maryannewaweru

A Kenyan Journalist Writing About Health

Archive for the category “Mothers”

Fistula: When Childbirth is a Cause for Misery

By Maryanne Waweru-Wanyama

Lovina Okwara is a bubbly 17-year-old whose broad smile, infectious laughter and carefree attitude is evident of a young woman enjoying her life. However, this has not always been Lovina’s attitude. For the last four years, her life has been one of misery.

Lovina traces it all back to four years ago when she gave birth to her daughter. An occasion that was supposed to bring her untold joy and happiness turned out to be the beginning of her nightmare. She recalls the day.

“My mother helped me birth my baby in our small house. Maternity services were not free back then so going to hospital was not an option as I had no money,” Lovina says, adding that the baby’s father, also a young man, had no financial means either.

Lovina comes from Teso district, Western Kenya. She comes from a poor background and so do many of her neighbours. Many of the women deliver their babies at home with no skilled care — among the reasons being personal preference, ignorance and poverty. While some women and children die during childbirth, Lovina and her daughter are among the lucky who survived.

But it was not an easy survival.

“I laboured for about 48 hours and when my baby finally came, I was exhausted, physically damaged and in pain. My private parts had been ripped apart during the delivery,” she remembers.

A few hours later, Lovina noticed she was unable to control her flow of urine and faeces.

“When I sat, I felt wetness overcome me and when I looked down, I noticed I was urinating on myself. I also noticed that my underwear had stool. Worried, I asked my mother about it.”

Lovina’s mother reassured her that the leaking urine and faeces were nothing to worry about, that many other mothers experienced it too.

This situation would see Lovina, who dropped out of school in class seven, eat very little food and take few sips of liquids to avoid quickly filling up her bladder and bowels.

“I would starve myself yet I was breastfeeding. I also stopped laughing as this would make my urine gush out. Even though I am grateful for my daughter, it has been a harrowing experience for me ever since she was born,” she says.

When Lovina, a causal labourer in Nairobi, tried to seek treatment for her condition, she learnt it would cost her about Sh30,000, money she could not raise. So it therefore came as a pleasant surprise when in July this year, she came across information about a free fistula medical camp at Kenyatta National Hospital.

Lovina wasted no time in going to the hospital for screening and a few days later, underwent a successful fistula repair surgery. Today, she is a happy teenager who has since regained her cheer and laughter which had been taken away by the fistula she suffered for four years.

Lovina Okwara

Photo: Lovina Okwara

Lovina’s fistula is likely to have been caused by the prolonged labour she went through. According to Dr Stephen Mutiso, a gynaecologist and fistula repair surgeon at Kenyatta National Hospital, obstetric fistula is a childbirth injury that develops due to prolonged and neglected labour which becomes obstructed.

“Obstructed labour causes destruction of vaginal tissue which leads to the development of a hole (fistula) between the bladder and birth canal. This causes urine to leak continuously through this hole. When the same damage occurs between the rectum and the birth canal, faeces leak continuously from the rectum to the birth canal,” he says.

Prolonged labour is that which goes on for more than 24 hours and according to the World Health Organization, obstructed labour accounts for up to six per cent of all maternal deaths. Dr Mutiso says that majority of the patients who present with fistula often have laboured for three to five days at home usually under the assistance of relatives or traditional birth attendants. In most of these cases, nine out of ten babies are born dead. Many of the women are from remote areas where the overall infrastructure is poor and they are unable to reach hospitals in good time.

In Mwingi district, Kitui County in Eastern province for example, women have to walk long distances in rough terrain to the nearest health centre. And when they get there, lack of personnel as well as lack of equipment and supplies is yet another challenge. A case example is Nyaani dispensary in Nuu location, where there is only one health worker, a community nurse who attends to all patients seeking services there. Nyaani dispensary serves a population of about 7,000 people.

Without a theatre or other basic equipment necessary for handling birth complications, the nurse has to call for an ambulance from Mwingi District Hospital which is 79km away. By the time the ambulance arrives and gets the pregnant woman to hospital, about four hours have elapsed. And this is when an ambulance is available. Many times it is not.

“A pregnant woman experiencing a birth complication and who is referred to the district hospital often has to use public transport. Public vehicles are hard to come by because of the poor state of the roads. Sourcing for transport and eventually getting to the hospital can even take a day,” says Damaris Wanjiru, the nurse in-charge at Nyaani dispensary.

Interestingly, while Damaris sees an average of 12 pregnant women a month attending antenatal clinics, she only delivers about three babies a month, with the rest delivering at home. Lack of transport is one of the major reasons the women cite for failing to make it to the dispensary when labour checks in.

Eastern province is one of the regions that bears the highest number of fistula cases. Other areas include Nyanza, Coast and Northern Kenya regions, as well as West Pokot. It is important to note that fistula can affect any woman regardless of her age, marital status, education level or income status. For as long as she experiences prolonged and obstructed labour and does not have access to emergency and quality obstetric intervention, then she can develop fistula.

