LOCKDOWN | TBAs | MOTHERS  

Birungi suffered postpartum hemorrhage while giving birth under the watch of a traditional birth attendant. Her condition was not helped by a nearby healthy centre that denied her blood and transport challenges while getting to a hospital. She died. 

Health workers say  Birungi’s condition of mothers that report to hospital late is not unique, especially during a lockdown, writes Agnes  Kyotalengerire.

Anna Mary Birungi, 28,  attended all her antenatal visits at Kakindo Health Centre IV in Kakumiro district as required.

She was looking forward to delivering her sixth baby. But on June 26, she visited a traditional birth attendant, who told her that she had been “bewitched and would die during delivery”.

The traditional birth attendant (TBA) warned Birungi against delivering in a health facility or hospital before the witchcraft was dispelled or she would die during labour.

Upon returning home, Birungi briefed her husband, Andrew Kaahwa, who immediately contacted a TBA, popularly known as Nnalongo, a resident of Murwerere village, to give her herbs before she was due for delivery.

The following morning on June 27, Kaahwa rode his wife on a motorcycle to Nnalongo’s place, about 8km from their home in Rurongo, Kisaije parish, Kakindo sub-county in Kakumiro district.

Kaahwa says he tried to persuade Birungi to drop the idea and instead proceed to Kakindo Health Centre IV for close monitoring, but she refused and started crying, saying she was afraid of dying while giving birth, as the TBA had ‘predicted’. 

Kaahwa explains that his wife believed the TBA’s prophesy because she had given birth to her fifth baby through caesarian section after suffering complications.

So she feared for the worst. Left with no option, Kaahwa delivered Birungi straight into the hands of the TBA  and rode back home. Little did he know that was the beginning of the unravelling of his life.

The next day, Sunday, when Kaahwa checked on Birungi, the TBA suggested she spends another night. Sadly, on Monday morning,  Kaahwa received news that Birungi had delivered, but the baby had died shortly after.

“The TBA told me my wife had a normal delivery, but the baby did not cry and died three minutes later,” he narrates.

Kaahwa was devastated by the news and immediately rode to the TBA’s residence, picked the body of the baby and took it home for burial, leaving Birungi behind.

When Kaahwa returned a few hours later, he noticed Birungi’s condition was worrying. She had bled profusely after delivery and the TBA said she had contacted a medical worker at a nearby clinic, who administered two injections of oxytocin to stop the bleeding.

Fearing for the worst, Kaahwa decided to hire a vehicle to take Birungi to Kakindo Health Centre IV, but the TBA advised him to wait for her condition to stabilise.

Kaahwa waited until 6:00pm, but his wife’s condition continued to deteriorate.

“She was complaining of severe pain in the abdominal cavity and birth canal,” he recalls. This prompted Kaahwa to hire a vehicle to the health centre. 

Upon arrival, health workers were reluctant to offer Birungi treatment. They demanded to know where Birungi had delivered from and why she had delayed getting to the health facility.

Later, the midwife on duty referred them to Hoima Hospital, which is 45km away, saying Birungi was anaemic and the facility did not have blood to transfuse her.

Even when an ambulance driver intervened and insisted that blood was available, the health workers insisted they did not have blood Group O, which was what she needed. 

“The ambulance driver could not understand why they would not transfuse my wife since blood Group O units were available in the store. He complained throughout the journey,”  Kaahwa recalls.

To transport his wife to Hoima Hospital, Kaahwa was asked to pay sh120,000. The money was meant to buy fuel for the ambulance, pay the driver and an allowance to the midwife who accompanied them.

“Initially, they had asked for sh150,000, but after pleading, I paid sh120,000. I felt this was unfair because patients being referred usually pay sh50,000 for fuel,” he notes.

The ambulance set off at about 10:00 pm and an hour later, they arrived at Hoima Hospital, where health workers acted fast. They immediately started transfusing Birungi and administered other medications.

Given the quick response, Kaahwa was hopeful that his wife would survive. But at about  3:30am, Birungi died. She was buried on June 29, leaving behind five children, all girls aged  13, 11, 9, 6 and two, in the care of her husband.

Kaahwa devastated 

At the time of the interview, Kaahwa,  33, was struggling to serve the children lunch during a downpour. 

He has not come to terms with the fact that Birungi is no more. “I lost my appetite and sleep the day my wife died,” he notes with a drop in his voice.

