Module 14: Strategies to Reduce Disease Among Women and Children

Introduction

Impoverished women and children are among the world’s most vulnerable and influential populations.  Women have the power to influence their communities for the better, and they are strong figures of change in the household.  Healthy and empowered mothers mean healthy children.  The complex health needs of women and children demand a “multipronged approach that moves solutions from innovation to impact: supporting new ideas through inception, development, and testing; paving the way for introduction in low-resource countries; and working with governments and communities to integrate and expand the most successful ideas”.(1)  Below are several “tried-and-true” strategies to reduce disease among women and children.

Vaccinations

Child and mother vaccination is one of the most effective public health interventions that can reduce child morbidity and mortality.  Vaccines can prevent many life-threatening illnesses including diarrheal disease, a killer of nearly two million children per year.(2) Oftentimes, however, mothers are not likely to obtain vaccines, even when available.  This is due to many well-known barriers to care including fear, lack of transportation, and cultural practices.  For example, mothers may prefer to utilize traditional practices rather than medical interventions.  

One study examined the association between mothers' use of traditional healer services and vaccination among Haitian children.(3) Researchers found that children whose mothers used the services of traditional healers were less likely to be vaccinated compared to children whose mothers did not use the services of traditional healers. Furthermore, mothers' use of traditional services was negatively associated with vaccination after controlling for maternal age, education, religion, and distance from the nearest health care facility. Findings from this study underscore the potential to enlist the help of traditional healers in promoting child health by educating and mentoring the healers in support of vaccination efforts.

Education is a powerful tool, and educating traditional healers and mothers can have positive consequences that extend to others in the family and the community. For example, Indonesia Demographic and Health Surveys show that the ownership of health educational materials, such as home-based immunization handbooks, leads to increased rates of immunizations. In 2002–2003, 70.9% of children whose household had handbooks had received all vaccines by the time of the survey, whereas only 42.9% of children who did not have handbooks had been immunized. (4)

Based on these findings, an Indonesian ministerial decree in 2004 stated that the Maternal and Child Health Handbook (MCH handbook) was to be the only home-based record of maternal, newborn and child health. This has increased immunization coverage through raising awareness of immunization among children's parents and community members and by allowing more accurate measurement of immunization coverage.

The MCH handbook implementation has several features that promote its effective use. For example, MCH handbooks are given to women in pregnancy and are kept at home, referred to at any time of need and brought to health service appointments. Health personnel give guidance to clients to help them learn the contents of the handbook and to encourage them to share the information with their family.

Recently, the United States Agency for International Development invested in 1 million handbooks as the core material to promote immunization(5) and GAVI, the Global Alliance for Vaccines and Immunization, approved its use to promote immunization under its health system strengthening program. “The MCH handbook also provides opportunities to improve other services, such as community strategies for the integrated management of childhood illness and birth registration, and is a potential platform for integrating health services to ensure a continuum of care.” (6)

Community-Based Health Interventions

Like the Maternal and Child Handbook, community-based health interventions are a well-established and proven strategy to educate and reduce disease among women and children.  A central pillar of community based interventions is the involvement of community health workers (CHWs).(7)  The World Health Organization defines CHWs as members of the communities where they work, who should be selected by the communities, be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers.(8)  

Since the 1980s, CHW programs have been a cornerstone of primary health care based on the Alma-Ata declaration of 1978.(9)(10)(11) CHWs have been considered as agents linked to behavioral change and play a key role in the expansion of formal health services.(12)  For example, interventions in several African countries have demonstrated that community-based health workers can effectively deliver “differential treatment for childhood illnesses based on clinical symptoms”.(13)   In this way, CHWs function to initiate referral for severe illness and can help save lives of children suffering from pneumonia, malaria, and diarrhea. (14)

HIV/AIDS Strategies

Two leading global health organizations, Partners in Health and mothers2mothers have developed best practice guidelines for the treatment of HIV/AIDS among women and children.  Their innovative and effective models are outlined below and provide important principles for other organizations to adopt.

Partners in Health: "Four Pillars" of the HIV Equity Initiative (15)

• AIDS prevention and treatment in the context of primary care: Providing general medical services is the fundamental intervention necessary for engaging the community, for improving overall well-being and for identifying and earning the trust of HIV patients.

• Advancing tuberculosis care: Tuberculosis is the leading cause of death among HIV-positive people worldwide. The two diseases must be battled in tandem.

