In our continuing series on Uganda and Millennium
Development Goals (MDGs), this week RICHARD M. KAVUMA
focuses on MDG 5; improving maternal mortality.
From her one-room house at Lwanda in Iganga district, Harriet
Kalembe rocks quietly with her three-week old baby, Mirembe,
looking up the iron roof with a shy smile.
“She is fine, except that she has some malaria; but
huuu,” Kalembe sighs as she sits behind the white
net-curtain that divides the room into a living area and
a sleeping quarter.
“It was tough.”
“Tough” is used to describe Monday, November
21 last year. Harriet, only 18, was rushed to Kiyunga Health
Centre, 15 miles from Iganga town, to deliver her first
At 1.00 a.m., the midwife announced that Harriet had a ‘big
baby’. She needed to be rushed to Iganga Hospital.
Luckily, Kiyunga has an ambulance under the Rural Extended
Service and Care for Ultimate Emergency Relief (RESCUER)
“But you see, we had to pay Shs 20,000 for the ambulance,”
recalls Harriet’s peasant husband Dhamba Samuel, 28.
“We thought it was Shs 15,000 but we had no choice.
I borrowed money from friends and thank God we are now fine.”
Many other mothers or their babies, however, never make
it. Only two days earlier, for instance, Farida Bagume had
arrived at Busesa health centre, expecting her seventh child.
Her uterus ruptured and by the time she got to Iganga Hospital,
the baby had died.
But as a nurse at the hospital put it, at least the mother
Ministry of Health figures show that for every 100,000
mothers who deliver, 505 die of pregnancy-related complications.
Although this maternal mortality ratio is better than the
figures of Kenya and Tanzania, it is still very poor when
compared with, for instance, Mauritius (24), Botswana (100)
or Germany (4).
Millennium Development Goal number 5 is to improve maternal
health, with a target to reduce the maternal mortality ratio
by three-quarters between 1990 and 2015. In 1990, Uganda’s
ratio was 523. In the last 15 years it has only reduced
by 18, yet the target is to reduce it by 374 over the next
Another mountain to climb.
The Ministry of Finance, Planning and Economic Development
says Uganda had hoped to reduce the rate to 354 by last
year; we are therefore unlikely to reduce it to the MDG
target of 131 over the next 10 years.
Underlying causes of mothers dying include malnutrition,
short birth intervals, poor health services and early marriages
and first births.
Barely 23 percent of Ugandan women of reproductive age (15-49)
use family planning (compared to 75 percent in many developed
countries). Another 35 percent need family planning services
but cannot access them – either because the supplies
are poor, they can’t afford the services, or the husband
is opposed to family planning.
According to Dr. Angela Akol, head of the Family Life Department
at the Population Secretariat in the Ministry of Finance,
it is critical that more Ugandan women start accessing and
using family planning.
Akol says surveys show that most women who don’t
use family planning fear mythical side effects: Many believe
that you could become infertile, get cancer or have deformed
babies as a result of using contraception.
“These methods have been thoroughly researched and
they wouldn’t be promoted if there was the slightest
indication that they could hurt human life,” Akol
Part of the problem is the lack of funding for family planning
activities. Since 2001, reproductive health has got an average
0.4 percent of the Ministry of Health budget – Shs
933 million in 2002/03. Because of lack of sensitisation,
even some health workers, who are supposed to deliver reproductive
health messages, now believe the dangerous myths.
The result is that besides poor spacing, Ugandan women
are having far too many children for their own good health
– 7 per woman. Yet this statistic doesn’t tell
the whole picture; figures are much lower among the minority
urban and educated women, meaning that the less educated
and poor majority will have over 10 children.
“The more children you have had, the bigger the risk
of complications,” says Dr. Chris Baryomunsi, formerly
United Nations Population Fund (UNFPA) Programme Officer
in Kampala. “The commonest cause of maternal deaths
is severe bleeding and it is more common in women with many
The resolution of last November’s annual health assembly
in Kampala was to improve uptake of family planning. Akol
revealed the Family Planning Working Group, comprising government,
donors and NGOs, was already working on revitalising family
planning in the country.
Under the initiative, for instance, contraceptive methods
like the intra-uterine device that had more or less been
abandoned are being promoted. A training module for reproductive
health has been developed for the Nsamizi Institute, which
produces community mobilisation personnel.
The hope is that once they are in the field, they would
help spread informed messages about reproductive health.
“But we need more funding for reproductive health,”
Other salient causes
Early marriages and teenage pregnancies also play a major
role. Harriet Kalembe, for instance, was barely 18 when
she was admitted to Iganga Hospital, meaning she became
pregnant at 17. About 32 percent of Ugandan adolescents
have conceived at least once. Many end up in delivery complications
or even abortions, which increase the risk of death since
abortion is illegal, and is therefore performed in very
According to Dr. Anthony K. Mbonye, the Assistant Commissioner
for Reproductive Health in the Ministry of Health, some
8 million adolescents require reproductive health services.
The government, he said, is trying to address that by providing
information and services, making sure that health workers
are trained to receive adolescents and counsel them.
“We think if we got funding for these areas to cover
the whole country, address the health system issues like
staffing, making sure drugs are available, making sure the
infrastructure has water and electricity, making sure that
the community monitors the quality of services in the health
units around them, we think we can go a long way in reducing
the high maternal mortality.”
