Source: Sinclair, Constance. (2004). Chapter 1: Normal Pregnancy.  A Midwife’s Handbook. St Louis, Missouri: Elsevier.

The pregnancy adolescent faces many risks.  Like all adolescents, she is at increased risk for substance abuse, sexually transmitted infections (STIs) including HIV, violence, abuse, depression, suicide, and accidental trauma.  Adolescents more often experience the following complications of pregnancy: anemia, intrauterine growth restriction (IUGR), preterm birth, preeclampsia, gestational diabetes mellitus (GDM), and increased perinatal mortality.  The pelvis continues to grow through late adolescence, and young teens have an increased risk for cephalopelvic disproportion.  Meanwhile, barriers to health care for these women include uninsured or underinsured status, limited availability of appropriate services, out-of-pocket co-payments, transportation, lack of culturally appropriate care, and confidentiality issues.  Teens more often have poor prepregnancy nutritional status, poor diets during pregnancy, and body image concerns that put them at nutritional risk during pregnancy.  Infants of adolescents may weigh less because the maternal need for nutrients (because of skeletal immaturity) competes with the nutritional needs of the fetus.

Pregnancy may complicate the emotional growth of the adolescent, making her achievement of the developmental tasks of adolescence and the completion of her education more difficult.  Family structure and living arrangements and the relationship with the baby’s father have been found to significantly affect her ability to attach.  In the first trimester the woman receiving emotional support from the father of the baby shows more differentiation of the baby from herself and more role-taking behavior.  In the second trimester, a good relationship with the father of the baby increases interaction with the fetus, attribution of characteristics to the fetus, and giving of herself.  After delivery, support from either the infant’s father or her own mother affects the adolescent mother’s ability to attach to the newborn.

Psychosocial Tasks of Adolescence as Related to Pregnancy

Early Adolescence: 11 to 15 years

During early adolescence, a girl has just moved from concrete to abstract operations and is learning to conceptualize.  In turmoil from hormonal influences and physical changes, the young adolescent girl may try to exert control by lashing out at her parents.  She is preoccupied with her appearance as her body changes.  Because of this concern with self, a fetus may seem abstract or unreal, and a girl in this stage of adolescence may deny and hide pregnancy.  She may conform to advice only to avoid punishment or obtain favors.  Pregnancy may interrupt and prevent indentity formation.  The relationship with the father of the baby is often casual, and a girl of this age usually looks to same-sex friends for support.  She needs parental or adult support to emotionally parent and to provide for the child.

Middle Adolescence: 14 to 18 years

The young woman in middle adolescence is developing her identity as a sexual being, and pregnancy changes may be unwelcome.  She is thinking about long-term plans and developing her self-image as an adult.  At this age, female teens want loving relationships with male counterparts, but male teens are focused more on the sexual aspect of relationships.  Women in this stage of adolescence are able to modify behaviors for the well-being of the coming baby but need parental or adult support  to provide for the child.

Late Adolescence: 17 to 20 years

In late adolescence the young woman assumes the identity formed in middle adolescence and begins to cope with adult challenges.  She may advance her education to assume a professional role.  She is usually capable of abstract thinking and adult decision-making processes and is able to curb activities in consideration of consequences for the fetus.  A woman of this age is comfortable with her adult body and is able to accept the changes of pregnancy.  Women in late adolescence are able to parent independently and may have clear career goals.

Interventions to Facilitate and Support Achievement of Psychosocial Tasks

Observe maternal-fetus and maternal-infant attachment behaviors.  During pregnancy assist the adolescent to focus on the fetus and her development as a mother.  Monitor the relationship with the father of the baby, including him in prenatal care, supporting his involvement, and assisting as both mother and father assume their parenting roles.  Encourage resolution of family conflicts if possible to allow provision of support to the new parents.

H 312 Class Lecture Notes

 

 

HIV/AIDS - Impact on Ethiopia

November 26, 2007

 

P.B.

C.D.

J.H.

A.S.

S.S.

Amy Zimmerman

HIV/AIDS - Impact on Ethiopia

Introduction   

            Ethiopia is the one of the world’s oldest nations.  This long history has led to a very diverse population from different ethnic backgrounds, representing different religions.  This diversity among the people of Ethiopia has led to a variety of conflicts and challenges concerning many aspects of their culture and environment.  Some of these challenges include the rising prevalence of AIDS, poverty, a changing economy and internal political conflicts, as well as religious conflicts between the large populations of Christians and Muslims in the area.    According to the most recent 1994 National Census, Christians make up 61% of the country’s population, Muslims 33%, and practitioners of traditional faiths 5% (Embassy, 2007).  As an example of the diverse population, there are more than 80 ethnic cultures and more than 80 indigenous languages spoken within Ethiopian borders. In a country strife with poverty and impacted by socio-economic instability, such factors lay the groundwork for the AIDS pandemic to flourish, which may lead to a massive national crisis within Ethiopia.

