A mother undergoes blood pressure test at Mulago National Referral Hospital during a medical camp in 2023. PHOTO/TONNY ABET
Habibah Muganza, a patient at Kawempe National Referral Hospital, says she was subjected to an emergency caesarian section (operation) because of complications of pre-eclampsia –high blood pressure that starts during pregnancy.
She says she endured a lot of pain and sleepless nights due to the late detection of the disease and hardships in accessing treatment.
“I ended up having seizures and the baby was removed at seven months because of [high blood] pressure. But maybe if I had the medication in time, I would have gone up to nine months and have my baby in a normal way,” Muganza narrates.
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Muganza says she also experienced challenges in accessing medication. “Medicines are so expensive because, at times in our hospitals, we lack the medicines. They can give you only for that particular time. Yet, for the [high blood] pressure, you don’t have to miss the medication,” she says.
This comes amid a new revelation from the health ministry that pre-eclampsia and its complicated form (eclampsia) are now a key cause of maternal deaths in major referral hospitals.
Pre-eclampsia is a type of high blood pressure that some people get during pregnancy.
“Pre-eclampsia, overall in the country, contributes around 16 percent of maternal deaths, making it the second leading cause of maternal deaths. Last year alone, in our health facilities, we lost around 1,300 mothers, and 16 percent were due to pre-eclampsia and its complicated form called eclampsia,” Dr Richard Mugahi, the acting commissioner for reproductive and child health at the ministry, says.
“But when you come to bigger facilities like regional referral and national referral hospitals, pre-eclampsia is the number one cause of death because it can be managed there,” he adds.
Diagnosing high blood pressure is based on the average of two or more readings taken at each different visits after an initial screening. PHOTO/PROMISE TWINAMUKYE
Dr Mugahi notes that lower facilities offer first aid but refer patients to higher facilities because they lack facilities and some may not have the expertise to handle women with pre-eclampsia and its complications, which can include failure or hampered functions of organs like the kidney, liver and brain.
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Dr Emmanuel Byaruhanga, the executive director of Kawempe Hospital, says pre-eclampsia and its complicated form (eclampsia) is the leading cause of maternal death at the facility last year and this year.
“We take this condition seriously. We have a labour ward and attached to it, we have a pre-eclamptic ward. So our labour ward has 40 beds and our pre-eclamptic ward has eight beds. In a month, we have 150 mothers with this condition and out of this, on average 10 have eclampsia, the severe form,” he reveals.
Activism
Currently, the government, in partnership with private sector and civil society organisations are running 10 days of activism against pre-eclampsia, aimed at raising awareness about the condition and its prevention.
Hypertension is a key cause of a variety of health issues, including stroke, heart attack and renal disease. Photo | Shutterstock
Prof Annettee Nakimuli, the chairperson of the Pre-eclampsia National Committee, says up to 25 percent of premature births, a growing concern in the country, is due to pre-eclampsia.
“Remember there are so many causes, about 100 different causes of maternal deaths but this one cause [pre-eclampsia] is responsible for 16 percent of deaths. The ultimate cure of pre-eclampsia is to deliver the mother,” she says.
“Many times, we deliver the mother prematurely. So, the babies die because of prematurity. Pre-eclampsia in turn contributes about 25 percent of the premature babies we see in hospitals. So, if we address it, we shall also improve the survival of babies because we shall also reduce the number of babies born prematurely,” she adds.
She says that due to increased training and investment in maternal health, the number of deaths have started to decline. She says that last month, for four weeks, health facilities didn’t report deaths.
Prof Nakimuli says deaths were high because there were no clear guidelines on how to manage these mothers and access to health workers was still limited.
“We also found that sometimes healthcare workers don’t really know how to manage the disease. Like the one called magnesium sulfate, which is for controlling fits. We also found that there was very little known about this disease outside healthcare workers, and the community,’’ she says.
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In a 2022 study report by Imelda Namagembe and colleagues, in Kampala, the most common causes of death were obstetric haemorrhagia (45 percent), hypertensive disorders of pregnancy (28 percent), and infection (27 percent).
Dr Diana Atwine, the Permanent Secretary of the Health Ministry speaks to the media at Kawempe Hospital in Kampala.
Dr Diana Atwine, the Permanent Secretary at the Ministry of Health, cautions the public against relating pre-eclampsia with witchcraft.
“Some women think that they are bewitched, and they go to church to pray to cast the demons out. By the time they come to the hospital, it is extremely late to save them. I want to tell you that this is not witchcraft, this is a disease that can only be treated from the hospital,” Dr Atwine highlights.
