Keeping the Next Generation Healthy

by Jessica Wiley

Merslyne Olanda, 26 years old, is 24 weeks pregnant with her second child.
She is taking antimalarial treatments as part of her prenatal care.

Merslyne Olanda, 26 years old, is 24 weeks pregnant with her second child. She had malaria during her first pregnancy and described that experience as miserable. “The [malaria treatment] drugs did not react well with me,” said Olanda. “I was dizzy all the time, so much so that you can’t sit, you just want to lie down. I didn’t have an appetite, and I could not sleep well.” She now receives antimalarial treatments as part of her antenatal care and said, “If I were unable to access these drugs, to me that would be a matter of life or death.”

Malaria is reported as the most common, yet preventable, cause of maternal and infant sickness and death in countries like Kenya that are within the malarial-endemic zone of sub-Saharan Africa. In these high transmission areas, 125 million pregnant women are at risk of contracting the disease every year, resulting in 200,000 newborns dying annually. In the face of such grim statistics, many hospitals and clinics in the area are committed to keeping mothers and their babies safe from the deadly disease. The majority of these healthcare facilities can provide this essential component of prenatal care through the assistance of foreign aid. This funding goes toward providing direct-care services, as well as strategic research that is designed to improve and measure the effectiveness of interventions.

At the end of a long and bumpy dirt road in the Nyanza province of Kenya is St. Mary’s Hospital*, a faith-based mission hospital. The journey down this road is breathtaking, by far the most beautiful ride to a hospital that I have ever experienced. The “piki-piki” (the Swahili term for motorbike) gets stuck in the mud a few times and I am able to take it all in. Cows and goats roam both sides of the road and I am surrounded by lush farms and vibrant green fields that extend into the infinite distance. The road is well traveled, evident by the constant flow of bicycles, piki-pikis and people on foot. Everyone waves to me with big smiles, shouting, “Mzungu! How are you?” as I pass by. Mzungu is the Swahili term for white person or foreigner; a name I quickly became familiar with during my time in Kenya.

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The entrance to St. Mary’s is a bustling waiting room, loud with chatter and babies crying. It is full of expectant mothers dressed in vibrant fabrics, swaddled newborns, toddlers and young children, all waiting to receive care at the maternal and child clinic. Preventing and treating malaria in pregnancy is one of the many crucial services that the clinic within this mission hospital is committed to providing. I am here to learn about the role that foreign aid plays in combating this disease that affects millions of lives.

The severity of maternal malaria

A community health nurse, Martha*, who provides prenatal care for around 20 expectant mothers a day explains that pregnant women are particularly vulnerable to malaria. Pregnancy greatly reduces immunity, while simultaneously increasing susceptibility. Malarial infection during pregnancy raises the risks of severe maternal anemia, resulting in spontaneous abortion, stillbirth, low birth weight, and premature delivery. A large part of Martha’s job is informing expectant mothers about the severe complications associated with maternal malaria, and to continually advise them to adhere to potentially life-saving measures that are part of their prenatal care.

Martha said that reaching all pregnant women can be difficult. “At this period we expect few mothers to come to clinic because it is a planting season and they are engaged in other activities at home,” said Martha, “The turnout can be low, but we always advise them on the importance of attending clinic regularly so they can get more information, like exclusive breastfeeding or infant-care after delivery. It is too much if given on one day.”

How to prevent malaria in pregnancy: the current intervention

National policy in Kenya seeks to reduce maternal and child death through IPTp, or intermittent preventative treatment in pregnant women. IPTp consists of a curative dose of an antimalarial drug, currently sulfadoxine-pyrimethamine (SP), starting in the second trimester during a routine prenatal care visit. All pregnant women that visit St.Mary’s for prenatal care receive SP, regardless of whether they have malaria symptoms. In order to be effective, women must receive at least two doses of SP during their pregnancy. In addition to SP, insecticide-treated mosquito nets are a critical component of preventing malaria and all women who visit this clinic receive one during their first visit at no cost.

5Sulfadoxine-pyrimethamine (SP) is the standard antimalarial drug given to expectant mothers during prenatal care. 6Newborn, Lydia Atieno, born malaria-free and ready to go home with her mother, Sofia Anyango.

