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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
AFRICA
395
reduction in maternal mortality rate between 2000 and 2015 has
failed. During these years, the global maternal mortality rate was
reduced by only 45%.
3
Around 80% of all maternal deaths occur
in areas of high birthrate and low healthcare access and there is
an alarming geographical disparity. Women from sub-Saharan
Africa (SSA) have a 100-fold greater risk of having a pregnancy-
related death than those living in North America.
4
Indirect maternal mortality is responsible for one-quarter of
the total maternal mortality rate.
5
Pre-existing cardiovascular
disease, pregnancy-related cardiomyopathy and aggravated
hypertension are among the conditions that contribute
significantly to high indirect maternal mortality in low- and
middle-income countries (LMIC). RHD, a disease linked to
poverty, which has almost disappeared in developed countries,
remains an important determinant of morbidity and mortality
in LMIC, particularly in SSA where a high prevalence of RHD
coincides with high maternal mortality rates. RHD contributes
to almost 30% of the cardiovascular disease seen in pregnancy,
6
is associated with a maternal mortality rate of 34% and is
responsible for substantial foetal loss.
7
TheGlobal RheumaticHeart Disease Registry (the REMEDY
study)
8
has shown a prevalence ratio of women to men of 2:1.
This multi-national, hospital-based prospective registry enrolled
3 343 patients presenting at 25 hospitals, mostly from 12 African
countries. Young females were in the majority (median age 28
years, females 66.2%) and had a higher prevalence of major
cardiovascular complications. There was sub-optimal use of
contraception, even in high-risk women. Only 5% of women
with prosthetic heart valves and 2% of those with severe mitral
stenosis were on contraception.
When the participating countries in REMEDY were grouped
into the income categories of low-income (LIC), low- and
middle-income (LMIC), and upper-middle-income (UMIC)
countries, according to 2011 World Bank definitions, there
was no difference in the predominance of females with regard
to males in the three groups: 728/1 110 (65.8%), 867/1 370
(63%) and 616/863 (71.3%). However, a statistically significant
difference was found in the proportion of women in their
childbearing years between the three groups of countries, with a
higher number in low- and low-middle-income countries: 86.5%
in LIC, 90.3% in LMIC and 66.9% in UMIC (
p
<
0.01).
Among the 1 825 women of childbearing age (12–51 years)
recruited into REMEDY, only 65 (3.6%) were on contraception.
8
This poor provision of family planning for women with heart
disease occurs in many regions of the world.
9,10
Among the
most important reasons for this are difficult access to health
facilities and/or providers with capacity to ensure comprehensive
family planning in several parts of the continent, as well as low
education levels and awareness of health personnel, inadequate
cardiovascular diagnosis, inadequate referral pattern and poor
overall management. Long distances to health facilities and lack
of funding to cover the travel fare are also important aspects of
late presentation to healthcare. Lack of women empowerment,
social pressure on women to conceive, and cultural aspects
related to use of contraception also play a role in determining
high parity.
11
Health concerns related to contraception and
opposition to family planning are equally leading reasons
hampering women from using modern contraception.
The low usage of contraception contributes to high fertility
rates in Africa and explains why pregnancy in the context of
RHD is very frequent in this region. In the REMEDY study,
72 women (3.7%) were pregnant at the time of enrolment, the
youngest being 14 years and the oldest 51 years.
8
The low use of
contraceptive methods by young women and the predominance of
high-risk women in the most under-resourced countries highlight
the urgent need to address the reproductive health requirements
of women with RHD in SSA. Fig. 1 shows the prevalence of
RHD, contraceptive usage, and fertility and maternal mortality
rates in the different regions of the African continent.
12-23
Determinants of the low usage of reproductive health services
by women with RHD in Africa are probably related to factors on
the side of both the providers and the users. On the providers’
side, training of health professionals to better diagnose and
manage women with RHD throughout their reproductive life is
an important aspect to address. This position paper is expected
to provide guidance and promote structural changes in the
health services to accommodate the particular needs of women
with RHD.
Methods
We performed a non-systematic literature review of published
studies on RHD worldwide. Briefly, we searched PubMed for
studies that had been published in the period 2000 to June
2017. Our strategy included search terms corresponding to
RHD diagnosis, management or prevention, combined with
the words ‘contraception’, ‘maternal mortality’, ‘pregnancy’
and ‘post-partum’. Additional searches were done in Google
Scholar for categories that yielded very few results in PubMed.
Studies were selected as relevant if they met any of the following
criteria: contained data on RHD in women, and pregnancy-
related maternal and foetal outcomes. Preference was given to
articles reporting data from LMIC worldwide, and from Africa
in particular. Sentinel articles outside the time period were
included.
In this position paper we especially aimed at reviewing
scientific evidence available to explore and answer the following
questions:
•
What specific issues need to be addressed in managing women
with RHD in Africa?
•
Does any contraceptive method work better or increase the
risk of complications?
•
Does pregnancy affect RHD? Does RHD worsen pregnancy
outcomes?
•
Are there specific interventions that should be considered for
pregnant women?
•
What service-provision models can be used to manage women
with RHD?
•
What are the health system considerations for developing and
supporting those services?
Diagnosis and management of RHD
RHD commonly affects the mitral, aortic and tricuspid valves, in
isolation or in combination.
24,25
It is one of the drivers of maternal
mortality beyond six weeks’ postpartum in SSA, because high-
risk women with RHD are often diagnosed during pregnancy.
During pregnancy, assessment of the valves affected, the
severity of lesions and risk prediction are complex, requiring
considerable experience. Despite the scarce information