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It is 10:00 am in Agago district, northern Uganda, and it is a beehive of activities at Dr Ambrosoli Memorial Hospital, Kalongo. Women in pairs and groups engage in domestic chores. Some peel cassava tubers and sweet potatoes, while others chop green leafy vegetables and grind sesame to make peanut paste to prepare meals.

Others sit in groups of three or four, having breakfast. A few metres away, women draw water from the borehole.

There is one protruding feature about the women, they are all pregnant. My curiosity compels me to ask what brings pregnant women together. They are in a pregnant women’s waiting shelter. A waiting shelter, also called a maternity waiting home, is a residential facility near a medical facility where pregnant women considered “high risk” can stay so that they can be transferred to the medical facility shortly before delivery or if complications arise.

Among the women is Achora, 28, of Amyel village in Lapomo sub-county in Agago district. She is carrying her third pregnancy. Achora’s home is 50km away. She was admitted to the waiting shelter because she developed pre-eclampsia, a potentially dangerous pregnancy complication characterised by high blood pressure.

“The environment here is conducive. The doctors and midwives keep checking my blood pressure. I am happy and feel I am in safe hands,” Achora says with a smile. Most women in the remote communities of Agago district and the entire northern region find it challenging to access obstetric emergency health care services. Some have to trek long distances to health facilities to access skilled birth attendants.

Janet Alimo, 32, is expecting her fi fth child. Alimo, a resident of Lira Paluo sub-county in Agago, was admitted to the waiting shelter because her unborn baby is in a breech position (lying across the womb).

“I was advised to come and stay at the hospital. My home is 30km away. So, I prefer to wait here, until I deliver. I walked all the way here. When labour starts, I will be operated on to save my baby,” she says.

Orishaba with her baby after delivery at Kisizi Hospital Mothers’ Waiting Home. (Photo by Agnes Kyotalengerire)

Achora and Alimo are among the several pregnant mothers benefiting from maternal health services offered by the waiting shelter at Kalongo hospital.

These women are considered fortunate compared to those in remote, rural Ugandan villages, where preventable pregnancy and childbirth-related complications often lead to the deaths of mothers and their newborns, presenting a significant public health issue.

The latest annual maternal and perinatal deaths surveillance (MPDS) report for 2022/2023 from the Ministry of Health indicates that maternal mortality increased from 1,226 in 2021/2022 to 1,276 in 2022/2023, representing a rise of 50 maternal deaths over the year.

According to the Uganda Demographic Health Survey 2022 report, the national maternal mortality rate is 189 deaths per 100,000 live births, significantly higher than global target of reducing mortality to less than 70 per 100,000 by 2030. The causes of death include complications from pregnancy and childbirth, such as bleeding, which is a primary cause representing approximately 34% of the cases (MPDS report 2022), as well as delays in reaching healthcare facilities due to inadequate transportation and poor road infrastructure.

The waiting shelter at Dr Ambrosoli Memorial Hospital in Kalongo was founded in early 1934 by the late Fr Dr Ambrosoli, an Italian Comboni missionary.

Initially, it served as a small centre assisting women during childbirth, with the Comboni Missionary Sisters caring for the mothers. In 1957, Dr Joseph Ambrosoli officially inaugurated the hospital, which is private and not-for[1]profit (PNFP).

DECREASED MORTALITY RATES

Dr Moris Okau, the medical director of Dr Ambrosoli Memorial Hospital, Kalongo, says the waiting shelter has substantially decreased the mortality rates of mothers and newborns in Agago district and across the entire northern region over the years.

Mothers experiencing pregnancy-related complications or deemed high-risk are advised to leave their homes early and seek delivery care from skilled health professionals.

High-risk mothers encompass various groups, including teenage mothers, first-time mothers, those who have given birth to more than four children and mothers who previously had a caesarean section.

Additionally, it includes women experiencing bleeding, those dealing with hypertension or diabetes, as well as those with an incompetent cervix, among others.

“Upon arrival at the waiting shelter, the mothers are closely monitored and helped to deliver safely,” Okau says.

SKILLED BIRTH ATTENDANTS

Hellen Drajia, the acting district health officer of Agago, notes that the waiting shelter has enhanced access to skilled birth attendants and emergency specialised care, especially for women who live far from healthcare facilities.

According to Drajia, the biggest challenge has been of mothers delivering at home in the hands of traditional birth attendants, in-laws and elderly relatives.

However, the situation has improved. About 76% of mothers now deliver at Dr Ambrosoli Memorial Hospital, Kalongo, thereby saving many, and their newborn babies, from preventable death. The intervention could not have been timelier.

Agago district is choking on teenage pregnancies at 28% against the national figure of 24%. Drajia says the intervention is spot-on since the bodies of adolescent girls are not fully developed to handle regular deliveries.

At the time of the interview, the shelter had 36 mothers against its 15-bed capacity. Ten of the 36 were teenage mothers and four were in labour. “They are examined by an obstetrician at least once a week,” Drajia says.

“A midwife checks the mothers and their unborn babies once daily.” Moreover, the mothers do not pay any fees for the services.

