Abstract
In Uganda, lack of resources and skilled staff to improve quality and delivery of maternity services, despite good policies and concerted efforts, have not yielded an increase in utilisation of those services by women or a reduction in the high ratio of maternal deaths. This paper reports a study conducted from November 2000 to October 2001 in Hoima, a rural district in western Uganda, whose aim was to enhance understanding of why, when faced with complications of pregnancy or delivery, women continue to choose high risk options leading to severe morbidity and even their own deaths. The findings demonstrate that adherence to traditional birthing practices and beliefs that pregnancy is a test of endurance and maternal death a sad but normal event, are important factors. The use of primary health units and the referral hospital, including when complications occur, was considered only as a last resort. Lack of skilled staff at primary health care level, complaints of abuse, neglect and poor treatment in hospital and poorly understood reasons for procedures, plus health workers' views that women were ignorant, also explain the unwillingness of women to deliver in health facilities and seek care for complications. Appropriate interventions are needed to address the barriers between rural mothers and the formal health care system, including community education on all aspects of essential obstetric care and sensitisation of service providers to the situation of rural mothers.
Résumé
En Ouganda, malgré une bonne politique et des efforts concertés, le manque de ressources et de personnel qualifié ont empêché un accroissement de l'utilisation des services de maternité par les femmes ou une réduction du taux élevé de décès maternels. Une étude, menée de novembre 2000 à octobre 2001 à Hoima, district rural de l'ouest de l'Ouganda, a tenté de comprendre pourquoi, en cas de complications obstétriques, les femmes enceintes choisissent des options à haut risque aboutissant à une morbidité grave, voire à leur décès. Les pratiques traditionnelles d'accouchement et la croyance que la grossesse est un test de résistance et que le décès maternel est un événement triste mais normal, sont des facteurs importants. Même en présence de complications, les unités de soins primaires et l'hôpital sont considérés comme une solution de dernier recours. Le manque de personnel qualifié au niveau primaire, les plaintes pour maltraitance, négligence et mauvais traitements à l'hôpital, la méconnaissance des procédures médicales, et le fait que les agents de santé jugent les femmes ignorantes, expliquent aussi le peu d'empressement de celles-ci à accoucher dans des centres sanitaires et à demander de l'aide en cas de complications. Il faut intervenir pour surmonter ces obstacles entre les mères rurales et le système de santé, notamment avec une éducation communautaire sur tous les aspects des soins obstétriques essentiels et une sensibilisation des prestataires de services à la situation des mères rurales.
Resumen
En Uganda, a pesar de buenas polı́ticas y esfuerzos concertados por mejorar la calidad y el sistema de prestación de los servicios de salud materna, no se ha logrado aumentar el uso de dichos servicios ni reducir el alto ı́ndice de muertes maternas, debido a la carencia de recursos y personal capacitado. Entre noviembre del 2000 y octubre del 2001, se realizó un estudio en Hoima, un distrito rural en Uganda occidental, a fin de profundizar en el por qué las mujeres, cuando enfrentan complicaciones de embarazo o de parto, escogen opciones de alto riesgo que llevan a una morbilidad severa y hasta su propia muerte. Los resultados demuestran que son factores importantes el apego a las prácticas tradicionales de parto, y el creer que el embarazo es una prueba de resistencia y la muerte materna un acontecimiento triste pero normal. Las unidades de salud primaria y el hospital de remisión se consideran opciones de último recurso, aun cuando se presenten complicaciones. La falta de personal capacitado a nivel primario, quejas de abuso, negligencia y malos tratos en el hospital, y una mala comprensión de las razones de las intervenciones explican por qué las mujeres se niegan a atenderse en estos lugares. Más aun, los trabajadores de la salud opinan que las mujeres son ignorantes. Se precisa abordar estas barreras entre las madres rurales y el sistema de salud formal con intervenciones apropiadas que incluyen la educación comunitaria sobre todos los aspectos de la atención obstétrica de emergencia y la sensibilización de los prestadores de servicios sobre la situación de las madres rurales.
