26 Sep 2011

Giving birth should not be a death sentence!

A  former assistant commissioner of Epidemiology and Surveillance in the Uganda Ministry of Health wrote an eloquent opinion piece discussing the ethics and morality of the Uganda health systems in light of its appalling record on maternal health.
Below I reproduce the opinion piece:
Nurses and doctors being led to Mbale CPS after she was arrested from Mbale Referral Hospital

shock and disgust
I read with consternation, shock and utter disgust, the story in the Sunday Monitor of September 18 about a pregnant mother (RIP Nambozo) who died following a ruptured uterus and subsequent bleeding after being neglected in obstructed labour for over 12 hours at the regional referral hospital in Mbale, allegedly because she could not afford Shs300,000 demanded by the medical workers.
As a health worker who started a medical career at Matany Hospital in Karamoja, a hard-to-reach area by all measures of imagination, and rose to a senior level position at the Ministry of Health headquarters, I feel ashamed about what my professional colleagues did, if the Sunday Monitor report is correct. For the record, we as medical professionals, have long been taught to practice medical ethics and that is why medicine is a vocation and those who cannot stand up to this calling should never have joined the profession or should quit it immediately to avoid bringing this noble profession into disrepute.
Medical ethics
Medical ethics is a system of moral principles that apply values and judgements to the practice of medicine. It encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology. Historically, medical ethics may be traced to guidelines on the duty of physicians such as the Hippocratic Oath that all doctors swear to uphold when they graduate from medical school, as well as the early rabbinic and Christian teachings. By the 18th and 19th centuries, medical ethics emerged as a more self-conscious discourse.
Since the 1970s, the growing influence of ethics in contemporary medicine can be seen in the increasing use of Institutional Ethics Review Boards to evaluate experiments on human subjects, the establishment of hospital ethics committees, the expansion of the role of clinician ethicists, and the integration of ethics into many medical school curricula. Six of the values that commonly apply to medical ethics are:
1) Autonomy - the patient has the right to refuse or choose their treatment;
2)Beneficence - a practitioner should act in the best interest of the patient;
3) Non-malfeasance - “first, do no harm or primum non nocere in Latin, which was the language of instruction in the early years of medical practice ;
4)Justice – Which concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality) ;
5) Dignity - the patient (and the person treating the patient) have the right to be treated with dignity; and
6) Truthfulness and honesty - the concept of informed consent, which gained importance after the historical events of the Nuremberg trials carried out by the Nazi military in Germany without the consent of the trial participants and the Tuskegee Syphilis Study that denied Penicillin to African Americans in the US even when all evidence showed that Penicillin was the best drug at the time to treat syphilis.
If the Sunday Monitor story is correct then in the Mbale incident, 4 of 6 values (2, 3, 4, and 5 above) were grossly violated and the explanations of the medical superintendent and hospital administrator to try to justify their actions, which to say the least can be best described as their negligence or lack of action are at best lamentable and should be condemned in the strongest terms.
MDR for maternal death review or audit
The World Health Organisation requires that every maternal death should be audited. I have for long held the considered view that every maternal death should be a reportable event such as Ebola, or Yellow fever. While I do not know the true circumstances that led to the Mbale regional referral hospital disgrace, what was reported can only be described as ethically unacceptable and repugnant, notwithstanding the poor pay of health workers and the poor working conditions that the government continues to ignore.
Giving birth is not a death sentence!
As a people who care about any life lost that could have been prevented, we demand that the Ministry of Health, the medical practitioner’s council and other relevant bodies thoroughly investigate this case, and take disciplinary and criminal action where necessary. Further, the minister of health should provide a full report to Parliament on the measures to prevent such incidents and many more that go un-reported.
In future, it should be mandatory to investigate any maternal death, whether it occurs at home or at health facilities, like we do for outbreaks or epidemics of Ebola, Maburg, Yellow fever, cholera, polio, measles, etc. with a detailed post-maternal death evaluation report to be provided to local and national level leaders. Any maternal death in this era is just unacceptable and we as a nation must say we have had enough-we cannot continue to lose between 400-500 mothers for every 100, 000 live births. Giving birth is not a death sentence!