In Kenya, there are an estimated 300,000 women living with fistula, with an occurrence of about 1,000 new fistulas each year, according to Dr Mutiso.

The consequences of fistula on the woman are dire. Stella Mburu, a nurse at Mbagathi District Hospital and who has been trained in fistula care, says that in most of the cases, the woman is emotionally pained following the loss of her baby. In addition, she has to deal with the continuous leaking of urine or faeces which make her smell foul. Most women from poor areas cannot afford fistula repair surgery and therefore use pieces of old cloth or mattresses to contain the leaking urine or faeces.

“They face rejection by their families and communities and because of the stigma, they soon stop going to public places such as the church or the market. They also stop attending social gatherings like weddings or chama. They also find it hard to find employment or engage in business. Some women experience domestic violence while some are disowned by their men who leave them to marry other women. Some women suffer depression as a result,” she says.

The good news is that fistula is treatable. Small fistulas can heal if a urinary bladder catheter is inserted for about four weeks immediately the fistula occurs. Surgery is the other option. However, the costs of surgery remain far beyond the reach of many women affected by fistula. In public hospitals, fistula repair surgery costs between Sh20,000 and Sh40,000 which is a subsidised fee. In private hospitals the price is much higher.

For women such as Lovina who cannot even afford the subsidised cost at government hospitals, they are lucky to benefit from organisations that sponsor their treatment through free fistula medical camps. Her surgery was made possible by the Freedom from Fistula Foundation, the Flying Doctors Society of Africa and Kenyatta National Hospital.

Fistula can be prevented by delaying the age of pregnancy and ensuring that all women have access to quality maternal care. The free maternity services in public health facilities are aimed at encouraging more women to deliver in hospitals under the supervision of skilled birth attendants to reduce negative maternal outcomes such as fistula.

Article courtesy: The Star

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Dads Have an Important Role to Play in Breastfeeding

By Maryanne Waweru-Wanyama

Many new mothers know that breastfeeding their babies is the best way to give them a healthy start to life. The good thing is that most fathers know this too! Indeed, the benefits of breastmilk abound.

Breastmilk is the perfect food for babies as it provides them with all the nourishment they need for their first six months of life. Because of the antibodies in it, breastmilk increases a child’s ability to fight off infection. This means that a breastfed baby has fewer trips to the doctor because of their strengthened immune system.

Less medical bills also means the family is able to save and channel their finances to other investments. In addition, the skin-skin touch during breastfeeding between mother and baby enhances the lifelong bond between them.

The World Health Organisation recommends that babies be exclusively breastfed for the first six months of life — meaning they take breastmilk only during this time. To achieve this goal, a mother needs support from the people around her and one of the most important people who can support her is the baby’s father.

Interestingly, breastfeeding does not come easy for most new mothers, and many need to be taught how to go about it. If her baby does not latch properly, then she may experience problems such as cracked, bleeding nipples which can cause her unbearable pain and discourage her from going on.

Also, when baby does not latch properly, it means he is not feeding well and this may cause him to become dehydrated. Her husband can assist in ensuring that she leaves the hospital having been taught how to place baby on the breast for a proper latch. He can be present as she is taught how to do so for purposes of assisting her after their return home in case she experiences latching difficulties.

Being a new mom can also take a toll on even the strongest of women. The fatigue of the nine-month pregnancy coupled with sleepless nights, changing diapers, rocking the baby to sleep, hosting visitors during the day, nursing a wound if she delivered via caesarean section, bathing baby and other such tasks can be quite challenging. When a nursing mother is stressed, it can affect her ability to produce sufficient milk for her baby.

Her partner can help by undertaking some of these chores, such as changing diapers, bathing baby or taking him out for walks to get some sunshine.

When the baby wakes up at night, the father can pick him up from his crib and bring him over to his mother for nursing. After the breastfeeding session, the father can take him again, burp him and then rock him back to sleep. This allows the mother to rest before the baby’s next feed.

Due to the dietary needs of a breastfeeding mother, her husband can ensure that her food is well balanced by doing grocery shopping and buying all the foods and supplements she requires. In between night feeds, he can offer his wife a glass of water, prepare her a cup of hot chocolate or warm some porridge for her.

More importantly, he should support her emotionally and offer her words of comfort on the days she feels overwhelmed. If left unchecked, the rigours of being a new mom could lead to post-partum depression. He should ensure her environment is stress-free and he should never stop showing her genuine love, concern and care.

When her husband is supportive, a new mother is able to breastfeed for longer thus giving her baby a healthy start to life. Men should remember that babies who are breastfed exclusively for the first six months have stronger immunity, meaning less hospital visits in the future and less financial costs for the family. They should know that investing in breastfeeding is investing in their child’s healthy future.

