Covid-19 Impact Series: Maternal Health in Uganda

“It’s like robbing from Peter to pay Paul”

Since the Covid-19 outbreak was declared a global pandemic by WHO on the 11th of March, all eyes have been on the disease’s impact on different aspects of our lives. While numbers of new Covid-19 cases and deaths from all over the world dominate our daily news, many other health concerns are put to the side which continue to persist and even exacerbate due to the pandemic outbreak. This is the first post of our new blog series that will address indirect health impacts of Covid-19 in low and lower-middle income countries. We are starting off with maternal health in Uganda, right where SOGH’s Mama & Family project is based.  Read what Professor Peter Waiswa, a member of the SOGH advisory board, told us about maternal health problems during the lockdown in Uganda and why it is so important to maintain care for mothers and their newborns during the pandemic:

Professor Peter Waiswa

SOGH: Professor Peter, thank you for the opportunity to discuss with us about the impacts of Covid-19 on maternal mortality in Uganda. Would you like to start with introducing yourself to our readers? Tell us a little bit about yourself and what you do.

Peter Waisa: My name is Peter Waiswa and I am a professor at Makerere University in Uganda and a visiting researcher at Karolinska Insitutet for over [some] decades now. I did my PhD and my postdoc at Karolinska. I have been teaching and coordinating the Maternal and Child health course in the Global Health program at Karolinska for about a decade now. I teach, I research, I do some charity work, I engage with policy, I write, and then also, I am a dad of three.


SOGH: And your specialization is within maternal health?

PW: My specialization is actually health policy planning and management, but I did my PhD on mothers and newborns in the context of health systems. I do most of my health systems work on maternal and child health and many people think I am a specialist in maternal health.


SOGH: Could you just briefly describe what the current situation in Uganda is like regarding the ongoing Covid-19 pandemic?

PW: It’s been about two months now since we got the first Covid-19 case and the government claims we have had 79 cases confirmed so far in Uganda. Most of them were related to travels among people that were coming back to Uganda. We have actually barely had community cases, which is great and for a week now, there have not been any new local cases.  Since we closed the airport, most of the new cases occurred in truck drivers that were crossing the borders coming from either Tanzania or Kenya.  We have been lucky we’ve not had any deaths related to Covid-19.  The main strategy has been trying to find cases and their contacts and either put them in hospitals or quarantine them at home. Whether you have symptoms or not, they would put you in the hospital and start supportive treatment. That seemed to have been helpful. The country has been under a phased lockdown that started by closing schools and later they closed the airport, public transport and private transport and we are now under what they call a total lockdown. You are allowed to move outside and walk for whatever number of kilometers you want. The markets for food are open and most industries, if they can find a way for people to do their work there. And then there is a curfew from seven in the evening to seven in the morning but I think in a week’s time they will give new instructions and most likely the lockdown will be ended.


SOGH: Do you expect Uganda to be hit harder by the pandemic in the coming months or does the spread of the novel coronavirus in the country seem to be under control for now?

PW: I am very hopeful, and I don’t think we will be hit hard directly through Covid-19. But indirectly – yes! The consequences of the control measures and of course the global nature of the pandemic are going to hit us hard. The lockdown has been interesting: We don’t have any deaths from Covid-19, but several deaths from other conditions like maternal health. There has also been fewer deaths from road accidents and definitely improvements in terms of pollution.


SOGH: Just as we have seen in previous humanitarian crises like Ebola outbreaks, do you expect an increase in maternal mortality in Uganda over the subsequent weeks and months, either directly or indirectly impacted by coronavirus?

PW: Even in places we do some of our work, we’ve had some maternal deaths, neonatal deaths, stillbirth, rupture of the uterus, reduced antenatal care attendance, reduced deliveries, more emergency caesarian sections and limited access to some commodities like family planning and condom use. We think, overall, in terms of the impact on maternal health, it is going to be quite significant. When Covid-19 infections came, it caused a sort of panic and fear in the population, but also among the health workers. One of the most significant things was, during the lockdown, access to public transport became a big problem. There were control measures that were put in place that you needed permission to go to the hospital. Imagine you are in a village 50km from the person having to give permission, how do you contact this person? How do you get a judgment if they don’t allow transportation? They set restrictions to move and permission to have a vehicle and motorcycles was needed. It meant that women didn’t have access to care facilities, but also the health workers did not get to their workplaces. Even the supply of things like blood which is used in emergencies also became problematic. Those were just some of the things. Of course, the national attention went to Covid-19 and even also the resources. They have in place a lot of money for Covid-19 but they have not given additional resources for maternal health. It’s like robbing from Peter to pay Paul. It doesn’t make a difference, you create a hole somewhere and try to fill another, but in the end, you still have a hole.


SOGH: In terms of funding, has money been shifted from maternal health to the Covid-19 response?

PW: The World Bank officially gave fifteen million dollars from maternal health to Covid-19. They said it is now the government’s preferred use and they will put it back, but they should have poured that money into the system to treat mothers. Some NGOs are also reprogramming to support Covid-19.


SOGH: This might be a very early stage to say, but has there been a noticeable decrease in coverage of antenatal care or skilled birth attendance in Uganda so far?

PW: The reports from the counties from all over the country say that there has been a reduction in antenatal care, in birth attendance, in delivery care and an increase in emergency care. Women are coming late, and they come as emergencies and they have to be operated on. Under such circumstances the outcomes are not optimal.


SOGH: Currently, what do you think is the risk for community health workers and midwives working in maternal health, in terms of passing on the disease or getting infected themselves? Is the government providing them with sufficient protection gear?