Maternal mortality in sub-Saharan Africa remains a burden to reckon with, and Uganda has one of the highest maternal mortality ratios in the world. World Health Organization revised estimates of 1990 figures for Uganda were as high as 1,200 maternal deaths per 100,000 live births.Citation1 More recent estimates of 500–600 per 100,000 in 2000 and 2001 are mostly based on small-scale, hospital-based studies.Citation2 Citation3 Given that the vast majority of Ugandan women live in rural areas and do not deliver in a health facility, the figures are likely to be much higher, with marked variation between districts.
In 2000, Uganda had a total fertility rate of 6.9 and a contraceptive prevalence rate of only 23%. The average age at first sexual intercourse was 16, the adolescent pregnancy rate was high at 43% and the average age at first birth 18.7. Only some 38% of births were attended by trained attendants.Citation4 Compared to a decade before, apart from a rise in the contraceptive prevalence rate (which was 5% in 1991) and a large fall in the HIV prevalence rate, these indicators have barely changed in the past ten years.Citation5
In the past, maternal mortality and morbidity in Uganda were largely and justifiably blamed on the country's socio-economic and political instability, characterised by the destruction of the health infrastructure, chronic shortages of both staff and material supplies, poor remuneration of health workers, low accessibility to health services and erosion of medical ethics. Today, there is a favourable and enabling policy environment, including good policies on gender equity, universal primary education, reproductive health and decentralisation of health services. These contain measures to be taken by both government and NGOs to increase health facilities, improve quality of services and care, and increase the numbers of professional health workers, equipment and supplies.Citation6
Yet there has not been an increase in utilisation by women of emergency obstetric services at health facilities nor a corresponding significant reduction in maternal deaths. This is due in large part to the fact that only minimal implementation of these new policies and interventions has been possible because of an endemic lack of resources at all levels—i.e. a continuing a continuing lack of skilled attendants, emergency obstetric drugs and supplies, blood, anaesthesia or facilities able to offer emergency obstetric care. All these resources are in great shortage with constant stock-outs.Citation7
Maternal deaths: contributory socio-cultural factors
The clinical causes of maternal deaths, the characteristics of women who die and the causes inherent to the health care system are well known in Uganda and elsewhere. Less is known about the cultural beliefs that may contribute to women's deaths. Many authors believe that maternal mortality in Africa has been influenced by socio-cultural beliefs, including gender and power relations, and differences in roles and status between the sexes.Citation8 Citation9 Citation10 Citation11 Citation12
Studies conducted in sub-Saharan Africa before 1990 often focused on socio-cultural factors related to health-seeking behaviour during pregnancy and delivery. An example is a study among the Bariba of Benin, which describes how women take pride in giving birth unassisted and are in turn “silently admired”. It notes that:
“Birth represents a rare opportunity for a woman to demonstrate the proverbial virtue of courage and bring honor to her and her husband's families by her stoic demeanour. The woman who manages to deliver without indication that she is in labour and without calling for assistance until the child is born is especially esteemed…” Citation13
The conceptualisation of childbirth as “the woman's battle” was also found to be prevalent in West Africa, where maternal mortality was explained as “she fell on the battlefield in the line of duty”.Citation14 However, the view that birthing wields immense power, attributed to the unique nature of childbearing, is especially noticeable in societies where women command much less power than men in the public domain.Citation15
In more recent studies from Botswana and Benin on the attitudes of women towards institutional and non-institutional deliveries, however, not only socio-cultural factors but also women's perceptions of the poor quality of health service delivery were found to be important. In Botswana, 47% of women respondents attended antenatal clinics at health facilities, but 82% preferred to give birth at home and virtually none attended post-natal clinics. Of the women who preferred to give birth at home, 41% said they did so for the use of traditional medicines (muti) and abdominal massage, and also because they were reluctant to entrust the disposal of their placenta and other products of conception to strangers like nurses. Significantly, 23% also felt that home deliveries were both more convenient and safer.Citation16
