Day Ten: More Women’s Health
I had a massive lie in today, and then discovered that the traffic at 8:15 around London is rather horrendous. Happily, arrived only 5 minutes late, in time for…
Towards culturally competent care
There has been lots of awareness throughout the course about the impact of culture. Most of the speakers through the last two weeks have mentioned the shocks and surprises of moving between the developed and developing world.
We all contributed things we’ve experienced in different cultures we were not expecting:
- Less personal space: people just turning up at our house.
- Less confidentiality.
- Personal questions: asking things polite British society doesn’t accept.
- Different expectations.
- Facial expressions.
- Hierarchy of generations/roles.
- Family values.
To many people, not complying with their culture is not an option.
I’ve had people who have come to me, and decided they want to accept Jesus. They’ve become Christians, and then said to me “Now I can’t go home”. Breaking cultural norms can lead to beatings, ostracising, deaths…
Culture has 3 layers
- Outer layer – artefacts and products.
- Middle layer – norms and values.
- Inner layer – laws, generational beliefs.
“It was not the women’s ignorance but their intelligence that led to their refusal to adapt or abandon certain habits. They sought to understand the reason for such changes in terms that made sense to them. Not all those put forward by the health care worker did.”
The impact of culture on healthcare can be huge. Pre natal sex selection, communication styles, work force issues, birth marriage and death rituals, issues of consent, organ donation.
Ask yourself the question: Who are you? Where do you get your identity, beliefs, values, skills from? Ethnocentricity is the feeling of “I’m right, you’re wrong”. The feeling that your idea of culture is correct and needs to be taught to others.
We need to challenge ourselves; sometimes the correct thing to do is the culture that has been there for years, not our shiny Western ideas.
Women: Key Issues
- Stewardship of natural resources – women may be in charge of securing food, water, fuel and overseeing family health and diet.
- Reproductive health – issues re-morbitity, expectations of role and childbearing. Could be seen as coercion/force. Infertility is a hugely ostracising problem in some cultures, as is having a female baby.
- Economic empowerment – more women than men live in poverty. potential for economic disparity, less access to food, essential resource for living, property ownership.
- Education empowerment - women do not have access to education: linked to child mortality.
Sociocentricity and Egocentricity is the contrast of being society centred or self centred. The former is often modelled in developing world cultures, with tribes and villages central, rather than the Western individualism. It can be argued that the Socio model is more modelled in Biblical theology and morality: the concern is that there also a huge potential for individuals to be disadvantaged within it.
If used well, Sociocentricity, can be empowering for individuals and communities: its another situation where cultural sensitivity can help us to improve current systems, rather than trying to implant our own.
“We had condom education in our village, and the men came, and demonstrated placing a condom onto a stick. Rather than seeing the example in the spirit it was intended, many people in the village started placing condoms onto sticks.”
Wherever we go, we need to consider: how culturally sensitive are we being, and how can we help by providing culturally appropriate care.
The rest of the day involved workshops of Contraception, Gynaecology case studies & Gynaecology Emergencies. It was great, and very interactive, but sadly not terribly conducive to note taking.
They also told us about Swinfen Charitable Trust, who provide an international medical advice service for professionals – very useful in the field!
Day Nine: Women’s Health
After a late night gig in London, I had a rather late night, followed by getting up at 6am to prepare for speaking at the early morning prayer meeting. I also washed everyone’s feet, which was a real honour for me. The upshot of all this was that I didn’t do my preparatory homework for today’s sessions, so apologies if it seems a bit sparse.
Women’s Health in the Developing World.
- There are 360,000 women dying because of childbirth each year.
- There are 2 million newborns dying within the first 24 hours per year.
- There are 2.6 million avoidable stillbirths per year.
- 2 million unplanned pregnancies per year.
- 70,000 deaths due to abortion per year.
Birth complications means many women end up with fistulas that leak urine and faeces continuously. Women are socially ostracised – we watched the story of a lady called Mastula, and her experience of her life being turned upside down by a fistula.
Lifetime risk of dying from childbirth and pregnancy. In the west it is 1 in 4300. In Afghanistan, it is 1 in 11.
