Category Archives: Women

Zika and Access to Reproductive Health Services in Brazil

Twice a year students in the Johns Hopkins Bloomberg School of Public Health write blog postings as part of the course “Social and Behavioral Foundations of Primary Health Care.” We often share blog posts that relate to tropical health issues.  Below is a posting by class members Linda Cho, Linda Chyr, Rebecca Earnest, and Sarah Rosenberg on Zika, family planning, and reproductive health in Brazil.


In the 1960s, the Brazilian government adopted a laissez-faire attitude, which lead to the predominance of private organizations in the provision of family planning services. Since then, Brazil has witnessed one of the most dramatic reductions in family size in modern history in part due to increased access to family planning services. (Photo New York Times: Members of the Union of Mothers of Angels.)

However, in early 2015, the widespread epidemic of the Zika fever caused by the Zika virus in Brazil caused persisting gaps in access to contraception to resurface. Since it was first detected it has instilled fear and uncertainty in pregnant women whose fetuses could be at risk of Zika-related birth defects like microcephaly should the virus be contracted during pregnancy. This makes access to comprehensive reproductive health services and education a critical need for women who are pregnant or considering becoming pregnant.

While contraceptive use is fairly high in Brazil with 75.2% of women using modern forms of contraception, barriers to access remain. Some women face challenges, some of which include but are not limited to incomplete insurance coverage or lack of reimbursement for long-acting reversible contraceptives (LARCs), high up-front costs, low number of contraceptive service sites, and/or a lack of supply of the implants in the public sector . This may be one driver behind why LARCs only make up 0.5% of all contraceptive sales. Furthermore, 55% of all pregnancies in Brazil estimated to be unplanned and 20% of all lives births are attributed to teenage girls, indicating that there may be substantial reproductive knowledge gaps  in how to effectively prevent pregnancy.

Amid the spread of a virus that poses unique health risks to pregnant women and their fetuses, there is an urgent need to address these gaps in reproductive health access and education. First, the Brazilian National Health System, which laudably provides most contraceptives free of charge to about 74% of the population, needs to reevaluate existing policies that may be still limiting access to contraceptive services. Secondly, organizations like the Brazilian Society for Family Welfare (BENFAM), which provides reproductive health services and education to underserved Brazilian communities, need greater financial and political support from policymakers, civil society, and even organizations traditionally opposed to such services like the Catholic Archdiocese.

Despite Brazil’s great strides to improve access to contraception and reproductive health education in recent years, Zika’s arrival highlighted gaps in the existing system that must be addressed through policy reform and greater political and financial support. Especially in the time of Zika, Brazilian women deserve no less.

Malaria Mass Drug Administration: Ensuring Safe Care of Reproductive Age Women

The potential impact of mass malaria drug administration (MDA) on pregnant women was the focus of Symposium 146 at the recent 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The symposium was co-chaired by Clara Menéndez and Larry Slutsker who opened the session with an overview.

mda-recommendations-whoAs malaria control interventions are scaled up and sustained and malaria transmission levels decline and prevalence falls, an increasing number of countries are starting to see elimination on the horizon. For pregnant women, the antimalarial antibodies that have provided some level of protection in moderate to high malaria transmission settings are reduced as malaria transmission declines.

Current evidence shows that as transmission levels decline, the consequences from P. falciparum malaria are even greater for pregnant women. As countries enter pre-elimination stage and move towards eventual elimination, it will be important to address the needs of pregnant women given their increased vulnerability.

To help achieve elimination, countries are exploring strategies involving widespread distribution of anti-malarials, primarily artemisinin-combination therapies (ACTs), to asymptomatic individuals, including both mass drug administration (MDA) and mass screen and treat (MSaT).

Animal studies have suggested potential embryo toxicity and teratogenic effects of artemisinin drugs in the first trimester of pregnancy.

Given the limited human data, ACTs are currently contraindicated in first trimester, except in documented cases of clinical malaria illness where quinine is unavailable. This poses a challenge in mass campaigns, as it requires the identification of women in early pregnancy who are not yet obviously pregnant. Screening including offering pregnancy tests and/or interview to ask a woman her pregnancy status directly may not work as many may not wish to reveal their pregnancy status.

Final Algorithm for Screening Prior to MDA in Mozambique

Final Algorithm for Screening Prior to MDA in Mozambique

While only about 5% of the population is pregnant at any given time, and only 1/3 of those are in the first trimester, approximately 20% of the population is comprised of women of reproductive age who may be pregnant. Thus, the number of women who need to be screened for pregnancy is substantial across countries. In addition to privacy issues, costs of screening processes are another barrier.

During the symposium Francisco Saúte from Mozambique and Samuel J. Smith from Sierra Leone shared experiences. Clara Menéndez addressed ethical issues involved in the potential risk of MDA with the ACT Dihydroartemisinin-Piperaquine (DHA-P). These two countries have addressed pregnant women in MDAs in two widely different contexts.

Mozambique is learning whether MDA is a valuable component to malaria elimination in the low transmission areas in the southern part of the country. In Sierra Leone MDA was seen as a lifesaving tool to prevent malaria deaths during the Ebola epidemic when taking blood samples for diagnosis was a major risk.

