The numbers for maternal mortality are dire in Uganda, with as many as 16 women dying daily, because of pregnancy/delivery-related causes. The UN Human Rights council, in June 2009, issued a historic resolution that explicitly recognised preventable maternal mortality as a human rights issue.
Our Parliament, in collaboration with the civil society coalition on maternal, newborn and child health, issued a statement on maternal, newborn and child health to the 126th Assembly of the Inter Parliamentary Union in March 2012, which upheld the right to life and to the highest attainable standard of physical and mental health, as an internationally-recognised fundamental human right.
For long, I carried misgivings against the medical profession especially those in reproductive health, because of what happened to my mother at Mulago hospital, 28 years ago. I recall the horror stories of how my mother lay in agony, seriously bleeding while all staff around seemed unbothered. They ignored her cries for help until she died. Thankfully, her child survived and is now a certified medical doctor.
My story is about accountability in regard to maternal mortality and I want to focus on the human rights aspect. Uganda is a signatory to many international conventions which provide for maternal health yet we still have 16 women dying daily. Why?
Are the health workers all negligent? If you have noticed, at least once a week, a newspaper carries a story of a maternal death in one of our health units. A constitutional petition of 2011, brought by CEHURD (an NGO that advocates for the right to reproductive health in Uganda), filed a Constitutional petition on behalf of Sylvia Nalubowa and Jennifer Anguko, two of the many mothers who have died in government health facilities during birth.
The petition blames the deaths on the manner in which hospitals and medical staff in the country are managed, and on government’s failure to provide basic healthcare to expectant mothers. The petition was dismissed but an appeal has since been filed. Newspapers have reported stories of poor equipment, negligence by midwives and mistreatment of expectant mothers at health centres.
While I do not doubt the veracity of these claims, has anyone paused to think about the bigger picture? Are the midwives and nurses to blame for what is wrong with the health system? (Daily Monitor of August 6, 2012 reported about a 20-year-old expectant mother who died in labour as the doctor allegedly asked for Shs 700,000 at Jinja referral hospital.)
Otherwise, the story of Esther Madudu, a midwife in Uganda’s rural Soroti district, is an exception to the negative reports on health workers. Dr Anthony Mbonye, a health commissioner in the ministry of Health and a world-renowned scholar on maternal health, is quoted as having said: “death resulting from pregnancy-related [complications] is a big issue in Uganda that requires urgent attention, yet these deaths are preventable with improved access to [quality] healthcare to the population and… positive attitudes towards… health workers.”
Leslie London, a writer on maternal health, opines that frontline health workers are frequently unable to provide access to care because of systematic factors outside their control, and because management systems disempower them from acting independently and effectively. Most of the negative incidents in regard to individual health workers focus on the conduct of the health workers, divorced from the situation they work in, and this results into a blame game.
In Uganda, we seek to find a health violation that has occurred; we seek to find a violator who made that violation occur for purposes of individual punishment. But there is really no need to find scapegoat in a health worker so as to pacify an ignorant public that is up in arms. When a health worker could have done nothing to save a woman, placing blame and liability on him/her distorts incentives and diverts attention from the systemic problems that would have caused the woman’s death.
For instance, there may have been a delay in going to the health facility, caused by lack of awareness of the danger signs, meaning that an expectant mother only shows up at the health facility when she is already in critical condition; or there may have been lack of supplies, drugs or transportation.
I recall during my initial class in Public Health Leadership, one of the lecturers, a vibrant and enthusiastic gynaecologist, shared a story of how a woman in a rural government health facility required an emergency cesarean, and while in theatre, power went off and the generator had no fuel and the ambulance was sitting on concrete blocks, its tyres long disabled.
The anaesthesiologist lacked anaesthesia to give the woman in order for emergency surgery to occur and the woman pleaded with the surgeon to save her yet the surgeon could not carry out the painful surgery when the woman was conscious. In the end the woman died while begging to be saved. Who was to blame for this?
Imagine the maternal mortality rate ten years back was 505 women dying per 100,000 live births. As per the recent Uganda demographic health survey report of 2011, that figure reduced to 438 maternal deaths (although latest figures now put it at 310). If we boosted our health workers, praised them, gave them incentives, increased their salary, gave them allowances monthly or weekly, wouldn’t that figure come down?
I had a near-death experience almost five years ago during the birth of my first born. The doctor was inducing me and yet the cord was wrapped twice around my son’s neck, slowly choking him to death. The same doctor refused my request for an ultra sound as I had had one two weeks before the inducement and I was already past my due date.
Thankfully, this doctor went off duty and the next one wondered how his colleague could cause an inducement while relying on a scan that was two weeks old. I had an immediate cesarean and five years later, I have a boisterous son and a quick-witted doctor to thank for this miracle.
The author is a Masters student in Public Health Leadership (Save the Mothers), Uganda Christian University, Mukono .