He adds: “We were rearing pigs and growing maize, tomatoes and beans for sale to pay school fees for our children. I do not know how I am going to fend for the children alone.” 

Unanswered questions 

Could timely blood transfusion have saved Birungi’s life? Kaahwa still thinks Birungi’s life could have been saved if health workers at Kakindo Health Centre VI had acted quickly and offered her a blood transfusion.

“I was hurt because my wife could not be transfused at Kakindo, yet the ambulance driver insisted the blood group she needed to save her life was available,” he notes.

Godfrey Ateenyi Kwamya, the ambulance driver, says: “They did not take the matter seriously and blamed Birungi for reporting late. Being a parent, I got so concerned because failure to get transfused when blood is available is a big issue,” Kwamya notes. 

There was blood at Kakindo 

George Wasswa, the blood focal person at Kakindo Health Centre IV, says the facility received blood on June 28, the day Birungi was admitted.

“That day we received all the blood groups and specifically, there were four units of blood group O,” he says.

According to Wasswa, the blood ran out of stock on July 2 and the facility restocked on July 7. He says the health facility rarely experiences blood stockouts.

In the event that blood runs out, Wasswa secures transport through the district health officer and travels as far as Fort Portal and sometimes to Hoima Hospital to pick blood for patients at the facility,” he notes.

Dr Aggrivine Byaruhanga, the senior medical officer at the facility, concurs.  “There is an improvement in blood availability. Every week, we receive blood, unless there is a stockout at Hoima Hospital,” Byaruhanga notes.

Kaahwa says he does not know how he will fend for the children without the support of his wife.

So, with the officials from the facility confirming availability of blood, why was Birungi not transfused at the time she needed blood to save her life?

She was anaemic 

The in-charge of the maternity ward at Hoima Hospital, only identified as Diana, confirmed Birungi’s death. 

“She had been referred from Kakindo Health Centre IV, but she died shortly after arriving at the hospital. What made it complicated was that the mother had previously undergone a caesarian section and was anaemic due to severe postpartum haemorrhage (bleeding after delivery).

Luuka district equally affected 

Esther Ahimbisibwe, in charge of the maternity wing at Kiyunga Health Centre IV in Luuka district, says because of restricted movement during the ongoing lockdown, the number of deliveries at the facility has dropped. 

She attributes the reduction to women choosing to deliver from clinics near their homes or at TBAs.

Protected by politicians 

Kakumiro district is a hotbed for TBAs.  The district health officer, Robert Ssenteza, says the issue of traditional birth attendants is still a tricky one, that the health system and leadership has failed to bring to a total halt.

“Even before the COVID-19 lockdown,  the TBAs have been operating against the guidelines because of political patronage,” Ssenteza says.

The 2016 Uganda Demographic Health Survey report showed that the national figure for skilled attendance stands at 74%.

This means 26% still deliver in the hands of TBAs. Similarly, Dr Byaruhanga decries the high number of TBAs in the district. 

“Sometimes we get into a home and find a TBA has admitted about 10 mothers,” he notes, adding that their efforts to apprehend the TBAs have been futile because sometimes they are protected by politicians.

“When we arrest a TBA, we receive calls from politicians, especially MPs, ordering us to release them. Actually, some TBAs do not enter cells,” he notes.

According to Byaruhanga, there are three renowned TBAs in the communities of Kikwaya, Murwerere and Kikora in Kigoma, who admit pregnant women, which has resulted in maternal and newborn deaths.

“We engage them in their homes and they promise not to admit mothers again. But as soon as we leave, pregnant women go back,” he notes

Complications of delivering in hands of TBAs 

Dr Imelda Namagembe, a senior consultant gynaecologist/obstetrician at Mulago Hospital, cites severe complications or morbidity as a result of pregnant women failing to access the hands of a skilled person to deliver them. 

“There is evidence that the conditions that kill mothers cannot be sorted out by traditional birth attendants. As such,  we may soon see a relative increase in the number of deaths resulting from mothers failing to access health care facilities due to restrictions on movement,” she says.

Although Byaruhanga could not estimate the number of mothers and newborns who have died in the hands of TBAs, he explained that data on the history of mothers reveals that some develop complications, such as ruptured uterus, inter-uterine foetal death (baby dying before delivery) in the hands of TBAs or after taking local herbs administered by the TBAs. 

