Maternal Health at the End of the Road

By Lindsey Pollaczek

For two hours we bump down a dusty red dirt road heading out of Soroti town toward the village of Kagwara, situated at the shore of Lake Kyoga, the second largest lake in Uganda. We are joined by members of AMREF Uganda and Terrewode, two organizations working in the Teso Region to improve outcomes for women during pregnancy and childbirth. AMREF Uganda, a longtime Direct Relief partner, is implementing a safe motherhood project in this region, and works with groups like Terrewode, which was founded in 1999 during the period of civil war to provide support to women and girls who were acutely affected by the conflict. Direct Relief works with indigenous groups like these to improve maternal health care, and today, we find ourselves heading deep into the bush of eastern Uganda, to the end of the road where maternal health complications often arise.

Ugandan women have an incredibly high fertility rate—nearly 7 children in their lifetime. Given long distances to health facilities, lack of means to cover the costs of transportation, and chronic shortage of supplies at all levels of the health system, the majority of births in the country happen in the village at home. Births which occur outside a health facility without the presence of a trained birth attendant are prone to risk and complication. Community sensitization and education is essential to promote the importance of attending antenatal clinics, having a birth plan, and delivering in a health facility, which takes the involvement of community-based organizations to be most effective.

A woman who experiences complications in delivery is in a really difficult spot if she comes from Kagwara village. The nearest health facility providing comprehensive emergency obstetrics care—a cesarean section—is back where we started our journey in Soroti town, two hours away in a sturdy 4×4 vehicle. The thought of making this journey quickly in unreliable public transport, or on a bicycle, is hard to imagine in the best of scenarios. It’s just too far. Add to that a woman who has been in labor for two or three days and you begin to understand why maternal death and disability remains high in this country. While there is a health center closer to the village which should be able to provide this service, there is no doctor that is on staff to oversee the operation.

If the delays in receiving a cesarean section are too long—delay in deciding to seek care when complications arrive, delay in reaching a facility where the procedure can be performed (for the laboring woman in Kagwara, only in Soroti General Hospital), and delay in receiving care at the facility (at Soroti General there is one theater that performs over 2,000 major operations every year)—major injuries, such as obstetric fistula, can develop. A woman left incontinent of urine and or feces due to obstetric fistula is a severe and heartbreaking consequence of lacking obstetrics care.

“We are mopping the floor but the tap continues to leak.”

The women in Teso Region are fortunate only in that competent fistula repair services are available at the regional referral center. Under the guidance of the consultant specialist Dr. Fred Kirya, about 50 women receive treatment annually. But here, like at all levels of the health system, there are challenges: lack of special supplies for the repair, the burden on the healthcare workers to take on additional work with no commensurate pay, and the demand on the one incredibly busy operating theater. Considering the barriers a woman with fistula will be confronted with all along the way, if she receives the repair it is truly a thing to be celebrated, as this is a procedure that is completely life-restoring. However, for every woman who is repaired, another will develop a fistula unless comprehensive improvements in obstetric care are made. Dr. Kirya acknowledged the great value and importance of fistula repair and his belief that there are many women with the condition which have not yet been reached. However, the preventive component is essential, because as he put: “We are mopping the floor but the tap continues to leak.”

Back in the village of Kagwara we talk with Terrorode volunteers and their local affiliate TEETE, a group of 26 community members concerned with uplifting the economic and health status of their people. Terrewode volunteers demonstrate the education which is provided on use of the mama kit—very basic delivery supplies including sterile gloves and blade, which can reduce the chance of infection and be a lifesaver for mother and child. In just two months since being trained by Terrewode, the volunteers have identified six women with fistula in their village and surrounding area. One of the ladies identified and educated about her condition sits quietly during the meeting—she has agreed to get treatment but is still unable to afford the transportation to the hospital. I fight the urge to put this woman who has already been through so much in our vehicle and drive her straight to the hospital; we discuss potential solutions to remedying this so that once a woman is identified and agrees to be treated, she can get the care she deserves.

We return by the same dusty road at dusk, whizzing past villages filled with children and pregnant mothers. I imagine the clock ticking down to the arrival of labor pains—I hope for the best outcome, but fear the worst. The challenges for a woman to receive proper care during her pregnancy and delivery are stark and myriad: distance, poverty, education, and a health system in need of serious repair. We at Direct Relief are working to equip midwives, doctors, and surgeons and the health facilities where they operate. This includes midwife kits (see above photo) which include basic materials for outreach to remote, lower-level health facilities; equipping the operating theater at the Health Center IV (one level below hospital) so that comprehensive emergency obstetrics care can be provided, bringing cesarean section capacity closer to the mothers while easing the demand on the hospital for this service; and equipping surgeons with tools for fistula repair.

During this brief visit, we have also identified areas where we hope to provide additional resources, working through local groups like Terrewode and AMREF at the village level and through government health centers and regional referral hospital. Our input alone will not solve all of the issues–deep-seated cultural, economic, and political challenges—but with these committed organizations and people, we’re moving toward improving health for mothers in pregnancy and childbirth.

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