Article courtesy: The Star

Does Being Short Disqualify a Pregnant Woman from Natural Birth?

By Maryanne Waweru-Wanyama

When Valerie Kasaya was in her eighth month of pregnancy, she one day noticed an unusual discharge. Having had a smooth pregnancy all along, the discharge deeply worried her.

A resident of Kawangware slums in Nairobi, 20-year-old Valerie decided to go for a checkup at a public health facility in Westlands, a distance of about 14km away. That is where she had been attending her antenatal clinics.

At the clinic, Valerie was informed that her cervix had started opening, that she could give birth anytime. The nurses further told her to begin preparing for a caesarean section as it would be impossible for her to deliver naturally.

“Nurses told me that because I was short, this meant that my pelvic bones were small, indicating that a natural birth would not be possible,” she recalls.

Valerie is just about five feet tall. The attending nurse then referred her to Kenyatta National Hospital (KNH) since the clinic did not have the facilities required for the surgery.

“Even though I was disappointed to learn that I would not deliver normally, I trusted the medic’s verdict because they are the experts,” she says. But back home, Valerie’s mother would hear none of it.

“My mother insisted that I could still give birth naturally. She said she had seen shorter women than me deliver naturally. She asked me to seek a second opinion, and accompanied me to a nearby clinic.”

Valerie Kasaya with her baby

Photo: Valerie Kasaya with her baby.

At FreMo clinic, a small privately-run health centre that serves the low-income population of Kawangware, Valerie and her mother were excited to learn that physical stature alone is not enough to determine if a woman will give birth normally or not.

“The midwife at FreMo said they would let me try natural birth first and if it failed, then they would refer me to KNH for a caesarean section,” recalls Valerie. She was then sent home and asked to return when labour started.

A few days later, labour started, and she immediately walked to the clinic — a distance of about two kilometres. During labour and while waiting for her cervix to fully dilate, the attending midwife helped Valerie engage in some exercises.

“She made me swing my hips, squat, and also instructed me on how to breathe. She said all this would help the baby descend, as well as ease my labour.”

Four hours after the onset of labour, Valerie delivered a healthy baby boy weighing 3.1kg. During delivery, it was just her and the midwife and she had a smooth delivery with no complications. She did not even have an episiotomy (surgical incision on the posterior vaginal wall during labour).

“I was surprised because I had successfully delivered my son naturally, yet other nurses had told me that I was a direct caesarean candidate because of my small stature,” she says.

Both mother and baby continue to enjoy robust health with no complications. Her son is now seven months old. Magdalene Katuku, the midwife who helped Valerie birth her baby, says that it is possible for short women to deliver naturally.

“Natural birth is determined by a number of factors, and it is wrong for one to make assumptions based on height alone. Having a small stature does not disqualify one from a natural birth. It all depends on the size of the baby, and the size of the pelvis. A big woman can have a small pelvis, which may not allow the baby to pass through, as her baby might be big. In the same breath, a small woman can have an adequate pelvis that may allow her baby to pass through,” she says.

At FreMo clinic, Magdalene says the emphasis is on natural delivery. Last year alone, of the 211 deliveries, 207 were natural births, with four being referred for caesarean section to KNH when there were obvious indications that a normal delivery would not be possible.

Magdalene says that their successful rate for natural births is by design, not coincidence. “Throughout the pregnancy, we help the women engage in certain activities that help keep her fit and which boost her chances for a natural birth,” she says.

Pregnant women who attend clinics at FreMo learn about chest stretches, which reduce pregnancy aches and pains and improve blood circulation. They also learn about exercises that reduce back pain — a common concern in pregnancy.

In addition, the midwives teach the women how to do special press-ups, which help prevent aches and pains due to the growing belly. “We encourage the pregnant woman to walk throughout her pregnancy. Walking is a good cardiovascular exercise, and helps keeps her fit. She should however be cautious not to walk to the point of exhaustion or breathlessness,” says Magdalene.

FreMo clinic also offers free childbirth classes for women in their last trimester. Here, they are given information about the birth process, where they are taken through the stages of a natural delivery.

“We encourage them to come with their spouses for moral support. It helps the couple prepare themselves psychologically for labour, and build their confidence about the birth process. During childbirth classes, we answer all their questions as they share their fears and expectations. We reassure them, helping them build confidence in the body’s ability to birth a baby,” she says. Their partners also learn how they can support the woman during labour, such as helping her with breathing exercises and massaging her back.

During labour, the pregnant women are encouraged to squat, as this not only speeds up labour but also fastens the opening up of the pelvis, providing room for the baby to descend. They are not encouraged to lie on their back, as this slows down baby’s descent therefore prolonging labour.

