“My wife was left unattended in the postnatal ward for close to five hours until I paid Shs205,000 to have blood brought to Kibuli Musilm Hospital for her diffusion. Without any medical records, they told me to take my wife to either Mulago hospital ICU if I still needed her alive. For the three days I was in Kibuli hospital, I never got anyone to explain the state of my wife even during transfer to Case hospital. I was never given her medical records. It’s only at Case Hospital that I was told that my wife is anaemic due to over bleeding and she had suffered from liver damage. Justice should be served for my wife and it should be a lesson that all women deserve good health care,” Mr Rafaile Omony shares what happened to his now deceased wife.
On July 2nd, 2020, The Center for Health, Human Rights and Development filed a complaint with the Uganda Medical and Dental Practitioners’ Council (UMDPC) against Kibuli Muslim Hospital, challenging the violation of medical professional ethics, and human rights of Mr Omony. Omony’s wife, Scovia Mary Alupo, died on October 27th, 2018 after undergoing a cesarean section, following which she bled to death.
Uganda suffers a persistently high maternal mortality ratio (MMR) currently at 336 per 100,000 live births which translates into 16 women dying every day during childbirth majorly because of lack of basic maternal health commodities like gloves, syringes, blood, medicines etc, which enable women to give birth safely. This is worsened by low political will to equip and sufficiently fund healthcare facilities, which sees two midwives working in more that 30 expectant mothers at a go.
“Women die everyday due to severe bleeding while giving birth. Blood is an essential life saving commodity that can’t be replaced and so should be freely given to those who critically need it. Health facilities should be held accountable for any life lost due to failure to pay for blood. This is unacceptable and we need UMDPC to exercise its mandate of general supervision and disciplinary control over medical practice to uphold health and human rights”, Ms Edith Sifuna shares.
Dr. Katumba Ssentongo, the Registrar at UMDPC says that their role as UMDPC is to supervise and exercise discipline action to all dental and medical practice in Uganda. In two (2) weeks time after reviewing the complaint (CEHURD & Omony), Kibuli hospital will be notified through an official letter from the council to get their defence.
Ms Alupo has become one of these tragic statistics and we cannot leave her death unaccounted for. CEHURD has therefore petitioned UMDPC seeking that Kibuli Hospital and the concerned health care workers be investigated and found culpable for the professional misconduct exhibited. CEHURD equally intends to bring these human rights violations to the attention of the courts of judicature, seeking compensation for the family of Ms Alupo. “ We want UMDPC to take action against its members that violate the medical profession ethics fulfilling their mandate of monitoring and regulating the practice of medicine and dentistry as per the Uganda medical and dental practitioners’ Act” Ms Ruth Ajalo, a lawyer representing CEHURD adds.
The writer is a Communications Officer at Center for Health, Human Rights and Development.
Sophia (not real name) could not easily access transport to the nearby health centre for maternal services. She therefore resorted to seeking the services of a traditional birth attendant (TBA) in a neighbouring village. She could not trek the long distance to deliver her child since she had gone into labour late in the night while she was home alone. An elderly TBA was her only option to deliver the baby. Unfortunately, Sophia suffered from obstructed labour and by the time she accessed a boda boda to get to the health care facility, she had lost her baby and had passed out. The midwife on duty could only give her first aid as they waited for an ambulance from the nearby private hospital to take her for further treatment. With the global outbreak of COVID-19, Uganda took steps to curb the spread of the virus. Some of these steps included the Presidential directives that put restrictions on movement. These restrictions included a ban on public and private transport, except for essential services. Sophia is one of the many expectant women in Uganda who have been reported to resort to TBAs to give birth from villages due to these restrictions. Women have lost their lives while giving birth, lost their babies and or left the labour ward with complications and other psycho-social effects. COVID-19 like many other pandemics attacked Uganda unprepared more so because of the need to strike a balance between control of the pandemic and provision of essential health services where maternal and child health have been at the peak. Uganda’s maternal mortality ratio stands at 336 deaths per 100,000 live births according to the Uganda Demographic and Health Survey 2016, with an average of 16 women dying daily while giving birth due to preventable causes. This figure is less likely to reduce to the projected indicators in the