In our continuing series on Uganda and Millennium Development Goals (MDGs), this week RICHARD M. KAVUMA focuses on MDG 5; improving maternal mortality.

From her one-room house at Lwanda in Iganga district, Harriet Kalembe rocks quietly with her three-week old baby, Mirembe, looking up the iron roof with a shy smile.

“She is fine, except that she has some malaria; but huuu,” Kalembe sighs as she sits behind the white net-curtain that divides the room into a living area and a sleeping quarter.
“It was tough.”

“Tough” is used to describe Monday, November 21 last year. Harriet, only 18, was rushed to Kiyunga Health Centre, 15 miles from Iganga town, to deliver her first child.
At 1.00 a.m., the midwife announced that Harriet had a ‘big baby’. She needed to be rushed to Iganga Hospital.

Luckily, Kiyunga has an ambulance under the Rural Extended Service and Care for Ultimate Emergency Relief (RESCUER) programme.
“But you see, we had to pay Shs 20,000 for the ambulance,” recalls Harriet’s peasant husband Dhamba Samuel, 28. “We thought it was Shs 15,000 but we had no choice. I borrowed money from friends and thank God we are now fine.”

Many other mothers or their babies, however, never make it. Only two days earlier, for instance, Farida Bagume had arrived at Busesa health centre, expecting her seventh child. Her uterus ruptured and by the time she got to Iganga Hospital, the baby had died.
But as a nurse at the hospital put it, at least the mother was saved.

Ministry of Health figures show that for every 100,000 mothers who deliver, 505 die of pregnancy-related complications.

Although this maternal mortality ratio is better than the figures of Kenya and Tanzania, it is still very poor when compared with, for instance, Mauritius (24), Botswana (100) or Germany (4).

Millennium Development Goal number 5 is to improve maternal health, with a target to reduce the maternal mortality ratio by three-quarters between 1990 and 2015. In 1990, Uganda’s ratio was 523. In the last 15 years it has only reduced by 18, yet the target is to reduce it by 374 over the next 10 years.
Another mountain to climb.

The Ministry of Finance, Planning and Economic Development says Uganda had hoped to reduce the rate to 354 by last year; we are therefore unlikely to reduce it to the MDG target of 131 over the next 10 years.

Family mis-planning

Underlying causes of mothers dying include malnutrition, short birth intervals, poor health services and early marriages and first births.
Barely 23 percent of Ugandan women of reproductive age (15-49) use family planning (compared to 75 percent in many developed countries). Another 35 percent need family planning services but cannot access them – either because the supplies are poor, they can’t afford the services, or the husband is opposed to family planning.

According to Dr. Angela Akol, head of the Family Life Department at the Population Secretariat in the Ministry of Finance, it is critical that more Ugandan women start accessing and using family planning.

Akol says surveys show that most women who don’t use family planning fear mythical side effects: Many believe that you could become infertile, get cancer or have deformed babies as a result of using contraception.

“These methods have been thoroughly researched and they wouldn’t be promoted if there was the slightest indication that they could hurt human life,” Akol said.

Part of the problem is the lack of funding for family planning activities. Since 2001, reproductive health has got an average 0.4 percent of the Ministry of Health budget – Shs 933 million in 2002/03. Because of lack of sensitisation, even some health workers, who are supposed to deliver reproductive health messages, now believe the dangerous myths.

The result is that besides poor spacing, Ugandan women are having far too many children for their own good health – 7 per woman. Yet this statistic doesn’t tell the whole picture; figures are much lower among the minority urban and educated women, meaning that the less educated and poor majority will have over 10 children.

“The more children you have had, the bigger the risk of complications,” says Dr. Chris Baryomunsi, formerly United Nations Population Fund (UNFPA) Programme Officer in Kampala. “The commonest cause of maternal deaths is severe bleeding and it is more common in women with many children.”

The resolution of last November’s annual health assembly in Kampala was to improve uptake of family planning. Akol revealed the Family Planning Working Group, comprising government, donors and NGOs, was already working on revitalising family planning in the country.

Under the initiative, for instance, contraceptive methods like the intra-uterine device that had more or less been abandoned are being promoted. A training module for reproductive health has been developed for the Nsamizi Institute, which produces community mobilisation personnel.

The hope is that once they are in the field, they would help spread informed messages about reproductive health.

“But we need more funding for reproductive health,” Akol said.

Other salient causes

Early marriages and teenage pregnancies also play a major role. Harriet Kalembe, for instance, was barely 18 when she was admitted to Iganga Hospital, meaning she became pregnant at 17. About 32 percent of Ugandan adolescents have conceived at least once. Many end up in delivery complications or even abortions, which increase the risk of death since abortion is illegal, and is therefore performed in very poor conditions.

According to Dr. Anthony K. Mbonye, the Assistant Commissioner for Reproductive Health in the Ministry of Health, some 8 million adolescents require reproductive health services. The government, he said, is trying to address that by providing information and services, making sure that health workers are trained to receive adolescents and counsel them.

“We think if we got funding for these areas to cover the whole country, address the health system issues like staffing, making sure drugs are available, making sure the infrastructure has water and electricity, making sure that the community monitors the quality of services in the health units around them, we think we can go a long way in reducing the high maternal mortality.”

