Poor maternal care leads to hysterectomies, antibiotic resistance

In Malawi, women's wombs are removed to stop infection, a life-changing operation that doesn't always work.

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    Poor maternal care leads to hysterectomies, antibiotic resistance
    At one hospital, doctors reported around five women a month were being given hysterectomies in an attempt to stop infection [Madlen Davies/TBIJ]

    Thyolo, Malawi - In a hospital room in Thyolo, a southern Malawian town nestled in tea plantations, Ngellina Chikopa unwraps her sarong 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 IV antibiotics but the wound started to release foul-smelling pus. The infection spread to her uterus. Doctors gave her more antibiotics but they didn't work. 

    Next, medics performed a hysterectomy, an operation to remove her womb.

    But afterwards, she suffered another infection and was transferred to Queen Elizabeth Central, a big referral hospital in the city of Blantyre, where she had another two operations to clear the pus and close the wound.

    By removing her uterus, they have taken away the entire future clan away from us.

    Bester, father of patient Ngellina Chikopa

    She was discharged but is back at Thyolo hospital because her stomach is not healing. She shares a room with a young woman called Margaret, who also lost her baby to asphyxia.

    Chikopa fears she will be ostracised now she cannot have children. There is a stigma attached to being both unmarried and childless. 

    "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." 

    She hopes to return to school when she recovers.

    Scores of women in Malawi face having their wombs taken out because of infections. 

    Dr Martha Makwero, acting head doctor of the maternity department at Queen Elizabeth Central Hospital, said 36 women had had hysterectomies due to infection between March and May this year.  

    At Zomba Central Hospital, around five women have their wombs removed every month, said Dr Maguy Kabeya, head of the maternity department, 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.

    Other central hospitals in Malawi did not provide figures on hysterectomies.

    Many hospitals in Malawi lack the facilities to treat infections, which has led to overzealous procedures and antibiotic resistance [Madlen Davies/Al Jazeera]

    In Malawi, malnourishment or diseases such as HIV - which affects around 10 percent of the country - suppress immune systems.

    Infection control in rural health centres and district hospitals 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 called a macintosh, a razor blade to cut the cord and a plastic tub to bathe the baby.

    These aren't sterile, which increases the chance of the mother catching an infection.

    Clearly getting the right antibiotics and blood cultures would be a better way of dealing with this.

    Pat O'Brien, consultant obstetrician at University College London Hospitals

    Florence Matandika, 18, cries out in pain at Queen Elizabeth Hospital.

    Her mother Judith comforts her when she occasionally vomits.

    After a prolonged labour on May 10, she gave birth to a stillborn baby 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 can be given a dose of antibiotics before a caesarean section. This is not always practised in Malawi. 

    A blood culture test could also be carried out if the mother does catch an infection - technicians would 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 don't have the resources. 

    Even Zomba, a referral hospital, sends samples to the lab at Queen Elizabeth in Blantyre, where blood culture facilities are provided by the Malawi Liverpool Wellcome Centre, the research institution next door. 

    The tests are prioritised for adult and paediatric patients and rarely sent for women on maternity wards. 

    There is also a limited number of antibiotics available in most hospitals.

    Pregnant women with infections are usually given penicillin, gentamicin and ceftriaxone. 

    Antibiotic resistance

    Rising antibiotic resistance, meanwhile, is another challenge.

    A study by Malawi Liverpool Wellcome Centre showed that while the number of bloodstream infections fell between 1998 and 2016, the proportion that were 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 2 percent to 30 percent over the same time period.

    Dr Makwero, acting head of the maternity department, believes resistance is hampering treatment of women with infections.

    The antibiotic 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 any more," she said.

    She has to seek permission to use meropenem, an expensive antibiotic which the hospital doesn't always stock. There are also concerns over resistance with using it more frequently.

    Pat O'Brien, a consultant obstetrician at University College London Hospitals, accepts that hysterectomies are sometimes life-saving, but says operations are more expensive and traumatic than a blood culture. 

    "If it's truly the case that doing a hysterectomy is the only way to save someone's life then clearly that's a better option regardless of all of this. But clearly getting the right antibiotics and blood cultures would be a better way of dealing with this," he explains.

    Women are being given hysterectomies in Malawi to stem infection, but the procedure is not always effective [Madlen Davies/TBIJ]

    Back in Thyolo, Ngellina's father Bester worries for his daughter.

    It was difficult to see her in pain and to shoulder the medical bills. 

    "I'm concerned that she lost her baby and she had her uterus removed," he said.

    "In our culture, this means a girl has no future at all as no man would be interested to marry her. By removing her uterus, they have taken away the entire future clan away from us."

    This story was written by Madlen Davies of The Bureau of Investigative Journalism and edited and published in partnership with Al Jazeera.

    SOURCE: Al Jazeera News


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