The hospital director, Dr Smart Okot, says the hospital is primarily (up to 80%) funded by the Dr Ambrosoli Foundation based in Milan, Italy. The facility is also funded by the Government of Uganda, through the primary healthcare conditional grant.

The mothers have clean water from a borehole just metres from their residence halls. In addition, they have a spacious kitchen where they prepare their meals. All they have to provide is food and firewood. The hospital and the shelters are overwhelmed.

They serve pregnant women from the Agago district sub-counties and neighbouring Abim, Otuke, Kitgum and Pader districts. The hospital is the only one that offers comprehensive emergency obstetrics care and is a referral for the district, making the overload even more backbreaking.

MORE HOMES OPEN IN REMOTE PARTS OF UGANDA

The Kalongo model has been replicated in Kisizi Hospital in western Uganda. Ritah Orishaba, 24, a resident of Ndoragi village in Ntungamo district, is among the mothers admitted to the Kisizi Hospital Mothers’ Waiting Home in Rukungiri in southwestern Uganda.

She gave birth to her first child at the same waiting home four years ago. Residents of Ntungamo often travel to this facility to access its high-quality maternal services.

Waiting homes are saving lives of mothers and unborn babies. (Photo by Agnes Kyotalengerire)

When Olive Kyomugisha, who is 36 weeks pregnant with twins first arrived at the facility, her condition was relatively poor.

“I was in pain. My legs were swollen. So, the doctors advised me to come to the waiting home for close monitoring,” Kyomugisha narrates. Indeed, the stakes are high for Kyomugisha. It is her fourth pregnancy after three miscarriages.

“The health workers here constantly check on me to ensure my health and that of the babies is fine.”

The medical superintendent of Kisizi Hospital in Rukungiri district, Dr Henry Lukabwe, says the mothers’ waiting home which is private and not-for-profit, was established in 2014, as a response to a tragedy where two pregnant mothers died on their way to Kisizi Hospital.

The deceased mothers had been delivered in the villages by traditional birth attendants and bled to death.

“Based on the bad terrain of the region, the mothers were carried on traditional stretchers, but did not make it to the hospital in time,” Lukabwe recalls.

The assistant District Health Officer in-charge of maternal and child health, Christine Kyomuhangi, says Rukungiri district has got one health centre IV and most health centres II and III do not have operation services.

As such, mothers would be referred as emergencies. Unfortunately, majority would die. “To date, the 24-bed capacity home has benefited over 4,550 mothers and has never registered a maternal death,” Lukabwe notes.

Most mothers come from sub-counties within the Rukungiri district. The facility also admits mothers from the neighbouring districts of Ntungamo, Mbarara and Kanungu.

According to Joan Akatukunda, the midwife in charge of the mothers’ waiting home, some mothers belong to the local community health insurance scheme which picks up the bills based on the mode of delivery.

Mothers registered under the health community health insurance scheme pay an annual membership fee of sh40,000, while non-members pay sh10,000 per month during the time spent at the waiting home.

GOVT SETS UP HOMES IN MOUNTAINOUS AREAS

“The Government is replicating the waiting homes model in bad terrain and mountainous areas, such as Kigezi, Rwenzori, and Elgon in eastern Uganda, to help in reducing the number of deaths of mothers and their newborn babies,” Dr Richard Magahi, the commissioner of reproductive and infant health at the Ministry of Health, says.

For example, Rubanda district in south-western Uganda launched two health facilities, Mukwe and Hamurwa Health Centres IV, into waiting areas for pregnant mothers.

The Rubanda district health officer, Dr Abdon Birungi, notes that each waiting centre accommodates 15 to 20 mothers weekly on average. Previously, most pregnant mothers would be transported to the hospital on makeshift stretchers because of the bad terrain.

CHALLENGES WAITING SHELTERS FACE

Kisizi and Kalongo hospitals are private, not-for-profit facilities, so managing the waiting shelters at both health facilities requires a lot of money.

The mothers pay sh10,000 at Kisizi Hospital and nothing at Dr Ambrosoli Memorial Hospital, Kalongo.

Despite their effectiveness, the efforts of the waiting homes are being frustrated by traditional birth attendants, elderly attendants, or in-laws who mislead the mothers by giving them wrong information, yet some of the teenagers require caesarean section delivery because their pelvises are not fully developed.

Poverty is another significant challenge that prompts mothers to leave the facility to engage in casual labour for money, thereby compromising their health and safety, Janet Aketo, the midwife in-charge of the shelter, notes.

For example, some mothers with complications are recommended to undergo fetal heart examinations twice daily. Still, this essential care can be neglected when they leave to go and work.

Patient transportation remains a challenge because the hospital has an old ambulance to pick up mothers from hard-to-reach areas. Kisizi district borders the Rukiga region, about 60km away, which creates another delay.

Another major limitation is congestion at the facilities, especially during the night when some mothers occupy the male ward. Additionally, health workers are overworked, and the influx of mothers pushes the electricity and water bills high, according to the Rubanda district health officer, Dr Abdon Birungi.

However, this initiative is the way to go,” Birungi says. “They save the lives of mothers and their unborn babies.”

The story was compiled with support from Science Africa and Africa Health Solutions Journalism