14/06/2014
Safe Blood for Saving Mothers
Blood is so essential in a hospital environment that major surgeries cannot be performed if blood is not on standby in the theatre. However, this essential health services’ commodity continues to be scarce in most blood banks in Nigerian hospitals. Often, many accident victims, women in labour and patients who need surgeries have died in many parts of the country because they could not get blood. It is not unusual to see relatives of patients in emergencies, running helter skelter to get blood or blood products. Shortage of this life-saving fluid is a recurrent problem in the delivery of medical care. Sadly, the shortage of blood and its products add to the persistently high maternal mortality in the country. Statistics of about 544 deaths per 100,000 has remained a recurring decimal within and without the medical parlance in Nigeria. This continues to give the country a ‘distressing’ image among the committee of nations. Although there are concerted efforts aimed at containing this challenge, it is more distressing to think about the effects this has on the average Nigerian woman who stands the risk of a higher chance of dying from a physiological process called pregnancy when compared with her counterparts in other parts of the world. More so are the economic impacts this could have on the country now and in the near future. Against this backdrop, the World Health Organization’s (WHO) through its World Blood Donor Day for 2014 focuses on “Safe blood for saving mothers”. This has become important considering that, although a multi-sectoral approach appears to be the driving force to address this perennial problem facing the country, efforts aimed at ‘‘Saving Mothers’’ should increase awareness about why timely access to safe blood and blood products is essential as part of a comprehensive approach to prevent maternal deaths.
Given the need to strengthen efforts at ‘‘Saving Mothers’’, there are however gaps that need to be reflected on with a view to addressing maternal problems associated with pregnancy. Notably are the challenges of transfusion-transmissible infections, such as HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis, and malaria; challenges of recruitment of voluntary non-remunerated donors; challenges of suboptimal use of non-pharmacologic and pharmacologic alternatives to allogenic blood as well as socio-cultural and awareness-related challenges associated with blood donors and their distribution in the country. As it is no longer hearsay that Nigeria faces considerable obstacles to ensuring a safe blood supply and safe blood transfusions, this stems from the fact the health system in the country continues grapple with inadequate ‘readily’ available blood supplies from the national blood transfusion services; hence the dependence on ‘family blood’ or commercially available blood. While ‘family blood’ or commercially available blood has its gains in filling the gaps in meeting blood services for optimal health care delivery, it however has its drawbacks. One of the major concerns is with transmission transmissible infections (TTIs). It is interesting to note, that as someone who is given to the clarion call of saving lives, reducing morbidity (diseases) and improving health outcomes in general, it would be rather improbable for me to remain silent on the issue of transfusion-transmissible infections which pose a big problem in blood transfusion services, whether that done for-profit or not-for profit.
As it were, is no longer an issue of contention that screening for TTIs among blood donors can be a cost-effective approach to monitor the prevalence, distribution, and trends of the infections among blood donors. Screening for syphilis, HCV, HIV and malaria inter alia have become routine in the country. Several screening approaches are being employed to reduce to the barest minimum the possibility of transfusing would-be recipients with infected blood. For instance, employing the use of Clinotech syphilis test strips for syphilis, OptiMAL (TCS Biosciences Ltd) and/or the Clinotech Malaria Cassette for malaria, ELISA strips for HIV amongst others. However, cost of TTI testing is still a major challenge to the provision of safe blood and blood products in the country. There still remains the problem of acquiring these kits, problems with standardization and regulation. More so, for diseases such as HIV, during its window period (period when antibodies can’t be detected in the circulatory system) viral particle remain undetectable for most of the available screening methods. Although, there are now sophisticated mechanisms to detect these particles such as the DNA polymerase chain reactors, these have continued to remain expensive, and largely out of reach for public and private blood service providers. These issues suggest the need for further reflection.
Secondly, the challenges of suboptimal use of non-pharmacologic and pharmacologic alternatives to allogenic blood (in order to reduce transfusion reactions) come to bear. The current thinking may be to scale-up alternatives such as the use of erythropoietin, use of oral and intravenous iron, that is to say, scale-up the use of alternatives in conditions where blood or blood products are scare. However, it is critical to note that a system that fails to provide the first line of defence may not be able to do that when a second line of defence is needed. Furthermore, socio-cultural and awareness-related challenges associated with blood donors and their distributions are pressing issues that bedevil blood transfusion services in the country. Although, some controversy exists about whether there are insufficient voluntary donations, nevertheless, my experience as a haematologist reveals that some of the obvious gaps we face in blood services stem from insufficient voluntary donations, poor public advocacy and international developmental support in this regards. It is saddening to note that only an insignificant number of eligible donors actually donate blood in the country. In brief, the reason why replacement donors remain the main source of blood in the country is that it cheaper in-principle to procure and fits well with the Nigerian culture of extended family support. The mentality of altruism through voluntary blood donation is still rudimentary in many parts of Nigeria when compared with developed countries. Only an insignificant number of eligible donors actually donate blood in many parts of the country. Several prejudices and misconception affects the principle of altruism in the country, including cultural differences and lack of information. There are the unfounded fears: fear of knowing one’s HIV serologic status, fear of being infected with diseases, and the erroneous belief that donating blood can decrease one’s libido, cause weight loss, cause high blood pressure, or even lead to death. I will be forced to submit that, in the fight to reduce maternal mortality it necessitates measures to find ways of maintaining sufficient blood supply from voluntary non-remunerated donors and improving blood safety from the available replacement donors. This also suggests more efforts at health promotion: advocacy, health education and motivation. Non-Governmental organizations (NGOs) such as the SBNF (Safe blood for Nigeria Foundation) have already adopted this as a strategy to increase the timely access to safe blood and blood products and as such reduce maternal deaths.
Ultimately, providing enabling policies, standardization of practice, regulatory environment and creating appropriate incentives for more private involvement in complementing government’s responsibility is of paramount importance for achieving regular and timely availability of blood and its products in an equitable manner. It will be impossible to eliminate maternal deaths at the current level of investment in blood transfusion services in Nigeria as the only option is for the government to constructively engage the private sector, international developmental partners, non-governmental organizations, civil societal organization and all concerned to support its efforts in this regards.
Dr. Isioma.Augustina Ikusemoro
MBBS, FMCPath.
Consultant Haematologist (+234 80 37021998)
Delta State University Teaching Hospital
President & Founder, Safe Blood For Nigeria Foundation.
