Women with heart disease in sub-Saharan Africa face challenges, but stigma may be worst of all

October 11, 2018 by Allison Webel And Andrew Chang, The Conversation
A nurse in Uganda uses a stethoscope to listen for heart problems at a screening and educational event Oct. 31, 2017. Credit: Tao Farren-Hefer, CC BY-SA

Heart disease is the No. 1 killer of women, claiming a female life every minute. Yet it is often seen as a "man's disease." This disparity is magnified in sub-Saharan Africa, where we have recently conducted an investigation into the experiences of women living with rheumatic heart disease.

Rethinking heart disease in the developing world

Another prevailing myth that we often encounter is that cardiovascular disorders are not a major issue in the developing world. To the contrary, is already the number one cause of death worldwide as well as in low- and middle-income countries.

This shift has, in part, been due to ongoing successes in fighting contagious epidemics, particularly HIV/AIDS and childhood infections. Industrialization and economic development of low-income nations has brought more food security and decreased reliance on manual labor. Yet, these changes have fueled an increase in noncommunicable disease such as diabetes, high blood pressure and high cholesterol, leading to a surge in cardiovascular disease.

In contrast to their high-income counterparts, patients in poor countries are struck by, and die from, cardiovascular conditions at younger ages. Their health systems are often unprepared to combat the dual tides of infectious and noncommunicable illnesses. Furthermore, the causes of heart disease are somewhat different in poor countries, where the proliferation of "Western" maladies like heart attacks and hypertension are accompanied by "endemic" cardiovascular diseases of poverty such as rheumatic heart disease.

An old foe, revisited

Rheumatic heart disease is a preventable disorder that is a late effect of rheumatic fever, which ravaged Western Europe and the United States only a generation ago, but is rarely seen now in these settings. It is triggered by Group A streptococci, which causes strep throat. Some individuals will develop a systemic reaction known as acute rheumatic fever, which can permanently damage the heart valves.

In the developed world, is rarely seen, because is regularly treated with antibiotics. In developing nations, however, appropriate medications are often missed or are financially unfeasible. Rheumatic heart disease afflicts up to 43 million people worldwide and leads to up to 1.4 million deaths each year. It can have terrible consequences, including heart failure, and debilitating stroke.

Impact on women

Women of childbearing age with rheumatic heart diseases are especially vulnerable, as the disorder places them at increased risk of complications during pregnancy. Furthermore, the blood-thinning medications used to treat RHD can also raise the risk of miscarriage and maternal hemorrhage. Although pregnancy in this population is high-risk, only 3.6 percent of women with RHD of childbearing age are on contraceptives.

Our research group recently concluded a mixed methods study in Uganda of women of reproductive age living with rheumatic heart disease to better understand the lived experience of this population.

Several themes emerged: First, we discovered that female patients understood that their disease increased their risk of complications and death during pregnancy. Nevertheless, they still felt pressure to take the risk, citing the societal pressures to have many children. In fact, 100 percent of our participants answered that society would look poorly upon a woman who cannot bear children.

Further, our findings suggest that it may not be women themselves who control reproductive decision-making: Male partners were usually drivers of reproductive intent, both directly (by petitioning their spouses for children) or indirectly (due to women's fears of abandonment if unable to bear children). Tragically, 28 percent of participants reported that they had been left by their husbands or boyfriends due to perceived limitations in fertility, while 36 percent of participants confessed fear of abandonment by their .

Compounding their challenges, participants suggested that contraception may be criticized, leading to poor adoption – a social norm previously reported in Uganda and its neighbors.

Perhaps the most striking finding, however, was that women living with heart disease experience considerable stigma. Because of its ubiquity, we do not consider to be the source of much stigma in the developed world, yet it was spontaneously reported by our group. Several participants were suspected by friends and family of having HIV because they were observed taking medications for a prolonged period of time (as opposed to short durations for drugs such as antibiotics).

More surprisingly, our patients reported that they felt it may be preferable to have HIV than heart disease. They attributed this to the fact that having HIV may not limit their reproductive potential the way cardiac conditions do.

