Across sub-Saharan Africa, new moms are at risk of falling into depressive states that can potentially damage their own mental health and well-being of their new born child.

In many parts of the continent, public health systems are ill-equipped to deal with post-partum depression which affects a significant number of women after giving birth. The situation is made worse by the absence of psychiatrists or clinical psychologists trained to help women cope with the condition.

According to researchers, post-partum depression (also called post-natal depression) affects as many as one in five women, particularly during the first year of motherhood. Less than 2 in 1,000 women are also at risk of developing postpartum psychosis.

The condition causes mothers to feel exhausted and emotionally empty and can potentially destroy the bonding between a mother and her new-born baby.

“Women seem to be particularly vulnerable to depression during their reproductive years: rates of the disorder are highest in females between the ages of 25 and 45. New data indicate that the incidence of depression in females rises, albeit modestly, after giving birth,” reports the Scientific America journal.

According to the journal, dramatic hormonal fluctuations that occur after delivery may contribute to postpartum depression in susceptible women, but causes of the disorder are not fully understood.

“A longer term consequence of not diagnosing and treating postpartum depression is the effects it can have on the family, including the parental relationship and the development of the child. Children of depressed women have been found to have attachment problems, higher rates of behavioural problems and lower vocabulary skills,” states a report titled Postpartum Depression: A Literature Review.

For some new moms, the situation can be so severe it can lead to cases of infanticide and suicide.

However, among African women, little to no studies have been conducted to better understand the condition, and the way that women cope in the absence of appropriate public health services.

It is possible to surmise from existing data from other parts of the world the general experience of African women following childbirth.

A study by the University of Iowa revealed that low-income women are much more likely to suffer from postpartum depression than wealthier women.

The research revealed that women who are poor already have a lot of stress, ranging from poor living conditions to concerns about paying the bills.  

The birth of an infant can represent additional financial and emotional stress, and depression negatively impacts the woman’s ability to cope with these already difficult circumstances, according to the study.

The study which focused on a sample of 4,332 new mothers from four Iowa counties showed that that compared to white or Latino mothers, African-American mothers are more likely to experience depression after having a baby.

Furthermore, the study revealed that African-American women tend to have weaker support networks, a major predictor of postpartum depression.

Like African-American women, African women that give birth are also affected by low incomes and high levels of general and live in stressful contexts which increases the onset of depression.

While there is clearly  a need for more research into the coping methods of African women, simple screening methods can be utilized to identify women that are at risk of postnatal depression. Nurses in public health settings need to be provided with training so that they are able to detect and assist new mothers from post-partum depression. The use of a simple tool, the Edinburgh Postpartum Depression Scale, translated into local language, can assist nurses, family members and new moms to detect depressive symptoms.

If anything, public educational and awareness raising programs or simple pamphlets and posters describing the condition need to be displayed in ante-natal clinics so that women are mentally prepared to deal with the problem.

As research shows, social support networks can also play a key role in helping women deal with postnatal depression.

Overall, it is essential for national government throughout the world to guarantee that new moms have access to clinical and maternal services that can help to avert the emotional upheavals associated with giving birth.   

Although the female condom has been heralded as a way for women to protect themselves from HIV and STI infections, its impact has been severely limited due to several reasons including its design, cost, access, stigma, and lack of political will.

Given the fact that women are the most affected and infected by HIV (in 2007, women represented half of all HIV infections worldwide, and 61% of HIV infections in sub-Saharan Africa) it is an imperative that evidence-based measures be undertaken to reduce their vulnerability.

The female condom is an essential sexual reproductive health tool that women can control but, disappointingly, it remains confined to the fringes of the response to the global AIDS epidemic.

According to a report by the Center for Health and Gender Equity titled “ Saving Lives Now: Female Condoms and the Role of US Foreign Aid” the US has an important role to play in the procurement, distribution and programming of female condoms.

As a leading provider of funding for HIV and AIDS prevention, treatment and care, and reproductive health supplies worldwide, the US can promote the wider use of the female condom, including reducing the cost which is beyond the reach of many of the affected women. 

The report notes that there is little knowledge among policy makers and advocates about what the current US role is and, thus, a lack of understanding of what more the US should do.

“Bureaucratic obstacles, funding restrictions, and a lack of high level commitment to female condoms have significantly hindered the expansion of U.S.-funded female condom distribution efforts,” says the report.

“The U.S. government has no policy guidance encouraging missions or contractors to promote female condoms, which has meant that female condom procurement is dependent on a few field-level champions who are committed to the method,” adds the report.

Currently, international donors and government are investing millions of dollars and energy into promoting initiatives such as male circumcision, and little attention is being paid to promoting female condoms which allow women to initiate protection.

