Publications

JOB OPPORTUNITIES – APRIL 2022

DAAS Africa Group through its Human Resource Development Department in partnership with Nid Apex Printers a business entity registered, dealing in Printing and Artwork services, located on Transport Road Arua town, would like to recruit capable, committed, determined, reliable, competent, and experienced applicants to fill the following vacant posts; –

  1. Secretary (2 Posts)

Requirements

  1. Should possess a Diploma or Certificate in Secretarial/ stenography & must have passed English and Mathematics
  2. Experience of 3 years in Secretarial work. Skills in computer programs such as Microsoft Office and graphic programs are an added advantage.
  3. Should be able to work under minimum supervision.
  4. GRAPHIC DESIGNERS (2 Posts)

Requirements

  1. Should possess Diploma or Certificate in Computer related field (ICT) & must have passed English and Mathematics
  2. Experience of 4 years in Graphic designs. Microsoft office is an added advantage.
  3. Should be able to work under minimum supervision.
  4. Cashier (1 Post)

Requirements

  1. He/she should have a Diploma in Finance and Accounting, Business Administration, and other related fields.
  2. Skills in computer programs such as Microsoft excel and access programs are an added advantage.
  3. Should be able to work under minimum supervision.
  4. Marketing managers (2 posts)

Requirements

  1. He/she should have a Diploma in Business Administration and other related fields.
  2. Should be able to work under minimum supervision.

Note: Candidates for all these positions should be between 18 and 32 years.

Application procedure 

Submit your Cover page and updated CV only to the Director of Administration DAAS Africa Group, P.O. BOX 387, Kampala on email at asiimwegk2@gmail.com not later than 14th April 2022 before 5:00 pm. 

Successful candidates should be able to work and reside in Arua City. 

Disabled & Sidelined: Highlighting Challenges Facing Refugee Women and Children With Disabilities In Uganda’s Refugee Settlements.

Overview

The International Classification of Functioning, Disability and Health (ICF) defines disability as a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives  (WHO, 2002). Using this ICF definition of disability, it is estimated that over a billion people worldwide have some form of disability (WHO & World Bank, 2011).

Several conventions and treaties have been put up mainly to improve the plight of refugees with disabilities such as; The Convention on the Rights of Persons with Disabilities (CRPD) and its optional Protocol that was adopted on 13th December 2006 at the United Nations headquarters in New York where in Article 18, it calls upon States Parities to recognize the rights of persons with disabilities to liberty of movement, to freedom to choose their residence and to a nationality, on an equal basis with others; and Article 11 explicitly addresses protection of persons with disabilities in situations of risk, including armed conflict, humanitarian emergencies and the occurrence of natural disasters.

The World Programme of Action (1982) also pinnacles the situation of displaced persons where it calls for the removal of social and physical barriers that confront persons with disabilities among refugee populations. The Standard Rules on the Equalization of Opportunities for Persons with Disabilities (1993) as well calls for the equalization of opportunities of refugees with disabilities to be integrated into general development programmes (Rule 21). Much as all these policies have been put up, a lot is still desired as far as improving the plight of women and children with disabilities is concerned. 

As of 2011, the United Nations High Command for Refugees (UNHCR), defines a refugee as a person “who are outside their country of nationality or habitual residence and unable to return there owing to serious and indiscriminate threats to life, physical integrity or freedom resulting from generalized violence or events seriously disturbing public order”.

Specific data on refugees with disabilities is limited (Rohwerder, B., 2017), however what is known is, as of 2019, nearly 26 million refugees around the world have been forced to flee their homes and around half of these are children under the age of 18 with women and girls accounting for 50 per cent of the world’s refugees  (UNHCR, 2019). 

It is evident that in situations of wars and natural disasters where people are forced to flee their homes and countries for safety of their lives, disabilities in form of physical, intellectual, sensory, and mental impairments are bound to happen. In all these harsh conditions, UNHCR, (2011) notes that refugees with disabilities are more likely to be sidelined in every aspect of humanitarian assistance due to physical, environmental and societal barriers against accessing information, health and rehabilitation services and human rights protection. Therefore it is with this background that challenges faced by refugee women and children with disabilities who are most vulnerable be highlighted so that host governments and other humanitarian agencies address them so that the conditions of these individuals are improved.

