GULU/SOROTI  - Despite the significant role midwives play in Uganda's maternal health programmes, they face numerous challenges, including lack of training, inadequate facilities and poor pay.

According to the Africa Medical Research Foundation (AMREF) just 38 percent of Uganda's estimated 11,759 midwives are either registered or have a college education. Yet they attend to 80 percent of all births in the country's urban areas and 37 percent of all births nationally.

Esther Madudu, a midwife in Uganda's rural Soroti District, explained to IRIN that many go to great lengths to help women deliver.

"Health centres lack electricity, water and other essential medical commodities to assist in delivery. In the past, I used to [hold] my cell phone in my mouth [and use its] torch to [assist delivering] mothers at the health centre," she said.

In a 2009 analysis by the UN Population Fund (UNFPA) found Uganda's health system "unsupportive to midwives, as characterized by poor remuneration, poor health service infrastructure, lack of essential equipment and supplies, eg, gloves, drugs - especially in public health facilities - inadequate protection from infections, high workload owing to few qualified staff" and lack of supervision or training opportunities.

Maternal deaths

Uganda grapples with high rates of pregnancy-related complications and maternal deaths, consequences of poor healthcare investment by the government, low education levels and an unmet need for reproductive health services.

Uganda's 2011 Demographic and Health Survey showed the maternal mortality rate at between 310 and 480 deaths per every 100,000 live births.

According to the Ministry of Health, 24 percent of these deaths are the result of severe bleeding, and many are due to infection, unsafe abortion, hypertensive disorders and obstructed labour.

Experts say much more must be done if Uganda is to meet Millennium Development Goals 4 and 5 - the goals on reducing child and maternal mortality and achieving universal access to reproductive healthcare - by the 2015 deadline.

"Death resulting from pregnancy-related [complications] is a big issue in Uganda that requires urgent attention," health commissioner Anthony Mbonye said, noting that these deaths are preventable "with improved access to [quality] healthcare to the population and... positive attitudes towards... health workers."

Too few health workers

Midwives say their small number has them struggling to meet demand. They have called on the government to recruit more midwives.

"We are only three midwives working day and night with [the] assistance of two nursing assistants," said Lydia Tino, a health supervisor and midwife working at a centre with 20 maternity beds in the rural Gulu District.

In 2006, the government stopped midwifery trainings, arguing that nurses could be given additional skills to take up the roles played by midwives. This has not happened.

And the few who have midwifery skills often leave the country.

"Uganda has trained many midwives, but [the] majority opt to work in places outside the country where facilities and remuneration are better," Mary Gorettie Musoke, senior midwife and trainer, told IRIN.

"...In the past, I used to [hold] my cell phone in my mouth [and use its] torch to [assist delivering] mothers at the health centre."
In a progress report by Uganda's Ministry of Health, tabled before a parliamentary committee in February, the government indicated that it had employed and additional 5,707 health workers to help plug the gap.

But many rural health facilities are still unable to perform either basic or comprehensive emergency obstetric and newborn care.

Government obligation

Government officials told IRIN it plans to carry out a countrywide maternal health audit as part of its efforts to deal with the problem.

"We are under obligation to perform our duties, so the government doing everything possible to address problem," said Sarah Kataike, the health minister.

While government health facilities in Uganda are supposed to provide free services, they are understaffed and lack essential medical supplies. At times, patients are forced to pay extra fees before they can receive services.

Florence Akio, 34, had to be transported to a private facility some 45km away after failing to receive any assistance at a nearby government facility.

"My labour started in the middle of the night, but I couldn't make to Atiak Health Center III. I waited until morning, when my husband borrowed a bicycle and carried me to the health centre. But, reaching the health centre, there was no sight of any staff to attend to me," she told IRIN.

In a landmark 2011 case, civil society organizations sued the government over the high maternal mortality rate, but the case was dismissed. The organizations had argued the government had failed to provide essential medical commodities and services to pregnant women.

Source:  Integrated Regional Information Networks (http://www.irinnews.org )