Cause and prevention
According to Dr Mugahi and available scientific information, the exact cause of pre-eclampsia is not well understood.
Information from the America’s National Institutes of Health (NIH), indicates that although “pre-eclampsia occurs primarily in first pregnancies, a woman who had pre-eclampsia in a previous pregnancy is seven times more likely to develop pre-eclampsia in a later pregnancy.”
Other factors that can increase a woman’s risk include chronic high blood pressure or kidney disease before pregnancy, high blood pressure or pre-eclampsia in an earlier pregnancy, women with overweight or obesity are also more likely to have pre-eclampsia in more than one pregnancy.
According to NIH, women older than 40 are at higher risk, multiple gestation (being pregnant with more than one fetus), family history of pre-eclampsia and being black can increase one’s risk of developing pre-eclampsia.
Dr Byaruhanga advises pregnant women to always go to the hospital for antenatal check-ups so pre-eclampsia can be detected early and treated.
“One of the biggest problems is that we get mothers late for one reason or the other and this condition is still not clearly understood. You get pregnant and you don’t know you have high blood pressure. By the time you present with symptoms such as convulsions, it is already late,” he says.
“Usually, we have to remove the baby and the placenta even when the baby is not mature. But if you come early, this can be controlled and you don’t reach the severe stage,” he adds.
Dr Byaruhanga says there are three grades of high blood pressure in pregnancy. “There is pre-eclampsia without severe features, usually you don’t have symptoms but when you go and check they will find you have elevated blood pressure and some protein in the urine. The severe feature comes in, and at this point you need admission,” he says.
“You may have a headache, blurring of vision, pain, and swelling of the body, especially the legs. Once you ignore these conditions then you start experiencing fits (seizures or convulsions) and then you will start to experience kidney, liver and brain injuries,” he adds.
Dr Mugahi says the condition can also happen six weeks after the mother has already delivered safely. “After delivering safely, the women should continue to have post-natal care, you must be checked at six hours, six days and six weeks otherwise the blood pressure can increase when you are at this period and it causes you fits and you go into eclampsia,” he adds.
Other drivers of maternal deaths in Uganda
Although high blood pressure in pregnancy is one of the major reasons behind high maternal deaths in Uganda, health experts say there are many causes, which are largely preventable.
Prof Annettee Nakimuli, the chairperson of the Pre-eclampsia National Committee, speaks to the media. She says due to increased training and investment in maternal health, the number of maternal deaths have started to decline.
According to Prof Nakimuli, an obstetrician and gynecologist, the common causes of maternal death include severe bleeding before or after birth.
“The common ones include women having severe bleeding before or after birth. We have infections that women can experience after delivery. This is called maternal sepsis,” she reveals.
She adds: “They can die from other infections like malaria, HIV/Aids and tuberculosis. Some women also initiate abortion causing complications that end up killing them. Then there is obstructed labour where the woman goes into labour but fails to progress to delivery.”
Dr Richard Mugahi from the Health ministry, however, says the death of mothers in hospital as a result of bleeding has reduced because the government plugged gaps in blood transfusion services and management of such cases.
Doctors advise mothers to always go for antenatal check-up and visit doctor if they experience suggestive signs and symptoms like headache, swelling of legs and body pain.
Dr Diana Atwine, the Permanent Secretary of the Health ministry, says men should improve the support they give to their women during pregnancy to reduce such deaths.
According to the recently released Uganda Demographic and Health Survey (UDHS) report 2022, the country is still losing 189 mothers in every 100,000 live births.
This means close to 3,000 women die every year in Uganda because of complications related to pregnancy and birth, with teenage mothers contributing about 18 percent of the deaths. There are around 1.5 million births in the country every year.
The 2022 figure is, however, a significant reduction from 336 deaths per 100,000 deliveries reported in the UDHS 2016.
A woman receives mosquito nets in Fort Portal City in November last year. Malaria is one of the diseases causing maternal death.
According to information from United Nations International Children’s Emergency Fund (Unicef) Uganda can significantly reduce the maternal deaths by preventing causes which they describe as “largely preventable and treatable with access to high-quality and respectful healthcare.”
“Community-centred primary healthcare can meet the needs of women, children and adolescents and enable equitable access to critical services such as assisted births and pre- and postnatal care, childhood vaccinations, nutrition and family planning. However, underfunding of primary healthcare systems, a lack of trained health care workers, and weak supply chains for medical products are threatening progress,” Unicef notes.
List
- Severe bleeding
-High blood pressure
-Pregnancy-related infections,
-Complications from unsafe abortion
-Underlying health condition such as HIV/Aids and malaria