Building systems, targeting future efforts

In light of these sobering findings, our team also asked participants how they thought the current medical system could better serve their needs. First, patients suggested that health care providers discuss the reproductive consequences of the illness and its therapies. This concern has been echoed by women living with serious chronic disease in Europe as well. In addition, women stated that doctors should involve male partners and family members in discussions about heart disease.

To that end, Uganda's health system has commissioned an initiative to better care for women of reproductive age living with heart disease. Uganda's first Women's Heart Center is a collaboration between cardiology and obstetrics, a multidisciplinary effort to cross-refer patients who are pregnant or plan to become pregnant and have conditions. From the lessons we learned from our study, we hope to incorporate family counseling and public awareness campaigns to fight stigma against in .

Our study suggests that there is still work to be done in identifying the comorbidities and downstream outcomes of this population. These are areas of ongoing investigation for our team. Nevertheless, we are optimistic that there are opportunities for improved family and societal education programs and community engagement, leading to better outcomes and patient empowerment.

Allison Webel, Assistant Professor of Nursing, Case Western Reserve University and Andrew Chang, Cardiology Fellow Physician, Stanford University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Explore further: Double danger: The peril of childbirth for women with rheumatic heart disease

Related Stories

Double danger: The peril of childbirth for women with rheumatic heart disease

March 28, 2018
Today, most people in the United States rarely think of rheumatic heart disease (RHD)-or the rheumatic fever that causes it-as more than a historical footnote.

Is it safe for women with heart disease to become pregnant?

August 28, 2018
Is it safe for women with heart disease to become pregnant? Usually, according to ten-year results from the ROPAC registry reported in a late breaking science session today at ESC Congress 2018.

Death rates from rheumatic heart disease falling since 1990

August 23, 2017
The risk of dying from rheumatic heart disease, a condition of damaged heart valves caused by bacterial infection that leads to rheumatic fever, has dropped around the world over the last 25 years, according to a new scientific ...

Study examines prevalence of rheumatic heart disease in developing country

March 2, 2016
Thomas Pilgrim, M.D., of Bern University Hospital, Bern, Switzerland, and colleagues conducted a study to determine the prevalence and incidence of clinically silent and manifest rheumatic heart disease in Eastern Nepal. ...

Study reveals prevalence of women with heart disease delivering babies is increasing

May 15, 2017
A study of more than 80,000 women with heart disease from 2003 to 2012 reveals that the prevalence of women with heart disease delivering babies increased by 24 percent over that 10-year period. This jump, reported in a Stony ...

Women with high blood pressure during pregnancy more likely to develop CVD risk factors

July 2, 2018
Preeclampsia and gestational hypertension are common pregnancy complications involving high blood pressure that develops for the first time during pregnancy and returns to normal after delivery. Previous studies have shown ...

Recommended for you

No sweat required: Team finds hypertension treatment that mimics effect of exercise

October 16, 2018
Couch potatoes rejoice—there might be a way to get the blood pressure lowering benefits of exercise in pill form.

New model suggests cuffless, non-invasive blood pressure monitoring possible using pulse waves

October 16, 2018
A large team of researchers from several institutions in China and the U.S. has developed a model that suggests it should be possible to create a cuffless, non-invasive blood pressure monitor based on measuring pulse waves. ...

Why heart contractions are weaker in those with hypertrophic cardiomyopathy

October 16, 2018
When a young athlete suddenly dies of a heart attack, chances are high that they suffer from familial hypertrophic cardiomyopathy (HCM). Itis the most common genetic heart disease in the US and affects an estimated 1 in 500 ...

Novel genetic study sheds new light on risk of heart attack

October 12, 2018
Loss of a protein that regulates mitochondrial function can greatly increase the risk of myocardial infarction (heart attack), Vanderbilt scientists reported Oct. 3 in the journal eLife.

Researchers say ritual for orthodox Jewish men may offer heart benefits

October 11, 2018
A pilot study led by researchers at the University of Cincinnati (UC) College of Medicine suggests Jewish men who practice wearing tefillin, which involves the tight wrapping of an arm with leather banding as part of daily ...

Markers of dairy fat consumption linked to lower risk of type two diabetes

October 10, 2018
Higher levels of biomarkers of dairy fat consumption are associated with a lower risk of developing type 2 diabetes, according to new research published today in PLOS Medicine. The study, in more than 60,000 adults, was undertaken ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.