As the sun set over the 2,500 year old stupa in Vaishali, Bihar and in the half-light of dusk, a young woman showed me an X-ray that she brought out of a dark and damp corner of her hut. She weighed less than 30kg, looked anaemic and weak and carried a 10 day old infant in her arms, while two other toddlers tugged at her sari.
Even in the poor light, I could see that her X-ray had a cavity and white patches in the right lung, a sure sign of tuberculosis, most likely of the infectious variety.
She had taken treatment for TB off and on 8 months ago but after several visits to the health centre that did not have a stock of drugs, had given up.
She had been to the local primary health centre recently complaining of cough and fever, had been given cough syrup by the pharmacist and she had also taken several courses of antibiotics from local private practitioners. When she finally had a sputum test done, it was heavily positive for TB bacteria and she was advised a fresh course of TB treatment.
Her 10-day old baby girl was underweight and showed no obvious signs of infection but both her other children were found to be infected with TB. I left with a heavy heart, hoping that she had the common or drug-sensitive form of TB where her chances of cure were high if she completed her full course of treatment.
However, I knew that she had a high chance of having drug resistant TB (because of previous irregular treatment), a form that is notoriously difficult to treat and is associated with a high risk of death.
It is not widely known that tuberculosis is the third major killer of women aged 15-44 years, accounting for approximately 700,000 deaths a year globally and causing illness in millions more. TB is more common during and immediately after pregnancy, possibly due to the changes in immunity that occur during that time.
This not only poses a risk to the life of the woman but also increases the chances of death in the newborn baby. Babies born to women with TB are also more underweight and are at high risk of developing the disease themselves due to the close contact with their mother. TB can cause infertility and chronic infections of the reproductive system.
Malnutrition and food insecurity can exacerbate the risk of TB disease; other threats such as rising tobacco use and diabetes among women, can also mean an increasing burden of TB.
The AIDS epidemic has had a major impact on TB rates in many countries, affecting more women and at younger ages than previously. Women living with HIV are 10 times more susceptible to TB than HIV uninfected women. A study in Pune found that TB increased the probability of death for HIV-infected pregnant women and their infants.
Further, HIV-positive women with TB during pregnancy had a higher risk of transmitting HIV to their babies compared to women without TB. While nationally, HIV infection in pregnant women is rare, there are 156 districts with higher (greater than 1 per cent) HIV prevalence, where extra attention needs to be paid to screening for both HIV and TB in pregnancy.
There is another, more indirect, but equally serious consequence way of suffering from TB. A study from Chennai estimated that 15 per cent of women who develop TB faced rejection by their families, highlighting the stigma that TB still has in our society today.
TB among women also affects children: they are at risk of infection from their main caregivers and are often pulled out of school to help care for sick family members or to provide additional income for the family. TB is associated with and exacerbated by poverty, overcrowding and malnutrition, conditions commonly faced by women, especially in urban slums.
In an attempt to reduce maternal mortality and improve pregnancy outcomes, the government, through the National Rural Health Mission, is making efforts to improve the quality of antenatal care and increase the proportion of institutional deliveries attended by trained personnel.
Screening and treatment of common infectious diseases (TB nationally, HIV and malaria in some regions of India) should be integrated into key entry points to the health system for women, notably antenatal care, family planning services and child immunization visits.
A simple screening tool with four questions (presence of cough, fever, weight loss or absence of weight gain during pregnancy and night sweats) could be used by health workers (ASHAs or Village health nurses) to exclude TB.
Those with any of these symptoms need to be further investigated for TB. All pregnant women should be counselled and offered HIV testing and if found to be HIV positive should be further evaluated for antiretroviral treatment, counselled regarding infant feeding and followed-up closely.
Many malaria-endemic countries in Africa use intermittent preventive therapy (IPTp) with anti-malarial drugs during pregnancy to reduce the impact of malaria on mother and child. In the highly malaria endemic regions of India, pregnant women should be counselled to sleep under bednets, screened and treated for malaria if symptomatic and receive preventive therapy if not.
In addition to attention to the obstetric causes of maternal mortality, it is time we acted on the less obvious but equally important killers of women.
Dr. Soumya Swaminathan
(Coordinator, Research at the Special Programme for Research and Training in Tropical Diseases, Geneva).