“We are also never in a hurry when the woman is labouring. We are patient with her, and attend to her throughout the birth process, the ultimate goal being a healthy baby. Due to the close monitoring, we are able to assess and anticipate any complications that would necessitate an immediate referral and transfer to KNH, which we facilitate as we offer them transportation. All the above are what we believe has led to our high success of normal deliveries,” she says.

 

An expert’s view

Is it possible to tell if a woman will not be able to have a natural delivery judging solely by her height? According to Dr Stephen Mutiso, an obstetrician / gynaecologist at Kenyatta National Hospital, a diagnosis of cephalo-pelvic disproportion (CPD) is often the key determinant in such cases. Cephalo refers to the size of the baby’s head, and pelvic means the size of the birth passage.

A diagnosis of CPD means that either the baby’s head is too big for the woman’s pelvis, or the pelvis is too small for a normal sized baby. In women diagnosed with CPD, normal delivery is difficult and at times impossible.

“Small women tend to have a small pelvis, and are likely to have difficulties during delivery. Any woman with a small pelvis and whose baby indicates being slightly bigger compared to her pelvis is not advised to try normal delivery,” he says.

However, Dr Mutiso clarifies that there are short women who have small babies and go on to have successful normal deliveries, hence the need for proper assessment by the health professional during antenatal care or when labour begins.

“This assessment will help determine if the pelvis is adequate enough to allow baby to pass through. If the baby’s size is small to average, then labour should be considered,” he says. Dr Mutiso warns of attempts to push a baby that cannot pass through a small pelvis.

“This could lead to prolonged labour and cause obstruction, which in turn may result in complications such as fistula, rupture of the uterus, serious infection, excessive bleeding after birth and foetal distress. In some instances both mother and baby may die.”

Dr Mutiso says that in the event vaginal delivery goes on to take place, the mother can sustain serious perineal tears or cause damage to her reproductive organs. Further, caesarean deliveries done when one has been trying to push are more difficult and associated with increased complications.

“In as much as most pregnant women plan to delivery naturally, it is necessary for them to understand that complications may arise during labour, and which may necessitate a caesarean section. These complications include failure for labour to progress despite good contractions, foetal distress and excessive bleeding.”

Article courtesy: The Star

Warning Sins in Pregnancy: When to Call Your Doctor

During pregnancy, many women have lots of questions and queries. Some of them we ask our moms, our aunts, our friends, our colleagues, and some of us go to Facebook to seek answers :) . But, when does it become obvious that you need to call your doctor or midwife, or visit the health center immediately?

Dr. Stephen Mutiso, a consultant obstetrician/gynaecologist at KNH is our guest writer today and he lets us in on the warning signs –when a pregnant woman should seek a medic’s opinion as soon as possible.

*Antenatal care entails monthly visits to the clinic till 28 weeks gestation, then visits every two weekstill 36 weeks, and thereafter weekly visits till delivery –for those progressing well. However, sometimes there is variation from this schedule, and this depends on the needs of the expectant mother.

However there are certain situations when it becomes necessary to get in touch with your gynaecologist on an urgent basis before the next visit. This is especially when certain complications develop.

Complications during pregnancy and childbirth are common. Infact, approximately two out of every five pregnant women experience some complication during pregnancy, childbirth and postpartum period. 15 percent of pregnant women develop life-threatening complications. Most complications cannot be predicted and can happen at any point during the antenatal period, during delivery or post-delivery. Therefore, all pregnant women should be prepared to respond appropriately when complications arise by contacting their care givers immediately.

There are certain symptoms which if present denote that they could be serious complications hence need to act immediately. These symptoms are referred as danger signs. Knowledge of danger signs of pregnancy emergencies and appreciation of the need for rapid and appropriate response when they occur is important to avert fatal outcomes. At times, getting medical help early  makes the difference between survival and death.

The danger signs in pregnancy are: vaginal bleeding, severe headache, severe vomiting, swelling of hands and face, difficulty in breathing, fits, fever, reduction or absent fetal movements, gush of fluid, intense abdominal pain and contractions before 37 weeks. Danger signs indicate a woman needs immediate medical care.

Bleeding is a very serious complication. It causes most of the maternal and foetal deaths in Kenya. Any bleeding in pregnancy –irrespective of the amount is abnormal. When bleeding is present during pregnancy it may indicate that the placenta position is on the lower aspect of the womb (placenta praevia). Bleeding may also occur when there is premature separation of the placenta. This premature separation cuts off delivery of oxygen and other nutrients to the baby, and this could lead to the baby’s death. Other causes of bleeding in pregnancy include: rupture of the uterus and bleeding from the baby (though this is rare). Heavy bleeding after delivery may arise from different causes such as relaxation of the uterus (atony), injuries in the birth canal, incomplete expulsion of placenta and sometimes bleeding disorders.

