During our first week in Mbale, there were four maternal deaths. From the end of February until mid June, there were 27 maternal deaths at the Mbale Regional Referral Hospital, yielding an average of approximately 6 deaths per month. The most recent Ugandan maternal death rate statistic from 2018 reports 336 maternal deaths per 100,000 deliveries; in other words, in Uganda 0.336% of women die during childbirth. If, on average, there are around 9000 babies per year born at MRRH (as reported by senior administrators), this means the maternal death rate at MRRH is 0.8%. Mbale’s maternal death rate is 2.4 times higher than the national rate.
The causes of death listed for these 27 women are not varied; repeatedly cause of death is listed as “hypovolemic shock, secondary postpartum hemorrhage, severe anemia”. After spending a month here, this common cause of death is unsurprising. I have witnessed the struggle to obtain blood from the blood bank (and have selfishly used my “white privilege” to procure units of blood for patients). I have helplessly held the hand of actively bleeding women, knowing there is no blood available, and have listened to case reviews of some of these women deaths days later. I have arrived on the postnatal unit, where 30 to 40 birthers and their attendants are crowded together, beds touching, bodies mashed together, to find only one midwife, or perhaps no midwife present on the unit. How would someone having a secondary hemorrhage obtain the medical care they need in such conditions? I have spent time in the high dependency unit (HDU) where women with severe postpartum hemorrhages are sent for close monitoring. Yet, there is no staff assigned to this six bed unit (the sole midwife assigned to the postnatal unit is also supposed to attend to the clients in HDU, nor are there stocked antihemorrhagic medications. Instead of being an ICU for severely compromised postpartum mothers, seizing, bleeding, gasping women who desperately need one-to-one nursing care are left alone in a room to be forgotten. A woman whose birth I attended was admitted to HDU - she watched three of her neighbors die and later told me she thought she would have a similar fate by virtue of being in that room.
The three delays model proposes that pregnancy related mortality is due to three delays in: (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached. While the delays that occur outside were evident, the delay in receiving adequate care while in MRRH was multifaceted and the most surprising to someone who has worked within hospitals for the last seven years. Not only would the delays happening in Ugandan hospitals be unacceptable in Canada, they would be shocking. No operating room availability because of a power outage or blood shortage. An actively bleeding birther with a placenta previa having to wait for an emergency c-section because there is no stretcher for transport to the O.R. Seizing, eclamptic women waiting for their attendants to return with anti-hypertensive medications. Anaethestists taking their lunch break when there is a woman with a ruptured uterus waiting for surgical care. Despite being taught about these delays, it was astonishing to experience first-hand. I found myself comparing how emergencies were handled in Uganda to how I think they would have been managed in Canada. In Uganda, health workers casually standing around waiting for O.R. availability as a uterus ruptures and a fetal heart rate disappears. In Canada, the woman would have been sectioned hours prior for the often cited reason “failure to progress”, maybe a family member or care provider wondering if the woman was a victim of rising cesarean section rates in developed countries.
Having a nursing background, I often found myself examining the clinical setting and events occurring within the Lira and Mbale Regional Referral Hospitals with a public health lens. On our first day in Lira, as we were touring the postnatal ward, the head nurse stated, “We have a problem with sepsis”. I can see why: no running water on the wards and no means of sanitizing clinicians’ hands between patients, postpartum beds that are touching, babies in the neonatal care unit lying adjacent to one another on adult sized beds, cracked vinyl mattresses, clients on an inconsistent or inadequate course of antibiotics due to insufficient staffing levels, porous floors that never seem to be clean, health care workers breaking the sterile field in the O.R. - these are just a few examples of infection risks observed while working in Lira and Mbale. Of all the ways to improve clinical outcomes, the one that seems the easiest to me would be to increase health care workers access to hand sanitation. I felt like I was taking a trip back to the 1800s when the Hungarian physcian Ignaz Semmelweis discovered the use of hand sanitation on obstetrical clinics drastically reduced the incidence of puerperal fever, and therefore the maternal mortality rate. While financing the cost of plumbing for running water on the units may be unachievable, frequent barrels of water with a spigot and drainage basin placed throughout the units could take the place of a tap and sink. Furthermore, alcohol rub is not that expensive and should be on the list of essential supplies needed on hospital units. In my opinion, respecting the principles of asepsis is as important as oxytocin in reducing morbidity and mortality on obstetrical wards. To say that I am leaving Uganda with a newfound appreciation of our Canadian hospitals and health care system at large is an understatement; I now realize I won the birth lottery jackpot by being born in Canada.
Uganda is not without its beautiful moments, despite the sometimes apocalyptic conditions on the wards. The origin of the word midwife, “with woman”, aptly describe the reason I was drawn to this profession. Even in Uganda, half a world away from Canada, immersed in an entirely different culture, across language barriers and despite my “otherness” as a muzungu, I am still able to find ways by which I can stand by women’s sides in a supportive role and help them navigate their birth experiences. The women in Uganda are so powerful and resilient, navigating an, at times, perilous health care system with so much grace, strength, and gratitude. There was the woman who, after three days of labouring on the ward decided she’d had enough of “them scaring me”, grabbed my hand, and walked away, preferring to give birth in peace outside behind the bushes next to the ward. There was the grandmother of a client who I had helped lift onto a stretcher for her emergency cesarean, who later, while waiting for her daughter to reappear from the operating room, held a stethoscope in place so I could auscultate the heartbeat of a newborn (unrelated to her) as I provided ventilation and Mary recruited more help. The sister-in-law who cautiously revealed to me my client had not taken any HIV prophylaxis during pregnancy. The sister who learned how to mix HIV antiviral medications for her neonatal niece. The auntie who softly encouraged her niece to keep pushing through 7 vacuum pop-offs before a cesarean section was finally called, then later gave me daily updates on her great-nephew’s recovery from “fits” while in the neonatal special care unit. The client with the coulevaire uterus and IUFD whose face lit up with a smile every day I came to visit her during her two week hospital stay, despite the incredible loss of her firstborn, a beautiful little boy. These women have shown me that even in the most dire conditions, there is always something you can find to be grateful for, and I have MUCH in life to be grateful about.
Juliette and baby Juliette in Lira Regional Referral Hospital
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