Mapping initiative slashes maternal mortality in refugee settlements

___________

STITCH IN TIME

The influx of refugees in Uganda is due to several factors in neighbouring countries, associated economic crises and political instability in the region.

However, refugees continue to have several difficulties in accessing social services despite the efforts made by the Government and development partners.

In Uganda, where refugee settlements often face significant healthcare challenges, a groundbreaking initiative has emerged, targeting one of the most vulnerable populations: pregnant women.

Hope Mafaranga and Rogers Sunday write about the Pregnancy Mapping Initiative that has been instrumental in not only addressing maternal deaths but effectively eliminating them within refugee communities.

If all healthcare facilities in Uganda conduct pregnancy mapping of expectant mothers, the country has the potential to eliminate maternal deaths.

Dr Justin Okello, a programmes manager at Medical Teams International which oversees Nakivale Health Centre III located in a refugee settlement, said the facility delivers 400 mothers monthly.  

He said they have encountered a distressing trend of maternal deaths during childbirth. 

Maternal death is defined as a fatality due to complications related to pregnancy or childbirth, occurring when a woman is pregnant or within six weeks of the end of the pregnancy.

In February 2023, the World Health Organisation released the Trends in Maternal Mortality report, stating that a woman dies every two minutes globally due to pregnancy or childbirth complications. Maternal deaths remain predominantly concentrated in the poorest regions and conflict-affected countries.  

In 2020, about 70% of all maternal deaths occurred in sub-Saharan Africa. In nine countries experiencing severe humanitarian crises, maternal mortality rates were more than double the global average, with 551 maternal deaths per 100,000 live births compared to the worldwide rate of 223, the report stated.

Dr Okello said they recorded 10 maternal deaths in 2020, eight in 2021 and five in 2022. His team conducted a thorough review to ascertain the causes of these deaths.  

“We accurately analysed each case, pinpointing the primary complications leading to these tragic outcomes and devised interventions accordingly,” he said.  

Collaborating with 283 village health teams (VHTs), they initiated the identification process for expectant mothers, taking crucial steps toward addressing maternal health challenges. Maternal mortality rates in these areas have historically been alarmingly high due to factors such as a lack of access to skilled birth attendants, insufficient antenatal care and delays in emergency obstetric services.

Recognising this critical issue, the Pregnancy Mapping Initiative was launched in collaboration with local health authorities, humanitarian organisations and community leaders.  

The initiative’s primary goal is to comprehensively plot pregnancy-related services within refugee settlements and ensure that expectant mothers receive timely and appropriate care throughout their pregnancies and during childbirth.

The initiative trained VHTs to help identify expectant mothers from the community.

A refugee mother with a malnourished child says she was helped by health workers at Nakivale Health Centre III. (All Photos by Ivan Kabuye)

“This mapping process ensured that pregnant women and healthcare providers were aware of the available services and their locations,” Dr Okello said. They started a programme to find all pregnant mothers in the community, whom they then sensitised to attend antenatal care at least four times during pregnancy.  

|“The outcomes are remarkable. Last year, no maternal deaths occurred and from January until now, we haven’t lost a single woman,” he noted.

Antenatal Care

Each mother faces unique challenges and they provide personalised support from the community, ensuring preparedness for childbirth. A specialised clinic for high-risk mothers was established to safeguard their health.

Dr Okello emphasised the significant contribution of the introduction of a theatre. “Between 25-30 mothers undergo C-sections weekly, and without a theatre, we could have lost these mothers,” he said.

Dr Okello said pregnant women were encouraged to attend antenatal care visits regularly.

The initiative facilitated these visits by providing transportation assistance, conducting outreach programmes and raising awareness about the importance of antenatal care for maternal and foetal health.

Skilled birth attendance

Dr Okello said access to skilled birth attendants during childbirth is crucial for reducing maternal mortality.  

“The initiative trained and deployed midwives and other healthcare professionals to provide obstetric care and attend deliveries within the settlements,” he said.

Agnes Baku Chandia, the acting commissioner in charge of nursing and midwifery at the health ministry, emphasised that no mother should fear for her life while bringing a baby into the world, especially when the knowledge and tools to treat common complications exist.

“We can save women’s lives if they visit a health facility promptly and give birth there,” she said.

Community engagement

Dr Okello said they have community involvement with local leaders, community health workers and women’s groups actively raising awareness about maternal health issues, dispelling myths and promoting positive health-seeking behaviour among pregnant women.

“This initiative serves as a model for improving maternal health outcomes in resource-constrained settings. It underscores the importance of targeted interventions and community collaboration in saving lives,” he said.

Women chatting as they wait for maternity services at Nakivale Health Centre III in Isingiro district.

Dr Okello added that 30% of women are accompanied by their husbands for antenatal care and other health services.

He said the number of men is still low and urged women to encourage their spouses to get involved in their health.

Nutritional intervention

Dr Okello said all pregnant women and children under five years are in the targeted group.  

“We have provided treatment to 1,059 children, with 216 currently receiving outpatient care, while four children are admitted,” he said. Sophia Kalyoma, a nutrition officer at the Bujuburi health facility in Kyaka II Refugee Settlement in Kyegegwa district, said the reduction in food rations for the refugees has increased malnutrition cases.

