In 2017, Catherine Akol, a resident of Jimos village, Losilang Parish, in Kotido District, Karamoja region delivered her first born by a caesarean section.
She was advised to have her next baby in a hospital. In the wee hours of January 17, 2020, a semblance of labour started. Since the pain was not intense, she and her husband Henry Angelo embarked on the journey to Kotido Health Centre IV .
Although the health centre has an ambulance for emergency cases, she was told it was unavailable at the time she needed it.
“It took us about seven kilometres to access the hospital. I would occasionally sit whenever the pain was too much. After eight hours in labour, we finally made it to Kotido Health centre IV. I gave birth at the entrance of the maternity ward,” Akol recounts.
Although she had a healthy baby, for two hours after admission, no health worker checked on her. “I was bleeding profusely. I did not think I would make it. In the same ward, there were many expectant mothers in labour. Sadly, some mothers did not make it. I thank God I am alive,” she adds.
When the health worker eventually showed up, Akol needed blood a transfusion. But the health centre had no blood reserves.
As luck would have it, her husband donated the blood she urgently needed. But they were given a list of medicine and other supplies to buy from a nearby clinic.
“We had to sell some of our possessions to buy these items and clear the bill,” says Akol.
On the other hand, Faridah Naru, a resident of Kyaliwajjala in Kiira Division in Wakiso District, was lucky to have a medical insurance cover for her hospital bills at Kampala Hospital.
A week after her due date, she went to see a gynaecologist, who, upon review, confirmed that her cervix was open. A membrane sweep was done, which drove her straight into labour.
“My husband took me to Kampala Hospital and the moment I checked in, I was given a midwife who recorded my particulars and took me to the labour ward,” she explains. The midwife announced she was 7cm dilated. “Serious labour pains started. I had two midwives, who kept monitoring me from time to time. I was in labour for two hours and on February 25, 2021, I delivered a healthy baby,” Naru says.
She says the hospital provided most of the supplies and meals to the mother and the baby.
Safe Motherhood Day is observed globally on April 11, every year. The day is dedicated to creating awareness for better medical facilities for expectant mothers and lactating women.
The World Health Organisation (WHO) guidelines say the timely management and treatment during childbirth can make the difference between life and death for both the mother and the baby.
Uganda registered a reduction in the number of mothers that die while giving birth, according to the Uganda Demographic Health Survey (UDHS) of 2016. Maternal mortality ratio which stood at 438 per 100,000, currently stands at 336 deaths per 100,000 live births.
Dr Jessica Nsungwa, the commissioner for Maternal and Reproductive Health at the Ministry of Health, says these statistics may have dropped further, adding that the Uganda Bureau of Statistics is yet to release a report with updated data.
The Annual Health Sector Performance Review of 2018/19 indicates a total of 1,083 maternal deaths were registered, with Tooro region reporting the highest number -117 of maternal deaths, followed by Bunyoro with 112 cases. Karamoja region reported the lowest number of maternal deaths, with only 21 cases.
Excessive bleeding, also known as obstetric haemorrhage, accounts for 46 per cent of all registered maternal deaths.
This is followed by hypertensive disorders at 11 per cent and infection of the genital tract-puerperal sepsis at six per cent. Abortion-related complications account for five per cent of maternal deaths.
The quality of maternal health services are generally perceived as poor across all dimensions, according to the client satisfaction survey in the same report. Clients’ expectations were not met in 90 per cent of the districts in Uganda and client dissatisfaction was the highest in all public health facilities.
What experts say
Sarah Rose Nakityo, a registered midwife, who has been practising for 17 years, currently works with International Hospital Kampala. She blames maternal deaths on failure by mothers to go for antenatal services.
“An expectant mother should visit the hospital for antenatal services at least six times. We do blood tests for sexually transmitted diseases (STI) and HIV/Aids, Hepatitis B and check haemoglobin levels. We also do at least two scans during pregnancy; earlier between 18-20 weeks to check whether the baby has any defects and between 30-36 weeks to monitor the position of the baby,” Nakityo explains.
She emphasises that regular antenatal care enables the expectant mother and the healthcare givers to know whether the pregnancy is normal or requires special attention. Nakityo also urges mothers to seek professional healthcare instead of giving birth at home. “Anything can go wrong at home. For example, the placenta may come out first instead of the baby, blocking its exit. The mother’s uterus might have scars due to operations, which might lead to rapturing of the uterus. Such cases can only be managed in a hospital,” she says.
Dr Rosette Namulindwa, an obstetrician, says safe-motherhood is a package of pillars that include family planning, antenatal care, skilled birth attendance, post abortal care, treatment of STIs, among others.
She insists it is not just about mother and baby but even the needs of a non-pregnant woman should be catered for. Currently, the Ministry of Health recommends eight visits to a skilled health provider.
Dr Namulindwa explains that problems linked to maternal and fetal deaths stretch to challenges facing individual or facing the facilities or the health system in a three-delays-model.
The three-delays model
Breaking it down, Dr Namulindwa says the first delay happens when a woman is making a decision to go to hospital. This includes seeking for alternatives such as going to traditional birth attendants or delivering at home.
The second delay, she says, is the time a woman takes to access a health facility. Poor roads, lack of funds, travelling longer distances and unprivileged communities face challenges, especially when an expectant mother has complications.
