My World AIDS Day commemoration with Alliance Zambia

BY MELUSE KAPATAMOYO

For most people, the commemoration of World AIDS Day (WAD) which falls on December 1 each year entails march pasts and listening to speeches filled with frightening statistics on the high levels of HIV, I celebrated the day with staff at Alliance for Community Action on HIV and AIDS (Alliance Zambia) who observed the day in a unique way by sharing their personal experiences with and about the disease.

The organisation which deliberately commemorated WAD on December 3, 2012 so as to coincide with World Disability Day also saw staff spend part of their afternoon visiting Cheshire Homes for the Disabled in Kabulonga where they donated baby caps and clothing to care-givers.

With staff gathered in the conference room, the day started early with a preview of the short South African film “The Sky in her eye”, a story about a young girl who loses her mother to AIDS and as the film progresses, she has  to deal with discrimination not only from her peers but elders in the community. This was followed by a general discussion on lessons learnt from the movie and alternative ways of how to better take care of children orphaned by the disease and those living with it.

From the discussion it was interesting to note, that while staff agreed that financial help to those orphaned with HIV and those living with it is key to limiting some of the problems they have to endure, the consensus was that a stable family structure offering hope and love was even more important. In such a set-up, challenges like discrimination would be handled more effectively and pave way for open discussion on matters relating to HIV and AIDS.

Interestingly enough, soon after the discussion, members of staff were asked to take a 45 minute break to reflect on how HIV had impacted their personal lives. To express their emotions, they were tasked to write stories or draw pictures.

Being a naturally inquisitive person, I was tempted to walk over to their tables  so I could find out before hand what their story  or picture was about, but their facial expressions told me, they needed that alone time. As I wrote my own story, what came to mind was the courage that people living with HIV exhibit on a daily basis. I thought about a woman like Clementine Mumba who has lived positively for more than 12 years. I have never met a woman so determined to live life despite the many challenges she has had to face in the past and may continue to face in the coming years.

I thought about children born with HIV, especially those who are now in their teen years. Unlike other children who have nothing to worry about except look forward to growing up, they have to worry about their health, and how to deal with love and relationships; to pretend otherwise about their status or tell the truth and risk discrimination. But even with such challenges, they somehow find the strength to wake up each day and go on. Without realising it, the exercise had led me to deal with some of the unresolved issues I had regarding HIV and how it had impacted my life.



  Later, when we all gathered back in the conference room and began to share our stories and pictures, I realised that everyone else had experienced the same thing. Most of the members had dug deep within and shared stories about losing relatives to HIV and those living with HIV. As I listened each person read out their story and explain the messages behind the pictures, I realised just how true the phrase “If you are not infected, you are affected” applies to every person living in this world today.

A drawing of a mobile phone presented by Alliance Zambia Executive Director, Jillian Johannsen particularly caught my attention. In her explanation, simply looking at her cellphone was a reminder enough of the impact HIV had had in her life as some of the numbers belonged to friends and colleagues, she will never call because they had passed on after succumbing to the virus.

At the end of the presentations, they were teary eyes around the table and not much to say. We were all soaked with different emotions at the reality of just how devastating HIV had been in each one of our lives. Although it had clearly affected us in different ways, the impact was the same.

However, while the session may have been emotional, a quiet time of reflection was exactly what the team needed. For people whose daily work involves dealing with different issues relating to health including HIV, it is very easy for one to get caught up in work and neglect ones family and even themselves.

Perhaps timely, the session was followed by another South African documentary, ‘The Moment.’ The funny and honest film features, people from different backgrounds who share their most personal thoughts about courtship and sexual behaviour. The discussion tackles the process of sex from the “moment you meet, the moment you connect, the moment you seduce, the moment you kiss, the moment you take your clothes off and the moment before penetration.” Unfortunately, for all the participants in the documentary, the “moment to wear a condom never came.”

By the time we left Alliance Zambia premises and all drove in a convoy to Cheshire Homes, we had all relaxed and looked forward to what lay ahead. Although we found the children had gone marching to commemorate World Disability Day, the sister in-charge gave the team a tour of the facility before presenting clothing and baby caps to the care-givers.