Sustainable Development Goals (SDGs). Even if the State worked hard to achieve the set indicators, the effects of the COVID-19 pandemic already show a failure to achieve them. As part of ensuring that this pandemic is suppressed, the President of the Republic of Uganda working with the COVID-19 task force in the Ministry of Health provided directives to the country that were welcomed at the time. The country was in fear and everyone thought that these were indeed great directives. Reality, however, set in when expectant mothers continued to die and others delivered by the roadside or at the entrance of facilities due to movement restrictions. The restriction on movement affected both women due for delivery and those due for antenatal care (ANC) visits. The World Health Organisation Guidelines (WHO), set at least eight antenatal care visits from the initial four as a measure for monitoring the well being of the expectant mother and the unborn baby. These are unfortunately not possible for most expectant women due to the COVID-19 restrictions. Many expectant women have instead been reported to have faced police brutalities while trying to access the health facilities. For example a video recording circulated on May 8th, 2020 showing a Local Defence Unit (LDU) officer shooting a boda boda rider and an expectant woman who were on their way to the hospital in Masaka. Both were reported dead. This happened despite the President relaxing restrictions on the movement of pregnant women on boda bodas. Women have also failed to access necessary health care due to the economic breakdown brought about by COVID. Many have lost jobs and cannot earn a living. Additionally, movement restrictions especially in regard to public transport have caused a hike in transport fares, which many find too high to enable them access services. The current curfew which stops movement at 7pm has not made things easier. These conditions, among others, have left expectant women with few options. The TBAs became the silent saviours of women’s lives. These were willing and ready to accord the much needed timely support for the expectant mothers in their communities for a number of reasons. First, they live within the communities and are therefore not affected by the movement restrictions. Secondly, the support and care TBAs accord women while they are in labour is sometimes not equivalent to the one provided in health facilities because the numbers attended to at a time is smaller. It should be noted that in 2010, the Government of Uganda outlawed TBAs. They were banned from conducting deliveries as they lack formal training to handle emergency cases such as C-Sections and haemorrhage. Haemorrhage contributes to 46 per cent of maternal mortality among women according to the 2018/2018 Maternal Perinatal Death Survey Report (MPDSR). Despite the ban, the traditional birth attendants are still very active, providing maternity care during and after pregnancy, especially in rural communities. Expectant mothers’ preference to traditional birth attendants’ services has risen even higher during the COVID-19 period. Beyond proximity, the current socio-economic and mobility challenges have seen women run to TBAs even more. Unfortunately, the delivery places and services are of very poor quality and usually take place under unhygienic conditions with no referral systems. Most TBAs in villages are old and have no training to offer timely technical assistance to expectant mothers but because they command a lot of respect, most people respect them and have resorted to their services. The outbreak of the pandemic saw the designation of some facilities to handle COVID-19 cases. This meant that attention to general sexual and reproductive health and rights services including maternal health services was minimised. Managing COVID-19 remains Uganda’s priority. Furthermore, there are myths and misconceptions about the behaviour of healthcare providers as being harsh and rude, although they have been found to be this way, especially towards expectant mothers. On the other hand, TBAs are perceived as approachable, friendly and are known to deal well with financially constrained mothers as they sometimes go to the extent of giving them tea and food in addition to some herbal concoctions. These factors therefore make TBAs more attractive to expectant women in the communities. However, the services of TBAs have been known to increase maternal mortality, mother to child transmission of HIV/AIDS (MTCT) and postpartum haemorrhage. These indicators are expected to worsen if mothers continue giving birth with the assistance of TBAs who are not equipped to handle such emergencies and cannot easily refer the women to health facilities where they can be skillfully helped. The presidential directives were put in place to protect Ugandans from COVID-19 and curb its spread in communities. However, the country has registered more maternal deaths than COVID-19 ones, which still stand at zero, due to the inability to access transport to health facilities. As CEHURD, we therefore recommend that the Ministry of Health