When childbirth becomes a deadly gamble

In Uganda, childbirth can be deadly. With 435 deaths for every 100,000 births, lack of modern family planning methods, a poor health care system and battered infrastructure means every pregnancy is a gamble,writes Evelyn Lirri:-

Ms Margaret Ajok is expecting her sixth child. The 26-year-old resident of Awere Sub-county in Pader District had come for antenatal checkup when I met her at Awere Health Centre. It is her fourth visit since she became pregnant.

A midwife at the health facility said Ms Ajok’s pregnancy has so far progressed well and there is no danger to the child and mother. But Ms Ajok’s experience of childbirth has not been without incident. When she was pregnant with her fourth child, she never attended any antenatal care.

“It was very expensive for me to move from home up to here. I have to walk more than 10 kilometres to access the health facility,” she said. And when it was time for her to have the baby, the journey to the hospital was too long, she decided to give birth at home - only with the help of a traditional birth attendant. It was a still birth.

While Ms Ajok said she had given birth to her other four children at the health facility, the daunting cost and expenses she needed to travel had forced her to deliver at home.

Slight improvement
According to the Uganda Demographic and Health Survey 2006, there has only been a slight improvement in the proportion of mothers who deliver in health facilities from 38 per cent in 2001 to 41 per cent.

“Now I don’t want to take any risk again. I have already saved some money for transport when the time to deliver this baby comes,” she said. A journey from Ms Ajok’s home to the health facility costs Shs5,000 on a boda boda.

But in a country where more than 10 million people live on less than a dollar or Shs2,100 a day, being pregnant can be potentially tragic for women like Ms Ajok who come from rural areas- and where services are scarce or expensive.

Pregnancy and childbirth-related complications are the leading causes of death among women in Uganda, where for every 100,000 women who get pregnant, 435 or 44 per cent die.

Daily deaths
This translates to an average of 16 deaths everyday. Most of these deaths result from complications of unsafe abortion, prolonged or obstructed labour where the woman’s body is too small for the baby to pass through the birth canal, massive bleeding, high blood pressure, malaria and HIV/Aids.

But often the underlying cause of death is the high cost of maternal care. Maternity care, like all other health services in Uganda, is supposed to be free but pregnant women are asked to provide their own delivery items like gloves, razor blades, cotton wool and birth sheets.

Dr Jotham Musinguzi, the African regional director for Partners in Population and Development (PPD), said many of the women are dying from causes easily preventable with basic medical care.

“Maternal mortality is not purely a health issue. If we want to get results, we need to have well functioning facilities in place with health workers. There must be good roads in order to transport women incase of emergencies and generally, there should be real investment in the health sector,” Dr Muzinguzi said.

Without a trained, experienced midwife on hand, women are more likely to die from complications like severe bleeding and obstructed labour. “If you have a skilled health worker with a mother during delivery, it will help her to detect if there is any complication and immediately do something to save the life of the baby and mother,” said Dr Hassan Mohtashami, the deputy representative of the UN Population Fund (UNFPA) in Uganda.

“If a mother needs specialised and sophisticated care by a doctor such as caesarean and blood transfusion, then there should be a centre equipped with these facilities where mothers can be referred,” he added.

This, intervention, according to Dr Mohtashami, has the potential of saving up to one-third of women who would otherwise have died. But saving lives of mothers requires more than just medical intervention.

Sensitisation lacking
Ms Thoraya Obaid, the executive director of UNFPA, told Sunday Monitor in an interview that the underlying reasons which make women not access information on reproductive health issues should also be addressed.

“We see that poor, uneducated young women have the least information and services, and the highest rates of death or injury during pregnancy and childbirth,” she said.
She said that poor sexual and reproductive health is a leading killer in Africa and the consequences are felt every day.

Explaining the task of reducing maternal deaths, Dr Musinguzi said while leaders have made several commitments to reduce maternal and child deaths, little effort has been put to realise the actual results. “If you are to look at the statistics, we are far from achieving the MDGs on maternal and child health,” he said.

