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.

1 Aug 2011

Hospital sicker than the sick: campaigners say Ugandan maternal health care harming rather than healing

In 2009, the following story appeared on national newspaper. I was sufficiently outraged and I penned a letter to the editor. Please read the story and the letter to the editor that follows:
Residents march to Mityana Hospital in protest of the death of a mother and her baby during labour
Residents march to Mityana Hospital in protest of the death of a mother and her baby during labour

Hundreds of angry residents stormed Mityana Hospital yesterday morning, protesting the death of a mother and her baby in the labour ward. 

The crowd entered the hospital, attempting to lynch the health workers whom they blamed for the death of Sylvia Nalubowa, 39, a resident of the nearby Bussujju village. They also accused the medical staff of demanding bribes and not caring about their patients, and held them responsible for the chronic drug shortage. 

The demonstration caused all medical personnel to either flee or go into hiding inside the hospital, leaving dozens of patients unattended to. 

Health ministry officials said it was the first time in Uganda’s history that a mob has attacked a hospital. 

Nalubowa, who was pregnant with twins and was referred to Mityana hospital for emergency care, died at about 2:00am on Thursday after waiting for seven hours without being attended to. 

She had delivered one baby at Maanyi health centre but the second failed to come out. Thus, the health workers referred her to Mityana, the district hospital. 

Following the incident, a senior midwife and three nurses were arrested over neglect of duty. The four were supposed to be on duty that night. 

But the arrest was not enough to convince the residents that justice was being done. At 9:00am yesterday residents of Mityana started demonstrating in the town. 

They were joined by about 100 men, women and children from Bussujju, 30km from Mityana town, where the deceased came from. 

The deceased’s husband, Stephen Ssebiragala, did not join the demonstration but his relatives were present, weeping and sobbing. 

In the afternoon, some nurses resumed work after armed Police men were deployed to protect them. 

From the hospital, the demonstrators marched into Mityana town, carrying placards denouncing the medics. They demanded that all medics in Mityana be dismissed and replaced. 

The Police, led by District Police Commander Ben Mubangizi, drove the crowd out of the town to the outskirts. They went to Busimbi Gombolola grounds. 

The district LC5 chairman, Joseph Musoke, made unsuccessful attempts to address them. The crowd shut him down, demanding for officials from the health department to be brought to them. 
Later the resident district commissioner, Harriet Kagaba, succeeded to address the demonstrators, appealing for calm as the authorities would address their grievances. 
“The arrest of the four nurses is just the beginning. We shall do our best to ensure that the matter is handled according to the law,” she said amid cheers. 

The director general of health services at the Ministry of Health, Dr. Sam Zaramba, described the action by the crowd as “unacceptable”. 

“Whereas they were right to protest the health workers’ actions, they should not have attacked the hospital that they will go back to for services,” Zaramba said. 

He also blamed the negligence on the part of the health workers and promised to have their case referred to their respective professional bodies for investigation. 

Dr. Tom Mwambu, the president of the Uganda Medical Association asked the Government to raise health workers’ pay to improve services. 

He said that the doctor, being alone, could not be at the hospital 24 hours a day but after being called, he should have responded quickly. He blamed the nurse who insisted on being given cash. 

“The doctor will have to answer questions from the medical council to establish if he acted unethically,” Mwambu said. He said the action of the mob would scare medics from working in Mityana.
My letter to the editor
The gruesome death of a mother in labour in Mityana Hospital due to professional neglect is as unfortunate as it is common. In Uganda almost four hundred mothers die out of a hundred thousand every year due to pregnancy and child birth. That is equivalent to six busloads of innocent Ugandan mothers being condemned to death every year. That is outrageous; but, most of these mothers die quietly without any publicity.

The main causes of maternal death in Uganda are mainly uncontrolled bleeding, obstructed deliveries, sepsis, complications from abortions, and other so called in-direct causes like malaria, TB, and HIV/AIDS.
On this list, I must add perhaps the biggest enemy of expectant
mothers: professional neglect and cruelty by health workers. Most of these deaths are preventable if timely and accessible emergency obstetric care is made widely available in health units of every parish and sub county in the country.

I condemn the callous manner that the health workers of Mityana hospital displayed in handling this unfortunate mother. Such behaviours are contrary to the sacred ethical standards of medical practice. Perhaps this incidence should highlight the need for results-tagged incentives to health workers. Much as health workers clamor for pay rise, it must be based on adherence to ethical and quality of work standards on their part. Government pays you; you should not pretend to work.
Patrick Odongo