Refugee status in Uganda

In a recent UNHCR Refugees and Asylum-Seekers report on Uganda dated 29 February 2020; Uganda tops the list in Africa in hosting refugees and stands fourth in the world, hosting a total of 1,411,098 of refugees and asylum seekers that are hosted across her 14 refugee settlements with Bidibidi in Yumbe District-West Nile being the largest hosting 232,109 refugees. In the same UNHCR report, most of refugees hosted in Uganda are from South Sudan at 873,741(61.9%) followed by DRC at 409,882 (29%) ( UNHCR, 2020).

General state of Disability issues in Uganda

Uganda has ratified the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Besides this, Uganda has friendly laws and policies relating to disability rights such as; The National Council on Disability Act 2003 (with additional amendments in 2013); The 2006 Disability Act; The 2006 Equal Opportunities Commission Act; The 1997 Local Government Act and the 1996 Children’s Statute (with amendments in 2016). Also a number of policies and policy guidelines support interventions for persons with disabilities that include; The 2015 Orphans and Vulnerable Children Policy, the 2006 National Policy on Disability; The 2012 Disability Guidelines and the Alternative Care Framework. Albeit all these laws and policies in place, there is still long way to go as far as implementing these policies fully is concerned.

Recent findings from Uganda Functional Difficulties Survey (2017), indicate that 17 per cent of adults (aged 18 years and above), 7 per cent of children aged 5 to 17 years and 4 per cent of children aged 2 to 4 years had a disability. This survey highlighted different categories of disabilities such as visual disabilities, hearing disabilities, mobility and upper body functioning; mental disabilities and other conditions such as dwarfism and albinism. Of these categories, Psychosocial and /or intellectual difficulties under mental disabilities were most among adults and children followed by difficulty in walking/climbing under mobility disabilities (Uganda Bureau of Statistics, 2018).

In Uganda major causes of disabilities according to Uganda Functional Difficulties Survey (2017), among children aged 2 to 17 years, were congenital (i.e., from birth) or because of sickness such as malaria (10%) and measles (5%). The survey further reports that causes of disability among adults were congenital & home accident (each standing at 7%) followed by road traffic accidents and violence at 4% and 3% respectively.  With no doubt the environment and setting in which refugees live in makes them get more prone to all these causes predominantly congenital, malaria and violence. 

It should be noted that lack of adequate, reliable, relevant and recent information on the nature and prevalence of disability in Uganda and in particular among refugee populace remains a challenge. 

Challenges faced by refugee women and children in Uganda’s refugee settlements

Refugees with disabilities are frequently faced with discrimination challenges from their peers and even their community at large. Considering the Uganda Functional Difficulties Survey (2017), that described discrimination as unfair treatment in various aspects of life, such as: relationships, religious, cultural and social day-to-day activities where for all forms of discrimination, more adults with disabilities experienced discrimination (41%) where as children aged 5 to 17 years with disabilities that experienced discrimination stood at 28%. 

Women of reproductive ages and are with form of disability in most cases have been denied their sexual and reproductive health (SRH) rights, yet universal access to sexual and reproductive health is a fundamental human right and its goal number three on the Sustainable Development Goals where efforts to  improve sexual and reproductive health worldwide have been laid out in relation to good health and wellbeing, and gender equality (Starrs AM et al., 2018).

Accessing reproductive health services such as family-planning, prenatal care, safe delivery, post-natal care, appropriate treatment of infertility; treatment of reproductive tract infections, sexually transmitted diseases, including HIV/AIDS; breast cancer and cancers of the reproductive system is a major challenge in refugee settlements especially by women who have any form of disability. This is because most of the health facilities that could provide such services are at a distance yet some of these women have mobility challenges.  For example in Kyangwali refugee camp, accessing health facilities such as Maratatu, Rwenyawawa, Ngruwe, Kasonga and Mombasa is not easy for women because they are too distant like 10-18km away. For Kinryandongo Refugee settlement, the nearest Health centre III which is located in the refugee settlement is 20 Km away from the Kimogola village host community and yet the village is remote and poorly served with access roads. All these make the lives of those children and women with disabilities even more complicated.

