When Scholastica Kasyoka conceived her first child six years ago, she was elated at the thought of becoming a new mother. To ensure that all would be well with her pregnancy, she immediately started her antenatal clinics at a health facility near her home in Kayole, Nairobi.
During her initial ANC visits, she was given iron and folic acid tablets and was told to take one tablet each day. These tablets, she was told, would help her have a healthy pregnancy and healthy baby. And indeed, Scholastica took one tablet daily -as instructed. But just for a while, for a few days later, she stopped.
“I would feel very sick every time I swallowed them. I would feel nauseated, weak, and would many times vomit. Hard as I tried to keep up with the tablets, I just could not. So I stashed them away and carried on with the pregnancy,” she remembers.
Nine months later, Scholastica gave birth to a baby girl. But something was wrong. The nurses told her that her newborn had a problem.
“They said my daughter’s spinal cord was not well formed,” she recalls of the disheartening news that cut short her celebrations as a new mum.
Scholastica was later to leant that her daughter had spina bifida. She had never heard of spina bifida; she had no idea what it was.
“The nurses told me that my baby was born with a deformed spine because I had stopped taking the iron and folic acid tablets I had been given,” she remembers.
Spina bifida is a neural tube defect characterized by the incomplete development of the brain, spinal cord, or the protective covering around the brain and spinal cord.
Anne Mulwa, a clinician at Bethany Kids Hospital –hosted by the AIC Kijabe Hospital in Central Kenya, says that in some cases of children with spina bifida, part of the contents of the spinal canal protrude through the spinal column. Spina bifida may lead to disability.
“Spina bifida may cause difficulties with bladder control, and can lead to paralysis at the point where the bifida is highest. Depending on the severity of the deformity, people with spina bifida may be paralyzed or may have challenged mobility,” she says.
Bethany Kids Hospital is one of the largest referral hospitals in Kenya for children with disabilities and who need surgical intervention. The highest numbers of referrals are those of neural tube defects. From its inception in 2004 to the year 2012, Bethany Kids conducted a total of 14,333 surgical procedures. Operations on children with neural tube defects accounted for more than half (51%) of the total surgeries. Scholastica’s daughter Grace, is among these statistics.
Though the exact cause of spina bifida is not known, research suggests that lack of enough folic acid in the pregnant woman’s diet, more so during the first trimester when the spinal cord is being formed as a key factor in causing spina bifida and other neural tube defects. Folic acid is particularly essential before the woman gets pregnant –and within 28 days after conception.
Esther Kariuki, a nutritionist with the Micronutrient Initiative says that women, especially those in the childbearing age should make it a habit to eat foods rich in iron and folic acid, and where necessary, boost this with recommended supplements. Some of the foods that contain high amounts of these essential nutrients, Ms. Kariuki says, include; liver, meat, green leafy vegetables and fruits rich in citric acid.
“Neural tube defects happen in the first few weeks of pregnancy; usually before a woman even knows she is pregnant. It doesn’t help matters that many pregnancies are unplanned, so by the time she realizes she’s pregnant, it could be too late to prevent these birth defects.” she says.
Women who have had prior pregnancies that resulted in babies with spina bifida or other neural tube defects are also at a high risk of having a subsequent similar pregnancy. Ms. Mulwa adds that such women are advised to take folic acid even when they are not pregnant.
It is for this reason that Scholastica was put on folic acid supplements after she delivered her daughter, even though she was not sure she wanted to have a baby again –not with the problems she was facing with her daughter -a child who would need lifelong care because of her disability.
The World Health Organization (WHO) recommends daily iron and folic acid supplementation for pregnant women. The recommended daily dose is 60mg of iron, and 0.4 mg of folic acid. Doing so reduces the risk of having a pregnancy affected with spina bifida or other neural tube defects, reduces the risk of having babies with low birth weight and iron defects. The supplements also reduce the risk of maternal anaemia.