Severe headache, swelling of hands and face, blurred vision, fits and difficulty in breathing indicate high blood pressure and need urgent attention. This complication is referred to as severe preeclampsia, and when fits are present it is called eclampsia. This disease is also deadly and delivery is the way out regardless of whether the baby is mature or not. Seekng immediate care from your gynaecologist is important.

Hotness of the body with or without vomiting may indicate presence of serious infection or malaria. Prompt treatment does save life.

When waters break it is important to call your doctor immediately, because there is a possibility that the baby’s cord can come out and get compressed by the baby’s head, thereby stopping blood supply to the baby. This can cause death of the baby. It is also very easy for infection in the uterus to set in once the waters break. This infection is life threatening. Urgent care is therefore crucial.

Pregnant mothers should be keen on foetal movements (kicks) throughout their pregnancy. Any decrease in baby’s movement may indicate that all may not be well with the baby, and so it is important for the woman to report this observation to her gynaecologist as soon as possible.

Intense abdominal pains require urgent evaluation by your doctor. Causes of severe abdominal pain include ectopic pregnancy; rupture of uterus, premature separation, infection of the kidney. At times, abdominal pain may be due to surgical diseases such as appendicitis, intestinal obstruction etc.

Contractions which occur before 37 weeks indicate premature labour. Babies born at this time could develop breathing difficulties which sometimes could prove fatal. Its advisable for expectant women to seek assistance when they start getting regular uterine contractions especially if there are more frequently than 10 minutes apart.

In conclusion, knowledge of danger signs is important because it improves complication recognition and ensures timely decision to seek care hence handling complications in good time and consequently saving lives and avoiding serious disabilities.*


Dr. Stephen Mutiso is based at the KNH Doctor’s Plaza, Suite 26/27. He provides a  wide range of  gynaecological services including: antenatal care, delivery (normal and caesarean),  infertility  treatment, fibroids, fistula surgery, screening for reproductive tract cancers and various  gynaecological operations.

Tel: 0722 678 002 or 0788 306 674

Website: drmutiso.com Email: mutisoh@yahoo.com

What Are Pregnant Women Dying From?

What are pregnant women dying from? Here are the answers.

WHO pregnant_moms

I Was Healed of Fistula Which Had for Years Embarrassed And Caused Me Agony

When nine-month pregnant Yvonne Njoki’s water broke at 7pm one Monday evening in June 2009, she was delighted as this only meant that she would soon hold her newborn in her arms. Then aged 26 years, she knew all would go well as she it had been a relatively smooth pregnancy.

Yvonne had religiously attended her ante-natal clinics at a private hospital in Gilgil, Nakuru County. So when her waters broke, she made her way to the same hospital where upon examination, she was told she had only dilated 2 centimeters.

With labor progressing slowly, the nurses attending to her decided to fasten it by inserting a tablet in her vagina to help quicken her baby’s arrival. The medicines used for artificial induction usually help soften the cervix, help it to open up, cause the uterus to contract, or stimulate contractions.

Twelve hours later and with no progress in her labor, Yvonne was inserted another vaginal tablet.  Another twelve hours later and still no sign of baby, she was inserted yet another tablet.

The following day, Wednesday morning at 7am, the medics used another induction drug, this time putting Yvonne on a drip to hasten the now stalled labor. It had been 36 hours since her waters had broken. This one worked fast for two hours later, she gave birth to a healthy boy. His birth weight was 2.7 kg.

She was attended to by two nurses who helped deliver her baby and who also stitched her episiotomy. An episiotomy is a surgical cut in the area between the vagina and the anus (perineum) made during labor to enlarge the vaginal opening.

Yvonne Njoki.

Yvonne Njoki.

Following the successful delivery, Yvonne, together with her newborn were discharged from hospital the following day. A week later, her stitches had healed quite well and she had no complications.

All went well until one month later when Yvonne began noticing some traces of stool in her vaginal discharge. After searching the internet, she was distraught to learn that she could possibly have fistula. She immediately sought the opinion of a gynaecologist who, after examining her, ruled out the possibility of fistula.

“He told me that as long I was holding my urine and faeces well, then it could not be fistula,” she remembers.

Yvonne returned home relieved, but this relief was short-lived as traces of stool in her discharge continued. Infact, the quantity of stool increased, leading her to invest in black panties to camouflage the discharge. A few weeks later, she was forced to begin putting on panty liners which would help effectively absorb the discharge.

Two years after the birth of her son and many panty liners later, Yvonne’s worry intensified as she had assumed that by then the discharge would have disappeared. She feared that she did indeed have fistula, a condition she considered shameful. She never confided in anyone what she was going through.

“I was too ashamed and embarrassed. How could I be suffering from a condition like this where I leaked faeces? Who would understand?” this pharmaceutical technologist asked herself many times.

As for her sex life, “I was lucky to be in a long distance relationship so my sex life was inactive and I liked it that way,” she remembers.

