The dilemma of Uganda's pregnant women and male midwives
The women of Agung Village, Todora Parish, Anaka Sub-County in Nwoya District in Uganda must think twice or plan ahead of schedule when they will go into labour, because they are not at liberty to entertain labour pains at any time.
With only one health worker within a radius of 30km, who is both nurse and midwife, and has other important duties (all of them legitimate) to attend to, the choice of when to go into labour is completely out of the women’s hands. And for good measure, the nurse-cum-midwife is a man.
Mr Wildred Adot carries the weight and hopes of an entire village on his shoulders. In essence, he is the health centre and when he is away, the entire Todora Health Centre II is effectively “under lock”.
As an Enrolled Comprehensive Nurse, Mr Adot is trained and equipped to administer antenatal care, family planning service, delivery, post-natal care and general treatment. But he too gets ill and fails to report for duty from time to time.
When that happens, the entire hinterland must wait for him to get better, or look for alternatives a long distance away.
Not a good option in a rural area where roads are bad and travel does not come cheap, especially when you have a pregnant woman on your hands who must get to the labour suite very quickly.
The fact that he is a man does complicate things quite a bit, because many women have a problem with this. However, the ladies have no choice as he is a ‘monopoly’ of sorts, they have nowhere else to go.
Today is a day for antenatal visit at the health centre. Martha, a middle-aged mother is awaiting her turn, but she is clearly apprehensive and shares her concern.
“I am a grown up woman, how can I be touched by a young man like this one? How will I come here to deliver when I have to open my legs before a man who is not my husband?” she asks.
Then, a look of resignation crosses her face.
“There are things that can only be told to a woman, not a man. But I have no choice, as the other place I could have gone to is far off and I do not have the money or energy to go there,” she concludes.
At that moment, she is called in to the examination room. Hand on hips, look of despair on her face, she gets up and reluctantly walks onto the bed, and lies down with a sigh.
Options are limited
Of the women waiting, three or four others express similar reservations, but still stay in the line, knowing their options are limited.
Male midwives appear to be a sensitive issue in Uganda's Greater North and no matter how efficient they may be, it does seem to be making the lives of many pregnant women quite difficult.
For many of them, it is the ultimate humiliation. Another reason why some continue to prefer Traditional Birth Attendants (TBAs), never mind that they were disbanded by government or that it is a risky venture.
Ms Diana Nassozi, a Community Resource Person (CRP) in Oyam District, narrates that at the Health Centre II in Adyegi Parish, apart from having no maternity ward, which is a big problem in itself, it has a male midwife whom some women fear to approach.
In an area where certain traditions are firmly entrenched, many women will still think twice about being naked before a man other than their husband.
“Some women fear him, so they have to go to Aber Missionary Hospital, which is far away and moreover where they also have to pay,” says Ms Nassozi.
“The HC II next to them is free of charge, but they’d rather pay at the missionary hospital than undress before a male midwife.”
Ms Grace Aloka, a CRP in Aber, Oyam District, says some women like the male midwives for one good reason: “They handle women with a lot of love and care. They do not abuse the mothers and they are very gentle.”
But this seems to be the exception rather than the rule. The scenario calls for a gender-sensitive approach to health staffing, especially in rural areas where health workers are few and women often have no choice.
In an attempt to stem the crisis occasioned by shortage of health workers, some NGOs have invested in some of the communities.
The Health Rights Action Group (HAG) and the Action Group for Health, Human Rights and HIV/Aids (AGHA) have began working with the District Local Governments, health centres and local communities in four districts of Greater North – Amuru, Nwoya, Oyam and Soroti.
Heavy with child
One of the innovations has involved the use of CRPs, who are selected from Village Health Teams (VHTs) and given special training to help in outreaches to pregnant women, at least once or twice every month.
The VHTs are established by national policy and do exist – at least in theory – in every village. It is out of these that HAG and AGHA have trained CRPs and facilitated them to reach out to certain health categories, especially pregnant women.
In the village of Agung, HAG and AGHA pay for a midwife (female) from Anaka Hospital–the biggest hospital for miles around–to attend these outreaches and talk to the pregnant women and offer antenatal advice after thorough checks.
This not only alleviates the burden that Mr Adot has to shoulder everyday, it also helps those who are shy to attend antenatal care administered by a man to get reprieve.
The monthly outreaches take place in various locations in the district; like Alero, Koch Goma, Purongo and Anaka - but not everywhere, owing to limited funds available to the NGOs. HAG and AGHA facilitate qualified midwives to attend to women in or near their homes.
“The outreach programmes also prevent women who are already heavy with child from having to endure long journeys to health centres,” says Claire Mugisha, a Programme Officer with AGHA.
This is a case of “if the people cannot come to the clinic, the clinic must go to the people” – and it is working good so far. The CRPs ensure a good attendance at the outreaches.
The community is enthusiastic because it fills an existing gap and reduces antenatal risks for women who wouldn’t have made it to the health centre.
State minister for Health (General Duties), Ms Sarah Kataike, says there was no national policy regarding the deployment of male midwives.
“I didn’t know that it has its own issues,” she admits. “That is a profession…it is the qualification and registration that counts. Anybody can be a midwife…it doesn’t matter whether it is a man or woman. Unless the midwife is sexually abusing the women, there should be no problem.”
Well, as it turns out, there is a problem; at least the village women think so.