“The World Food Programme used to distribute either food or money to the refugees, enabling them to sustain themselves. However, with the current cuts in food rations, most households in the refugee community can barely afford balanced meals,” she said.

Kalyoma said many households do not prioritise the nutritional status of their children.

She said the nutrition unit is currently handling 123 cases of severe malnutrition, most of which involve children under the age of five.

She added that an additional 200 cases of moderately malnourished expectant and lactating mothers are being monitored.

ALSO READ:

How cutting food rations spurred innovation among refugees

Elizabeth Kahindo, a mother, revealed that her three-year-old child was malnourished but recovered with the help of health volunteers. “I learned how to prepare nutrient-rich meals, especially for my children. Within just five months, I started seeing positive results,” she said.

Dr Gerard Naluwairo, a public health officer at the United Nations High Commissioner for Refugees, highlighted their efforts in tackling malnutrition among the refugees and host communities, citing it as a significant contributor to maternal mortality.  

He emphasised the perilous consequences of pregnancy amidst malnutrition, underscoring the heightened risks for both the mother and her unborn child.

Dr Naluwairo outlined the efficacy of their pregnancy mapping approach in identifying at-risk mothers and facilitating timely medical intervention and treatment.

Leveraging the VHTs, they ensure prompt referrals of high-risk mothers to healthcare facilities for comprehensive management.

In addition to aiding expectant mothers, Dr Naluwairo noted the VHTs’ role in disseminating vital information and identifying children under five facing malnutrition challenges.

Water  

Dr Naluwairo emphasised the critical connection between water and health, highlighting the significant challenge of access to water in the Nakivale Refugee Settlement.  

He said the water in Isingiro district contains high levels of iron and carbon, making it hard water and expensive for the Government and its partners to treat.

Additionally, Dr Naluwairo said Nakivale is a receiving centre, with new people coming in daily.

Naluwairo

This constant influx strains their operations and impacts the availability of essential drugs. Dr Okello added that due to funding limitations, a staff reduction had led to overwork and extended hours for the remaining staff.

Solution

Dr Naluwairo said to address the water issue, the Ministry of Water and Environment is constructing a water system from River Kagera to supply water to Isingiro residents. “Our hope lies in the completion of this project by the ministry, which will provide clear and safe water to the people,” he said.

Dr Okello added that they have also trained 136 care group mothers who are assisting in identifying malnourished children and making necessary referrals.  

Godfrey Kaviiri, the commandant of Kyangwali Refugee Settlement in Kikuube district, home to 136,306 refugees, said the district has significantly benefited from health services originally intended for the refugees.

“Partners have constructed health facilities and employed staff from both the host and refugee communities, enhancing the overall health sector,” he said.

Amlan Tumusiime, the Kikuube resident district commissioner, acknowledged that partners have been crucial in managing disease outbreaks like cholera and Ebola.

“They were instrumental during the COVID-19 crisis, providing all the necessary support we needed as a district,” he said.

The Sustainable Development Goals (SDGs) target for maternal deaths is for a global maternal mortality ratio of less than 70 maternal deaths per 100,000 live births by 2030.

Kalyoma

The global maternal mortality ratio in 2020 was estimated at 223 maternal deaths per 100,000 live births, down from 227 in 2015 and 339 in 2000.

During the Millennium Development Goal era from 2000 to 2015, the global annual rate of reduction was 2.7%, but this fell to negligible levels during the first five years of the SDG era (from 2016 to 2020).

Emergency Obstetric Services

In obstetric emergencies, timely access to appropriate medical care can mean the difference between life and death, Dr Isaac Opio, the head of the maternal and child health department in Rwamwanja Refugee Settlement, said.  

“Emergency obstetric services are available and accessible within the settlements, including transportation arrangements for urgent referrals to higher-level healthcare facilities if needed,” he said.

Rwamwanja Health Centre IV in Kamwenge district is a high-volume facility, handling 360-400 newborn deliveries each month. Records indicate that the outpatient department attends to over 100 patients daily. The facility boasts a fully equipped modern theatre where at least 100 expectant mothers deliver their babies each month.

“Obstructed labour is the primary reason for most of the caesarean sections we perform at Rwamwanja Health Centre,” Dr Opio said.

Opio

Mothers share their experiences

Jane Nsombe, a former nurse at Masango Health Centre in DR Congo, is now a refugee.

Nsombe said when she sought care at the health facility, the chances of saving her baby were limited.  

“I had severe bleeding, high blood pressure and malaria. The nurses at Nakivale Health Centre III told me during an antenatal visit that these conditions were the leading causes of maternal deaths.

“Upon my arrival here, I was put on bed rest and received treatment, which enabled me to give birth to a healthy baby. This would not have been possible without proper medical attention,” she said.

Nsombe urged the Government and partners to increase resources for maternal health, especially in vulnerable communities like refugee populations.

Sharon Akampwera is expecting her second child. “The last time I came here to give birth to my firstborn, I received exceptional care. The health workers were very professional and friendly. The facility has continued to grow and develop, introducing more modern medical equipment and services,” she said.

This story project is supported by WAN-IFRA Women in News Social Impact Reporting Initiatives grant. However, the views expressed are not those of the sponsor.