Sister Marjorie, thanked the team for the donation making note that while the centre has received donations in the past, none were ever directed for staff, something she greatly appreciated.

Thankfully, the children arrived back in time for us to say hello. As we drove back to Alliance Zambia, I remember thinking just what a privilege it was for me to work with such an amazing group of people.PYM

Birth Attendants in Zambia to continue as escorts

By MELUSE KAPATAMOYO

For many years, Traditional Birth Attendants (TBA’s) were considered life savers, helping pregnant women, especially those living in rural areas, to deliver safely.

Statistics from the Ministry of Health indicate that Zambia functions on a limping health staff of 33, 000 as opposed to the required 60,000, therefore, TBA’s filled the gap in the healthcare system. Their role included paying expectant mothers periodical visits to educate them on the importance of delivering with a trained person and the importance of attending ante-natal.

However in December 2010 government made a shocking announcement putting an end to the main role that TBAs had been known for; they would no longer help pregnant women to deliver. Instead their new role would involve educating women on the benefits of delivering at health care facilities as opposed to home.

Under the new rules, traditional birth attendants are to give information to communities and women on the danger signs in pregnancy, the need to go for ante-natal, testing for HIV and all other reproductive issues that maybe necessary. They are also to escort the pregnant woman to health facilities to deliver.

At the time Ministry of Health spokesperson, Dr Kamoto Mbewe told the press that because TBA’s were unable to address complicated and life-threatening complications such as excessive bleeding which can occur during birth, they were contributing to high levels of maternal mortality rates in Zambia.

He said such complications needed the attention of qualified medical personnel. Unfortunately,  because of women’s dependence on TBA’s due to long distances to health care centres and limited staff, they were shunning healthcare centres were they could receive comprehensive check-ups, treatments and care, during ante-natal, actual delivery and post-natal.

The World Health Organisation (WHO) estimates that out of every 100, 000 women who give birth, 591 die. And for each woman who dies, an estimated 100 survive child bearing but are afflicted by disease, disability or physical damage caused by pregnancy-related complications.

In addition, while ante-natal coverage in Zambia currently stands at 94 percent, only 47 percent of births are attended to by a trained midwife.

Government’s decision to halt the delivery of babies by TBA’s was highly criticised, more so in rural parts of Zambia where people have to walk long distances to get to health centres where they would have to wait in a long queue before being attended to. That is, if the health post was lucky enough to have trained medical staff.

Some people living in remote areas such as Mungule in Chibombo district, feel instead of saving lives as intended by government, realigning the duties of TBA’s from delivering to being mere escorts, has led to increased fatalities among pregnant women and their babies.

“Since the ban, the situation has become worse. Many women are dying. Some people live very far, and it’s worse during the rainy season. How do you expect a heavily pregnant woman to jump on a flooded river, most of these health centres do not have shelters so you can’t expect a woman to come weeks before delivery,” noted a former TBA who preferred anonymity.

As an alternative to discontinuing part of their services, she said they should have been offered additional training to help them cope with rare complications which sometimes occur during delivery.

She was trained back in 1996 by UNICEF and says she has delivered more than 300 babies in rural areas.

“A woman who has gone through labour knows the pain of labour, but when a mother delivers and hears that first cry from her baby, she is overwhelmed by joy. Unfortunately, there are now fewer women experiencing that joy. In our community, we are seeing more women and their babies die during delivery.”

Without the availability of trained birth attendants, pregnant women have been left with no choice but to rely on family members who have no training.

She described a recent incident where both mother and child died during labour. The neighbour who had been called upon to help with delivery accidentally pulled the umbilical cord too hard that it cut.

“Such an incident could have been avoided. We have been trained to handle such unexpected occurrences. If it was something we could not handle, we tried our best to get the woman to a health centre, or get a health staff to the woman,” the TBA explained.

It is because of such incidences that she has gone against governments regulations and helped women deliver. Some women gave birth on their way to the health centre while others simply lived too far to travel.

“If a woman comes to me for help, I cannot chase that person away because if I did their blood will be on my hands. I know what the law says but I can’t bear to see a woman in such pain and do nothing,” she said.

