Archives July 2020

MATERNAL MORTALITY IN SUB-SAHARAN AFRICA STILL A MAJOR CHALLENGE: UGANDA’S PERSPECTIVE

Introduction

World Health Organization (WHO) defines Maternal mortality as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” while Maternal health as “the health of women during pregnancy, childbirth, and the postpartum period”

Maternal health status of the mother which includes the environment before and during pregnancy matters greatly since it significantly impacts a lot on the health and well-being of a child’s health. Therefore, achieving optimal child health highly depends on the health and well-being of a child’s mother.

State of maternal mortality in Sub-Saharan Africa

Every day in 2017, according to WHO, approximately 810 women died from preventable causes related to pregnancy or childbirth. Sub-Saharan Africa accounts for more than two-thirds of all these maternal deaths per year worldwide.

A whopping 533 maternal deaths per 100,000 live births occur in Sub-Saharan Africa (WHO, 2019). Recent data from WHO shows that inequalities in access to quality health services between rich and poor have accounted for the high maternal mortality rate (MMR) in low-income countries. For example in 2017 according to WHO, MMR was 462 per 100 000 live births in low-income countries and only 11 per 100 000 live births in high-income countries. This shows that there is a lot needed to be done in Sub-Saharan Africa especially if a Sustainable Development goal of reducing the global maternal mortality ratio to less than 70 per 100 000 live births between 2016 and 2030 is to be achieved.

It should be noted that the complications in pregnancy and childbirth are higher among adolescent girls of ages 10-19 compared to women aged 20-24 (Ganchimeg, et al., 2014). This is because younger girls are at high risk of developing deadly obstetric fistula which is a serious medical condition in which a hole develops between the vagina and rectum or the urinary bladder and this often leads to death. Still according to WHO report, Adolescent girls (ages 15–19) are at high risk of childbirth pregnancy-related complications, where “The probability that a 15-year-old woman will eventually die from a maternal cause is 1 in 3,700 in developed countries versus 1 in 160 in developing countries” (WHO, 2014).

Major causes of maternal deaths 

According to WHO (2014), the main causes of maternal deaths are severe bleeding after birth, post-childbirth infections, high blood pressure during pregnancy, unsafe abortion, sepsis and diseases such as malaria and HIV/AIDS.

Hemorrhage such as obstetrical bleeding which occurs before, during, and after childbirth remains the leading cause of maternal mortality, accounting for over one quarter (27%) of deaths. Postpartum bleeding specifically which is as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth has been a great challenge in Sub-Saharan Africa due to poor road networks to connect expectant mothers to good health facilities in time and also mothers preferring to give birth from homes.

Gestational Hypertension also referred to as Pregnancy-Induced Hypertension (PIH) is a condition characterized by high blood pressure during pregnancy. This can lead to a serious condition called Preeclampsia and has led to increased cases of maternal deaths in most low-income countries.

Unsafe abortion is still leading to high maternal deaths in sub-Saharan Africa, according to WHO (2019), it is estimated that 3 out of 4 abortions that occurred in Africa and Latin America were unsafe and Each year between 4.7% – 13.2% of maternal deaths can be attributed to unsafe abortion.

Much as most of these complications leading to maternal death can occur at any time without warning during pregnancy, during child delivery and after childbirth, most of these maternal deaths can be prevented if births are attended to by skilled health personnel such as doctors, nurses or midwives who are equipped and have access to quality obstetric services and are furnished with life-saving drugs, such as antibiotics, and are able to provide blood transfusions needed to perform cesarean sections or other surgical interventions.

Uganda’s maternal mortality Perspective

Maternal mortality ratio in Uganda remains high at 343 deaths per 100,000 live births (UBOS, 2016) though dropping over the period from 684 in 1990. This is however still way far below the Global Sustainable Development goal of achieving less than 70 per 100,000 live births by 2030.

