); the hospital has to cover the bill, which is a huge challenge for resource-strapped facilities; or, most likely, the patient goes without treatment.

With adequate therapy, Burkitt’s lymphoma has a high cure rate. In developed countries, 90 percent of children with the disease are cured. For countries in sub-Saharan Africa, the disease has been a low priority, given the high prevalence of other illnesses that affect more children and are cheaper to treat. With limited disease-management capacity and treatment available, the mortality rate for Burkitt’s lymphoma in Africa remains high.

When a child is put on treatment, as Jacinta was at SHED Foundation, the improvement is remarkable, even after just one course of chemotherapy. As quickly as the tumor grows, it shrinks away faster. This almost instant visible change which occurs in many cases is incredibly hopeful for the child, their family, and the healthcare providers overseeing their care. During our visit at SHED, Dr. Kawira asked us to take a photo of Jacinta, which we left with her when we departed. She in turn sent us a photo that a group of medical students had taken just two weeks before, when Jacinta first arrived at the clinic. The transformation is incredible. Jacinta’s mother said to Dr. Kawira when she arrived, “She used to be beautiful.” Dr. Kawira had replied, “She will be beautiful again.”

Maternal Health at the End of the Road

Soroti, Uganda
July 21, 2010
For two hours we bump down a dusty red dirt road heading out of Soroti town toward the village of Kagwara, situated at the shore of Lake Kyoga, the second largest lake in Uganda. We are joined by members of AMREF Uganda and Terrewode, two organizations working in the Teso Region to improve outcomes for women during pregnancy and childbirth. AMREF Uganda, a longtime Direct Relief partner, is implementing a safe motherhood project in this region, and works with groups like Terrewode, which was founded in 1999 during the period of civil war to provide support to women and girls who were acutely affected by the conflict. Direct Relief works with indigenous groups like these to improve maternal health care, and today, we find ourselves heading deep into the bush of eastern Uganda, to the end of the road where maternal health complications often arise.

Ugandan women have an incredibly high fertility rate—nearly 7 children in their lifetime. Given long distances to health facilities, lack of means to cover the costs of transportation, and chronic shortage of supplies at all levels of the health system, the majority of births in the country happen in the village at home. Births which occur outside a health facility without the presence of a trained birth attendant are prone to risk and complication. Community sensitization and education is essential to promote the importance of attending antenatal clinics, having a birth plan, and delivering in a health facility, which takes the involvement of community-based organizations to be most effective.

A woman who experiences complications in delivery is in a really difficult spot if she comes from Kagwara village. The nearest health facility providing comprehensive emergency obstetrics care—a cesarean section—is back where we started our journey in Soroti town, two hours away in a sturdy 4x4 vehicle. The thought of making this journey quickly in unreliable public transport, or on a bicycle, is hard to imagine in the best of scenarios. It’s just too far. Add to that a woman who has been in labor for two or three days and you begin to understand why maternal death and disability remains high in this country. While there is a health center closer to the village which should be able to provide this service, there is no doctor that is on staff to oversee the operation.

If the delays in receiving a cesarean section are too long—delay in deciding to seek care when complications arrive, delay in reaching a facility where the procedure can be performed (for the laboring woman in Kagwara, only in Soroti General Hospital), and delay in receiving care at the facility (at Soroti General there is one theater that performs over 2,000 major operations every year)—major injuries, such as obstetric fistula, can develop. A woman left incontinent of urine and or feces due to obstetric fistula is a severe and heartbreaking consequence of lacking obstetrics care.

“We are mopping the floor but the tap continues to leak.”

The women in Teso Region are fortunate only in that competent fistula repair services are available at the regional referral center. Under the guidance of the consultant specialist Dr. Fred Kirya, about 50 women receive treatment annually. But here, like at all levels of the health system, there are challenges: lack of special supplies for the repair, the burden on the healthcare workers to take on additional work with no commensurate pay, and the demand on the one incredibly busy operating theater. Considering the barriers a woman with fistula will be confronted with all along the way, if she receives the repair it is truly a thing to be celebrated, as this is a procedure that is completely life-restoring. However, for every woman who is repaired, another will develop a fistula unless comprehensive improvements in obstetric care are made. Dr. Kirya acknowledged the great value and importance of fistula repair and his belief that there are many women with the condition which have not yet been reached. However, the preventive component is essential, because as he put: “We are mopping the floor but the tap continues to leak.”

Back in the village of Kagwara we talk with Terrorode volunteers and their local affiliate TEETE, a group of 26 community members concerned with uplifting the economic and health status of their people. Terrewode volunteers demonstrate the education which is provided on use of the mama kit—very basic delivery supplies including sterile gloves and blade, which can reduce the chance of infection and be a lifesaver for mother and child. In just two months since being trained by Terrewode, the volunteers have identified six women with fistula in their village and surrounding area. One of the ladies identified and educated about her condition sits quietly during the meeting—she has agreed to get treatment but is still unable to afford the transportation to the hospital. I fight the urge to put this woman who has already been through so much in our vehicle and drive her straight to the hospital; we discuss potential solutions to remedying this so that once a woman is identified and agrees to be treated, she can get the care she deserves.

