“The baby is coming! Doctor, the baby’s here; come!” one woman calls out, desperately, from the corner of a small cubicle in Kapchorwa hospital’s maternity ward, which doubles as a labour ward.
Jocelyn Cheptoris, the midwife on duty, is busy behind the curtains in the delivery room, attending to another woman who is already in labour, while five others wait in the maternity ward, occasionally wailing as they embark on a journey to bring a new life into the world.
Cheptoris says she wishes she had two sets of hands to handle the workload, which never seems to reduce, since the hospital is badly understaffed. It serves the district population of 87,000 people. The ward is constantly overflowing with women in labour, and the numbers only keep rising.
Kapchorwa district’s fertility rate (average number of children that would be born to a woman over her lifetime), at 7.4, ranks among the highest in the country, whose national average is 6.7. But Cheptoris says women here have eight to 15 children, and she sees many returning to give birth every year.
The hospital has nine midwives and no obstetrician or gynaecologist. Cheptoris and her colleagues must be miracle workers to discharge healthy mothers and babies everyday – even though Kapchorwa, at 600 out of 100,000, is among districts with the highest maternal mortality rates (number of pregnant women dying during or shortly after pregnancy) in the country.
“We’re understaffed, yet patients have increased here. Some (members of staff) go for maternity leave and we find that the workload is so heavy that we have to call them back,” Cheptoris says. “Sometimes, we have six mothers delivering on the floor (because the beds are occupied).”
Government structure of health units was done when the population was 18 million. Now at over 33 million the structure has remained the same. Government policy today is that there is a ban on recruitments of more midwives because there is no money to recruit more.
Besides low staff numbers, the hospital also sometimes suffers shortage of medicine and supplies. Materials as basic as gloves, gauze and cotton wool run out and it takes about two months for the next stock to arrive. In the interim, mothers and other patients have to provide their own supplies.
“One day, I delivered a baby barehanded,” says Rose Akalo, a midwife at the hospital. “We need protective gear, like boots, aprons and gloves. I complained to the management, but it has become a song.”
During the women’s day celebrations in March, the minister for Gender, Labour and Social Development, Gabriel Opio, acknowledged the government health facilities’ limited capacity to manage pregnancy-related complications.
This is mainly due to inadequate budgetary allocation. While the ministry of Health needs at least Shs 40 billion annually to reduce maternal and child mortality, it receives a paltry Shs 80 million – only 0.2% of the required amount.
With such low funding, a hospital like Kapchorwa stands very little chance of providing excellent services. The district’s main referral hospital badly needs rehabilitation. It currently occupies an old building that was constructed at a time when the area population was so much lower than today.
Like all the other sections, the maternity ward is chocking. Women fill up every available space – both on the beds and the floor. The delivery room has only two beds and when these are occupied, women spread plastic sheets on the floor and deliver there.
When the maternity ward is full, women are often sent to the general ward, where their newborn babies are at a high risk of contracting infections.
Besides, the hospital building has no provision for tap water. Staff and patients’ care-givers have to fetch water from a spring a few kilometres away, and store it in a tank.
There is no equipment that one expects to find in a hospital worth the name – the maternity ward lacks ultrasound scan facilities, blood pressure machines, and even forceps are not enough.
“Infection control is a problem,” Cheptoris says. “We don’t have an incinerator or a steriliser; we use a hotplate for sterilising and when it breaks down, we refer patients who come with complicated labour to Mbale hospital. Women get sepsis, especially those who deliver at home.”
Mbale hospital is more than 50 kilometres from Kapchorwa. Uganda’s health system in general has challenges securing proper infrastructure such as functional operational theatres for health centre IV, hence these do not provide emergency obstetric care. Yet they are more likely than hospitals to be within reach of most pregnant women.
In Kapchorwa, deliveries at health facilities are poor, with only 13.3% of women, compared to the national average of 38%, giving birth under the care of a professional health worker. Kapchorwa has two Health Centre IIIs and no Health Centre IV. Like the bigger Kapchorwa hospital, the Health Centre IIIs have to deal with the problem of irregular supply of relevant medicines and supplies, and lack running water and electricity.
Low staffing levels pose a major challenge. Districts like Kapchorwa have no capacity to provide incentives that would attract quality health personnel. The available trained personnel are mainly in urban areas. According to the Status of Reproductive Health Indicators 2009/2010, more than 80% of doctors and 60% of midwives and nurses are located in urban hospitals, which mostly serve the urban population.
The ratio of population per nurse/midwife ranges from five to 13 times higher for rural areas. The ratio of doctors is even higher. Sister Kevin Inyangat, a nursing officer at Kolonyi Health Centre, says medical personnel fear to specialise in midwifery because it is believed to be a delicate field. “If you lose a mother, you may go to jail for seven years and lose your practising certificate,” she says.
But even for the few maternal health workers available, staff accommodation at Kapchorwa hospital is inadequate; so, most of the staff live away from the hospital.
Akalo, one of the midwives, couldn’t express her frustration in a better way.
“A midwife on night duty may go to the theatre three times because of an obstructed labour (when the presenting part of the foetus fails to descend in spite of uterine contractions),” she says.
“The phone is not functioning and when you call for back-up using a personal phone, they do not respond to calls from private numbers. When you’re lucky and you get them, they ask you to send them transport. You have to go, pick up the anaesthetist, the nurse and the doctor. By the time you return, mother and baby are in distress. In fact, they survive on the mercy of God. Handling emergencies is a challenge.”
Lack of adequate transportation is another problem in Kapchorwa. The only ambulance in the district keeps breaking down, a phenomenon common in many other districts, where ambulance services are mostly absent, making hospitals less responsive to maternity and other medical emergencies.
However, John Kakooza, the minister of state for Primary Health Care, promises a brighter future for maternal health in Uganda. He says the government has acquired a loan of $30 million (approximately Shs 75 billion) to improve maternal and reproductive health. An additional $6 million (Shs 15 billion) has been acquired to equip hospitals with an additional 2,000 midwives.
“We’re not where we want to be, but we have gone a long way,” Kakooza says.
With this promise, Cheptoris can hope that with the next delivery, she will have those much needed additional pairs of hands to help her with the mothers. But until it comes to fruition, she will continue to hop from one woman in labour to another, helping to make the birth of their babies as safe as she possibly can – even though it’s sometimes on the floor.