strengthens the Public- Private Partnership (PPP) in this era to extend quality, accessible and affordable health services to all places in the country but more so to rural communities. This can be done through working with different civil society organisations and other private actors to provide services and information to the masses. These collaborations are also an avenue to advocate for better service delivery and accountability. They also contribute to strengthening the local community structures such as Village Health Teams (VHTs), Health Unit Management Committees (HUMCs), and Community Health Advocates (CHAs). VHTs if extensively trained and given the skills training, can take record of all expectant mothers in their constituencies and constantly monitor them till delivery time. They can further support them to access health facilities for ANC and child delivery, not forgetting social distancing and personal protection with protective gear, constant hand washing and use of alcohol-based sanitisers. They can also offer health education to their constituencies. HUMCs can be further strengthened to continuously update the communities about the available services at facilities and encourage them to go for health care. They can further monitor the activities of the health workers and quality of services. However, health workers should be equipped with the adequate personal protective gear such as emergency drugs, gloves, masks and disinfectants, among others as they are also working in fear of their safety while dealing with different categories of people from diverse locations. Lastly, Center for Health, Human Rights and Development (CEHURD) has trained a team of Community Health Advocates (CHAs) who are advocating for the realisation of right to health within communities. They also report cases such as Sophia’s. CHAs can sensitise communities about their rights and responsibilities amid COVID-19, record and report health rights violations and refer those who may need legal aid to CEHURD through the toll free line – 0800 31 3131. All this should be done in respect to MOH guidelines. The right to health is inherent and ought to be protected especially the lives of mothers and their newborn babies. Health workers should be supported to save lives and mothers taken good care of while bringing life to earth. Despite the pandemic, reproductive and maternal functions are ongoing, even escalated by the lock down, characterised by high sexual engagement both consensual and non-consensual. COVID-19 is a big public health threat but not worse than maternal deaths, this is evidenced by the fact that mothers and babies have been and are continuing to be lost due to effects of the lock down. Under these circumstances, isn’t it time for the country to re-think its restrictions and prioritise access to quality maternal and child health services? It’s unacceptable for women to die at the hands of traditional birth attendants and COVID-19 should be a learning opportunity for the Ugandan government. At the moment, Uganda is exposed and we need to work harder to ensure that women’s lives are protected and not lose another woman due to preventable child-birth related complications. For God and my Country. The writer is a programme officer at Center for Health, Human Rights and Development (CEHURD).
A version of this article was originally published in the Daily Monitoron 11th July 2020.
Every year on 31st May the World Health Organisation (WHO) and Global Partners celebrate the “World No Tobacco Day”, an annual campaign aimed at raising awareness on the harmful and deadly effects of tobacco use and second-hand smoke exposure, and to discourage the use of tobacco in any form.
This year, the World No Tobacco Day was celebrated under the theme “Protecting youth from industry manipulation and preventing them from Tobacco and Nicotine use”. The 2020 global campaign serves to equip young people with knowledge about the tobacco and related industries’ intentions and tactics to hook current and future generations on tobacco and nicotine products.
Tobacco use and COVID-19
This year’s commemoration came at a time when the world was facing the coronavirus pandemic. This brought forth an opportunity for countries all over the world to step up tobacco control efforts, heighten information sharing on tobacco use and COVID-19, and broaden understanding of the link between tobacco use and COVID-19 infection. It is also an opportunity to accelerate contextualised tobacco control, informed by the WHO FCTC Guidelines on the obligations of member states to counter tactics used by the tobacco industry. This is because the tobacco industry has for a long time deliberately employed strategic, aggressive and well-resourced tactics to attract people to use tobacco and nicotine products.
According to the WHO Fact sheet/Detail on Tobacco published on 26th July 2019, tobacco use continues to kill up to half of its users. The fact sheet adds that it kills more than eight million people each year of which more than seven million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.