Experts say that the main reason for the maternal deaths
stems from the fact that most mothers are not delivered
by trained medical personnel. While 94 percent attend antenatal
clinics at least once, only 42 percent make up to four antenatal
visits and only 39 percent deliver in health centres.
According to Dr. Mbonye, 15 percent of all pregnant women
anywhere in the world develop complications; Uganda’s
problem is that when mothers get these complications, they
cannot get timely attention.
“When mothers get complications, they cannot easily
access a hospital or facility where there is a competent
person to address that problem,” says Dr. Baryomunsi.
Hariet Kalembe was lucky, first that she lived near a health
centre and that the health centre had an ambulance that
took her to Iganga Hospital. Most of the 505 who die are
not so lucky.
Dr. Mbonye: “The reason mothers die is because the
direct causes of maternal mortality [are of an emergency
nature] and the preparedness at the community, family and
individual levels and of our health units [is not good enough]
to respond to these emergencies.”
In Uganda, the major direct causes of deaths include bleeding
(26 %), infections (22%), obstructed labour (13%), and unsafe
abortions (8%). Other causes like HIV/AIDS, malaria and
heart diseases account for 25%.
“They are emergencies because if not immediately
handled, mother and/or baby will die,” Mbonye says.
“When a woman is bleeding after delivery, she needs
to reach the health unit to receive blood and to address
the cause of that bleeding... As for obstructed labour,
– often because the pelvis is narrow, if the mother
is not rushed to hospital so that a caesarean section is
done, the baby could die or the uterus could rupture and
the woman will die and you lose both.”
This is what happened to Bagume Farida. Her uterus ruptured
but after 10 days in hospital, the mother was saved. Again,
she was able to get to hospital thanks to an operational
The road to the labour ward of a sound health centre is
one only a small percentage of mothers take. The reasons
for failure to go to hospital vary. Often, the family does
not believe that getting the mother to hospital is an emergency,
the hospital is several miles away and transport is difficult.
More often the only available means of transport is a bicycle
or a boda boda motorcycle, none of which is suitable for
a mother already in labour.
“One big problem we have is that the husbands don’t
want to take their wives to hospital,” says Naabirye
Angela Ikiring, who received Kalembe at Kiyunga Health Centre.
“Maybe it is because of poverty, but it becomes a
problem for us…We have the ambulance, yes, but the
husbands have to buy the fuel.”
Just like the Uganda NGO Forum, Kiyunga LC-1 chairperson
Robina Tadhuba argues that poverty is a key issue in maternal
health: “Some mothers are so poor that they can’t
afford the basic necessities of a pregnant woman such as
good feeding,” she said.
Under the RESCUER programme, now in about 20 districts,
UNFPA and the government are trying to address three killer
delays: the delay to transfer mother from home or traditional
birth attendant (TBA) to a local health centre, delay to
transfer mothers to a referral facility and the delay to
attend to the mother once they are in the health centres/hospitals.
The programme sensitises communities about the importance
of skilled medical personnel and healthcare providers in
handling life-threatening situations. Then, TBAs get walkie
talkies to contact the health centre in case a woman under
their care develops delivery complications. The health centres
like Kiyunga, which have base radio communication, can then
dispatch an ambulance to pick up a woman who needs emergency
care. And if the woman needs more advanced attention, the
ambulance can transfer her to a referral hospital.
It also equips theatres so that once mothers are admitted,
they receive quality health care.
Both Baryomunsi and Mbonye stressed the need for massive
family planning campaigns, not least to change the attitudes
of mothers, husbands and even community leaders.
“When you talk to mothers and families, you find
that many do not appreciate the need to [practise] family
planning. They cherish many children,” said Baryomunsi.
Doctors agree that the quality of services needs to improve.
For instance, most health units are understaffed, with only
68 percent of hospital positions filled. The district service
commissions do not have enough money to hire and pay staff.
But even more, many mothers feel the medical staff do not
For instance, some mothers want to deliver while squatting
but your average midwife will not allow that.
“When you go to our health centres… [the health
personnel] are either not there, or they delay or sometimes
their attitude is not very good,” says Dr. Jotham
Musinguzi, director of Uganda’s Population Secretariat.
“Some women see us health workers as not receiving
them very well, not giving them the options that they want.
We have also learnt the women don’t like the way
we make them deliver, they want to take on their own positions;
or sometimes they want a cup of tea or to use hot water
and some of these things are not available in our health
And local perceptions cannot be ignored because they determine
how mothers will respond to government interventions. Some
women refuse to use anti-malarial fansidar during pregnancy
because they think it will affect their pregnancy. Others
prefer to use herbs instead of visiting antenatal clinics
where possible complications could have been detected.
So what must be done to save Uganda’s mothers? Musinguzi:
“Make sure there are enough health workers in the
health centres... make sure the quality of our services
is improved and thirdly, make sure the services we are talking
about like the obstetric care are widely available to all
those women who need them.”
In the end, though, as Dr. Mbonye says, the war to save
Uganda’s mothers must be fought by almost all government
departments, including Defence, Agriculture and Gender.
The Water ministry should ensure safe water and sanitation;
the roads should be fixed so that ambulances can quickly
get to health units; and education is key to ensuring that
family planning is practised and women attend antenatal
As Harriet Kalembe’s experience showed, emergency
obstetric care is often the difference between a mother’s
life and death.
Only in The Weekly Observer Next Thursday: we look
at HIV and Malaria.