Furthermore, Uganda Functional Difficulties Survey (2017) reports that women with disabilities often feel disrespected while accessing health facilities. The survey shows that 9% of persons with disabilities felt disrespected or humiliated by the treatment and behavior of staff at health facilities while 7% of females reported that they had been mistreated when seeking help for physical problems. This is problem of disrespect and humiliation can be worse in humanitarian settings due to limited health facilities and sometimes attitudes of healthy workers.

Women and girls with disabilities are frequently exposed to sexual and gender based violence, domestic abuse and physical assault. Most of those with intellectual and mental disabilities are regularly exploited and neglected from the community either by their own fellow refugees or host communities. Their life is further toughened by the fact that they may have difficulty in accessing support and services that could reduce their risk and vulnerability (Pearce, 2014). In a 2007 report by Rachael Reilly to assess the situation of those living with disabilities among displaced and conflict-affected populations, it was revealed that in the Dadaab refugee camp in Kenya, Somali children with disabilities were sometimes tied up and had stones thrown at them, or suffered verbal abuse from other people in the community. It was also revealed by Trani et al., (2011) that young girls with disabilities are especially vulnerable to violence and abuse on their journeys to school in conflict affected states. Anecdotal reports inform the same type of mistreatment and abuse in Uganda’s refugee camps especially those in Adjuman and Yumbe districts in West Nile. 

In most African cultures, it is reported that mothers are often blamed for their children’s disabilities and may suffer physical or sexual abuse from their husbands and other family members. This has increased stigmatization among these mothers and for those elderly women with disabilities, it has been widely reported that they are abandoned by their family members making them exposed to numerous challenges of life as it may be hard for them to access basic health care.

In regards to education access, refugee children with disabilities attending schools are extremely low. In most of Uganda’s refugee settlements, enrollment by children with disabilities is low and at the same time dropout rates is high to those few who happen to enroll due to diverse challenges they face such as lack of appropriate teaching aids, flexible curricula and assistive learning devices. Also lack of special needs support staff and some schools being located far away from homes made it hard for those children with physical disabilities to reach. Even when they can reach those schools, buildings are physically inaccessible for those ones on wheel chairs due to poor structural designs that do not favor this category of people. Another issue that discourages most of these children with disabilities in refugee settlements to attend school was language barrier. For example in most refugee camps in West Nile such as Rhino camp and Bidibidi, teachers were teaching in English yet these children from South Sudan were initially taught in Arabic in their home country before flight. This greatly demotivated them from proceeding with school.

Safety challenges are seriously faced by refugee women and children with disabilities where most of them have ended up losing their lives or getting more severe injuries in case of danger. For example women and girls with disabilities reported finding it difficult to escape violence in conflict affected parts of northern Nigeria and were often abandoned (Jerry et al., 2015). This is eminent that the same happens in Uganda’s refugee settlements as well mainly because those with hearing and visual impairments may not see or hear what is going on and thereafter may find themselves in traps of the enemy due to the environment they live in. 

Livelihood challenges such as lack of income generating opportunities due to the fact that these women with disabilities are often discriminated. For example Refugee women with disabilities living in urban contexts report that poverty and a lack of income-generating opportunities increase the likelihood that they may engage in sex work and/or exploitative relationships (Rosenberg, 2016). This has been hardened by the fact that they cannot favorably compete for humanitarian assistances given to them as they are outcompeted by their counterparts who have no disability challenges. 

Recommendations

Policies that integrate both disability and gender should be translated to local community leaders so that they can understand them in order to easily defend and protect the rights of those with disabilities. This can be done through practical on ground trainings with all stake holders. With this being done, community leaders and stake holders’ negative attitude to people with disabilities can easily be overcome. 

Identifying capabilities and skills possessed by women and girls with disabilities should be focused on and supported rather than focusing mostly on their weakness. In some refugee camps such as Bidibidi, fast cash based beneficiaries have been extended to refugees, but this has not been the case to those with disabilities. This therefore calls for equal consideration to even those that are vulnerable. When this is done, women refugees can be empowered and in the long run they can improve on their own individual conditions.