The third delay is when the expectant mother makes it to the hospital, but absence of health workers, health worker’s attitude, lack of supplies and equipment delays their care, leading to maternal deaths or death of babies or both.
Dr Namulindwa says many women are dying because of the third delay.
Just like Akol bled excessively without the attention of the health workers, more of these cases have been registered, some worse than others, where health workers in private and largely, public hospitals have been reported to be negligent while handling new mothers.
To understand the complexity of safe motherhood, I sought the views of a certified midwife at Kawempe General Hospital, who preferred anonymity. Having practised for more than 15 years, she believes any sane midwife would never neglect a woman in labour deliberately.
She, however, largely blames the conditions in which they work as one of the cardinal reasons both health caregivers and new mothers get frustrated or even lose their lives.
“We have a chronic shortage of supplies, medicine and equipment at the hospital and the numbers are overwhelming. There are times when we do not even have basic supplies such as gloves, cannulas, needles, painkillers or medicine to prevent mothers from bleeding. The beds are few, so some mothers have to be put on the floor,” she opens up.
She adds that in some cases, some mothers with emergency cases do not get the right specialists to attend to them, especially during night shifts.
“A storekeeper in charge of medical supplies or an anaesthetist may be absent from work and as a midwife, I cannot do much,” says the midwife.
Whereas the journey to safe motherhood sounds like an uphill task, not all is doom and gloom. Strides have been made and new technologies are emerging.
“We used to have a fetoscopy to feel the heartbeat and collect the baby’s data. Today, we use the cardiotocography machines (CTGs). This portable machine detects baby’s heartbeat, uterine contractions and the baby’s position. In case of a problem, it makes an alarm. However, not every health centre has such machines because they are quite costly,” says Nakityo.
The process of bringing a baby into this world is too painful, but with more advancement in skills and technology, if the mother has the money to spare and is willing, that pain can be prevented by using epidural anaesthesia.
This prevents the mother from experiencing protracted pain, in case of prolonged labour, which can be exhausting and fatal to both the mother and the baby. However, the mother must have a midwife to monitor the fetal heart and the contractions at all times until she delivers.
The ease with which the C-section can be carried out has improved. Previously, the mother had to be put under total anaesthesia. Today, it is only partially done, reducing the risks of the procedure and it’s toll on the mother.
The upsurge in the number of C-sections performed in the country in the recent times cannot be underplayed. According to the 2018/19 health sector performance review, the procedure stood at 29 per cent, making citizens wonder whether the growing numbers were driven by money.
“The medical sector is more than ever before committed to issues of maternal health. A lot has been invested in research, which was not the case previously,” says Dr Namulindwa
She adds that a number of cases that would have had negative results can be avoided through C-section. Although it is not the only way, she believes that health workers are more vigilant on having the best maternal and neonatal outcomes.
Are we making progress?
As private healthcare providers take steps in bettering care, one may wonder whether the country is making progress in maternal health care.
Dr Jessica Nsungwa, the commissioner for Maternal and Reproductive Health in the Ministry of Health, hints on some initiatives that have been taken to reduce maternal mortality in Uganda. These include training of more health workers to attend to the needs of women, construction of new and upgrading of old healthcare facilities in different parts of the country, equipping hospitals and health centres with medical supplies.
Some of initiatives Nsungwa enlists are also embedded in the Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda 2007-2015. It highlights increasing numbers and skills of human resource in hospitals to handle maternity and newborn cases, improving infrastructure for easy access to health facilities as well as making health centres functional in terms of equipment and human resource to meet demands of the people.
It also underpins a step-wise referral system from community to health centre to hospital for easy case management, increased provision of equipment and supplies to hospitals as well as monitoring and evaluation of maternal and newborn care as some of the ways to reduce MMR in Uganda.
In addition to these, expectant mothers are supposed to have free services in public health facilities.
“They are supposed to go to the hospital and find everything there. Sometimes, we give them mama kits to ease delivery. However, hospitals experience shortage in supplies since our budget is limited. Only 60 per cent of our budget is met. Although this has been increasing over time, it does not cover our needs. This is the reason mothers are asked to buy some supplies,” the commissioner says.
Traditional birth attendants
We also sought to understand whether TBAs are working in partnership with government. Dr Nsungwa says there is no policy and TBAs are operating illegally. “Government previously supported them by training and supervising them. But this was stopped. In the same light, the World Health Organisation also phased out the policy of working with TBAs,” she says.
Dr Nsungwa says government has brought healthcare closer to expectant mothers within their communities. “Districts have Health Centre IIs, where mothers can access minimal maternal health care. From HC III, mothers can deliver their babies safely. In case of any emergency, mothers can access services at HC IV. For cases that are more complicated, district hospitals, regional referral hospitals and national referral hospitals come in handy,” she explains.
Cost of healthcare
Depending on the health service provider, having a baby can cost hundreds of thousands or even millions.
Dr Rosette Namulindwa explains that there are purely private for profit health providers, private not for profit providers, and the purely public.
“There is a wide range of facilities and women can decide where to go depending on their socioeconomic status, but even with that provision, there are still challenges related to the economic status, putting into consideration the cost of maternal health,” she says.
Even in public health facilities where care is supposed to be free, patients often incur costs to have services delivered.