Over several rounds of MDA, Mozambique refined its pregnancy screening procedures over several rounds of MDA as seen in the attached slide.  Costs, confidentiality, convenience and efficiency entered into the equation that saw a greater focus on communicating with women rather that testing. Lessons learned from MDA in Mozambique included –

  • Screening for early pregnancy in the context of MDA is challenging, particularly among teenage girls where disclosing pregnancy can be problematic
  • Need to train field workers (preferably women) about the need to ensure confidentiality of pregnancy testing/results
  • Confidentiality is also crucial to ensure adherence to t
    MDA Rationale in Sierra Leone during Ebola Outbreak

    MDA Rationale in Sierra Leone during Ebola Outbreak

    he pregnancy testing

  • Women not accepting pregnancy test must be warned on risks/ benefits of ACTs in 1st trimester
  • Health authorities must understand that IPTp and MDA are not mutually exclusive

The Ebola epidemic in Sierra Leone and its neighbors, Liberia and Guinea, devastated the health workforce, and the availability of any sort of testing supplies was low.  The country experienced a major drop in utilization of clinic based MCH services including those for malaria during the period.

MDA Goals in Sierra Leons

MDA Goals in Sierra Leone

Because of initial similarities in presenting symptoms between Ebola and malaria, people were often fearful of going to the health center in case they were detained for Ebola care or were exposed to other patients who had Ebola. Community MDA seemed to be one way to protect the population from malaria in this emergency situation. The attached slide offers a rational for the MDA. A second slide explains Sierra Leone’s goal for MDA with Artesunate-Amodiaquine in the context of Ebola. Though not completely, the Sierra Leone MDAs were able to exclude pregnancy women in their first trimester.

Pregnant women excluded from MDA in Sierra Leone

Pregnant women excluded from MDA in Sierra Leone

In conclusion MDA is a tool conceived primarily for countries and areas of countries as part of the pre-elimination strategy. It presents a variety of logistical challenges, but a major concern should also be the ethical issues of giving a potentially toxic drug to women in their first trimester of pregnancy. Alternative strategies to protect these women, including insecticide treated nets, must be explored.

Leading by Example: Senegal’s Minister of Health supports the “Zero Malaria! Count Me In!” campaign

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

iwd_squareInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the second feature on women fighting malaria.

Pr. Awa Marie Coll Seck, the former Executive Secretary of the Roll Back Malaria Partnership pursues her fight against malaria in her own country, Senegal, as Minister of Health. Known for her smooth diplomatic skills and experience in policy formulation, she leads an aggressive reform striving to eliminate all deaths due to malaria in Senegal.

Pr. Awa Marie Coll Seck, Minister of Health and Social Action, Senegal

Pr. Awa Marie Coll Seck, Minister of Health and Social Action, Senegal

As global leadership increasingly realizes that the international strategy demands a strong local response and the most active engagement of beneficiaries, Senegal’s Minister of Health walks the talk. The Zero Malaria! Count Me In! campaign aims at creating a movement around the importance of accountability and individual responsibility when it comes to putting an end to this preventable disease. Malaria elimination demands the coordinated efforts of all sectors of society.

As the Minister of Health pledges to build capacity within health facilities so that they are able to properly manage simple and severe cases of malaria, the Zero Malaria! Count Me In! campaign insists on the necessary parallel commitment that Senegalese people need to make in order for the country to reach its malaria elimination objective.

Since the past decade, the country has made tremendous progress and reduced malaria mortality by 62%. Over 6.5 million of insecticide treated mosquito nets were distributed throughout the country and lifesaving medicines are now available in public health facilities free of charge.

Women being the primary caretakers of their families, International Women Day is the perfect occasion to celebrate the leadership of Senegalese women throughout the country, without whom, malaria elimination could never become a reality.

Thank you Minister for leading by example and proving that actions speak louder than words.

Happy International Women Day to all!

*****

Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

Association of Women Doctors of Senegal joins the “Zero Malaria! Count Me In!” campaign to eliminate malaria in Senegal

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

International Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the first feature on women fighting malaria.

Amy Ndao Fall

Amy Niambo Ndao Fall, President of the Association of Women Doctors

Dr. Amy Ndao Fall is the President of the Association of Women Doctors of Senegal (AFEMS). This Association, composed of 400 members across the country, aims to undertake sustainable activities for the health of the Senegalese populations.

On the eve of Women International Day, in partnership with the Ministry of health and UN women, AFEMS organized in Dakar on March 7, a conference on the theme “women’s health for an emergent Senegal”.

This conference attracted approximately 150 women from all over the country and was chaired by Professor Awa Marie Coll Seck, Minister of Health and Social Action of Senegal.

The conference started with Dr. Ndao signing a pledge, on behalf of AFEMS to support the “Zero Malaria, Count me In” campaign and the National Malaria Control Program in their elimination efforts.

Dr. Ndao stated the association’s commitment to support all efforts toward malaria elimination in Senegal and abroad and concluded with the following words:

ZeroPalu“It is a pleasure and an honour for me, to sign this engagement on behalf of AFEMS, to mobilize all our efforts to eliminate malaria in Senegal. We need to keep in mind that women are particularly vulnerable to this disease and that they can be change agents in their families for more efficient vector control in particular by promoting the systematic use of long lasting insecticide-treated mosquito nets for all their family members.”

On this International Women Day, we celebrate and thank Dr. Ndao and all the women Doctors of Senegal for their leadership and commitment to eliminate malaria and are proud to see such amazing partners joining efforts to make Zero Malaria a reality in Senegal.

*****

Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.