It is 2015, the deadline for the WHO Millennium Development Goal 5 (MDG5) to reduce 1990s’ maternal mortality by 75%. On May 23, the world will observe United Nations International Day to end obstetric fistula (a breakdown of the birth canal caused by obstructed labour, leaving women incontinent, infection-prone and ostracized). 2015 is also the deadline for WHO MDG4 to reduce 1990s’ under-five child mortality by two-thirds.
A London-educated obstetrician gynaecologist and fetal medicine specialist, I’ve just returned to South Africa after 14 years. I’m delighted to be joining the WITS Maternal and Fetal Medicine Centre at Morningside Mediclinic in Sandton in Johannesburg and with the extra day I’ll spend every week as an Honorary Consultant at Chris Baragwanath Hospital in Soweto.
As a Ugandan-Rwandan, I also return as a sub-Saharan African, fully aware that sub-Saharan Africa made the slowest progress (under 20%) in reducing maternal mortality, that its share of the world’s maternal deaths actually grew from 42% in 1990 to 62% in 2013, and that the projection is it will fail to meet the MDG5 target. I’m also aware that nearly three million women and girls, mostly sub-Saharan African, live with obstetric fistula. Sub-Saharan Africa also has the highest under-five child mortality – 16 times that of developed countries, with more of the 6.6 million child deaths (44% in 2012 compared to 37% in 1990) occurring in the newborn period, clearly linked to a deficit in safe maternity care.
Coming from a UK system, my conscience is heavy. I have worked within clinical governance frameworks where maternity health workers manage obstetric emergencies in multidisciplinary teams, have unrestricted access to updated evidence-based protocols, emergency drugs, blood products and broad spectrum antibiotics and are regularly appraised and supported through enforced emergency drills and continuous professional development. In sub-Saharan Africa, there will be an isolated traditional birth attendant dealing with a post-partum haemorrhage on her own, an unknown expectant mother walking in labor to get help, and I can remember the midwife I met traveling through rural Uganda in 2013 who, when I asked about clinical audit in her unit, responded saying “we are too demoralized by what we face everyday to be dealing with audits”.
However, against the bleak backdrop of sub-Saharan Africa’s high maternal and under-five child mortalities, I’m hopeful. The speed of mobile phone penetration in sub-Saharan Africa over the last decade, faster than anywhere else in the world, points to Africa’s potential. In 2007, mobile subscriptions were already three times faster than in Europe, and in 2009, there were 10 times as many mobile phones as fixed-lines, Kenya being a shining example.
Aside from clear evidence that GDP increases with mobile phone penetration in developing countries, the possibilities are countless.
Relevant to me are the growing number of mHealth projects. Programs and applications that provide real-time intelligence, monitoring and response to disease outbreaks (Nigeria’s ‘EOCs’), provide remote diagnoses (Botswana’s ‘Kgonafalo’), prompt patients to take their medication (South Africa’s ‘Cell-Life’), and prevent drug counterfeiting (Ghana’s ‘mPedigree’). I’m excited by the mHealth projects in maternal health – Nigeria’s ‘mCBS’, South Africa’s ‘MAMA’ and Uganda’s mobile electronic fetal heart monitor ‘Winsenga’.
I owe something to the 800 women and 25,000 children under five who die every year, from preventable causes.
The United Nations has called for accelerated interventions and prioritization in maternal and child health and we await political will, sound strategies and adequate resources. I’ve decided I must take advantage of the great strides Africa is taking in mobile infrastructure and have taken to mHealth, developing a mobile App targeted at safer childbirth as most maternal deaths are due to complications occurring around pregnancy.
Mismanaged labour is also a direct cause of obstetric fistula and newborn deaths. The App will prompt community birth attendants on timely assessments during labour and detect deviation from normality for both mother and fetus. These remote assessments will be electronically visible through a real-time location-based platform for skilled obstetricians and midwives.
Pre-existing medical conditions are another cause of maternal death. The App will therefore in the first instance, perform a risk-assessment to guide on the safest venue for delivery. Patient data and outcomes will be captured into an electronic system to facilitate audit and accuracy of maternal mortality estimates for central monitoring.
I can’t be a bystander as Africa goes through this historic boom in technology while women are evicted from our world simply because they are deprived the safe experience of childbirth. I have to do this because my heart is heavy knowing that with every hour, 33 women die in childbirth from preventable causes. Investing in maternal health will not only improve a mother’s health and her family’s, but will increase women’s numbers in the workforce and promote the economic wellbeing of their countries. I have to do this because women hold up half the sky.
Quote Of The Day
“We have grown past the stage of fairy-tale. As women, we have one common front and that is to succeed. We have to take the bull by the horn and make the change happen by ourselves.– Folorunso Alakija, Billionaire Businesswoman
Quote Of The Day
“The best view comes after the hardest climb.”– Unknown
Covid-19 In Kenya: ‘We Are No Longer Dreaming’
Kenya is perhaps one of the quieter domains of the global Covid-19 pandemic. However, as its hold intensifies across the country, Kenyans, from all walks of life, have found themselves not only preparing for the worst but also taking stock of the impact it has already had on their lives.
