Agnes KABAIKYA | 28/09/2022
Vicky Abalo 30 yrs lost her 6th
baby on her way to hospital. She delivered along the way before she could reach
the hospital. It was a complicated delivery, the baby coming with the leg and she
bled heavily. Vicky was lucky the ambulance picked her and took her to Anaka
hospital for immediate attention. According to Josephine Okumu, midwife in
charge of maternity at Anaka Hospital, she says Vicky delayed to come to
hospital and by the time she made the decision to come to hospital, it was
late, she lost the baby during delivery. The midwife says, Vicky arrived with
post-partum haemorrhage and was given more blood.
Sarah Atim delivered a dead baby
on her way before she could reach Langol Health Centre. she bled heavily during
the delivery process. From Langol health
facility she was referred to Anaka General Hospital for further specialised
attention where she arrived with a retained placenta. On arrival at Anaka hospital, she was
immediately taken to theatre and the placenta was removed. Kenneth Ojara,
Ambulance Driver at Anaka General Hospital, confirms that the ambulance was
called at 12.13 pm and he arrived in record time to pick her at 1.18 pm to save
her life. The situation is not different
for Eva Kiden 36 years, who also being attended to at Anaka hospital when I
visited the hospital where she was assisted to deliver her 5th baby.
She was referred to Anaka hospital with an abnormal lie of foetus and with
foetal distress on a motorcycle from Gonycogo Health Centre, 40 kms away. She
was referred on a motorcycle because she needed urgent specialised attention
and the ambulance had taken long to arrive. Josephine Okumu, the midwife in
charge of the maternity ward at Anaka Hospital confirms that, Eva arrived in
labour with foetal distress and had a previous scar, she was immediately rushed
to theatre.
A mother with a previous scar is
one who has delivered before through caesarean and there are high chances of
delivering through the same, so she has to be referred to a higher health
facility which has an operating theatre such that in case she fails to push the
baby normally, then she can be rushed to theatre and have the baby removed.
The above and many other such
cases that go undetected are a few among the preventable complications mothers
face during childbirth. Many have lost their lives in the process especially
those who delay to reach hospital at the onset of labour.
Although in the past five years’
institutional mortality ratio reduced from 108 to 92 per 100,000 deliveries,
Ministry of Health Annual Health Sector Performance Report of 2020/21, indicate
that, there are still many incidents of mothers dying during childbirth. In
2020/21, Uganda registered a total number of 1,228 maternal deaths as compared
to 1,102 in 2019/20, an increase by 126 cases. In Acholi region alone, according to statistics
in the national District Health Information System (DHIS2), in 2021, 45 lives
of mothers were lost during childbirth processes, whilst this year, (by April
2022) 35 mothers lives have already been lost. By the end of year, these
numbers are likely to go higher.
Many of the maternal deaths are
due to haemorrhage at 42%, followed by hypertensive disorders of pregnancy at
15%. Other indirect causes include malaria, HIV/AIDS, severe anaemia, Covid 19
as well as pregnancy related sepsis among others.
Several of these deaths are due
to failure to be detected in advance thus requiring referral to a higher health
facility for better specialised management.
And many of these complications that develop at the onset of labour,
during or after delivery are preventable if detected and managed early by
health workers, However, the challenge is many are detected and reported late,
with not enough time left to save the mothers through referrals. Why timely management
and access to quality care during pregnancy, child birth and after is critical
in preventing maternal deaths Many would-be timely referrals
are delayed due to the long distances on poor inaccessible roads mothers travel
to the nearest health facilities at the onset of labour but also the
unavailability of reliable ambulances makes it difficult to transfer mothers from
health facilities in real time. Very
often the unavailable health workers to attend to mothers who arrive with
complications at health facilities makes timely referrals and assisted-child
birth process, a wish for many mothers in vulnerable communities.
The few available ambulances are
overstretched and therefore are not available to pick mothers whenever they
need them. At Atiak Health Centre IV, in
Nwoya District, they have an ambulance donated by Enabel. However, they lack a
driver to pick mothers with complications whenever they need the ambulance. The
facility has one active Doctor without an Anaesthetic officer. The one
available doctor again doubles as the facility administrator with additional
administrative work, making it difficult for him to be in theatre to attend to
mothers who arrive with complications needing urgent operation.