Characteristics of the Country

Ethiopia is a country that has, in the past 50 years, suffered government instability and rapid change in policies that have either not been well enforced or not been incorporated by the people.  Ethiopia’s economy is mainly based on agricultural exports, holding the rank of Africa’s second largest producer of maize (Economist).  The nation’s economy is greatly impacted by several factors:  climate, politics (such as border conflicts), world market prices, and cultivation practices.  Economic instability is a reflection of fluctuating climate, reliance on the world markets, and changes in internal policies. 

Ethiopia’s failing economy contributes greatly to the level of poverty.  The citizens of the country do not have equal access to necessities required for survival such as food, shelter, medicine, a reliable income and clean water sources.  Poverty is the underlying factor contributing to disease prevalences in the nation.  Not only does poverty increase a persons risk of acquiring a disease but it also increases emotional and psychological distress.  Contaminated water sources are breeding grounds for bacteria such as E. coli.  Availability of and access to safe drinking water is a crucial problem in Ethiopia for approximately 2.7 million Ethiopians (Unicef 2).  Not only is this the case in Ethiopia but in a great number of developing countries in Africa and throughout the world.

Other environmental issues include deforestation, overgrazing, soil erosion, desertification, and water shortages due to water-intensive farming and poor management (Fact Book 3).  Environmental-International agreements can be created to help prevent some of these issues.  Not only must Environmental Aid agreements take place in Ethiopia, but in all developing countries and in an effort to improve the human and environmental impacts of a failing economy. According to the CIA world fact book, Ethiopia’s natural resources include small reserves of gold, platinum, copper, potash, natural gas, and hydro power.  Similar to many other countries with failing economies, they are sitting on valuable resources which are highly in demand throughout the world.  An organized trade/export system would bring in large amounts of money and create more jobs for the unemployed.  Therefore, this would be an efficient way for the economy to improve.

            Another factor contributing to the failing economy is lack of education.  Historically, education in Ethiopia has been dominated by the Christian Orthodox church.  Access to education has been limited to the elite Christians and has failed to focus on educating minority populations within the country (Damtwe, 2003).  This is an affect of the government failing to provide public goods and services such as competent schools and education systems.  In Ethiopia only 42.7% of people over the age of fifteen are able to read and write, compared to over 90% of the people in the United States being literate (author, 5).  This does not only affect the Ethiopian people on a personal level, but it affects the economy of the entire country.   Due to lack of education and low literacy rate, citizens of developing countries do not have the skills for high income jobs.  In a country starving for education, there is a struggle to implement medical advances and inequality in the availability of treatments.

Impact of AIDS in Ethiopia

 

            “The first Ethiopian patient with AIDS was documented in Addis Ababa, the capital city in 1986 (Sanders, 2003).  Although this first case of AIDS in the country is well-documented, most cases in this country go undocumented as a result of lack of resources, improper burial and stigma of the disease.  Due to the lack of documentation, it is hard to get an accurate handle on the prevalence and incidence rates. In most texts, a large range for the estimates are found.  Sanders performed a study in Ethiopia’s capital, Addis Ababa, that counted the estimated death rate.  Sanders had to travel around to the seventy local cemeteries and talk with families to verify verbal autopsies.  Data collected through his study confirmed that “68% of deaths are related to AIDS” (Sanders, 2003).  Sanders also added that the probability of death by age 60 years, and by  age 15 years was 42% and 35% for men and women respectively. (I don’t understand this…is the probability the same per age or per gender?)  This data is only focused in the country’s capital city. Data shows that the country’s prevalence rate is estimated at 2.8-6.7 (Numbers without units) among the adult population (WHO, 2004).

            Transmission of AIDS in the Ethiopian population is mostly transmitted through heterosexual relations.  The most common transmitters include, but are not limited to, sex workers, truck drivers, farmers, personnel in uniform and migrant workers.  Commonly distinguished at-risk populations such as women and girls, refugees, people in conflict and post-conflict situations, among other at risk groups not mentioned, are all represented within the borders of Ethiopia.