In the UK in 1930, maternal mortality rates were similar to the developing now. The UK changed due to 4 changes in services & skills:
- Midwifery care
- Blood transfusion
- Caesarean section
It is felt that there are three areas of delay that cause many of these deaths: delay in deciding to seek care (due to socio-cultural constraints, values put on women, beliefs related to pregnancy, traditions, non medical attributed causes), delay in reaching facility (financial constraints, poor transportation, no local facility) & delay in recieving care(Lack of staff (24/7), training, equipment, drugs and money).
92% of Bangladesh births are at home, with 89% totally unattended by health care providers. We worked at the only hospital in Bangladesh (population 160 million) that had an obstetric service available 24/7.
What is needed?
- Increase in the value put on women by society/ community
- Increase in community awareness of danger signs and preparedness
- Increase in the community’s confidence in EOC (Essential obstetric care) facilities
- increase in comprehensive and in basic EOC facilities
- Increase in skilled personnel in an integrated system
The LAMB hospital is a mission hospital in Bangladesh. Find out more at LHCF.org.uk.
Bible studies for all staff on created in His image, and violence against women. Teaching on how New Testament teaching on how a husband should treat his wife – “husband ought to love his wife as he loves his own body“.
We’ve seen a drastic effect: people working through the verses together: Christians, Muslims, Hindu, all reading the Bible together, and together coming to an understanding of how things should be.
We work with traditional healthcare attendants, giving them some simple points of when they need to refer to the hospital – the WHO feels this is not an effective policy worldwide, but we find it has been helpful in our area. We also train our own community skilled birth attendants, who receive 6 months training, then return to their villages..
Involvement of mother-in-laws and husbands, as decision makers, is very important; mothers will often agree with all our plans, but do not have the authority to make it happen.
That makes this the third day on this course where mother-in-laws have been recognised as an international threat to health. The hospital uses the community to pay for itself. Subsidies are provided for those who cannot afford. Households donate 1 tk per month (less than 1p), with further donations at religious festivals. We have advanced trained midwifes and advanced anaesthetic assistants – an area of contention at the moment. However, having audited our anaesthetic assistants, we have had no deaths directly due to anaesthesia in 5 years.Appropriate review definitely improves our service quality:
- “No blame”, confidential meetings
- Facilitates interdepartmental communication & teamwork
- Addresses areas for improvement
- Regular review of protocols
- Saving Newborn Lives initiative – pilot project in PNDA
- ‘Verbal autopsy’ of all maternal and child deaths in the community
I joined the “Basics” rather than “Advanced” Obstetrics workshop, which was being taught by Mary Hopper, who spoke on Saturday.
Some useful bits and pieces
- Grandmultigravida – more than 5 births.
“In Zimbabwe, we had one lady who was having her 23rd baby. In the next bed, we had her daughter, who was also having a granddaughter for our original patient!”
- Due date can be calculated: add 5 days and 9 months to the beginning of the last period.
- Foetal heart rate should around 130-140 – in the absence of other tools, using a loo roll over where you think the shoulder of the foetus is.
- Amniotic fluid should be around a litre, and should be strawberry coloured. Polyhydramnios (too much) is often seen in twins, pre-eclampsia, and seems to be more common in congenital abnormalities. Oligohydramnios (too bad), if bad, can lead to baby being held in uterus by adhesions.
Stages of Labour:
Onset of labour: from start of contractions until the cervix is completely dilated. Make a peace sign with your index and middle fingers: the distance between fingertips is around 10cm. The cervix generally progresses at around 1 cm an hour.
Our nurses in Zimbabwe couldn’t say ‘dilated’, so they would run and find me and say ‘The patient is fully delighted!’.
Second stage of labour: from full dilation to delivery of the baby. Once the woman feels she is ready to push, check the cervix.
Third stage of labour: from delivery of baby to delivery of placenta. Breastfeeding releases oxytocin, which will speed this up. Usually takes up to an hour.
Presentation, Lie & Position
- Presentation – what is near the cervix: cephalic presentation, shoulder presentation, breach presentation.
- Lie – Longitudinal or transverse.
- Position – Commonest is OA – occipito-anterior. This means the back of the baby’s head is at the front of the mother. OP is the reverse of this, the occipital region of the baby’s head faces backwards. Often, OA you will easily be able to palpate the back of the baby in the abdomen, and mum will say the kicking is mostly to the sides. OP, you won’t easily palpate the back, and mum will say that kicking is all over the place.
