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When having a baby is a life-or-death issue

Uganda maternal-health story Hadja Nansubuga, 29 years old. She lost her baby in childbirth (and had to have her uterus removed) because she was turned away from an operating theatre at night, even though the hospital staff said she needed surgery, and the operation was delayed for 14 hours, by which time her baby was dead and her uterus had to be removed. Both photos were taken at Mulago Hospital, the biggest hospital in Uganda, located in Kampala.

Edward Echwalu/The Globe and Mail

She had been in labour all day, and her baby's head was halfway out when the poorly equipped clinic decided it could not help her. It sent her to Uganda's biggest hospital, where nurses rushed to put her on a gurney and wheel her to the operating theatre.

But at the door of the operating theatre, she was turned away. "We're already closed," the staff said. "Our schedule is done."

The woman, Hadja Nansubuga, spent the night in agony. The operation was finally performed the next morning, 14 hours later. By then, her baby was dead, and her uterus had to be removed.

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At least the mother survived. In several infamous cases recently, Ugandan women have died when they were denied treatment at hospitals – sometimes because they were unable to pay bribes to the staff, or because the staff claimed to be overworked. One woman, an elected politician named Jennifer Anguko, bled to death in a major public hospital when nobody examined her for 12 hours.

Perhaps the biggest scandal of African health care is the inequity of it. The risk of dying in childbirth is more than 300 times greater for African women than for Canadian women. For every 10,000 women in Canada, only one will die in pregnancy or childbirth. Among the same number of African women, 355 will die from entirely preventable causes.

In Uganda, for example, only 42 per cent of women deliver their babies under professional supervision in a clinic or hospital. Nearly 6,000 women in Uganda die in childbirth every year, and 70 per cent of those deaths could be prevented by proper health care. Meanwhile, wealthy and politically connected Ugandans routinely fly out of the country for treatment in expensive private hospitals abroad.

While the rich can fly to another country for abortions, ordinary Ugandan women have little access to basic contraceptives. Only 24 per cent of married women use family planning, and 58 per cent have never used a modern contraceptive. As a result, Uganda has one of the highest rates of population growth in the world, with an average of 6.7 children per woman.

Technically, health care is free in Uganda, yet many pregnant women who seek admission to hospital are ordered to buy the medical supplies that the hospital will need to treat them – everything from surgical gloves and delivery mats to razor blades and cotton wool. In other cases, doctors or nurses demand bribes from the patients. Faced with those costs, many women give up and go home. "When they're told to buy those supplies, they just don't come back," says Denis Kibira, an activist at the Coalition for Health Promotion and Social Development in Uganda.

More than a year after the Muskoka summit at which the G8 leaders announced a $5-billion plan for maternal and child health, most African countries are suffering the same crisis of death and injury that they've always seen.

Maternal health seemed to be an obsession for global leaders last year. It was the focus of major summits by the G8, the African Union and the United Nations, and it was announced as one of the priorities for the U.S. administration's $63-billion global health initiative. "It is no exaggeration to call 2010 the year of maternal and child health," the University of Washington said in a report on health financing.

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The reasons for this concern are obvious: Hundreds of thousands of women are dying in childbirth worldwide every year, and the number has declined by barely 2 per cent annually since 1990. About 80 per cent of the world's maternal deaths are occurring in just 21 countries, of which 15 are in sub-Saharan Africa.

Canada's minister of international co-operation, Bev Oda, boasted this month that the G8 maternal health plan has brought "great progress" since it was announced in June, 2010. Yet in countries like Uganda, there is little progress that anyone can see. Analysts and even government officials acknowledge that the maternal health system is still plagued by enormous problems: chronic shortages of health staff and medical supplies, huge pressures from fast-growing populations, corruption, neglect and overcrowding.

"Pregnant women have always been neglected," says Asuman Lukwago, the top official in Uganda's health department. "We wait until the last minute, and then we leave them in the hands of God."

When he is informed about Ms. Nansubuga and her delayed surgery, he says the Ugandan police should investigate the case to find out if she was a victim of criminal negligence. But her case is far from unusual, he admitted. As a former obstetrician, he knows the horrors of Africa's impoverished health system and how it kills and injures women such as Ms. Nansubuga every day.

"In Africa, this story is reproduced in every country," he said in an interview. "We lose people who are not sick. The majority of the women who die are not sick."

After her baby died and her uterus was removed, Ms. Nansubuga's ordeal was far from over. Because of her internal injuries, she needed surgery for fistula, a painful condition that causes chronic incontinence and often leads to its sufferers being ostracized. She had to wait months for the operation – including three weeks in an overcrowded hospital room. And then, while still weak and recovering from her surgery, she was evicted from her hospital bed and ordered onto a mattress on the floor, beneath a bed, because of the shortage of space.

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Asked about her long nightmare at the hospital, she only smiles and shrugs fatalistically. "It would be nice if the doctors could help us faster – maybe I wouldn't have lost my baby," she says. "I feel bad about it, but there's nothing we can do about it. We just have to accept it."

Dr. Lukwago, the senior health official, rattles off a long list of reforms and programs that the government is introducing in response to the maternal health crisis. Dozens of hospitals are being built or rehabilitated, hundreds of midwives are being trained, scores of ambulances are being acquired and the government will distribute 1.2 million "mama kits" containing the basic supplies that pregnant women need when they enter hospital.

The government is also trying hard-line methods: It has threatened to lay criminal charges against doctors and nurses in high-profile cases where women have died in hospital. Critics say it's a cynical attempt to distract the public from the failings of the health system itself. But the Health Ministry is insisting that criminal prosecutions are justified.

"We saw that the doctor who attended Michael Jackson was charged," Dr. Lukwago said. "Charging them is not a bad idea. We've allowed our people to expose these ills."

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