This year, we emphasise the fact that tobacco use and smoking in particular is a risk factor for COVID-19, an infectious disease that primarily attacks the lungs. As smoking is a leading risk factor for heart disease, lung cancer, reduces immunity and makes us more susceptible to respiratory infections including pneumonia, it is also a risk for COVID-19 infection. This is especially because smokers touch their mouth and face more. A review of studies by public health experts convened by WHO on 29th April 2020 found that smokers are more likely to develop severe cases of COVID-19, compared to non-smokers.
Recent studies have continued to show that smokers who contract the virus are more likely to suffer severe symptoms and even die. Once a smoker has been hospitalised for COVID-19, the outcome is likely to be even worse. Smoking is detrimental to the immune system and its responsiveness to infections makes smokers more vulnerable to infectious diseases like Coronavirus. (Zhou Z Chen P Peng H are healthy smokers’ really healthy? Tob Induc Dis. 2016; 14 (November). Doi: 10.1186/s 12971-).
There are also higher percentages of current and former smokers among patients that need ICU support, mechanical ventilation, or who have died and a higher percentage of smokers among the severe COVID-19 cases (Guan WJ, Ni ZY, Hu,Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020). Smokers are therefore more likely to have severe symptoms of COVID-19, and are more likely to be admitted to an ICU, or require mechanical ventilation or die compared to non-smokers.
Impact of the covid-19 pandemic on tobacco control implementation in Uganda
Since the start of the pandemic, tobacco control efforts have since been significantly impacted. Implementation of tobacco control measures is coordinated under the Ministry of Health (in one of the departments that tackles tobacco use, NCDs, mental health, alcohol and substance abuse), and yet the MOH’s involvement and efforts are entirely directed towards response to COVID-19 as a priority.
The government has also continued to receive donations from tobacco industries (Leaf Tobacco and Merchandise Ltd, Meridian Tobacco Company) towards the COVID-19 National Taskforce/Response as stated in the national address by His Excellency the President on Tuesday 14th April 2020, contrary to Section 22 of the Tobacco ControlAct 2015 and the WHO FCTC.
The Government must be weary of donations that compromise public health as it is their duty to protect the public health, laws and policies from commercial and other vested interest of the Tobacco Industry. By donating, the Tobacco Industry is trying to improve their corporate image by showing social responsibility to the population, and sending deceptive messages to the public about Tobacco industry operations and their products. Partnership with the Tobacco Industry also undermines Government’s credibility in protecting people’s health since there is a fundamental and irreconcilable conflict between the Tobacco Industry’s interests and Public Health Policy interests.
This comes at a time when Ugandans are in a lock down for over 2 months now and are at home bored, which makes many of them easily get the temptation to smoke cigarettes or related products, contrary to what the law provides.
Way forward and Conclusion:
As we commemorate the World No Tobacco Day on 31st May 2020 and recognizing the fact that smoking could increase the risk of people contracting COVID-19 more, we call upon Government, young people, and the entire population to;
Support implementation of the Tobacco Control Act 2015 and the WHO FCTC.
Join hands to make healthy lifestyle choices through avoid the use of tobacco and related products
Educating themselves and others to support the Tobacco Control cause through complying with the tobacco control and public health measures in place
Adhering to these will help reduce the morbidity and mortality of cancers caused by tobacco smoke and COVID-19 as well.
The writer is a Programme Officer in the Campaigns, Partnerships and Networks Programme.
In February 2020, the government of Uganda under the Ministry of Health announced the outbreak of COVID-19 s. The state under the directives of His Excellency President Yoweri Kaguta Museveni enforced measures to curb the spread of COVID-19, which is reported to be airborne, contagious and easy to spread.
Unfortunately some of the state measures have hindered young people, women and men’s access to health services & rights, living, and finances. Most notable of these measures are the ban on public and private transport, and the ban on the majority of business, as long as they don’t provide essential services.
The above means that everyone who operates different types of business such as taxi drivers, conductors, tailors, bar attendants, shopkeepers are not working but instead staying at home, idle. As a result of this idleness, we have seen an increase in reports of gender based violence (GBV) among men and women and alcoholism. Gender based violence refers to the violence directly against a person because of their gender. While both women and men experience GBV, the majority of victims are women and girls.