Despite these concerns, government says it will not rescind its decision. But, in emergency cases, such as when a pregnant woman is ready to deliver while being escorted to a health facility, the TBA can help with the birth.

“We understand that sometimes it’s difficult to find transport in time. Some people also find it difficult to tell when they are about to deliver. During those emergency cases, there is little anyone can do. The TBA can help deliver but it must be emphasized that we want all deliveries in a health facility,” explained, Dr Mbewe.

He said when TBA’s were introduced the idea was to help in the reduction of maternal mortality, but it was later discovered that they were unable to manage the five major causes that lead to death.

They are; hemorrhage (bleeding) during or after pregnancy, hypertensive disorders, unsafe abortion, infection and obstructed labour. Malaria in pregnancy, anaemia and HIV are other indirect causes that can lead to death.

“If you look at all these causes, if a woman is bleeding, the TBA will not be able to stop the bleeding. If she has an infection, again the TBA will not be able to manage the infection. It was with that realisation that we are now encouraging as many women as possible to deliver in the health facility.”

Another concern was that while in the past experts believed they could tell a woman whose pregnancy was at risk, recent data shows pregnancies considered to be at higher risk experienced recorded fewer deaths.

For example, a woman who had delivered at least five children would have been said to be at higher risk of bleeding after delivery, because of undergoing too many deliveries, the uterus may become flabby and not contract well after delivery.

At low risk were women who had never been pregnant before.

But overtime, results have shown that most of the deaths occurred in women between ages 20 and 29, women considered to be at low risk.

In a developing country like Zambia where access to emergency obstetric care is not readily available, for a woman who has delivered and starts to bleed, she only has two hours or less to seek medical attention. Those with obstructed labour can last upto 72 hours.

Dr Mbewe added, “If she is in hospital and is bleeding, the nurse will give the women a drug to stop the bleeding, if it’s a tear in the birth canal, we can suture, if the placenta has gotten stuck, we have trained the staff to conduct manual removal of the placenta. They can actually push in the hand and remove the placenta. Nurses are also trained on how to manage incomplete abortions e.g women who have had miscarriages or induced abortions. All these things can’t be done at community level.”

In 2010, government launched the Campaign on Accelerated Reduction of Maternal Mortality and formed Safe Motherhood Action Groups (SMAGs), where TBAs have now been incorporated.

A 2011 report on the Planned Parenthood Association of Zambia’s Global Poverty Action Fund “No woman Should Die While Giving Life,” a project funded by the UK Department for International Development (DFID), SMAGS are trained to assist women during their pregnancy.

They disseminate information to community members about pregnancy, childbirth and family planning, and work to challenge local awareness on maternal health, sensitise the community on the importance and benefits of seeking early ante-natal care, and educate people on the benefits of birth preparedness and transferring to a healthcare centre in advance to seek skilled and specialised care once in labour and during labour.

However, the overall objectives of the SMAG programme are; to strengthen community participation in maternal, newborn, child health. To improve community knowledge on safe motherhood and issues through health education, enhance the community’s utilization of reproductive health services, increase male involvement in safe motherhood activities and also strengthen partnerships between the community and health system.

Government is also up-scaling the training of midwives to meet the country’s demands.

“We have introduced direct entry into midwifery whereas before they had to train as a nurse and work before going for the midwifery course, they train for two years. We have also increased uptake of nurses and doubled in schools, all this in an effort to increase the workforce,” said Dr Mbewe. 

In addition, in its 2013 budget, government has allocated K3.6 trillion, equivalent to 11.3 percent of the budget to health, and it intends to recruit not fewer than 2, 000 front line medical personnel.

The topic of whether or not, TBA’s contribute to the reduction of maternal and mortality remains a hot-button issue in many African countries.

In 2007, TBA’s were banned in Malawi, but reinstated later in 2010, with Malawian president Mbingu-wa-Mutharika admitting the Ministry of Health had made a ‘grave mistake.’

UNICEF Zambia recommends the involvement of traditional birth attendants to create demand for government-led maternal and child health and nutrition services, including encouraging pregnant women to go for ante-natal care.