In Benin more recently, antenatal care was sought when symptoms of complications were experienced, but the women had to negotiate with their husbands for the money to pay for the visit, which often led to quarrels and anger over their financial dependency. Nor were they always given enough to pay for the medications they needed. Then they found they were sometimes refused care on a return visit if they had not purchased all the medicines prescribed, even though it was because they had not had enough money. Moreover, the 24 women interviewed, who all gave birth in a hospital, half by caesarean section, said they were unable to ask questions and were often humiliated and mistreated by midwives during their stay.Citation17
In Uganda, the literature on the socio-cultural aspects of maternity care is scant. In the FIGO Save the Mothers Initiative needs assessment in Kiboga district, Uganda,Citation18 which investigated socio-cultural factors in reproductive health and maternal mortality, community perceptions and cultural expectations were found to have a significant bearing on reproductive health and on maternal mortality in particular. In the Kiboga community, as in most ethnic communities in Uganda, where continuation of the lineage is a central dynamic and the individual is subordinated to the group, the importance of a woman still lies in her ability to produce children. It was evident that pregnancy and childbirth were one of the major areas where women still command power and status, which they would strive to keep to enhance their status within the household and community.
It was commonly said that pregnancy prepares women for the “woman's battle” of childbirth (lutalo lwabakyala), which every woman was expected to win, with stoicism and without showing signs of fear. The woman who delivers herself was said to be highly respected. Those who need to deliver by caesarean section and those who die in childbirth were said to display weakness. Death was considered the woman's failing, even when external factors such as lack of transport or funds prevented her from seeking medical help.Citation18 These perceptions and expectations may have a bearing on how women and the community respond to medical problems related to pregnancy, and may offer at least a partial explanation as to why women did not present or presented late for antenatal care, or chose to deliver at home unassisted despite having attended antenatal care.
The study on which this paper is based was conducted in Hoima, a rural district in mid-western Uganda, where subsistence farming, cattle keeping and fishing are the main means of livelihood. It aimed to find out whether additional approaches to reducing maternal deaths were required, in addition to addressing clinical causes of deaths, and what the role of socio-cultural factors were in households and communities where maternal deaths were still occurring.
Methodology
The study was carried out from November 2000 to October 2001. A cross-sectional and descriptive design was adopted, utilising qualitative and quantitative data collection methods—focus group discussions (FGDs), key informant interviews, a quantitative survey and maternal death enquiries. A total of 808 women with more than one birthing experience were interviewed in the quantitative survey (Table 1). Several villages (clusters) were randomly selected from each of the two counties in the district. In each village, all households with eligible women were interviewed using a pre-tested questionnaire with both open and closed questions. Topics included socio-demographic profiles, reproductive histories and problems experienced, use of health facilities, maternal mortality and gender relations.
Table 1 Demographic profile of survey respondents (n = 808)
A total of 24 FGDs were also held, involving 240 participants (with men only and women only in each of five localities). These aimed to establish cultural concepts, traditional practices and rituals related to pregnancy; level of knowledge and recognition of danger signs during pregnancy, birth and the post-partum period and actions taken; and the extent to which gender factors at family level affected women's pregnancy-related behaviours. Key informant interviews were carried out in various parishes in the district with 20 purposively selected elders (men and women), some respected TBAs and traditional healers, and health care workers providing maternity care in government health facilities.
Maternal death inquiries (verbal autopsies) were conducted, using a guide, in the form of conversations with relatives and near kin of the deceased and in some cases the birth attendants of women who died of maternal causes in the community in the last 1–12 months from the time of visit. The families were identified during FGDs. The enquiries aimed at establishing the stage of pregnancy, labour or puerperium when complications were first recognised, the sequence of events that followed and the actions taken. Attempts were also made to establish or assess the level of fatalism and resignation—or hope—shown by the deceased woman and her attendants as events unfolded.