Efforts put up to reduce maternal mortality in Uganda

Uganda has put up measures to reduce high maternal deaths in the country through different programs such as; The Second National Development Plan 2015/16-2019/20, National Health Policy II 2010-2020 and the Health Sector Development Plan (HSDP) 2015/16-2019/20. These programs are to guide the health sector in building a supportive community network, developing a modern maternal health system, and putting up interventions to forecast high-risk obstetric events and strengthen referral systems, in the long run, reducing morbidity and mortality.

Different policies aiming at empowering a girl child have also been designed and implemented. These policies such as National Gender Policy (2007) has helped in ensuring that girls access education in Uganda, are empowered economically, and also their opinions heard. This will also in the long run reduce maternal deaths since women will be empowered economically and will be able to access better health care. Studies show that women who have access to Education and are economically empowered have reduced risk of succumbing to pregnancy-related deaths (Alvarez, et al., 2009).

Challenges faced in reducing maternal deaths in Uganda

Like any other sub-Saharan country in Africa, Uganda still has many challenges hindering the reduction of maternal death. Among many, Uganda has poor health care services, these services are also not easily accessed and where they are available, there is under-staffing and also common is low medical supplies of essential medication. All these have a direct effect on determining the health outcomes of expectant mothers and their babies.

Malaria remains high in Uganda and is the leading cause of death. Out of 30-50% outpatients, 15-20% of hospital admissions and 20% of hospital deaths are due to malaria according to Uganda Ministry of Health, (2014) and malaria prevalence among pregnant women stands at 8% and this has continued to cause maternal deaths in Uganda. In a study by Ngonzi, et al., (2016) to establish the causes and predictors of maternal deaths in a tertiary University teaching Hospital in Uganda, Malaria was found out to be the commonest indirect cause of maternal mortality accounting for 8.92%.

Much as 97% of pregnant women in Uganda seek Antenatal care services from skilled health personnel at least once in their pregnancy and 60% attending four or more times (UBOS, 2016), still, only 73% of the deliveries that occur, are in a health facility. This puts 1⁄4 of women delivering from home most of them coming from rural areas at risk. More efforts should be done to correlate ANC attendance and delivery from a health facility in order to save the life of the mother and their babies.

Low health funding remains a challenge in Uganda and still below the Abuja Declaration target agreed on in 2001 that set health financing at 15% of their annual budget. According to The National Budget Framework Financial year 2019/20 Uganda’s Health financing stands at 8.9%. This low funding hampers progress in maternal health improvement.

Conclusion

Maternal deaths are still very high in Uganda and sub-Saharan Africa in general and there is a long way to go in achieving a set target of reducing maternal deaths to less than 70 per 100,000 live births by 2030. Therefore individual governments should put up robust measures early enough to ensure that maternal health is improved. This can be done through increasing women empowerment, through education, economic support, and also governments increasing funding to their health sector. Efforts such as sensitizing women on the complications associated with pregnancy and how they can overcome them should be increased.

REFERENCES

Alvarez, J.L., Gil, R., Hernández, V. et al. Factors associated with maternal mortality in Sub-Saharan Africa: an ecological study. BMC Public Health, (2009).

Ganchimeg T, Ota E, Morisaki N, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG 2014 “Maternal Health”. World Health Organization (2018)

Ngonzi, J., Tornes, Y.F., Mukasa, P.K. et al. Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda. BMC Pregnancy Childbirth
(2016)

UBOS & ICF. (2016). Uganda Demographic and Health Survey, (March), 7–71. https://doi.org/10.2307/41329750

Uganda Demographic and Health Survey (2016) Key Indicators Report

Uganda Ministry of Health. (2014). The Uganda Malaria Reduction Strategic Plan 2014-2020, (May), 1–83. https://doi.org/10.1109/ISCO.2015.7282339

WHO. (2014a). Progress & impact series. The contribution of malaria control to maternal and newborn health.

ABORTION IN UGANDA; THE NEGLECTED DANGERS.

Introduction

Abortion can be defined as an ending of a pregnancy by removal or expulsion of an embryo or fetus before it can survive outside the uterus. An abortion that occurs without intervention is known as a miscarriage or spontaneous abortion while deliberate methods done to end a pregnancy is called an induced abortion.

