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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
AFRICA
401
However, in the majority of African countries, school health
services either do not exist or function sub-optimally. Where they
do function, the main focus is on screening and prevention in
younger children.
22,66
This represents a huge missed opportunity
to support and educate young women as they enter their sexually
active and reproductive health period. Where school health
services exist, these should extend their activities to include
health promotion and SRH to support young women in general,
incorporating modules for endemic cardiovascular diseases,
such as RHD, peripartum cardiomyopathy and hypertension
in pregnancy. Where these do not exit, other mechanisms via
existing primary healthcare services should be initiated to
accommodate the SRH support to young women with RHD.
Maternal health services
A recent systematic review, conducted on the state of maternal
health services for women with disabilities in SSA,
67
found that
current maternal health services for women who live and are
dependent on public sector service provision in SSA are wholly
inadequate. This state of affairs extends to all women and not
just those with disabilities, and would include women with RHD.
A key factor is the significant lack of human resources, both
in numbers and technical skills, across all countries, including
obstetricians and gynecologists, midwives, and support staff
such as laboratory technicians. This needs to be considered when
planning for screening, diagnosis, management and follow up of
women with RHD in these services.
Linked to the availability of human resources are issues
such as financial resources to support diagnostics, drug supply
chain, and support schemes for women who fall pregnant and
face the possibility of cardiac complications. Finally, we must
take into consideration that the selective development of any
service response, as demonstrated by several vertical disease-
linked programmes, poses many drawbacks to the current global
efforts to support strengthening of the overall health system, and
therefore the recommendation of this review for an integrated
service response to RHD.
The service response to address the needs of women with
RHD will therefore have to be considered in the context of
strengthening reproductive and maternal health services in
general. Within such a system, we must ensure that health
workers are sufficiently aware of the importance of RHD and
that the system requirements are in place to identify, diagnose
and treat women with this condition.
The
Lancet
series on sexual and reproductive health
services
68
emphasises the importance of matching sexual and
reproductive health rights with accessible and good-quality
services. Recognising the rights of more vulnerable groups,
such as women with RHD who generally live in conditions of
poverty, challenges the current status quo where SRH services
are generally designed to address the needs of women without
additional medical complications.
Fathalla
et al
.
68,69
call for action to prioritise SRH services for
all, and they strongly question the decision of leaving out SRH
as an explicit and stand-alone sustainable development goal
as they posit that this has the potential to influence progress
in access to SRH services in SSA. For instance, a significant
number of countries in Africa have no or restricted termination
of pregnancy services, and in at least nine countries, the unmet
needs for family planning services are more than 30% for
married women. The extent of the unmet needs is unknown for
unmarried women, many of whom would be in their adolescence
and most likely to present with RHD in pregnancy.
Research needs and the way forward
Based on this review, the PASCAR taskforce identified several
areas that need research. These include increase in awareness
about RHD and its complications, improvement in management,
and adequate counselling for women of reproductive age. The
use of protocols that incorporate equipment such as hand-held
echocardiography and point-of-care laboratory testing (for early
detection of rheumatic fever and follow up of anticoagulation)
should be explored. Access to reproductive health services,
availability and affordability of efficient contraceptive methods,
and acceptability of pregnancy termination options are among
the issues that need to be understood in the different African
contexts.
Shortage of human resources with adequate technical abilities
and supplies to appropriately diagnose, treat and follow up
women with RHD requires careful consideration. Education
of health professionals and testing of models for integration
of services may avoid loss of opportunities for the diagnosis
of RHD and promote adequate management when patients
make contact with the health system. Innovative financing
and logistical mechanisms are required to support diagnosis,
ensure consistent drug supply, and increase availability of
interventions, allowing a continuum of care. Community-based
financing mechanisms that ensure community engagement and
sustainability must also be explored.
Health promotion and educational campaigns directed at
young people, in particular girls, should be prioritised. The
vehicles to deliver information need to be adapted to the
young population in both rural and urban communities. The
education and research areas identified stress and the need for
a comprehensive approach to prevention and control of this
condition of poverty, involving sectors such as health, education,
social services, communications and finance.
We acknowledge the work of Janette Lombard in scheduling and organising
the working meetings. We also express our appreciation to Sylvia Dennis for
her help in editing and formatting the manuscript for submission.
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