Maternal health in Uganda

Almost all women in developing countries have at least four antenatal care visits, are attended to by a skilled health worker during childbirth, and receive postpartum care. In contrast, only 47% of Ugandan women receive antenatal care coverage and only 42% [16] of births are attended by skilled health personnel. Among the poorest 20% of the population, the share of births attended by skilled health personnel was 29% in 2005/2006 as compared to 77% among the wealthiest 20% of the population.[17] The case of Jennifer Anguko,[18] a popular elected official who bled slowly to death in the maternity ward in a major hospital, aptly exemplifies the poor state of maternal health care that is provided to women, even in major urban healthcare facilities.

Despite the national policy of promoting maternal health through promoting informed choice, service accessibility and improved quality of care through the national Safe Motherhood Programme (SMP), it remains a challenge to the Ugandan government as to how it would achieve its 2015 Millennium Development Goals of reducing maternal mortality rates and 100% births attended to by skilled health personnel. In order to achieve future economic growth, it is vital that the population remains healthy.

A study was done in 2007 in 54 districts and 553 health facilities in Uganda to determine the availability of emergency obstetric care and its related maternal deaths. The study found that few of these units had running water; electricity or a functional operating theater.[19] However, having these items was shown to have a protective effect on maternal deaths.[19]

The availability of midwives had the highest protective effect, reducing the case fatality rate by 80%. This study found that while 97.2% of health facilities were expected to have emergency obstetric care services, few had provided these services. This is the most likely explanation for the high health facility-based maternal death rate of 671 per 100,000 live births in Uganda in 2007. The study concluded that addressing health system issues, particularly among human resources, and increasing access to emergency obstetric care could reduce maternal mortality.[19]

There is not only the issue of a lack of resources in healthcare services, there are also cultural barriers in women seeking professional care. Ugandan women adhere to very traditional birthing practices and believe that pregnancy is a test of endurance and maternal death is merely a sad but normal event. This cultural view hinders the chances of women seeking professional maternal care. In the Kiboga community it is evident that pregnancy and childbirth are some of the major areas where women still command power and status, which they strive to embody in order to enhance their status within the household and community.[20]

Another factor preventing women from seeking emergency obstetric care among Ugandan women is the cultural desire for Ugandan women to 'protect their own integrity.' A common birthing practice is for women to give birth completely alone and the individual is the one who decides if outside help is needed.[21] It has also been found that women feel that they have the most power and control during the birthing process, which is something they often lack in other aspects of their lives. Women are considered to be strong and independent if they can handle the birthing process by themselves. These beliefs often lead to very dangerous circumstances as women often delay assistance, which sometimes costs their life or the life of the baby. Oftentimes one of these main issues is obstructed labor. When women realize labor is not progressing normally they first seek female friends or traditional birth attendants. This can result in a further delay in seeking medical attention from someone who is trained to handle such complications.

A study conducted in 2001 found that one common remedy used for obstructed labor in home births was herbs. As high as 80% of childbirths used herbs. Ugandan culture also sees the birthing process as a woman's affair and therefore oftentimes there is little male involvement. Transportation is also another issue in Uganda. Most families do not own personal cars and cannot afford taxi fares. More remote and rural areas cannot be reached by car but must be reached using a motorcycle. These conditions are not ideal in transporting a woman in labor, so women tend to choose to stay home during labor. Women also avoid healthcare facilities as this also inhibits their own integrity. They feel that they are powerless in a hospital, have little say in decisions, and know little about procedures being done to them. There is also a lack of medical supplies in Ugandan hospitals and healthcare is run on a fee for service basis. Many women do not have the funds necessary to both travel to a hospital and pay for hospital services and supplies. Or if they do have the funds, hospitals could also be out of supplies. This further discourages them from giving birth in a healthcare setting.

There is an urgent need to educate both men and women on the risks of having home or solitary childbirths that are not assisted by a skilled attendant. A study conducted in 2011, suggests that birthing outcomes would improve if men were intimately involved in the process and could assist in making decisions regarding obstructed labor or other complications.[21] The integrity of women could be maintained if health workers were more compassionate and more able to support women and provide understandable information during labor. There is also a great need to improve both access and quality of healthcare offered to the masses in Uganda.

One major issue in regard to maternal health is access to quality emergency obstetric care and the many barriers Ugandan women face to gain access to such care. A needs assessment of emergency obstetric care was carried out in 197 health facilities in 19 out of 5 health districts in Uganda, covering 38% of the total population.[22] The study found in 2005, that there was a large number of missing signal functions at health facilities and an urgent need to improve the availability of emergency obstetric care. It was found that the improvement of care begins by improving district health workers' skills in emergency obstetric care so that they can effectively manage and treat obstetric complications. Part of this training includes hospital staff on how to properly manage data systems to better monitor and evaluate program implementation. An effective advocacy tool, known as REDUCE, has already been developed for Uganda to stimulate policy dialog and strategic planning. The REDUCE tool uses computer models to estimate the human and economic consequences of maternal mortality, and generates data that can be used to create arguments for giving higher priority to maternal mortality reduction in creating policies, strategy development, and resource allocation.[22]