In this paper, emphasis was put on induced abortion where globally 56% of unintended pregnancies end up in induced abortion. (Singh S et al., 2016). In Africa, from 2010-2014, an estimated 8.2 million induced abortions occurred each year and the annual abortion rate in this continent is estimated to be 34 per 1,000 women of reproductive ages of 15-44 according to Guttmacher Institute, (2017) with about 1.6 million women being treated with abortion complications each year. (Singh S and Maddow- Zimet I, 2015).

Unsafe abortions performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities are of great concern worldwide because they cause injury and death to women and other severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to 2 internal organs (Okonofua, F. 2006). It is estimated that deaths from unsafe abortion account for around 13% of all maternal deaths (Darney, et al., 2010).

State of abortion in Uganda

Abortion in Uganda is illegal however the Ugandan Ministry of Health’s 2006 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights gives a number of specific cases in which women have the right to seek an abortion, that includes rape, sexual violence, or incest, or when the woman has pre-existing conditions such as HIV or cervical cancer. It can also be performed by a licensed medical doctor in a situation where the woman’s life is deemed to be at risk.

In Uganda, 52% of all pregnancies are unintended, and about a quarter of these unintended pregnancies end in abortion each year (Sedgh G et al., 2016). It is estimated that 314,300 abortions took place in 2013 alone translating to 14% or at a rate of 39 per 1,000 of all pregnancies of women aged 15–49 in the country with Kampala leading at a rate of 77 per 1,000 and western Uganda region least at 18 per 1,000 according to a 2013 brief from Guttmacher Institute.

Uganda’s existing laws and policies on abortion are interpreted inconsistently by law enforcement officers and the judicial system in most cases. This has made it difficult for women and the medical community to understand when abortion is permitted and thus fueling the need for pregnant women to resort to unsafe abortion practices consequently leading to around 5 million Ugandan women annually getting injured or getting disabled due to abortion-related consequences and 5.3% of maternal deaths occurring as a result of abortion complications. (Larsson, et al., 2015).

Ugandan women mainly seek abortion because the demand for modern contraception especially emergency contraception is still unmet with modern contraceptive prevalence rate (mCPR) of women ages 15-49 in Uganda reported at 41.8 % according to the World Bank collection of development indicators, compiled from officially recognized sources in 2018 and Total Fertility Rate (TFR) estimated at 5.0 live births per woman in 2020 (Worldometer, 2020).  This unmet need for modern contraception has led to many unintended pregnancies where many have ended up being aborted.

General dangers of abortion in Uganda.

It is reported that women of ages 20–24 tend to have the highest abortion rates mainly because they feel they are not ready to have a child, they want to continue schooling and also fear parents’ reactions towards them. All these compel these young ones to terminate the pregnancy. In Uganda pre-marital sex is common where one in three never-married women aged 15 to 24 years admitting to having already had sex (UBOS, 2011). These young women are also reluctant in seeking contraceptive services since culturally and socially premarital sex is not acceptable. This danger of abortion as a result of this pre-marital sex has led to an estimated 1,500 girls dying from complications resulting from unsafe abortion as reported in Uganda’s New vision news paper of 22nd October 2013.

Abortion has an impact on future pregnancies where it is reported that having multiple abortions may make it difficult for a woman to have children in future and also increases the risk of low birth weight, preterm birth, vaginal bleeding during early pregnancy, blood clots in the uterus which produce severe cramping. Abortion also leads to tearing of the cervix, hemorrhage (heavy bleeding), tearing of the wall of the uterus and placenta problems such as retained placenta.

Emotional or Psychological risks as a result of abortion should also not be underestimated since this can create a lasting positive and negative impact on a woman. One woman may feel sad and emotionally down because of ending a life of an unborn child and may live with this guilty for some time or the rest of her life while another one may feel some relief especially if her life was at stake in case the pregnancy was due to rape, incest, sexual violence and also in instances where a woman had cervical cancer. Negative emotional risks are so dangerous and should be discouraged seriously since they can lead to suicidal thoughts, an acute feeling of grief, loss of self-confidence especially school-going adolescents, shame in the community where one comes from, anger, nightmares, depression, Increased alcohol/drug abuse and sometimes repeated abortions in the future.