If a cord is visible before the baby, it often means the cord has come out, which means it can get stuck, with the baby squashing it, giving the baby hypoxia. Push the baby back in vaginally with your fingers, and get mum on hands and knees with head down.
Is the cord still vibrating? If not, baby is dead. Very occasionally, the cord can start vibrating again once you apply pressure. If the baby is dead, you need to deliver it, but there is no time pressure beyond keeping mum well.
Baby gets it shoulder stuck in the pelvis vertically. You need HELPERRS!
Help – call for help.
Lift the legs.
Enter vagina – to try to turn the baby.
Remove posterior arm – try to deliver arm through the vagina.
Rotate the mother onto all fours.
Symphesiotomy if not resolved – pop in a solid catheter, so you can move the urethra out of the midline, then cut through the synthesis pubis and pull out the baby.
Our first afternoon session was with Jacqui Hill, who has been in Afghanistan for the last 3 years, working in Obs & Gynae…
Sepsis is a huge killer in maternal deaths – even in the UK, there were 43 maternal deaths in the last 3 years from sepsis, 13 from Group A Streptoccus/
- Sepsis is a systemic infection.
- Severe sepsis is sepsis with organ dysfunction. (40% mortality in pregnancy)
- Septic shock is sepsis with hypotension. (60% mortality in pregnancy)
Sepsis is dangerous in pregnancy, because the woman is under a lot of physical duress, so has more susceptibility, and pathology presents abnormally, so is picked up late.
The evidence shows that the most important treatment is to get antibiotics into the patient.
A pregnancy specific sepsis can be chorioamnionitis. This occurs from rupture of membranes early, leading to infection in the amniotic fluids.
With cases of chorioamnionitis, delivering the baby is going to be better for both the child and the mother. Non delivered foetal survival rates are almost non existent.
Inducing a birth is usually done with medication or pessaries in the UK. One thing you can do in the developing world. Putting a catheter into the cervical os: you inflate the balloon to start stimulating the cervix. Also give an oxytocin IV infusion.
We also had session on haemorrhage and eclampsia. I failed to get many notes, but they were awesome! Then I went for a curry and finally got Peshwari chips for the first time!
Day Four: HIV/AIDS
Whilst I drove to Oak Hill College, I listened to Radio 4, with a very relevant Thought for the Day, that I’ve completely forgotten. If I get an opportunity, I will look it up. I then drank lots of apple juice, then sat in the lecture hall…
The Global Picture of HIV
Gisela Schneider opened the day on HIV. She told us two stories, one of a bishop at a national conference, washing the feet of those with HIV, and another, of a pastor apologising, in tears, to a woman who said how she has been unable to speak publically about her HIV status. The pastor apologised, because Christians too easily judge it as a moral problem, and forget that there are people in the midst of it who simply need the love of Christ.
When she first worked in Gambia in the 80s, HIV arrived, but it was simply referred to as “the disease”. No-one would talk about it, no one would accept it, and it was simply hoped that the patients would die and take away the shame from the family. The Lancet article in 1985 was the first to describe a hetrosexual disease spread by sexual contact. At that time, patients simply died.
We have seen a wonderful precedent in the speed that civil society identified that ARVs needed to be patent free. If left to pharmacutical industry, ARVs would not be patent free until 2016 – whereas since 2000 we have actually had more than 6 million people started on treatment.
We asked our clinic users what they wished to be called by us. They did not want to be “patients”, or “clients”. They said “Call us friends”. We must be in a partnership to defeat HIV.
In global politics, HIV is beginning to be seen as a resolved problem: governments are starting to reduce funding, public interest is waning: new causes such as global warming are taking a place on the global agenda. We must fight to keep a public interest alive in HIV. If not, funding will be cut, patients will not recieve medications, and a treatment resistant form of the disease will spread, unopposed.
There have been some successes – 20% reduction in HIV Transmission from 2006-2011. The numbers of infected people are stablising, but there are still 7,000 new infections a day worldwide.
Some examples, of the varying leading risks for infection.
