Maternal health in Uganda

{User sandbox}}

Maternal Health

Maternal Health as a Capability and Why it Matters

The World Health Organization defines health as the enjoyment of the highest attainable standard of health and is one of the fundamental rights of every human being. Sen adds to that as he said that health is among the most important conditions of human life and a critically significant constituent of human capabilities which we have reason to value.

It has been found that healthier nations, or those with a greater life expectancy and lower infant mortality, see greater economic growth and prosperity. The argument has also been made the other way. That economic growth attributes to healthier nations. It's not just the overall availability of resources that improves health, but the availability the overall public has to those resources. Sen argues that health only improves during economic prosperity if there is a shift in resource allocation towards health and education, equitable distribution of income, and extensive employment programs to decrease the unemployment rate. Severine Deneulin, L. Shahan. "An Introduction to the Human Development and Capability Approach : Freedom and Agency"]. London: Earthscan. </ref>

Sen writes, "The factors that can contribute to health achievements and failures go well beyond health care, and include many influences of very different kinds, varying from (genetic) propensities, individual incomes, food habits and lifestyle, on the one hand, to the epidemiological environment and work conditions, on the other...We have to go well beyond the delivery and distribution of health care to get an adequate understanding of health achievement and capability." Severine Deneulin, L. Shahan. "An Introduction to the Human Development and Capability Approach : Freedom and Agency"]. London: Earthscan. </ref>

UNICEF found that healthy children need healthy mothers. A woman in Sub-Saharan Africa has a 1 in 16 chance of dying in childbirth. The report found that at least 20% of the burden of disease in children below the age of 5 is related to poor maternal health and nutrition, as well as quality of care at delivery and during the newborn period. Yearly, 8 million babies die before or during delivery or in the first week of life. Further, many children are tragically left motherless each year. These children are 10 times more likely to die within two years of their mothers' death. It has also been found that the health of the mother vastly effects the health of all of her children. The health of our mothers vastly impacts the health and success of our future generations.

Maternal Mortality and Morbidity

The World Health Organization (WHO) defines maternal health as the health of women during pregnancy, childbirth and the postpartum period . According to estimates from UNICEF, Uganda’s maternal mortality ratio, the annual number of deaths of women from pregnancy-related causes per 100,000 live births , stands at 435 after allowing for adjustments. Women die as a result of complications during and following pregnancy and childbirth and the major complications include severe bleeding, infections, unsafe abortion and obstructed labour.

Uganda is slow in its progress in the fifth goal of improving maternal health in its Millennium Development Goals. With the 2015 target for maternal mortality ratio at 131 per 100,000 births and proportion of births attended by skilled health personnel set at 100% , Uganda has a long battle in reaching its intended goals. Moreover, the methodology used and the sample sizes implemented by the Uganda Demographic Health Survey (UDHS) do not allow for precise estimates of maternal mortality . This suggests that the estimates collated are erroneous and it is conceivable that the actual rates could be much higher than those reported.

High maternal mortality rates persist in Uganda due to an overall low use of contraceptives, limited capacity of health facilities to manage abortion/miscarriage complications and prevalence of HIV/AIDS among pregnant women. Despite malaria being one of the leading causes of morbidity in pregnant women, prevention and prophylaxis services are not well established.

==Poor Quality of Healthcare Services==

Almost all women in developing countries have at least four antenatal care visits, are attended to by a skilled health worker during childbirth and receive postpartum care. In contrast, only 47% of Ugandan women receive antenatal care coverage and only 42% of births are attended by skilled health personnel. Among the poorest 20% of the population, the share of births attended by skill health personnel was 29% in 2005/2006 as compared to 77% among the wealthiest 20% of the population . The case of Jennifer Anguko , a popular elected official who bled slowly to death in the maternity ward in a major hospital, aptly exemplifies the poor state of maternal health care that is provided to women, even in major urban healthcare facilities.

Despite the national policy of promoting maternal health through promoting informed choice, service accessibility and improved quality of care through the national Safe Motherhood Programme (SMP), it remains a challenge to the Ugandan government as to how it would achieve its 2015 Millennium Development Goals of reducing maternal mortality rates and 100% births attended to by skilled health personnel. In order to achieve future economic growth, it is vital that the population remains healthy.

