How Nakapiripirit has pushed up hospital births

PIC: Epou giving Nakut instructions while demonstrating how a birth cushion is used during delivery. The birth cushion was developed to give mothers their preferred position option. (Credit: Maria Wamala)

Our white double cabin Toyota pick-up truck pulled into the chain link fenced compound of Natirae Health Centre II in Lolachat sub-county, Nakapiripirit district, in northeastern Uganda.

A young man in a white coat stood at the end of the small block to receive Dr. John Anguzu, the district health officer, as he took round a ‘Midwifery4all' campaign team to see for themselves how services for mothers had improved.

With his quiet, unassuming demeanour, Emmanuel Epou could pass for a Senior Six student, but he is in charge of this health facility, assisted by two nursing assistants. He leads us to his small labour ward. It is spick and span.

The five of us have to negotiate our movements around each other to avoid bumping into each other and messing up his neat unit. A comprehensive nurse by training, it is here that Epou delivers an average of 30 mothers every month. However, a year ago, this was not so. There was no skilled health worker to handle deliveries and most of the mothers delivered with the help of traditional birth attendants (TBAs).

"TBA deliveries have reduced. TBAs now work as transporters or escorts of mothers to the health facility," Epou explains.

For each mother accompanied to the health unit, the TBA gets a transport voucher worth a few shillings that she can get a refund for. The TBAs have largely complied and understand why they can no longer deliver mothers.

"We were told that we were not hygienic, yet we lacked gloves. At the hospital, the mothers get a mama kit, free basin and soap. It is better for them," says Jennifer Nakut, now an ex-TBA at Tokora, who claims to have last delivered a mother four years ago.

Mothers' health seeking behaviour has also improved. Kodet Nakut is one such mother. She sits quietly outside the building, her blue sleeveless top concealing her fourmonth pregnancy under her pleated skirt. She has a fever and came earlier in the morning to the health unit for treatment.

Epou invites her into the ward to help demonstrate to us how a birth cushion is used to deliver mothers. Cognisant of traditions where women squat or kneel to have their babies, the birth cushion was developed for use in health facilities to give such mothers their preferred position option.

It is a more private position.

The midwife sits by the mother's side as she holds onto handles at the side of the cushion to assist her to stabilise her position as she pushes. The midwife receives the baby from between the mother's knees, puts it on her chest before cutting the cord and taking it away.

Nakut obediently follows Epou's instructions as he demonstrates how the cushion is used. She is a mother of two, but doesn't appear to be comfortable with the cushion, so we ask what she would prefer during labour — the delivery bed or the cushion?

"The bed," she says pointing at it, "because it would allow me to have my baby lying down. That is how I had my two."

As Nakut stands to leave, Dr, Anguzu stoops over her and pulls down her lower eyelid to study the colour of her eyes. He then asks her to show her tongue. It is almost cream white. "Has she been dewormed and given supplements?" he asks.

Here, Epou showing off the birth cushion, which gives mothers more privacy during delivery. (Credit: Catherine Mwesigwa Kizza)

Epou explains that this is Nakut's first antenatal visit and that he was going to give her the drugs. Nakut had malaria and had come for treatment, but the facility has run out of malaria drugs. However, UNICEF recently delivered some drugs for the village health teams.

"We may have to use some of those and replace them when the government stock is delivered," Anguzu mutters to himself. Behind the single block of the health centre, a group of mothers and their babies sit patiently under a tree as their babies are weighed, before they can be given nutrition supplements. All this activity brings pride to the district staff.

When Anguzu moved to Nakapiripirit district in April 2008, only 2.9 of 100 mothers delivered at health facilities.

"There were no proper maternity wards; what they had were like small offices," Anguzu describes the state of the health facilities then.

Today, they have eight standard maternity wards. UNICEF furnished them with beds and mattresses. Health Centre III maternity wards now have at least 10 beds each. Health facility births in this Karamoja region, have gone up to almost 60%, above the national average of 57%.

However, antenatal care visits dropped to 77%, from 90%, in the last financial year. And women who complete the four visits are only 29% of pregnant women.

"They start antenatal care visits late so they do not complete all the four visits, but this doesn't stop them from delivering from hospital," Anguzu observes.

He adds: "When a midwife is not there, they do not come. They have realised that going to the health facility helps them avoid certain risks." Anguzu explains that some health workers leave their stations to go to school without notifying the district office, creating gaps that affect service delivery.

"We have adopted a policy that no health facility run by a doctor should at any one time be without a doctor and this is helping," he says.

However, for midwives, it is difficult to ensure this happens. Some of the health facilities are 100km away. When contacted, health workers tell lies on phone. So the district has devised a new method - monthly report reviews. If a report has no antenatal attendance record, it means no clinic was held.

This is an indication that the midwife was not at station and would be required to give an explanation for their absence. The district now has 17 health centres, two of them functional health centre IVs, able to carry out caesarian sections and blood transfusions.

"We used to refer such cases to Matany Hospital. But during the 2008 end of year party, I joked to the team when they asked for an ambulance, that I would be the first person to conduct surgery in Nakapiripirit," Anguzu says.

So, they started putting together what they needed with the few resources they had, but without a start date in mind, until one day the inevitable happened. A mother in labour, expecting her seventh baby, was referred from a lower health unit. She arrived at night. There was no ambulance and driver. They had no sutures, but there was an anaethetist.

"We went to the stores and started looking for materials. We found something that looked like sutures. At midnight, we carried out the surgery.

A week later, I received a phone call. It was the mother. She wanted to know what my name, Anguzu, meant. I told her it was from West Nile and meant "one coming from far away."

She named her baby Anguzu. And since then, several "little Anguzus" as Sister Jane Margaret Atai likes to call them, have been saved in Nakapiripirit and more are likely to escape death at birth as more young locals, like Epou, enroll for medical courses and return to work in their home district.

(This story was originally published in the New Vision newspaper on Monday, May 11, 2015)