From drug shortages to insufficient staff to having to pay for 'free' treatment, pregnant women face countless challenges. And that's presuming they can even reach a health centre.
Kabale - From her small garden in the village of Mirindi, located in the Kabale District of south-western Uganda, Precious Tumuhaise, a 27-year-old woman and mother of four, rests her weight against her efuka, a traditional hand-hoe, and glances over her shoulder at her one-year old daughter tied to her back with colourful cloth.
"Being pregnant cannot stop you," Precious explains, as she pauses from preparing the ground to plant sweet potatoes, the staple food crop that feeds her family year round.
"You dig, you deliver at home, and days later you go back to the garden with the baby on your back," she says with a laugh. But Precious knows all too well that giving birth in her village, a two-hour walk from the Kabale Regional Hospital, is no laughing matter.
For Precious, and many other pregnant women living in south-western Uganda, giving birth to a child isn't only a matter of life - but can be a matter of death.
Uganda has one of the highest maternal mortality rates in the world, and reports from the World Health Organisation (WHO) estimate that 435 women per 100,000 live births in Uganda die from preventable pregnancy- and childbirth-related complications.
Although the Ugandan government has succeeded in reducing the maternal mortality rate by 5.1% over the last ten years, it will nevertheless fail meet the target set by the Millennium Development Goals of reducing maternal mortality by three quarters from 1990. And furthermore, with fertility rates increasing by 3.4% per year, Uganda's maternal health crisis could deepen if more action is not taken.
Out of reach
One of the main challenges with Uganda's public healthcare system is that it currently struggles to reach rural communities which make up over 80% of the population. In south-western Uganda, for example, many women living in villages may be able to access basic antenatal healthcare at a Health Centre II, but have to travel far further to reach a Health Centre III to give birth.
Health Centre IIIs, however, are modestly equipped with four to ten beds, and staffed only by nurses and midwives. In the case of complicated births therefore, women must travel even longer distances to urban centres where they can find a Health Centre IV or the Regional Hospital, where there may be some operating capacity for Caesarean sections.
Edisa*, a registered nurse who currently works in Kabale, completed her qualification serving at a rural Health Center III in the Kabale District. She recalls the enormous task of finding emergency transportation to transfer women in labour to a Health Centre IV or Regional Hospital.
"There was no ambulance as it was far away in the village," she says. "If a mother got a complication, we would all suffer.
"It's an emergency if the mother [has] delivered, and the placenta remains, and you're looking [for a way] to take her to the main hospital."
The main mode of transportation from rural to urban centres in south-western Uganda is by bicycle, motorcycle, or by walking. Hiring a car is a huge expense that most subsistence-farming households cannot afford so in the case of maternal-related emergencies, many village groups use ngozi stretchers made from papyrus reeds to carry women to health centres. But many only arrive after it is too late.
Given these challenges and uncertainties, many women prefer not to take the risk of trying to access public healthcare and instead give birth at home, attended to by family members or traditional birth attendants. It is estimated that approximately 70% of women in the Kabale District give birth outside medical healthcare centres and without the support of trained professionals. These women face the highest risks of emergency complications and dying in childbirth.
Overwhelmed and understaffed
However, even for the lucky ones who are able to reach a Health Centre IV or the Regional Hospital, survival is far from guaranteed. The Kabale Regional Hospital is often overwhelmed, and hospital beds, supplies, and medical staff are in short supply.
"Visiting the hospital at seven or eight o'clock at night," says Rosemary*, a nurse who has worked at the Kabale Hospital for over 15 years, "you see the pregnant women [waiting] outside the labour ward."
Many women, particularly those from distant villages, arrive at the hospital only to be asked to return when they begin 'true labour'. Most women cannot afford to travel back to their villages and then return again so they seek alternative measures.
"In the night, women lay down their mattresses outside [the hospital] and wait for labour to start," says Rosemary.
When labouring women are eventually admitted into the delivery ward, they face other risks, including the lack of quality care due to few nurses and midwives on staff, and the inconsistent availability of supplies including gloves, syringes, and anaesthesia.
"People are exhausted and they are not motivated," says Rosemary, describing the reality of what happens when too few medical professionals have to attend to large numbers of women in labour.
Furthermore, despite the fact that the Kabale Regional Hospital is government-run and services are supposed to be free, it is widely known that in order to receive effective care and support, patients must pay what Rosemary describes as "a secret fee" to doctors.
According to nurses working inside the hospital, doctors charge around $39 to perform a Caesarean section. Meanwhile, Edisa explains that drugs have to be bought too.
"If you're not rich enough to get some drugs for the pain killers, you would not get the operation - or you'd get it but you'd die in pain," she explains. If there is no pain medication available in the hospital, family members are often forced to go to private pharmacies to buy the necessary drugs.
For the average woman in Kabale earning less than $2 a day, these costs mean giving birth in a hospital is not an option.
"Poverty is the problem," comments Edisa.
Eating public funds
Both the issue of staff asking for payment and the problem of supply shortages can be attributed in part to government underfunding. Some believe doctors and nurses are paid too little and inconsistently, and staff are known to accept bribes from patients or steal medicine to sell to private clinics.
"Doctors and nurses are earning less in government hospitals - they also have to live," says Edisa. "[Health workers] are also looking for survival."
Corruption higher up in Uganda is also a major barrier to improving maternal healthcare. Anti-corruption organisations in Uganda, including the Anti-Corruption Coalition of Uganda, argue that government funds are often mishandled and 'eaten' by public officials instead of being allocated to hospitals and health centres.
Uganda also has one of the worst reputations in the East Africa for corruption of public funds and bribery to access essential services. The 2013 East African Bribery Index claimed that Uganda has the highest prevalence rate of bribery in East Africa at 26.8%, with Burundi following in second at 18.6%.
"If corruption was not so high, I have a feeling that by the time I was born in the village, health facilities would've been there," remarks Robert Byamugisha, President of Kick Corruption Out of Kigezi (KICK), an anti-corruption community organisation operating in south-western Uganda. "Up to today, we still have mothers giving birth at home because corrupt officials take public funds."
An uncertain future
Under this current climate of under-spending and endemic corruption that extends from low-level bribes all the way up to high-level government, pregnant women - particularly those living in rural areas - will continue to face major barriers in trying to access affordable, quality maternal health services unless the government takes more concerted action. Uganda has one of the highest fertility rates in the world and it is crucial that more funding and targeted policies are instigated by the government in order to help ensure the safety and wellbeing of the country's many mothers and children.
In south-west Uganda, a number of NGOs have taken it upon themselves to plug the gaps in public healthcare, and some are doing valuable work in helping improve access and services from the ground-up. But large-scale, lasting and tangible change for all Uganda's pregnant women in all its rural areas will require comprehensive state intervention, something Precious Tumuhaise knows is likely to be slow. In the meantime, life for Tumuhaise continues amidst uncertainty, digging in her garden until the ninth month of pregnancy.
"Being a woman here is difficult," she says. "Imagine if you go [to the garden] and it rains. You have no alternative. It's not easy, but there's no alternative."
*Names have been changed to provide anonymity.
Trina Moyles is a Canadian freelance writer and photographer currently living and working in south-western Uganda. Follow her on Facebook and Twitter at @The_Bean_Tree.