 A study done by Blerk showed the relationship between sex work and the traveling mobility of transmission of the disease.  It explained that sex workers who become infected with the disease, and are showing visible symptoms, often travel to a new town where people are unaware that they are carriers of HIV.  Some of the reasons that the girls justify their mobility are: new adventures, to escape regular clients and boyfriend dilemmas, more money or resources, and even to hide being HIV positive when regulars know.  All of these reasons contribute to the uprising of transmission to rural Ethiopia.  The biggest problem with spread is the lack of availability of resources for both the sex workers and the clients.  Many of the girls make comments on this such as, “changing places can lead to problems…many places don’t have NGO’s” (non-government organizations) (Blerk, 2007). 

Another common means of transmission is long haul truck drivers.  One article states, “some transport workers have multiple sexual contacts without condoms because they believe they are not at risk of being infected.  This behavior is a major factor in the spread of AIDS in Ethiopia” (WFP, 2001).  These workers oftentimes contract the disease while on the road, and then will bring it home, unknowingly, to their significant other.  The United Nations World Food Program has become aware of this problem and has recently implemented an education program for their employees.  This training is specifically designed to instruct these companies 2,300 truck drivers, and thrives to “raise their awareness on HIV/AIDS.” (WHP, 2001)  This education process for specific occupations is just one way of controlling the spread of HIV/AIDS in Ethiopia.

Most literature is united in saying that the Ethiopian government does not have the resources to conquer this problem alone.  As a result, there are many non-government organizations that have stepped in, to fill the void.  Some of the major contributors to Ethiopia are The Ministry of Health, World Health Organization (WHO), UNAIDS, Armed Forces and the United States Emergency plan for AIDS relief.  The main concerns that these organizations are trying to provide support for are education, providing resources, and distribution of antiretroviral drugs.  For example, WHO had implemented a 3 by 5 program that set out to provide treatment for 100,000 people (50% of the need), by the end of 2005. 

There is antiretroviral treatment available in Ethiopia, but the current system makes it challenging for many to receive it.  The average cost is estimated to be US$360 per year, although many NGO’s will help cover payment if the patient is unable to afford it.  One downside to this drug is the fact that it must be administered in a hospital physician-led setting.  However, the policy does allow antiretroviral drugs to be administered in a health center to prevent mother-to-child transmission in utero.  WHO reports that, “Ethiopia has 119 hospitals and 412 health centers” (WHO, 2004). Many of these hospitals are located in the larger cities and are not accessible by rural area residents, which accounts for 85% of Ethiopia’s population. The World Health Organization in its 2006 World Health Report gives a figure of 1,936 physicians (for 2003), which comes to about 2.6 doctors per 100,000 citizens.

In order to try and provide healthcare for rural areas, Ethiopia uses community based reproductive health agents (CBRHA).  “30 NGO’s contribute and 12,840 CBRHA’s work in 7 out of 9 regions in the country” (Creanga, 2007).  These workers use the doorstep approach to inform and educate community members on topics such as: contraception, education about transmission and they provide some reproductive health services.  Currently, the prevalence rate in Ethiopia is rising, and even though these methods and organizations are in place, AID/HIV is still an increasing problem, which signals a weakness in current prevention and treatment programs.

In Ethiopia, the conditions are already poor and this disease adds more elements of hardship.  The work productivity suffers with the presence of HIV/AIDS, due to increased use of sick days, and lower stamina due to illness.  Many families have been forced to take in orphans from deceased family members and therefore are faced with further strain on an already suffering income.  The stigma of AIDS is still prevalent in Ethiopia even though we see the statistics of how many people are suffering from it.  This causes people to hide the disease or be ostracized from the general public.  Stigmatization is a result of poor education and therefore is preventable with solid education on the prevention and treatment of HIV/AIDS and other facts and information concerning the virus.  Overall, HIV/AIDS in Ethiopia is making a country that is impoverished suffer even greater, both financially and emotionally.

AIDS/HIV affects the Economy

            Also relating to the general health and economy of a country is the unemployment rate.  When people are suffering from deadly diseases such as HIV/AIDS or are faced with Vitamin A deficiency due to malnutrition, they will not be in working condition. According to the CIA world fact book, the population below poverty line was 50% as of 2004.  The GDP per capita or amount of income per year of the average Ethiopian, is $800.  This amount of income is so low that a family cannot possibly provide shelter or necessary nutrition.