Recommendations

The writer recommends the following in order to reduce induced abortion rates and its dangers in Uganda;

 The government should ensure that there are free or affordable family planning services accessed by all women plus giving them a wide range of contraceptive methods to choose from putting much emphasis on those women who are young, poor, and in rural areas. This will help in reducing the unmet need for contraception in turn reducing unintended pregnancies in the country.
 Men involvement in reproductive related issues is very pivotal in reducing these high abortion rates. In Uganda, issues of reproduction and especially using family planning services have been left to women and in most cases, men have not taken heed to get the views of their partners. Ensuring that men get involved in all these issues that involve planning for their children and family would help much in reducing the unintended pregnancies that have ended up in unsafe abortion.
 Different health campaigns should be enrolled countrywide through different line ministries especially the health ministry highlighting the dangers and risks involved in abortion. This can be done on radios, Television stations, school outreaches, and seminars in Universities and other tertiary institutions where these young women are.
 Religious and cultural leaders have a great task of counseling and preaching against premarital sex to their followers highlighting the dangers of abortion. These leaders should drop their strong conservative beliefs on abortion by explaining to their followers avenues when abortion can be done in line with the law. When this is done plus post-abortion counseling, it would reduce the shame and fear associated with abortion and women would go for safer abortions.
 Much as in Uganda, 89% of health centers can offer post-abortion care services, most of these centers are hard to reach and also women fear revealing to health personnel their complications resulting from unsafe abortion mainly because of fear of reprimand and this hampers effective treatment. It is recommended therefore that women should be empowered to seek post-abortion health care services without fear.

In conclusion,

A clarification on Uganda’s abortion law and policies should be done at all levels in all languages since this will raise awareness on the contents and the scope of Uganda’s abortion law among the medical community, the judicial system, and women.

REFERENCES
“Annual Health Sector Performance Report 2017/18 | Ministry of Health Knowledge Management Portal”. library.health.go.ug. Retrieved 2020-05-15.
“Fertility rate, total (births per woman) | Data”. data.worldbank.org. Retrieved 2020-05-20

Darney, Leon Speroff, Philip D. (2010). A clinical guide for contraception (5th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 406. ISBN 978-1-60831-610-6.

Guttmacher Institute, Adding it up: Investing in contraception and maternal and newborn health, 2017, Fact sheet, New York: Guttmacher Institute 2017.

Guttmacher Institute. Abortion and unintended pregnancy in Kenya. 2012: No. 2. Larsson, Sofia; Eliasson, Miriam; Klingberg Allvin, Marie; Faxelid, Elisabeth; Atuyambe, Lynn;
Fritzell, Sara (2015-06-25).

https://www.worldometers.info/demographics/uganda-demographics/2020

“The discourses on induced abortion in Ugandan daily newspapers: a discourse analysis”. Reproductive Health. Okonofua, F. (2006). “Abortion and maternal mortality in the developing world” (PDF). Journal of Obstetrics and Gynaecology Canada.

Sedgh G et al., Abortion incidence between 1990 and 2014: global, regional, and sub-regional and trends, Lancent, 2016, 388(10041):258-267

Singh S and Maddow-Zimet I, Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: A review of evidence from 26
countries, BJOG, 2015.

Singh S et al., Abortion Worldwide; A Decade of Uneven Progress, New York: Guttmacher

Institute, 2009, https://www.guttmacher.org/report/abortion-worldwide-decade-uneven-
progress.

Special tabulations of updated data from Sedgh G et al., Abortion incidence between 1990 and 2014: global, regional, and sub-regional and trends, Lancent, 2016, 388(10041):258-26

Uganda Bureau of Statistics (UBOS) and ICF International Inc. (2011). Uganda Demographic and Health Survey.

World Health Organization (WHO) et al., Trends in maternal mortality: 1990 to 2015. Geneva: WHO, 2015