Maternal Health Care in Rural Uganda Leveraginig 71raditional and Modern Knowledge Svstems Q 23313 U _ gand 1 is onc of the least urban- address the high maternal mortalitv iCzed countries in Africa, hlere problk. l The prolect wvas initiated by U over X) pereellt ot the popula- the MoH, UNFPX and the Uganda Popu- tion of abont 0() million people lation ,Secretariat A multi-sectoral live in rural areas. IUganda's ccon(oY1V Igama, district task force implements depenids mainly on agriculturc andt the project, x-hiIe IJNFPA and the MoH w xomen contrihutc ((0-SO perecnt of do the overall molnitoring. the labour. \Onien s health, therctore, RESCUER has three components: has vital social and ccojnomic iniplica- comnunication, transport and quality tions for national development. Ilow- health services delivery ever, among I1 andall womVeIn of repro- ductive age. miaternal health issues are (CormmLnication a mntjor problem as demonstrated by- he type of information communica- the followving indicators: a high mater- tions technology (ICT) selected was nal mortalitv rate estimated at 506// dictated bv a number of factors, some 1 00,000; an equally higlh fertility ratc of -which include: unavailabilitv of elee- of about 6.9; only ab)out 3S percent trie pow-er supply in most rural areas, births are attended to 1ws trained lack of wvired telephones, the need for health w-orkers, the rest (02 percent) the ICT to be accessed twenty four are attended I)v Traditional Blirth At- hours a dav flexibility, the need to re- tendants' (TBAs) and relatives)' To ad- use the svstem in other parts of the dress these problems, the I'gandan countr'y and the economic No. 40 MIinistry of Health (MolI) idientified sustainabilityof the system,,-hen donor January 2002 several strategies and activities. Some of these activities inicluded expanding the referral system and improving the ~~~~ 1~~~~~K Note-s repo,rts periodicaXv on TBA network as wvell as training TBAs. Indigenous Knowledge (1K) initiatives The Rural Extenided Services and Care in Sub-Saharan Africa. It is published for Ultimate Emergenev Relief ( RES- by the Africa Region's Knowledge and - Learning Center as part of a-n evolving CUER) project wvas started as one of IK partnership between the World these initiatives. Bank, conimunities, NGOs, develop- rnent institutions and multilateral organizations. The views expressed in +_ Project description this article are those of the authors ._. __.... ____ and should not be attributed to the The RESCVEB, projeet was lautnclhed in World Bank Group or its partners in this initiative. A webpage on 1K is oAlarch 1996, on a pilot basis, in available at //wwwwordbank.org/afr/ Iganga D)istrict -Elastern Ulganda. It is ik/default,htn basicallv a refernrl project, designed to 2 support cnded. For these reasons, the VIF radio wvas the type Results and impact of ICT selected to be used in the proicct. This included fixed base stations at the healtlh units, mobile walkie-talkies with In July 1999, the author carried out a study to investigate the the TBAs, and vehicle radios in the referral hospital ambu- effect of the communication system on maternal health care, lance and the District Medical Officer's vehicle. The VHF ra- and its contribution to the referral project. She identificd dio communication is solar-powered, avoiding the common factors affecting the project, as well as the costs and electric power shortage or surge problems. sustainability of the project. D)ata wverc collected fromii both 'rhe RlESCUER project was designed to link the traditional secondary and primary sources. Secondary sources includlced rural community hcalth proxiders wvith the formal health de- progress reports and other project documents. Primary data livery systeni in a cost-effective way, such that when an ob- were collected qualitatively, through interviews and based stetric emergency occurs in a village, a TBA uses a wvalkie- on incidents narrated by health workers and TRAs. The study talkie to call for assistanec from the nearest health unit. A sample focused on Iganga district where the project had message on what to do is immediately relayed over the radio been running since March 1996. system. If thc TBA cannot manage the case, transport is dis- The increased number of deliverics under trained personi- patched from the health unit with a midwife to collect the nel and increased referrals to health units led to a redutction patient. If a case cannot be managed at the health centre of about 50 percent in the maternal mortality rate (MMRl) in level, the hospital is called and an ambulance is sent to trans- three years as indicated below: port the patient to the referral hospital. 'A survey carried out recently in three districts of Ar.n, Iganga and Tororo, which all had got their TBAs trained, Transpport showved that Iganga's MMR had reduced from 500/1 00.000 in Tricycles wverc provided to each of the participating pri- 1996 to 271/100,000; whereas rates for Tororo and Artia had mary-level referral health units which were genierally sub- reduced, but both were above 3501100,000. This indicated county lhcalth centres. An old ambulance at the rmain referral that commrlunication and transport facilities in Iganiga con- hospital was repaired and cquipped with radio communica- tributed to a reduction in MMR. Bcfore the project. thcre tiOn. Tr.\s xvere given hicycles to assist them with transport were problems of lack of communication facilities and trans- to the health units to charge the walkie-talkie battery and to port, which made referrals slow and sometimies led to thc collect monthly statistics. death of the mother or baby or both" (Administrator). Six health units and onc referral hospital participated in Quality heatlth ser-cices deliver:Y the project. Of these, four health units and thc referral hos- This included capacity building (e.g., training of TBAs, pital were studied and their midwives interviewed. In addi- midwives, technicians), reertlitment of at least two midwives tion, ten TBAs, three project administrators and four wvomen a,nd a clinical officer in all the participating health units, beneficiaries wvere interviewed. renovation of the maternity wards (including provision of To the TBAs, the w-alkie-talkie technology wvas a great deliverv beds, oxvgen, and I.