Challenges of being a mission hospital

When St. Mary’s was established, it was funded entirely by Catholic missionaries. Every element of care, even some food, was covered for all patients who came to the hospital. As direct funding from the Catholic Church has waned in recent years, the sisters who run the hospital have been successful in attracting other donors, ranging from private foundations to bilateral agencies like United States Agency for International Development and the US Centers for Disease Control and Prevention. One international donor the hospital has continued to benefit from is Terre des Hommes, a Dutch organization that supports health, education and independence projects worldwide. The majority of these funds have helped the hospital purchase general treatments like malaria prevention therapies.

One hospital administrator, Sister Gloria*, comments that, without the assistance of these international donors, “the health of many people would deteriorate, and there would be even higher mortality rates, both maternal and neonatal.”

The role of research in foreign aid assistance

One major avenue for patients to obtain free care at St. Mary’s has been participation in donor-funded research. In fact, because they are enrolled in clinical research trials, three quarters of the patients who visit the mission hospital receive entirely free care, including transportation reimbursement. “This hospital has been a research area for a number of years,” said Sister Gloria, “It adds an advantage to some extent because we get an opportunity to get first-hand information [on clinical treatments and interventions] before it is disseminated internationally.”

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Taking advantage of this kind of benefit is the only way for some people in Nyanza province, where 63% of the population lives on less than $1 a day, to receive adequate health care. But many in the community don’t see the benefit and are reluctant to be involved in research. “Those who know the value have gotten the benefit,” said Sister Gloria, “…there is a fear. Africa believes so much in giving birth. When research is being done, especially on women, the first questions is, is that drug going to make a woman sterile?” She finds that many husbands of pregnant women also express concerns about their wives and unborn children being used as research subjects.

Only a quarter of the patients who visit St. Mary’s actually pay for health care services and necessary medications. In a time of donor fatigue, the hospital relies on income generated from this small portion of its client-base to continue to function. Fees for paying clients remain small. For instance the medicine needed for IPTp costs around $2 US for the entire pregnancy. A diagnostic blood test for malaria costs around 50 cents.

How foreign aid affects the community

Sister Gloria thinks donor assistance has helped improve community health but has also bred an attitude of dependency. “They have not owned up to their health. It is still somebody else’s health,” she said, “This is not a lasting solution. At some point the help will go away and our health will still be with us.”

Another hospital administrator, Sister Joan*, noted that being a mission hospital that could initially provide the community with free health care has created a deeper challenge. “They [the community] still are of the mentality that things should be free because it is a mission hospital,” said Sister Joan. “They don’t realize that things have changed.”

An assumption of entitlement has developed, to the point, Sister Joan said, that if the hospital does not stock a medication that a patient needs for a certain illness—and therefore it is specially ordered at a higher cost—the patient often will refuse to pay for it. Even patients who do have the means to pay often are not willing to do so because St. Mary’s traditionally offered entirely free care in the past. Sister Joan said these patients will manage to pay for the medication at a different hospital, but not this one.

Sister Gloria said the community often is reluctant to accept the fact that this assistance, through research or donors, is temporary: “Suppose all these donors go away, will our health facilities still be able to function? And will the community still be able to take care of their own health?” She said community health workers continue to visit villages to raise awareness of health risks like malaria in pregnancy. This effort is intended to mobilize people to take ownership of their personal health, but also to combat widespread fears of participating in research.

One mother, Beth, has just given birth to a healthy baby boy at St. Mary’s days before my visit. She is a full-time teacher in Nyanza province and passionately explains to me how much she thinks the presence of government-funded research is helping the community. She said that life-saving treatments, like IPtp, are not locally available, and the research is an incentive for women to receive their prenatal care at the clinic. “The research is helping the community because people are poor and the services are free. We are no longer losing a high percentage of pregnant women anymore,” she said. “Those that participate and support research initiatives are not at risk of dying in the hands of local women in the villages.”

She acknowledges that the rumors about clinical research continue to perpetuate a fear of participating among pregnant women. Her message to researchers? “Just know you are touching lives, even if other people are saying bad things about the research, just do what you know is right for the Kenyan people, for the Kenyan pregnant women like me.”

*Disclaimer: Certain patients have wished to remain anonymous in order to protect their privacy. The name of the hospital and certain staff have also been changed in order to ensure confidentiality of the research being conducted.