What is happening to health profession in Uganda?

One week ago, the press in Uganda reported a case of a pregnant mother (who was a practicing school teacher) who died from hemorrhage from Mbale Regional Referral Hospital. This latest deaths attracted condemnation from all sector of the Ugandan community.
The following letter to the editor from a public health specialist is an example; read on and weigh in with your own thoughts.
A typical Ugandan hospital maternity ward.

I write to condemn the behaviour of the medical personnel whose negligence led to the death of a teacher in Mbale last week. Medical personnel are bound by medical ethics and they are expected to respect those ethics. An emergency obstetric case brought to the referral hospital at 8am and left for 12 hours unattended to until she died is the highest degree of negligence. How shall we prevent such deaths in the future?
I personally believe medical work is charitable work. Some medical personnel consider their work unpleasant and of high occupational risks. A TB patient may cough blood right into your mouth. During difficult delivery, you may swallow the fluids from the womb. During surgical operations, you may get HIV through a needle pricks. They wonder whether the occupational risk they face is equivalent to the money they earn. The economy is hitting the medical personnel hard as well. Some may even be failing to send their children to good schools.
Government needs to review the pattern of expenditures in this country. The possibility of having excess money enough for all the services in the country is distant. The option we have is to prioritise our areas of expenditures so that the salaries of the people working in the health sector are reasonable. To reduce maternal deaths and improve the health of our population, let the government consider very seriously the pay of medical personnel.
May the soul of the teacher rest in eternal peace!
Dr Michael Amone Liri,
Public Health Specialist

23 Aug 2011

Reducing the unmet need for Family Planning in Uganda

The following thought provoking article appeared on the Uganda newspaper, The new vision. It provides very useful suggestions that I feel Reproductive Health practitioners in Uganda can translate to pratice. Please, read on:

"We didn’t know that there is Family Planning until we produced seven children in nine years. Our usual thinking was that this is God's plan. We are now regretting because we are unable to look after our children and we are a laughing stock in the village". Such is a tale of a young couple of less than 40 years of age, about the problems it is facing because of lack of Family Planning.

But if we all became true to ourselves and planned for our families, we would get part solutions to most of the challenges affecting our planet today.

This is because Family Planning is almost the driver for every global problem.

Currently, around 200 million women say they want to delay or prevent pregnancy but are not using effective contraception. Either they have no access to it or they think they will not get pregnant.

This has resulted into millions of unintended pregnancies, ill health and maternal deaths.

Dr. Godfrey Mugyenyi an obstetrician at Mbarara Diagnostic Centre and Mbarara University Teaching Hospital says that access to contraceptives empowers women and can save their lives. Family planning gives good maternal health, in the same way immunization gives good child health.

Contraception can prevent 2.7 million infant deaths a year worldwide, it can reduce poverty, slow population growth, ease the pressure on the environment and make for a more stable world. He adds.

Being able to plan how many children to have and when to have them is a recognized human right. But this right is not yet realized, especially among the poor, says Dr. Emmanuel Byaruhanga, a consultant obstetrician/gynaecologist at Mbarara and Ibanda Hospitals.

Current global situation
In 56 developing countries, the poorest women average six births, compared to 3.2 for the wealthiest.

Fewer than 20% of sexually active young people in Africa use contraception. Apart from lack of money, barriers include insufficient knowledge, fear of social disapproval, side effects, myths and misperceptions about the partner's opposition.

Every year, 190 million women become pregnant and nearly 50 million resort to abortion.

An estimated 68,999 women die every year from unsafe abortions. Millions more suffer long term disability.

The Ugandan situation
According to the 2006 Uganda Health demographic Survey, over 1.4 million women would like to delay a pregnancy in order to space their children or stop child bearing but have no access to contraception. Only 24% of married women in Uganda aged 15 - 49 use family planning.

This survey identified lack of accurate information about the benefits of family planning, poverty, cultural/religious and also lack of women empowerment as the major obstacles to contraception in Uganda.

Therefore as the world population rises it is imperative to focus on meeting the unmet need for family planning and in the process, help solve many problems and contribute to the Millennium Development Goals (MGDs). More than 190 nations have committed to achieve the MDGs, eight International Development targets, which range from reducing poverty by half to improving maternal health, by 2015.

