Maternal Deaths Focus Harsh Light on Uganda

ARUA, Jennifer Anguko was slowly bleeding to death right in the maternity ward of a major public hospital. Only a lone midwife was on duty, the hospital later admitted, and no doctor examined her for 12 hours. An obstetrician who investigated the case said Ms. Anguko, the mother of three young children, had arrived in time to be saved.
Her husband, Valente Inziku, a teacher, frantically changed her blood-soaked bedclothes as her life seeped away. “I’m going to leave you,” she told him as he cradled her. He said she pleaded, “Look after our children.”
Half of the 340,000 deaths of women from pregnancy-related causes each year occur in Africa, almost all in anonymity. But Ms. Anguko was a popular elected official seeking treatment in a 400-bed hospital, and a lawsuit over her death may be the first legal test of an African government’s obligation to provide basic maternal care.
It also raises broader questions about the unintended impact of foreign aid on Africa’s struggling public health systems. As the United States and other donors have given African nations billions of dollars to fight AIDS and other infectious diseases, helping millions of people survive, most of the African governments have reduced their own share of domestic spending devoted to health, shifting to other priorities.
For every dollar of foreign aid given to the governments of developing nations for health, the governments decreased their own health spending by 43 cents to $1.14, the University of Washington’s Institute for Health Metrics and Evaluation found in a 2010 study. According to the institute’s updated estimates, Uganda put 57 cents less of its own money toward health for each foreign aid dollar it collected.
Rogers Enyaku, a finance expert in Uganda’s Health Ministry, disputed the assertion, saying the country’s own health spending had increased, “but not that substantially.” Still, the government set off a bitter domestic debate this spring when it confirmed that it had paid more than half a billion dollars for fighter jets and other military hardware — almost triple the amount of its own money dedicated to the entire public health system in the last fiscal year.
Poor people surged into Uganda’s public health system when the government abolished patient fees a decade ago. Increasingly, African countries are adopting similar policies, and experts say that many more people are getting care as a result. But Uganda’s experience illustrates the limits of that care when a system is poorly managed and lacks the resources to deliver decent services, experts say.
At regional hospitals like the one here in Arua, more than half the positions for doctors are vacant, part of a broader shortage that includes midwives and other health workers. A majority of clinics and hospitals reported regularly running out of essential medicines, while only a third of facilities delivering babies are equipped with basics like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report.
The hospital where Ms. Anguko died handles obstetric emergencies for a region of almost three million people, but it recently had no sutures in stock to sew up women after Caesarean sections. Dr. Emmanuel Odar, the hospital’s sole obstetrician, said that even in childbirth emergencies, families must buy missing supplies themselves, typically at nearby pharmacies. Patients without money must beg or borrow it, Dr. Odar said.
“We are overwhelmed with cases of people looking for free services, and they expect a lot despite supplies not there, human resources lacking and the beds not enough,” he said.
Dr. Olive Sentumbwe-Mugisa, a Ugandan obstetrician and adviser with the World Health Organization, participated in the Health Ministry’s investigations of the deaths of both Ms. Anguko and Sylvia Nalubowa, a second woman named in the lawsuit against the government, and concluded that both women arrived in time to be saved.
“We are in a state of emergency as far as maternal services are concerned,” Dr. Sentumbwe-Mugisa said. “We need to focus on the quality of care in our hospitals and address it in the shortest period of time. That will mean more resources. We cannot run away from that.”
In its lawsuit filed in March, the Center for Health, Human Rights and Development, a Ugandan nonprofit group, contended that the government violated the two women’s right to life by failing to provide them with basic maternal care.

Source: http://www.nytimes.com/2011/07/30/world/africa/30uganda.html?hpw

Constitutional Court begins hearing maternal deaths case

The Constitutional Court in Kampala, Uganda, started a case against the Government of Uganda on preventable maternal deaths and the right to health.
The case, Petition Number 16 of 2011, argues that by not providing essential medical commodities and health services to pregnant women, the government is violating the constitutional rights of Ugandans, including the right to health, the right to life, and the rights of women.
The petition highlights the case of two women who died in childbirth; their families were also present at the hearing. Many reports of additional maternal deaths from across Uganda have come to light since the case was filed on 3 March 2011.
The court case was started by a group of activists representing health, HIV/AIDS, human rights, and womenʼs organisations in Uganda. According to the activists, cases of preventable maternal death such as of the two women are commonplace in Uganda.
One of the complainers, Hilda Kironde of Uganda Community Based Association for Child Welfare (UCOBAC) said: “With sufficient funding and leadership, these deaths would stop. We are hopeful that the Constitutional Court will understand the unacceptable plight that expectant mothers face in Uganda.”
The activists call for a 2011/2012 supplementary budget that increases investments in the life-saving emergency care, health workers, commodities and services that could end Ugandaʼs crisis of preventable maternal death.
Source: www.ifhhro.org

