Archive for Maternal Health

Keeping women’s and reproductive health on the agenda for sustainable development

Maternal and child health has been in the limelight for at least two decades and was prioritised by the Millennium Development Goals (MDGs). We have seen great progress. Maternal mortality fell by 45% and 17,000 fewer children die each day, than in 1990. The focus has, however, been narrow but thankfully worldwide priorities are now changing to much broader more inclusive framework of sexual and reproductive health and the concept of women’s health. In September 2015, at the UN New York summit, the proposed 17 Sustainable Development Goals (SDGs) and their 169 targets will be finalised.

The current draft goals include: achieve gender equality and empower all women and girls; ensure inclusive and equitable quality education and promote lifelong learning opportunities for all; ensure healthy lives and promote wellbeing for all at all ages; and reduce inequality within and among countries. The focus for the next 15 years will be on sustainability. This month has seen a particular focus on women’s health and sustainable development with a Lancet issue devoted to it. See for a range of articles. Dr Ana Langer from the Women and Health Initiative at Harvard T H Chan School of Public Health writes “Sustainable development needs women’s social, economic, and environmental contributions, which will increase when women are healthy, valued, enabled, and empowered to reach their full potential in all aspects of their lives, including in their roles as providers of health care.”

Many issues remain which should now be tackled. Although gender equality has been achieved in primary school education, a large proportion of girls do not complete secondary school which means their choices for their future lives are severely limited. Bangladesh has one of the highest rates of child marriage in the world. Around 20% of girls become wives before their 15th birthday, even though 18 is the minimum age allowed by law. Child marriage can have a damaging impact on young girls, and allowing them to continue their education is a way to avoid the future potential of sexual exploitation, dependency, domestic abuse and adolescent pregnancy. Adolescent bodies are not ready for childbirth and complications in pregnancy and childbirth are the leading cause of death in girls aged 15-19 in low- and middle-income countries.

Despite admirable efforts, female genital mutilation continues in its various forms. In seven countries the national prevalence is almost universal (more than 85%) whilst in four countries there is high prevalence (60–85%) and medium prevalence (30–40%) is found in seven countries. National averages, however, often mask marked variation in prevalence in different regions of countries.

Source: MICS, DHS and other national surveys, 1997-2006. Map developed by UNICEF, 2007

Finally, a somewhat forgotten issue is that of maternal morbidity. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity. Maternal morbidity adversely affects families, communities and societies. There are multiple causes, with varying duration and severity ranging from transient to permanent. Diagnosis and treatment options, as well as rehabilitation approaches, exist but in low- and middle-income countries these are rarely freely available. Ladeisha Lombard, Rosemary Geddes and Liz Grant from Edinburgh University and colleagues recently published a review ( on rehabilitation experiences after obstetric fistula repair. There is a paucity of research in this area but it was found that for women resuming social roles as wives and mothers is a positive rehabilitation experience, whilst concerns and fears about longer-term emotional, economic and physical consequences cause negative experiences of rehabilitation. There is a real need for community health education and counselling services post-repair for women and their families, in order to reintegrate and restore the dignity of these women in society.

Dr Rosemary Geddes, Programme Coordinator Global Health Challenges, University of Edinburgh



Nkhoma Hospital Cervical Cancer Screening Programme: a Scottish–Nkhoma partnership

In Malawi, cervical cancer is the most frequent cancer among women of reproductive and economically important age (45.4% of female cancers) and an 80% mortality. Numbers are projected to increase over the next 2 decades as improvements in other areas of health (eg treatment for HIV) increase length of life. There is no national programme for cervical cancer prevention through immunisation or screening and many women now survive childbirth only to die later of preventable cervical cancer. Inadequate access to treatment, ostracisation of women with severe symptoms of cervical cancer, and limited palliative care services are additional features.

We received funding from the Scottish Government International Development Fund for Malawi (2013-2016) to set up a sustainable programme of cervical cancer reduction in Nkhoma Hospital and 10 surrounding health centres. The project is jointly led by Professor Heather Cubie, Consultant Clinical Scientist in NHS Lothian until recently / Honorary Professor, Global Health Academy, University of Edinburgh and by Dr Christine Campbell, Senior Research Fellow, Centre for Population Health Sciences, University of Edinburgh. The principal clinicians are Sr. Hilary Brown and Dr Graeme Walker from NHS Lothian who participated in ALSO courses (Advanced Life-Saving in Obstetrics) in Malawi a few years back and others from round Scotland have helped / are helping for short periods through sabbatical or unpaid leave.

The Scottish and Nkhoma teams, October 2013

The Scottish and Nkhoma teams, October 2013

In the first two years of the project, our Malawian colleagues have provided information on the value of cervical screening to 4 Traditional Authorities and 84 Group Village Headmen and obtained their permission to speak to around 30,000 people in the region. In addition, a potential 120,000 (50% of the population) has been reached by local radio broadcasts. Twenty-four Malawian healthcare professionals (mainly midwives and clinical officers) have been trained to provide cervical screening using a procedure called VIA (visual inspection with acetic acid) and treatment of early lesions using cold coagulation. Case load is audited and competency of each provider is assessed by Scottish clinicians using similar standards to the UK.

Talk to women to explain what would happen in VIA clinic, Nkhoma Hospital

October 2013

October 2013

In the new outside classroom, October 2014

In the new outside classroom, October 2014









Over 7000 women have had their first-ever cervical screen. Those with early signs of abnormality have been offered treatment and 75% received it the same day. At the start of the project, a number of women said they would need to ask permission from their husbands to receive treatment but this is no longer a big issue. Hopefully this is because the information messages have reached the whole population, men and women, giving women a sense of empowerment. Two-thirds have returned for follow-up visits, despite this being considered difficult to achieve.

Sadly, the VIA clinics still see too many women with cancers which are too advanced for immediate treatment. There is little Malawi can offer in terms of chemo- or radiotherapy, but the project does ensure that these women have their diagnosis fully explained and are offered surgery or palliative care where appropriate.

The project now has daily clinics in Nkhoma Hospital and weekly clinics in 5 surrounding health centres, some Government and some CHAM. Year 3 of the project will extend to weekly clinics in 5 more health centres and consolidate training to allow sustained service. We are currently looking for further funding to extend the ‘hub and spokes’ model to additional hospitals and their health centres.


Sustainable Programme of Cervical Cancer Screening


Professor Heather A Cubie  (Global Health Academy)  and Dr Christine Campbell (Centre for Population Health Sciences), University of Edinburgh



Global Health Academy