Thursday, August 9, 2012

A Holistic Approach to Family Planning

A Service Provider shows a man how vasectomy is done as a male family planning method at Marie Stopes Centre, Mbale district

By Senfuka Samuel

Uganda’s population growth rate is one of the highest in the world at 3.2% and the biggest percentage of is the population is young people. In addition, Uganda’s women are very fertile with each producing an average of 6.2 children. According to the Uganda Demographic Health Survey (UDHS) 2011 preliminary findings, the maternal mortality rate is still unacceptably high at 354 from 435 per 100,000 live births.

The World Health Organization estimates that about 300,000 abortions are carried out every year in Uganda and abortion related complications are one of the leading causes of admissions to gynaecological wards in hospitals across the country. There is no doubt that most of unsafe abortions are because of unintended pregnancies and the failure to prevent those pregnancies through access to timely family planning services and information.

To reverse this trend, we must ensure universal access to family planning services and commodities to Ugandans, who have demanded for it. Uganda’s unmet need for family planning currently stands at 41% and the contraceptive prevalence rate (CPR) is below average at 30%. The CPR varies by residence, region and methods used. It stands at 46% and 27% in urban and rural areas respectively whereas 26% use modern methods and 4% still use traditional ones.

It is known that Family Planning is one of the key proven strategies to reduce maternal mortality and an opportunity to reduce unintended pregnancies, this is especially important in Uganda where abortion is illegal under the Constitution if not recommended by a medical officer for saving the life of a mother. During my independent visits and interactions with key players in family planning and maternal health in general including NGOs, Donor agencies and development partners, private healthcare providers, health professionals, media representatives, politicians and  maternal health champions, I found out the following key issues which limit uptake of the services. Addressing these barriers need a holistic approach.

  • More information -It was evident that the biggest barrier to family planning use rotates around accessibility to information and services. The approach of stocking and storing contraceptives at health facilities is not very attractive to would be users.  Family planning is not a disease that will force people to seek medical attention hence an urgent need to rethink about the approach and adopt some innovative ways such as social marketing, use of pharmacies, clinics, integrating it to the antenatal care among others. There growing views of adopting a community based approach for administering some methods which do not require high skills training. It was also noted that some rural based health facilities close early without being insensitive to women’s time poverty due to their gender roles. It should also be noted that nearly 95% of contraceptives are procured by donors and the little that government allocates it is not released at times making the supplies inadequate.
  • Tackle myths -Myths and perceptions about family planning impact negatively on the uptake of the services.  There so many negative views held by different people including some health workers on family planning methods. For instance there myths and perceptions that it causes infertility, abnormal fattening, weakening women’s sexual libido and energy to work on their farms among others. There is need to package appropriate and harmonized messages and information at all levels before it is disseminated to the target audience. It is also widely perceived that family planning is for only women-few people are aware about methods for males. There should be deliberate efforts to mobilize and work with community structures to raise awareness and ensure confidence among the targeted community members.
  • Increase choice - Method mix. In some instances there is limited choice available to the clients. It is important to ensure that all methods are available at access points because some are preferred against the others. It has been reported that contraceptive pills get expired at health centre IIs and IIIs where the procurement and supply of drugs and supplies is based on a push approach (supply driven).  
  • More health workers - Skills gap to deliver various methods and management of side effects is also a critical obstacle to family planning. Some methods like implants, intrauterine devices (IUDs)/coils and vasectomy require a well trained provider to give adequate information about the methods, likely side effects and carrying out the procedures and managing the side effects. Such skilled health workers are inadequate or lacking in some communities or health facilities.
  • Empower women - Gender and cultural biases have also proved to limit utilization of family planning services even where they are accessible. Still being a patriarchal society, women have to get consent of their spouses before making a decision to use family planning. Most of the times they face stiff resistance from their spouses and the consequences are always regrettable including a lot of pressure from the man’s family members. It’s strategically important to target and increase the male involvement in provision of family planning services and information.
  • Work with faith based groups - There strong faith based views which do not recommend or accept some family planning methods. It will be important to use some biblical views and approaches to engage faith based leaders for their buy in. For instance in the book of Genesis 1:28 it says that: God blessed them and said to them “Be fruitful and increase in number; fill the earth and SUBDUE it. Rule over the fish of the sea and the birds of the air and over every living creature that moves on the ground.”
  • Include young people - Youth friendly environment for family planning services lacks in most access points. This prevents the young adolescents who are most vulnerable to access information and family planning services.
Linking the above, it was a very important political statement from the Uganda head of state to attend the London Summit on Family Planning on 11th July 2012 which coincided with the World Population Day. From an advocate point of view there were some wins and opportunity for continuous engagement.    
  • The President made a commitment to increase the family planning budget to US $ 25 million for over the next five years translating into US $ 5m each financial year from the current US $ 3.3m. This will be a good tool for holding him and the government accountable but also to ensure that the funds are allocated in priority areas. Increasing domestic budget allocation for family planning supplies and commodities is a good pointer to sustainability.
  • The President has always been perceived to have negative attitude towards family planning by asserting that Uganda and Africa need a big population to propel economic growth through provision of market for goods and services. There is need to use this opportunity to nurture his interest and views on family planning and enlist him as strategic ally for family planning.
Simultaneously, the Prime Minister Hon. John Patrick Mbabazi as a Chief Guest at the official marking of World Population Day pledged to follow on an earlier government decision to waive taxes on the contraceptives. This is an opportunity for CSOs and other players to advocate for immediate issuance of an instrument by Government of Uganda stopping Uganda Revenue Authority from collecting the tax.

