Vicky Abalo 30 yrs lost her 6th baby on her way to hospital. She delivered along the way before she could reach the hospital. It was a complicated delivery, the baby coming with the leg and she bled heavily. Vicky was lucky the ambulance picked her and took her to Anaka hospital for immediate attention. According to Josephine Okumu, midwife in charge of maternity at Anaka Hospital, she says Vicky delayed to come to hospital and by the time she made the decision to come to hospital, it was late, she lost the baby during delivery. The midwife says, Vicky arrived with post-partum haemorrhage and was given more blood.

Sarah Atim delivered a dead baby on her way before she could reach Langol Health Centre. she bled heavily during the delivery process.  From Langol health facility she was referred to Anaka General Hospital for further specialised attention where she arrived with a retained placenta.  On arrival at Anaka hospital, she was immediately taken to theatre and the placenta was removed. Kenneth Ojara, Ambulance Driver at Anaka General Hospital, confirms that the ambulance was called at 12.13 pm and he arrived in record time to pick her at 1.18 pm to save her life.

The situation is not different for Eva Kiden 36 years, who also being attended to at Anaka hospital when I visited the hospital where she was assisted to deliver her 5th baby. She was referred to Anaka hospital with an abnormal lie of foetus and with foetal distress on a motorcycle from Gonycogo Health Centre, 40 kms away. She was referred on a motorcycle because she needed urgent specialised attention and the ambulance had taken long to arrive. Josephine Okumu, the midwife in charge of the maternity ward at Anaka Hospital confirms that, Eva arrived in labour with foetal distress and had a previous scar, she was immediately rushed to theatre.

A mother with a previous scar is one who has delivered before through caesarean and there are high chances of delivering through the same, so she has to be referred to a higher health facility which has an operating theatre such that in case she fails to push the baby normally, then she can be rushed to theatre and have the baby removed.

The above and many other such cases that go undetected are a few among the preventable complications mothers face during childbirth. Many have lost their lives in the process especially those who delay to reach hospital at the onset of labour.

Although in the past five years’ institutional mortality ratio reduced from 108 to 92 per 100,000 deliveries, Ministry of Health Annual Health Sector Performance Report of 2020/21, indicate that, there are still many incidents of mothers dying during childbirth. In 2020/21, Uganda registered a total number of 1,228 maternal deaths as compared to 1,102 in 2019/20, an increase by 126 cases.  In Acholi region alone, according to statistics in the national District Health Information System (DHIS2), in 2021, 45 lives of mothers were lost during childbirth processes, whilst this year, (by April 2022) 35 mothers lives have already been lost. By the end of year, these numbers are likely to go higher.

Many of the maternal deaths are due to haemorrhage at 42%, followed by hypertensive disorders of pregnancy at 15%. Other indirect causes include malaria, HIV/AIDS, severe anaemia, Covid 19 as well as pregnancy related sepsis among others.

Several of these deaths are due to failure to be detected in advance thus requiring referral to a higher health facility for better specialised management.  And many of these complications that develop at the onset of labour, during or after delivery are preventable if detected and managed early by health workers, However, the challenge is many are detected and reported late, with not enough time left to save the mothers through referrals.

Why timely management and access to quality care during pregnancy, child birth and after is critical in preventing maternal deaths

Many would-be timely referrals are delayed due to the long distances on poor inaccessible roads mothers travel to the nearest health facilities at the onset of labour but also the unavailability of reliable ambulances   makes it difficult to transfer mothers from health facilities in real time.  Very often the unavailable health workers to attend to mothers who arrive with complications at health facilities makes timely referrals and assisted-child birth process, a wish for many mothers in vulnerable communities.

The few available ambulances are overstretched and therefore are not available to pick mothers whenever they need them.  At Atiak Health Centre IV, in Nwoya District, they have an ambulance donated by Enabel. However, they lack a driver to pick mothers with complications whenever they need the ambulance. The facility has one active Doctor without an Anaesthetic officer. The one available doctor again doubles as the facility administrator with additional administrative work, making it difficult for him to be in theatre to attend to mothers who arrive with complications needing urgent operation.