“While the unique nature of female condoms in providing women with their own source of protection should be reason enough for donors and governments to promote the method, female condoms hold other advantages as well. They fill their own niche, as consumers often alternate their use with that of male condoms, thus increasing the total number of protected sex acts,” states the report.

“They can be used by women living with HIV who do not wish to become pregnant, to protect against superinfection and to reduce the chance of HIV transmission to seronegative partners.”

In addition, female condoms also provide an additional option for protection during anal intercourse for men who have sex with men and heterosexuals, says the report.

In spite of the apparent benefits of the female condom, there are still major challenges in promoting its use.

Apart from the fact that female condoms are prohibitively expensive in many parts of the world, users find them noisy, physically unappealing, or difficult to use.

“However, female condoms are a cost-effective mechanism for HIV prevention when measured against thevcosts of potential HIV infections or other HIV prevention mechanisms. Also, as more and more female condoms are produced and purchased, their cost will drop,” states the report.

With greater financial investment and commitment, the design of the female condom can be improved increasing the likelihood of uptake by women.

Furthermore, there is need for educational and social marketing programs aimed at reducing the stigma associated with use of the female condom as well as improving consistent and accurate use.

According to the report, civil society groups can be extremely valuable in developing effective programming because of their access to populations vulnerable to HIV infection and their experience working with these groups.

The report makes the following recommendations to improve US’s role in the distribution and use of female condoms:

• USAID and OGAC should issue policy guidance promoting female condom procurement and programming within US-funded development programs, including PEPFAR. As a signatory of ICPD, the US should promote female condoms as a vital tool to prevent both pregnancy and HIV infection.
• The US should expand technical assistance for female condom logistics and procurement to additional countries to increase HIV prevention efforts.
• The US should apply intensive programming efforts to an additional three countries for scale-up and replication. These efforts could be used to create a more realistic assessment of global female condom needs for scale-up.
• The US should increase HIV prevention efforts by expanding the scope of female and male condom promotion to encompass the general public. Programming for female condoms will depend on each area’s epidemiological profile, and should be free of messages and attitudes that stigmatize condom use.
• The US should invest more funds in female condom promotion and programming. The US should subsidize female condoms for PEPFAR-funded programs.
• At the country level, the US should include civil society, especially women’s health and rights groups, in stakeholder meetings and encourage financing mechanisms that increase government-civil society collaboration in female condom programming.
• Congress should remove all earmarks and funding directives for abstinence-only, abstinence-until-marriage and fidelity prevention programs and fund comprehensive, integrated, and evidence-based HIV prevention programs that include female condoms and that promote and protect women’s health.

Zimbabwean culture, like many cultures in sub-Saharan Africa, places a high value on procreation. Child-bearing is regarded as a rite of passage into becoming a normal adult member of society.

As a result, reproductive health choices and practices often play second fiddle to pressures to reproduce that are exerted by traditional and cultural norms. Usually, these pressures are covert so they tend to be ignored in the design of reproductive health programs and interventions.

Reproductive health generally implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.

But in Zimbabwe, men and women’s ability to exercise this right is curtailed by the unseen force of tradition and culture.

In many parts of the country, a woman is expected to have been married at roughly age 24, and within two years of marriage is expected to have a child. Young women, in spite of their educational status, are under immense pressure to fulfill this social expectation. On the other hand, a man who goes beyond 30 without getting married or having a child attracts significant social ridicule.

Failure to procreate especially in a marriage, even if it is by choice, is interpreted in negative light and is equated to reproductive health failure. For a man, becoming a father is associated with a sense of achievement, and failure to reproduce severely undermines the sense of masculinity. A woman’s place within a marriage is regarded as secure when she reproduces. If she fails to do so, she can become ostracized within the household and community.

“Failure to reproduce can strain family and other social relationships, particularly when the negative views of extended family members are taken to heart,” says a study conducted in Zimbabwe in 2001 titled Culture, Identity and Reproductive Failure in Zimbabwe.

“Generally speaking, about one year after entry into marriage or a stable sexual partnership, others expect there to be a child, irrespective of the reproductive choices of the partners.”

It is clear that traditional and cultural attitudes play a significant role in how both men and women construct their reproductive capabilities and choices.

As Danielle Toppin notes “given the often covert nature of socialization, certain gendered behaviours are often left untouched, resulting in reproductive health policies that fail to meet the specific needs of women, and of men”.

In Zimbabwe, the family, a primary unit of socialization, is often the root of pressure for men and women to prove that they can reproduce. The desire to conceive in order to gain social acceptance is given preference to adopting tools and methods that promote safe sex.

