High maternal mortality: Where is the problem?

By Joseph Wasswa

The country was awakened by the unfortunate death of a mother in Mityana Hospital having bled out (Post-partum Hemorrhage) due lack of a blood giving set at the hospital.

This is one of the many causes of maternal mortalities that have robbed us of our mothers leading to the observed high maternal mortality ratio (MMR). Most maternal deaths occur due to the poor quality of care.

This must be an embarrassment to all stake holders in maternal health as we have all along been requesting mothers (accompanied by their husbands) to use health centres to be attended to by qualified health professionals, in which case that is what this couple did! The condition (PPH) that killed this mother is among the top two main causes of high MMR in Uganda.

Therefore, it was a grave oversight by the workers to admit the mother without ensuring that every item of the required comprehensive emergency obstetric and newborn care (CEmONC) package was available given that this was a hospital, as trained health professionals what was their plan in case this emergence (PPH) occurred having started the delivery process without this very significant item knowing how fast PPH can kill a mother!

Equally, the other greatest concerns remain availability and affordability of essential medicines on a sustainable basis, currently a responsibility of National Medical Stores (NMS).

Someone should be held responsible for the death of Nansubuga because between NMS and the staff responsible for ordering medicines at Mityana hospital, one was responsible for the unavailability of this blood giving set.

I only hold attending staffs accountable for not referring the mother having realized that they missed such an important item to carry out their job professionally at a level of a hospital.

Efforts should be made to ascertain that the hospital ordered for these medicines on time but NMS just failed to deliver and vice versa! 

Why is it that whenever there is a maternal health death due to lack of an item or public outcry due to drug stock outs, with in two days or less medicines find their way to the affected facility and the question becomes how NMS manages to receive, sort, confirm, pack and deliver these medicines with such utmost urgency?

Similarly, while it was a good move for Uganda to be a signatory to the Abuja Declaration of 2001 where participating African governments committed to allocating at least 15% of their total annual government budgets to the health sector by 2015, also calling upon donor countries to meet their commitment of devoting 0.7% of Gross National Product (GNP) as official development assistance and cancel African external debt in order to allow increased investment in the social sector, up to now the share of the health sector is below this required percentage and worse still, most of this budget allocation goes to the other departments compared to the reproductive/maternal health services.

Way forward

The Government policy on drug procurement for government facilities is that this is solely a responsibility of NMS (and I truly support this) but I think there should be an evaluative discussion between government and NMS to improve on the terms of references (not revoking the policy) but to find out how NMS can be more effective and efficient while executing this-not-so-easy mandate.

Similarly, although decentralisation of health services has helped a lot to improve maternal health services closer to people not mentioning the empowerment it has given health workers, health managers at District level should find means of improving maternal health indicators in their respective Districts which calls for them to;

carry out more participative support supervision of staffs, devise means of carrying out capacity building of their staffs prioritising maternal health not forgetting some financial and material resource management courses.

In line with the above, as health workers we should not only refer patients presenting with conditions above our qualifications but also those cases where we realize we miss any item on the Basic emergency obstetric and newborn care (BEmONC)-seven essential medical interventions, or ‘signal functions,' that treat the major causes of maternal and newborn morbidity and mortality:

1) antibiotics to prevent puerperal infection;

2) anticonvulsants for treatment of eclampsia and preeclampsia;

3) uterotonic drugs (e.g., oxytoxics) administered for postpartum hemorrhage;

4) manual removal of the placenta;

5) assisted or instrumental vaginal delivery;

6) removal of retained products of conception; and

7) neonatal resuscitation for Health center IIIs and below and for Comprehensive emergency obstetric and newborn care (CEmONC) add on;

Blood transfusions, surgery (e.g., cesarean section), neonatal intubation and advanced resuscitation (intubation and respirator available) for Health center IVs and above, unless we just want to continue regarding these maternal mortalities as a mere statistic than as tragic.

Further still, although I give government credit for the abolition of user fees in all government health facilities we need campaigns to reach families; either to step up the use of family planning or accept to start saving some money for regrettable eventualities which may just require some little money to solve at both government and private hospitals.

With the Public-private partnership for health reform hence co-financing of the health sector, my opinion is that government and partners should gradually shift their focus in terms of funding maternal services to the rural communities as they either cannot completely afford services in private facilities or even the few who can afford cannot access private services leaving them with only one option of using government centers as compared to their counterparts in urban areas.

Besides, meaningful interventions are required; to control corruption, accountability and regulatory quality as these are serious problems affecting maternal health services in Uganda.

As well and quite important, is the need for thorough research putting emphasis on the different community cultures, needs and beliefs otherwise resources are sometimes wasted on some strategies which fail to yield any intended result in the struggle to improve maternal health indicators.

The writer is a medical practitioner; Public Health Specialist)

Email: josy28was@gmail.com