To achieve the MDGs by 2015, countries must reduce the number of mothers who die in childbirth by 75 per cent. This means Uganda will have to significantly reduce this figure to 131 per 100,000 from the current 435 - a figure that already looks out of reach given the five years left to the MDG deadline.

Health and development experts say action on maternal and child health will do well to focus on family planning and basic care and to ensure women do not have too frequent or too early pregnancies that increase their risk of death.

But in Uganda contraceptive use among sexually active women has remained at a low 24 per cent, which is below the minimum needed to impact on fertility while the unmet need for family planning is 41 per cent.

“Family planning services enable women not only to plan their families but also to plan the rest of their lives. If a woman cannot decide voluntarily on the number and spacing of her pregnancies, then she cannot decide on anything in her life,” said Ms Obaid.

Many women admit they want to space or stop producing more children than they already have but they do not have access to contraceptives - especially long term contraceptive methods because of frequent stock-outs in public health facilities.
The result has been the high number of unwanted pregnancies, which have consequently led to a high number of induced abortions-297,000 every year, according to a study conducted by the Guttmacher Institute and Mulago Hospital.

According to the Uganda Demographic and Health Survey, at least 16 per cent of the estimated 6,000 annual maternal deaths are due to abortions.
The report reveals that 56 per cent (519,000) of the 1.2 million births that occur in Uganda every year are unintended.

Averting danger
The report says these births could be averted if all the women who wanted family planning services had access to them. Ms Margaret Akello, the in-charge of the Family Planning Unit at Lira Regional Hospital for instance said because of stock outs, they have registered a high number of women with successive unintended pregnancies.

Health experts say more women now prefer the long-term birth control methods, usually given in a single jab or fitting because it’s convenient and more effective than the oral contraceptives which must be taken every day to prevent pregnancy.

Ms Aidah Edonga, a 35-year-old mother of seven children for example said she wanted a long term method but she could not get it at the health facility. This forced her to resort to a private clinic. But even here, she said the cost was very high.

Part of the problem is that policy makers are sometimes reluctant to make long term birth control methods part of the mix of contraceptive method because of perceived cost barriers.

On the other hand, short term methods are readily available - even through commercial outlets and community distribution programme.
At a clinic run by Reproductive Health Uganda in Lira Town, a senior clinical officer, Mr Geoffrey Lapat, said contraceptives like Pills cost Shs500 while longer term birth control methods like inplants go for as high as Shs20,000.
“When the women come here and find the costs for the long term methods are high, they just leave without taking it. The next time you will probably see them again is when they are pregnant,” said Mr Lapat.

Studies show that addressing the unmet need for family planning in Uganda can potentially avert some 16,877 maternal deaths and more than 1.1 million child deaths by 2015.

Meeting the unmet need for contraceptives can also potentially reduce maternal deaths by 40 per cent while unplanned pregnancies and induced abortions would decline by 84 per cent.

Because of the huge unmet need for family planning, fertility rates have also remained high with each woman having on average seven children - some even more over their reproductive lifetime.

The Guttmacher report shows that when women delay their next birth or have fewer children, the rate of population growth declines and the potential to educate, train, and meet the economic demands of a young population becomes easier.
“Slower population growth can yield savings on the costs of providing health, clean water, sanitation, and social services,” the report reveals.

To address the huge challenge of maternal deaths, health experts say more investment will be needed in the health sector. “Leaders will have to make reproductive health a priority and devote 15 per cent of their budgets to health as they agreed in Abuja.”

“They also need to invest resources in training doctors, nurses and midwives to tackle the gap of health workers,” said Ms Obaid. In Uganda only half of the jobs in the health sector are currently filled while health budget spending is 9.7 per cent of the national budget far below the commitment agreed to in Abuja in 2001.

According to a report by the Population Secretariat, the body that advises government on population policy issues, the high population is already having huge implications on the health sector.

It shows that currently there is one nurse for every 4,000 people while for every 9,500 people, there is one health facility. Ms Obaid said reducing maternal deaths eventually will require commitment and funding and a functioning health care system.