Monday March 8 2010

Women and the cross of childbirth

By Muniini K. Mulera

Letter to a Kampala Friend
Dear Tingasiga,
During my recent visit to Kabale Hospital, I was very anxious to get to the maternity and newborn baby units, this being the place where I expected to feel professionally most at home. Things started off very well as my host, Dr Michael Odongo Osinde, an obstetrician who doubled as the hospital’s medical superintendent, led me into the unit. Two very pleasant midwives cheerfully informed me that they had already delivered 12 babies since the start of their shift in the maternity unit. It was still very early in the afternoon.

When I asked how many midwives were on duty, the duo informed me that they were it, along with the hospital’s other obstetrician, Dr John Wanyama, who was as jovial as his nursing colleagues. Their cheers belied the enormous burden, risks and private stress they shouldered as they did their best to help women realise their dreams of safe motherhood. Their smiles did not blunt my instant anguish as I watched new mothers, with their fresh bundles of joy in their hands or at their breasts, packed like bananas, unknowingly sharing all sorts of bugs that were likely to claim the lives of some of these vulnerable patients. The 30-bed maternity unit was well over its maximum capacity.

In the 12-month period that ended on June 30, 2009, the Kabale unit had admitted 4,434 pregnant women and others with other reproductive problems. 2,448 babies were born alive and 152 were born dead (stillbirths). Of those born alive, 22 died before discharge, with an unknown number dying after they went home. 23 of the mothers died. This touched me more than everything else I saw, for no subject is dearer to my heart than the urgent need to drastically reduce the deaths of Sub-Saharan Africa’s women, especially Ugandans, while pregnant or within 42 days of termination of pregnancy, from causes related to or aggravated by pregnancy or its management.

And so as I walked through Kabale’s maternity ward, various figures began to swirl in my head, reminding me that the women before my eyes were perhaps the lucky ones. At least they had a slightly better chance than their peers who were in the smaller health centres, let alone those who were carrying their pregnancies without any hope of ever receiving antenatal care or trained assistance during delivery in the villages.

The African woman bears a cross with deadly thorns that sprout each time she conceives. To put the tragedy of motherhood in Uganda and in Sub-Saharan Africa into context, let us look at some recent global and national figures from the World Health Organisation and the Uganda Demographic and Health Survey.

Globally, 529,000 women die every year from pregnancy-related causes. 50 per cent of these deaths occur in Sub-Saharan Africa. (Uganda loses 6,000/year.) A common way of expressing this is the maternal mortality ratio, which is defined as the number of maternal deaths during a given time period per 100,000 live births during the same time period.

The worldwide maternal mortality ratio is 400 per 100,000 live births. The maternal mortality ratio in Sub-Saharan Africa is 1,000 per 100,000 live births. The most recent figure for Uganda is 435 per 100,000 live births (range 345-524.) The numbers for Kenya, Rwanda and Tanzania are 1,000, 750 and 578 respectively. The figures for Australia, Canada and the USA are 4, 5 and 11 respectively.
Of note is that when I was a student at Makerere University Medical School 35 years ago, we were taught that Uganda’s maternal mortality ratio was 500 per 100, 000 live births. Thus the most recent figure of 435 per 100,000 live births could be interpreted as a positive trend in the right direction.

However, the authors of the 2006 Uganda Demographic and Health Survey (UDHS) Report pointed out that the sampling errors successive estimates were large and so it was impossible to say with confidence that maternal mortality had declined.
“Moreover,” the UDHS report stated, “a decline in the maternal mortality ratio is not supported by the trends in related indicators, such as antenatal care coverage, delivery in health facilities, and medical assistance at delivery, all of which have increased only marginally over the last 10 years.”

So there has been no change in the rate at which Ugandan women have been dying of pregnancy related causes over the last four decades. Remember the number of babies who were born alive at Kabale Hospital in one year? Yes, 2,448. And how many women died? 23, which translated to a staggering maternal mortality ratio of 940 per 100,000 live births!

Another way of looking at the scope of the problem is the odds or probability of death during a woman’s reproductive life. Whereas the global figure for the probability of a woman dying during her reproductive life is 1 in 74, the figure for sub-Saharan Africa is 1 in 16 and for Uganda, it is 1 in 13. While Uganda is not as badly off as, say, Sierra Leone, which weighs in at a risk of 1 in 6, we clearly have a very long way to go before our women can enjoy the low risks of reproduction of their Canadian or Swedish counterparts which are 1 in 8,700 and 1 in 30,000 respectively.

What is killing our women? The top five killers are severe hemorrhage (bleeding), hypertensive diseases, infection, obstructed labour and induced abortions. Of the 166,000 deaths from hemorrhage that occur globally each year, about 50 per cent occur in sub-Saharan Africa. The tragedy of childbirth in Uganda and sub-Saharan Africa is not limited to the preventable deaths of mothers, of course. The rates of death and disability are equally high among the newborns.

Of the 2,448 babies born alive at Kabale Hospital in the year ending June 30, 2009, 22 died before being discharged home. Add this number to the 152 who were born dead and truly tragic picture emerges. And no doubt many more died after going home.

Is it possible to give the Ugandan and African woman a reason to view her pregnancy with joy and assured optimism, and not with fear of the cross of thorns that bring tears – and even death – to thousands every year? Most certainly yes! It has been done elsewhere.
To be continued…

Dr Mulera is a consultant pediatrician and neonatologist