\V tluid stands) and regular pro- source of empowerment as it improved their image and cred- v ision oft maternal emergency kits and other supplies. ibility, thus increasing compliance w'ith referral advice, and also augmented their income by increasing the nuimber of women they attended to. Those whol are not able to w\rite Implementation further pointed out that: "Since I can't w'rite, it was difficult for me to refer womiien; A district task force comprising of the Director of District I had to go with them to the health unit and explain. .. but llcalth Services (D)DIIS - formerly known as the District now-, the wvalkie-talkie saved me all that trouble, because I medical Officer), and officials from other sectors in the dis- just call the midwife and cxplain the condition of the personi trict w.as set up to oversee the planning, development and I am referring... I don't have to go escorting every person I implementation of the project. It is answerable to the high- refer" (TBA7). est tier of district leadership, namely, the LC5 chairperson. The communication technology brought thc rural mzidl- The task force is chaired bl the DDIlS, and comprises repre- wives closer to each other, thereby reducing isolation and sentativcs from the sectors rele-aint to health in the district, facilitating consultation. Panic situations and the uncertain management of complications were reduced considerably. 3 In the referral hospital, communication was reported to * The public audibility of the radio communication sy-stemll have made the work of midwives easier as they were able to renders it difficult to abuse or misuse. Intervie\eces re.- know in advance what to expect and prepare for emergen- ported that calls made are usually brief and to the point. cies. Women beneficiaries reported that this communication and that the nature of this ICT protects it from thucft. link gave them hope in critical situations. * A multi-tiered ICT approach can help bring the benefits of advanced technology to the rural population in Sub-Sa- haran Africa. Such an approach w ill cater to the dlifferenit Lessons learned capabilities in African situations. For examiple, telemedicine and other advanced technology facilitics The study highlighted a number of lessons. (e.g., the Internet) can be adopted at the district hospitl. Ciiomplernzarfty v,while simple technologies like radio can servTe lowver levels critical mRtass of complementary activities is neededto (rural health units, TBAs, etc.). The consultations made lb *A critical mass of complementarv activities is needed to lower units to the district hospital would ensure that the achieve maximum impact. For example, the study found rural population benefits indirectly from the technologv that although the communication component made a very significant contribution to the success of the RESCUER Institutional capacitv project, it could not stand on its own. For the project to The project built on existing infrastructure and loeal ca- achieve its objectives of improved referrals leading to in- pacity, including traditional knowledge systems. The creased deliveries by trained personnel, the other two TBAs' knowledge of local culture, values and their abilirt components (transportation and quality of services deliv- to connect traditional and modern pr-actices -vis critical to ery) had to play their complementary role. When transport the project. Indeed the project started at the grassroots broke down, however, it was reported that the presence of vith the traditional knoxledge held by the TBAs, and mv a midNvife and the communication svstem played a big role proved it by conducting refresher courses and eq nipping in saving lives: the TBAs called to consult health units, these also called to consult colleagues and seniors. How- T, asport an regul suples. ever, *vhere the emergenev necessitated a referral, the IT rnpr n eua upis ever xvhere the emergency necessitated a referral, the Leveraging traditional and modern knowledge systems can need for transport became very crucial. increase impact. For example, the RESCUEIR project Technology brought together traditional and modern healtlh practitio- Technology ~~~~~~~~~~ners and inculcated mutual understanding and trust thlat * The impact of ICTs is enhanced if the technology is appro- has and mater heal care. priate to the local conditions. As indicated, the ICT choice was made after careful considerations of the local problems in rural Uganda. * The use of solar power by the radio communication system 1 A Traditional Birth Attendant (TBA) is a person froim thc eoiononnitv could also benefit rural health units, which have no elec- with no formal training, hut who has knsowlcdgc of indigcnous prine- tricity. In particular, the studv recommended that the solar tices which has becn aeqtiired through apprcntieeship and being part tricity. In particular, the studyrecommended that the solar of a local community's eulture and value system. Sh'c,1hC attendsl to poxver should be extended to provide light in the mater- women in childbirth, advises on and treats matters of family hcalth nity wards / labour suites in the first-level referral units. (udapted irom: National T other traditional nlAedteines atnd plratices. * The simple design of the radio communication system fa- Uganda. MoH / Maternal alnd Child Health and Family Planninig- dIiNi- cilitated its use according to all the people interviewed. sion. Kampala.) 2 Source: UNDP (1998). Uganda Human Development report. 3 Iganga distict had a population of 7(6,476 of whom 52 percenit werc females. This was before Mayuge was split from Igarngn in 2()(1. Source: Iganga District Planning departmernt. '.t - S 4