Maternity Care in Uganda

Last Friday, our Masters of Public Health Leadership students took a trip to a national referral hospital in Kampala to see what it's like for mothers who deliver there.  The hospital provides emergency obstetric care to manage complications such as obstructed labour, eclampsia (high blood pressure which can lead to seizures and death), haemorrhage. This is the highest level of care in the country for those who cannot afford to pay for care in a private hospital.  What I saw there was a shock to my system after having worked and studied as a nurse in Toronto hospitals. The tour gave me a view to the challenges of caring for women in setting where system resources are lacking. As we entered the labour and delivery ward, staff were wheeling out a woman on a stretcher for an emergency C-section. Her uterus had ruptured.  This is a life-threatening complication which results from major internal bleeding of the uterus.* This mother had to wait for care due to large volumes of patients and few staff to care for all of them. She had been referred from a lower level care centre for obstructed labour, as that facility could not offer the necessary surgery. Due to the delay in receiving a Caesarian section, her baby had died and her life was also at risk. 
We walked further into the ward and saw rows and rows of women in the waiting area, some lying on the floor, in various stages of labour. Staff were busy attending to deliveries in a curtained off area and these women were waiting to be assessed. Someone yelled for assistance as one of these women delivered her baby right there on the floor unassisted. Staff did their best to attend to the woman and newborn, rushing over to cut the cord and then eventually moving her to a more private area. In another corridor, women who had just delivered were lined up in a row on the floor resting with their babies next to them where they could be observed.
In the pre-operative area, we briefly met a few obstetricians who were performing surgeries in the facility's one functioning operating theatre. Typically there will be 25 - 30 C-sections done per day! One of the doctors shared the frustration of not having adequate supplies to do their job and to offer care free of charge. On that particular day, mothers would have to purchase their own sutures and spinal needles for surgery. Otherwise they could not operate.
We moved on to the post-surgical recovery area. The little one in the photo was just a few hours old and was born by Caesarian section. Thankfully this baby is alive and healthy! His mother was able to get the C-section that she needed. Unfortunately for mum, she is in a lot of pain. The only post-surgical pain medication available at the hospital was diclofenac. This is usually used for mild to moderate pain and is similar to Advil (ibuprofen). Ideally, a women would receive a morphine related drug for post-surgical pain. When pain is managed well, a mother can better attend to the needs of her newborn.
Moving on to the NICU, we found a neatly organized ward full of cribs, isolettes, and adult sized beds lined with infants. The paediatrician informed us that they currently were caring for 102 babies infants, all who required extra support! The ward is well organizes but manages by relying on the mothers who come in every 2 hours to feed and check on their babies. I saw a handful of medical and nursing personnel. This hospital has nowhere near the staffing levels that we expect and rely on for safe and quality care in Ontario. My own community hospital staffs the NICU with 1 nurse per 3 babies. But they do their best with what they have.

Health care workers like our guide, Dr. Eve, continue to work with a conviction for helping women in their country even in the face of overwhelming needs. It is a struggle for health workers who know what kind of care they would like to give to patients, but cannot due to lack of resources. Although they work hard, staff become demoralized in this work environment. But Dr. Eve is also a passionate leader in the organization Save the Mothers, which exists to equip local leaders to tackle the social, political, cultural barriers to safe motherhood for women in East Africa. To understand these barriers, see the short film Why Did Mrs. X Die, Retold.
Dr. Eve told us a few days later that the woman with the uterine rupture who we had seen on the stretcher had survived but was in the intensive care unit. She had kept her life at least but had lost her baby. These are sad stories, but I am hopeful that through Save the Mothers' Masters program, leaders will be equipped to advocate for change.

*According to a World Health Organization review, in a developing country, the risk of death for the mother with uterine rupture is 1 - 13 percent of cases, and risk of death for the baby is 74 - 92 percent. (Source: G. Justus Hofmeyr, Lale Say, A. Metin Gülmezoglu, (2005) BJOG: an International Journal of Obstetrics and Gynaecology 112, pp. 1221 - 1228, retrieved from www.who.int/reproductivehealth/topics/maternal_perinatal/bjog_112_pp1221-1228.pdf )