Reproductive health issues of women and adolescents with disabilities should take a Centre stage at all times by planners. Village health teams should be facilitated to reach out to different homes where these categories of people are so that issues relating to reproductive health are addressed such as family planning, antenatal and post natal attendance, all of which will reduce risks such as forced sex, violence, maternal mortality and morbidity among these refugees with disabilities. 

Additionally regarding reproductive health rights, in almost all refugee settlements in Uganda, information gap about family planning and low male involvement in maternal health issues of their wives is reported. This can be even worse among those with disabilities. Therefore community leaders, health workers have a duty to ensure relevant information is disseminated to all in a comprehensible language so that access to these services is improved.  

Teachers should be taught and trained with special needs education so that they learn how to handle learners with disabilities in these refugee settings. This can be done by government through ministry of Education and other humanitarian agencies. Brails for visually impaired learners can be provided; wheel chairs can also be extended to those learners with mobility challenges. Above all environmental settings of schools should be designed in the way that they favor learners with disabilities where walk ways, buildings that are easily accessed by these individuals are put up both at schools and health facilities in these refugee settings. 

Counseling services should be enhanced especially to those refugees with disabilities that have faced gender based violence including sexual violence that is highly reported in these settings. Counseling brings about psychological healing and reduces mental disabilities.

Cultural beliefs and practices that have continued to block opportunities for refugee women with disabilities need to be discouraged. For example anecdotal findings in Nakivale refugee camp in western Uganda, revealed that existing family planning services are very low because the refugees believe that the more you produce more number of children, the more the chances of accessing food aid. Culturally it was also found out that most women have no power to determine the child control as men are not comfortable with stopping child production and they influence and control the decisions. All these beliefs and practices affect women with disabilities critically and should be discouraged at all times due to their imminent challenges.   

Conclusion

It is evident that a lot of factors have contributed to the many troubles facing refugee women and children with disabilities in Uganda’s refugee settlements.  Some of these factors include negative attitudes of family members, health practitioners and the community. It is also no doubt that gaps in policy implementation have remained where most of good policies have kept on paper and follow up to ensure that these policies are executed on ground is less.

The government of Uganda through the office of the prime minister and ministry of Gender and social development plus humanitarian organizations including local partners should prioritize issues facing refugee women and children with disabilities in order to improve on their plight in their communities.

This article is dedicated to all women and men all over the World who have advocated greatly the rights of individuals with disabilities, your efforts are greatly treasured. 

REFERENCES

Jerry, G., Pam, P., Nnanna, C., & Nagarajan, C. (2015). What violence means to us: women with disabilities speak. Nigeria Stability and Reconciliation programme & Inclusive Friends.

Pearce, E. (2014). Disability Inclusion: Translating Policy into Practice in Humanitarian Action. WRC.

Rohwerder, B. (2017). Women and girls with disabilities in conflict and crises. K4D Helpdesk Report. Brighton, UK: Institute of Development Studies.

Rosenberg, J.S. (2016). Mean Streets: Identifying and Responding to Urban Refugees’ Risks of Gender-Based Violence – Refugees with Disabilities. WRC.

Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet. 2018; 391(10140):2642–92.

Uganda Bureau of Statistics (2018). Uganda Functional Difficulties Survey 2017. Kampala, Uganda.

United Nations High Commissioner for Refugees, UNHCR. Figures at a Glance-Statistical Yearbooks. 2015.

World Health Organization and World Bank, 2011, World report on disability, viewed 10 December 2020, from http://whqlibdoc.who.int/publications/2011/9789240685215.

World Health Organization, 2002, Towards a common language for functioning, disability and health: The international classification of functioning, disability and health, viewed 23 November 2020, from http://www.who.int/classifications/icf/ training/icfbeginnersguide.pdf

World Health Organization, United Nations Population Fund: Promoting sexual and reproductive health for persons with disabilities WHO/UNFPA guidance note. World Health Organization; UNFPA, Geneva, New York (2009).