- Lesotho – stable heterosexual couples
- Kenya – multiple partners
- Benin – sex workers
In Lesotho, being married is the best indicator of risk for HIV infection!
Africa is ahead of the game. In places such as India and the rest of Asia, there are some shocking statistics – in Lahore, 82% of sex workers did not think they were at risk of HIV infection.
History of HIV
- 1981: First AIDS case reports
- 1984: First HIV tests
- 1990: First HAARTs
- During 80s & early 90s: the focus was on Prevention. Scaring patients, increasing awareness. This wasn’t terribly effective. Spending on AIDS globally was around 200 million.
- Late 90s & 00s: we began aiming for Universal Access, with a political backing. The key change was DOHA, which created a mechanism to allow WTO members to issue compulsory licences to export generic versions of patented medicines to countries with poor. Spending on AIDS globally is now around 20 billion.
One downside is that drug companies are now showing hesitancy to invest in HIV treatments due to the risk they will have their drugs stolen as generic drugs, and make no money.
Discussion: What are the main challenges in HIV today?
- Western economic crisis, increasing instablity in Africa leads to programmes falling apart.
- Primary Care settings, often the drugs are not available.
- Some places, such as PNG, are way behind the curve.
- Sustaining the enthusiasm politically and locally.
- Treatment has meant that people are less scared of the disease, and more complacent.
- Stigma is still a huge problem.
- Cultural norms, gender inequalities.
Stigma is worldwide. In Germany in 2012, a lady from Togo with HIV and Cervical cancer, wasn’t being treated for the cancer, because the Gynacologists were scared to operate due to the virus.
The New Approach – SAVE
Safe practices – ABC, Circumcision, Safe infections, etc.
Access to treatment – Reduction in Viral load reduces transmission, PMTCT, etc.
Voluntary counselling and testing – Stigma free counselling, etc.
Empowerment of children, women and youth – families, communities, leadership, PLWHA, etc.
“The greatest good you can do for another is not just to share your riches, but to reveal to them their own.”
A tea break, before she sent all the experts out, leaving just the idiots like me who don’t know anything about HIV…
There are a number of different viruses involved, HIV1 M, HIV N, HIV O, HIV 2. The process of CD4 infection is through CD4 attachment, then Co-receptor binding with gp120 joining to surface proteins, with gp41 joining to CCR5 receptors in the cell wall, allowing the RNA inside to be released into the cell.
Once inside the cell, the RNA is integrated into the DNA of the cell, creating provirus. This process takes several days. This is the point at which lifelong infection begins. Once the RNA is integrated into one cell, the virus (currently) cannot be eradicated from the body.
The initial stage, of introduction of RNA to the cell takes around 2 hours – some preventative drugs work on this process – which is why post exposure prophylaxis ideally needs to happen within 2 hours.
Once CD4 cells are infected, they become disorganised. They are still there, but they can no longer react to immune problems correctly. Over the next 12 weeks, the virus is replicated, sometimes causing an acute viral “conversion” syndrome – click the graph on the right for a larger version. There is an excellent explanation of this process that Gisela mentions in her slides at The Naked Scientist.
Testing is a key area of discussion, with the basics of 5Cs – Consent, Confidentiality, Counselling, Correct testing, Linked to Care.
Telling a patient they have HIV is so life changing, so painful, that you should not test patients if you cannot provide them with this fivefold support.
After infection, progression to an AIDS syndrome can take <5 years (10-20%), 7 years (60-70%), >10-15 years (5-10%). Less than 1% do not progress.
She advised us to print this list, and laminate it. We won’t be able to remember it, but we can refer to it as we see patients.