“Some women deliver tired babies who cannot be resuscitated and we end up getting an early neonatal death,” he adds.

What has been done 

Not all hope is lost, however. Byaruhanga says they have continued sensitising the community through radio talk shows.

Additionally, they are engaging village health teams (VHTs)  to sensitise mothers on the dangers of delivering under the care of TBAs.

Will Uganda meet the SDG goals? 

Dr Jessica Nsungwa, the commissioner maternal and child health, warns that if mothers and newborn babies continue dying in the hands of traditional birth attendants, chances are high that Uganda may not be able to achieve the sustainable development goal number three (SDG3), which calls for a global maternal mortality ratio of below 70  deaths per 100,000 live births.

This translates into national targets of at most 25 deaths per 1,000 live births and neonatal (0-28 days) mortality to at most 12 per 1,000 live births.

What needs to be done 

As the public continues to observe the lockdown, government should ensure that communities have access to ambulances or other forms of transport that can readily move mothers, Dr  Namagembe says.

“The ambulances if available have to be functional and fuelled,” she notes. Even prior to the lockdown, the burden of maternal and newborn deaths was unacceptably high, at 336 maternal deaths per 100,000 live births and 43  infant deaths per 1,000 live births.

Although Birungi had delivered the first five children well, things did not go well with her sixth child. She died from complications that are already documented as causes of maternal deaths. So stamping out TBAs and associated complications, including deaths, requires a multi-sectorial approach, where communities work together to support pregnant women.

“Each pregnancy should be treated as unique and pregnant women should be cared for from the start to the end of delivery,” Namagembe notes.

Fuelling ambulances 

Dr Aggrivine Byaruhanga,  the senior medical officer at the Kakindo Health Centre IV  acknowledges that the facility has a functional ambulance which was donated by the Infectious Disease Institute in  2010.

However, he says they have fuel challenges “Sometimes, the facility can go for two months without money to refill the ambulance. 

The facility last had fuel for the ambulance in May,” he notes and is quick to add;  in the event that the facility cannot refill the ambulance,  the mothers meet the fuel costs.

He says in case of referrals, the patients negotiate the charges with the driver, which usually do not go beyond sh100,000. This includes clinical charges for the escorting nurse.  So one wonders why Kaahwa was charged sh120,000?

Are lockdowns pushing mothers to TBAs? 

The in-charge of the maternity ward at Hoima Hospital, only identified as Diana, said  Birungi’s case of reporting late to hospital was not unique. 

Anna Mary Birungi

From the onset of the COVID-19 second wave lockdown, the number of women who deliver at the hospital had dropped drastically, she stated.

The medical workers at the facility suspect that some mothers are going to traditional birth attendants (TBAs) as the case was with Birungi.

As a result, the facility is recording cases of women who report late with complications,  such as retained placenta or when the babies are either tired or dead after making attempts to deliver with TBAs.

“Some women have confessed to opting to deliver with TBAs because they fear getting infected with COVID-19 since most health workers have contracted the virus. Others say they cannot access health facilities due to restrictions in movement due to the lockdown,” she notes. 

Dr Aggrivine Byaruhanga, the senior medical officer at Kakindo Health Centre VI, recalls that during last year’s lockdown, there was a directive that all district vehicles under the mandate of the district health officers had been given fuel to transport mothers to health facilities in case of emergencies, which is not the case with the ongoing lockdown.

Additionally, the current lockdown has crippled people’s sources of income. As such,  some mothers cannot afford to hire a motorcycle or vehicle to transport them to a health facility when labour starts. 

Consequently, many are turning to TBAs who live within their communities for delivery. Worth noting, some facilities that have registered infections among their health workers are also struggling with gaps in human resources as the staff seek treatment. 

Uganda's maternal, child mortality rates high 

Uganda’s maternal and child mortality rates are still unacceptably high at about 336 maternal deaths per 100,000 live births. Infant mortality is 43 deaths per 1,000 live births, with 42 of the mortality occurring during the neonatal period.

And while the lockdown is necessary to curb the spread of COVID-19, it presents new dangers to mothers who have trouble accessing transportation to health facilities for antenatal check-ups or when labour starts.

Resorting to traditional birth attendants, who are more easily accessible, has exposed mothers to more danger. 

We need transport solutions during and after the lockdown to ensure that mothers can be quickly transferred to health facilities so they can get professional help.

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