“Pregnancy isn’t always a happy time here. So many women, they die. And the other women see it. So when you find out that you are pregnant, you think, ‘Oh no. Maybe this time, it will be me.’ Pregnancy as a death sentence… it shouldn’t be this way.”
A death sentence. As if conception was a crime, pregnancy a trial, and birth, the harsh penalty for a grave offense. The imagery used by the Ugandan midwife, so matter-of-fact, sank my soul to the bottom of my stomach. How could women relate birth to capital punishment? As I quickly learned while leading medical trips to Uganda, birth and death are often simultaneous events...
Worldwide, 1,000 women die in childbirth every day. Every year, 3,000,000 babies are stillborn, 2,800,000 die within 1 week of life, and an additional 1,000,000 by week 3. While recent efforts have reduced maternal and neonatal mortality, they are still staggeringly high in the developing world--particularly in sub-Saharan African countries.
Uganda is among those countries. Besides an alarmingly high maternal mortality rate (560/100,000 live births), all facets of reproductive health are severely lacking. Only 42% of births are attended by a skilled care provider, only 23.7% of people use contraceptives, and 40.6% of people have unmet family planning needs--resulting in an average family size of 7.
While these general statistics are already cause for alarm, conditions are much worse in rural areas of the country, particularly Iganga District. It is the second largest district in the country, with more than 700,000 people, of which more than 85% live in rural farming communities and extreme poverty. The average family size is 8, although it can reach as high as 18 or 19 in polygamous families. There are two paved roads in the entire district (more than 4000 square km). Many homes have no road-access at all, and dirt roads frequently wash away during the rainy seasons. This creates severe transportation problems, which greatly hinders the ability of most people to reach the ONE hospital that serves them.
The Iganga District Hospital, although originally built to serve 200,000 people, now cares for more than 1,000,000 (when also considering neighboring districts that rely on it). There is never enough staff, particularly at night, and supplies and medications run out within weeks of shipments that are intended to last 3-4 months.
These conditions greatly impact maternal and neonatal health. When women go into labor they are required to bring their own supplies for delivery (gloves, IV, needle, sterile razor, etc). Many cannot afford the supplies, and those that don't have them are turned away. It can furthermore take women up to 13 days to reach the hospital, at which point they and their babies often die. Even if they can reach and are admitted to the hospital, the patient load is so high that women are often forced to deliver on the floor or on a metal delivery table that may or may not be sterilized between uses (depending on availability of bleach supply). There are no oxygen tanks in the hospital and only 1 resuscitating device. Power outages are frequent, which prohibit the ability to conduct cesarean sections.
Although there are many NGOs working in Iganga District whose programs are relevant to maternal health, they are largely ineffective. They focus more on education than addressing cultural barriers, strengthening relationships between medical professionals and traditional healers (like traditional birth attendants who are often preferred to clinic midwives), or addressing family planning and STDs in culturally appropriate ways. Of those organizations that do address these issues, projects largely originate from the initiating organization, not from the intended recipients. This alienates local people, and establishes a relationship of condescension, rather than empowerment. Combined, these factors have resulted in very little progress being made in improving reproductive health, for which women, their babies, and families are paying the price.