Pregnancy and childbirth as a sojourn on a thorn-strewn path
In all the communities, community members shared common perceptions of conception, pregnancy, labour, birth and the post-partum period. These are to a large extent issues still shrouded in myth and superstition in Hoima, reflecting a lack of even rudimentary knowledge of the physiology of the birth process. Pregnancy is perceived as an inevitable burden, unique but essential for continuation of life and lineage. The first pregnancy marks the crucial transition in status from woman to mother. Subsequent pregnancies enhance that status, moulding the mother into a mature and responsible member of society. In all the communities visited, continuation of the lineage emerged as the most important value associated with childbearing. In this context a woman's ability to conceive, go through pregnancy and give birth is regarded as a virtue, which gives her a high social status. Mothers were often not referred to by their own names, but by those of their children. In contrast, childless women (engumba) were regarded negatively, often associated with evil, bad luck or sin and relegated to the lowest social status.
Conforming to this birth culture not only familiarised women with pregnancy and childbirth, but also gave value to their experiences. Traditionally, pregnancy and childbirth are equated with “walking down a hazardous, thorn-strewn path” where death or survival are the only two possible outcomes. A woman who goes through pregnancy and gives birth to a healthy baby is seen to have bravely endured the dangers. Her resilience is proudly recognised with the traditional praise garukayo (dare to go back), to which she should respond haliyo amahwa (there are thorns). A woman who dies during pregnancy, labour or birth is seen as the hapless victim of the thorn-strewn path. Though her death is viewed with sadness, fundamentally it is regarded as normal and thus a non-event.
The traditional praise garukayo far supersedes mere praise of the new mother but is also meant to remind her that the hardships experienced notwithstanding, she has no option but to prepare to get pregnant again. The metaphoric “thorn-strewn path” also has other implicit meanings, for example that the woman will be unprotected, that injuries and death are unavoidable risks, beyond human power and control, and that that is a woman's fate.
The way a woman endures pregnancy and birth therefore has implications for her position in her household and community. One who experiences no problems and needs no assistance is held in much esteem, having walked bravely and emerged unscathed. One who experiences a difficult pregnancy, perhaps requiring hospitalisation, an episiostomy or caesarean section, is not respected and is referred to as omugara (lazy), though the circumstances are beyond her control. To seek external help is to stumble and such women even after delivery do not deserve a genuine garukayo.
Rationalising the dangers of childbearing
Most women were of the view that since pregnancy and childbirth were mysterious phenomena beyond human control, distinguishing between what is normal or abnormal is irrational. In regard to danger signs, for instance, it was not their occurrence that mattered as they were expected to occur. Only severe complications tended to evoke a response from the woman or her relatives, including to danger signs such as oedema, fever, vomiting, back pains, dizziness, yellowing, haemorrhage, foul vaginal discharge or fainting. The brave woman was expected to endure less severe manifestations of these. Even if symptoms became severe a proper woman would not communicate that pain to just anybody. Close relatives, TBAs or friends were often preferred to health workers, who were often strangers or outsiders and not recognised as part of the local birth culture.
The verbal autopsies revealed cases of women who, in total disregard of the severity of danger signs or their condition, declined to seek medical care and ended up dying. Such extreme fatalistic tendencies were sometimes rationalised by their relatives as having conformed with expectations that women must resign themselves to their fate, because they are powerless to influence the outcome of events. This is viewed (or rationalised) as more honourable than attempting, in vain, to influence the course of events and dying in hospital.
Maternity services: option of last resort
The quantitative survey indicated that many mothers in the district did not utilise available maternity services. Though antenatal care attendance in respect of first pregnancy was high (89%), 58% delivered their first child outside a health facility, and only 45% gave birth with a skilled attendant present. Of the rest, 8% delivered themselves, 26% were delivered by a TBA, 9% by a relative and 12% by another unqualified practitioner. A similar trend was reflected in respect of subsequent pregnancies and births.
