BY GILLIAN NANTUME
Wednesday October 23, 2019 was Stella Chepkemoi’s second last day on earth. Several days before her death, Chepkemoi, who was 34 weeks pregnant did not feel any foetal movements. A scan would have helped her detect any problems with the pregnancy, but the hospital near her home had none. In fact, Bukwo, the district where she hailed from–at the border with Kenya has only one ultrasound machine, which is located at a private health facility. The facility charges Shs30,000 (about $8) for its use—an amount that is prohibitive for most people like Chepkemoi.
And so, on that fateful day, a nongovernmental organisation, Hinds Feet Project was holding a free health camp at Bukwo Health Centre IV. They carried along a portable M-scan—a low cost mobile phone based ultrasound system and Chepkemoi lined up with 79 other pregnant women to use it.
Innocent Menyo, a medical radiographer received Chepkemoi into the tiny room where he was working.
“There was no cardiac activity coming from the foetus. Actually, the baby had died and her uterus was going to rot if she had not come to the hospital. I referred her to the resident doctor, who recommended that she be monitored and then later induced,” Menyo recounts of what happened that day.
A few hours later, Chepkemoi was induced by a midwife and delivered the dead foetus. But she lost a lot of blood. The entire district did not have any blood and Chepkemoi was referred to Kitale County Referral Hospital in Kenya. She died in an ambulance on her way to Kitale.
Chepkemoi became part of the statistic of Uganda’s maternal mortality—where up to 16 women continue to die every day due to pregnancy and childbirth related complications. Most of the deaths are from causes that can be easily preventable.
Human rights organisations say failure to provide essential maternal health services and commodities at government health facilities is an infringement on women’s right to health and life as guaranteed under the Constitution and other international human rights instruments such as the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) to which Uganda has signed to.
A landmark petition filed in 2012 against the government by the Center for Health, Human Rights and Development (CEHURD), Mr Valente Inziku and Ms Rhoda Kukiriza hopes to compel the government to be held liable for failure to provide adequate maternal health services and commodities in public health facilities. The case is currently before the Constitutional Court awaiting judgment.
Back to Chepkemoi’s case, one wonders why was referred to Kenya for a blood transfusion–58 kilometres away. Bukwo District does not have a single tarmac road. And, with its numerous hills and steep slopes, the dirt roads are uneven, slippery, and muddy and become impassable in the rainy season. Getting to the nearest districts such as Mbale and Kapchorwa also become difficult with the poor state of the roads.
Sarah Atiang, a midwife at Bukwo Health Centre IV, says the roads are so bad that some women end up delivering their babies on the road, before they can reach a health facility.
“We have had cases of women who deliver on the road but the placenta does not come out. By the time she arrives here, she is paper white. There is also the perennial blood shortage in the eastern region. What if we refer such a woman to the nearby districts, only to find that there is no blood there as well? To be on the safe side, patients prefer being referred to Kenya,” she says.
Although the road from Bukwo to Kitale is also muddy and slippery during the rainy season, residents prefer it because it has less steep slopes and sharp corners.
On the night Chepkemoi died, we were traveling to Bukwo using this road, but at Endebess—at about 1.30am, our car got stuck in the mud and we had to spend the night in the car. The ambulance that was transporting Chepkemoi to Kitale bypassed us along the way. Unfortunately for her though, she did not make it on time to be saved.
Although the government announced in 2016 that it was earmarking
Shs395 billion to tarmac the Kapchorwa-Bukwo-Suam road, do date no work has commenced.
This has also made it difficult for lower health facilities to make referrals within the district, in the case of an emergency.
Besides roads being in poor state, Irene Cheptegai, a nurse at Chesimat Health Centre II says the district has only one ambulance, further contributing to an already dire problem.
“If a mother is bleeding excessively, we convert a chair into an ambulance and carry her on it to Kortek Health Centre III, which is eight kilometres away. In the rainy season, the roads disappear so you will not find a vehicle or a motorbike willing to be hired to transport an emergency case,” she explains.