In the sub-counties of Mayuge District such as Wairasa and Magamaga, local leaders such as the LC1, LC II and the police agree that there has been an increase in cases reported ever since the President issued the different directives to prevent COVID-19. As Community Health Advocates, one of our objectives is to stop family conflicts and gender based violence in our societies. Therefore, when we heard of these violations happening in our communities, we reached out to the local leaders to identify the likely causes. Some chairpersons at local council level believe that all these violations are as a result of people being idle as they stay at home.
The LC1 chairperson of Kawudu Zone Village, Magamaga town council in Mayuge District, Mr Mohammad Waibi said, “A big number (60 per cent) of men from his village were not staying at home [for this long] but due to the presidential directives, they have been forced to stay at home. These are the very people fighting with their wives and mistreating them.” He further stated that during the COVID-19 lockdown, he has received at least one case every three days, which was uncommon in the past.
Mr Waibi added, “Recently, I received a case of a pregnant woman who was beaten by the husband accusing her of asking him for money for food. I called the husband and he told me his wife knows very well that he had to stop working due to the COVID-19 directives but still insists on asking for money.” The LC1 therefore calls upon the government to lift some of these measures to enable some men go back to their jobs in order for these cases related to gender based violence to decrease. He was grateful to the Center for Health, Human Rights and Development (CEHURD) in collaboration with Community Health Advocates for supporting communities in matters of health, gender based violence and human rights through sensitisation, raising awareness and dialogues.
As Community Health Advocates trained by CEHURD to fight against such human rights violations in our societies, we appeal to the government of Uganda to hear the outcry of the people and adopt a human rights based approach in minimising the spread of COVID-19. This will save lives of people, especially women who are at a high risk of experiencing gender based violence. Failure to do this may unfortunately negatively impact the most vulnerable in the communitings (women/girls) resulting into death due to poor medical health care and increased rape, sexual harassment, poverty due to lack of jobs, family neglect, high health violations, teenage pregnancy, early child marriages, unintended pregnancies due to lack of access to family planning, and discrimination among other issues.
The writer is one of CEHURD’s Community health advocates in Mayuge District.
Earlier this week, the world marked International Day to End Fistula. Edith Sifuna , a programme officer in the CPN Programme discusses the condition and how the response to COVID-19 is an opportunity to create awareness about obstetric fistula.
In May 2020, the World Health Organisation (WHO) declared Obstetric fistula as preventable and can largely be avoided by delaying the age of first pregnancy; the cessation of harmful traditional practices; and timely access to obstetric care. The fight to end fistula, one of the most serious and tragic injuries that can occur during childbirth, could be threatened by the current COVID-19 pandemic. Due to the pandemic, it is expected that 13 million more child marriages could take place by 2030 that would have otherwise as a result of economic pressure. As we marked this year’s International Day to End Fistula under the theme; “End gender inequality! End health Inequalities! End Fistula Now!” it is important that the international community comes up significantly to raise awareness and intensify actions towards ending Obstetric Fistula.
At the beginning of 2020, the World Health Organisation (WHO) confirmed COVID-19 as a public health emergency of international concern. The virus has put a strain on health systems worldwide. Countries including Uganda have put guidelines and directives in place to curb its spread. While these have indeed worked to stop the spread of the virus, they have adverse effects on public health systems, particularly maternal health.
In the midst of all these efforts, there is a danger that may take many women’s lives or inflict permanent physical and social injury. This seldom talked about danger is obstetric fistula. Obstetric Fistula has been placed among the most neglected components of maternal health during COVID-19 yet it is likely to have a devastating impact on the wellbeing of both women and girls of ages 15 to 49 years. Obstetric Fistula occurs as a result of prolonged obstructed labour, which is usually associated with delays in seeking and receiving appropriate emergency obstetric care. This leads to a hole developing either between the rectum and vagina or bladder and vagina leading to odour, infertility and chronic infection.