Lamono, Nurse at Pawell HC II
further explains the danger of not having enough human resources, “one time, I
referred and travelled with a mother to Atiak, when we reached the health
centre, the doctor on duty told me to continue in the same car with the patient
to Lacor hospital”. Anything could have happened to that mother due to the
delays we took to come to Atiak health centre and then to Lacor hospital.
Enabel supports the referral system in Uganda
The World Health Organization
(WHO) defines referral as the process in which a health worker at one level of
the health system, having insufficient resources (drugs, equipment, skills) to
manage a clinical condition, seeks the assistance of a better or differently
resourced facility at the same or higher level to assist in, or take over the
management of, the client’s case. On ground the referral system is
not effective as stipulated that the different levels of the system are
supposed to reinforce and complement each other. This is due to lack of
sufficient ambulances and fuel or both which prevents patients from quickly
being transferred from one facility to another. Anaka hospital administrator
explains the situation further. “Before Enabel gave us another ambulance
recently, we only had one ambulance and mothers used to be referred on motorcycles.
Josephine Okumu, midwife in charge of maternity ward at Anaka Hospital further
argues that “mothers who arrive on motorcycles many of them arrive without
referral notes and this means their complications are not documented and that
takes time again for us begin the assessments afresh”.
The referral system also faces
the challenges of poor road networks because of poor terrain, ineffective
communication system, inadequate emergency medicines and supplies including
blood for transfusion. So most times, the referrals are never on time.
Sometimes it is due to with the time the ambulance takes on the road to pick
the patient.
Enabel recently donated 3
ambulances to Amuru, Nwoya and Omoro districts to support transportation of
critical patients from one health facility to another. It is our wish that the
donated ambulances complement other efforts in the region. Enabel is also considering
training drivers and other health workers in managing emergencies.
Away from the ambulances, Enabel
has been supporting health facilities in Acholi sub region with additional
funding to purchase essential drugs and supplies thus minimising the unending
drug stocks at health facilities. Enabel has also supplied health facilities
with medical, lighting and IT equipment, all in the hope of addressing patients’
diagnosis, treatment and keeping and tracking patients’ records for easy follow
up. Enabel also supports construction and renovation of health facilities so as
to put in place the right conducive environment for health workers and
communities to offer and receive appropriate treatment.
Attitude of mothers on referrals.
While many mothers are positive
about referrals, others, aren’t. Sometimes mothers refuse referrals because
they fear a caesarean. According to Auma – midwife Koch Goma, “mothers have a
perception that when they are referred, they are always taken to the theatre
for caesarean birth. So majority throw away referral notes once they are
referred. “other mothers drop referral notes on the way because they think when
they arrive with referral notes, they will straight be taken to the theatre for
caesarean operation” – Midwife Amaro
“Sometimes mothers refuse to be
referred because they feel attached to midwives at health facilities where they
have been attending their antenatal visits to assist them deliver their babies.Other mothers say they don’t have
money to survive on in the hospital even when we tell them that not all
conditions upon which we refer them lead to operation. In Uganda when you are
admitted with any health condition, you are expected to have money and an
attendant to cater for your personal requirements including meals, so mothers
fear when referred to faraway facilities where they don’t have relatives to
look after them as midwife Auma at Koch Goma narrates “The moment you mention a
referral, attendants disappear and we cannot refer a mother without an
attendant. In Uganda, a patient admitted for close monitoring requires a
relative/attendant available to cater for the patient, unlike in other
countries where it is done by hospital nurses. I found Adako 19 yrs old
attending immunisation of her first born who was delivered at 5 months. She was
all praises of the nurses at Koch Lee health facility who saved her life and
her baby. said she was referred to Anaka Hospital after delivering an exceptionally
premature, under-weight baby at 5 months. She confirms they called the
ambulance at Koch Lee to Anaka, and she was transported with an accompanying
nurse. After 2 months she was discharged and given tips to raise her premature
son who is now a healthy growing baby.
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Oeganda UGA180371T