A study was done in 54 districts and 553 health facilities to determine availability of emergency obstetric care and its related maternal deaths. The study found that few of these units had running water; electricity or a functional operating theater. However having these items was shown to have a protective effect on maternal deaths. The availability of midwives had the highest protective effect, reducing the case fatality rate by 80%. It was also found that 97.2% of health facilities were expected to have emergency obstetric care services, but were not doing so. This is the most likely explanation for the high health facility-based maternal death rate of 671/100,000 live births in Uganda. The study conclude that addressing health system issues, particularly among human resources, and increasing access to emergency obstetric care could reduce maternal mortality.

==Limited Access to Healthcare Services==

Cultural Barriers in Seeking Access

There is not only the issue of lack of resources in healthcare services, there are also cultural barriers in women seeking professional care. A study was conducted in Hoima, Uganda whose aim was to enhance understanding of why, when faced with complications of pregnancy or delivery, women continue to choose high-risk options leading to severe morbidity and mortality. The study found that women considered the use of primary health units and the referral hospital when complication occurred as a last resort. Women reported that a lack of skilled staff, complaints of abuse, neglect, and poor treatment in the hospital and poorly understood reasons for procedures, plus health workers’ views that women are ignorant, also explain the reason many women consider going to a hospital for delivery as a last resort. Ugandan women also adhere to very traditional birthing practices and believe that pregnancy is a test of endurance and maternal death is merely a sad but normal event. This cultural view also hinders the chances of women seeking professional maternal care. In the Kiboga community it is evident that pregnancy and childbirth were one of the major areas where women still command power and status, which they would strive to keep to enhance their status within the household and community.

As stated in studies cited earlier, one major issue in regards to maternal health is access to quality emergency obstetric care and the many barriers Ugandan women face to gain access. A needs assessment of emergency obstetric care was carried out in 197 health facilities in 19 out of 5 health districts in Uganda, covering 38% of the total population. The study found that there were a large number of missing signal function at health facilities and an urgent need to improve the availability of emergency obstetric care. It was found that the improvement of care begins by improving district health workers' skills in emergency obstetric care so they can effectively manage and treat obstetric complications. Part of this training includes hospital staff on how to properly mange data systems to better monitor and evaluate program implementation. An effective advocacy tool, known as REDUCE, has already been developed for Uganda to stimulate policy dialog and strategic planning. The REDUCE tool uses computer models to estimate the human and economic consequences of maternal mortality, and generates data that can be used to create arguments for giving higher priority to maternal mortality reduction in creating policies, strategy development, and resource allocation.

Another factor involving emergency obstetric care among Ugandan women is the cultural desire for Ugandan women to 'protect their own integrity.' A common birthing practice is for women to give birth completely alone and the individual is the one who decides if outside help is needed. It has also been found that women feel they have the most power and control during the birthing process, which is something they often lack in other aspects of their lives. Women are considered to be strong and independent if they can handle the birthing process by themselves. These cultural implications often lead to very dangerous circumstances as the women often delay assistance which sometimes costs their life or the life of the baby. Oftentimes one of these main issues is obstructed labor. When women realize labor is not progressing normally they first seek female friends or traditional birth attendants. This can result in a further delay of seeking medical attention from someone who is trained to handle such complications. A study found that one common remedy used for obstructed labor in home births was herbs. As high as 80% of child births used herbs. Ugandan culture also sees the birthing process as a woman's affair and therefore there oftentimes there is little male involvement. Transportation is also another issue in Uganda. Most families do not own personal cars and cannot afford taxi fairs. More remote and rural areas cannot be reached by car but must be reached using a motorcycle. These conditions are not ideal in transporting a woman in labor, so women tend to choose to stay home during labor. Women also avoid healthcare facilities as this also inhibits their own integrity. They feel that they are powerless in a hospital, have little say in decisions, and know little about procedures being done to them. There is also a lack of medical supplies in Ugandan hospitals and healthcare is run on a fee for service basis. Many women do not have the funds necessary to both travel to a hospital and pay for hospital services and supplies. Or if they do have the funds, hospitals could also be out of supplies. This further discourages them from giving birth in a healthcare setting. There is an urgent need to educate both men and women on the risks of having home or solitary child births that aren't assisted by a skilled attendant. The study suggests that birthing outcomes would improve if men were intimately involved in the process and could assist in making decisions regarding obstructed labor or other complications. The integrity of women could be maintained if health workers were more compassionate and more able to support women and provide understandable information during labor. There is also a great need to improve both access and quality of healthcare offered to the masses in Uganda.