Though the majority of women (65%) said they had experienced problems related to pregnancy, only 10% consulted health workers, while 42% consulted no one, 18% consulted their partners and the rest sought advice from TBAs (6%), relatives (7%), mothers (7%), friends (7%) or traditional healers (3%). The most frequently cited problems included high fever, abnormal discharge, lower abdominal pain and shortness of breath during pregnancy; prolonged labour, haemorrhage, exhaustion and abnormal blood pressure during labour and birth; and excessive bleeding, foul vaginal discharge, high fever and headache, and acute abdominal pain during the post-partum period. Most women sought advice or treatment when the symptoms became clearly manifest, persistent or severe (95%).
The source of treatment or help obtained by mothers who experienced problems is summarised in Table 2. A substantial minority used only formal health services, and a much smaller number used neither traditional nor biomedical options, especially during the post-partum period. The tendency of the great majority of women, however, was to utilise traditional therapies at each stage of pregnancy and resort to the health services only if absolutely required.
Table 2 Nature of treatment or help obtained by women with obstetric problems
Traditional therapies included a herbal concoction (emumbwa) taken orally, which was utilised by all women at various stages of pregnancy. Other therapies mentioned included abdominal palpations by TBAs to “feel the baby”, gentle back massages for relaxation, sitting in a container of herbal medicine mixed with water to clean, disinfect and widen the birth canal; drinking various types of herbal medicines for protection; smearing or insertion of certain herbs in the vagina; drinking herbal concoctions to enhance contractions or expel the placenta; and abdominal massage. The significance of these practices in the women's eyes cannot be emphasised enough. Overall traditional midwives, grandmothers and traditional healers were regarded as the custodians of the local birth culture. Women who utilised only their services, consulting them during pregnancy, giving birth with their assistance and seeking post-partum care from them were seen as well-equipped and earned more respect if they survived the hazards, i.e. delivered normally.
Almost 60% of the 808 women surveyed knew of someone who had died of a maternal cause in the previous year. Of these, 17% had occurred during pregnancy, 52% during labour or childbirth, 17% within 24 hours of birth and 15% from one day to a week post-partum.
Most mothers expressed cynicism about the efficacy and nature of maternity services at local health facilities. Giving birth at a health facility was viewed as an anti-climax, which compared negatively with traditional options. Formal government health services were described as a place where impersonal health workers focused on efficiency, hygiene, orderliness and above all the suppression of mothers' emotions, which were viewed as interfering with efficient birthing.
Figure 1 Ggaba, fishing port on Lake Victoria, Uganda, 1997
Some women complained about the supine position which they were compelled to adopt for delivery at hospitals, when the traditional kneeling position was preferred. One woman who had previously delivered by caesarean section felt that the doctors were always in a hurry to send women for surgery:
“…I hadn't even pushed for a long time, and was still feeling strong. Yet they took me to the theatre and cut me. I feel they just wanted me out of the labour ward to make room for other important women. Even now I am suffering with the incision scar.” (Focus group discussion, Mparangasi village)
Other women complained that even for what would have been a normal delivery, the midwives were always in a hurry, tended to try to turn them into passive and dependent patients, and ignored the value and meaning they attached to their birthing experiences. Many mothers with prior experience of hospital deliveries pointed out the insensitivity of health workers to women's labour and birthing pains. In a hospital labour suite, they said, women found it impossible to express and communicate their pains to the health workers or receive an appropriate sympathetic response.
Yet, as one participant pointed out, this is traditionally part of a woman's upbringing, and women giving birth consider the free expression of pain as part and parcel of childbearing. Having to suppress this not only undermined the meaning and value women attached to the experience but also made them feel that the sensations taking place within their bodies were being disparaged.