- Moderate weight loss (<10%)
- Recurrent respiratory infections (sinusitis, bronchitis, otitis media etc)
- Herpes Zoster
- Angular cheilitis, oral ulcers and sores
- Papular pruritic eruptions (PPE)
- Seborrhoeic dermatitis
- Fungal infections of nails
- Unexplained weight loss >10%
- Unexplained chronic diarrhoea > 1 month
- Unexplained persistent fever > 1 month
- Persistent oral candidiasis
- Oral hairy leukoplakia
- Pulmonary tuberculosis
- Severe bacterial infections (e.g. pneumonia, empyema, meningitis, pyomyositis etc)
- Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
- Unexplained anaemia (<8g/dl), neutropaenia (<0.5 x 109/l), thrombocytopaenia (<50 x 109/l)
- HIV wasting syndrome
- Pneumocystis pneumonia (PCP)
- Recurrent severe bacterial pneumonia
- Chronic herpes simplex infection (> 1 month)
- Oesophageal candidiasis
- Extrapulmonary tuberculosis
- Kaposi’s sarcoma
- Cytomegalovirus infection (retinitis or other organ)
- Central nervous system toxoplasmosis
- HIV encephalopathy
- Extrapulmonary cryptococcosis
- Disseminated non-tuberculous mycobacterial infection
Case studies of HIV
Gisela then walked us through some case studies, through common presentations of ?HIV patients. Opportunistic infections - important markers for clinical stages. Need to be treated before initiating ART:
Fever of unknown origin – commonly due to TB, Malaria, PCP, Cyptococcus, Toxoplasmosis.
Focal neurological lesions – commonly due to Toxoplasmosis, Tuberculoma, Primary CNS lymphoma, Brain abscess, Stroke.
Diarrhoea – less common now in areas with high ARV treatment, but in ARV naive areas, commonly due to Cryptosporidium, Microspora, Cyclospora, Isospora.
Basic preventative therapy:
Good studies showing that provision of the following can make a difference – but the community needs to be involved, as had been said all week. Go to a village, given them nets, they won’t use them. Work with a village, if they ask for help, then it becomes part of the village culture.
- CtX prophylaxis.
- Malaria protection (ITN).
- Clean water supply.
- Nutritional support.
Anti Retrovirals Therapy
A 5 minute break during which people laughed on hearing that the BMA just passed a motion calling for Andrew Lansley to resign. Then back to ART…
Nucleoside Reverse Transcriptase inhibitors (NRTI)
- Backbone of therapy.
- Side effects of Anaemia (AZT), Polyneuropathy(D-drugs), lipatrophy, lactic acidosis.
Non Nucleoside Reverse Transciptase inhibitors (NNRTI)
- NVP – Can cause hypersensitivity, lead in. Hepatotoxic
- Efavirenz – Teratogenic.
- 2nd line treatment (but first for HIV 2). More expensive but effective.
- Difficult to take due to side effects – Diarrhoea bad. Also cause hypergylcaemia and hyperlipidaemia, long term cardiac risk.
- Generally two types, combined. Commonly 2 NRTI + 1 NNRTI. Sometimes 2 NTRI + PI.
- Important to avoid some combinations due to side effects.
Response to ART
- Virological – Ideally level falling to an undetectable viral load.
- Immunological – Rise in CD4 count, around 10/month.
- Clinical – Weight gain, Disappearance of symptoms.
Highest risk of ART toxicity will be in the first 1-3 weeks. After this, the next few months 16% of patients in stage 4 starting ART will respond with an IRIS (Immune Reconstitution reaction). Common cause is CMV, TB or cryptococcal disease. Highest risk of death in in the first 3 months, worsened risk by low CD4 count – can be avoided if we start treatment early!
Clinical treatment failure: a new or recurrent stage IV event.
Immunological treatment failure: fall of CD4 to baseline. 50% fall from peak. Persistent low levels of CD4.
Virological treatment failure: viral load > 5000 copies.
Counselling is one of the most important factors in useful ART treatment. You need cultural sensitivity, there must be understanding, real communication and community support. Indigenous health workers are the most effective at this, so they can be the best contributors to good compliance.
HIV in Pregnancy and Childhood
Lots of Quorn sausages later, I walked through the gardens barefoot in the 27 degree heat, chatting about Somalia with a fellow CMFer, and wishing that there was ice-creams. Then we returned to the expert world of Gisela…
“No child should be born with HIV, no child should be orphaned from HIV, no child should die from HIV”
11 year old HIV orphan, Ebube Taylor, speaking to a UN panel
48% of eligible adults are receiving ARTs. Only 23% of eligible children receive ART.
Seven year follow up of Gambian pregnant women living with HIV-1. Mothers who died within 7 years: 34%. HIV infected children who died 69%. Orphans who died irrespective of their HIV status. In other words: being an orphan is as bad for your mortality as being a child with HIV.
