MATERNAL HEALTH

1. Problem Analysis

Maternal health; refers to the health of a woman; before she becomes pregnant, during pregnancy, child birth and in the period following delivery especially the first 6 weeks (post partum period). Health care that ascertains maternal health therefore encompasses health care prior to conceiving, during pregnancy, childbirth during the first 6 weeks following delivery, newborn care is part of health care because ensuring that the baby is born alive and healthy will encourage a mother to make proper reproductive health decisions, especially those pertaining to family planning.

Uganda’s population growth rate is at 3.2%[1] making it the highest in the world after Niger and Timor with a fertility rate of 6.9 children for every woman in reproductive age in 2001 and 6.7 in 2006. Out of 100,000 women who give birth every year 435 do not make it out of the labor ward alive[2].This translates into loss of about 6000 women annually due to pregnancy-related complications, most of whom die from purely preventable causes[3]. Most Ugandan mothers just like from any other developing nation, the majority of who are Young girls under 30 years still do not have access to antenatal care services;[4] walk long distances when going to deliver while others end up dying due to lack of qualified personnel. In fact only 32% of women who give birth in Uganda receive care from trained personnel while the majorities give birth at home or under the supervision of traditional birth attendants. The high prevalence of illegal abortions sometimes ends up in deaths.[5]Abortion in Uganda is illegal and is a sign of immorality in society[6]

Health facilities especially in rural areas are not easily accessible due to the poor state of the roads and in addition face drug stock outs, have inadequate equipment and personnel , under skilled workers who are overworked, under paid and the situation is worsened by corruption.

The majorities of women in Uganda are subordinate to their male partners and therefore lack decision-making power and thus cannot decide the number of children they should bear, negotiate for safer sex measures, contraceptives or child spacing. It is largely when men agree to limit the number of children that a woman can go for contraception. Only 18.5%[7] of Ugandan women use modern contraception methods, the unmet need stands at 41%; the highest in Africa[8]. The major causes of maternal mortality and morbidity in Uganda include severe bleeding, high blood pressure, unsafe abortions and obstructed labor[9].

The Ministry of Health has tried to set up interventions to fight maternal mortality by scaling up to attain the MDG 5 by increasing skilled attendants at birth, access to Family Planning services in order to avoid pregnancies that occur at an early age, “too frequent” or too late in the reproductive age of a woman, prevention and management of pregnancy related complications by increasing access to Antenatal care and Postnatal Care.

The government has tried to integrate reproductive health programmes with malaria control programmes specifically with the inclusion of intermittent preventive treatment (IPT) as part of the antenatal care package. There is promotion and provision of free or subsidized insecticide treated nets (ITN) to pregnant mothers and children under the age of five. There are also ongoing efforts to upgrade and equip health centers with the necessary drugs and attendant equipment to manage emergency obstetric care, blood transfusion and post abortion care.

2. Existing policies

Uganda has been one of the pioneering countries in undertaking health sector reforms within the framework of decentralization. This has definitely scored many achievements such as reduction in infant mortality rate (IMR) from 88/1000 live births in 2001 to 76/1000[10] live births in 2006 (UDHS 2006). Similarly, the under five mortality rate (UMR) decreased from 152/1000 live births in 2001 to 137/1000 live births in 2006. There has been a decline in maternal mortality rate over the years that is from 527/1000 live births in 1995 to 505/1000 live births in 2001 and 435/1000 live births in 2006. Maternal mortality however, is still below sector strategic plan (HSSP11) target of reducing maternal mortality rate 505 to 354 per 1000 live births.

Primary health care (PHC) and Minimum Health Care Package (MHCP) were also introduced and have significantly contributed to improving the health of the population. Resultantly, there has been an improvement in a number of input and output indicators. In particular patient department and immunization coverage exceeded the Poverty Eradication Action Plan (PEAP) and the Health Strategic Plan 2004/05 set targets.