By his own admission, Musa Esevwe, a 49-year-old sculptor and entrepreneur, had never, in his life, experienced trouble with his sleep. That is until Covid-19 arrived in his hometown, Nairobi, in mid-March.
Within the space of a week, a national curfew was announced via Presidential address. Not long after, as confirmed cases jumped to 91, a partial lockdown was imposed around the Nairobi Metropolitan Area, restricting the movement of people in to, and out of, the city.
Travel was tightly regulated and international flights temporarily suspended. The few who do manage to make it to the country, by road or sea, must endure a mandatory two-week quarantine, at the border, before they can obtain official approval to proceed to their final destination.
Meanwhile, inside Kenya’s borders, lives changed overnight. Intensive lockdown measures severely hampered trading for both informal vendors and businesses, causing upheaval in some areas. In April, small business owners clashed with police over the forced closure of their establishments, in Nyeri, a busy provincial hub in Central Kenya.
Schools have been shut since March and, while official numbers are yet to be published, thousands have lost their jobs and livelihoods. Those, still fortunate to be in employment, have had to transform their homes into offices.
“It is like a very bad dream that we are living in now. The happiness and security we once had has gone… we are no longer dreaming, even for those who can still sleep,” says Esevwe whose own business, which was heavily dependent on the disposable income of the middle class and occasional tourists, has been destroyed by the pandemic.
Along with Esevwe, among the hardest hit are the nation’s families, who, for months now, have been confined to their houses.
The lockdown period has been particularly difficult for Kamweti wa Mutu, an international development professional and amateur nature photographer, living in Nairobi. Currently out of work, and with his wife, now the family’s sole breadwinner, stationed in Tanzania, he’s had to play multiple roles to keep his household afloat.
“The quarantine order [on March 13] was sudden, but commendably prompt, meaning it was a somewhat tough transition getting our two children; Charlie, 11, and Adia, 8, settled into home-schooling routines. After a week, we [had to] put our house-help on leave, with some pay, so as not to place [any] undue risk on either her or us,” he says.
Prior to the pandemic, Mutu was actively looking for work. However, the economic turmoil set off by the virus is now a cause for concern.
“I have struggled to find full-time employment for a while [now] but my family has been very supportive with understanding and prayers. The kids have a good grasp of this, in light of the pandemic, but it’s not [yet] getting them anxious. As a household currently on one income, this aspect is a grave one. Most worrisome is my wife losing her post [because of the pandemic], or worse, one of our family members falling ill,” he continues.
Perhaps the most traumatic impact of Covid-19 on the family is their separation. With travel into Kenya currently restricted, Mutu’s wife won’t be able to return until her consultancy with an environmental organization in Tanzania concludes.
When she does, it will probably have to be by road as international flights are suspended. After crossing the border, she’ll have to spend 14 days at a quarantine center, receiving a special permit to enter Nairobi only once she tests negative for the virus.
While this has added an extra layer of anxiety to their situation, the family is choosing to focus on the bigger picture, insists Mutu.
“We have talked a bit about this, and what it would mean for a normal life, even beyond the current situation. However, we have not delved deeply into worst-case scenarios other than how Covid-19 is devastating other families and societies. We have stocked up on enough essentials including non-perishable foodstuffs, water, face-masks, and power to last us a while.”
Elsewhere in the city, Sophie O, who asked that we change her name for this report, is also finding life under lockdown a challenge. The 30-year-old Marketing Manager works for a major multinational in Nairobi and is doing her best to adapt to the ‘new normal’ of being based from home.
“It’s been quite difficult especially because I have three children; a nine-month old, a two-year-old and a six-year-old. It’s been hard for the two-year-old to understand that I am ‘at work’, he keeps barging into [work] calls and expecting us to play. Now, I have to keep my camera off during conference calls although ideally, as a standard, it would have to be on,” she says.
With schools now closed, and most students across the country taking classes virtually, many parents, especially those with younger children, are burdened with the added responsibility of home-schooling. In this, Ms O admits that she is struggling.
“Personally, I’ve really done my best just keeping track with all the lessons they have to do. I think probably if I didn’t have to be ‘at work’, I could have done a better job in terms of being there for my daughter but it’s quite a challenge. You have to work because work pays the bills and work also pays the school fees,” she says.
Factors, firmly out of her control, are also impacting her productivity.
“The practicalities of working from home, like having a workstation, I have had to figure out. But with the internet… some days it’s good, some days it’s bad, and some days you have a blackout and there’s nothing you can do!” she laments.
The experience of both these families hints at the wider setbacks being faced by businesses and the Kenyan economy, as a whole. From Nairobi, Edwin Macharia, Global Managing Partner at multinational advisory firm, Dalberg Advisors, has been leading a fortnightly webinar series advising African leaders and policymakers on how best to respond to the ongoing crisis. He insists that they must appreciate the severity of the pandemic’s impact and act accordingly.