C-section deliveries in Uganda; Why you should get concerned

By, Asiimwe Godfrey (asiimweg1@gmail.com)

C- SECTION DELIVERIES IN UGANDA; WHY YOU SHOULD GET CONCERNED

OVERVIEW

Cesarean delivery (C-section) is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus.

The World Health Organization (WHO) suggests that a caesarean delivery rate of 15% of all births should be taken as a threshold that should not be exceeded rather than a target to be achieved (WHO, 2009). WHO statement further states that medical practitioners should not undertake cesarean sections purely to meet a given target or rate, but rather should focus on the needs of patients.

However studies show that in High income countries and other middle income countries, C-section is being provided at higher rate above what is recommended and in most cases when there is no medical or obstetric indication (Thomas J & Paranjothy, 2001). For example Cesarean birth rates continue to upsurge globally with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. In Africa it stands at a rate of 7.3 % (Betran AP et al., 2016).

Medically, C-section can be recommended  in case of breech birth where a baby is born bottom first instead of head first, as is normal, when there is obstructed or prolonged labor, when there is problems with the placenta, when a mother is carrying multiples, Prolapsed umbilical cord, if a mother had a previous C-section, high blood pressure of the mother and intrapartum fetal distress among other reasons (WHO, 2009). In such situations C-section is considered essential in averting major obstetric complications that lead to maternal and neonatal, morbidity and sometimes mortality (Gibbons L, et al., 2010).

State of Health care in Uganda

Uganda’s healthcare system encompasses multiple levels of care, including health centers II, III, and IV, general hospitals, and finally referral hospitals.

According to Uganda Ministry of Health, (2020) there is a total of 155 hospitals in Uganda both Public and private. Of these 2 (Mulago and Butabika) are National referral hospitals while others are regional referral and General hospitals. 65 are government owned, 63 private not for profit (PNFP) and 27 private. As of 2014/15 financial year, a total of 36% of all deliveries were produced by hospitals.

For services related to childbirth, health center IIs and small clinics are required to provide crucial obstetric care services such as antenatal care, preventive services, and treatment of common illnesses.

Health center IIIs on the other hand provide a broader range of services, such as normal deliveries and first aid for complications related to pregnancy, labor, and delivery, assisted vaginal delivery, manual removal of placenta, and removal of retained products for women with pregnancy-related complications. All 139 General hospitals in Uganda provide maternity, emergency surgeries and blood transfusion services among others (Ministry of Health, 2020).

Health center IVs are the first referral level for low or moderate-risk pregnant women. Both health center IVs and hospitals are mandated to provide comprehensive emergency obstetric care, including cesarean section and blood transfusion services as well as the lifesaving interventions provided at lower health centers (Wilunda C, et al., 2015).

State of C-section deliveries in Uganda

As already discussed above, a C-section can be planned ahead of time especially if a woman develops complications while pregnant or had a previous C-section and aren’t considering a vaginal birth. In Uganda according to recent statistics from Uganda Demographic and Health Survey (UDHS, 2016), 7% of all live births are C-section deliveries. Most C-section deliveries have been reported in Kampala at 14%. C-section deliveries stand at 13% in urban residences of Uganda as compared to 5% in rural residences and 16% of the richest use C-section deliveries in relation to 3% of the poorest (UBOS 2016).

Concerning timing on decision to go for C- section according to UBOS, (2016), 33% of women decided to go for C-section before labor started as compared to 67% who decided to go for C-section after labor had started. Among those in urban residences, 40% decided to go for labor before labor begun compared to 29% of women in rural residences. 45% of the richest decided to go for C-section before labor begun compared to 20% of women who belonged to poorest category. Among those with higher education, timing of the decision to go for C-section stood at 47% compared to only 19% of those without formal education.

Different reasons inform why there is high demand for planned C-section deliveries in Uganda especially among the educated, urban and rich populations. In most cases some women request C-sections with their first babies mainly to evade labor and associated complications of vaginal birth such as perineal laceration (Vaginal tear). Others because they want to take advantage of the convenience of a planned delivery. This is however; highly discouraged since women who have multiple C-sections are at increased risk of placental problems as well as heavy bleeding, which might require surgical removal of the uterus.