Future of HIV in Ethiopia

            .  The government is taking small steps to help with the country’s lack of food.  “Ethiopia’s government has initiated a process to strengthen the links with its development partners to find a lasting solution to the country’s chronic food insecurity (author, 7).  If the government does not take strong action the economy will not only fail to prosper but will likely decrease.  The famine and droughts which take place often in Ethiopia affect not only the health of the citizens, but also the transmission of HIV/AIDS.  Food and water shortages, along with increased occurrence of communicable diseases, have led to high levels of malnutrition (Unicef 1).  The lack of essential supplements in food rations, such as pulses and oil, are worrying nutritional conditions, especially for children and pregnant or breastfeeding mothers (author, 1).  This struggle for survival hinders education opportunities.  This effects the school drop out rates, increasing it to create a need for psychological counseling and recreational activities which are not available (author, 1).    Drought, in general, pressures the population to rely on migration into urban areas with more job oppurtunities, which promotes the acceleration of the transmission of HIV/AIDS.  This is due to the potential or increased sexual violence and sex work as a survival strategy (author, 1).  These are serious issues, which the Ethiopian government and relief groups must consider and attend to. 

            Starvation is a serious matter and largely affects Ethiopian citizens.  It is said that food security in Ethiopia is a matter of life and death (Carter, 7).  More than 5 million people are enlisted for food relief each year even when conditions are favorable (author, 7).  The population is currently growing by 1.8 million each year.  Therefore, an additional 340,000 tons of food grain are needed each year in order to maintain per capita food grain consumption at its present level (author, 7).  Ethiopia needs sustainable changes in agricultural development.  This must include restoration of depleted soil nutrients, the introduction of an efficient marketing system, and a reduction in population growth (author, 7).  With these changes, along with many others pertaining to other various economic issues, the economy may begin to stabilize and even escalate.

            The future remains uncertain in Ethiopia. There is progress: the HIV/AIDS epidemic appears to have stabilized in urban areas, where prevention education is much easier to conduct and prevention materials are much easier to distribute (UNAIDS: Joint United Nations Programme on HIV/AIDS, 2007). However, Ethiopia remains one of the poorest countries in the world, especially rural areas (the majority of the country), and there is little sign that conditions are improving. The drought continues with no end in sight, so clean water and food remains out of the reach of many (Heavens, 2006). Continuing poverty assures that the HIV/AIDS epidemic will continue to spread quickly in most of the population, which will only be compounded by the difficulty in reaching isolated populations.

To counteract this, international aid to Ethiopia has increased significantly in the last few years, although implementing real-life programs continues to be a struggle (UNAIDS: Joint United Nations Programme on HIV/AIDS, 2007). Furthermore, doctors and nurses are scarce, and the few that are working - .03 and .2 per 1000 population, respectively (World Health Organization, 2007) are becoming even more overwhelmed as HIV spreads and demand for services increase. Incentives need to be offered to physicians, nurses, and other medically trained personnel who volunteer to work in Ethiopia (as well as other African countries). The world must also attempt to negotiate with drug companies to lower prices on HIV/AIDS-related drugs (including those used to treat opportunistic infections). Approximately only 7% of individuals infected with HIV are receiving antiretroviral treatments, and while UNAIDS is working furiously to provide universal access to treatment for HIV/AIDS (UNAIDS: Joint United Nations Programme on HIV/AIDS, 2007), that goal is still a long way off.

Prevention programs, while showing successful results in urban areas, are still having difficulty reaching much of the isolated areas of Ethiopia. Only 36.1% of men and 14.6% of women reported using a condom during their last sexual experience (UNAIDS: Joint United Nations Programme on HIV/AIDS, 2007). It is clear that prevention programs must be significantly ramped up, and must focus on a renewed effort to reach isolated populations. However, programs must also be appropriate to the severity of the epidemic. According to the PEPFAR program website, only 1 million individuals received prevention training involving “condoms and related prevention services” in 2006, while 12 million received abstinence prevention techniques (The United States President’s Emergency Plan for AIDS Relief, 2007). Abstinence is a valid preventative measure against HIV, but abstinence programs often do not include information about other prevention methods, and abstinence is not an option for all individuals, so comprehensive programs need to be offered for all.