Lamono, Nurse at Pawell HC II further explains the danger of not having enough human resources, “one time, I referred and travelled with a mother to Atiak, when we reached the health centre, the doctor on duty told me to continue in the same car with the patient to Lacor hospital”. Anything could have happened to that mother due to the delays we took to come to Atiak health centre and then to Lacor hospital.

Enabel supports the referral system in Uganda

The World Health Organization (WHO) defines referral as the process in which a health worker at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the assistance of a better or differently resourced facility at the same or higher level to assist in, or take over the management of, the client’s case.

On ground the referral system is not effective as stipulated that the different levels of the system are supposed to reinforce and complement each other. This is due to lack of sufficient ambulances and fuel or both which prevents patients from quickly being transferred from one facility to another. Anaka hospital administrator explains the situation further. “Before Enabel gave us another ambulance recently, we only had one ambulance and mothers used to be referred on motorcycles. Josephine Okumu, midwife in charge of maternity ward at Anaka Hospital further argues that “mothers who arrive on motorcycles many of them arrive without referral notes and this means their complications are not documented and that takes time again for us begin the assessments afresh”.

The referral system also faces the challenges of poor road networks because of poor terrain, ineffective communication system, inadequate emergency medicines and supplies including blood for transfusion. So most times, the referrals are never on time. Sometimes it is due to with the time the ambulance takes on the road to pick the patient.

Enabel recently donated 3 ambulances to Amuru, Nwoya and Omoro districts to support transportation of critical patients from one health facility to another. It is our wish that the donated ambulances complement other efforts in the region. Enabel is also considering training drivers and other health workers in managing emergencies.

Away from the ambulances, Enabel has been supporting health facilities in Acholi sub region with additional funding to purchase essential drugs and supplies thus minimising the unending drug stocks at health facilities. Enabel has also supplied health facilities with medical, lighting and IT equipment, all in the hope of addressing patients’ diagnosis, treatment and keeping and tracking patients’ records for easy follow up. Enabel also supports construction and renovation of health facilities so as to put in place the right conducive environment for health workers and communities to offer and receive appropriate treatment.

Attitude of mothers on referrals.

While many mothers are positive about referrals, others, aren’t. Sometimes mothers refuse referrals because they fear a caesarean. According to Auma – midwife Koch Goma, “mothers have a perception that when they are referred, they are always taken to the theatre for caesarean birth. So majority throw away referral notes once they are referred. “other mothers drop referral notes on the way because they think when they arrive with referral notes, they will straight be taken to the theatre for caesarean operation” – Midwife Amaro “Sometimes mothers refuse to be referred because they feel attached to midwives at health facilities where they have been attending their antenatal visits to assist them deliver their babies.
Other mothers say they don’t have money to survive on in the hospital even when we tell them that not all conditions upon which we refer them lead to operation. In Uganda when you are admitted with any health condition, you are expected to have money and an attendant to cater for your personal requirements including meals, so mothers fear when referred to faraway facilities where they don’t have relatives to look after them as midwife Auma at Koch Goma narrates “The moment you mention a referral, attendants disappear and we cannot refer a mother without an attendant. In Uganda, a patient admitted for close monitoring requires a relative/attendant available to cater for the patient, unlike in other countries where it is done by hospital nurses.

I found Adako 19 yrs old attending immunisation of her first born who was delivered at 5 months. She was all praises of the nurses at Koch Lee health facility who saved her life and her baby. said she was referred to Anaka Hospital after delivering an exceptionally premature, under-weight baby at 5 months. She confirms they called the ambulance at Koch Lee to Anaka, and she was transported with an accompanying nurse. After 2 months she was discharged and given tips to raise her premature son who is now a healthy growing baby.