27 December 2012

Uganda: Childbirth Is Not the End - Mothers Still Need Lots of Care

Photo: Florian Lems/MSF
Mothers and their children at a feeding centre in Chad.

The story of Christmas' miraculous birth of Jesus in a cowshed stops after the baby is born. Even for many people, the first cry of a baby at birth, to many, signifies that the mother's battle is over. The baby is born, all is well.

However, it is not always so, as a mother still needs a lot of attention and could die during the postnatal stage. "The postnatal stage is the period immediately after the birth of a child. It extends for about six weeks," Dr Judith Ajeani, an obstetrician with Mulago Referral Hospital explains.

During the postnatal period, a woman may develop life threatening complications. According to the 2006 Uganda Development Health Survey (UDHS), evidence has shown that a large proportion of deaths occur during this period, with bleeding and infections being important causes.

Therefore, a postnatal visit to the hospital is crucial and an ideal time to educate a new mother on how to care for herself and her newborn. "The six weeks is when the mother needs the most care and special attention, just as much as the newborn baby," Ajeani explains.

Unfortunately, in numerous communities, the complications of childbirth are considered over as soon as the baby pops out. "A healthy baby does not mean the mother is fi ne. That is why there is the six-week period for them to get back to normal," says Eve Nakabembe, an obstetrician at Mulago Hospital.

Prof. Pius Okong, the chairperson of Health Service Commission, says in Uganda, of the ten women who die from pregnancy-related complications, two die from abortion complications infections such as malaria, or cases of high blood pressure.

"The causes of death for the remaining eight can be split between those dying during birth and those dying during the postnatal stage," Okong explains.

Therefore, approximately four out of every eight women who die due to pregnancy-related complications die during the postnatal period. According to Okong, the number is not exact because not all deaths are registered, considering that a number of mothers deliver away from a health facility and deaths may occur at home or at the homes of traditional birth attendants.

The death of a new mother usually reduces the survival chances of the baby. Overall, in Uganda, maternal mortality ratio, which is defined as the number of women who die during pregnancy and childbirth, per 100,000 live births, is 438, according to the 2011 Uganda Demographic and Health Survey (UDHS), up from 435 in 2006.

Postnatal deaths, Okong notes, are worst in rural areas where many women do not get any medical follow up after delivery. Nakabembe adds that nonetheless, every pregnant mother, even in the urban areas, is potentially at risk of dying during the postnatal period, if care is not taken.

"A mother who has delivered at a health facility should stay around the facility from up to at least 24 hours after, so they can be monitored for danger signs such as excessive bleeding that could lead to their death," says Ajeani.

After discharge from the health facility, a mother is expected to return for a checkup within seven days of delivery. Mothers who deliver outside a health facility are expected to seek postnatal care immediately after giving birth, within the fi rst six hours.

For all mothers, the next follow-up visit is recommended within the fi rst seven days and then within six weeks, when mothers bring their infants for immunisation.

However, on average, in rural areas, only 20% of new mothers return to the hospital for a follow up in the first seven days or so, and even fewer at six weeks.

Regarding regions, postnatal care from a doctor, nurse, or midwife is highest in Kampala, at 57%, but lowest in the southwest region (Kisoro, Kabale, Ntungamo, among others), at 18%.

Nonetheless, according to the UDHS report of 2011, the percentage of women who have had postnatal visits in the two days after birth has increased over the last fi ve years, from 26% in 2006 to 33% in 2011.

The percentage of mothers who did not receive any postnatal checkup declined from 74% in 2006 to 64 % in 2011, which is still high.

Nakabembe notes that bleeding is the leading cause of deaths from pregnancy- related complications at 25%. She blames the critical 24-hour window after birth.

"The 24-hour window is the most dangerous and requires attention of a trained health worker. With the shortage of human resource, if one midwife is in charge of 12 mothers or more, they are not in position to pay critical attention to that woman overly bleeding."

Furthermore, a mother could pass away as a result of infections, having had undue risk to infections during pregnancy or around delivery time. Ajeani explains that infections account for 13% of maternal deaths. She says the length of period a woman has been in labour also determines the level of her risk to infections.

"If a woman has stayed in labour for long, for example for a day, she is more likely to get infections which spill over to the postnatal period. The infections are caused by bacteria that live within her system, but during the process of childbirth, move upwards from their private parts up to the birth canal and into the bloodstream," Ajeani explains.

Further, malaria is a common killer of mothers after delivery. They are easy prey since their immunity system is low. Nakabembe says malaria is ommon in fi rst time mothers, second time mothers, adolescent mothers and HIV-positive mothers.

Furthermore is delivery from a non-health facility. Nakabembe notes that a big percentage of postnatal complications can be predicted at the health facility by the trained health worker because they build up during the pregnancy.

However, in cases of unskilled persons helping the mother deliver, the complications which could have been predicted build up unnoticed.

How to know something is not right

After giving birth, a mother can be in position to tell if something is amiss, judging by a number of signs.


Headache due to insufficient sleep is normal. However, persistent headache after enough sleep, fluids and food is cause for worry and should be checked out by medical personnel.


Nakabembe notes that the biggest killer of women during the postnatal period is bleeding; "It could kill even within the  rst two hours of delivery."

Furthermore, after birth, Okong notes that bleeding excessively with big clots or pieces of blood is abnormal.

"After delivery, clots should stop. Also, if the bleeding is more than her monthly period, six hours after delivery, the mother should contact the medical personnel," he advises. Okong also notes that losing blood makes the body's resistance to infection weak.


Excessive sweating is abnormal.


After delivery, if a woman feels like she might faint because of hunger, it is normal. However, if the condition persists, even after a cup of tea, then something is amiss.


A foul odour after birth, whether at C-section site or private parts is abnormal.


Swelling of the whole breast, when the breasts full up with milk, is normal, however, swelling at one particular spot with pain could point to an infection.


If a woman is not able to pass stool or urine for more than 24hours after birth, she should consult medical personnel.


Okong explains that the body cannot get rid of all the accumulated water during pregnancy immediately, hence some swelling after delivery. However, he warns that if the swelling goes on for more than seven days, alongside general

body weakness, it could point to high blood pressure.

Okong notes that the new mother should follow the instructions from the health worker, including looking out for abnormal signs they are warned about, or signs they find suspicious.

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