The social pressure on women to become pregnant and give birth leads them into conditions of vulnerability, where they have to acquiesce to their partner’s sexual demands. It can also lead men to have multiple sexual encounters exposing them to a high risk of contracting HIV.

Put simply, the effectiveness of sexual and reproductive health tools is inhibited by culturally and socially constructed layers that define people’s sexual behaviors.

However, instead of being an impediment, culture can be used as a stepping stone to promote reproductive health rights. To have effective reproductive health programs, therefore, a full understanding of a given society’s values and beliefs is required.

There’s need for an approach that is sensitive to contextual, cultural, traditional and gender practices that impact on reproductive health choices.

The traditional, spiritual and cultural beliefs that shape and define sexual identities and attitudes towards sexual and reproductive health need to be given serious attention in the design of programs and interventions. Traversing the cultural and traditional can be very difficult and requires a lot of sensitivity, investment and patience.

It’s imperative to involve the target communities in the design and implementation of reproductive health policy, planning and practice in order to challenge cultural norms that may put women and men at risk. 

To respond effectively to the growing epidemics of AIDS and TB around the world, a strategy for communicating messages that influence change of individual behavior, community attitudes and socio-political dynamics is absolutely critical.

In order to make communication effective, there is a need to fully and rigorously understand the audiences, including contextual factors (political, cultural, economic, gender etc.) that determine the health choices people make.

The underlying factor is that communication does not occur within a vacuum, and thus it is essential to be aware of elements that may deter effective communication in the design, distribution and measurement of AIDS or TB messages.

Communication that saves people’s lives, improves health and enhances well being is about ideas, creativity, research, knowledge and money. Given the fact that resources are finite, strategic communication needs to consciously build upon existent social capital to ensure sustainability of processes.

Strategic communication can help to shape context and build relationships that enhance the achievement of objectives to respond effectively to AIDS and TB.

To be effective, strategic communicators must understand attitudes and cultures, respect the importance of ideas, adopt advanced information technologies, and employ sophisticated communication skills and strategies. To be persuasive, they must be credible.

More importantly, strategic communication for better health appreciates what works scientifically combined with flexibility to adapt it to specific cultural contexts.

As already stated, it should go beyond simply addressing individual behaviour to structural and institutional realities that are largely responsible for driving diseases and epidemics. In many ways, public policies tend to be responsible for social and health inequalities and cannot be ignored in the communication process.

Therefore, an effective communication strategy puts people and structural realities at its heart in the design, development, implementation and evaluation of messages.

In essence, strategic communication for better health needs to be informed by a process that identifies behaviours and attitudes, identifies policy priorities, and embarks on a process to influence a broad section of society through appropriate themes and messages.

In that respect, communication is not an end goal, but rather a means to influence dialogue and engagement through relevant mediums.

Labouring over which medium to choose when targeting a specific audience is a critical component in the communication for health process. In many ways, the medium defines the message in as much as does the target audience. A chosen medium has its limitations, and key messages and themes have to be aligned to the limitations of the medium to ensure effective message delivery. Obviously, the research-based needs of a target audience determine what delivery mechanisms to utilize.

It is important to know at the outset what goal seeks to be achieved with the particular choice of a medium so that the measurements of success or failure are specified.

Events, activities, messages, and materials must be designed with your objectives, audiences, partnerships and resources clearly in place. Building a communication strategy is about directing and focusing evidence-based messages and themes according to clearly defined pathways to achieve intended objectives.

The process of strategically positioning communication needs to ensure the participation of intended beneficiaries in the designing of messages, no matter what the level of focus.

Strategic communications shifts away from communicating to, and instead focuses on communicating with target groups in order to establish solutions., with emphasis being on how to build a relationship that allows for communication to take place so that appropriate action is taken. In that sense it is a significant shift from the magic bullet theory of communication which treats audiences as inactive recipients of messages.

Fact-based communication research is necessary for demonstrating and validating the need for resources required to increase the impact of communication. It is also essential that message platform for key initiatives are identified through the research process.

According to Wikipedia, “strategic communication provides a conceptual umbrella that enables organizations to integrate their disparate messaging efforts”. In other words, it enables organizations to “create and distribute communications that, while different in style and purpose, have an inner coherence”.

New media offers a significant opportunity to unify organizational health communications in order to achieve that inner coherence which is often times based on the vision, mission, goals and values of the organization.

New media offer an opportunity to encourage conversation and promote collaboration in creating appropriate messages. It is essential to integrate social media into the communication infrastructure and tap into its potential to create dialogue and reach a wide audience. New media make it easier and faster to communicate and collaborate, and essential element to public health communications.

The ability of new information tools to alter the way we communicate needs to be tapped into but as with any component of the health communication process the focus must be on people and not just the technology.