The problem

Experts say that the main reason for the maternal deaths stems from the fact that most mothers are not delivered by trained medical personnel. While 94 percent attend antenatal clinics at least once, only 42 percent make up to four antenatal visits and only 39 percent deliver in health centres.

According to Dr. Mbonye, 15 percent of all pregnant women anywhere in the world develop complications; Uganda’s problem is that when mothers get these complications, they cannot get timely attention.

“When mothers get complications, they cannot easily access a hospital or facility where there is a competent person to address that problem,” says Dr. Baryomunsi.

Hariet Kalembe was lucky, first that she lived near a health centre and that the health centre had an ambulance that took her to Iganga Hospital. Most of the 505 who die are not so lucky.

Dr. Mbonye: “The reason mothers die is because the direct causes of maternal mortality [are of an emergency nature] and the preparedness at the community, family and individual levels and of our health units [is not good enough] to respond to these emergencies.”

In Uganda, the major direct causes of deaths include bleeding (26 %), infections (22%), obstructed labour (13%), and unsafe abortions (8%). Other causes like HIV/AIDS, malaria and heart diseases account for 25%.

“They are emergencies because if not immediately handled, mother and/or baby will die,” Mbonye says. “When a woman is bleeding after delivery, she needs to reach the health unit to receive blood and to address the cause of that bleeding... As for obstructed labour, – often because the pelvis is narrow, if the mother is not rushed to hospital so that a caesarean section is done, the baby could die or the uterus could rupture and the woman will die and you lose both.”

This is what happened to Bagume Farida. Her uterus ruptured but after 10 days in hospital, the mother was saved. Again, she was able to get to hospital thanks to an operational ambulance.

Roadblocks

The road to the labour ward of a sound health centre is one only a small percentage of mothers take. The reasons for failure to go to hospital vary. Often, the family does not believe that getting the mother to hospital is an emergency, the hospital is several miles away and transport is difficult. More often the only available means of transport is a bicycle or a boda boda motorcycle, none of which is suitable for a mother already in labour.

“One big problem we have is that the husbands don’t want to take their wives to hospital,” says Naabirye Angela Ikiring, who received Kalembe at Kiyunga Health Centre. “Maybe it is because of poverty, but it becomes a problem for us…We have the ambulance, yes, but the husbands have to buy the fuel.”

Just like the Uganda NGO Forum, Kiyunga LC-1 chairperson Robina Tadhuba argues that poverty is a key issue in maternal health: “Some mothers are so poor that they can’t afford the basic necessities of a pregnant woman such as good feeding,” she said.

Rescue initiatives

Under the RESCUER programme, now in about 20 districts, UNFPA and the government are trying to address three killer delays: the delay to transfer mother from home or traditional birth attendant (TBA) to a local health centre, delay to transfer mothers to a referral facility and the delay to attend to the mother once they are in the health centres/hospitals.

The programme sensitises communities about the importance of skilled medical personnel and healthcare providers in handling life-threatening situations. Then, TBAs get walkie talkies to contact the health centre in case a woman under their care develops delivery complications. The health centres like Kiyunga, which have base radio communication, can then dispatch an ambulance to pick up a woman who needs emergency care. And if the woman needs more advanced attention, the ambulance can transfer her to a referral hospital.

It also equips theatres so that once mothers are admitted, they receive quality health care.
Both Baryomunsi and Mbonye stressed the need for massive family planning campaigns, not least to change the attitudes of mothers, husbands and even community leaders.

“When you talk to mothers and families, you find that many do not appreciate the need to [practise] family planning. They cherish many children,” said Baryomunsi.

Healthcare quality

Doctors agree that the quality of services needs to improve. For instance, most health units are understaffed, with only 68 percent of hospital positions filled. The district service commissions do not have enough money to hire and pay staff. But even more, many mothers feel the medical staff do not respect them.

For instance, some mothers want to deliver while squatting but your average midwife will not allow that.

“When you go to our health centres… [the health personnel] are either not there, or they delay or sometimes their attitude is not very good,” says Dr. Jotham Musinguzi, director of Uganda’s Population Secretariat. “Some women see us health workers as not receiving them very well, not giving them the options that they want.

We have also learnt the women don’t like the way we make them deliver, they want to take on their own positions; or sometimes they want a cup of tea or to use hot water and some of these things are not available in our health centres.”

And local perceptions cannot be ignored because they determine how mothers will respond to government interventions. Some women refuse to use anti-malarial fansidar during pregnancy because they think it will affect their pregnancy. Others prefer to use herbs instead of visiting antenatal clinics where possible complications could have been detected.

So what must be done to save Uganda’s mothers? Musinguzi: “Make sure there are enough health workers in the health centres... make sure the quality of our services is improved and thirdly, make sure the services we are talking about like the obstetric care are widely available to all those women who need them.”

In the end, though, as Dr. Mbonye says, the war to save Uganda’s mothers must be fought by almost all government departments, including Defence, Agriculture and Gender.

The Water ministry should ensure safe water and sanitation; the roads should be fixed so that ambulances can quickly get to health units; and education is key to ensuring that family planning is practised and women attend antenatal care.

As Harriet Kalembe’s experience showed, emergency obstetric care is often the difference between a mother’s life and death.

rimkav@ugandaobserver.com

Only in The Weekly Observer Next Thursday: we look at HIV and Malaria.