Saturday, July 23, 2016

Uganda rural based doctors play God

By Esther Nakkazi

Only two years into medical practise, the youthful doctor Gamukama Tuhaise is the in-charge of Rwekubo health centre IV, where a new born baby dies almost every day. With limited resources and a small workforce tough choices make him play God.

On the eve of Uganda's 2016 World Population day celebrations, commemorated world over on the 11th of July, I travelled to Isingiro the land of highland bananas (Matooke) and the venue for Uganda’s big event celebrated and attended by President Museveni and non profits like UNFPA-Uganda.

As the road snaked into the hilly, ridged terrain of Isingiro, you would think all the Matooke eaten in east Africa is grown here as almost the entire vegetation was of Matooke and the many lorries on the road from this Uganda-Tanzania border district were all loaded with them with just a few carrying milk cans.

At least 20 lorries of Matooke leave Isingiro for Kampala everyday and 700,000 litres of milk are produced per month. For the thousands of guests who attended the World Population day  celebrations in Isingiro, refreshments served to us were between a choice of water or milk. I am certain if lunch was served too, it would be a mountain of Matooke on our plates.

The 2016 theme, ‘investing in teenage girls’ was timely and relevant to especially Uganda, which tops the East African region in teenage pregnancy. Everyday over 20, 000 girls under age 18 give birth in developing countries according to UNFPA.

In Uganda, 140 per 1,000 teenage girls get pregnant annually compared to 41, 101 and 128 in Rwanda, Kenya and Tanzania respectively according to UNFPA.

Stillbirths and death in the first week of life are 50 percent higher among babies born to mothers younger than 20 years than among babies born to mothers 20–29 years old, says the WHO.

Furthermore, deaths during the first month of life are 50–100 percent more frequent if the mother is an adolescent versus older, and the younger the mother, the higher the risk.

The rates of preterm birth, low birth weight and asphyxia are higher among the children of adolescents, all of which increase the chance of death and of future health problems for the baby.

The statistics for Isingironian pregnant teens are not available but when I interviewed some of them most were impregnated by fellow teen boys and I am not sure I got an explanation to pin this to. Later when I visited Rwekubo health centre IV and also talked to some teen mothers and their youthful mothers ( now grandmothers) my heart sunk.
A teenage mother with her son Austin in Isingiro district

Seventeen year old Rosemary Kukiriza lay on the bed staring blankly at the ceiling her face showing no particular emotion, not exactly sad, eyes darting from her mother who was standing by her bedside to other teen mothers like her holding their new borns.

She was only 3 hours out of theatre and had lost her first born baby, another statistic at Rwekubo health centre IV where at least a new born dies everyday.

Isingiro has about half a million people. Its located in western Uganda, on the Uganda-Tanzania border, a newly established young district with no referral hospital with Rwekubo health centre IV as one of two biggest and busiest health providers.

Kukiriza’s 36 year old mother was making all the noise, seemingly restless and talking in undertones with an elderly woman attending to a patient on the left bed next to Kukiriza’s. It was her first grandchild afterall who had passed on and she told me she had given birth to Kukiriza at 14 years so why did fate have to follow her daughter and not any other?

She narrated ‘the story’ from when they had arrived at Rwekubo health centre in the night at about 4pm to when they got her daughter in theatre at 10am in the morning, occasionally opening her eyes wide or clasping her hands or slapping one finger into the palm of her left hand to emphasise a point - the whole system was full of delays- she said.

“Why didn’t they take Kukiriza to be operated upon as soon as we arrived? That nurse really delayed. They only took her to the theatre this morning at about 10 o’clock,” she said with near anger or regret in her voice.

Doctor Gamukama dressed in a faded, dark green, cotton health workers uniform and half listening to our conversation explained the circumstances under which Kukiriza had been admitted.

She was in distress, pain and before taking her to theatre certain practical things had to be done; blood type established, vitals taken, the theatre cleaned and prepared, fuel for the generator bought and the lone anaesthetist called in.

The health centre has one oxygen point; no running water - every week a water truck delivers water; it has a few health workers - this happens everywhere as few health workers want to be based in rural areas like Rwekubo health centre IV,  it is powered by a generator-sometimes this jams; and Rwekubo almost serves an entire district of half a million people.

“We have only one anaesthetist will he stay here day and night without doing anything else? Preparation of theatre takes about 40 minutes. The generator has to be fuelled and the theatre powered,” if an operation is to happen said Gamukama.

Kukiriza’s baby was born alive but died a few hours afterwards. It was tired. Efforts to resuscitate it did not help something partly blamed on herbs. “Many women take herbs which thicken the fluids so it becomes difficult when you try to resuscitate the baby,” said Gamukama. Asked which particular herb was responsible for this outcome he said he did not know.

His advise is for women to stop taking herbs when pregnant although in Africa, herbal knowledge for pregnancy is passed on across generations and herbs are preferred to antenatal visits. So outlawed traditional birth attendants still remain women’s preferred choice when giving birth and for nursing pregnancy sickness.

“If you resuscitate a baby for an hour and there is no response you take a decision,” said Gamukama. The oxygen has to be turned off. It is only rational.  It could also be playing God?

He explains; if only there was another doctor-led team in the theatre to handle the baby it would be easier but he has to handle both mother and baby concurrently. Usually, the preference is to save the mother.

Understanding doctor Gamukama’s perspective of the theme in terms of teen mums and saving new borns was real important afterall he is the star of the Isingironian film.

Of the 70 maternal related operations that take place in a month at Rwekubo health centre IV, most of them done by him, 20 percent are of teenage mothers aged 16-19 years and their babies often die. Looking at the centre’s records from 1st July almost a baby had died a day most of them born to teen mums.

“It does not affect them much. After one year they will be back here. They are usually pregnant within the next three months after losing a baby,” said Gamukama with certainty.

Some want to fill the void immediately while others want to stop the scorn and stigma by village communities ‘as the daughter of so and so who has failed to bear a child for our son’.

But there is also prestige in switching names to ‘mama boy’ or whatever name the first born child bears and merely just to prove themselves.

Seventeen year old Ainembabazi Brenda is also camped at the Rwekubo health centre for the last one month and 2 weeks. She has no complications yet in her third trimester of the pregnancy but being a teen and at the advise of the health worker she has stayed.

“When the teen mothers stay here it reduces the risk of losing the baby and it keeps us health workers updated on every step,” said Gamukama. However, its expensive on both the health centre which has limited space and resources and on the family that has to ferry daily meals to the otherwise not sick pregnant woman. Not forgetting the overall confounding factor- poverty.

But its worth it. For instance, in doctor Gamukama’s opinion if Kukiriza had come in at least 24 hours before the onset of her symptoms her baby would be alive. For all those reasons, ‘you cannot stop babies from dying,’ he says. As well, poverty cannot let teen pregnancies stop, he concludes.

As we drive out of Rwekubo health centre's gates, Kukiriza's mother is holding a box wrapped in Africa fabric cloth bearing the body of her grandchild. She waves back to us limply and we wish her well.

Hopefully, her next grandchild born born by teenage Kukiriza will live to see another day and drink of Isingiro's thousands of litres of milk and eat of its mountains of matooke.

This trip was facilitated by UNFPA-Uganda 

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