Bukwo District rarely has blood. The general hospital, which serves a catchment area of over 150,000 people, is entitled to 15 litres of blood supply every fortnight. However, Dr Collins Satya, the district health officer says the blood is not enough to meet the demand, especially in cases of emergency and also because of the shelf life of the blood.
“We get blood from Mbale Regional Blood Bank and store it at Bukwo General Hospital. But blood has a short shelf life, so either the units get used up within ten days, or they expire. We cannot replenish it immediately because of financial constraints. We do not have the fuel to drive to Mbale to restock,” he says.
Patients also often have to foot the cost of fuelling the ambulance, in the event of a referral. A referral to Mbale and Kapchorwa districts cost Shs250,000 ($69), while a referral to Kitale Hospital in Kenya costs She200,000 ($55). With majority of people engaged in subsistence agriculture, this is a cost above what they can afford. Many end up selling the only available asset they have—land, to foot the bills.
“You either fuel the ambulance or you die,” says Dr Satya.
Bukwo General Hospital receives Shs105million ($29,166) annually from the government but three quarters of this money goes to paying service providers. Only a quarter is spent on operations, such as buying fuel for the ambulance.
“It is very costly for us to find the money to fuel the ambulance to pick blood. It is only when a patient is being referred to Mbale Hospital that we squeeze our laboratory personnel onto the ambulance. This is because the patient has to fuel the ambulance at his or her own cost. If there are no referrals to Mbale, we go without blood,” Dr Satya says.
All these challenges are contributing to the poor maternal health outcomes in the district.
According to the annual Health Sector Performance Report, Bukwo General Hospital was among the hospitals with the highest facility based maternal death ratio in the 2017/2018 financial year—with a maternal death risk of 615 per 100,000 deliveries.
Statistics from the district also show that that only 47 per cent of pregnant women give birth in health facilities. This is an improvement from 36 per cent for the past several years.
Dr Joseph Mangusho, a medical worker at Bukwo General Hospital, says, diagnosis is an important part in the life of a pregnant woman.
“If a mother develops a problem in at a lower health centre, by the time she is referred, she may have developed complications. Today, at the health camp, that portable ultra sound machine has saved many lives, including that of the midwife. She is pregnant but she did not know that she was expecting twins,” said Mangusho,
Dr Satya says the lack of an ultrasound in the district has heavily affected the provision of proper maternal care.
“Many women in this district go through pregnancy without having an ultrasound examination. Many times, we perform C-sections through guesswork. Sometimes, you enter the theatre thinking you are going to deliver one baby by C-section, only to find that the expectant mother is carrying twins, and you have to make fresh provisions for that,” Dr Satya says.
What can stop this problem?
In Uganda, the leading causes of maternal death are haemorrhage, unsafe abortions and eclampsia. In the last 20 years, the country has reduced its maternal mortality rate by 20 per cent.
Dr Olive Sentumbwe-Mugisa, the Family Health and Population Advisor at the World Health Organisation says every woman has a role to play in her own health.
“There are three delays that could lead to maternal mortality and the first one is at the individual level. Women need information about their pregnancies. Some women think that the way their grandmothers delivered is the way they will deliver, but they need to be told that every pregnancy is different and it is best delivered in a health facility because you cannot predict what kind of complication you might have,” says Dr Sentumbwe.
She says there should also be a commitment to address the factors that relate to the movement of pregnant women – or the lack of it. For instance, the mobility problems, and lack of proper roads in Bukwo District are almost the same in the rural areas of the country.
“The transport and communication arm is a critical factor in saving the lives of women who develop complications and need to be transferred to a better facility. Town dwellers may have the option of using motorcycle taxis, but we know that when you have an obstetric complication, a boda boda may not be the best means of transport because by the time you reach hospital, the complication may be worse,” Dr Sentumbwe says.
The state of maternal health is considered a litmus paper for how a country values its women and their health—and unless Uganda makes serious commitment to invest in healthcare systems, ending maternal mortality will remain an uphill task.
BY GILLIAN NANTUME