Overall, a strategic communication process needs to be planned, directed, coordinated, funded, measured and conducted in ways that promote the wellbeing of individual in a manner that aligns with organizational values and goals.

Lusaka, Zambia - Just a stone’s throw away from the posh Manda Hill Shopping Mall in Lusaka, Zambia’s capital city, little kids mill around traffic lights sniffing glue and pestering motorists and pedestrians alike for money, food and whatever else they can scrounge.

Many of the kids, dressed in filthy rags, are regarded as a menace to society due to their antisocial behavior. Near the traffic lights a big poster warns the public not to give money or food to the children, euphemistically referred to as “street kids.”

According to the poster, giving money or food only causes the children to remain on the street. Put in other words, the social menace that many of the nouveau rich in this leafy and suburban area fear will continue to grow.

Many of the so-called street kids are part of a generation of children in Zambia that is growing up without parental care, support or guidance. The children are vulnerable to exploitation, abuse and disease.

The United Nations Children’s Fund (UNICEF) estimates that there are approximately 1,250,000 orphans in Zambia — that is, one in every four Zambian children — with about 50 percent under nine years of age.

Orphans are defined as children who have lost one or both parents. The extended family network, a traditional safety net for orphaned children, is breaking apart due to the enormity of the HIV crisis throughout the country.

Additionally, the huge number of orphaned children is overwhelming national health, social welfare and education systems in Zambia, as in many parts of sub-Saharan Africa.

Most of the children face a bleak future, without parents to care for them and with little, if any, assistance offered by the government.

The children are often traumatized by the death of parents, stigmatized through association with HIV and often thrown into desperate poverty by the loss of breadwinners. They live under enormous pressure and suffer depression and other psychological problems.

Young girls, in particular, are the first to be denied educational opportunities in favor of boys and are forced into early marriages with older men, which put them at higher risk of HIV infection.

Children, both girls and boys, turn to the streets in search of a better life but the reality that confronts them can only be described as grim. Street life creates extreme vulnerability to violence, exploitative and hazardous labor, sex-work and trafficking.

In fact, internal trafficking of children has become rampant in Zambia. Sadly, there is little to no awareness of this social malaise.

Nothing short of a Herculean effort is required to help the growing legion of orphans in Zambia to lead normal lives. A holistic approach that includes provisions for nutrition, health and cognitive development, and educational and psychosocial support is required to effectively respond to the orphan crisis in the country.

Addressing these basic needs at an early age would give orphaned children a healthy start and a more-hopeful future.

Strengthening family systems and community care mechanisms is fundamental to this holistic approach because putting children into institutional homes can have a devastating effect on their self-worth and identity.

Furthermore, there needs to be a concerted effort to keep children in school because school is one recognized shelter that can help the children to discover their own potential.

The government must protect the children of Zambia with improved institutional, legal and social conditions, hopefully bringing an end the need to “protect” motorists from “street kids” at traffic lights.

On a scorching day in Zimbabwe’s Buhera District, approximately 300 people queue to receive food handouts. All of them are beneficiaries of the food packs that local NGO Dananai Home-Based Care (HBC) has been distributing to people living with HIV and AIDS for the past five years.

Though Dananai HBC’s main mandate is to provide care and support to critically ill people living with HIV and AIDS it became apparent to the group that further interventions were needed to help improve patients’ living conditions.

In 2002, Dananai HBC partnered with Africare and WFP to provide food handouts in an attempt to meet the nutritional needs of people living with HIV and AIDS involved in the home-based care program and their dependents.

As the sun threw its hot rays across the sky, a slight easterly wind breezed through the slender gum trees at the local clinic, which serves as the food distribution point. The hordes of people chatted among themselves, some waiting for their turn to receive the food handouts, while others pushed wheelbarrows filled with maize sacks back and forth.

Some sat on the sacks, waiting for cattle-driven scotch carts to take them across the hot landscape to their homes. Meanwhile, an old woman crouched onto her knees and began picking at the grains of maize that had fallen to the ground, putting them slowly into a green plastic bag. As the bags of maize are pushed and shoved, some inevitably tear, and maize grains fall out.

Three women in the queue told her stop but she shot a retort back at them and they turned their attention back to the business of receiving food rather nonchalantly. The old woman began curtsying as she concentrated on picking the fallen maize grains.

‘We see this all the time. The people cannot tolerate the sight of maize grains on the ground. No grain can be wasted, so they pick it, one by one,” an Africare program officer responsible for overseeing food distribution said.

Africare, an INGO is responsible for the actual distribution of the food and the recipients of the aid are identified through the Dananai Home-Based Care project. If a recipient living with HIV dies, their family is allowed to continue collecting the food for six months before their handouts are cut.