Families sue Ugandan government over women’s deaths in childbirth

The families of two women who died following obstructed labour begin an historic legal action today, in a bid to force the Ugandan government to tackle the shortages of doctors and midwives, drug stock-outs and absence of emergency transport that kill 16 women a day
The families of two women who died in childbirth are starting a legal action against the government of Uganda today, alleging that the inadequate care and facilities provided for pregnant women caused the deaths and violates their country’s constitution and women’s rights to life and health.
The case is unprecedented in Uganda. Aid agencies and medical charities and donor governments can condemn the death toll in pregnancy and childbirth, but the most powerful argument is the devastating testimony of those who suffer.
Sylvia Nalubowa died in Mityana hospital on 10 August 2009 from the complications of obstructed labour. She was carrying twins, one of whom was delivered. The second died with her. Jennifer Anguko died in Arua regional referral hospital on 10 December 2010 when her uterus finally ruptured after 15 hours of obstructed labour. Her status as a district councillor brought her no favours – she was said to be the fourth woman to die in that hospital that day.
Campaigners point out that 16 women die unnecessarily in Uganda of the complications of pregnancy and childbirth every day. In much of the country, there is little in the way of emergency obstetric care. There are shortages of doctors to carry out a caesarean to save the lives of mothers and their babies in obstructed labour and few ambulances to get the women to the theatre in time even if a doctor is available. I’ve seen it myself in Katine, in eastern Uganda – as I wrote here.
The families, who are supported by Ugandan health advocates and campaigners, argue that women in childbirth are denied the care and facilities they need. There are too few doctors, nurses and trained midwives, maternity units are ill-equipped and there are frequent drug stock-outs. And too many of the staff who are on the units treat women with abuse and contempt. This is from their petition Expectant mothers have continued to die in government hospitals under similar circumstances. Nurses and doctors solicit money out of them and other maternal health consumables and in the event that they fail to raise the money or other materials they are left unattended to which leads to their death and this violates their right to life.
I would find this hard to believe if I had not heard the same accounts from people in Katine, which I visited several times while the Guardian was sponsoring a development project there.
The petition argues that Uganda is not spending the money it promised on maternal and child health. The World Health Organisation mother and baby package, which the government agreed to implement, specifies spending of $1.40 per capita. Uganda spend just 50 cents, it says.
It is dispiriting that the legal action is needed, but for the sake of all Ugandan women, it clearly is.
Source: http://www.guardian.co.uk/society/sarah-boseley-global-health/maternal-mortality-uganda

