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Making it easier. In an effort to improve the state of maternal health in the district, Rosemary Aturinda, a senior midwife, came up with the idea of waiting shelters where mothers would leave home days before their expected date of delivery, be accommodated at the shelter and go in labour under the care of skilled birth attendants such as midwives and nurses or doctors. Brian Mutebi explores the successes and challenges of the initiative.
Pains began in the middle of the night and Agnes Ashaba knew this was nothing but labour pains. The darkness of the night covered Ishaaya village in the hills that define the remote district of Kanungu, found more than 400km away from Kampala via Masaka in south western Uganda. Ashaba’s husband could rush her, on a bicycle, to a health centre to deliver their ninth child, but the nearest health centre, Kanungu Health Centre IV (KHCIV), was far away – about 20km. Yet besides the long distance, it had rained for days, making the roads almost impassable. For 24 hours, Ashaba laboured in pain, helplessly.
Information finally reached Rosemary Aturinda, a senior midwife, who, with her team from KHCIV, was in a nearby village for a family planning camp.
“We rushed and found her in a terrible situation,” Aturinda recalls. “Her genitals were swollen and using a stethoscope, I noticed there was no foetal movement in the womb. I think the baby struggled so much to come out and in the process got too tired and died,” Aturinda reveals.
The focus was to save the mother. She was rushed to KHCIV in an ambulance but there were no blood transfusion services. She was transferred to Kambuga hospital, 9km away from where she was operated to remove the dead baby.
Fate of expectant mothers
In 2010, a maternal health audit conducted in Kanungu District noted that mothers were delivering at home alone or with assistance of Traditional Birth Attendants (TBAs), which exposed them to the risk of maternal death. “TBAs lack that technical edge that a minor complication can turn out to be disastrous,” says Aturinda. She explains, for example, when a mother experiences delayed delivery at nine months, TBAs administer herbs to induce delivery in which case the baby is literally forced out yet the uterus may not be as ready. Besides causing damage to the uterus, the baby may inhale the herbs and in the process fail to breath and die.
Mothers cited long distances as reason for failing to get to health centres when due for labour. The hilly terrain, coupled with poor murram roads, and inadequate information on maternal and reproductive health, among others, were found to be some of the obstacles.
The waiting shelters
In an effort to improve the state of maternal health in the district, the idea of waiting shelters was birthed. Aturinda, a senior midwife at KHCIV, came up with the idea in 2008. “I noticed we had largely overcome the problem of malaria and the ward where we admitted malaria patients was empty. I said why not accommodate mothers here so they can be under our care.”
Mothers would leave home days before the expected date of delivery, be accommodated at the shelter and go in labour under the care of skilled birth attendants such as midwives and nurses or doctors.
Kanungu District local government, with funding from United Nations Population Fund (UNFPA) for maternal health programmes in Uganda, managed the shelter. UNFPA had also supported the district carry out the maternal health audit and conduct family planning and reproductive health camps in villages where health centres were far distant.
The district also benefited from UNFPA’s midwives scholarship scheme where girls are given scholarships to study midwifery and upon graduation, work in the district for at least two years. Thirty two midwives have graduated since 2008, and according to Dr Stephen Ssebudde, the Kanungu District health officer, the district, being a hard-to-reach area, the scholarships helped in boasting personnel in health centres, KHCIV, where a shelter was started, being one of them.
However, while the shelter provided relief to women for whom the health facilities were miles away, it had its share of challenges. In Bwindi, for example, according to an account given by Dr Julius Nkalubo, a gynaecologist at Bwindi Community Hospital, a mother was admitted at the shelter for a week and her husband came fuming that if she did not give birth that day, she had to pack up her things and return home, regardless. He even attempted to beat her up. It took the intervention of hospital security personnel to calm the situation.
Some men did not want their wives to use the shelters because there would be no one left at home to take care of the children. Husbands or relatives also had to carry food to the shelter every day since at the shelter, food and other necessities such as soap were not provided. The long journeys were exhausting. In some cases, mothers also took with them beddings, leaving their husbands with nothing to sleep on.
Change in perception
However, there seems to be change in perception. Today, Kanungu District has two shelters; one at KHCIV and another at the privately run Bwindi Community Hospital. More mothers use them, some escorted by their husbands. At KHCIV, beds have increased from three in 2008 to the current 10. Bwindi Community Hospital has 28.
“We explained to men that the time their wives would stay at the shelter is shorter compared to the indefinite time it would be if she died in labour or the inconvenience that would be caused if she got a disability while delivering at home,” says Dr Nkalubo. Fitting shelters with beds and mattresses, bed sheets and mosquito nets helped relieve men the worry of having nothing to sleep on while their wives took with them beddings to the shelter. The shelters are fitted with kitchens, water and electricity.
“I have everything I need such as beddings and, above all, the care of nurses. I know I am going to give birth to my child safely,” said Justine Asiimwe, 23, from Burondo Eastern Ward in Kanungu Town Council, who was at the shelter to give birth to her third child.
August Amutahire, 28, escorted his wife, Rosette Akankwasa, 20, as the couple awaited the birth of their first born. “They (midwives) told us to escort our wives. I am here to take care of her,” he said.
“It gives me assurance that these kinds of simple, home-grown innovations tailored to the needs of the communities are what we need,” said Dr Abraha Kidane, UNFPA’s chief technical specialist maternal health and family planning during celebrations to mark Safe Motherhood Day at Kihihi, Kanungu on October 17.
Dr Ssebudde, the Kanungu District health officer, said the district plans to start shelters in other health centres located in harder-to-reach villages.
Dr Kidane said the concept of waiting shelters should be replicated in the rest of Uganda. “If Kanungu can do it, other districts can and so can Uganda,” he urged.
From family planning, breastfeeding and nutrition services, psychosocial support and relief from domestic violence, waiting shelters offer more than skilled birth attendance. It is an innovation contributing to leveling Kanungu’s hilly maternal health terrain.
More than shelter
According to Dr Emily Tumwakire, the in-charge at KHCIV, some mothers come to the shelter earlier than expected, some as early as seven months pregnant.
Dr Tumwakire says it is good for mothers to stay longer after giving birth because “the first 1,000 days are important in the life of a newborn, so this helps us take close watch on the health of the mothers and their newborns.”
Mothers, especially teenage and first-time mothers, are educated on breastfeeding. Some mothers get casual employment from the health centre. “Remember these mothers only came to give birth so it is okay to engage them in some productive work and the money helps them to buy basics,” clarifies Heph Muteisa Kwesiga, KHCIV’s senior nursing officer.
Mothers also receive counselling services at the shelters.
Mothers who have experienced domestic violence are also rehabilitated.