“Our job [on the webinar] is to make sure that [leaders] are sufficiently shaken and begin acting appropriately. China bought the world a couple of weeks to prepare and get ‘ahead of the curve’ in terms of intervention but, unfortunately, that jolt wasn’t hard enough in some places. This is very quickly moving from being a health concern to actually being an economic concern,” Macharia warned attendees in early April.
At the time, despite relatively low levels of confirmed cases, African economies were already feeling the pinch with stock markets plummeting and currencies devalued. A few weeks later, as the threat escalated, the UN Economic Commission for Africa (UNECA) declared that a funding gap of $100 billion needed to be filled in order for governments to battle the pandemic, and its consequences, across the continent.
“The long-term economic effects will become more apparent in the coming months. Inputs not available locally will be inaccessible due to tighter border controls, while markets, for producers serving several industries, will be diminished, leaving many households without a sustainable income,” predicts Macharia.
If they are to have any hope of success, Macharia emphasizes that responses to Covid-19 in Africa will have to be a collaborative effort.
“Flattening the curve demands that governments, institutions, and business leaders are intentional in how they implement their response strategies. Organizations will need to go beyond [their] usual business continuity planning while the public sector needs to re-model institutions in order to slow down the current trajectory of infections while ensuring long-term resilience.”
An example of these wider response strategies are already at work in a number of Kenyan hospitals. Dr Michael Mwachiro, Secretary-General at the Surgical Society of Kenya, is currently stationed at Tenwek Hospital, a faith-based teaching and referral hospital in Bomet County, 230 kilometers west of Nairobi. On May 13, the county recorded its first Covid-19 fatality, at Longisa Hospital, the only public referral hospital in the area.
“We’re now seeing more community-transferred cases in Kenya. I think the advantage that we may have had [compared to] other parts of the world is that we were watching as things were unfolding and, because of that, we had a bit more time to prepare [as a country], and put some measures in place. But if you read the news, or listen to the radio, you’ll hear people complaining that we should have intervened earlier but that’s a difficult thing [to do] if you look at how many stakeholders are involved along with the nature of our economy and public health system,” he says.
Part of these preparations, Mwachiro says, included immediately training the country’s health workers on Covid-19 procedures along with introducing measures preventing the movement of people from hotspots in major cities into rural Kenya, where a bulk of the population lives.
“Nairobi and Mombasa already have containment measures in place. The bigger concern is that, if Covid-19 moves out of the cities to other parts of the country, the effects would be much scarier. These [rural] areas are where the older people are, who are much more vulnerable.”
In addition to the supplementary training for medical personnel, some elective procedures and non-essential surgeries have been put on hold so that all available resources can be committed to fighting the virus at hospitals. However, besides preparedness, maintaining the morale of doctors and nurses will continue to be an ongoing concern throughout the crisis.
“We’ll have to deal with the levels of anxiety and motivation experienced by healthcare workers and first responders taking care of these patients. Doctors and nurses are human, too, and they are experiencing the same emotions as everyone else. You can imagine that, in as much as [their] families are worried about them, they, too, are also worried about their families, and themselves, as well,” he says.
Some medical professionals responding to the crisis, in parts of the country, have had to make the difficult decision to live apart from their families as they work to contain the virus. But the taxing nature of their work, coupled with extended periods of isolation, means that counseling and support services will need to be made available to them as the cases continue to rise.
“We’ll have to deal with the levels of anxiety and motivation experienced by healthcare workers and first responders taking care of these patients. Doctors and nurses are human, too, and they are experiencing the same emotions as everyone else. You can imagine that, in as much as [their] families are worried about them, they, too, are also worried about their families, and themselves, as well.”
As it stands, Kenya, like most of the continent, has not been as badly hit when compared to epicenters in Europe or North America. However, this may be due to the fact that the worst is still on its way. In May, the World Health Organization estimated that up to 190,000 Africans may be killed by the pandemic, at its peak.
With Covid-19 due to exert immense pressure on our public health systems, it does offer some important lessons for the future, explains Mwachiro.
“What this outbreak has brought about, for us in Africa, is [the fact] that we need to invest more in our healthcare systems. This has been said so many times… there have even been a number of strikes [in Kenya] by various stakeholders, all of them trying to highlight these issues. This is a good wake up call. I honestly believe that, if we had spent more on health [before the crisis], it would have gone a long way in helping us to be better prepared. Hopefully, once this [pandemic] resolves, we can keep the momentum going and we can continue looking inwardly for solutions.”
Naturally, Covid-19, with its grim predictions and disruption of lives, has many Kenyans worried about the future. Nevertheless, the challenges of the moment are being met in stride. Families have quickly adjusted to new ways of living while their leaders seek sage advice on how best to address the crisis, and doctors continue to make sacrifices, day in and day out, as they brace for the worst.
Perhaps, most important of all is that, in the pandemic’s wake, hope has become an obstinate presence in all quarters of Kenyan society.
– Marie Shabaya
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