Despite these reforms, the health and poverty indicators in Uganda remain some of the worst on the continent. The performance of primary health care is generally poor as compared to the end of HSSP 11 2005 target of 68%. Physical access to PHC services registered a huge improvement with 72% of the population being within the kilometers of the health facility. However, the improved physical access to PHC services reported above, does not reflect the full picture of persisting inequality in access with coverage ranging from 7.1% Kotido to 100% for Kampala. The government of Uganda has tried to come up with a number of policy interventions to improve reproductive health in Uganda which seek to reduce fertility rate, maternal morbidity and mortality by promoting informed choice, service accessibility and improved quality of care. These include:

a). The Uganda National Reproductive Sexual and Reproductive Policy is the roadmap to reduction of Maternal and Newborn mortality, but both policies clearly state type of services expected at the different levels of care while the National Health Policy and the Health Sector strategic Investment plan prioritize maternal health or current period up to 2015.

. b) The Uganda Gender Policy intends to empower women in decision making processes as a key to development.

C). The Adolescent Health Policy intends to promote adolescent friendly services, sex education and building life skills. In addition, the Adolescent Health Policy sets the minimum age for marriage at 18 years to counter the high rates of adolescent pregnancy. The governments with the help of the Millennium Development Goal implementer (UNDP) are working harder to achieve Universal Primary Education and in future this will help on the improvement of maternal and reproductive health indicators.

D). The Safe Motherhood programme and it is the major promotion of maternal Health in Uganda. This has helped the civil society organizations to come on board. For example MJAP (Mulago-Mbarara Teaching Hospitals' Joint AIDS Program) does outreaches for Home Based HIV Counseling and Testing, Integrated Community Based Initiative does Prevention of Mother to Child Transmission (PMTCT) thus helping a rural woman to know her status and at the same time reducing on maternal mortality.

Despite the above interventions, the following still remain unresolved issues as far as maternal health is concerned and as such form the basis for Alternative proposals and recommendations.

§ The provision of high quality, voluntary family planning services,

§ Enhancing access to safe abortion where it is legal,

§ Working to improve the status of women and girls; sufficiently integrating HIV treatment into maternal health,

§ Implementing targeted interventions, such as providing Magnesium Sulfate and improving transport for pregnant women at risk, while aiming to strengthen health care systems and supporting financial investments that will improve the strength of health systems and increase access to skill attendance at birth.

3. Policy Options/Alternatives

The table below describes different alternatives and policy proposals that would strengthen already existing efforts by different state and non state actors to improve the Access to Maternal health care services in Uganda. It draws from lessons of other developing countries and projects which are very applicable in the Ugandan context. The table also looks at the advantages and disadvantages of these proposals and informs the recommendations in the chapter following.

Alternatives	Advantages	Challenges
Strengthen access to more wholesome reproductive care facilities. That target mothers and their partners.	Ensures a collective action and concern on issues of maternal health.	Cultural barriers which inhibit men from getting involved and supporting maternal health issues
Invest in research on alternative knowledge on maternal health such as traditional birth attendants to improve the services rendered by the traditional birth attendants. Provide for a legal framework to regulate the work done by the Traditional Birth Attendants(TBA)	Ensures that more inclusive policies are formulated. Helps to integrate indigenous knowledge into internationally recognized practices. Ensures procedures in herbal or alternative healthcare are standardized.	There is limited accessible knowledge on alternative knowledge and these sources of information must be created
Invest massively in human capital development of community health workers. E.g. nurses, clinical officers and midwives.	Reduces Doctor/midwife to expectant mother ratio Increases the Human Resource base for maternal healthcare	Limited training facilities for nurses and midwives countrywide
Government should rehabilitate dilapidated structures and improve public health infrastructure.	Improves access to maternal healthcare services as services are brought nearer to the people	Limited resources allocated to the Health sector in the National Budgeting process
Government should devise means of monitoring and evaluating health programs that improve access to maternal and reproductive health.	Improves accountability and checks corruption. Strengthens government’s capacity to monitor the effectiveness of programs.	Strengthen community monitoring of Public funds initiatives
Government should revive and strengthen primary health care facilities with components of reproductive/ maternal health to reduce maternal mortality occurring from purely preventable causes.	Significant reduction of maternal mortality e.g. PMTCT	Limited resources allocated to the Health sector in the National Budgeting process