Overall rural women bore negative feelings towards providers of maternity care at government health facilities, and expressed doubts about the efficacy of specific therapies. The delivery of maternity services was not perceived as culturally appropriate, and interpersonal relations between women and health workers were far from ideal. Health workers were said to be rude, poorly trained and unwilling to dispense prescribed drugs. They were also said to deliberately avoid maternity patients, abandon them in critical situations, expect to be bribed, give false information and lack ethics. Negative bias expressed towards nurse–midwives, the health workers who interact most with pregnant women, was strong. Only a minority of women said some health workers could be kind.
Most mothers said they therefore only went to the hospital or health centre as a last resort, i.e. in case of an emergency. They were aware of some of the shortcomings of unskilled and TBA-assisted births, but they preferred them. TBAs and relatives were known or seen as fellow community members; their services were familiar and acceptable in the community. Embarrassing questions were not asked, delivery was in the preferred position and when the pains came, a woman could respond as she wished.
“Nobody will restrain/rebuke you and sometimes the attendant will sympathetically cry along with you. More important nobody will be in a hurry to cut you, pull out the baby or rush you to the operating theatre.”
One mother with both traditional and hospital birth experiences pointedly remarked thus:
“Once you go to deliver in hospital you are treated like a child or a fool, in total disregard of your age, experience and status. Imagine a young nurse fit to be your granddaughter telling you how to lie down or when and how to push… Why should I be treated like a helpless and passive patient? After all, the pregnancy and its consequences are my personal concern and not anyone else's.”
Access to maternity care and the perspectives of health workers
There are 33 primary health care units in Hoima district, that is, four health centres, seven domiciliary maternity units, 21 dispensaries and the Hoima referral hospital. Two of the four health centres and four of the 21 dispensaries are non-governmental (NGO) facilities. The distribution of primary health units across the district is fairly good, and there is at least one dispensary for every sub-county except one, which is in close proximity to the referral hospital. The domiciliary maternity units are government health units at the local level (sub-county) providing antenatal care and normal deliveries; these are normally the first contact for women in need of maternal health services.
At the time of this study, the district had an acute shortage of trained health personnel, especially in rural health units, where 63% of the staff were nursing aides. There were only 11 clinical officers, three enrolled nurses and five enrolled midwives to cover the 19 primary health units in the district. The recommended minimum number of full-time reproductive health staff for a health centre in Uganda includes one clinical officer, two registered midwives and two enrolled midwives. Each of the four health centres in Hoima district was staffed with at least one clinical officer, an enrolled midwife and a nursing aide. Mothers presenting with emergency obstetric complications at a rural primary health unit were referred to Hoima hospital, where there was supposed to be an obstetrician–gynaecologist and several medical officers capable of dealing with a wide range of obstetric emergencies. As the verbal autopsy of Annet shows (Box 1), however, the obstetrician–gynaecologist was apparently away while she was dying.
Box 1. Verbal Autopsy 1
Annet, died aged 15
Annet, who died at age 15, was unmarried and still in primary school. This was her first pregnancy and delivery of the baby was by caesarean section. Annet used to reside with her grandmother. She realised she was pregnant during the fourth month when she developed food cravings. The father of the baby was not known, at least to others. She attended antenatal care once for a routine check-up. The rest of her prenatal care was provided by her grandmother and involved administration of herbal medicines, including emumbwa. Pregnancy went to full term without major mishaps but labour and birth proved problematic. Annet was in labour at home for four days. A TBA was called in to assist with delivery but failed. On the fifth day she was taken to hospital 3km away. Her grandmother abandoned her there, without any provisions. She told hospital staff that labour had just started. She was admitted to the maternity ward where she spent three days, all the time in severe pain. Throughout this time, the qualified obstetrician was away. On the third day, emergency surgery was carried out. The caesarean section was done by an intern and a live baby was delivered. Annet also survived and believed the worst was over. Annet had no regular relative looking after her at the hospital. Her elder sister came to visit after the caesarean section and applied a herbal medicine to the incision twice. She developed a high fever and severe cough. Her coughing made the incision stitches rupture, leaving a gaping wound, which became septic. She was taken back to surgery after six hours, thinking she was only going for fresh stitches, but she did not recover. Death was attributed by her relatives to incompetent health workers.