The food handouts are popular in the community due to the high levels of poverty. The rainfall pattern in the area is erratic and subsistence farming, which many of the people in the district practice, has suffered immensely as a result. The district has experienced four consecutive droughts in the past decade alone.

“I have been to many households in the district, and many do not have any grain stocks. The situation is pathetic,” said Nonia Temberere, coordinator of Dananai Home-Based Care project.

Many of the households in the community are headed by women, either because they have been widowed or because their husband works and lives elsewhere. It is through the eyes of women that the impact of HIV and AIDS on this community is best reflected because they have been forced to work hard to feed their families as well as to provide care and support to the sick.

It is no coincidence that many of the people in the food queue are women. According to Africare workers, special care is taken to make sure that women are the main recipients as men tend to be less responsible with the provision of the stocks.

But the availability of food is creating a schism within the community and has resulted in increases in the numbers of people requesting HIV tests. Due to the levels of food, those receiving food through the home-based care program are perceived as better off than others because they have access to food.

So the demand for inclusion in the program is growing and hordes of people have been reporting to the HIV-testing facility at the Roman Catholic-funded Murambinda Mission Hospital.

“Some people get sad when they test HIV-negative,” said the coordinator of the New Start Voluntary Counselling and Testing centre, which conducts provider-initiated HIV testing at the Murambinda Mission Hospital.

If patients tests positive for HIV, they are immediately referred to the hospital or the Medecines San Frontieres (MSF) opportunistic infection clinic that distributes antiretroviral drugs (ARVs). Critically ill patients are incorporated into Dananai HBC programs through volunteer caregivers living in their community.

But testing positive for HIV is not enough and to enroll in the program patient must be on ARVs, in a critical and disadvantaged state and they must need food assistance.

This message does not seem to have reached some members of the community and there have been some accusations that community leaders, responsible for selecting beneficiaries, are biased and have only selected their friends and relatives.

As the old grandmother picked the fallen maize, it was clear from her bedraggled stature that she badly needed some assistance. She is, however, not on the list of beneficiaries and she is angry at the blood tests she took.

“I have taken three blood tests but they have not said anything to me. They can take more of my blood if they want, but for God’s sake, they should also give me food,” she said, scooping a handful of maize grains mixed with soil from the parched ground.

“I have a problem with my back from a pregnancy operation that I had in 1952,” she said, adding, “If my son was still alive, this could never happen to me.”

She pulls a wad of documents out of her green plastic bag and selects the record of her son’s death.

“I look after his three children. I also showed them this but they still refused to include me in the list. These organisations should go to the community and see the favouritism that takes place in the selection process,” she said.

“One of the problems is that as sick people receiving ARV treatment become well, and are able to perform normal duties and still receive food ahead of household that may be less privileged. There are always accusations of favouritism,” an Africare worker said. “The food is meant for those that are ill.”

According to Africare’s records, the number of people on the waiting list for food aid is overwhelming. MSF, which is also partnered with Dananai HBC, has seen a huge increase in the number of people needing ARVs.

The availability of food is one of the keys to helping Dananai HBC recipients to regain control of their lives. In the absence of nutritious food, the success of ARV treatments is severely compromised.

Many of the households in this district, which relies on subsistence farming, face food insecurity and find themselves hard hit by a disease that preys on society’s weakest. The challenges faced by Dananai’s HBC project mirror the challenges facing the country in general. At the heart of the problem is the need for food.

Poor access to water is also a problem for many communities. It is ironic that though the Bangure area in Buhera has the large 1970s Rundi Dam, the only benefit to the community is the supply of fish from the water catchment.

The need for food makes many of the communities in this area overly dependent on external assistance. Hungry stomachs appear to make many of the communities lie on their backs with legs crossed and lethargy seems to stalk the land.

The communities are just beginning to awaken to the need for HIV testing and the power of ARVs, but they are also fully aware of the fact that food security remains a big challenge.

 ”If you’re a man, get cut today”

Male circumcision (the cutting of the foreskin from the male penis) is increasingly gaining currency among medical researchers as an alternative method to reduce HIV-infection.

But will this solution really work? 

Researchers say that if all men in sub-Saharan Africa — the worst HIV/AIDS affected region in the world — were circumcised over the next decade, roughly two million new infections and 300 000 deaths could be averted. 

An additional 3.7 million new HIV infections and 2.7 million deaths could be avoided in 20 years.

Put simply, while the benefit of male circumcision to an individual man is immediate, a large scale impact of the intervention will be realized in two decades. 

