For want of an ambulance

Today I had the pleasure of meeting Sitshengisiwe, our HIV/AIDS and Reproductive Health Coordinator in the Zambezi Valley. In the valley there’s no safe water, electricity, transport or communication systems. So if someone gets ill they will have to walk, or at best be transported in an ox-cart, to the nearest basic health centre.

This wasn’t always the case. Sitshengisiwe tells me that there used to be a functioning ambulance for referrals to the district hospital 46 kilometres away. But as with many things, this is no longer functioning.
Lack of transport dealt a serious blow to one family that Sitshengisiwe managed to support. Following childbirth at home, a young mother had suffered post-partum haemorrhage. In attempt to get his wife to the nearest clinic, her husband tried to sell one of his goats to pay for transport, but nobody he asked could afford to buy his goat. He tried to take her in an ox-cart instead, but sadly she died before they made the 10-kilometre journey.

The husband then chose to brave the 46-kilometre walk to the district hospital, to register his wife’s death at the district hospital. This is where Sitshengisiwe was informed of his case. She visited the family soon after – walking only a 12 kilometre round trip this time.

On arrival she and her Ministry of Health counterpart provided health and nutrition advice to the family, and gave them a ‘baby kit’ that contained essential items for caring for newborns, including a baby-grow, warm clothes and a hat, nappies, towels, soap and Vaseline.

She also discussed options for feeding the baby with the husband, aunt and grandfather who are now left to care for him. They resolved to feed the baby with modified goat’s milk using a cup and spoon as it was seen as the only sustainable option for them.

Save the Children feels strongly about the importance of infant feeding and actively supports the ‘Operational Guidance on Infant and Young Child Feeding in Emergencies’ which provides the do’s and don’ts in this area. The current international guidance is that modified animal milk should not be promoted as it lacks some important nutrients.

I was interested to find out more about this so I spoke to Ali Maclaine, an Infant Feeding Consultant who is working for Save the Children in this area. Her role in Zimbabwe is work with the Zimbabwe Nutrition Cluster (a group of organisations involved in nutrition) to ensure that breastfeeding is supported and that agencies know and follow the international guidance.

She told me that breastfeeding, especially in emergencies, saves lives and protects infants from diseases such as diarrhoea, malnutrition and death. In fact, non-breastfed infants in non-hygienic conditions are 6-25 times more likely to die than breastfed infants. Moreover, breast milk specifically helps protect infants from cholera. When infants are not-breastfed pre-crisis or when the mother dies usually a ‘breast milk’ option is looked at as a first resort as it is such a life saving intervention.

Other options include wet nursing (breastfeeding by someone other than the mother), milk banks or re-lactation (re-starting breastfeeding – if the mother had stopped pre-crisis or by a grandmother if the mother has died). In places, like Zimbabwe, where there is a high prevalence of HIV the guidance is that wet nurses should be counselled and have an HIV test.

Where a breastfeeding option is not available infant formula should be provided for as long as the infant required needs it – along with additional support such as education on making up the formula as safely as possible, provision of additional materials e.g. cooking equipment and it should be fed to the child by cup as bottles and teats are very hard to clean.

Yet even if the caregivers get formula and extra support it is not easy: The child must be monitored and health care provided as they are likely to get sick more often and more severely than a breastfed child, collecting the additional water and fuel to make the formula and then feeding the child takes time, etc.
As part of her routine work, Sitshengisiwe carries out infant feeding support sessions for young mothers. In these sessions they talk about things like the importance of exclusive breastfeeding, the reduced risks of HIV transmission with exclusive breastfeeding compared to mixed feeding and how to breastfeed successfully.

She also talks to them about when to introduce other foods/fluids and what foods they should use. The sessions are generally a mixture of sharing experiences and concerns, and providing mothers with information.

It is hard not to get angry at the unfairness of what the people Sitshengisiwe works with have to face.

Cholera and malaria are easily preventable illnesses and the vital information and resources health workers like Sitshengisiwe and her Ministry of Health counterpart can provide saves lives. But, with the terrible road conditions making each home visit into a cross-country trek, the amount of families benefiting from such services is never enough.