Not such a different world: providing contraception services in Lesotho.

Introduction “PTP”: three letters scrawled in the tattered notebook that served as her medical record. What did it mean? For me, it explained why my previous patient was crying inconsolably onto a nurse’s shoulder. For her it signified far more: another mouth to feed, another nervous wait for an HIV test, a shortage of blankets, an unwanted shift in her world. Clinic over, I went outside and gazed at the zig-zag skyline of the mountains. Pregnancy test positive: one of those deceptively simple acronyms that tames the complexity of our patients’ lives into something writeable, something understandable, something medical. I was on my elective in Lesotho, a country about the size of Wales and entirely surrounded by South Africa. It was late June, winter in Lesotho, a season of glaringly bright days and densely cold nights. That day I was working at an ‘outreach clinic’ run by Maluti Adventist Hospital: each Tuesday an assortment of nurses, doctors and students crammed into a minibus and drove 2 hours from the main hospital to run a rural primary care clinic that offered contraception services. Dozens of people would be sitting on the ground waiting for us to arrive, wrapped in their traditional blankets and exchanging village gossip. The woman who was now so upset had attended for a repeat dose of injectable contraceptive. Unfortunately one of her children had been unwell and so she had been unable to travel to the clinic for several weeks. Access to abortion in Lesotho is very restricted, so all we could offer was antenatal care. This essay explores the general challenges facing contraception services in Lesotho before discussing specific problems encountered with current contraceptive methods and how the situation might be improved for Lesotho’s women. Background to contraceptive services in Lesotho The Kingdom of Lesotho has a fascinating history, only becoming independent from Britain in 1966.1 Today it is an extremely poor country, with most of the population relying on subsistence farming.2 In Lesotho HIV is like the mountains – the backdrop to every story; 23% of the adult population carry the virus.2 The epidemic contributes to a low life expectancy, which declined from 59 years in 1996 to 41 years in 2006.2 There are several reasons for the high prevalence of HIV, but local people believe the main problem is that most men of working age leave for months at a time to work in the mines of neighbouring South Africa. There many men contract the virus through paying for sex or having another partner, and then infect their wives when they return home. Antiretroviral drugs are available free of charge, but I saw many patients presenting with late-stage undiagnosed disease for whom such medication was of little use. Women in Lesotho are generally better educated than men; in 2009, 97% of adult females were literate compared to 80% of men.2 In recent years the fertility rate has gradually declined and was 3.3 births per woman in 2008.2 However, childbearing remains risky. In the same year, the lifetime risk of maternal death was 1 in 62 compared with a global average of 1 in 140.3 Women who know they are HIV-positive are no less likely to wish to give birth, and in some cases are keen to have a child to conceal their status.4 Contraception services are an important part of global efforts to reduce mother-to-child transmission of HIV, but such services are poorly integrated with HIV care in Lesotho.4 5 Perhaps surprisingly, HIV-positive women report less unmet contraceptive needs than those who are HIV-negative, but in both groups over half say that services Final Year Medical Student, Medical School, Newcastle upon Tyne, UK