e-Health: A new frontier for safe motherhood

Last Saturday, as the world commemorated Safe Motherhood Day, stakeholders in the health sector called on government to improve community systems to reach more women and girls to reduce the unmet need for family planning.

Uganda’s unmet need for family planning services stands at 28 per cent. While safe motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth, it is important that mothers access sexual reproductive health (SRH) services and information as they plan their next pregnancy.

New innovation to combat unmet need

Like many women of childbearing age who could not access SRH products during the lockdown that was declared in mid-March, Shagidah Nakyanzi, a mother of one, went through difficult moments. 

 “When the lockdown was declared, I did not have contraceptives at home. I always bought what I needed, when I needed it. So, money became scarce. I could not spend the little money we had on contraceptives. We tried to abstain, but it was difficult,” she says.

 Nakyanzi’s story was replicated in a number of households across the country as women could not circumvent the ban on public and private transport and the curfew to visit health centres. Dr Kenneth Buyinza, the clinical services manager at Reproductive Health Uganda (RHU), says the number of women seeking SRH services greatly reduced during that time.

 “As RHU, we had an 80-85 per cent decline in our services because all outreaches were stopped. Only our clinics remained open, though we were operating at 25 per cent. Basically, only the people who live within walking distance of the clinic attended. We have three clinics in the Greater Kampala area, so someone in Mukono obviously found it hard to come for SRH services,” he says.

 Now, with life in almost every sector back to normal, there remains a general fear of visiting health centres because of Covid-19 cases and deaths. This means the reduced demand for SRH services has continued. For example, although outreach services have been reinstated by community-based organisations, Dr Buyinza says RHU is now operating at half capacity (50 per cent) in line with the social distancing rules.

 In August, Nakyanzi stumbled upon a picture of an online health platform that caters to SRH needs, on her friend’s Facebook page.

 “I was interested. I wanted to see if it could work for me because I always felt shy walking into a pharmacy to buy family planning commodities,” she says.

 The platform is an e-Health shop on Safe Boda, a ride hailing mobile app. In July, UNFPA, Marie Stopes Uganda and Safe Boda, with funding from the Embassy of Sweden in Uganda, set up the e-shop to make SRH services more available in Kampala and Wakiso districts.

How it works

The transactions and payments happen online. A client orders for a product, which is picked up by a rider from a clinic or pharmacy run by Marie Stopes Ladies (mostly retired midwives or women who own drug shops). The rider then delivers the product to the client.

 “I started by purchasing morning after pills but now I order for anything I need and also get information about family planning and how to cope with life during the Covid-19 pandemic,” Nakyanzi says.

 The online shop has emergency pills, oral contraceptives, condoms, injectables, pregnancy test kits, sanitary pads and menstrual caps.

Faith Kyateka, the head of communications and policy at Marie Stopes Uganda, says the platform was an answer to the barriers created by Covid-19 social restrictions.

 “The need for SRH products does not stop because of pandemics, so we needed to create a platform where users can access these products at the click of a button in the convenience of their homes,” she says.

 Kyateka adds that the shop is more popular among young people. “The most demanded products – 41 per cent – are oral contraceptives. Over one million condoms and 1,500 oral contraceptives and emergency pills have been accessed through the platform.”

The non-tech savvy left out

Unfortunately, because of the high Internet costs and high price of smartphones, the urban poor woman has been left out. Kyateka says coverage and reach is a challenge.

 “Much as we would like to be all over Uganda, it is not possible. We are working with a ride hailing app and can only operate in the areas where they operate. However, because of the huge demand for SRH products out there, we have a toll free number that can be accessed on any mobile platform for information and referrals,” she says.

 Hajarah Nalubowa, one of the service providers, owns a clinic in Nansana Municipality in Wakiso District. She says those who cannot access the Internet can still visit clinics.

 “Before the pandemic, we used to get 50 clients per month, on average. I also used to move door-to-door, selling contraceptives at a cheap price. But now, those who cannot access the e-shop can call me to make an appointment. Altogether, nowadays I get about 25 clients a month.”

More needs to be done

The e-shop is just one innovation, but more needs to be done to ease the access to SRH products and services. For starters, since family planning is a personal choice, the fact that a rider – who is a stranger – carries a product openly to the client raises concern.

 “e-Health, and ordering products online is a relatively new concept, so there are still issues of privacy in the use of the online platform. The Ministry of Health needs to provide guidelines so that we can know how the riders should act as they deliver these products to the clients,” Kyateeka says.

