Involving men in maternal health

By Ronald Musoke

Will it work where most of the community thinks pregnancy room is a woman only issue?

When Janet Aloyo and her newborn baby died in the corridors of Gulu Regional Referral Hospital in northern Uganda on July 31, health workers were blamed for failing to attend to her in time.

When Remmie Wamala, the coordinator of a loose parliamentary forum for children and member of the civil society committee on Maternal and New-born survival, died later at the country’s top medical facility, the International Hospital Kampala (IHK), it was not so easy to explain why.

Unlike the 24-year old Aloyo who died alone, IHK said Wamala was having her fifth child and was attended to by a host of top medical personnel.

Both were added to the faceless statistic of 16 mothers who the government health technocrats know are dying every day due to pregnancy-related complications.

“When a woman gets pregnant in Uganda, they put one foot in the grave and literally struggle not to have the other there,” says Dr. Charles Kiggundu, a consultant Gnaecologist and Obstetrician at Mulago Hospital.

Dr Ian Clarke, the executive director of IHK agrees.  “A mother can die at home, at a smaller health facility or even a bigger health facility because of so many things,” he says.  Although maternal deaths have been declining in Uganda, latest WHO figures show that up to 438 mothers die for every 100,000 delivered babies.

This means Uganda will not beat the fifth Millennium Development Goal set by the UN in 2000 that seeks to cut back expectant mothers’ deaths to at least 135 per 100,000 live births by 2015. International health experts now say Uganda will most likely attain that target in 2031.

Asia Russell, the director of international advocacy at Health GAP, a US-based health rights NGO says there are four major drivers of deaths of expectant mothers in Uganda; unsafe abortions, haemorrhage, obstructed labour and sepsis.

These occur because hospitals lack transfusion blood, manual vacuum aspiration kits, and critical medical personnel like midwives and nurses.  But another cause of women dying, especially in the rural areas is, according to Dr Kiggundu, due to the irresponsibility or negligence of their partners who do not understand the gravity of the problem when for instance a woman goes into labour.

Community involvement

He says since Uganda is largely male-headed, the time to bring men to fully participate in the reproduction process is now.

“We need each other to reproduce and we need each other’s support to reproduce safely. Men and women have complementary roles as far as the reproduction process is concerned,” he says.

“Since women carry the burden of pregnancy and motherhood, men must carry the burden of fatherhood with its responsibilities,” he adds.   He says the government needs to identify and regularly remind men of their fatherhood roles. Men involvement, he says, could help women space children, access pre-natal, obstetric and post-natal care.

Dr Sam Lyomoki, the Workers MP who has previously worked as Chairperson of the Social Services Committee in Parliament wants the involvement of men in maternal health pushed even farther, as happens in Rwanda.

In Rwanda, he says the government has deliberately involved the communities to the extent that if a woman died due to pregnancy related causes, the husband, neighbours and local leaders are answerable.

“In Rwanda, if a pregnant woman died, it is a serious matter, and therefore community participation is strong…We don’t have that consensus here in Uganda yet,” Lyomoki told The Independent in an interview.  Dr Margaret Mungherera, the president of the Uganda Medical Association agrees that the population needs to be mobilised to reduce mothers dying.

“Had all the stakeholders been effectively mobilised,” she says, “Uganda would have succeeded in beating the target even with the little resources that go into the sector.”

Lyomoki whose committee visited many countries around the world to attempt benchmark best maternal health practices was also impressed by the Sri Lankan model.

He says while in Uganda medical personnel wait for mothers to come to the hospitals, in Sri Lanka, maternal health care tremendously improved when the government trained midwives based in the communities. These do basic diagnosis, remind mothers about antenatal visits, do immunisations, and refer emergency care to the hospitals.

According to John Wakida, a registrar at the Uganda Nurses and Midwives Council, only 20% of health workers are working in rural Uganda, while 80% are based in the urban areas. On the contrary, 85% of Ugandans live in rural areas.

To plug the gap in rural healthcare, the government created Village Health Teams (VHTs) similar to Sri Lanka’s midwives but, Lyomoki says, many of these are ineffective due to inadequate funding.

“Beyond rhetoric, health has never been taken as important and the political leadership has not been so much useful to functionalize the health system,” he says.

Although it is a signatory to the 2001 Abuja Declaration agreed by African governments to increase health funding by at least 15% of their budgets, Uganda has failed to even make it 10%.

Teopista Kabalisa, a senior nursing midwife who is also the secretary of the Health and Safety of Uganda Nurses and Midwives Union is a victim of this underfunding.  Kabalisa says in her senior position, she earns about Shs 500,000 every month, which is far below the cost of living.

She says this meager salary is expected to cater for her rent, transport, and uniform. She says many of her colleagues in rural stations are even worse off because some walk up to 10 kms daily to their work stations.

“Then she [nurse] will find a long queue of dying patients waiting. And she has to contend with the lack of supplies.”

Dr Mungherera wants the nurses to be compensated for their work.  “These nurses are expected to work on weekends and at night and yet they are not getting any on-call allowances,” she told MPs during a recent civil society symposium designed to push for more funds.

The strategy is working. Last year in September, the government provided an extra Shs 49.5 billion in the budget specifically to recruit 10,231 professional health workers. Salaries for medical doctors at these two health centre tiers were also enhanced from Shs 1m to Ushs 2.5m per month to strengthen their retention.

Next the lobbyists are asking the government for another Shs84.5 billion, Shs 43.5billion of which should be invested in the enhancement of junior staff salaries. They also want Shs 41billion to be provided in the health budget to cater for water, electricity, fuel for ambulances, and other critical inputs for health facilities.

Civil Society Demands

• Improve oversight of private health facilities.
• Start public complaints system that is easily accessible to particularly poor rural women.
• Follow up on the recommendations given in the maternal death audits.
• Presents to Parliament an annual audit report on expectant mothers’ deaths.

Table shows number of women dying due to pregnancy related issues