When a woman bleeds a nation bleeds; tackling maternal deaths in the Rwenzori ranges

Mitandi is one of the areas that in our government policy we always call hard to reach areas. It took us wrong turns before we got our way around to the Mitandi health center in Mitandi sub-county Kabarole off Fort Portal – Kasese road.

I was with the US Mission in Uganda on a visit to US government-supported projects on maternal health and family planning. This trip was organized for Lois Quam, the Executive Director of President Obama’s Global Health Initiative (GHI). The visit to Mitandi was one to find out how the projects are fairing and the progress of Uganda government efforts to reduce maternal deaths by 50 percent in four western Uganda districts by end of 2012.

Uganda has one of the highest maternal mortality rates in the world at 435 per 100,000 live births. Mitandi is one of the difficult places to reach in Uganda where health services and indicators are always way below the national average. We found our way up the mountains to where the health centre sits atop a hill next to secondary school in the Rwenzori ranges.

A view of the Rwenzori ranges from Mitandi health center

Mitandi is a not-for-profit health center III run by the Seventh Adventist Church. The Health Center serves an area of about 40,000 people and it is the major health facility in the whole sub county. The nearest bigger health center is Kibiito health center IV about 20 km away.

Before 2010, Mitandi delivered less than five mothers per month; two years down the road the center delivers more than 20. This magic increase in number of women delivering at a health center that is even still understaffed is connected to a voucher system which has been getting funds from the US government.

Through Maries Stopes, implementers of this voucher project went through the villages carrying what they called ‘poverty grading’, looking out for the poorest of the poorest. A voucher would be sold to pregnant mother at 3000 shillings (less than 2 USD) and this entitled her to four antenatal checkups, free delivery and transportation in case of complications to a large health facility.

In 2011 at Mitandi more than 300 mothers delivered their babies and only 9% were referrals to Buhinga and Virika because the two hospitals work with voucher system and have capacity to handle emergency obstetric cases.

Most of those referred had obstructed labour. This is an area where you find girls as young 13 pregnant. These girls’ lives are in danger if they are not brought to the health facilities in time because of the high chance of complications.

The existing roads here are bumpy and when we headed there the rainy season had just started which will make most of them impassable. Transportation continues to be the problem for many communities living up in the mountains.

The voucher system might have increased deliveries by 72 percent but health workers were worried if it stopped many mothers would stay away.

“It could fall again unless the project is continued,” said Onesmus Turyahumura, in-charge Clinical Officer at Mitandi.

The worries are that those gains could be lost in an area where 54 percent of women still don’t come to deliver at health centers. Although the target for the Mitandi is 1900 pregnant mothers per year in the area, only 46 percent are coming for antenatal.

L-R: US Ambassador to Uganda Jerry P. Lanier, Christopher Dorval, Senior Advisor; Strategy and External Relations at the Global Health Initiative and Lois Quam listening to a clinical officer at Mitandi on Feb 23rd.

The voucher system alone is not enough to raise the umbers of deliveries at health centers to a desired level. So at Mitandi, a small outreach program has been on to get traditional birth attendants (TBAs) to bring mothers to health centers. The day we visited Mitandi we met more than 6 TBAs who are cooperating after education on the dangers like HIV and mothers dying.

These TBAs have changed their role from delivering mothers to facilitating the transfer of mothers to health centers.  For every woman they bring to health center they are paid 5000 shillings (about 2 USD) and but few are consistent.

One health worker said “It is like we are in competition with TBAs here.  Few have so far cooperated many remain and refuse women to come to health centers. Community mobilization must happen otherwise such projects will not last. Most mothers are illiterate and they don’t know the difference between the care of a TBA and that of a midwife.”

At Mitandi Quam held a talk with the TBAs to find out about their problems and what they thought of their changed roles.  Many expressed willingness to work in the very difficult terrain to bring mothers but the pay currently is not as good as they were earning from mothers as TBAs. They also indicated that in an area where access to health services hasn’t been good for decades TBAs are sort of demi-gods and some even threaten mothers if they suspect they will go to a health center to deliver.

One of the TBAs explains their challenges.

Even with the few TBAs in this program there has been a good rise in mothers knowing the advantages of having antenatal checks and delivery from hospital but just like the entire project I found myself wondering about how sustainable is this? Would the government of Uganda in a few years be able to re-think their approach to maternal health and looks at these small issues that can mean life or death for pregnant women?

Quam said that the Ugandan government should do more to ensure that that maternal health is addressed. Quam, who a mother of twins, always amazed me with her question of how twins deliveries had been handled. I had a quick chat with her of what she thought of Mitandi and the other 7 health centers we visited

I think the test of all us is how we can ensure that a family living in a village can get health care that makes it possible for children from these areas achieve their potential.  I know the suffering that comes when a mother dies in family, it means the end of there life and end of so much for her family.  There are opportunities through voluntary health teams (VHTs) and having TBAs playing a different role instead of having to be responsible for the delivery.

A mother may have had three children and it went fine and the fourth child it could totally different so it important to bring the women to hospitals. The tricky thing about labour and delivery is that it is a timing thing.  You don’t decide when your time has come, it decides for you. And when your time comes for delivery it happens whether you are ready or not. The moment is now to act up. When a woman bleeds a nation bleeds.  When a woman cannot get safe delivery it is very telling of that country.


Just like most health centers in the country, Mitandi faces challenges of equipment; in fact here equipment is still sterilized using a stove. The health center though faith based gets some money from government but 50 percent of this money for primary health care goes to buying of drugs.

In the rest of 7 other facilities we visited transportation of women to health facility was always cited as a big problem as well the persistent cheaper TBAs.

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