Why you should get concerned

C-sections deliveries can cause significant complications including disability or death, especially in settings that lack the facilities to conduct safe surgeries or treat impending complications because of their increased cost.

A study by Keag OE, et al., (2018) to establish Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies, the authors reveal that “while pregnant women are usually well-advised of the short-term outcomes of having a cesarean, they are less informed about the long-term impact of a C-section – not only on their health and that of their baby, but also on their ability to carry future pregnancies”.

It is also revealed in this study that children delivered by cesarean were 21% more likely to develop asthma within the first 12 years, and 59% more likely to become obese by the age of 5.

The study further reveals that, the risk of placenta previa (a condition when a baby’s placenta partially or totally covers the mother’s cervix), was 74 percent higher for mothers who had a C-section and the risk was even higher for placental abruption. When compared with women with previous vaginal delivery, women with previous cesarean delivery had increased odds of miscarriage.

Furthermore, C-section deliveries should concern all of us mainly because of the following risks associated associated with it;

  1. Breathing problems. A study by British medical journal (2007) shows that Babies born by planned C-section are more likely to develop transient tachypnea  which is a condition of breathing disorder seen shortly after delivery in early term or late preterm babies
  2. Postpartum hemorrhage which is heavy bleeding during and after delivery.
  3. Surgical injury. Sometimes accidents can happen on the baby’s akin during surgery.
  4. Infections such as endometritis which is the infection of the lining of the uterus. This too might occur due to C-section.
  5. Blood clots. High risks of developing a blood clot inside a deep vein can occur as a result of C-section deliveries, especially in the legs or pelvic organs and if a blood clot reaches the lungs and blocks blood flow, the outcome can be life-threatening.
  6. Increased risks during future pregnancies. After a C-section, a woman might face a higher risk of potentially serious complications in a subsequent pregnancy than she would after a vaginal delivery meanly because of placenta previa and uterine rapture of which all these conditions block a woman from getting pregnant again.

Conclusion

The writer recommends that much as C-section can be a life-saving intervention when medically indicated, this procedure can also lead to short-term and long-term health effects for women and their babies.

Planned deliveries seem to be safer than emergency caesarean section ones, when medically indicated; but in case they are not medically recommended, they should be highly discouraged due to major risks involved as discussed earlier. This can be done in many ways mainly at a health facility setting.

On the other hand however, Emergency obstetric services of which emergency C-section deliveries is part of, should be extended to all populations in Uganda especially the rural places that are hard to reach so that life of the mother and the fetus is saved. It should be noted that in Uganda majority (67%) of pregnant women decide to go for C-section after labor pains have begun (UBOS, 2016). This is deadly because there might be no room for preparation like incase blood transfusion is needed.

Further qualitative research studies can be done especially among women of certain class like the rich, highly educated to find out their views informing their high desire for planned deliveries even when not medically recommended.

Appreciation

My sincere gratitude goes to all the mothers in Uganda; you pass through a lot to give life.

REFERENCES

  1. Betran AP, Torloni MR, Zhang JJ, G.lmezoglu AM for the WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates. BJOG. 2016;
  2. Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014. PLoS ONE. 2016;11(2):e0148343. pmid:26849801
  3. Betran AP, Ye J, Moller AB, Zhang J, Gumezoglu AM, Torloni MR. The increasing trend in cesarean section rates: Global, regional, and national estimates: 1990–2014. PLoS One. 2016;
  4. Gibbons L, Belizan JM, Lauer JA, Betra AP, Merialdi M, Althabe F. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report (2010).
  5. Keag OE, Norman JE, Stock SJ (2018) Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. https://doi.org/10.1371/journal.pmed.1002494
  6. Monitoring Emergency Obstetric Care: A Handbook. World Health Organization, 2009. Geneva, Switzerland.
  7. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press; 2001.
  8. UBOS & ICF. (2016). Uganda Demographic and Health Survey, (March), https://doi.org/10.2307/41329750
  9. Wilunda C, Oyerinde K, Putoto G, Lochoro P, Dall’Oglio G, Manenti F, Segafredo G, Atzori A, Criel B, Panza A, et al. Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey. Reprod Health. 2015;

 

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-
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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