Thursday October 24, 2019 was Stella Chepkemoi’s last day on earth. That day, after doing household chores, she walked to Bukwo General Hospital to attend a safe motherhood camp organised by Hinds Feet Project, a health organisation.
The camp was conducting free ultrasound services - a joy to Chepkemoi, and 104 other pregnant women.
Bukwo District has one ultrasound machine, which constantly breaks down and can go for months without functioning.
Bukwo Health Centre IV, which owns the machine charges Shs30,000 for its use, a fee many cannot afford in the district. Chepkemoi, a 27-year-old mother of four, was a market vendor, selling vegetables. She was the breadwinner in her family because her husband, a former police officer, was crippled by a motor accident.
Throughout her 34-week pregnancy, Chepkemoi had not attended an antenatal clinic because it was her custom.
Dr Collins Satya, the district health officer, says only 47 per cent of pregnant women give birth at Bukwo hospital.
This is considered a great improvement because the figures were stuck at 36 per cent for a long time.
For days, Chepkemoi had not felt fetal movements in her womb, and since the ultrasound machine was being used for free at the camp, she decided to go.
Mr Innocent Menyo, a radiographer, examined Chepkemoi.
“There was no cardiac activity coming from the fetus. The baby had died and her uterus was going to rot if she had not come to the hospital. I referred her to the resident doctor who recommended that she be monitored and later induced,” Mr Menyo says.
That evening, a midwife induced Chepkemoi and she delivered the dead baby. However, she lost a lot of blood.
There was no blood in the district at the time and she was referred to Kitale County Referral Hospital in Trans Nzoia County, Kenya, for a transfusion.
Kitale Hospital is 58 kilometres away from Bukwo Hospital. Chepkemoi died in the ambulance, 17 kilometres from Kitale.
Bukwo, a hilly district with steep slopes, has only murram roads which can be slippery and muddy during the rainy season, making transportation difficult.
The roads to Mbale and Kapchorwa can be death traps. Ms Sarah Atiang, a midwife at Bukwo Health Centre IV, says the roads are so bumpy that some women end up delivering on the way.
“For some, the placenta does not come out. So, by the time she arrives here, she is paper-white. And with the perennial blood shortages, what would happen if we refer her to Mbale or Kapchorwa, only to find that they also do not have blood? Patients prefer being referred to Kenya where they know the facilities, though expensive, are well equipped,” Ms Atiang says.
Why refer emergence to Kenya?
Although the road from Bukwo to Kitale is also muddy and slippery in the rainy season, it is straight and does not go over steep slopes.
On the night Chepkemoi died, I was travelling to Bukwo – through Kenya – using this road.
At Chepchoina in Endebess, at 1.30am, our car got stuck in the mud and we spent the night there. The ambulance transporting Chepkemoi to Kitale manoueuvred through the mud and bypassed us.
In 2016, government announced that it had earmarked Shs395b for tarmacking Kapchorwa-Bukwo-Suam road.
Two years later, President Museveni and Kenyan Deputy President William Ruto commissioned the groundbreaking ceremony of the project in Kapachorwa District. The roadworks are ongoing on both sides.
However, it is difficult to make referrals in different health centres. Ms Irene Cheptege, a nurse at Chesimat Health Centre II, says because the district has only one ambulance, making referrals is almost impossible.
“If a pregnant woman is bleeding excessively, we sit her on a chair and carry her to Kortek Health Centre III, which is eight kilometres away. In the rainy season, no vehicle or motorbike can risk travelling in the mud,” she says.
Dr Satya says a patient has to fuel the district’s ambulance in case of referrals. A referral to Mbale and Kapchorwa districts cost Shs250,000 in fuel, while a referral to Kitale costs She200,000.
Many families have to sell off plots of land to afford the fuel. And, in an emergency situation, selling off a piece of land in a space of one or two hours is an uphill task.
“People have to fuel the ambulance. You either fuel it or you die,” Dr Satya says.
Bukwo hospital, which serves a catchment population of 112,500 people, is entitled to 15 litres of blood every fortnight. However, Dr Satya says they often run out of blood.
