There is a preventable tragedy that hardly engages sustained public interest. The Monitor newspaper, among others, has faithfully reported stories of women who have had bad experiences in labour, some of whom have died.
Such news quickly disappears, unless the victim is a prominent person, or her death is alleged to have been the result of a healthcare provider’s malpractice. Even then, the story does not grab as much attention as, say, the private adventures of a popular musician, soccer player or prostitute. Rarely do we read follow up reports to ascertain the causes of the tragedy, and corrective measures, if any, that have been taken to prevent a recurrence.
This situation is not unique to Uganda. Reports from other parts of Africa and Asia continue to paint a dire picture. Whereas a 38 percent worldwide reduction of maternal deaths has occurred in the last decade, the statistics remain dark. The current global maternal mortality ratio (MMR) for women aged 15-49 is about 211 deaths per 100,000 live births. That is more than 800 maternal deaths every day. This is three times the United Nations’ Sustainable Development Goal (SDG) of reducing the global MMR to less than 70 per 100,000 live births by the year 2030. At least two-thirds of these deaths occur in Sub-Saharan Africa.
Uganda’s reported maternal mortality ratio is 336 per 100,000 live births. While this is not the worst in Africa (it is 1150/100,000 live births in South Sudan), the Ugandan statistic has only marginally changed in recent decades. Many more suffer long-term severe handicaps. The worst hit are rural women.
The main direct causes of death due to pregnancy are (i) bleeding, (ii) pregnancy-induced high blood pressure disorders, (iii) infection, (iv) complications of abortion, and (v) blood clotting. The indirect causes of death include complications of HIV/AIDS, and malaria.
Ugandan obstetricians (doctors who specialise in the management of pregnancy and childbirth) are very highly skilled and knowledgeable about the latest standards of practice that prevent and treat these life-threatening conditions. Furthermore, doctors trained at the country’s well established medical schools are highly skilled in life-saving obstetric interventions. A significant body of recent publications by Ugandan obstetricians and other scientists in peer-reviewed journals demonstrates that our country has a fund of cutting-edge knowledge on the subject.
However, the number of available specialist physicians remains small for the rapidly increasing child-bearing population. I do not know the number of active obstetricians in Uganda. The Association of Obstetricians and Gynaecologists of Uganda (AOGU) has only 88 paid up members. Even if we hypothetically assume that an equal number of obstetricians are not members of AOGU, it is still fair to say that there is a very inadequate number for a country with a population of more than 48 million. If we had 200 obstetricians practicing in Uganda, their ratio would be 0.4 obstetrician per 100,000 population, a very tiny fraction compared to the ratios in high-income countries like Canada where the figure is 6 per 100,000 population.
Furthermore, very few obstetricians practice in Uganda’s small towns, and practically none are in the rural areas where the majority of the country’s citizens live. Their highly essential expertise is concentrated in the urban areas, especially Kampala and other cities and large towns that offer better incomes, better lifestyles, better continuing educational opportunities and collegial support, and better schools and other amenities to support their families.
So, round-the-clock availability of highly skilled, and well remunerated non-physician practitioners with adequate obstetric equipment is mandatory at any centre where pregnancy and birth management are anticipated.
Before the Covid-19 pandemic, 97 percent of pregnant women in Uganda attended at least one antenatal care (ANC) visit at a healthcare facility. However, only 60 percent of pregnant women attended antenatal care (ANC) visits the recommended four or more times during their entire pregnancy. Only 29 percent received antenatal care during the first three months of pregnancy.
Approximately 74 percent of births in Uganda are managed by a skilled birth attendant, the bulk of them registered midwives. However, 44 percent of mothers do not receive postnatal care within 2 days following childbirth. Clearly a significant number of women and babies do not receive critically needed care during the first week of life, which contributes to the large number of neonatal deaths. .
The reasons why so many women continue to die or suffer long-term complications of pregnancy and childbirth are summarised by the concept of ‘The Three Delays.” These are delays in: (a) deciding to seek care; (b) arriving at the healthcare facility; and (c) receiving appropriate care. Understanding these three delays is central to developing effective, sustainable, and transformative interventions.
The delay in deciding to seek care is driven by financial, and cultural factors, together with negative experiences with the health care system, and basic lack of knowledge of warning signs. Though health services in government facilities are theoretically free, official, and unofficial fees that are levied by midwives and doctors can deter many women from seeking timely care.
For some women, their male partners and family members have a significant influence on the decisions they make about their lives. Husbands often veto their wives’ attempts to seek routine antenatal care or professional attention for concerning symptoms. Other women are reluctant to subject themselves to rude and often physically abusive midwives and doctors.
The delay in reaching care is a consequence of long distances to health care facilities; unavailable or unaffordable transportation; and poor roads and other transportation infrastructure. A woman in labour needs a comfortable four-wheeled vehicle, not a bodaboda or bicycle. Those of us who have never been in labour cannot understand the pain inflicted by the simultaneous combination of a vehicle bouncing across potholes and contractions of the womb.
The delay in receiving adequate care is caused by poor referral systems; lack of medical equipment, medications, and blood; inadequate training and poor availability of highly skilled and knowledgeable healthcare workers; and lack of adequate capacity of surgical care, including safe and effective anaesthesia.
One of the major challenges of health care in upcountry health centres, especially in rural areas, is the attraction and retention of doctors, nurses, and other members of the team. Staff housing is often very limited. Local schools may not be attractive to parents of primary-school-age children. Recreation and entertainment facilities may be limited. Roads to many areas become treacherous during the rainy seasons. These and other challenges discourage some professionals from moving to or keeping their families in rural settings.
Clearly the most important strategy for eliminating preventable maternal mortality and morbidity must be an integrated approach that addresses the cultural, social, economic, infrastructural, communication, and comprehensive health systems deficits that continue to kill and maim women in the child-bearing years. The first step is to rethink our local and national spending priorities.
© Muniini K. Mulera