The women who deliver babies in hard-to-reach areas

Susan Apiyo is a 26-year-old enrolled midwife at Cwero Health Centre III in Gulu District, northern Uganda. Cwero is 32km from Gulu town. Apiyo has not practiced midwifery for a very long time; about four years since graduating in 2011 with a certificate in midwifery from Kalongo School of Nursing and Midwifery in Agago district but has already had a taste of the challenges midwives go through in helping mothers bring a new life on earth.
One of those instances happened at Rukony Health Centre II in September 2013, 30km from Gulu where she worked before being moved to Cwero.

Uterus failing to contract after delivery
“She was a mother delivering for the eighth time and I expected the process to be normal,” Apiyo recalls, “but on arrival and checking her, the foetal heart was not okay; the baby was in distress. I thought of way of quickening the delivery so both the baby and mother could be saved. I succeeded in helping her push, the placenta was expelled too but the uterus failed to contract thereafter. She started breeding profusely.”
Apiyo, alone at the health centre, had two big tasks on her hands; one, help the baby attain normal breath or what is technically referred to as resuscitation and two, do something to stop the mother from bleeding to death. Any delay could potentially lead to death of either the mother or the baby.
“I resuscitated the baby for about five minutes until when I saw the baby had coped a little and handed it to a nursing assistant. I moved to the mother, stimulating the uterus to contract. The stimulation was by manual compression, compressing with one hand on the mother’s stomach and fixing another through her vagina.”
Then a glimmer of hope. “Soon I started seeing blood clots being expelled from the uterus, and with the uterus slowly contracting, the bleeding gradually subsidized. I moved first and put her on a drip. I did that while observing the baby’s health. Slowly I helped her move to the ‘recovery’ room where she spent two days before she was discharged with her baby girl alive.”

Mother whose uterus almost ruptured
Filda Gloria Amono, 26, is another enrolled midwife at Tekulu Health Centre II with a harrowing story. The nearest trading centre to Tekulu is at St Thomas Junction on the Gulu-Kampala road, 7km away.
It is at Tekulu where Amono attended to a mother whose uterus almost ruptured before she gave birth. The mother’s previous delivery was by caesarean. Health workers recommend that a mother who has given birth by caesarean spends at least two years before conceiving again but Amono’s patient had barely spent a year. A caesarean had been done somewhere in 2013 and she was due for another baby somewhere in 2014. “She came in with two kinds of pain,” narrates Amono, “the labour pains and pains from the (caesarean) scar. It was a difficult situation in the middle of the night at 2am. I thought anytime the uterus would rapture. While I could possibly help, at my level (enrolled midwife), I am not allowed to handle such cases. I called in an ambulance that came one hour later. Hadn’t the ambulance come, I was going to risk it all and help the mother.”

Shortage of midwives
The problems faced by midwives sometime cause them to forget the would-be good moments. Jacline Aceng, an enrolled midwife at Awoo Health Centre II in Gulu district said the greatest joy in practicing midwifery is being the first person to see a newborn, first even before the baby’s mother. But that is often overshadowed by the overwhelming number of mothers to attend to amidst shortage of equipment and personnel.
The 2014 State of World’s Midwifery report indicated that Uganda has a shortage of 3000. The World Health Organisation recommends one midwife to care for 175 births per year; therefore about 9,000 midwives are needed in Uganda. However, Uganda has only 6,000 midwives licenced to practice, according Uganda Nurses and Midwives Council. With the midwives demand in the country standing at 9, 000, the country has a deficit of 3,000. Government allocates only one midwife at Health Centre IIs yet in Gulu District, according to the Grace Anena, the Senior Nursing Officer in the office of the Gulu District Health Officer, most deliveries are conducted at Health Centre IIs. Health Centre IIs, she said, account for about 30 per cent of deliveries in the district. The rest is distributed among Health Centre IIIs IVs and hospitals.
The shortage of personnel means midwives are overworked. “Midwives have no reporting and resting time,” remarked Aceng. “Even when I am eating and a mother comes, I leave the food and attend to her. During day, I attend to mothers for antenatal services and conduct deliveries. Sometimes I spend two or three days without sleeping in my bed. All the time I have to be at the health centre, for who will I leave behind if am not there.”
The nature of work of midwives affects their families and marital homes. Amono wedded on Saturday April 25 and on Thursday April 30th les than a week after her wedding, she had to be at the health centre to help to mothers deliver. “He (husband) understands that I should be at the centre anytime,” she said, seemingly suggesting all was well. But that was not really it. “I wish,” she noted in a low tone, “I wish, I wish I can be near my husband.”
This year’s IDM theme is “Midwives: for a better tomorrow”. It is a cause for reflection on the critical role of midwives in creating a brighter future for mothers, babies and families. It is no wonder that the Ministry of Health in collaboration with the Uganda Private Midwives Association together with the United Nations Population Fund (UNFPA) and reproductive health partners are engaged in activities highlighting the crucial roles played by midwives and also advocating for investment in midwifery.
While progress has been made towards reducing preventable maternal and newborn deaths, the practice of midwifery still has challenges as the world and country Uganda transits from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs).
Sustainable development may however not be reality unless mothers and babies survive and thrive, and midwives are central in ensuring that happens.

Bridging the gap

In 2007, UNFPA introduced the Bonding Scheme for midwives in order to scale up the number of midwives in hard-to-reach areas. The scheme is operated in districts of Gulu, Kabong, Kanungu among others. Through the scheme, girls from such areas are given scholarships to study midwifery and commit to work there for at least three years after graduation. Apiyo and Amono are two of the Bonding Scheme beneficiaries.
Anena said the scholarship is helping bridge the gap in midwives in the district where studying midwifery is expensive. Studying a two-year course in midwifery, she said, costs not less than eight million shillings, which money many people cannot afford. Midwives, Anena said help not only in helping mothers deliver but in other complimentary services like family planning.

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