By Joan Kabayambi
Nineteen-year old Kasengeja, a rural girl in a remote village in Bundibugyo, was forced in marriage that resulted into an abusive relationship.
She had suffered a late miscarriage in her first pregnancy and had been very careful with seeking antenatal care (ANC) early in this pregnancy. She had moderate anemia which was not identified or treated during her ANC visits.
She completed three antenatal visits and also came to the community health centre for delivery. There were three other women in labour at the time. The staff present included a dental surgeon, a nurse and lab technician, none of whom were trained in conducting maternal deliveries.
The dental surgeon went home to rest at one point and delegated the management of the delivery to the nurse. They tried to hasten delivery process by shouting and beating Kasengeja and also abused her.
The dental surgeon was called back and he complained to the family that she was not cooperating. She finally delivered a still-birth and then started bleeding profusely.
The dental surgeon gave her injections to contract the uterus but did not diagnose the cervical tear. Since she continued to bleed, she was then transferred to a higher-level health facility where she died on arrival.
Kasengeja case is typical of what happens in most health facilities in Uganda. As a remedy to these maternal deaths, in 2000, Uganda initiated maternal and perinatal death reviews (MPDR) to document death.
Since then, the Ministry of Health, international and civil society organisations have been documenting maternal deaths and reporting them through the Health Management Information System.
All of these reports bring out very clearly the need for a more comprehensive approach which goes beyond technical and narrow indicator-oriented approaches and must address the social determinants such as nutrition, violence, poverty as well as healthy systems.
However, although MPDRs have been implemented since 2000, experts disagree as to whether they have served the purpose that they were meant to serve.
This is largely due to lack of analysis on the actual causes of maternal deaths and limited or no follow-ups made to reinforce the recommendations made to address these causes.
“Maternal death reviews (MDR) are mandated and are being done in hospitals and HC IVs but many maternal deaths still fail to get reported and there is no public disclosure of the analysis of maternal deaths, or of the measures planned to address the causes of maternal deaths” says Moses Mulumba, Executive Director of Centre for Health Human Rights and Development (CEHURD), a local human rights non-governmental organisation whose mission is to advocate for social justice in health.
Activists engaged in monitoring the state of health services in Uganda have pointed out that women still continue to die during pregnancy and labour because health facilities in many parts of the country are not equipped to provide Emergency Obstetric Care.
Screening during antenatal care is inadequate, and safe abortion services are inaccessible to women in rural areas. The current approach to maternal care in Uganda is fragmented and focused on promoting institutional deliveries alone, while overlooking the need for a continuum of quality care, including reproductive rights.
A review of institutional delivery data of government hospitals and HCIVs from five districts suggests that adverse outcomes after institutional delivery were significantly higher after MoH intervention, particularly with respect to maternal mortality, and increased rates of vaginal bleeding.
Institutional delivery cannot be a uniform or mandatory solution for all Ugandan women of child bearing age. But provisions for skilled support for women who have their delivery at home with provision for emergency transport to adequately equipped Emergency and Obstetric Care facilities should be made.
Training Traditional Birth Attendants (TBAs) in remote areas without all-weather roads for normal deliveries at home and basic management of complications is not adequate. All maternal deaths must be notified through facilitating incentives to frontline workers and institutions.
All maternal deaths – whether en route, or at the gate of institutions, or at home, or during referral, or in private institutions or of migrating women, must be notified and recorded.
There must be a rapid response to verify the maternal death and check if there was any rights violation involved. A maternal health ombudsman should ensure that a proper MDR is carried out and report submitted.
Any abusive and unethical behaviour towards poor and socially marginalised women and their harassment for informal payments must be made punishable.
The MDR teams must be objective – not comprise local doctors who fear litigation, and to avoid conflict of interest. The team should not only have hospital staff (over-focus on bio-medical aspects) but must include community members to ensure that socio-economic factors are recognised.
The reports must be reviewed confidentially and the MoH must bring civil society/women’s organisations on board in hospital review committees.
MDR findings must be made public through annual reports for each hospital, and these reports should identify gaps in the health system that contributed to the death.
The MDR reports should indicate the remedial action taken to prevent similar deaths in the future. Grievance redress mechanisms must be made simple and accessible for the poor and the illiterate.
Local communities (through village health teams) must be enabled to carry out social audit of health facilities and community-based monitoring of maternal health services.
The writer is on the MaKSPH/CDC fellowship programme