Maternal Deaths Against Constitutional Rights

When Valente Inziku’s wife, Jennifer Anguko, went into labour they had decided she would go to the local referral hospital just to ensure a safe delivery.
But Anguko bled to death because nurses and doctors could not be bothered to treat her. Her unborn child died as well.
“We attended antenatal clinics and each time they advised us to be near the health center when the delivery time comes. We did just as we were told and when we arrived the services were not provided,” Inziku said.
He had arrived at the hospital after his wife did and found her bleeding. “All the nurses were telling me was I had to clean the blood myself. I had my sister so we cleaned the blood,” said Inziku. “It was purely negligence of the nurses I kept calling them and they would tell us it is not yet the time for her to deliver the baby.”
So Inziku and his sister literally sat down holding his wife as she bled to death. “She died in my arms. She told me: ‘We have children, we have love but all this seems nothing if we have no help.’” Inziku said.
Inziku says the only doctor appeared 12 hours after his wife was admitted. “When the doctor finally arrived he told me it was too late and he asked why the nurses had called him,” Inziku said.
Inziku, a primary school teacher, is now left to look after their three children, all under the age of 10, alone.
Inziku is part of a group that has petitioned the Uganda Constitution Court to pronounce the escalating maternal deaths in Uganda violates the Constitutional rights of Ugandans.
The case was brought to court in March by the Centre for Health, Human Rights and Development together with three individuals: Professor Ben Twinomugisha, a lecturer at Makerere University; and two health activists, Rodah Kukkiriza and Inziku.
They want government to address maternal mortality and compensate the families that have lost mothers to negligence or poor services.
In the petition, the activists argue that by not providing the essential services for pregnant women, and many others, the government of Uganda is in violation of the fundamental obligation of the country to uphold the Constitution and defend, protect and promote the right to health and the right to life.
“I am here today because I want the court to know there’s an injustice going on. I have pain in my heart,” said Inziku.
The court was scheduled to hear the petition on Jul. 7 but the case was postponed because they did not have the required quorum of five judges.
Noor Nakibuuka Musisi, the programme coordinator at Centre for Health Human Rights and Development said securing a court declaration would be a great start in getting government to act.
“We want a declaration that the non-provision of essential services in the government facilities is a violation of the right to life,” she said. “The reason many women die is because there are no maternal kits, there’s no blood in hospitals and we have poorly paid health workers not behaving in the most ethical way.”
In June the Ugandan government announced an increase in the health budget for the 2011/12 financial year. It increased from 270 million dollars to 412 million this year.
However, Francis Runumi, the commissioner of health services and planning at the ministry of health said most of the budget was going to infrastructure and would not address the human resource crisis that has contributed to maternal mortality figures.
Still activists question the political commitment and health sector accountability. Recently government spent 760 million dollars on fighter jets and other defense equipment, which many question as a priority for Ugandans.
Robinah Kaitiritimba, the executive director of the Uganda National Health Consumers Organisation, part of the coalition that brought the case to court, said Ugandans must fight for their rights.
“There are no rights which are given on a silver platter, we must continue to fight and ensure our government responds to the cries of mothers and families.”
Maternal death in Uganda has remained high over years, every day at least 16 women die in childbirth. Uganda’s maternal mortality figures are at 435 deaths of every 100,000 live births, which translate to 6,000 deaths annually. Also child mortality remains high with infant mortality rate at 78 per 1000 births.
Most of the maternal deaths in Uganda are preventable and mainly caused by the massive shortage of trained and motivated professional health workers to attend births, lack of access to emergency obstetric care for responding to emergencies, lack of access to quality antenatal care, and lack of access to family planning services.
The gap in access to life-saving HIV treatment and malaria prevention and treatment are also major causes of maternal deaths.