A nurse-midwife unpacks a safe birthing kit at Tiriri Health Center.

We return by the same dusty road at dusk, whizzing past villages filled with children and pregnant mothers. I imagine the clock ticking down to the arrival of labor pains—I hope for the best outcome, but fear the worst. The challenges for a woman to receive proper care during her pregnancy and delivery are stark and myriad: distance, poverty, education, and a health system in need of serious repair. We at Direct Relief are working to equip midwives, doctors, and surgeons and the health facilities where they operate. This includes midwife kits (see above photo) which include basic materials for outreach to remote, lower-level health facilities; equipping the operating theater at the Health Center IV (one level below hospital) so that comprehensive emergency obstetrics care can be provided, bringing cesarean section capacity closer to the mothers while easing the demand on the hospital for this service; and equipping surgeons with tools for fistula repair.

During this brief visit, we have also identified areas where we hope to provide additional resources, working through local groups like Terrewode and AMREF at the village level and through government health centers and regional referral hospital. Our input alone will not solve all of the issues--deep-seated cultural, economic, and political challenges—but with these committed organizations and people, we’re moving toward improving health for mothers in pregnancy and childbirth.

By Lindsey Pollaczek, Program Officer for Africa

Soweto
November 4, 2009
I woke up this morning to thunder rattling the window panes. Unlike yesterday’s brief and powerful storm, the rain has not stopped falling for the past two hours. I keep thinking about Gloria’s family in their small tin shell of a home. I hope it’s not raining in Snake Park.

Conditions in many townships of Soweto have improved markedly in the last few years—in the vast, sprawling area of 3 million some are living rather comfortably. Homes have TVs, running water, a gas stove. But you don’t travel far before you meet abject urban poverty. Our visit yesterday in the Soweto township known locally as Snake Park illustrated how dire the situation is for many, particularly those who are sick and poor.
 
The dark sky has been threatening rain for an hour, but the deluge starts just as we enter the final home of the day. I watch Sr. Freda and Wilhelmina, Soweto Hospice’s nurse and community health worker, offer words of support to their patient Gloria when  the downpour on the tin roof becomes deafening. The conversation fades as the sound of the rain overtakes the small space. Gloria’s daughters hurry to place small containers around the one-room home to catch the rain falling through the holes in the roof. The small puddles outside quickly turn to muddy rivers that begin to rush through the settlement. Twenty minutes pass and the rain stops as quickly as it has begun.  Sr. Freda and Wilhelmina say their parting words to Gloria and we pick our way through the mud back to our 4x4 vehicle and wave goodbye.  Freda and Wilhelmina are already thinking about when they’ll be able to come back—to bring a lifeline to Gloria and her family, to ensure she has adequate support to live comfortably with HIV in this terribly impoverished neighborhood of Soweto.

We are in Snake Park. The name conjures up a wild, inhospitable place. Nearly a decade ago, informal settlements started appearing in the grassy fields, apparently the original home to a number of resident snakes.  It didn’t take long before the fields were overtaken with tin shacks, the homes of tens of thousands of people who couldn’t afford to live anywhere else. I’m told that the government’s Reconstruction and Development Program is  undertaking infrastructure improvements here to provide better housing, water, and sanitation. Unfortunately, this is not at all apparent from Gloria’s neighborhood. 

Gloria was diagnosed with HIV in 2006. Freda, a specialized nurse with six years of training, received a call from Gloria’s brother in 2007 and was asked to come by for a visit. When they first met, Gloria was very sick and barely able to care for herself. Since then, Freda has provided support all along the way through the many ups and downs in managing Gloria’s illness. This week Gloria is feeling relatively well, but she still has some chest pain and is coughing a fair amount. Last week Freda referred her to get a sputum test for tuberculosis and she is still awaiting her result. There is a good chance Gloria has TB, as co-infection among HIV patients is very high.

Gloria adheres closely to the antiretroviral regimen therapy she receives for free from the government. However, without a consistent supply of food, she struggles to remain healthy. The family has no source of income aside from the small government grant that her eldest daughter receives for her child. This is less than $28 a month to feed a family of five--not remotely enough.  Her HIV drugs will not have the maximum benefit if she is not able to keep herself well nourished. Food scarcity also affects her family. Her eldest daughter has epilepsy and had a seizure last time Freda visited. When asked if she took her medicine, she admitted she had not because it made her ill to take it on an empty stomach, and there was no food with which she could take it.