A number of barriers to the use of professional maternal health services have been identified, including distance to facilities and perceived quality of services. A study conducted in 2003 examined the proportion of deliveries from individuals in local area and the number of deliveries each year for several different facilities to assess barriers influencing an individual's access to maternal health care. The results of the study found that many people travel outside their local area, bypassing several other healthcare facilities, to reach more popular services–facilities with a high number of deliveries per year. Women associated popularity with a higher quality of care and costs, making the extra travel time worth it. As a result of this perceived quality of care, some facilities are underutilized and others over-stretched, decreasing the availability of staff and supplies.[23]

In 2003, a study was conducted in Hoima, Uganda, whose aim was to examine the reasons why women continued to choose high-risk options when faced with complications of pregnancy and delivery, ultimately leading to severe morbidity and mortality.[20] The study found that women considered the use of primary health units and the referral hospital when complication occurred as a last resort. Women reported that a lack of skilled staff, complaints of abuse, neglect, and poor treatment in the hospital, and poorly understood reasons for procedures, plus health workers’ views that women are ignorant, also explain why many women consider going to a hospital for delivery as a last resort.[20]

Many women do not utilize healthcare services because they do not understand reasons for procedures.[20] Health literacy is a large issue among women in Uganda. It not only affects birthing outcomes but also information on reproductive care. Another study conducted in 2012, found that many Ugandan women rely on myths, rumors, and misconceptions that discourage them from using reproductive health services, particularly family planning.[24]

Another study conducted in 2011 found that even those pregnant women who attended antenatal classes had very little knowledge of danger signs during pregnancy. An association was found between birthing preparedness and knowledge of danger signs. The most common birth preparedness practice was saving money to facilitate referral in case of complications. While only 68% of women in the study had attended at least four antenatal care visits during their last pregnancy. Only 19% of women in the study could indicate at least three danger signs.[25] This shows that a considerable share of those who seek professional care are not receiving or retaining vital information. It was found that women appear to be unaware of the risk they take by subjecting themselves to prolonged labor. The study found that among women who went to antenatal visits 40% had not been advised where to deliver and the staff were allegedly unfriendly. There also seems to be an association between having a delivery by skilled birth attendants and being under the age of twenty. It is hoped that it is becoming more culturally acceptable to give birth with the assistance of a skilled attendant than it is among the older generations. The study concluded that every woman should be made aware of the likelihood of complications during pregnancy, childbirth, labour, and the postpartum periods. There has also been success using mobile phones to provide health information in HIV programs in Uganda. Since mobile phones are becoming more and more common, it appears this could also be a good route for antenatal education.[25]

In rural areas, conceiving pregnant women seek the help of traditional birth attendants (TBAs) due to difficulty in accessing formal health services and also high transportation or treatment costs. TBAs are trusted as they embody the cultural and social life of the community. However, the TBAs’ lack of knowledge and training and the use of traditional practices have led to risky medical procedures resulting in high maternal mortalities.

In 2006 it was found that some rural areas of Uganda up to 90% of the population uses traditional medicine for day to day healthcare needs. The World Health Organization estimates that 80% of the developing world uses traditional medicinal practices. It was found that over 80% of child births that are conducted at home use herbal remedies in the Bushenyi district of Uganda.[26] Over seventy five plants have been recorded for use to induce labor and some of these plants could be oxytocic.[26] The danger lies in levels of dosage as to whether or not the plants could potentially bring harm to the mother and baby. These medicinal herbs are often used because Ugandans cannot afford western pharmaceuticals. These herbal remedies are also socially and culturally accepted. In Uganda reproductive health issues such as maternal mortality and morbidity, account for the number one disease burden. Perinatal and maternal-related conditions account for 20.4%, malaria 15.4%, acute lower respiratory infections 10.5%, AIDS 9.1%, and diarrhea 8.4%. These conditions account for over 60% of the total burden.[26]

In Uganda, it is viewed that a woman who had died in childbirth is equated to a soldier who had died during a war. Maternal death is considered a natural phenomenon and encourages the use of herbs, while undermining safe birthing practices with a skilled birth attendant. Women in Uganda are generally more disadvantaged than men. There tends to be a patriarchal order of communities. Therefore, women have a very limited control of resources and in most cases have poorer health. The study found that dosing and toxicity levels need to be monitored in the use of medicinal herbs during labor. There is a need for further field and laboratory research to establish appropriate dosage levels. In 2006, the maternal mortality rate in Uganda is 506 deaths per 100,00 live births. There is a need for health provision programs, safe motherhood programs, health policies in reproductive health care, and collaborative approaches involving traditional medicinal practitioners such as traditional birth attendants. It is possible that a lack of knowledge on plant species used to induce labor and speed up childbirth could be one of the main factors that contribute to high maternal mortality in Uganda.[26]

Malaria is a leading cause of morbidity and mortality in Uganda. It is especially lethal among pregnant women and children under five. The mortality rate for all ages is estimated at 32.1% in 2004. A study in Mukono, Uganda, determined that the most effective delivery system of intermittent preventive treatment (IPTp) for pregnant women was that education was a factor in health seeking behaviors. Those who were a part of the study accessed IPTp early and most of them adhered to the two doses of SP. Women experienced a reduction in malaria episodes, anemia, parasitaemia and low birth weight. While these results cannot be attributed to the intervention alone, after controlling for age, education, parity, and occupation, there were still significant differences for parasitaemia, reported malaria episodes and birth weight, indicating the importance of access and adherence to IPTp.[27]