In Malawi, women’s wombs are removed to stop infection, a life-changing operation that does not always work, MADLEN DAVIES, the health and science editor at The Bureau of Investigative Journalism, writes.
In a hospital room in Thyolo, Angelina Chikopa unwraps her chitenje to reveal a long wound filled with pus. The cut stretches from her lower abdomen through her belly button and up past her stomach.
The 18-year-old gave birth by caesarean section in April 2018, but the baby died of asphyxia after becoming stuck and suffering brain damage from lack of oxygen.
While she was grieving, the wound became infected. She was given a drip of antibiotics, but the wound started to release foul-smelling pus and spread to her uterus. Doctors gave her more antibiotics, but they did not work.
Next, medics removed her womb. But afterwards, she suffered another infection and was transferred to Queen Elizabeth Central Hospital (Qech) in Blantyre, where she had another two operations to clear the pus and close the wound.
She was discharged, but was back at Thyolo District Hospital because her stomach is not healing. She shared a room with a young woman, who also lost her baby to asphyxia.
Chikopa fears she will be ostracised now she cannot have children. “I know that I will never ever have children in my lifetime, I have accepted it with a lot of pain as there is nothing I can do about my situation,” she said. “Some relations are aware of my situation and by now I know the social discrimination that I will be facing out there.”
Scores of women in Malawi face having their wombs taken out because of infections.
Dr Martha Makwero, acting head of the maternity department at Qech, said 36 women had hysterectomies due to infection between March and May 2018.
At Zomba Central Hospital (ZCH), around five women have their wombs removed every month, said Dr Maguy Kabeya, who carried out a three-month observation this year.
He said they were referred from district hospitals and health centres where infection prevention is substandard.
Some of the women died.
In the country, malnourishment or diseases, including HIV which affects around 10 percent of the country, suppress immune systems.
Infection control in rural health centres is poor. Half the healthcare facilities lack clean water and sanitation. Electricity blackouts mean equipment used during labour may not be sterilised properly. Hospitals frequently run out of essential supplies such as chlorine, soap and antiseptic gloves.
Women are also asked to bring certain items to the hospital for the birth: a plastic sheet, a razor blade to cut the cord and a plastic tub to bathe the baby.
These are not sterile, which increases the likelihood of the mother catching an infection.
Florence Matandika, 18, cried out in pain at Qech. Her mother Judith comforted her as she occasionally vomited.
After a prolonged labour on May 10, she gave birth to a stillborn by caesarean section.
The wound became infected and her stomach started to swell. The infection spread to her uterus and doctors were forced to perform an operation to remove it.
She has been given two types of antibiotics, but still has an infection.
“I have given up on the husband,” says Judith, commenting on her daughter’s partner. “I know he will marry another woman because my daughter cannot have children anymore. I’m in pain but I will accept God’s will.”
To prevent infection, women are sometimes given a dose of antibiotics before a caesarean section.
Technicians can also carry out a blood culture to identify which bacteria is causing the problem and which antibiotics might work. But blood culture facilities are expensive; they require sophisticated laboratory equipment and trained staff.
Most hospitals in Malawi do not have the resources.
Even ZCH sends samples to the lab at Qech, where blood culture facilities are provided by the Malawi Liverpool Wellcome Trust (MLWT) research centre next door.
There is also a limited number of antibiotics available in most hospitals.
Pregnant women with infections are usually given penicillin, gentamicin and ceftriaxone.
Rising antibiotic resistance, meanwhile, is another challenge.
A study by MLWT centre showed that while the number of bloodstream infections fell between 1998 and 2016, the proportion that was resistant to antibiotics increased.
The data is for adults and paediatric patients. There are no statistics relating to resistance patterns in mothers.
In Klebsiella, an infection causing bloodstream infections, resistance to the two major classes of antibiotics available in the hospital—penicillin and cephalosporin—rose from 12 percent to 2003 to 90 percent in 2016.
In E. coli, a leading cause of sepsis, resistance rose from two percent to 30 percent over the same time period.
Makwero believes resistance is hampering treatment of women with infections.
Ceftriaxone does not work for many, she said.
“It really affects our management. We tend to clear the infection through surgery but it is not always working… It would be catastrophic if we could not use ceftriaxone anymore,” she said.
She has to seek permission to use meropenem, an expensive antibiotic which the hospital does not always stock. There are also concerns over resistance with using it more frequently.
Pat O’Brien, a consultant obstetrician at University College London Hospital, accepts that hysterectomies are sometimes life-saving, but says operations are more expensive and traumatic than a blood culture.
According to the expert, getting the right antibiotics and blood cultures would be a better way of dealing with this,” he explains.
Back in Thyolo, Angellina’s father Bester worries for his daughter.
It was difficult to see her in pain and to shoulder the medical bills.