How we started caesarian sections in two rural Health Centre IVs in eastern Uganda
“Doctor, doctor, please wake up. Doctor, doctor, we have an emergency”, said Edward my cousin. It was 2 am in my village and someone was at my window. Deep in my sleep, I heard somebody talking from outside my door. I was scared because my window did not have curtains and so under the bright light of the village moon somebody outside could see me through the glass window. “Who could it be?”, I asked myself. “Dokita, situka, omukazi afa”, Edward shouted in Lusoga, my mother tongue, meaning “doctor, wake up, a woman is dying”. The mention of a dying woman jerked me off my bed.
Outside the house were my mother, aunties, other relatives and a woman lying in the dust. She was wailing, and from the sight of things, I definitely knew she was in labour. Also outside was a motorcycle, which I later learnt, had been used to transport her from her village, 10 Kms away. She had been in labour for 10 hours in a small clinic, and they realized the baby was too big for her to have a normal birth. But what could I do without any gloves, medicines etc. even if I am a doctor, I asked myself. After quick thinking, I run back to my house, changed clothes, and run back to her with my car keys ready to play the ambulance driver. I immediately guided them into the car and off in the night we drove to Iganga hospital, 40 Km away. My sister, Josephine, a senior nurse at Iganga hospital, was waiting and she had already mobilized a doctor, an anaesthetic- assistant, and the theatre. In a few minutes, mother and baby where out of theatre and well.
Dr Jude Mulowoza (left) the head of obstetrics at Iganga Hospital leads the mentors at the facility discussing some literature with his mentor Dr Peter Waiswa
This experience- a woman in labour for ten hours, motorcycle and my car as the ambulance, and accessing a hospital 50 Km away never left my head. I asked myself:
- What would have happened if I was not there with my personal car?
- What happens to many such women and their unborn babies?
- What is the capacity of these lower level health units?
- How can referral care be improved?
- Why is the nearby Health Centre IV at Kiyunga with a theatre built 15 years ago not functional?
- Was this pregnancy planned?
I got back to my team at the Makerere University Centre of Excellence
for Maternal and Newborn Health Research (www.mnh.musph.ac.ug ) and we wrote a project code named RefNet (Referral Network) and the World Health Organisation (WHO) gave us some funding. The project started by mapping out: 1) What are the health facilities that refer women in labour to Iganga Hospital (Iganga referral hospital network)? 2) What is the capacity of these health facilities? 3) And can we improve the performance of these facilities by using Quality Improvement methods?
The team worked with local leaders to form Quality Improvement Teams at Iganga hospital, and these started visiting health centres to build their capacity. Having
a champion in a local obstetrician was helpful. As I write today, we have been able to support two health centre IVs (Kiyunga in Luuka District and Busesa in Iganga District) that have been dormant since 2000 to begin C-Sections for rural women. They have been doing so for the last one month and surprise, surprise; all needed in-puts were in place (theatre, equipment, staff). Okay we have so far not been successful at two HC IVs: one lacks a doctor and the other lacks an anaesthetic assistant.
I am happy women in my and neighbouring villages can now get emergency obstetric care from the nearby Health Centre IV. There are still many challenges: human resources issues (staff numbers, motivation, skills), availability of medicines and equipment, and poor referral management. But we have started on this – one step at a time!
None-the-less, from our two case studies, we have learned that through mentorship, quality improvement in health care and support, we can operationalize most of our Health Centre IVs and this can take us a step towards realizing universal coverage for maternal and newborn health.
*This blog was witten by Dr Peter Waiswa, the Principal Investigator for the Makerere University Centre for Maternal and Newborn Health Research.