Prevention training for younger children, at least to a certain degree, is also an important effort in the fight against AIDS. However, with the rising number of children orphaned by AIDS, this goal is becoming ever more difficult to achieve. Not only do these children receive no information from parents, they are also are far less likely to attend school (only 26% of orphaned children attend), where prevention education is easier to conduct; even so, only 46% of children with living parents attend school (UNAIDS: Joint United Nations Programme on HIV/AIDS, 2007). This highlights the need to alleviate the extreme poverty in this nation, as many children, who may very well decide the future of the epidemic, often cannot attend school even if they wish to because of family needs.

Implementing these programs will admittedly cost vast amounts of money, and is a logistical nightmare. However, with the lives of millions hanging in the balance, we must ask ourselves which we value more: human life or material goods.

Conclusion

            Ethiopia is a country wrought with many challenges. As a result of numerous economic issues in the country, the prevalence of the HIV/AIDS epidemic is very high. Some of these issues include poverty, poor sanitation, starvation, low levels of education, lack of advancement in equitable healthcare, and poor government funding. Many are working to improve these conditions and increase awareness in Ethiopia. As a third world country facing all of the afore mentioned issues, there are still resilient people with the will to live and the desire to make their country better for future generations.  Fortunately, there are those that rise above it and help those that are entrenched in the difficulties.       

           

 

 

 

 

 

 

 

 

 

 

 

 

Citations

 

1. Abebe, Tatek (2007). Children, AIDS and the politics of orphan care in Ethiopia. Social Science and Medicine 64, 2058-206
2. “At a glance: Ethiopia.”  UNICEF. http://www.unicef.org/infobycountry/ethiopia.html   October 8, 2007
3. Blerk, L. Van (2007).Aids, Mobility and commercial sex in Ethiopia: implications for poilcy. Aids Care. 19, 79-86.
4. Creanga, Andreea A (2007).Delivery of integrated family planning and AIDS/HIV dervice influence community based workers client loads in Ethiopia. Health Policy and Planning. 22, 404-414.
5.  “Ethiopia.”  THE CARTER CENTER. http://www.cartercenter.org/countries/ethiopia.html  October 8, 2007.
6. Embassy of Ethiopia., (2007). Ethiopia. Retrieved November 27, 2007, from Country Profile Web site: http://www.ethiopianembassy.org/population.shtml
7.  “Ethiopia.” The World Fact book.  Anonymous. http://www.cia.gov/cia/publications/factbook/geos/et.html#EconOctober 8, 2007.
8. Gebreeysus Hadera, H. Using the theory of planned behavior to understand the motivation to learn about HIV/AIDS prevention among adolescents in Tigray, Ethiopia. Aids Care 19, 895-900.
9. Heavens, A. (2006, February 20). Coping with severe drought in Ethiopia’s southern Moyale district. UNICEF. Retrieved November 10, 2007, from http://www.unicef.org/infobycountry/ethiop ia_31214.html.
10. Howard A. Gutman.  “Starvation in Ethiopia, help slowly arriving, death toll cannot be determined.”  EXODUS.  Http://www.exodusnewws.com/worldnews/world026.htm  May 19, 2000.
11. Ljungvis,B. (2006). Ethiopia, from UNAIDS Web site: http://www.unaids.org/en/Regions_Countries/Countries/ethiopia.asp
12. Lulseged, Sileshi (2006). Maternal and Child Health in Ethiopia: Challenge in the AIDS era. Ethiopian Medical Journal. 44, 2.
13. Sanders, Eduard J. (2003).  Mortality impact of AIDS in Addis Ababa, Ethiopia. Ethiopian Medical Journal. 17, 1209-1216.
14. The Economist, (June 7th, 2007). Middle Esast and Africa. Retrieved November 27, 2007, from Get the Gangsters out of the Food Chain Web site: http://www.economist.com/world/africa/displaystory.cfm?story_id=9304411.
15. The United States President’s Emergency Plan for AIDS Relief. (2007). 2007 Country Profile: Ethiopia. Retrieved November 10, 2007, from http://www.pepfar.gov/pepfar/press/81577.htm.
16. The World Health Report, (2006). Annex Table 4 Global Distribution of Health Workers in WHO Member States. WHO Statistics, p. 19., from http://www.who.int/whr/2006/annex/06_annex4_en.pdf
17. UNAIDS: Joint United Nations Programme on HIV/AIDS. (2007). Ethiopia. Retrieved November 10, 2007, from http://www.unaids.org/en/Regions_Countries/Countries/ethiopia.asp
18. World Health Organization. (2007). Core Health Indicators. Retrieved November 10, 2007, from http://www.who.int/whosis/database/core/co re_select_process.cfm?country=eth&indicator s=healthpersonnel.