A few months later, when she couldn’t take it anymore, Yvonne decided to consult another doctor. She saw a gynaecologist who discovered a small hole between her vagina and rectum. He diagnosed the condition as rectovaginal fistula.

It was bitter-sweet news for her.

“I was sad because my worst fears had been confirmed – I had fistula, a highly embarrassing condition. But it was good news because at least my problem had been diagnosed and I could be treated. No more panty liners and stool-laden discharge,” she remembers.

She was then referred to a fistula repair specialist in Nairobi.

“The doctor examined and confirmed that I had fistula, and he further informed me that it had to be repaired as soon as possible because the hole had been getting bigger with time. Which was true because by then the stool in my discharge had continued to increase in quantity. I was doing up to five full panty liners in a day!”

Two and a half years after the birth of her son, Yvonne underwent a successful fistula repair surgery at Kenyatta National Hospital (KNH).

But she wondered what had caused the fistula.

“I had no obstructed labor and my baby was only 2.7 kg’s at birth, so I wondered how I could possibly have developed fistula. But upon further enquiry, I was informed that it could be that my episiotomy was not repaired well. I later found out that the hospital I delivered in had some unqualified staff,” she says.

“My advice to women is that they should not be blown away by the lure of private hospitals and their luxurious facilities. Sometimes they do not have competent medics. Atleast with government facilities you are sure the staff are skilled,” She advises.

Yvonne also advises people to seek second, third or fourth opinions if uncomfortable about a diagnosis.

It has been almost three years since the operation, and she is completely healed.

“I have no more leakages and I now live my life fully. I can now wear white panties and I have never worn a panty liner since the operation,” she says, beaming with joy.

Yvonne's four year-old son.

Yvonne’s four year-old son.

What is Vaginal Fistula?

A vaginal fistula is an opening that allows urine or stool to pass into a woman’s vagina – in what is known as incontinence. Women with fistula suffer from constant leaking of urine and / or feaces. Fistula is mainly caused by a prolonged and or obstructed labor

According to the World Health Organization, between 50,000 to 100,000 women worldwide develop obstetric fistula each year. Most of these cases are in developing countries.

A 2010 study published in the BioMed Central Journal on select hospitals in Kenya found that some of the risk factors for developing obstetric formula included: delays in making decisions to seek delivery services after six hours of labor onset, taking more than two hours to reach a healthy facility, and labor duration of more than 24 hours.

Women with fistula face a myriad of problems. Leaking urine and faeces can in turn lead to other medical problems such as genitals sores or ulcerations, frequent infection, dehydration and kidney disease. A lot of stigma is also associated with women who have fistula. Because of the leaking urine or feaces, they emit a constant unpleasant odour, and it is this that makes people reject, isolate and abandon them. Furthermore, because of difficult sexual relations, some husbands leave their wives. Many such women live a sad life, sometimes leading to depression and in some cases, suicide.

Fistula also has economic repercussions. Many women with this condition often experience a disruption in their normal living. Because of the associated stigma, they soon find themselves cut off from their families and friends, finding it hard to attend family, community, religious or social gatherings. Many eventually find it hard to work and earn money, driving them into poverty.

Obstetric fistula is both preventable and treatable. One way is through strengthening health care systems, which should then be able to provide accessible and quality maternal health care by skilled attendants. Access to emergency obstetrics services to all women around the country should also be a priority.

 

*This is a story that I originally published in the County Newspaper. 

What Foods Should a Pregnant Woman Eat? Should Pregnant Women Eat Liver?

What foods should a pregnant woman eat to ensure she maintains a healthy pregnancy and delivers a healthy baby? There is also lots of talk that pregnant women should not eat liver. How true is that? Dr. Stephen Mutiso, a consultant obstetrician / gynaecologist gives us answers to this.

What Foods Should You Eat While Pregnant?

Pregnant women should eat healthy foods in order to provide adequate nutrition to the growing baby. A pregnant woman must strive to eat a balanced diet, as this is crucial for the healthy development of the baby.

A diet is balanced if it contains the following: starch, proteins, vitamins and minerals. Thankfully, many of our locally available foods are rich in these nutrients, and they are affordable.

Foods rich in starch include ugali, rice, chapati and potatoes. Common sources of proteins include beans, peas, fish, milk, eggs and meat. There are many fruits and vegetables available locally which are a good source of vitamins and nutrients and include spinach and sukuma wiki.

It is also important to note that the demand for iron in pregnancy is very high and cannot be met purely through foods. That is why iron supplementation is recommended during pregnancy.

A high intake of fiber and water is recommended during pregnancy, as it helps to reduce constipation because pregnancy slows down bowel movement.

What about Liver During Pregnancy? Should you or Should you not Eat?

It is not advisable to eat foods rich in vitamin A –such as liver or if eaten, they should be eaten in moderation. This also applies to supplements that contain high doses of vitamin A. This is because high doses of this vitamin have been associated with significant birth defects, hence caution to avoid prenatal vitamins containing this vitamin. This caution is especially important for women planning to get pregnant, and during the first trimester of pregnancy when the organs are forming.

