Birgit Stümpfl, a German midwife, runs the Doctors Without Borders/Médecins Sans Frontières (MSF) Chamanculo clinic for Prevention of Mother-To-Child Transmission (PMTCT). On her second mission with MSF - her first was working with refugees on the Thailand-Burma border - Birgit is well aware of the possible benefits but also the difficulties the project faces.
The clinic is small and unassuming - three little rooms in a self-contained, yellow-painted annex under a spreading mango tree in the grounds of Chamanculo Maternity Hospital. Not exactly the place you associate with life-and-death struggles. And yet this clinic is the site of one - the desperate attempt to stem the mother-to-child transmission of HIV.
Birgit Stümpfl sighs. "We've only been open for two months and already I can see how tough it is going to be," she says.
The hospital is one of only a handful in Maputo, the capital of Mozambique. HIV infection among mothers is chillingly high here: 17% according to some prevalence studies, roughly similar to the rate in the overall population, and double what it was only six years ago. What's worse, HIV infection can easily be passed from mother to child: transmission will occur during pregnancy, delivery or breast-feeding in 25-40% of cases.
Maputo, Mozambique. September 2002. Inside the MSF Alto Mai health Center. Photo by Francesco Zizola/Magnum Photos for MSF
The good news is that there is a medical solution. If the mother is administered a single dose of the drug nevirapine at least four hours before delivery, and if the baby is given a small dose within 72 hours of being born, the chances of transmission can be reduced by as much as 50%. When this is combined with a program encouraging mothers living with HIV to feed their babies formula rather than breast milk, maybe a generation of Mozambicans can be spared from childhood infection.
The clinic provides two services: voluntary testing and counseling aimed primarily at the mothers who come through the hospital, and the PMTCT program for those who test positive, which includes further counseling, the administration of nevirapine to mother and child, and the free provision of formula milk.
MSF's links with the maternity hospital are good and getting stronger. Every morning, some 80 mothers who gather for pre-natal consultations in the maternity hospital hear a short presentation about the clinic and the PMTCT program. A more detailed education program, for groups of 20 mothers, will begin in early 2003.
Birgit also hopes to run more training programs for the hospital staff. On average, they deliver 450 babies each month and are desperately under-resourced. Other hospitals are also starting to refer pregnant mothers to the clinic. In the two months since it opened, 50 mothers have been tested, with 70% found to be HIV positive. Twenty-four women are currently in the PMTCT program.
So far so good. But solutions are never that easy to implement.
"Take feeding," says Birgit. "Nevirapine is great because it's so simple, but it's no use if we don't tell the mothers that breast feeding transmits the virus and then encourage them to switch to artificial milk."
For a midwife who firmly believes "breast is best," this is very hard to accept. "I never thought I would come to a country to promote artificial feeding - and yet that's what I have to do if I want to stem mother-to-child infection."
For the mothers, it can be even harder to accept. Artificial feeding is rare in Mozambique and is associated with illness and bad mothering. If a relative sees her with formula, it might raise some dangerous questions.
"It is almost impossible for a mother to artificially feed if she hasn't disclosed her HIV status to her closest family. But most women are afraid to disclose, they're afraid they'll be thrown out of the house," Birgit says.
In most cases, it is not even the mother who is making decisions about what to feed the child - it is the grandmother or even the husband's mother, who might not be sympathetic.
Tete, Mozambique. September 2002. In the pediatric ward at the day hospital managed by MSF, Dr. Silvia cares for 4 year old, HIV-positive, Garido H. Photo by Francesco Zizola/Magnum Photos for MSF
There are even economic pressures. "One woman came back early saying she had no more formula," Birgit remembers. "When I confronted her, she admitted that her husband had sold it at the market. Each tin costs US$5 and they're poor; how can you blame them?"
But for all the hard stories, Birgit says there are an equal amount of positive ones, of mothers who enter the program and find hope in it, of babies who don't contract the virus because of PMTCT.
Beatriz, the clinic's receptionist, found out a year ago that she had the virus, when she was already pregnant with her second child. She was put on the PMTCT program, received nevirapine, and started artificial feeding. It is still too early to know if her baby daughter is HIV positive or not.
"I don't have the emphasis that I'm here to save the world," Birgit says. "There are so many things which are imperfect and lots of things make me think. But you also have to see the reactions of some of the mothers whose babies don't contract the virus. That is a definite, positive thing. We have to start somewhere, find a way somehow."
In addition to its work on HIV/AIDS prevention and care in Maputo, MSF is running HIV/AIDS programs in Niassa and Tete provinces in Mozambique. In early 2003, MSF will launch a program to provide antiretroviral treatment for people with HIV/AIDS in Maputo's Alto Maé Health Center. Mothers from the PMTCT program in nearby Chamanculo will be eligible for the program.