Maternal deaths: Uganda’s ultimate challenge

In Uganda, a staggering number of women still die in childbirth. Maternal mortality rates have been reducing slowly, largely because most deliveries occur outside health facilities. But an innovative solution--a maternity waiting facility is helping to change this, writes Saturday Monitor’s Evelyn Lirri;

There are many challenges facing women in childbirth in Uganda. From a weak health care system to the lack of specialist staff and widespread poverty, many mothers deliver at home and without the supervision of a health worker. Majority rely on the “expertise” of traditional birth attendants (TBAs).
Ms Iruata Lokol is one of them. Now nine months pregnant with her eighth child, this will be her first delivery at a health facility.

Ms Lokol, who hails from Lopechapecha village, Kaabong District in Karamoja sub-region, gave birth to her other seven children from home. “It was usually hard to make the journey up to Kaabong Hospital. By the time the labour pains start, you can’t even walk for a kilometre yet the hospital is 40kms away from my home,” she says.

“Besides the distance, there was no money to hire a motorcycle or call for the hospital ambulance which would require that I pay for the fuel. I opted to rely on the services of a traditional birth attendant,” she explains.
Ms Namoe Longole, another expectant mother has to walk 30kms to access health services. With just weeks before she gives birth, Ms Longole has been booked at a waiting maternity house nearer the hospital. This will make the journey for her much easier once the labour pains start.

In Kaabong District, like much of the country, many women are faced with high levels of illiteracy and poverty. As a result, money is a determining factor of whether a woman will deliver in a health facility or not.

Complicated deliveries
However, for many pregnancies facing complications, delivering at home or without the help of a skilled health work can have devastating consequences. Health experts say without a trained, experienced midwife on hand, women are more likely to die from complications like severe bleeding and obstructed labour. In fact, pregnancy and childbirth related complications are the leading causes of death among women in Uganda.

Yet according to the Ministry of Health Annual Sector Performance Report 2010, only 33 per cent of mothers in Uganda deliver in hospitals or a health facility supervised by a midwife. The other 67 per cent deliver either alone or with the help of a traditional birth attendant.

But a novel solution to this, where expectant mothers are brought to a waiting maternity facility closer to a hospital, two to three weeks before their delivery date is encouraging expectant mothers to appreciate hospital deliveries. Many mothers in Kaabong will for the first time have a chance to deliver in a hospital, with a skilled health worker at hand. Ms Loko and Ms Longole are just one of them.

The initiative which was started by a local organisation, Action for Women and Awakening in Rural Environment (AWARE) is being supported by Médecins Sans Frontierès. Ms Grace Loumo, its founder, said hospital deliveries in Kaabong are lower than the national average—at 27 per cent.

“Through this initiative, we hope to increase the number of women who deliver in hospitals. The biggest obstacle to hospital deliveries is the limited infrastructure. There is no public transport system here that the women can use to reach hospitals when the need arises,” says Ms Louma.

Coupled with this, Ms Louma says the insecurity in the region makes it hard for women to walk especially at night when the labour pains start. Under this initiative, Ms Louma said the first priority is given to women with high risk multiple pregnancies, HIV positive mothers, first time mothers and those with a history of obstructed labour.

Dr Sharif Nalibe, the acting director of Kaabong Hospital, explains that deliveries at health facilities are still low in the district because of several factors, including cultural and social. At Kaabong for instance, he says between two to three deliveries take place every day.

“Most of the women deliver with the help of traditional birth attendants. When they come for antenatal services, we encourage them to come and deliver from the health facilities. We also tell the traditional birth attendants to accompany the mothers,” explains Dr Nalibe. Despite the social challenges, it is clear there is a long way to go.

Limited human resource
Dr Nalibe said Kaabong, like many health facilities around the country, is struggling to cope with a huge work load with limited human resource. The hospital, which is at a regional referral level, has only one doctor for a population of 350,000 people. This means that although mothers are being encouraged to deliver in health facilities, the pressure is also growing on overstretched health workers.

Many mothers therefore have to rely on community programmes like the waiting facilities to access care. Health experts say innovations like the waiting maternity house have the potential to save lives, especially in rural areas where infrastructure is still poor.

Dr Jotham Musinguzi, a health and population expert and Africa regional director for Partners in Population and Development, explains the benefit of such an initiative. “For rural areas where services have not reached many people, such innovations can act as a stop gap. The facilities don’t have to be sophisticated and are relatively cheap to put up,” says Dr Musinguzi.

But to increase the overall hospital deliveries across the country, huge investment in the health system including recruiting more health workers will be key. In its latest report titled “Missing Midwives”, Save the Children says globally, nearly 48 million women—about 1 in three give birth without the help of a midwife, exposing them to a higher risk of death.

It also found that 1,000 women and 2,000 babies die every day from birth complications which can be easily prevented. Statistics from the Uganda Demographic and health survey show that for every 100,000 women who get pregnant, some 435 end in death, with the contributing factors being prolonged or obstructed labour, massive bleeding, malaria, HIV/Aids and high blood pressure.

But often time, the survey reveals the underlying cause of death is the high cost of maternal care.
Maternity care, like all other health services in Uganda, is supposed to be free but because of stockouts, pregnant women are asked to provide their own delivery items like gloves, razorblades, and cotton wool and birth sheets.

They also have to bear the cost of transporting themselves to the health facilities—costs which many women in rural areas like Kaboong find prohibitive and which government says it is considering reducing in a new plan to cut maternal deaths.

“Reducing out-of-pocket payments for women’s medical care will encourage access to health care while protecting poor families from financial hardship,” the plan reads in part.

Off -target goal
Cutting maternal deaths is one of the goals the UN set to be achieved by member countries by 2015. But Uganda is still a distant call away from reaching these goals. According to the UN, countries must reduce by 75 per cent the number of mothers who die in childbirth by 2015.

This means Uganda will have to significantly reduce this figure to 131 per 100,000 in the remaining five years. The government acknowledges now that that goal is unachievable in the remaining five years. Instead, according to Uganda’s MDG report, more focus is now going to be shifted on addressing bottlenecks in the delivery of emergency obstetric care, skilled attendance at birth, family planning and access to antenatal care-interventions which are crucially required to improve maternal health.

In its proposed plan, the government also says it will introduce inexpensive alternative transportation as an incentive for women to seek care promptly. Dr Musinguzi says to address challenges of maternal health in Uganda, government needs to focus more on encouraging institutional deliveries, antenatal care, emergency obstetric and postnatal care and making family planning services available to women who want to space or control births.

Studies show that addressing the unmet need for family planning in Uganda can potentially avert some 16,877 maternal deaths and more than 1.1 million child deaths by 2015. But the unmet need for family planning in Uganda remains high at 41 per cent while contraceptive prevalence rate is as low as 24 per cent.

Meeting the unmet need for contraceptives can also potentially reduce maternal deaths by 40 per cent while unplanned pregnancies and induced abortions would decline by 84 per cent. He says access to emergency obstetric care plays an equally huge role in reducing maternal deaths.

“One of the biggest challenges now is that most mothers stay more than 5kms from a health facility where they don’t have access to emergency obstetric,” Dr Musinguzi explains.