The caseload for a midwife in the Kotido district of Karamoja, tucked in a remote part of north-eastern Uganda, strains belief: with just 18 midwives serving 9,600 mothers, according to district health officials, each midwife cares for at least 533 mothers a year.
That’s more than triple the number recommended by the WHO (1 midwife/175 mothers a year).
As a result, midwives are overloaded, says Phillip Oringa, MD, the Kotido District Health Officer (DHO), “which affects the quality of services provided.”
But the heavy caseload is not the only issue confronting midwives. They face a complex array of problems, I learned during a visit earlier this month to examine the state of health and midwifery in Kotido and the Karamoja sub-region.
Food security is one challenge. Karamoja is at the mercy of extreme weather conditions, such as prolonged drought—and when the rains finally come, they cause flooding. Agriculture, despite the fertile soil and the best efforts of the government and several NGOS, is failing. In response, the World Food Programme gives food rations to expectant and breastfeeding mothers—but this has an unintended consequence: Mothers avoid family planning services, in order to stay eligible for food rations. “(A mother) wants to ensure that by the time she weans one child, she is pregnant again, because being pregnant is the only way to get the food rations,” explained Angella Emmanuelle, 23, a midwife at Moroto Health Centre IV. “So when you tell her about child spacing, she will think you are denying her food.” Although the use of modern family planning services has increased from 0% in 2006, it is still very low, at 6.5% in 2016, according to the Uganda Demographic and Health Survey.
It is also concerning that amid the serious shortage of midwives, myths and misconception about family planning are rife. For example, Sarah Adiaka, a midwife at Rupa Health Centre II in Moroto district says mothers subscribe to the myth that a mother on family planning should not come near a fireplace. Thus, in an area where mothers cook and burn charcoal for a living, many are shunning family planning services.
More educated midwives could help counter some of the myths surrounding family planning, as well as the shortage of skilled health workers. In response, UNFPA introduced a bonded scholarship scheme for midwives, to sponsor young women in the region to study midwifery. In exchange, the young women commit to work in the area for at least 3 years after graduation. The program has trained 126 midwives since 2010, deployed throughout the sub-region’s 7 districts. “We encourage mothers to deliver at the health centres under the care of skilled attendants, and we are seeing results,” says Caroline Akello, 23, a bonded midwife at Loktelabu Health Centre III, “We used to have over 12 BBA (Born Before Arrival) cases a year, today we are seeing less than 5.”
Across the whole sub-region, the UN agency also pays salaries for 30 midwives. In a bid to ensure its sustainability, last April the agency asked the government to take over salaries for that group of midwives after 1 year. It remains to be seen whether or not the government will raise to the challenge—but the need for the government to support these recruits, and indeed train and incentivize more midwives to work in this hard-to-reach part of the country is clear.