Health workers interviewed recognised that the maternal health situation in the district was bad, but they attributed it to women's ignorance and refusal to deliver in health facilities, despite the educational efforts that had been carried out in various parts of the district. They acknowledged that facilities at the health centres were not adequate for dealing with the severe complications women were presenting with, and that in most instances, women had to be referred to Hoima hospital. However, many women did not want to be referred to the big hospital and did not understand why their condition could not be dealt with by health workers at lower levels.
The health workers had not been trained to deliver women in the kneeling position women preferred and felt wary of it. Many felt quite critical of the women as well.
“There is no way I'm going to deliver women in that position. What if the baby dies? Who will be responsible?”
“These women expect too much… They don't know that we do not have all the drugs they need… You also need to handle them with great seriousness, otherwise they will kill the baby.”
They affirmed that in total disregard of both the nature and severity of obstetric problems, and the competence or capacity of the care provider to render appropriate care, women often obtained care or advice from relatives, friends and neighbours. But they pointed out that the type of care women sought and where they went for help with complications often depended upon the views of the local TBA or other traditional provider, as well as the woman herself or her close relatives. In other words, traditional birth culture was partly responsible for convincing women not to seek care from the health services even when it was needed.
“It is not uncommon for a woman with an ectopic pregnancy to consult a neighbouring, semi-literate drug shop attendant about the problem, rather than the qualified obstetrician at the nearby referral hospital.” (Key informant, Health centre)
“Advice or care given to women by friends, neighbours or relatives, although well intended, is always unprofessional, inadequate and outright dangerous, often resulting in severe morbidity and death. Deaths from abortions are always traced back to such care or advice.” (Midwife, Health centre)
One health centre nurse agreed with this, but felt that women's care-seeking behaviour at any stage in the pregnancy process was not a result of individual preference or choice, but was conditioned by illiteracy and poverty, which were strongly evident among all the rural communities studied.
Discussion
This study demonstrates that adherence to traditional birthing practices because they are familiar and accepted, and beliefs that pregnancy is a test of endurance and maternal death a sad but normal event, are all risk factors for maternal mortality in this part of Uganda. Attendance at primary health units for minimal antenatal care was high, but use of primary level maternity services for a normal delivery was low, and attendance at such a unit for treatment of complications, which usually led to a referral to the hospital, was considered only as a last resort. Similar conditions were described in Kiboga district, Uganda, along with a similar low level of use of services by women.Citation3
Lack of skilled staff at primary level, the absence of the obstetrician–gynaecologist for at least three days, complaints of abuse, neglect, lack of respect and sympathy, and poor treatment from midwives in the hospital had all led to mistrust and cynicism about attending these facilities. It is also obvious that women and their families did not understand the reasons when or why it was urgent to seek medical care nor why the use of particular procedures such as caesarean section were necessary to save their lives. When they saw women dying in the hospital, they assumed the care provided had been bad and not that a woman may well have arrived too late to be saved.
Health workers' views that women were ignorant would literally have added insult to injury from the women's point of view. However, the use of herbal concoctions inside the vagina and the fact that in the case history of Annet the sepsis in the C-section wound may have been caused by the introduction of a herbal paste by Annet's sister, at least partly justify the concerns expressed.
The lack of knowledge about pregnancy, reproduction and related health care on the part of the women and their communities, as one health worker pointed out, was mostly due to poverty and lack of education generally. Rural communities fully recognise the life-threatening risks associated with pregnancy and childbirth, but by emphasising endurance and tolerance of physical pain and other life-threatening symptoms, they have unwittingly taught women to suppress concerns about conditions which require urgent attention, so that they may not communicate with anyone until it is too late.