• Improving screening and treatment of sexually transmitted infections: Untreated sexually transmitted infections can elevate the rate of HIV transmission up to tenfold, cause cervical cancer and infertility, and put pregnant women and their babies at increased risk.

• An emphasis on women’s health: Childbirth is the second leading cause of death for women in Haiti. Focusing on women's health holds the key to reducing the toll of maternal mortality and to reducing the incidence of infant mortality and low birth weight. It also provides an entry point for HIV counseling and testing, for preventing mother-to-child transmission of HIV, and for earlier HIV diagnosis for newborns.

mothers2mothers (16)

mothers2mothers (m2m) offers an effective, sustainable model of care that provides education and support for pregnant women and new mothers living with HIV/AIDS.   With the advent of “prevention of mother to child transmission” (PMTCT) treatment in Africa, the key obstacle to its effectiveness is the need for outreach, education and support for HIV-positive pregnant women and new mothers so they can overcome the barriers that keep them from accessing medical care.  

As an educational, psychosocial mentoring and support organization, m2m trains and employs HIV-positive mothers who have themselves gone through the program. These ‘Mentor Mothers’ then provide peer education and psychosocial support to HIV-positive pregnant women and new mothers, empowering them to access life-saving treatment for their babies and for themselves. The Mentors become an integral element of clinical prevention of mother-to-child transmission.  Located in antenatal clinics, maternity wards, post-delivery clinics and hospitals, m2m works alongside established PMTCT treatment programs. M2M services include:

• Regular support groups

• Formal and informal individual counseling

• Help with issues of stigma and disclosure to family and friends

• Comprehensive education sessions about HIV/AIDS, and prevention of mother-to-child transmission

• Daily gatherings for nutritious lunches and nutrition education

Malaria Strategies

In addition to HIV/AIDS, malaria infection is a major cause of morbidity and remains the biggest cause of lost days of healthy life.(17)  In many areas of the world, malaria is mainly a childhood disease because adults enjoy some level of protection due to acquired immunity.  However, pregnant women constitute an important exception to this protection against malaria in endemic areas.

In fact, pregnant women are twice as likely to become infected with malaria as non-pregnant women living under the same conditions.(18) The adverse consequences of pregnancy-associated malaria (PAM) include infant low birth weight and anemia in newborn babies, as well as maternal anemia.(19)(20)(21) Other parasitic infections, especially hookworm, and micronutrient deficiencies also contribute to anemia in pregnant women.(22)

One study evaluated the PAM situation in a rural, coastal community of Ghana to allow for implementation of an intervention against this major cause of maternal and child morbidity and mortality.  Researchers found that increased public education, the use of insecticide-treated bed nets and intermittent preventive treatment as well as treatment of malaria with effective anti-malarial drugs during pregnancy can help to control PAM.

Insecticide-treated bed nets (ITNs) are often promoted as a cost-effective means to prevent the transmission of malaria; their use by pregnant women has been shown to reduce the incidence of low birth weight by 23%, and use by children reduces mortality by 17%.(23)(24)   Because infants in sub-Saharan Africa and elsewhere typically sleep with their mothers, distribution of bed nets benefits pregnant mothers and subsequently their infants.

In fact, the World Health Organization recommends that pregnant women and children less than five years of age in sub-Saharan Africa have the highest priority for receiving ITNs.(25)  However, possession of ITNs in sub-Saharan Africa remains low, with only 6.7% of households owning one.(26)  It has been suggested that antenatal clinics are a logical target for bed net distribution because 70% of women in sub-Saharan Africa will visit the antenatal clinic during their pregnancies.(27)  Also, “integrating programs and using existing infrastructure can contain costs, an important objective in resource-poor countries that must choose between many needed interventions.”(28)

Footnotes

(1) "PATH: A Catalyst for Global Health." https://www.path.org/.

(2) Countdown to 2015 Working Group, Tracking Progress in Maternal, Newborn & Child Survival: The 2008 Report (New York: UNICEF, 2008).

(3) Muula, A., Polycarpe, M., & Job, J. et al. (2009). Association between maternal use of traditional healer services and child vaccination coverage in Pont-Sonde, Haiti. International Journal for Equity in Health 8:1

(4) Osaki K, Hattori T, Kosen S, & Singgih B. (2009). Investment in home-based maternal, 35 newborn and child health records improves immunization coverage in Indonesia. Trans R Soc Trop Med Hyg. 103(8):846-8.

