Tuesday, May 10, 2016

Phalombe’s long road to sexual reproductive health services

The thick, brown dust along the Chitakale-Phalombe earth road symbolises challenges encountered by Phalombe District residents in accessing free public health services very well: Without a public district hospital, the road to good health has never been smooth and clear.

“The challenges associated with accessing healthcare services, especially sexual reproductive health (SRH) care services, have been more pressing on women than men,” observes Philles Jailosi, Phalombe Women’s Forum chairperson.

Her forum provides a platform for women to discuss issues that affect them, and Jailosi observes that two issues often crop up during meetings: Poor access to SRH services and violence against girls and women.

“One of the challenges we face is that some men, in most cases married men, impregnate school girls. Worse still, some men forcibly sleep with their step daughters, leading to increased cases of unwanted pregnancies. Of course, we have established committees at Traditional Authority level, but it is impossible to completely bring these cases to a halt,” says Jailosi.

However, while acknowledging that pregnancies arising out of acts of incest, defilement or rape may be a burden on girls, Jailosi clearly states that advising the affected girls to go for safe abortion services is out of the question.

“We do not condone the practice of terminating pregnancy, whatever the case, because we believe that, under whatever circumstances, a girl or woman is not supposed to terminate pregnancy. It does not matter whether a girl wants to terminate the pregnancy in a public or private health facility, we do not condone that and all women and girls here know that,” says Jailosi.

This, more likely, may increase chances of pregnancy-related deaths. A report titled ‘Epidemiology of Maternal Mortality in Malawi – 2nd edition’, produced by Cameron Bowie and Eveline Geubbels under the Department of Community Health, College of Medicine, University of Malawi, indicates that pregnancy-related death refers to “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death”.

This is the definition used in Malawi demographic health surveys, but not the one that was used by the United Nations in calculating maternal mortality for the Millennium Development Target 6 of Goal 5— which sought to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. The Millennium Development Goals have been replaced by Sustainable Development Goals.

Challenges faced by the victim of incest, rape or defilement in Malawi are compounded by the fact that the medical procedure of terminating pregnancy is allowed only on the ground that the life of the woman is in danger. But, for the Phalombe girl, other challenges come into the balance, among them lack of a public district hospital and the fact that the hospital that serves as a district hospital— Holy Family Mission Hospital— is affiliated to a religious institution, the Catholic Church.

Just on March 13 this year, in a Pastoral Letter titled ‘Mercy of God as a Path of Hope: On Current Socio-Political and Economic Issues in Malawi’, Catholic Bishops condemned pro-abortion campaigners.

“On the evils of promoting abortion and its unlawfulness, we already made our position clear to you through our 2013 Pastoral letter titled ‘Catholic Teaching on Homosexuality, Abortion, Population and Birth Control’. In the face of the new campaign termed ‘safe abortion’, we are compelled to reaffirm our position on the matter as a way of offering direction and guidance.

“We reiterate our position on the right to life and dignity of every human person. In a country little by little marked by trends in the declining respect for human life, the Catholic Church proclaims that human life is sacred and that the dignity of the human person is the foundation of a moral vision for society. Our belief in the sanctity of human life and the inherent dignity of the human person is the foundation of all the principles of the social teaching. Through the agents of the culture of death, campaigning for abortion legislation, human life is under direct attack,” the bishops observed.

The Pastoral Letter was signed by Archbishop Thomas Msusa of the Archbishop of Blantyre, Archbishop Tarsizio Ziyaye of the Archbishop of Lilongwe, bishop Martin Mtumbuka of Karonga Diocese, bishop Peter Musikuwa of Chikwawa, bishop Emmanuel Kanyama of Dedza, bishop Montfort Stima of Mangochi, bishop George Tambala of Zomba and Monsignor Michael Muwowo, Diocesan Administrator of Mzuzu.

Indeed, a clinical officer at Holy Family Mission Hospital said when we visited the facility in February this year that the institution “does not offer services related to the termination of pregnancy”, but was quick to point out that it was under obligation to treat women seeking post-abortion care services.

“We do not turn women who seek post-abortion care services down. We do not even consider the circumstances that led them to terminate pregnancy. As a hospital that serves as a district hospital [in the absence of a public district hospital in Phalombe District] we find no problems providing post-abortion care services because Mulanje District Hospital also offers similar services,” said the official.

He said Holy Family Mission Hospital offers services such as consultation, casualty, dental, pharmacy, haematology, maternal and child health, labour, delivery and post-natal care, obstetrical and gynaecological services.

According to Phalombe District Health Office spokesperson, Daniel Chilomo, Phalombe public health institutions do not offer services related to the termination of pregnancy, but access to post-abortion care services is not restricted.

One commercial sex worker (CSW) from Mkhumba Village in Traditional Authority Mkhumba in Phalombe reveals, in an interview at Phalombe Boma, that CSWs in Phalombe have discovered ways of beating the system, and relocate to Blantyre City whenever they fall pregnant.

“CWSs are always in touch and that is why you will find that we easily move from one part of the country to another. We use our links to access health services away from where we work. Otherwise, we are subjected to bad attitude when we visit public health centres close to us,” she says, only identifying herself as Maggie.

Some of the public health facilities in Phalombe include Phalombe Health Centre and Namphungo Health Centre.

Chilomo also said, in cases of health complications, patients are referred to Zomba Central Hospital for further attention.

Phalombe has five constituencies— Phalombe Central, Phalombe East, Phalombe North, Phalombe North East and Phalombe South.

Healthcare challenge

The College of Medicine report, ‘Epidemiology of Maternal Mortality in Malawi – 2nd edition’ makes a number of observations.

“The main risks associated with induced or spontaneous incomplete abortion are the same as those of delivery, i.e. infection and bleeding. However, for induced abortion, lack of adequate family planning can be seen as a risk factor, because without unwanted pregnancies, no induced abortions would be carried out.

“A study in Kamuzu Central Hospital reported that admissions for abortions constituted 40 percent of all admissions to the gynaecology ward. Seventy-one percent occurred in first trimester. Incomplete abortions made up 85 percent of total and of these women, 38 percent were septic on arrival. One third needed blood transfusion. Thirty-three cases (5.5 percent) were obvious induced abortions, 30 had sticks introduced in the vagina by traditional healers and three admitted having taken ‘home medicine’. This is most likely an underestimation,” reads the report in part.

It adds that, of the women who had induced abortions, 72 percent were school girls, with the case fatality rate among women with obviously induced abortions being pegged at 9 percent while the overall case fatality rate was 0.5 percent.

The report quotes another study performed in Queen Elizabeth Central Hospital in Blantyre, Kamuzu Central Hospital in Lilongwe, Ekwendeni Mission Hospital in Mzuzu and Mangochi District Hospital. In total, 1,325 incomplete abortions were recorded in these facilities.

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