“We get blood from Mbale Regional Blood Bank but it has a short shelf life. So either the units get used up within a few days, or they expire. We cannot replenish the blood immediately because of financial constraints. We do not have the money to buy fuel to drive to Mbale to restock,” he says.
“It is only when a patient is being referred to Mbale hospital that we transport our laboratory personal into the ambulance because the patient has to fuel it. If there are no referrals to Mbale, we go without blood,” he adds.
Bukwo hospital receives Shs35m per quarter from government but three quarters of this money pays service providers.
Only a quarter is spent on operations. Previously, the hospital charged Shs20,000 for every unit of blood given to a patient to cover the fuel costs. However, local politicians have since stopped the charge.
According to the Annual Health Sector Performance Report, Bukwo hospital was among the facilities with the highest maternal death ration in the Financial Year 2017/2018. It has a maternal death risk of 615 per 100,000 deliveries.
This corresponds to what citizens think of health service delivery. A 2017 Sauti za Wananchi survey found out that 59 per cent of Ugandans said poor health facilities was one of the country’s top problems.
However, according to the report, 51 per cent of Ugandans said they use government health facilities because private ones are more expensive and are not well spread.
The survey also highlighted that only two per cent of Ugandans had health insurance cover.
The lack of an ultrasound machine in Bukwo is not only a disservice to pregnant mothers but to health workers as well because they need it for proper diagnosis.
“We perform C-sections through guesswork. Sometimes, you enter the theatre thinking you are going to deliver one baby, only to find that the mother is carrying twins, and you have to make provisions for that operation,” he says.
Dr Joseph Mangusho, a health worker at Bukwo hospital, says diagnosis is an important part in the life of a pregnant woman in case of complications.
“That portable ultrasound machine has saved many lives, including that of the midwife. She is pregnant but she did not know that she was expecting twins. At Kapkoloswo Health Centre III, a pregnant woman did not know she was expecting twins, and that one of them was dead. We referred her to Kitale hospital. Another one had very little amniotic fluid in the uterus,” he says.
What can stop this menace?
Chepkemoi’s death was preventable. But, there are two sides to the coin. While government bears the brunt for not providing basic services in many of its health facilities, every woman has a role to play in her health.
Village health teams need to encourage women to seek information about their pregnancies.
“We are at 54 per cent in terms of staffing, yet the recommended level is 84 per cent,” Dr Satya says, adding: “As a mitigating measure, we are sensitising traditional birth attendants (TBAs) to bring pregnant women to health centres. In Riwo and Kotek parishes, we give a token to a TBA who refers or escorts a mother to a facility.”
Equipping health centres
Health facilities need commodities such as the comprehensive emergency obstetric and newborn care package. In Stella Chepkemoi’s case, it was a mistake to begin the delivery process without essentials like blood. To run such a robust healthcare system, huge financial investments need to be made. For the women of Bukwo, this is still a pipe dream. “We will continue leveraging on the chance referrals to Mbale hospital to get blood. Right now, we do not have funds to procure an ultrasound machine, but we are going to request the Ministry of Health for funds,” Dr Satya says. Airtel Uganda has pledged to buy a portable ultrasound machine for the district in January 2020.
What law says
Maternal mortality rate is a litmus paper for how developed a country is. With a maternal mortality rate of 336 deaths per 100,000 live births, Uganda has reduced its mortality rate by 20 per cent over the last 20 years.
The Constitution does not specifically have an article that defines the right to health. And, the Patients’ Rights and Responsibilities Bill 2019 is still a long way from being signed into law.
However, Uganda has ratified a number of laws, such as The Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), that place an obligation on states to ensure that women get appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary.
In 1994, the International Conference on Population and Development (ICPD) sat in Cairo, Egypt and 179 governments, including the Uganda government – adopted a Programme of Action, where it was agreed that sexual and reproductive health is a human right, and no mother should die while giving life. This year, 25 years after the ICPD conference, the Nairobi Summit on ICPD25 came up with a non-binding Nairobi Statement as a way forward to complete the unfinished business of Cairo’s Programme of Action, with specific commitments to zero preventable maternal deaths and maternal morbidities, and a comprehensive package of sexual and reproductive health interventions. Uganda did not make any concrete commitment to adopt the Nairobi Statement.