(5) Ibid.

(6) Ibid.

(7) Winch PJ, Gilroy KE, Wolfheim C, Starbuck ES, Young MW, Walker LD, & Black RE (2005).: Intervention models for the management of children with signs of pneumonia or malaria by community health workers. Health Policy Plan, 20:199-212.

(8) World Health Organization: Strengthening the performance of community health workers in primary health care: report of a WHO study group. https://apps.who.int/iris/handle/10665/39568.

(9) WHO, UNICEF: Primary Health Care, Report on the International Conference on Primary Health Care. https://www.who.int/social_determinants/tools/multimedia/alma_ata/en/.

(10) Walt G, Ross D, Gilson L, Owuor-Omondi L, & Knudsen T (1989). Community health workers in national programmes: the case of the family welfare educators of Botswana.  Trans R Soc Trop Med Hyg, 83:49-55.

(11) Rowe, S. Y., Kelly, J. M., Olewe, M. A., Kleinbaum, D. G., McGowan Jr, J. E., McFarland, D. A., ... & Deming, M. S. (2007). Effect of multiple interventions on community health workers’ adherence to clinical guidelines in Siaya district, Kenya. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(2), 188-202.

(12) Winch, P. J., Gilroy, K. E., Wolfheim, C., Starbuck, E. S., Young, M. W., Walker, L. D., & Black, R. E. (2005). Intervention models for the management of children with signs of pneumonia or malaria by community health workers. Health policy and planning, 20(4), 199-212.

(13) Perez F, Ba H, Dastagire S, & Altmann M. (2009). The role of community health workers in improving child health programmes in Mali. BMC International Health and Human Rights, 9:28

(14) PMI Communication and Social Mobilization Guidelines. Rep. Fighting Malaria. https://www.usaidassist.org/resources/pmi-communication-and-social-mobilization-guidelines.

(15) Partners In Health. https://www.pih.org/.

(16) Mothers2mothers. https://m2m.org/.

(17) Stephenson LS, Latham MC, & Ottesen EA. (2001). Malnutrition and parasitic helminth infections. Parasitology, 121(Suppl):S23–S38.

(18) Lindsay, S., Ansell, J., Selman, C., Cox, V., Hamilton, K., & Walraven, G. (2000). Effect of pregnancy on exposure to malaria mosquitoes. The Lancet, 355(9219), 1972.

(19) Brabin, BJ. (1983). An analysis of malaria in pregnancy in Africa. Bull World Hlth Org. 61:1005–1016.

(20) Brabin, BJ. (1991). The risks and severity of malaria in pregnant women. Applied Field Research Report No. 1, UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva. 1–52.

(21) Cot, M., Le Hesran, J. Y., Miailhes, P., Roisin, A., Fievet, N., Barro, D., ... & Breart, G. (1998). Effect of chloroquine prophylaxis during pregnancy on maternal haematocrit. Annals of Tropical Medicine & Parasitology, 92(1), 37-43.

(22) Steketee RW, Nahlen BL, Parise ME, & Menendez C. (2001). The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg 64:28–35.

(23) Gamble, C, Ekwaru, JP, & ter Kuile, FO. (2006). Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database Syst Rev Issue2: CD003755, doi: 10.1002/14651858.CD003755.pub2.

(24) Lengeler, C. (2004). Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev Issue2: CD000363, doi: 10.1002/14651858.CD000363.pub2.

(25) World Health Organization. Guidelines on the Use of Insecticide-treated Mosquito Nets for the Prevention and Control of Malaria in Africa. https://apps.who.int/iris/handle/10665/63609.

(26) Miller JM, Korenromp EL, Nahlen BL, &Steketee RW. (2007). Estimating the number of insecticide-treated nets required by African households to reach continent-wide malaria coverage targets. JAMA297: 2241–2250.

(27) World Health Organization, 2003. Reducing the Burden of Malaria in Pregnancy. https://www.who.int/malaria/publications/atoz/merajan2003/en/.

(28) Becker-Dreps, S. I., Biddle, A. K., Pettifor, A., Musuamba, G., Imbie, D. N., Meshnick, S., & Behets, F. (2009). Cost-effectiveness of adding bed net distribution for malaria prevention to antenatal services in Kinshasa, Democratic Republic of the Congo. The American journal of tropical medicine and hygiene, 81(3), 496-502.