Reducing the unmet need
How then can we solve the unmet need for family planning in Uganda and the developing world? Dr. Mugyenyi says that there are many ways to reduce the unmet need and may include the following:

Health education campaigns
The ministry of health should revitalize massive health education campaigns. There is need to realize that the current population growth trends are unacceptable and something needs to be done urgently. Everybody should be brought on board including political leaders. Most of us remember how it was done in the 80s and 90s against the scourge of HIV/AIDS, that drum that sounded before and after every news and headlines on radio Uganda and Television. If we managed to bring down the prevalence of HIV from as high as 30% in 1992 to 5% in 2002, why not improve contraceptive prevalence from 23% to at least 60% in 5 years?.

The menstruation cycle and natural contraception methods
Many women will tell you that they are avoiding pregnancy using natural methods including safe days and breastfeeding. When you ask them which days are safe, the answers are dangerously variable. The need to give the right information to our women cannot be over emphasized.

Mobile and wireless technologies:
In Uganda today the emergency of mobile and wireless technologies is widespread, because today the mobile phone subscriber base in Uganda is about 12.5m. The old woman even in the most remote areas of Uganda has a radio and a mobile phone. Partnership with the rich and successful telecom companies, the numerous radio stations in the country would enhance transfer of health related information from the textbook/health worker to the population who are in dire need.

Even the obvious is great news to the very learned population in Uganda. In Cuba, health education talks on radio stations and television is synchronized in a way that all stations are talking about the same thing at a particular time. When mobile phone companies are introducing new products see how they advertise, how they paint buildings and road carnivals and so forth, we need to partner with them to help increase the contraceptive awareness in our population.

Social gatherings
Social gatherings such as churches/mosques, market places, funerals etc. proved to be important in curbing the HIV epidemic in Uganda in the 90s. The role of dance and drama in social mobilization is clear. We need to develop programs to mobilize and utilize these available talents and opportunities in reproductive health education.

Political will:
We hear that members of parliament and all other politicians move 'door to door' during times of campaigns, convincing the electorate. While they can do that to get votes, they should also do that to sensitize their communities about the need for family planning. I have never read any ones campaign program that stipulates health education and mobilizing the masses for good health.

Let us not promise bridges where there are no rivers. Many times we tell them that we are going to build hospitals and health centers… when we know the resources are limited and we can't achieve this in the short political term of office. Education is the only long term investment that we can impart to the masses.

Local council meetings:
How often are health matters an agenda at the LC meetings? When did you last invite the health worker at your health unit to talk to the committee members about maternal mortality, family planning or a reproductive health issue? How will we mobilize the masses when we don't have the facts? What are the roles of the secretaries for health? And the secretaries for women affairs? Time has come to make women's health a priority from the grass root because they are the mothers of our nation.

The condom
The condom is an integral means of controlling unintended births and Sexually Transmitted Infections. The stigma that has been attached to its use by especially religious sects must be broken. Why would we listen and take as gospel truth the facts about the condom from a religious leader whose basic science knowledge is very limited. Even I believe the word condom is not reflected in the book of God, the Bible.

An undesired child is your household burden, you will bear it alone God being your guide.
Long term contraception

Vasectomy, bilateral tubal ligation and the intra-uterine device must be promoted because of their high effectiveness and reduced undesired effects. Counseling the couples together for family planning should be emphasized. Distigmatizing these effective methods is critical to the success of the programs targeting increasing the contraceptive prevalence and reducing the unmet need in Uganda.

Family planning and people with disabilities
People living with disabilities have been left out on Family Planning programs as in many issues of our social life.

While contributing to Kampala Conversations an online discussion about Family Planning by participants of the International Conference on Family Planning that was held in Uganda in November last year, James Aniyamuzaala, the President of Uganda Federation of Hard Hearing, says that there is a need to have inclusive family planning programs that target persons with disabilities such as the visually impaired, hearing impaired, physically impaired and mentally impaired women.

The Thai experience
I recently attended an International Conference on Women's Health and Unsafe Abortion in Bangkok, Thailand and I was amazed at how one man has mobilized Thai people to embrace family planning with tremendous success.