Kenya’s Ministry of Health has been implementing the WHO recommendation of daily supplements for pregnant women through its antenatal care strategies. However, the current uptake and adherence rates of iron and folic acid supplements among pregnant women has been low, according to Ms. Evelyn Kikechi, a nutritionist at the Department of Nutrition. This could be due to a combination of many factors.
One of them is pregnant women’s failure to follow the instructions given to them about taking the tablets.
“When the women are given the supplements during their ANC, many of them stop taking them once they start experiencing side effects. The side effects include nausea, vomiting, a general feeling of weakness as well as a taste of ‘metal’ in the mouth”.
Ms. Kikechi aptly describes some of the side effects that Scholastica experienced, which made her stop taking the supplements. Many women, Kikechi says, do not understand the importance of these supplements. It also doesn’t help that women delay their first ANC visit, thereby missing out on the opportunity to be given the supplements in their first trimester.
Some religions don’t allow visits to hospitals or taking of ‘Western’ medicine, thus women don’t visit ANC clinics –missing out on opportunities for the needed supplements. Pregnant women are also reluctant to vist ANC because they fear they will get tested for HIV. Others are not able to attend ANC clinics because the health facilities are far off, and they may not have money for transport. Getting to the health facility is therefore not a priority –over tilling the land and preparing meals for their families.
According to the 2008-09 KDHS, less than half (47%) of pregnant women make four or more ANC visits and only 15% access antenatal care while in the first trimester of their pregnancy. The report adds that about half (52%) receive care before the 6th month of pregnancy. The median number of months of pregnancy at first visit is above the first trimester –at 5.6 months.
Some cultural practices also stand in the way of women accessing iron and folic acid supplements. Some communities prescribe certain herbs and specific soils and stones to the pregnant women, claiming these are sufficient enough to enable them have healthy babies. But this is not always the case, where infact, eating the soils and stones could lead to even bigger health problems for the woman.
Another reason for the low uptake of iron and folic acid supplements by pregnant women is some health provider’s limited understanding on the reason for giving their clients the supplements.
“Because some health providers in the ANC clinics do not have a clear understanding of the importance of these supplements, they fail to give the pregnant women sufficient information on the same. They do not stress on the need for these women to take these tablets, so the women do not take it seriously either,” Ms. Kikechi says.
According to her, all staff at public health hospitals are currently being sensitized on the need to inform women on the importance of iron and folic acid supplements, and give them to every pregnant woman who visits an antenatal clinic. The government, in collaboration with other partners and stakeholders is also engaged in various awareness campaigns, including the use of mass media to pass on messages of the importance of iron and folic acid supplements.
But the government too has its contributory role in the low uptake of these iron and folic acid supplements among pregnant women. A Kenya Service Provision Assessment (KSPA) survey done in 2010 showed that not all government facilities were stocked with these supplements. Only 2 out of every 5 health facilities had iron tablets, while 74% had folic acid tablets.
In addition, for facilities that stocked the supplements, there were frequent stock-outs, caused by among others: communication breakdown between facilities and depots, low prioritization of IFA supplements by government, differences in forecasting by different MOH units, and inadequate budget allocation.
Even further, the current country policy on iron and folic acid supplementation requires that all pregnant women be given these supplements whether they have been screened for anaemia or not. However, current practice at the facility level is that health workers insist on screening pregnant women for anaemia before prescribing the tablets. This is despite statistics from the 2010 Kenya Service Provision Assessment (KSPA) showing that just about 36% of ANC facilities have the capacity to test for anaemia –thereby denying supplements to the ‘eligible’ target group.
To reduce the health burden of the country, stringent efforts to educate the public, especially women, on the essentials of good maternal and child health is of utmost importance. If Kenya is to achieve MDGs 4 and 5, then it needs to seriously pull up its socks. Creating awareness on the importance of iron and folic acid supplements to childbearing women and health workers, as well as policy makers will go a long way in reducing the number of children born with birth defects.