For efficient and effective delivery on the commitments there is a need to strengthen the technical and institutional functionality of the key players involved in the supplies distribution chain. This calls for strong Public Private Partnerships to close the gap where government does not have existence (public health facilities).

Wednesday, August 8, 2012

Functional health delivery system is the right answer, not legislation

Posted  Saturday, August 4  2012 at  01:00

I would like to respond to the story titled, ‘Kabale considers a by-law to force pregnant women into hospital’ in the Daily Monitor of July 27. The story said the by-law will compel pregnant mothers to deliver in a health facility and penalise those who deliver under the care of a traditional birth attendants.

Experience from around the world suggests that about 15 per cent of all pregnant women will develop obstetric complications and that not all these complications can be predicted. Delivery under the care of a skilled health care provider - midwife, doctor, or nurse with midwifery skills - is the safest method for saving the lives of mothers and their newborn.
Countries with the highest skilled attended deliveries such as Sweden and Malaysia are also the nations with the lowest maternal and newborn deaths. Every year, 350,000 women worldwide die during pregnancy, or during labour, almost 1,000 a day. Of these deaths, 99 per cent occur in developing countries such as Uganda.
Every year, up to 2 million newborns die within the first 24 hours of life. Uganda looses 45,000 newborns annually; many more suffer birth trauma that impairs their development and future productivity.
In recognition of the critical role of skilled care in reducing maternal and newborn mortality and morbidity; Uganda has committed itself to increasing skilled attended deliveries from 53 per cent to 90 per cent by 2015.
I would like to commend the local leadership in Kabale District for recognising the importance of skilled healthcare and their intentions to encourage mothers to deliver in a health facility instead of under a traditional birth attendant. However, enforcing skilled attended delivery through a by-law is not the answer.

A survey conducted by White Ribbon Alliance for Safe Motherhood in six districts in Uganda (Assessment of Maternal Health Services in Six Districts in Uganda, 2010) showed that health facilities in Kabale had only 2 per cent of the required midwives and only one doctor. None of the health centre IVs could provide blood transfusion services or caesarian sections. Many facilities lacked essential supplies, transport for referral of obstetric emergencies at HC4 and 3.
I would like to request the decision makers in Kabale District to examine the current healthcare delivery system and make it attractive to the clients by providing an attractive healthcare delivery package to women. That means adequate supplies, equipment, provision of emergency obstetric at HC 3 and 4, adequate midwives. Conduct community awareness raising about the benefits of skilled attended births in addition to addressing social-cultural factors that limit a woman’s ability to access her maternity care services.
The government should play its role of ensuring adequate financial and human resources towards meeting its national and international commitments on Millennium Development Goal 5 and support local governments to deliver quality services to its citizens. Uganda committed itself to giving the health sector 15 per cent of its annual budget.

Robina Biteyi,
National Coordinator
WRA Uganda 

Kabale considers law to force pregnant women into hospitals

A nurse attends to a mother and her baby at Kabale Hospital yesterday. Some women shun health centres in favour of TBAs. Photo by Robert Muhereza 

By Robert Muhereza   (email the author)

Posted  Friday, July 27  2012 at  01:00
Kabale District is working on a by-law to compel pregnant women to give birth at health facilities and penalise those who deliver aided by traditional birth attendants (TBAs).

District speaker Pastoli Twinomuhangi said on Wednesday that he is ready to present the draft by-law for the council’s consideration.
This follows a recent survey in Rukiga, one of the four counties in Kabale District, where it was found that nearly one in every two expectant women that TBAs help to give birth, die.
“An ordinance is already being drafted to compel mothers in labour to deliver at the established government health centers in order to save their lives and that of the babies,” Mr Twinomuhangi said.
However, according to District Health Officer Patrick Tusiime, the number of women delivered by TBAs has reduced due to intensified mobilisation through media and community meetings.
Half of pregnant women in the district now deliver at health facilities, up from 12 per cent five years ago, the doctor said.
However, Ms Allen Busingye, a businesswoman in Kabale town, said some of them prefer the services of TBAs because they offer “motherly care unlike in the health centres where we are attended to by young and abusive nurses.

“The young nurses are rude to the mothers in labour pains,” she said.
The government outlawed the traditional birth attendants, but they continue to thrive especially in rural areas where public health services are either lacking or unaffordable.
The District Deputy Resident District Commissioner, Mr Nickson Kabuye, said his office is investigating reports that some health workers in the district on government payroll extort money from women seeking antenatal care, forcing them to turn to TBAs. The culprits, he said, will soon be exposed.
TBA head responds
The head of TBAs in the district, Mr Charity Mugisha, said an accusation pinning them on causing maternal deaths is baseless because reports of women dying in labour at hospitals are a common place hence not of their (TBAs) own making.
“Traditional Birth Attendants are complementing the government efforts in assisting pregnant mothers to have safe deliveries,” he said.
District vice chairperson Mary Bebwajuba noted that a shortage of qualified staff coupled with lack of ambulances are the reasons behind the delay of referrals, leading to many deaths of expectant women in the area due to delayed birth.