Limited Reproductive Health Literacy

As found in the previous study, many women do not utilized healthcare services because they do not understand reasons for procedures. Health literacy is also a large issue in among women in Uganda. It not only affects birthing outcomes but also information on reproductive care. Another study found that many Ugandan women rely on myths, rumors, and misconceptions that discourage them from using reproductive health services, particularly family planning.

Another study found that even those who attended antenatal classes had very little knowledge of danger signs during pregnancy. An association was found between birthing preparedness and knowledge of danger signs. The most common birth preparedness practice was saving money to faciliatat referral in case of complications. Only 19% of women in the study could indicate at least three danger signs while 68% of them had attended at least four antenatal care visits during their last pregnancy. This shows that of those who are seeking professional care are not receiving or retaining vital information. It was found that women appear to be unaware of the risk they take by subjecting themselves to prolonged labor in the community. The study found that among women who went to antenatal visits 40% had not been advised where to deliver and the staff were allegedly unfriendly. There also seems to be an association between having a delivery by skilled birth attendants and being under the age of twenty. It is hoped that it is becoming more culturally acceptable to give birth with the assistance of a skilled attendant then it is among the older generations. The study concluded that every woman should be made aware of the likelihood of complications during pregnancy, childbirth, labour, and the postpartum periods. There has also been success using mobile phones in HIV programs in Uganda. Since mobile phones are becoming more and more common, it appears this could also be a good route for antenatal education.

Reliance on Traditional Medicine

In rural areas, conceiving pregnant women seek the help of traditional birth attendants (TBAs) due to difficulty in accessing formal health services and also high transportation or treatment costs. TBAs are trusted as they embody the cultural and social life of the community. However, the TBAs’ lack of knowledge and training and the use of traditional practices have led to risky medical procedures resulting in high maternal mortalities.

In some rural areas of Uganda up to 90% of the population uses traditional medicine for day to day healthcare needs. The World Health Organization estimates that 80% of the developing world uses traditional medicinal practices. It was found that over 80% of child births that are conducted at home use herbal remedies in the Bushenyi district of Uganda. Over seventy five plants have been recorded for use to induce labor and some of these plants could be oxytocic. The danger lies in levels of dosage as to whether or not the plants could potentially bring harm to the mother and baby. These medicinal herbs are often used because Ugandans cannot afford western pharmaceuticals. These herbal remedies are also socially and culturally accepted. In Uganda reproductive health issues such as maternal mortality and morbidity, account for the number one disease burden. Perinatal and maternal-related conditions account for 20.4%, malaria 15.4%, acute lower respiratory infections 10.5%, AIDS 9.1%, and diarrhea 8.4%. These conditions account for over 60% of the total burden. In Uganda, it is viewed that a woman who had died in childbirth is equated to a soldier who had died during a war. Maternal death is considered a natural phenomenon and encourages the use of herbs, while undermining safe birthing practices with a skilled birth attendant. Women in Uganda are generally more disadvantaged than men. There tends to be a patriarchal order of communities. Therefore, women have a very limited control of resources and in most cases have poorer health. The study found that dosing and toxicity levels need to be monitored in the use of medicinal herbs during labor. There is a need for further field and laboratory research to establish appropriate dosage levels. Currently the maternal mortality rate in Uganda is 506 deaths per 100,00 live births. There is a need for health provision programs, safe motherhood programs, health policies in reproductive health care, and collaborative approaches involving traditional medicinal practitioners such as traditional birth attendants. It is possible that a lack of knowledge on plant species used to induce labor and speed up childbirth could be one of the main factors that contribute to high maternal mortality in Uganda.

Malaria and Pregnancy

Malaria is a leading cause of morbidity and mortality in Uganda. It is especially lethal among pregnant women and children under five. The mortality rate for all ages is estimated at 32.1% in 2004. A study was done in Mukono, Uganda to discover the most effective delivery system of intermittent preventive treatment (IPTp) for pregnant women. It was found that education was a factor in health seeking behaviors. Those who were a part of the study accessed IPTp early and most of them adhered to the two doses of SP. Women experienced a reduction in malaria episodes, anaemia, parasitaemia and low birth weight. While these results cannot be attributed to the intervention alone, after controlling for age, education, parity, and occupation, there were still significant differences for parasitaemia, reported malaria episodes and birth weight; indicating the importance of access and adherence to IPTp.