Pregnant women are also advised to avoid raw and undercooked meat which may increase risk of acquiring toxoplasmosis which may affect the baby.

Alcohol must be avoided at all times.

Should I be Eating for Two When Pregnant?

From a nutritional point of view, a pregnant woman eats for two, hence the need for her to eat nutritious food. However, this does not mean eating twice as much in pregnancy. She should focus on ensuring she eats quality food, not quantity food. Eating too much is bad both for the mother and baby and could lead to problems.

How Much Weight Should I Gain During Pregnancy?

Weight gain during pregnancy is vital in preparation for breastfeeding. The recommended weight gain for non-obese women by the end of pregnancy is 10-12kg.This translates to about 0.5kg per week. If one is obese, the recommended weight gain is about 8kg.Weight loss during pregnancy is not recommended, so one should not be on a weight-loss diet.

Most of the weight gain occurs after 20 weeks of pregnancy when nausea and vomiting has reduced or even ceased.

Gaining too much weight increases the risk of gestational diabetes, backache, high blood pressure and a likely caesarean section due to a big baby. Too little weight gain can lead to low birth weight and premature birth.


Dr. Stephen Mutiso is based in Nairobi, and he provides a wide range of gynaecological services including: antenatal care, delivery (normal and caesarean), infertility treatment, fibroids, fistula issues, and screening for reproductive tract cancers, and gynaecological operations.

He is based at KNH Doctor’s Plaza, Suite 26/27

Tel: 0722 678 002 or 0788 306 674

Email: mutisoh@yahoo.com Website www.drmutiso.com

Post originally published in Mummy Tales – A blog by a Kenyan mom.

 

Kenya on Awareness Campaign to Increase Uptake of Iron and Folic Acid in Pregnant Women

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 Kasyoka. Her daughter was born with spina bifida --a neural tube defect.

Scholastica Kasyoka. Her daughter was born with spina bifida –a neural tube defect.

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.

Bethany pie 2_img_0

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.

Various fruits and vegetables are rich in iron and folic acid.

Various fruits and vegetables are rich in iron and folic acid.

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.

A mother and her child at Bethany Kids Hospital. The child has spina bifida.

A mother and her child at Bethany Kids Hospital.

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.

Kenyatta National Hospital. The government is sensitizing all health workers on iron and folic acid supplements for pregnant women.

Kenyatta National Hospital. The government is sensitizing all health workers on iron and folic acid supplements for pregnant women.

“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.

A happy mother with her healthy child.

A happy mother with her healthy child.

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.

How Can I Prepare for a Healthy Pregnancy?

Are you planning on becoming pregnant? Do you know what measures you should be taking to ensure that you have a healthy pregnancy and a healthy baby?  Our guest writer today tells us more on this.

By Dr. Stephen Mutiso, Consultant Obstetrician/Gynaecologist

A healthy pregnancy culminating into birth of a healthy baby is the ultimate desire of any mother. The outcome of any pregnancy is determined long before conception. To optimize pregnancy outcomes, it is important to have good health prior to conceiving.

Achieving good health before pregnancy includes adopting a healthy lifestyle. A healthy eating habit ensures you have adequate nutrients such as folic acid –which are important for baby’s good growth.

Diet rich in fruits and green vegetables provide high levels of micronutrients, hence should be encouraged to be taken by women contemplating getting pregnant. Weight reduction for those who are obese is important as obesity is associated with bad pregnancy outcomes. Ceasation of smoking and alcohol and other substance abuse is critical as these substances are harmful to the growing baby.

In addition to lifestyle changes, it is important to have a health check up by your gynaecologist before getting pregnant. This health checkup usually 3 months before conception, and is called preconception care. The goal of preconception care is to provide the woman with the best chance of a having a healthy pregnancy and a healthy baby. Preconception care involves review current and past medical and pregnancy history, physical assessment and laboratory testing to screen and detect any new and pre-existing diseases. If you have any chronic disease, it is important to inform your doctor. Any new or preexisting diseases must be treated or controlled well before pregnancy.

Education and counseling are important services offered during preconception care. Key topics usually covered include diet, HIV and other STDs, smoking and alcohol cessation. Folic acid supplementation is also provided during preconception care.

Chronic medical diseases which may affect pregnancy include: diabetes, hypertension, asthma, heart diseases, obesity, hypothyroidism, sickle cell anemia, HIV, Hepatitis, Venous thrombosis, kidney disease and epilepsy. Chronic medical diseases should be put under control before becoming pregnant. In some cases, a change in treatment may be needed because some medications are harmful to the baby.