Chief of Communications, Patrick Slavin said “TBAs are part of UNICEF-supported Safe Motherhood Action Groups (SMAGs) in all 10 provinces of Zambia, an important approach to lower Zambia's unacceptably high maternal mortality rate. TBAs can also provide care for women when they are recovering following giving birth.”

He said UNICEF is also advocating for more mothers shelters in the country, which are urgently needed.PYM

Mungule women hatch new family plan for 'overbearing' hubbies

By Meluse Kapatamoyo

When couples get married, they become one, literally meaning all decisions and plans made are done jointly and in consultation with each other. But, when it comes to matters of family planning, the women of Mungule have no say. The men plan the family and choose the kind of birth control method to use disregarding the women.

There is a case of a young woman in Mungule who had three children within a space of five years. She bore her first child at age 16. Before she turned 18 she had her second and the third one came when she was celebrating her 21^st birthday.

There are a lot other women who have similar situations of having that many unplanned children in the area.

During Alliance Zambia’s community dialogue at Mungule Rural Health Care, mothers aged between 17 and 43 testified that despite being the ones that carry the pregnancy, the decision of when to get pregnant was made by the husbands - many of whom unfortunately, have not embraced the different birth control methods available at health centres.

In areas like Mungule, the old belief that a man is defined by the number of children he has, still very much exists. Even when the man agrees to use condoms during the first few months after delivery, the rubber is put aside as soon as the child turns a year old. Thus many women find themselves pregnant soon after, as their spouses do not allow them to be on birth control.



One woman shared her that: “my husband demanded I get pregnant soon after my baby turned six months old. He said by the time I delivered, the child would be old enough to have a sibling. I insisted that we needed to wait until the baby was at least two years. He refused and threatened me with divorce. I got pregnant two months later and delivered my second child when my first born was 1 year 7 months.”

The consensus among the group was that given a choice, women would have preferred to have waited at least three years to allow for the proper growth of their children before getting pregnant again. They worried about their inability to provide their children with good nutrition and a good education.

Having realised the benefits of child spacing on the family, especially on the children, the women have taken a more aggressive approach to prevent further pregnancies.

They are now using different and discreet birth control methods without the knowledge of their spouses. Injectables, are quiet popular. Unlike contraceptive pills, the mothers say the possibility of the man finding out about the injections was zero.

One woman explained that for some who prefer contraceptive pills, they have devised interesting ways of ensuring that the tablets are well hidden from their husbands.

“I have dug a hole outside in the field. They are wrapped in a plastic bag just in case it rains. Sometimes it’s difficult to take the pill especially when he (husband) decides to stay home but most times I take them freely. I plan on telling him when the time is right. Maybe if he realises that I am not getting pregnant, he might accept that the six children we have are enough. Right now, we are struggling to feed, clothe and educate them,” she said.

And in Malupande Village, located about 4 kilometres from Mungule Rural Health Centre, the story was the same. The women, too, have had to find clever ways of keeping their husbands from finding out that they were using birth control.

They hide the contraceptive pills under rocks or with neighbours. Those afraid of being seen at the health centre, rely on a traditional herb called Nkankalamba, also popularly known as Kalulalula. The herb is soaked in water and the juice consumed soon after sexual intercourse.

While some women are willing to go to extremes to ensure they do not become pregnant, others have avoided using family planning methods because of the belief that they cause various tumours and diseases such as cancer. Others simply believe family planning methods as advocated at health centres do not work. Some of the mothers revealed having friends who got pregnant despite being on birth control.

But Isaac Phiri the facilitator of the dialogues from Bwafwano Integrated Services (BISO) advised the women to seek medical advice from trained health experts at clinics and also Neighbourhood Health Committees (NHCs).

He assured mothers that none of the family planning methods available at health centres caused tumours or different types of cancers as was the fear by some women.

Mr Phiri also warned the women against burying contraceptive pills in the ground as the temperature in the ground was likely to interfere with the effectiveness of the pill.

The community dialogue in Mungule was organised by the Alliance for Community Action on HIV and AIDS (Alliance Zambia), with support from Save the Children Sweden (SCS), under the project, “A Concern for All: Maternal and Child Health Interventions Towards 2015.” PYM