Mothers do not deliberately choose the riskier option of home-based, unskilled care; rather, the environment in which they live to a great extent limits their choices. One health worker claimed there were essential drugs available, but could women afford to pay for them? The case history of Sefuroza (Box 2), which describes how she refused to go to hospital because she had not prepared for it, had nothing decent to wear and no cash put by to pay for her treatment, is indicative of why women may feel they have no choice but to endure.
Box 2. Verbal Autopsy 2
Sefuroza, died aged 47
Sefuroza was married, had no formal education and died at the age of 47 from complications of her 14th pregnancy. As in all previous pregnancies, she never attended antenatal care, but relied entirely on traditional herbal medicines. All of her deliveries were at home, without supervision of a skilled health worker. She had no history of serious pregnancy or delivery-related complications. In this pregnancy, her problems started during labour. The contractions were described as weak and sporadic, at times disappearing completely. Altogether she spent 48 hours in labour. A relative who was attending her saw nothing abnormal and eventually assisted in delivering a live but tired baby. After delivery and expulsion of the placenta, bleeding did not subside. Sefuroza haemorrhaged for several hours and started feeling very weak and faint. A herbal concoction meant to stop the bleeding was prepared for her by the relative. Some herbs were also stuffed into her vagina to plug the flow of blood. The bleeding continued, however, and she also developed fever, shivering, shortness of breath and heart palpitations. Her husband was called in and the relative suggested taking her to hospital. Both husband and wife refused. Despite her critical situation Sefuroza said she was confident of recovery. In addition, she had not prepared for going to hospital, had not attended antenatal care, had nothing decent to wear and had not saved any cash. When her condition deteriorated further, a traditional healer/diviner was called in and found her unconscious. He chased everyone away from the house except the husband, and started “working”. Almost immediately “foul play” (bewitchment) by the co-wives was “diagnosed”. Ancestral spirits were invoked and various herbal medicines administered, in vain. Sefuroza died two hours after the traditional healer's visit. Her death was largely attributed to malevolence, the rationale being that a woman with such a normal birth experience cannot just die the way she did.
Furthermore, the number of skilled health workers available in government facilities was far below what it should have been, and as numerous other studies have shown, must be considered an important reason why women perceived they were being neglected in hospital, as most probably they were, a situation over which health workers too would have had little control. Complaints that bribery was needed, presumably to get attention, need to be taken very seriously, not only for ethical reasons but because they indicate how low health workers' pay must be. All of these factors help to explain the unwillingness of women to deliver in health facilities or to seek medical care for complications of pregnancy, delivery and unsafe abortions.
Part of the reason for the poor quality of care for delivery and complications may be linked to the comparative lack of resources of rural health districts as well as to women's lower status in Ugandan society, especially rural women. Delivery care may be perceived by rural district health managers with few resources as a low priority, not least because most women do not use it, and perhaps because it is women's work and a service only for women, when the main locus of care and status remains in the home in rural communities.
Appropriate interventions are needed to address the numerous barriers uncovered in this study between rural mothers and the formal health care system. Community education is needed on all aspects of maternity care, unsafe abortion and treatment for obstetric complications. The sensitisation of service providers to the situation of rural mothers is also necessary. Communities need to understand that women can survive pregnancy, and that the “thorns” and other hazards on their paths can and should be removed as a community obligation. Active community participation in such education, including that of men as leaders and as partners, is required for this, as well as the delivery of adequate and culturally appropriate maternity services.
Acknowledgements
A version of this paper was presented to Amanitare African Women Sexual and Reproductive Health Conference, Johannesburg, 4–7 February 2003. The research was supported by the Rockefeller Foundation Africa Career Awards Programme.
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