AIDS risk lowered by 60% 

In fact, evidence from observational studies in sub-Saharan Africa has shown that circumcised men have a lower risk of acquiring HIV infection than uncircumcised men. A study in South Africa showed that male circumcision might reduce by about 60 percent the risk of men contracting HIV through sexual intercourse with women. 

The study focused on 3000 HIV-negative, uncircumcised men ages 18 to 24 living in a South African township. Of these, half were randomly selected for circumcision while the other half remained uncircumcised and served as a control group. 

For every 10 uncircumcised men who contracted HIV, about three circumcised men contracted the virus. Researchers believed the findings were so significant they deemed it was unethical to proceed without offering the option to all males in the study. 

The argument is that the inner surface of the penile foreskin contains Langerhans cells, which have HIV receptors, and is also vulnerable to disruptions during intercourse. Second, an intact foreskin exposes a man to a greater risk of ulcerative sexually transmitted infections, which in themselves are a risk factor for HIV acquisition.

Furthermore, the virus’ chances of survival might be higher in a warm, wet environment like the one under the foreskin. 

How will it affect society? 

The evidence that circumcision may protect against HIV infection is now considered strong enough that further trials evaluating the efficacy of circumcision as part of an HIV prevention program have been advocated.

This could herald a new era in HIV-prevention methods. But the question remains: what are the societal implications of such a solution? 

Male circumcision has been practiced extensively in some sub-Saharan communities in rites of passage ceremonies from boyhood to manhood. The gruesome circumstances under which such practices occur may be exacerbated in the light of this new evidence. Other communities have not practiced it at all. 

However, qualitative studies in the Botswana, Haiti, Tanzania, Zambia, and Zimbabwe revealed positive attitudes toward male circumcision in populations that do not traditionally practice it.

From 45 to 85 percent of uncircumcised men in surveys expressed interest in the procedure if it is safe and affordable. In spite of the interest in male circumcision, it is not a magic bullet in the fight against HIV-infection. To be effective, circumcision has to be promoted alongside condom use and faithfulness, long-established approaches in the fight against HIV. 

Education and money will be essential 

Some men may be tempted to engage in unprotected sex because they perceive they are protected by male circumcision. And some women may get a false sense of security when having sex with a circumcised man. 

In itself, male circumcision provides little or no protection against urethral STDs such as gonorrhea and chlamydia and certainly cannot prevent unwanted pregnancies. This issue will need to be strongly emphasized in social campaigns. 

To be successful, male circumcision will have to be complemented by a massive investment into education and counseling programs. There will be need for widespread and culturally sensitive dissemination of information that outlines the benefits and potential complications of male circumcision. 

Another danger is that male circumcision can be risky or fatal if conducted by untrained personnel. There’s no doubt that with increased knowledge of male circumcision as a barrier against HIV, many men will try to perform it on their own.

There will be obviously costs involved in getting circumcised which some people will try to circumvent. Circumcising large numbers of adult men will be a major undertaking. If circumcision is not performed correctly it will increase the risk of infection.

A major surgical system infrastructure needs to be developed. Who will fund this and how long will it take? Also, most health facilities in sub-Saharan Africa are in a shambles and ill-equipped to perform widespread male circumcision.

In addition, there’s also lack of social acceptability of circumcision in many of the sub-Saharan communities that have not traditionally practiced it. Besides the safety and acceptability issues, perhaps the greatest drawback is the financial means required to undertake circumcision whole scale.

Male circumcision will come with high costs through social mobilization efforts and upgrading of medical facilities. The more the men get circumcised, the more the success — and that’s tough ground. 

Imagine the social marketing message: If you’re a man, get cut today.

The natural process of menstruation comes as a big problem to women and girls in many parts of Africa, contributing to both disempowerment and health risks. For young girls, menstruation is an addition to the heap of gender disparities they have to face in life.

In order to stem the flow of monthly periods, the women and girls use anything from rags, tree leaves, old clothes, toilet paper, newspapers, cotton wool, cloths or literally anything that can do the job. Most girls from poor, rural communities do not use anything at all.

Menstruation is perhaps one of the most regular individual female experiences, but in sub-Saharan Africa, the experience impacts general society negatively due to the absence of products required by women and girls to cope with menstrual flow.

To state it bluntly, menstruation has become like a curse not only to the women and girls but to society in general on the continent. Because menstruation is largely a private act, the social damage is hidden and never makes the news headlines. Also, there are cultural and social attitudes that render discussion of menstruation almost impossible.

Affordable and hygienic sanitary protection is not available to many women and girls in Africa, and governments have done very little to address this reproductive health issue which has serious public health consequences.

In sub-Saharan Africa, millions of girls, in particular, that reach the age of puberty are highly disempowered due to the lack of access to sanitary wear. Many of the girls from poor families cannot afford to buy sanitary pads.