Senator Mechai Viravaidya who is also known as Mr. Condom has added flavour to family planning campaigns with a very high degree of success.

He has introduced condom blowing contests in schools between school children and teachers and at tertiary institutions, organized miss condom beauty pageants, introduced ideas of Santa condom and condom Christmas trees to help make the condom friendly.

He has also organized vasectomy festivals where men are given prizes and sensitized about the benefits of vasectomy, like vasectomy means better life and bigger inheritance; non pregnancy gifts where a woman who has not had a pregnancy for three years is given let’s say a prize of a heifer, etc.

22 Aug 2011

WASH for Mothers: Water, Sanitation and Maternal Health: Inter-dependent Systems Challenges

Aug 22, 2011 10:04 am

The following post is part of a series of posts, WASH for Mothers, exploring water, sanitation, and hygiene (WASH) and maternal health. It is written by Margaret Catley-Carlson who is currently Chair of the Board of the Crop Diversity Trust, and the Foresight Advisory Committee for Group Suez Environment. She is a patron of the Global Water Partnership, a member of the UN Secretary General's Advisory Board, World Economic Forum Global Advisory Council on Water, the Rosenberg Forum, and serves on the boards of the Syngenta Foundation, IFDC (Fertilizer Management), the World Food Prize And Tyler prize. 

All of us working to break the cycle of poverty that holds hostage too many people in the world are tracking closely the progress of the Millennium Development Goals which are set for review in 2015. The eight MDGs cover the gamut of issues that keep that cycle of poverty spinning, and they are inextricably linked. Goals 5(a) and 7(c) are perfect examples. The former aims to 'reduce by three quarters the maternal mortality ratio, and the latter aims to "halve... the proportion of the population without sustainable access to safe drinking water and basic sanitation."

Experts agree: access to clean water and sanitation is essential for healthy pregnancies and childbirth. Vitamin deficiencies, trachoma and hepatitis can be caused by unsanitary conditions and poor hygiene. Anemia, one of the 5 major causes of maternal death and disability, is most often associated with malnutrition, but it can also be caused by intestinal worms or malaria both of which occur when clean water and safe sanitation are lacking.

Fifteen percent of all maternal deaths are caused by infections in the 6 weeks after childbirth mainly due to unhygienic conditions during home deliveries and in institutions. Another of the 5 major causes of maternal death and disability, sepsis, is caused when clean water and adequate sanitation are not available to a woman during labor and childbirth.

Environmental stability and maternal health are both systems issues. Clean water and sanitation are essential factors in our collective efforts to eradicate preventable maternal mortality and morbidities. The logic here is clear: If humanity is to break the poverty cycle once and for all, we must address concomitantly the fundamentals that weaken the systems needed to provide and sustain good health.

Providing Nairobi’s mothers with top-quality maternal care at a low cost

The following was originally posted on Jacaranda's blog. It is reposted here with permission

Five weeks ago, Jacaranda Health opened our doors to the low-income mothers of Nairobi. In the peri-urban neighborhood of Kariobangi, our nurses, receptionists, marketing staff and our clinical advisor all pitched in to set up the exam rooms, lab tests and welcome tent on the grounds of Full Gospel Church, the community partner who hosted our mobile clinic for the day.

Our first antenatal patients walked in off the dirt road as soon as the gates were open, and the day brought us more patients than we could see in a single day -- we had to reschedule several women for future dates. In the weeks since, we have rotated clinics among our seven community partners, and have been fine-tuning our clinical processes, testing different marketing approaches and doing focus groups with patients to improve services – all working toward our goal of creating a scalable, cost-effective model of maternity care for urban mothers.

A few highlights for us:

We are reaching the women we intended to: from a single mother of 17 getting her first medical visit 36 weeks into her pregnancy, to a mother on her fourth pregnancy who had experienced preterm labor and didn’t know where she should plan to deliver.

