Uganda turns to novel approaches to save more of its mothers
George Ssenyonga of Kimbugu village in Buikwe district cannot forget the gruelling hiccup of a long distance that cost him his daughter. It was about 6pm on April 3, 2013, that Ssenyonga’s heavily pregnant daughter, Sophia Nansubuga, started complaining of pain.
“We are far away from any hospital. So, to get a bicycle to take her was difficult. I, instead, called the other family members, about six, and we carried her,” Ssenyonga recalls.
Kimbugu is about six, 16 and 15 kilometres away from Buikwe, Nkokonjeru and Lugazi hospitals respectively. Instead, the family decided to go to Ssi health centre III, about four kilometres away. By the time they got there, it was late, around 8:30pm, and the patient was very weak.
Worse, the health centre was all dark, as it had been without power for five years. Accordingly, expectant mothers were expected to carry their own paraffin for lighting, if delivery was to happen at night.
“The midwife did not even have a torch and only a small candle flame flickered. She had to rush to a nearby house to borrow one. In the meantime, my daughter panted and winced in pain. By the time the midwife returned, she had died,” a dejected Ssenyonga shares.
Ssenyonga’s is not an isolated case. Some 16 women die in childbirth every day, according to the 2011 Uganda Demographic and Health Survey (UDHS).
Robinah Kaitiritimba, the executive director of the Uganda National Health Consumers Organization (UNHCO), says that there are three delays that may culminate in a woman’s death. One can delay at home, on the way to the health facility and at the health facility.
“Delay at home may be caused by women seeking services of traditional birth attendants first. But these home-assisted deliveries are not safe because of challenges such as poor lighting and security, limited emergency management and limited access to drugs,” says Katiritimba.
Delay in reaching the health facility is caused by long distance from the health facility, limited availability of transport means and high financial costs of transport. This is what cost Nansubuga her life. At the health facility, delays are caused by shortage of supplies, equipment and trained personnel, ineffective communication and poor patient management.
According to Uganda’s maternal perinatal death review, inadequate staff numbers were the commonest cause of death of expectant mothers between 2009 and 2011. It accounted for 63 per cent of cases. Janet Obuni, the president of Uganda Nurses and Midwives Union, says that Uganda is short of 2,000 midwives and thus, 42 per cent of women deliver without the help of a midwife.
“This lack is costing the country quality obstetric care and with all posts filled, the country would have the potential to reduce [by] 80 per cent maternal fatalities occurring in health facilities,” says Obuni.
But the most important direct cause of maternal mortality, according to a survey of 553 health facilities across Uganda, recorded in Uganda’s 2013 MDG status report, was found to be haemorrhage. It accounted for 42 per cent of maternal deaths. Others included obstructed or prolonged labour (22 per cent) and complications from abortion (11 per cent).
As a strategy to nip maternal deaths in the bud, several simple, yet effective, innovations are springing up. The latest are: Maternity waiting homes (MWHs): These are homes located near a medical facility where high risk expectant mothers from far may reside for a couple of weeks before they deliver. MWHs were first launched in Eritrea in 2007 and registered 56 per cent success rate.
In Uganda, they are being used in Kaabong district under the auspices of a local organisation, Action for Women and Awakening in Rural Environment (AWARE), funded by Médecins Sans Frontierès. Grace Loumo, AWARE’s founder, says over 200 babies have been safely delivered using this initiative since its inception in 2011. Transport vouchers: This is a US-initiated system of giving subsidised or free transport vouchers to expectant mothers and the transporter is reimbursed for the cost and given some profit after delivery has been verified.
It is being implemented through the five-year Saving Mothers, Giving Life (SMGL) programme in Kabarole, Kibaale, Kamwenge, and Kyenjojo districts. Here, health facilities are first accredited to receive vouchers on the criteria that they have basic-level laboratory capacity, clean water supply and basic equipment such as gloves. These facilities then distribute the vouchers to patients, entitling them to services at any contracted facility of their choice.
The vouchers, that cost as low as Shs 3,000 (about $1.2), help expectant mothers attend antenatal and postnatal visits, receive screening for malaria, HIV and other sexually- transmitted infections (STIs). They also get transportation to a hospital in case of complications, regardless of the distance from the health facility.
Since the programme’s inception in 2012, more than 30,000 transport vouchers have been distributed. Owing to this success, SMGL announced expansion into six other districts of Nwoya, Dokolo, Gulu, Pader, Lira and Apac. Transforming TBAs into village health teams: Uganda National Health Consumers Organisation is currently training traditional birth attendants into village health teams (VHTs), to scale up awareness on the importance of delivering from a health facility.
So far, more than 50 people have been trained in the organisation’s eight target districts of Oyam, Nwoya, Soroti, Mayuge, Hoima, Sheema, Mityana and Mubende. VHTs do not earn salaries, but receive tokens of appreciation such as soap, T-shirts and boots.
Mangeri Nalyazi Musaazi, the LC-I chairperson of Kitandwe village in Mubende district, is testimony to this.
“At first, I did not like the training because it encouraged me to stop delivering women at home and this meant that I would forego gifts such as poultry and food which I was receiving from the community as a reward for my work,” Musaazi recalls.
“But later on, I discovered that I was putting the lives of the women and my own at risk of infections like HIV. Imagine I didn’t even have gloves, where could I get the testing kits?”
For two years now, she has fully assumed the role of being a member of the village health team (VHT) and has been doing referrals.
Uganda’s 2013 MDG report records that the country has made strides in five of the six maternal health indicators such as health worker-assisted delivery and increasing the contraceptive rate. It is, however, clear that Uganda will not achieve MDG 5 of reducing the maternal mortality ratio by three quarters (to 131 deaths per 100,000) by 2015. Some analyses indicate that it will take us until 2031 to achieve this.
Ministry of Health and its partners are currently scaling up strategic shifts highlighted in the 2013-2017 Sharpened Reproductive Maternal Neonatal and Child Health (RMNCH) strategic plan. These include focusing on areas with the highest number of child and maternal deaths, increasing access of health services to deprived and vulnerable populations, and emphasising high- impact interventions that target the direct causes of death.
“With the potential of saving the lives of an additional 120,000 children and 6,100 women by 2017, over and above those who would be saved on the current path, all health partners across Uganda must now work together in earnest to adopt and implement them,” says Dr Jane Ruth Achieng, the director general of Health Services in the Health ministry.