Preconception care therefore is not a luxury but a very key intervention to improve pregnancy outcome. It’s very necessary for every woman regardless of age and number of previous births. If you’re planning to get pregnant its important you adopt a healthy lifestyle as well as schedule an appointment you’re your gynaecologist.

Dr Stephen Mutiso is based in Nairobi, and he provides a wide range of gynecological services, including; antenatal services, delivery, Vaginal Birth after Caesarean (VBAC), Obstetric Fistula, Infertility issues and Fibroids among others. He has admission rights in various private hospitals.

He is based at Kenyatta National Hospital Doctors plaza, Suite 26/27

Telephone: 0722 678 002 or 0788 306 674

Email: mutisoh@yahoo.com   —    Website: www.drmutiso.com

What Happens to a Kenyan Woman’s Family After She Dies While Giving Birth?

Every two hours in Kenya, a woman dies during pregnancy or childbirth. Quite unfortunate.

A new report on maternal health in Kenya has further amplified the devastating impact of a mother’s death on her family and in her community. The study, titled: ‘Price Too High to Bear’, reveals that that the unfortunate deaths of these women (mostly preventable), gravely affect her immediate family, the survival of her newborn, the health and opportunities of her surviving children, as well as the economic productivity of her family and her community.

The report by Family Care International (FCI), the International Center for Research on Women (ICRW), and the KEMRI/CDC Research and Public Health Collaboration in cooperation with Kenya’s Ministry of Health highlights the financial costs of the deaths of mothers in poor remote communities on their households, as well as the impact of these costs on family well-being.

The study was done in three sub-counties in Western Kenya (Rarieda, Gem and Siaya town -all in Siaya County) between 2011 and 2013. These were the following key findings:

The loss of a mother harms her surviving family members, her children’s health, education, and future opportunities.

The report states that of the 59 maternal deaths in the study, 14 women died during the last three months of pregnancy, one died during labour, and 44 died post-delivery. It is also important to note that over 70% of the maternal deaths occurred in the course of a normal delivery, while the remaining ones who died had experienced a caesarean section, use of forceps, or other intervention during delivery.

The link between maternal death and high neonatal mortality was also demonstrated:

Of the 59 women who died, 31 infants survived delivery. Of these, 8 died in the first week of life, with another 8 dying in the next several weeks. This left a total of only 15 surviving babies from 59 pregnancies.

In most of the households, the women who died used to carry out various tasks in their homes. These women used to contribute an average of 61 hours of household work each week, with tasks including; childcare, cooking, laundry, and fetching water and firewood. Following their deaths, the women’s husbands, mothers-in-law, older children, or other surviving family members had to pick up the slack, with 88% of families reporting that this had reduced these members’ ability to contribute earnings to household income.

Some of the deceased women were also involved in farming. For these, their deaths in some cases forced the household to allow land to lie fallow, or to cultivate fewer crops. Some families indicated that they had lost crops after the death of the woman, because surviving household members were not able to allocate to farming the time they had when the woman was alive.

A mother carries her son on a farm in rural Kenya.

For the surviving school-going children, they were in some cases withdrawn from or forced to miss school, because economic disruptions made it difficult to afford school fees. The household could no longer afford to pay the school fees, because the mother’s income was not available any more. Even when there was some money, it was used to hire casual farm labour.

Where children continued their schooling, often their grief and new household responsibilities negatively affected their schoolwork. In a number of cases, families reported that children withdrew from school altogether. Others who remained in school often had less time for schoolwork — and less time to actually attend school due to the additional household chores and because they had to take care of their younger siblings.

Social, emotional and other non-­economic consequences

In many parts of Western Kenya –where the study took place, a ‘household’ is made up of all those who eat under the same roof. Before the mother’s death, majority of individuals in the household ate in the woman’s home. But after she died, only about a quarter of individuals from her household continued eating in her house. Of those who changed where they had their meals (most of them children aged below 18 years), they said they did so because of the death of the mother. In most cases, children began taking meals in the home of their grandmother. Other children were removed from household and given out to relatives for foster care.

When a woman dies, her funeral costs are a crippling hardship for her family.

Funerals are a big deal in Africa, and Kenya is no exception. Many communities strive to give their departed relatives a ‘grand, respectable’ send off which could see them spend huge amounts of money. Across all wealth levels of households interviewed, families’ funeral costs exceeded their total annual expenditure on food, housing, and all other household consumption. On average, economically active members took a month off from work during the funeral period. Given the already high costs of the funeral, this lack of economic activity is an additional burden for the household.

A mother selling potatoes by the roadside in rural Kenya.

Those are just some of the key findings of the study. Indeed, it only goes to show that Kenya continues to have a high maternal mortality rate, despite commitment from the government to address the issue. It only means that the country needs to pull up its socks in reducing maternal mortality rates. Meanwhile, 2015 is just around the corner, and I wonder if my country will be able to achieve MDG5, that of reducing maternal mortality.

I can only hope for the best.

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