SIRONKO – When teenager Mwajuma Kakule, 18, started experiencing labour pains, her mother Ms Rukia Nasigwa, of Busedani ward, Buweri town council, in Sironko district encouraged her to push the baby.
And when the labour pains intensified, Ms Nasigwa kept telling her daughter [Kakule] to push but later she could not push any further, she lay on a mat silent.
This being Kakule’s first child being a teenager, her mother knew that she was headed for trouble.
And convinced that she could only deliver well in the hands of a qualified medical worker, Ms Nasigwa looked for the transport to Budadiri Health Centre IV.
Although everyone was busy preparing for National Resistance Movement Elections, Ms. Nasigwa rushed to the stage at Buweri town council; got a Boda Boda cyclist who wedged Kakule who was half-dead on a bicycle to Budadiri health centre IV, just about 4 kilometres away to seek the attention of a qualified medical worker.
They pushed furiously for four kilometres through the bushy village road of Bunabela village, in Busedani parish to the muddy and almost abandoned road, riddled with potholes for 4 kilometres.
But on reaching the nearest Budadiri Health Centre IV, despite the great pain the teenager was in, there was no medical worker, no medicine and they were told to wait and they reportedly sat for almost two hours before seeing a medical worker.
Ms Nasigwa says her daughter was taken to the labour ward and that at about 1.00 pm she progressed well and delivered a baby girl of 1.6Kg.
Ms Nasigwa says that as soon as she was brought back to the ward, she started bleeding without help as the only midwife at the facility had retired home.
But Ms Nasigwa’s relief quickly turned to despair when the teenager mother’s condition changed at about 4.00 pm, she was put on blood later but could not respond, she collapsed and died at about 7.30 pm on leaving an six-hour baby alive.
A death report from the hospital signed by the nursing officer in charge of Maternity ward dated 3 September says although she had delivered well, the teenager mother sustained a tear on the cervix which was ruptured in the theatre before she was brought in the ward.
Mr Yahaya Nakyeza, the father to the diseased and relatives claim their kin, teenager mother, died of negligence at the health facility.
“I am dragging the health centre Iv to court for negligence and I am sure this is not the mother to die of this,” said Mr Nakyeza at the burial of his daughter in Busedani.
Ms Nasigwa’s traumatic experience is not unusual in rural health centres of Uganda, where the healthcare system is inaccessible despite the billions of shillings of mostly donor money flowing in every year.
A visit to a few health centres in Sironko district reveals a chronic shortage of beds, drugs and medical personnel, confirming a verdict by the Anti-Corruption Coalition of Uganda that service delivery and general care is almost not there.
The LCV chairman Sironko Mr Herbert Mulekwa said if the health centre had had medical workers to attend to this teenager mother on time, she would have survived to see her child.
He explained that there were a number of mothers who have died at Budadiri Health centre IV because of negligence on part of the health workers and warned that if it does not end he would intervene himself to change the situation.
“This death makes one of the many who have died at this facility which makes the death rate and this lady died because of bleeding and lack of maternity care due to lack of proper medical care,” said Mr Mulekwa.
Ms Judith Nakidde, the nurse in charge of maternity ward in Budadiri health centre IV says the teenager mother died due to the tear she sustained on the cervix which was ruptured but the Ms Nasigwa [mother to the diseased] insists her girl died due to over bleeding after she was neglected by the medical workers at the facility.
The death report by Ms Nakidde says the teenager mother was delayed at home and that if they had acted sooner she would have survived.
“But even then it was unavoidable death because even at Mbale regional referral women still die of over bleeding or post-partum haemorrhage,” said Ms Nakidde.
Very low awareness among pregnant women and limited skills of health workers to manage this condition persist as the top bottle-necks towards the fight against post-partum haemorrhage and pre-eclampsia.
Dr Muhammad Mulongo, a gynecologist at Mbale referral hospital says the most common cause of deaths during delivery and after deliver is severe bleeding [haemorrhage].
He says it most often happens after the placenta is delivered, but that it can also happen later and “this teenager mother could have died of Postpartum haemorrhage (PPH), a leading cause of maternal mortality rates in rural Uganda,” explains Dr Mulongo.
Dr Mulongo said in many rural areas in Uganda, there is scarcity of information on magnitude of and risk factors for PPH (blood loss of 500 ml or more) adding that it is important to understand the relative contributions of different risk factors for PPH.
“Ministry of health has already assessed the incidence of, and risk factors for postpartum hemorrhage among rural women in Uganda and soon there will be awareness and prevention interventions in rural health units,” said Dr Mulongo.
A report released by Ministry of Health; the National Annual Maternal and Perinatal Death Surveillance and Response (MPDSR) 2018/2019 titled; Every Mother and New-born also names haemorrhage as the leading cause of maternal mortality, accounting for nearly half of all deaths in Uganda and attributes 46 per cent of the maternal deaths to haemorrhage.
Dr Alex Muhereza, a senior advisor for maternal newborn and child services in Acholi sub-region while speaking at the release of the report said postpartum haemorrhage accounted, more maternal deaths than any other cause.
Dr Muhereza explained that 84 per cent of the mothers who have haemorrhage die after they have delivered due to ruptured uterus, previous scars and health workers not monitoring the bleeding very well.
“While we talk about bleeding as a big problem it is bigger among women who have already delivered and the causes of this postpartum haemorrhage are due to ruptured uterus, mother got complicated labour… and ruptured before they got interventions and they bleed and die,” Dr Muhereza said.
However, for the late teenager Kakule, a patient who didn’t want to be mentioned said shortage of blood at the health facility and failure by medical workers to monitor the situation after delivery was the cause of this death.
According to a paper “Your pregnancy matters” https://utswmed.org/medblog/postpartum-hemorrhage/ by Dr Jamie Morgan, M.D. Obstetrics & Gynecology about 70 to 80 percent of the postpartum hemorrhage cases we see are the result of the woman’s uterus not contracting after delivery, a condition called uterine atony.
Dr Morgan adds that in a normal delivery, the uterus contracts substantially once the placenta is removed, which prevents bleeding from blood vessels that previously supplied blood to the placenta.
“And other postpartum hemorrhage risk factors include: genital tract lacerations: Tissue damage or trauma of the lower genital tract that occurs during the birth process, retained placental fragments; Retention of the placenta or fetal membranes within the uterus following delivery and clotting defects and delayed formation of blood clots after delivery occurs and abnormalities of the labor process, such as prolonged labor or need for labor induction,” Dr Morgan adds.
In the past three years, there has been a relative reduction in institutional maternal mortality ratio from 108 per 100,000 deliveries in financial year 2016/17 to 92 per 100,000 deliveries in financial year 2018/19.
According to the National Annual Maternal and Perinatal Death Surveillance and Response (MPDSR) 2018/2019 report, Tooro sub-region reported the highest number of maternal deaths followed by Bunyoro while Karamoja region reported the lowest number of maternal deaths.
The District Health Officer Dr Paul Wakoko said five direct complications account for more than 70% of maternal deaths: haemorrhage (25%), infection (15%), unsafe abortion (13%), eclampsia (very high blood pressure leading to seizures – 12%), and obstructed labour (8%).
“While these are the main causes of maternal death, unavailable, inaccessible or poor quality care is fundamentally responsible for many expectant mothers in rural hard-to-reach areas,” he said.