Hence they resort to the use of unhygienic rags and cloths which puts them at the risk of infections. Some of the girls engage in transactional sex so that they can raise the money required to buy sanitary pads, putting themselves at the risk of HIV and STI infection.

Alternatively, young girls are forced to skip school during the time they experience monthly periods to avoid both the cost of pads or use of cloths.

UNICEF estimates that one in 10 school-age African girls either skips school during menstruation or drops out entirely because of lack of sanitation.

“Less-privileged girls and women who represent substantial percentage in our contemporary Africa will continue to suffer resulting to school absenteeism and also compromising their right to health care,” says Fredrick W. Njuguna, Program Director of Familia Human Care Trust in Kenya.

A girl absent from school due to menstruation for 4 days in 28 days (a month) loses 13 learning days equivalent to 2 weeks of learning in every school term.

It is estimated that within the 4 years of high school the same girl loses 156 learning days equivalent to almost 24 weeks out of 144 weeks of learning in high school.

Consequently, a girl child potentially becomes a “school drop out” while she is still attending school. In addition, the girl child has to deal with emotional and psychological tension associated with the menstrual process.

To make matters worse, according to Familia Human Care Trust, many schools in underprivileged areas lack sufficient sanitation facilities which are vital not only during a girl’s period but at all times generally such as water, adequate toilet facilities and appropriate dumping facilities for sanitary wear.

As a result, menstruating girls opt to stay at home due to lack of facilities to help them manage their periods than go to school.

For orphaned girls, the prospect of coping with bodily changes can be a significant challenge because they have no-one to turn to for information or advice. In addition, due to the use of improper methods to contain their menstrual flow, young girls may develop bodily odors that will lead to social exclusion within peer groups thereby impacting negatively on the young girl’s confidence.

The need for affordable sanitary wear for women and girls in Africa is indeed a major public health issue that governments need to prioritize in their planning.

On the other hand, there is need for social innovation around this issue because the need for sanitary wear among girls and women will forever be there, at least in the long term future.

The bottom line is that no girl child must be disadvantaged by the natural process of menstruation, and governments, civil society organizations and other players need to work together to ensure that the appropriate services are made available.

As it is, menstruation has becomes the undeclared basis for the social exclusion of young girls. Sanitary protection is an urgent need among women and girls and needs to be made affordable so that poor and marginalized groups can have access.

Global alliances between women in the rich and poor worlds can be a key solution to the problem of access to sanitary wear. But governments also need to recognize that ensuring women and girl’s access to sanitary wear has positive public health implications.

Access to affordable, sanitary is human right but one that is never discussed in our male dominated world. Whatever the case, the fact remains: every woman should be able to have access to the right products which can enable them to happily experience menstruation.

No woman should be cursed to disempowerment by the natural act of monthly periods.

Tuberculosis (TB) has a major impact on women’s sexual reproductive health and that of their children.

For pregnant women living in areas with high TB infection rates, there are increased chances of transmission of TB to a child before, during delivery or after birth.

The disease, especially if associated with HIV, also accounts for a high incidence of maternal and infant mortality.

Unfortunately, there is little to no attention about women’s vulnerability in the current discussion and media blitz of a resurgent TB internationally, and in particular, sub-Saharan Africa.

In sub-Saharan Africa, TB is threatening to unravel public health developments gains around increased HIV awareness yet the solutions are not easy, particularly where they concern the well-being of women.

There is need for huge financial, human, research and technological investments to fight the problem, but such investments will work only if they radically put women’s health needs at the core.

More importantly is the need to align TB services and sexual reproductive health services, so that men and women know about the implications of the disease to their sexual lives and households.

In sub-Saharan Africa, however, there are pervasive systemic factors driving TB and drug resistance which cannot be ignored in the search of an effective solution to the problem.

A myriad of social and economic factors, as well as weaknesses in the health care system, inadequate laboratories combined with high HIV infection rates are fueling the resurgence of the TB in the region. Food insecurity, poor sanitation and overcrowding also contribute to the easy spread of the disease.

According to WHO, although Africa has only 11% of the world’s population, it accounts for more than a quarter of the global TB burden with an estimated 2.4 million TB cases and 540,000 TB deaths annually.

Governments in the region are grappling with inadequate infrastructure and the increasing threat of drug-resistant strains and co-infection with HIV.

HIV infection increases the likelihood of active TB more than 50-fold. An estimated one-third of the 24.5 million people living with HIV (PLHIV) in sub-Saharan Africa also have TB.

For women in the region, the prospect of a growing TB epidemic is harrowing, but discussion about the disease rarely sheds light nor seeks to address women’s specific needs.