 SRH information should be provided to the clients beyond the e-shop. For instance, some women have side effects when using hormonal contraceptives, injectables, and implants, so they need a space where they can raise their concerns and receive help. 

 Denis Kibira, the executive director of the coalition for Health Promotion and Social Development (HEPS Uganda), says the urban poor woman can still be reached through the existing health system structures. HEPS Uganda is a health and human rights organisation that advocates for health rights and health responsibilities of Ugandans.

 “We need to utilise the members of the village health teams and parish development committees to reach out to women and adolescents. Unfortunately, the biggest challenge is in whether these people have been trained sufficiently to administer SRH commodities, and more importantly, if those commodities are actually available,” he says.

Combating drug stock outs

In the rural areas, stock outs of family planning commodities remain a challenge. Dr Buyinza says the National Medical Stores (NMS) needs to revise its distribution systems to public health facilities.  

 “NMS uses two systems; the push system, where low-tier health centres get pre-determined SRH packages – some of which they do not need, and the pull system where higher level facilities are free to request for whatever commodities they want. NMS needs to revise the packages to ensure that the facilities in the push system get what they need region-by-region,” he says.

 The impact of contraceptive stock outs is that women will not have a choice if they come to a facility and find that their favourite product is not available.  In this case, they are forced to take up another method or go back home without taking a product as they wait for the facility to be stocked. The latter often get unintended pregnancies as they wait. Therefore, e- health and online SRH shops ensure that the unmet family planning need does not grow higher.

Worrying rise in teenage pregnancy rates

 At the beginning of the year, Uganda’s teenage pregnancy rate stood at 25 per cent. The lockdown that began in mid-March and precipitated the closure of schools has proved to be a time when many adolescent girls met their waterloo.

 According to a survey carried out in district health, education, probation and social welfare departments by this newspaper, over 2,372 girls got pregnant in the districts of Ngora, Luweero, Rakai, Kayunga, Ntungamo, Kitgum, Ngora, Kyegegwa, Kasese and Lyantonde during the lockdown.

 The survey found that in Ngora District, the number of antenatal care visits made by teenagers between January and June was 2,341.

 Also, a report by Human Right Focus Uganda (HURIFO) revealed that a total of 4,062 teenage pregnancies had been recorded in six districts of the Acholi sub-region, while the West Nile region has recorded over 1,779 teenage pregnancies.

Causes

Poverty has been touted as the cause of early marriages and teenage pregnancy, but Annah Kukundakwe, the policy advocacy and partnership manager at Uganda Youths and Adolescents Health Forum, says the lockdown made the poverty levels worse.

“There are people who have always been poor, but they had just enough money to keep them going. But during the lockdown when very few people were working, the poverty escalated and many girls were forced to go out and try to look for money. It is in these situations that they are taken advantage of,” she says.

 Last week, the police raided a sex party in Kireka, Wakiso District and arrested 20 women and men. However, among the females was a 16-year-old girl, who claimed her elder sister had sold her to the organisers.

 The girl said her sister brought her to Kampala from Masaka under the guise of getting for her a job since schools were still closed. Her case highlights the dilemma that poverty has caused to a number of girls and their families that they have resorted to early (criminal) sex to survive.

Strict policies needed

Last week, schools were reopened after a closure of seven months, but only for students in their final years. The Ministry of Education and Sports has instructed all primary and secondary schools to allow pregnant students in their final years to complete their education. This was a departure from government policy that only allows learners to continue their education after delivering their babies. 

 Hadijah Mwanje, the executive director of High Sound for Children, hails this as a step in the right direction.

 “It is a good thing that the ministry is rolling out a programme of psychosocial support for students and teachers as they return to school. This will give an opportunity for children to remain in school, although they need a lot of support from their parents,” she says.

 However, much as this is a good initiative, maybe it is time that we came up with realistic policies as a country to stem the high teenage pregnancy rates.

 “We should give them (teenagers) contraceptives. There are interventions such as the Vision 2040 to help Uganda attain middle-income status, but the young people who are a crucial part of that vision are dropping out of school with zero employment skills. We need to realistically embrace the Sexuality Education Framework, which included the use of contraceptives, if adolescents cannot abstain,” Kukundakwe says.  

 Adopting the use of contraceptives for teenagers who cannot abstain will go a long way in ensuring that the number of teenage girls who die in childbirth because of lack of access to health facilities, poor medical care, or just because their bodies are not yet developed, goes d