Maternal Deaths Emblematic Of Rot In Uganda’s Healthcare System

Uganda has the uncanny ability of always popping up in the news. The last time my home country captured the imagination of the American public was in early June when the profane, potty-mouthed and hysterical musical “The Book of Mormon” won nine Tony Awards. The happily paradoxical “Book of Mormon” is about two dewy missionaries from Salt Lake City transported to Uganda and their misadventures.
Now the New York Times has come out with this: Maternal Deaths Focus Harsh Light on Uganda.
The article was spot-on. Wielding a slingshot that had its fingers on the pulses of Uganda’s expectant women, the piece threw brickbats at Uganda’s floundering public health system. Foreign aid donors were not spared either as the article questioned the unintended consequences of development aid.
The Birth And Genesis
The embers in the most-recent fiery debate about maternal mortality rates in Uganda were stoked on May 27, 2011 when the Centre for Health Human Rights and Development (CEHURD), a Ugandan NGO, and the families of two mothers who died in government hospitals in 2009 approached the Ugandan Constitutional Court alleging the women’s deaths were caused as a direct result of Uganda’s failing healthcare system. CEHURD, in this landmark petition, alleged that the circumstances that led to the death of these two women were both emblematic and symptomatic of the government’s failure to fulfill its constitutional obligations to provide basic maternal healthcare to expectant mother. They sought to arm-wrestle the government into increasing its budget for maternal healthcare and compensation for the families of the two women.
Accounts of the events that led to the death of the two women are almost the same. Councilor Anguko Jennifer, a civic official in Arua district, sustained a ruptured uterus while waiting for over ten hours to be attended to by a doctor while she was in labor.
She died on the theater table. Sylvia Nalubowa, a mother of seven, was not aware that she was to have twins. The antenatal clinic she attended in her area in central Uganda did not have adequate scanning facilities. When she went into labor, her husband could not raise money to transport her to Mityana Hospital and, according to reports, they had to ‘improvise’ transportation to reach that hospital, 15 kilometers away.
Unable to purchase a Ush 50 000 ($ 25) ‘mama kit’ for use at the hospital’s labor ward, she was left unattended and died. The mama kit package contains a meter piece of cotton cloth, laundry soap, a pair of gloves, a piece of cotton wool, small gauze, cord ligature, and a meter of polythene sheet for the delivery table.
The Sick Life Of Uganda’s Systems
Uganda’s health care system needs CPR. The NY Times story, emphatic in its articulation, painted the picture of a battered, bankrupt and decrepit tragedy.
“At regional hospitals like the one here in Arua, more than half the positions for doctors are vacant, part of a broader shortage that includes midwives and other health workers. A majority of clinics and hospitals reported regularly running out of essential medicines, while only a third of facilities delivering babies are equipped with basics like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report.”
The government’s response to the joint suit by CEHURD and the families of the two deceased expectant women was telling. Unaccustomed to such Zeus-style thunderbolts on the efficacy of its governance and the healthcare system, government officials dabbled uneasily in obfuscation, saber-rattling and shifting of responsibilities as they guarded their fief.
Uganda has seen rosier times. The Uganda Bureau of Statistics pegged Uganda’s inflation rate at 18.7 percent in July 2011, the highest since February 1993. According to data compiled by Bloomberg, Uganda’s shilling is Africa’s worst performing currency this year after weakening 12 percent against the dollar. Uganda is one of the countries with the highest child mortality rates in the world, according to the State of the World’s Children report.
She holds the 21st last slot out of 189 countries. At least an estimated 45,000 newborn deaths occur in Uganda each year and an equal number are stillborn, making her the country with the fifth highest number of newborn deaths in sub-Saharan Africa.
According to the World Health Organization, Uganda has the world’s highest malaria incidence, with a rate of 478 cases per 1000 population per year. The overall malaria-specific mortality is estimated to be between 70,000 and 100,000 child deaths annually in Uganda, a death toll that far exceeds that of HIV/AIDS. Tuberculosis remains a major public health problem in Uganda, ranking her 18th among the 22 TB high burden countries of the world. About 100,000 new cases of all forms are recorded every year.
A Post-mortem Analysis
Giving handouts to Africa remains one of the biggest ideas of our time — millions march for it, governments are judged by it, celebrities proselytize the need for it. Whenever funds are doled out, press conferences are held and kumbaya moments invoked. What is not ever sufficiently articulated is that development aid has, in some cases, done more harm than good to Africa.
“For every dollar of foreign aid given to the governments of developing nations for health, the governments decreased their own health spending by 43 cents to $1.14, the University of Washington’s Institute for Health Metrics and Evaluation found in a 2010 study. According to the institute’s updated estimates, Uganda put 57 cents less of its own money toward health for each foreign aid dollar it collected.”
In the history of mankind, no country has ever developed by depending on foreign aid. Dambisa Moyo, whose book Dead Aid I plowed through in January 2011, opines that Africa needs to be gradually weaned off development aid and the spigots finally shut off and African governments left to their own devices. Previously a lone dissenting voice, Ms Moyo is garnering a rapidly increasing roster of supporters willing to toll the death knell for foreign aid. More are jumping onto this bandwagon.
What should Uganda do to avert its maternal mortality crisis? Here is a list of suggestions from Ms. Magazine, a blog that prides itself in its ‘fearless feminist’ reporting. Emphasis needs to be placed on adequate remuneration for doctors and other healthcare workers. For a long time, it has been expected that health care workers should toil and serve with their morality’s engines powered by altruism, humanism and nationalism alone. That hasn’t worked. This may be anathema to donors but it needs to be put out there that health care workers with a ‘sufficiently oiled’ vested interest in Uganda are the key to preventing Uganda’s slide into healthcare Armageddon. With that in place, we will probably be seeing the last of the hemorrhage caused by maladies such as absenteeism, presenteeism, healthcare-related corruption and the brain drain. Next would be to institute an overhaul of Uganda’s healthcare system starting with the management of training of healthcare workers being returned to the Ministry of Health from the clearly over-burdened Ministry of Education and Sports.