In Uganda, apart from the low quality health care, fistula cases have been on the increase due to different cultural practices such as child marriages for economic gains by the parents/guardians, child prostitution resulting into early unplanned pregnancies, and traditional practices like female genital mutilation. These have highly exposed women within the reproductive age to complications at delivery as their bodies are not biologically ready to support a pregnancy, increasing chances of complicated child deliveries. This has been coupled with high poverty rates, especially among women, which deters access to quality health care services.
According to a Uganda Demographic and Health Survey (UDHS) report, a reduction in fistula prevalence from three per cent in 2006 to two per cent in 2011 was reported. Notably, 62 per cent of the affected women received treatment. Despite the treatment and efforts to curb the disease, it still affects the health, social, economic and psychological wellbeing of women, gradually affecting their productivity as individuals and the family.
In addition to the effects already mentioned, fistula also leads to inability to hold urine for a long time, persistent abdominal pains, failure to give birth again, low sex drive and discrimination from family, society and premployment.
Despite the fact that Fistula can be prevented and treated, the survivors continue to suffer from shame, rejection, isolation, trauma and stigma from partners and communities even after treatment and recovery. Gender based violence has also been noted to increase as men opt to find other women who are free from fistula. Domestic violence also stems from the economic strain on the family in the form of costs for surgeries to repair the damage, and purchase of recovery materials and equipment like adult pampers and medicines. With this, most Fistula cases go untreated as women are afraid to admit to the condition or too poor to afford the treatment. As women continue staying safe at home, they are likely to give birth at home assisted by traditional birth attendants or while they are trying to access healthcare facilities. These circumstances can lead to obstructed labour.
“COVID19 has increased the effects of fistula due to restricted movement, patients with fistula repairs were not able to access hospitals to have their repairs done as only emergency cases were being handled while others were stranded as they could not go back home after treatment. Fistula cases have increased due to failure to access hospitals early for delivery or antenatal care resulting in obstructed labour complications such as bladder injuries, fistula and morbidity. It was really absurd that a lady lost her baby as she could not reach the nearby health facility in Bussi and receive treatment as a result of restricted movement and she is now suffering from effects of birth complications and fistula. If this woman had accessed healthcare services on time, her baby would have been saved and complications avoided. With the current trend, there will be many cases of women suffering from fistula, childbirth complications and morbidity. It is therefore important that women are given easy access to hospitals despite COVID-19 and the restrictions. Proper structures for management of complications due to obstructed labour should also be put in place. It is important to strengthen community structures to identify, monitor and refer women for treatment.” A Fistula Surgeon!
With all efforts geared towards COVID-19, it is easy to overlook conditions such as fistula. It is therefore necessary that a comprehensive and holistic fistula care and prevention approach is put in place to restore and preserve the confidence and dignity of victims. This can only be realised if the Government and different stakeholders create awareness about prevention and treatment of obstetric fistula in this era, integrating this into the current guidelines. As women continue staying safe at home, they are likely to give birth at home, from Traditional Birth Attendants or along the way while trying to access health care facilities and may be faced with obstructed labour. Health services have become overloaded and maternal health care services somehow neglected as all efforts are geared towards COVID-19.
It is imperative that there is timely access to comprehensive safe delivery services and emergency obstetric care through bridging the unmet need for maternal health care to prevent women from suffering as they perform their natural maternal function. Maternal mortality is a major challenge in Uganda and any set back in the health system will increase the rate at which women die hence the need to come up with quick and effective medical interventions and guidelines for women to easily access health care services to minimize preventable complications due to delay to access health services and information.
In the current COVID-19 situation, it is important that sexual and reproductive health services such as timely obstetric care and treatment for fistula patients are easily accessible. Information on the same should also be available, not to mention the need to strengthen patient referral and follow up mechanisms.
We must therefore stand together to prevent childbirth complications such as Obstetric Fistula. We can do this by providing comprehensive and universal quality maternal health care services and information, and prioritising women with existing fistula conditions in the face of COVID-19. This is because Obstetric Fistula is a serious and potentially tragic condition. A multi-sectoral approach to raising awareness and intensifying actions towards ending it would therefore restore hope, joy and self-esteem among women as they continue performing their maternal right during the COVID-19 pandemic.