Hundreds of thousands of women worldwide die as a result of childbirth each year. Millions more survive to tell the tale – and researchers believe they could help cut deaths.
Halima Nakalanzi was married to a man almost the age of her father when she was 16. Over 23 years she gave birth to 12 children, each of them delivered in her bedroom with her help of her neighbour Sayidat Namatovu, a traditional birth attendant. While Halima went through labour her husband reads the Quran in the sitting room until the delivery was over. But on the delivery of her thirteenth child, things began to go wrong.
"I was struck by fever during the last three months of my pregnancy. I was feeling hot but I didn't visit a doctor, instead I would dip a piece of cloth in water and tie it around my head to reduce the temperature. The fever was on and off. It weakened me and I got worried whether I would have a normal delivery," she recalls, dressed in the clothes she usually puts on for morning gardening.
"When I begin experiencing labour pains, I send one of my children to call her," says Nakalanzi. The birth attendant assured her she would have a normal delivery. "As the labour pains intensified, I continued getting weaker and weaker. I spent a whole day crying and getting assurance that I would deliver."
The birth attendant realised after 24 hours that she could not handle the delivery. "She reached out for my husband in the sitting room and broke to him the bad news that she had failed to handle the situation," recalls Nakalanzi.
The village has mobile phone coverage, but there was nobody to call since the village expert Sayidat Namatovu had given up. The alternative was to call for an ambulance but the nearest is 35 miles away at Masaka district main hospital they could not afford it.
Nakalanzi says the only means of transport at home is a bicycle. Her husband ran in panic to look for transport and managed to find a car about a kilometre away. "At this time, I was in a terrible state. I needed to be supported to walk. They lifted me and dumped me into the car and we drove off."
She was taken to a sub-county health centre in Kyazanga five miles from home. The nurses at this three-room, iron-roofed health centre assured her she would deliver. The health centre has no graduate medical staff, no operating theatre, and no equipment or skilled staff to carry out a Caesarean operation.
"At this health centre, they never gave me any medicine. I spent another day here crying of too much pain. By the end of the second day, I lost my voice and I could no longer see. I even couldn't hear the baby kicking inside. I thought the baby was dead and I was to follow next. I waited for my death, till I became unconscious."
Her husband, Hussein Bukenya, again ran to the highway about 100 metres away to look for a taxi. Since he did not have enough money, the crying Nakalanzi had to share the taxi with other passengers going to Masaka.
Nakalanzi does not know what happened in between losing consciousness and arriving at St. Joseph Hospital in Kitovu. "I gained my consciousness only to see myself on a drip in Kitovu. I could see again." At first she thought her baby had died. "I no longer had the baby kicking inside. I was taken to the Caesarean unit for an operation to remove the baby. Luckily the baby survived and I too didn't die," she recalls as she smiles at her child.
It was the first time she had ever delivered her baby in a hospital. Her uterus had ruptured during the three days of labour. Doctors carried out an emergency hysterectomy and she spent a total of 13 days in hospital.
Uganda remains among the countries with the highest maternal mortality rates in the world. Professor Paul Hunt, a UN health envoy, recently warned Uganda was unlikely to meet the Millennium Development Goal of cutting maternal deaths by three-quarters.
Dr Anthony Mbonye is Assistant Commissioner for Reproductive Health in the Ministry of Health. He says Uganda's maternal mortality rate stood at 557 per 100,000 live births in 1995, and that it has dropped to 505 in the past few years. "The situation has improved but not to the desired levels," he says, "Although we see an improvement in service delivery, our indicators are still poor, for example compared to Sweden where maternal mortality rate is reported to be three per 100,000 live births."
Some researchers argue that for maternal services to improve, more attention should be paid to women, like Halima Nakalanzi, whose terrifying experiences are classed as 'near misses'. Dr Pius Okong, who is based at Nsambya Hospital, in Kampala, and fellow researchers tracked the experiences of 685 Ugandan women who nearly died in childbirth. They identified substandard care and records, and delays caused by the patients themselves in more than half the cases they examined.
At up to 58 per cent of deliveries in Uganda, the sole supervisor is a traditional birth attendant like Hairat Namugerwa, 55, who works in Kyazanga. She started this job on 15 March 1970 and keeps the records of her deliveries in a dirty 36-page exercise book. Listed in her book are the names of 75 women. Against each name there are figures indicating the number of times each of the women has delivered under her.
"I think I have administered between 200 and 250 births," she says. In case of emergency, Hairat refers her patients to Kyazanga Health Centre, five miles away. This health centre has no theatre and patients are referred to the district hospital, 35 miles from the village if they need an operation.
In her village there are more than 10 traditional birth attendants but in 37 years, Hairat Namugerwa has been trained only once by gynaecologists. "I acquired this knowledge from my mother. She trained us with my sister Mariam Nalwanga. We are both experts now," she says with a smile.
Dr Mbonye says no study has been carried out to establish the exact number of traditional birth attendants the government has trained. They are supposed to be supervised by midwives at the main health centres in their locality. "Their curriculum includes recognising complications and referring mothers to main health centres. That is something they are taught," says Dr. Mbonye. Each birth attendant is supposed to receive a "Maama kit" a bag containing gloves, a polythene bag, razor blades and some antibiotics.
"Problems are not always lack of skilled personnel or equipment," says George Michael Mukula, former minister of state for health. "Some mothers prefer to deliver at home and others shun antenatal care as opposed to local herbs."
Nakalanzi backs up this view, "You know this is how we deliver in villages. We don't attend antenatal care. Instead, we use herbal medicine that we pick from the bush," she says. Poverty can also deter patients from seeking care, either because they cannot pay for transport or because they fear medical costs.
Hairat recalls with sadness on her face the death of Babirye Nakabiri, 37, one of her charges. "I had helped her deliver her first three children but she had a lot of complications. Her vagina would close before the placenta came out," she recalls.
On the day of Babirye's death, Hairat collected her herb medicine from home and walked to the place where she was, about 200 metres. She says, "I told them to take her to hospital but they told me they had no money." Babirye Nakabiri delivered normally but the placenta did not come out. "I gave her herbs I usually give to people with the same problems but nothing changed." She died minutes later.
The government has made improvements in some of the areas highlighted by Dr Okong and his fellow researchers. It has recently created a 'credit line' which allows every district health authority to order drugs and equipment from the National Medical Stores.
Under this initiative, each district is allocated money by the government and they are supposed to spend their money on areas of critical need. In the past the equipment was distributed centrally making it harder to meet local demand. It also recently pledged to buy 215 new ambulances, one of each constituency in the country; around half are estimated to have been delivered.
But deep-seated problems caused by poverty remain. These ambulances are not free and with many villages situated up to 30 kilometres away from the centre of a constituency along poor roads, it is likely that many poor women who face birth complications will continue to depend on good luck for their survival.