Given the high rates of HIV infection among women in the region - the majority of people living with HIV in sub-Saharan Africa (61% or 13,1 million) are women – it is clear that they are the largest group at threat to develop active TB, and more likely drug resistance.

Even with the availability of TB drugs women’s socio-economic status and gender roles including child-bearing and caring puts them at high risk of both HIV and TB infection.

For many women in the region, the costs required to access health care centers for TB treatment are usually out of reach due to poverty and undermined socio-economic positions.

The social stigma associated with a TB diagnosis and its association with HIV forces both men and women to delay going to get tested for the disease. In some cases, when men in marital relationships test positive for TB, they are likely to withhold the information, thereby increasing the likelihood to spread the disease to both their partner and children.

Moreover, women in the region are largely responsible for the upkeep of the family, including looking after children, which may also affect consistent uptake of TB drugs. When a woman is infected with TB, the likelihood of spreading the disease to young children is very high.

An additional concern for women is that the uptake of TB drugs interferes with contraceptive use, pregnancy, and fertility.

According to researchers, Rimfampicin, a key component of TB treatment can reduce the effectiveness of oral contraceptive pills and possibly other hormonal methods, such as implants, injectables and emergency contraception.

TB in pregnant women not only increases the rate of maternal mortality, but is also a major factor contributing to the risk of mother-to-child transmission of the disease.

A study conducted in South Africa revealed mother-to child-transmission of TB in 15% of infants born to a study cohort of pregnant women in which 77% were HIV-infected. Maternal HIV/TB coinfection also increases the risk of mother-to child transmission of HIV.

Screening and treatment for TB in pregnant women at antenatal clinics must therefore be a major public health priority in the region. Information about TB needs to be an integral component of sexual reproductive health services.

To be precise, women infected with TB need to be empowered so that they can take control of their own care and lives.

Populations that are displaced as a result of conflict face reproductive health challenges that require existent service delivery models to be adapted to suit their needs, especially those of women and girls.    

In many parts of the world, women and girls in conflict zones find themselves victims of a silent war that infringes their sexual and human rights.

According to statistics, 80% of the approximately 37 million refugees and displaced persons globally are women and children, yet little funding and programming goes into addressing their requirements.   

A UN report titled - The Shame of War: Sexual violence against women and girls in conflict, released early 2007 – says that “of all the abuses committed in war, rape is one specifically inflicted against women”.    

“The brutality and viciousness of the sexual attacks that are reported from the current conflicts in Democratic Republic of Congo, Myanmar, Iraq and Sudan, and the testimonies from past conflicts in Timor-Leste, the Balkans and Sierra Leone are heartbreaking,” writes Yakin Ertuk, UN Special Rapporteur on Violence against Women in the foreword to the report.    

“Girls and women, old and young, are preyed upon by soldiers, militia, police and armed thugs wherever conflict rages and the parties to the conflict fail to protect civilian populations.”    

The victims are often afraid to report of their rape due to social stigma and shame, threat to personal security, or simply because there are no services available.    

As the report notes, women and girls lose their family and community after experiencing rape due to feelings of shame and discriminatory attitudes. Their only option may be further victimization through sexual exploitation.    

A major condition for the well-being and development of women and girls is their ability to exercise control over their sexual and reproductive lives.    

World Health Organization (WHO) describes sexual health as a state of physical, emotional, mental and social wellbeing in relation to sexuality; and not merely an absence of disease, dysfunction or infirmity. It implies pleasurable and safe sexual experiences that are free of coercion, discrimination and violence.    

For women and girls in conflict zones, the consequences of rape are many: sexually transmitted infections and reproductive health problems, unwanted pregnancy, fistulae, maternal mortality, and HIV/AIDS, says the report.    

Female sexual vulnerability poses a grave public health problem, during the conflict and post conflict period.    

Women and girls in conflict areas have a myriad of reproductive health needs that policymakers at national and international levels need to take into account in the design of programs.      

Programs may involve working with community leaders, men’s and women’s groups and the military to sensitize about the need to prevent the problem of sexual violence. Women and girls need to be empowered to be able to prevent themselves from becoming victims of sexual violence through economic empowerment and access to reproductive health services.    

As Theresa McGinn, 2001, succinctly puts it: “Understanding the ways in which refugee women’s reproductive health problems are both similar to, and different from, those of women in settled populations can help policy makers and programmers.”    

Women and girls in conflict zones must have access to medical treatment, including access to drugs that can prevent sexually transmitted infections, psychosocial and legal support and access to abortion services to terminate forced pregnancies.    

With conflicts popping up in every corner of the globe, there’s need for more public discussion about how to bring much needed reproductive health and psychosocial support services to women in conflict areas.