During their near-weekly visits, Freda and Wilhelmina often bring food if the hospice has it available. It is not always possible, because the hospice itself is very strapped for resources as it attempts to care for over 1,250 patients at home and many more in their pediatric and adult in-patient units for those requiring around-the-clock care. Gloria is just one of Freda’s 250 patients to which she provides home- based palliative care. But in Soweto, a township of 3 million, there are undoubtedly many people that cannot be reached.

Soweto Hospice is a member of the Hospice Palliative Care Association of South Africa (HPCA), an umbrella organization that provides financial and technical support to develop the capacity of its more than 150 member hospices. The hospice and palliative care approach is to improve the quality of life of patients and their families facing a life-threatening illness through prevention and relief of suffering. In sub-Saharan Africa, over 90 percent of patients have HIV/AIDS. Fortunately, with the support of nurses and community health workers like Freda and Wilhelmina, many HIV patients in hospice care are becoming healthier and learning to manage their illness as a chronic condition that can be kept under control. Direct Relief has supported the efforts of HPCA and its member hospices by providing donations of medical supplies which are needed in home-based settings and in-patient units. Wound care dressings, through support of Johnson and Johnson, are currently being distributed throughout the HPCA network. 

The amount of compassion and commitment shown by the hospice and palliative care staff is admirable. With very limited resources they are managing to uplift many to good health and provide relief from suffering and pain for those that are nearing the end of their lives. They are just touching the surface of caring for people living with HIV, but they are wholly dedicated to providing the best care they possibly can.

By Lindsey Pollaczek, Program Officer for Africa

October 28, 2009
It’s Saturday night on one of the main streets of Kisumu town. Against the backdrop of a busy night scene—music blaring from a nearby shop, people of all ages milling about in the street—are six Coleman camping tents which have been set up on the side of the road. Three bare lightbulbs strung across the row cast a pale light over the tents, which tonight are serving as private consultation rooms for voluntary testing and counseling of HIV. People congregate outside the tents, waiting their turn for the free service, asking questions and raising concerns about HIV and its mode of transmission, treatment options, and what it will means to know their status. Inside the tents, which are all occupied, HIV counselors provide information on these very issues for people who would otherwise not make it to a health center.

Several days later, many miles north of Kisumu in Wenyila village of Bungoma East District, Florence and Matutu, two skilled counselors, go door-to-door in an HIV counseling and testing program designed to leave no one behind. This is their second week canvassing the village to reach all 140 households, which were alerted prior to their visit by a respected member of the community. Florence and Matutu carry their green Home Counseling and Testing bags over their shoulders, stocked full with HIV testing accessories, and the electronic handheld device on which they gather detailed information about the household and the individual’s HIV status. If someone in the household is HIV positive, the counselors will set up an appointment for them at the nearest health center, will even offer to accompany them to the facility, and will return to do a follow-up if the person does not make their appointment. High priority is given to pregnant women that are HIV-positive to ensure they will be able to access treatment to prevent the transmission of the virus to their child. 

Innovative approaches such as the Twilight Voluntary Counseling and Testing and the Health at Home Initiative are important for making HIV testing and counseling accessible to more people. HIV testing and counseling is often referred to as the gateway to prevention, treatment, and care, because it is essential for people to know their status in order to stop the spread of the virus and to be referred to treatment without delay. While the number of health facilities providing HIV counseling and testing in sub-Saharan Africa has grown rapidly in recent years as governments work toward universal access to HIV prevention, treatment and care, a very large part of the population remains unaware of their HIV status.

Community-based approaches have great potential to reach the segment of the population that is not able to invest the time, effort, and resources to get to a health facility for testing. During the night I visited the Twilight VCT, supported by Ringroad Clinic in the Nyalenda slum and Marie Stopes Kenya, I talked to men and female sex workers who thought it very convenient that these services were being offered at a time (6 to 10 pm) and in a place where they could be easily reached. Men in general and commercial sex workers are two groups that often do not come for testing in a facility setting.  Florence and Matatu, the counselors with AMPATH (Academic Model for the Prevention and Treatment of HIV) were essentially reaching all community members, many of which did not have access to testing prior to the visit.  More than half of the people I met that day in their homes had never had an HIV test and knew very little about the virus.

The 2009 United Nations report on universal access to HIV prevention, treatment, and care discusses where the global health community stands on this internationally endorsed goal. Although many indicators are moving in the right direction, many countries are still far from reaching the goal of universal access. While the number of people in 2008 who received HIV testing and counseling increased over the previous year, recent surveys indicate that more than half of all people living with HIV are unaware of their status.

Direct Relief is helping to address this issue by providing donations of Determine rapid HIV tests in partnership with Abbott, so that more people are able to know their status, primarily pregnant women to work to prevent the transmission to their child. The rapid test is an important tool in diagnosing HIV, but universal access to testing and counseling—and to the essential treatment and care which must accompany it—is only going to be accomplished if a variety of strategies are used. Innovative approaches like the Home Counseling and Testing and Twilight VCT are bringing us one small step closer.