Reducing vertical transmission
20% of maternal deaths in Africa are due to HIV. Avoid this by using ART, and aiming for quick normal deliveries, avoiding instrumental delivery. Where feasible, elective CS.
Ideally start combined ART for all pregnant women, continuing for life. Some places use a single dose nevirapine to prevent mother-to-child transmission – but there is a widespread resistance to this. When mother on ART, breast is best, and relatively safe!
Mother on ART throughout pregnancy reduces transmission from 30-40% to 2%.
- Category 1: Die within 1 year. (25%-30%)
- Category 2: Symptoms early in life, die aged 3-5 (60%)
- Category 3: Develop symptoms >age 8. (10-15%)
Test all children with a dried blood spot test with the first review after birth. HIV children present commonly in first year of life with PCP. Treat with high dose ABx.
Treating children is very complex. Much better to heed Ebube Taylor’s words, and prevent vertical transmission.
Palliative Care in Resource Poor Settings
Unsurprisingly, the 27 degree heat, coupled with 5 hours of very intense discussion of medications with long names and scary side effects, I nearly fell asleep. 2 pints of coffee later, and AC turned on in the lecture theatre, I steeled myself for our final lecture from CMF’s own Vicky Lavy.
Vicky spent several years establishing and running Paediatric Palliative Care in Malawi. She then wrote a Palliative Care toolkit for use by others, and much of her teaching is from that.
A nurse we had been working with for several months said “Doctor, I do not see how this Palliative Care can work – the patients, they just keep dying!”
Caring rather than curing. A revolutionary concept to many places in the world.
Palliative care is looking after people with illnesses that cannot be cured, relieving their suffering, and helping them through difficult times. The “care” is key. As Jesus said:
“When I was sick, you looked after me”.
In the developing world, very often Doctors say “There is nothing we can do”. But Palliative Care never says this – no matter how small, there is always something we can do.
Counselling and psycological support is a vital part of palliative care. Often forgotten in favour of exciting discussions of oxycodone doses, but actually is probably more important. Truth is one of the most powerful medicines available to us, but we still need to develop a proper understanding of the right timing and dosage for each patient. Despite cultural differences, there are studies across the world showing that telling patients the truth has a positive medical effect.
Pain management should be done by the mouth, by the clock, by the ladder. Oral, regularly, and according to the WHO pain ladder. Codeine is very expensive, so we usually pass from Step 1 to Step 3 quite quickly.
- Topical metronidazole for smelly wounds. Smelly wounds are stigmatising, but just crush metronidazole can resolve problems.
- Metronidazole pessary for vaginal discharge. Similar to above, with Cervical Ca
- Opiates for breathlessness and diarrhoea.
- Gentian Violet paint for candida and skin sores.
- Prednisolone for mouth ulcers.
- Franjipane juice for Herpes Zoster. Common African flower, sticky juice inside a flower.
Taking a spiritual history
Always something that can be helpful, but a very important part of Palliative Care
- “I ask everyone about this, as part of our routine assessment.”
- Do you have a faith which helps you through difficult times?
- Do you ever pray?
- What helps you make sense of life?
- What things are most important to you?
- Have your thoughts about life changed since you became ill?
The waiting game
Kat was due to have our baby on Monday. Two days later, she still looks pretty fat, and I can’t see any soiled nappies anywhere, so I guess that hasn’t happened. This isn’t a new, or shocking phenomenon; first babies are often a week late - in some countries your due date for the first is 41 weeks rather than 40.
However, what’s weird for me is that the reality of the situation seems to be decreasing. For three weeks now, I’ve been going to work, expecting a call at any moment, “IT’S COMING!”, followed by a frantic dash back home, en route to the hospital.
Instead, nada. Every day that passes it feels less real. A week ago, I was like, “I’m literally going to have a son any moment”. Now, I’m more, “Is this actually going to happen?”
I can almost believe that the whole thing is going into reverse now, that the baby peaked, we missed our opportunity, and now its getting smaller again. I said this to Katherine yesterday, and then the midwife visited, telling her that the baby was smaller than last week! Apparently this was because he is curled up under her rib cage, and thus harder to measure… but I’m not so sure.
In other words, we may, or may not be having a baby this week. Beyond then, who can say?