Our systems and protocols are working: We've been putting to test the application that lets us create medical records by mobile phones, our inventory management system and our clinical and emergency protocols. And they’re working: Our patient data is at our fingertips. Patients have successfully been referred to partner facilities for complications and delivery, and are already returning to us for postnatal care. Meanwhile, our partners from Harvard’s School of Public Health are progressing quickly on their baseline evaluation that will enable us to measure and report on our impact.

Integrated care works: Our patients get a truly one-stop antenatal visit, with every step from beginning to end– history taking, counseling, physical exams, lab tests, and birth planning -- done by our nurses in the exam room. This integrated service means less wait time and continuity of care from a single provider. Our patients love it, and it's clearly paying off in terms of patient retention. . Our nurses have loved it too: One said that in her previous jobs, she had never been able to treat a "whole patient." Overall, our nurses are responding well to the job’s mix of autonomy, training, emphasis on customer service, and involvement in quality improvement and problem solving.

Patients are sticking with our services: One of the big tests came last week, four weeks after the first clinic day. Would the women who'd come to the clinic on our first day come back for the antenatal follow-up visits that we'd recommended? Ten out of 11 of them showed up and paid full price, a level of customer retention and satisfaction that even surprised us. Our clients are pushing us hard to get our first fixed clinic up and running so they can deliver their babies with us, and our feedback forms so far show 95% of customers giving us 5-stars for patient satisfaction. As much as any of our clinical and technology innovations, this customer satisfaction is what will change the way that maternity care is delivered in Africa.

These are still early days and there are plenty of challenges ahead, but we're optimistic based on what we've seen so far. We're moving quickly toward launching our next clinic -- the fixed facility that will provide deliveries. We have started a blog to record the thinking behind our business and our experience providing maternal healthcare in east Africa. We hope you will stop by to learn more about our progress.

12 Aug 2011

Uganda: Now Maternal health funds diverted to seminars

minister of  health: Dr. Christine Ondoa

The Ministry of Health has diverted Shs2 billion meant for maternal health to seminars and workshops, MPs heard yesterday.
The revelation by ministry officials infuriated the legislators, who then refused to pass the maternal health budget for this year. Health Minister Christine Ondoa and her team were asked to work out a budget that addresses key maternal health concerns.
Mothers dying
“I don’t know where this country is going and this is corruption using the pen. We shall not pass this money meant for training,” Ms Naome Kabasharira (Ntungamo), said. Statistics from the ministry and World Health Organsation indicate that 16 women die everyday in Uganda while giving birth.
The country is also a long way from achieving the Millennium Development Goal of reducing maternal death by three quarters and improved access to reproductive health services by 2015.
The maternal health indicators for Uganda have generally remained poor in the last two decades. Over the years, maternal mortality stagnated at about 435 deaths per 100,000 live births.
The estimated maternal mortality from the Uganda Demographic and Health survey is 435 deaths per 100,000 live births. To meet the MDG target, Uganda needs to reduce its mortality rate from 435 to 131 deaths per 100,000 live births by 2015. “Much of the money is for workshops and hotels yet several women are dying while giving birth. You people should go back and redraft your budget to reflect key issues as per the set objectives,” the committee chairperson, Dr Sam Lyomoki said.
Government allocated Shs24 billion from this year’s budget towards the improvement of maternal health in addition to a $130million (Shs390b) loan from the World Bank for the same.
The MPs queried the Shs64m allocated in the ministry’s budget for training of trainer’s workshops and Shs310m for post internship training. They also questioned the Shs165m for hands-on skills building for service providers and Shs390m for skills building for health workers.
Kinkizi West MP Chris Baryomunsi said the ministry is not committed to ending maternal deaths. “They must come with interventions which will result in impact otherwise maternal health will remain a problem,” he said.
The MPs also queried the criteria used to choose districts that would benefit from the Shs24b allocated in this year’s budget. “There must be a balanced distribution of resources in this country,” said Ms Judith Franca Akello (Agago Woman) said.
The MPs accused Ms Ondoa of being insensitive about women issues. “You are a woman and the budget must address women issues countrywide. The ministry should raise 100 per cent capital investment on maternal health. You can’t provide mama kits,” Ms Betty Amongi (Oyam South, UPC) said yesterday.
The MPs tasked the government to improve the health service provision and equip hospitals with the necessary drugs.