4. Recommendations

If Uganda is to hit the MDG target, what should be in place? Are the resources allocated to safe motherhood programmes sufficient, and who is responsible for ensuring that women of Uganda do not die due to complications of pregnancy and child birth? The following analysis proposes some alternative policy recommendations for consideration.

· There is need to invest in training and retaining health care personnel especially those who provide maternal health care services and allocate adequate resources to the health sector with a view of improving maternal and child health.

· Provision of an attractive salary package for professionals to work in their country to prevent them from moving to developed nations in search of greener pastures

· Monitoring and evaluation of health programs by the Ministry of Health to ensure value for money and improve the quality of services delivered. The sector should also ensure that drug supplies dispatched from central medical stores reach the intended districts and health facilities.

· Budgetary allocation needs to be stepped up and specific budgets have to be created to address not only the health (safe motherhood) but also the socio-economic and cultural dimensions of safe motherhood.

· Health service providers and Ministry of Health must cease to consider safe motherhood as “an add-on” program and should institute budget line for the purpose with meaningful allocations for reaching wider communities.

· There is need for decentralization of drug management and distribution mechanisms to improve on the timely distribution of drug so that health units at levels have sufficient drugs to serve the population at any given time.

· Health personnel should undertake refresher courses/trainings to enable them have a “human face” and to adopt the ethics of handling expectant mothers as well as having a positive attitude towards them.

· Government needs to allocate resources to address issues of gender based violence, promotion of adolescent reproductive health to match with the gravity of safe motherhood concerns.

· There is need to construct health centers in every parish so that pregnant women do not walk more than 5km to access maternal services. This should be accompanied with the procurement of “Mama Kits” which must be compulsory at district levels to promote safe motherhood concerns.

· Allocation of sufficient resources for implementation of government commitment made under the Abuja Declaration on health, the AU commitment on the campaign on accelerated reduction of maternal mortality and the National roadmap on maternal health.

Cited references

Republic of Uganda (2006a) Uganda key findings from the UDHS: a gender perspective, Kampala, UBOS

Republic of Uganda 2009a :) health sector ministerial policy statement financial year 2009/2010 Kampala ministry of health

Republic of Uganda (2006b) Uganda demographic and health survey, Kampala, UBOS

Republic of Uganda (2001/2002) Uganda demographic and health survey, Kampala, UBOS

Guttmacher institute (2009) “Benefits of meeting the contraceptive needs of Ugandan woman” in brief, 4, 1-9

Daily monitor Saturday, May 28, 2011 | By Evelyn Lirri

Republic of Uganda Annual health sector performance report financial year 2009/2010 Kampala ministry of health

Singh, s, Prada, E, Mirembe, F and Kiggundu, c (2005) “ the incidence of induced abortion in Uganda, international family planning perspectives, 31, 4, 183-191

UNICEF (2005) report on the situation of women and children in the republic of Uganda, Kampala UNICEF

Sibbald, B (2007) Uganda government revolves to make safe mother hood a priority “Canadian Medical Association journal, 177(3) 244-245

http:/web.worldbank.org

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[1] Republic of Uganda 2006a:10

[2] Republic of Uganda 2009a:3)

[3] Daily monitor Saturday, May 28, 2011 | By Evelyn Lirri

[4] Guttmacher institute 2009:1-9

[5] Singh et al 2005:183-191

[6] Sibbald 2007:244-245

[8] Republic of Uganda 2006a:11

[9]Daily monitor Wednesday, June 8 2011