While launching the 2014 report on midwifery titled, ‘The State of World’s Midwifery 2014, a universal pathway, a woman’s right to health,’ at Rock Classic Hotel in Tororo Town on October 17, the State Minister for Health, Ms Sarah Opendi, looked peeved. “This is way too high,” she exclaimed, her voice taut. “We need to do more.”
The report compiled by the United Nations Population Agency (UNFPA), International Confederation of Midwives (ICM) and World Health Organisation (WHO), carried numbers that painted the picture of the state of midwifery in 73 countries, Uganda being one of them.
By publishing the report, the authors stated that they wanted to provide evidence based on the state of the world’s midwifery in 2014 to support policy dialogue between governments and their partners.
WHO 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 licensed to practice. With the midwives demand in the country standing at 9, 000, the country has a deficit of 3,000 midwives. This is what alarmed Ms Opendi.
Effect on maternity and child health
These figures are not good for mothers in the country where maternal mortality is still high and there is reportedly an exodus of midwives to neighbouring countries like South Sudan where midwives, like other health workers, reportedly earn higher than their Ugandan counterparts.
Masereka Zakayo Black, the General Secretary of Uganda Nurses and Midwives Union (UNMU), a labour and professional organisation for nurses and midwives in the country, says the shortage of midwives is responsible for a high maternal and child mortality rate in the country.
“You know Uganda has a high maternal and child mortality rate, and do you know how that comes about? Well, midwives are central in this mix. They care for mothers right from the point of conception, assist them during antenatal visits, in actual labour and administer post labour services. A deficit, any gaps in this process therefore is detrimental to the health of the mothers and their babies,” states Masereka.
Rural areas affected most
Maseraka adds that the situation is more precarious in rural areas. There, he says, because of lack of social services and amenities like housing for staff, electricity and good schools, midwives, like other health workers shun working there. This means out of an already small and overstretched number of midwives, a fewer number is willing to work in rural and hard-to-reach areas.
Yet this is where mothers would need them most, for there is a high child birth rate among mothers living in poor communities with lesser levels of education as compared to their urban-dwelling counterparts.
The result is that the fewer midwives who brave the hard conditions attend to a large number of mothers, which often is overwhelming, and that has a bearing on quality of services delivery.
The 2013 Save the Children report indicates that midwives in rural health centres assist mothers deliver babies at night using torches in centres where basic sanitation facilities like running water are lacking. Newborns and or mothers lose lives because they are unattended to by a professional midwife or simply because there are no facilities for proper childbirth.
In its 14th annual Mothers’ Index, Save the Children placed Uganda in 132nd position out of the 176 countries that were graded. According to the report, 16 mothers die every day in Uganda during delivery and 106 children under the age of five die within the first 28 days of birth annually; and another 41 die on the day they are born every day.
The 2014 midwifery report noted that 73 countries included in the report account for more than 92 per cent of global maternal and newborn deaths and stillbirths, but have only 42 per cent of the world’s medical, midwifery and nursing personnel.
One hopes that the “rehabilitating and equipping” goes down to health centre IV, III and II because it is the poor state of these centres that have contributed to Uganda not being able to meet the Millennium Development Goals on child and maternal health (MDG No.4 and 5).
While the Millennium Development Goal Report for Uganda 2013 categorised Uganda’s performance on MDG No.4 (reduce child mortality) as “On track”, the report described it as “Stagnant” the country’s performance on MDG No.5 (improve maternal health). One indicator to this effect is the country’s Maternal Mortality Ratio that is still high at 438 per 100,000 live births per year.
As to why it is still stagnant, there are many reasons, one of them being lack of skilled attendants. Ms Maria Najjemba, the country midwifery adviser at the Ministry of Health, says the numbers of mothers attended to by skilled personnel, technically referred to as Skilled Attendance stands at 59 per cent, way below WHO recommended 90 per cent. The shortage can partly be attributed to the small number of well trained and competent midwives.
UNFPA’s State of Midwifery Training, Services and Practice in Uganda, Assessment Report (July 2009) identified a high student to tutor ratio in the health training institutions. It was 1:60 against a recommended 1:10.
The training colleges were also poorly equipped, lacking basics such as books, laboratories and with outdated curricula for midwifery education which compromised the quality of education in the institutions. And a high student to tutor ratio also means tutors are unable to pay attention to specific needs of students which affects their learning.
Dr Franko Inshallah of Africa Humanitarian Action whose organisation supports Rwamwanja Health Centre III said the solution lays in recruiting more health personnel and expanding the health facility especially the maternity ward.
Recruiting more health personnel would mean increasing funding to the health sector or reallocation of resources within the sector to prioritise human resource welfare and development.
This would reduce the disparities that exist especially between rural and urban healthcare service delivery. But while funding to Uganda’s health sector has been growing (from Shs852bn in 2012/13 to Shs940bn or 7.2 per cent of 2013/14 budget and now Shs1.1trillion or 8.5 per cent in 2014/15), it is far lower than the 15 per cent African countries committed to in the 2001 Abuja Declaration. Uganda signed the declaration.
The acting assistant commissioner for nursing at the Ministry of Health, Catherine Odeke, said the solution lies in training of midwives. “We need to double the number of midwives and physicians and improve the efficiency by providing all equipment and materials that midwives need to care for mothers,” she said.
Najjemba advises that government ought to change the mode of staffing for midwives. Currently staffing for midwives is according to levels. At Health Centre II, there is one midwife and two midwives at Health Centre III. “Staffing for midwives should be according to population,” advises Najjemba. “For if there are more people served by a Health Centre II, more midwives should be deployed.”
MIDWIFE'S APPALING TALES
The agony of Shamim Nansubuga cannot illustrate better the poignant state of shortage of midwives in hard-to-reach areas. Nansubuga is a midwife at Rwamwanja Health Centre III, Kamwenge District in western Uganda. Rwamwanja is 350km from the capital, Kampala.
“We receive about 20 mothers in labour in 24 hours,” Nansubuga narrated to this reporter. Rwamwanja is also a settlement for refugees from Democratic Republic of Congo. The health centre serves both the host community and refugees. “Sometimes, the numbers shoot up, and at times, I am alone on the shift, (and) I attend to many mothers delivering at the same time.”
“If more than one mother is in active labour at the same time, I have to find a way of handling the situation. I instruct some mothers on what to do while I attend to those who do not; especially if they delivering for the first time. Such mothers will not push unless you are there to assist them.
Many of them are teenage mothers. Those on their second or third time in labour, I assume they know what to do. Yet that is not absolute for they too need help but what can I do? I try to instruct them so they can push as I attend to the inexperienced ones.”
“Once the baby is out, I receive it, cut the cord and remove the placenta. Sometimes the mother is bleeding intensely and I have to find a way of stopping it. I apply cotton and other stuff. Yet that is not the only complication in the labour process. I have to remove the cord around a baby’s neck which must be done carefully not to strangle the baby.
That is done despite the urgency to attend to another mother needing my help. “For safety reasons, I change the gloves, move to the next bed and assist another mother. At times two mothers share a bed. Some mothers like those who are HIV positive need special care so that they do not infect their babies while giving birth.
I try to do my best by setting in advance everything like the tray with needles and blades, gloves that I would need to assist the mothers in labour then I am ready for the task but it is a difficult task.”