PW: There is not enough PPE (Personal Protective Equipment) for everybody, so they have to be prioritized. Those things are expensive, and they may not be available in the country. Although now the country is trying to manufacture most of the PPE itself. One of the positive things has been that the country has noticed that every country needs PPE and Uganda cannot just import. There are a couple of industries and innovators in the country that have started producing PPEs. But definitely there is not enough available for all community health workers. Health workers don’t usually handle sick patients, apart from children where they do integrated case management. I think the negative thing is that the community health workers are not even working. They have not been guided in what to do during Covid-19. They have not yet had training and remember, community health workers in Uganda are volunteers so sometimes they go by the way. I don’t think they will be prioritized now or any time soon.


SOGH: How do communities in rural areas receive news on current Covid-19 measures that the government is introducing?

PW: There are two main sources of information. First, the media. Especially radio and TV and then social media for those that have access to internet. I think subsequently they are going to devote more information tools and they will also engage community health workers. They’ve been sending some people to the field to communicate with the communities, but it becomes very expensive if you tell people they should be at home and then at the same time try to educate them. They don’t have TVs or more fancy phones. In the villages, people don’t have smartphones, there are just a few younger people who might have a smartphone. There is also a problem here, that the government actually charges a social media tax. You must subscribe to that tax to access Facebook and WhatsApp. People are not having good income during these times and internet is expensive down here. I think that is also a limitation.


SOGH: How would you describe the general perception of the pandemic in the population at the moment? Are many in disbelief or are more shifting towards panic?

PW: I think there has been panic, especially when people watch what is happening in Europe and the US. We were given time, that is one reason why the African governments acted quickly. If you look at Covid-19, in the end, for the first three months, it has been a disease of connected countries. The countries that are less connected imported it late, but it eventually had to come. We have been watching from Wuhan to Europe to the US and now to Africa. We started fearing, we don’t want it here. But having spent two months with Covid-19 here and the cases have not been going up, so there is sort of hope. Many people start to think we should even stop the lockdown. There is a belief that maybe Covid-19 is not serious in Africa although it has killed over a thousand people. Till now, it kills more than two thousand a day in the US. We had a webinar in our school today, on what should be done after the lockdown, how we should go about the opening up and many people, including myself recommended air open up and monitoring and controlling the borders. So, there is more hope that this is something that we might put behind us.


SOGH: Do you see community health workers contributing to Covid-19 response in communities? How can they explain safety measures to the public and help enlighten the people?

PW: Community health workers are a complex, informal group. I think that is the starting point of understanding them.  Because they are informal, they are not paid. This does not mean that they don’t need the money, because they do. If we are to involve them, they will need to be identified, trained, facilitated and  supervised. If that is done, if they receive training, it means they have the knowledge and skills. And if they are facilitated and supervised and given PPE, then they can educate communities. But you should know that such training will take time because they are in remote places. The advantage is that they reach many places but there remains their informality and the need for response which is limited. Imagine a country whose economy is going down, how can it manage to train so many people of an informal group?

The community health workers have a big role to play as they can go house to house, but it will be expensive. I believe the best way to involve them during this period is to find a way they can do a package of services which are addressing other issues like hygiene, immunization, nutrition, HIV, prenatal health and referrals. Offering such services, they could be an effective group. They will also be easier to manage in smaller areas. I wrote a document for a human rights organization and one recommendation I gave is the importance of maintaining primary health care. Delivering primary health care to communities is important and community health workers should be at the center of this implementation. I think if we focus on Covid-19 alone, it might not be so strategic. Of course, if the disease spreads more, then, it will be necessary. But right now, we need to balance the consequences of Covid-19 and the other conditions that are perhaps killing children and mothers even without Covid-19.


SOGH: You have been highlighting the importance of primary health care and the role of community health workers.  Do they also play an essential role in maternal health care?

PW: Yes. Like I said, they go for antenatal care visits, advise, refer women, provide support after birth and they promote family planning. They have quite a lot of things they do around maternal health.


SOGH: In the coming months, what do you think will be the biggest risks and challenges for pregnant and postpartum women and their newborns in Uganda?

PW: Covid-19 has posed a new problem which requires resources. Already, Uganda was struggling with maternal health, and I think it’s going to be worse because the resources will soon be limited. There are a cohort of women who have missed care during this time, there are the young girls and women who are conceiving, and it will come with consequences. I think it is going to be more challenging if the system does not respond. The challenge is that the peak dissolves and everybody goes to rest, and they think, ‘Problem solved’. Everybody has come together to solve Covid-19 but now we don’t know whether Covid-19 will be gone. Covid-19 might be gone from your country today and it comes back tomorrow. And there is the need for continuous testing. And when you test, what do you do? What if these exposed people have developed some immunity? So, we need to control Covid-19 within the broader air system. We need to get from this acute phase to a phase where we integrate Covid-19 control within the system. We need to strengthen air systems and everything wrong within Covid-19.

When you look at Covid-19, every measure that is being taken are things that we should be doing normally. I mean, hand washing, infection control, care in hospitals, referral and stuff like that, it should all be routine. I think smart countries and organizations will be able to learn from Covid-19 and use it to strengthen their systems.


SOGH: So what recommendation would you give to pregnant women and new mothers to keep themselves and their newborns safe, in this crisis now that there is limited access to healthcare, especially in low and middle income countries?

PW: If you are not pregnant, I think the best thing is to continue as you are. Make sure to only conceive when you must. If you are pregnant keep yourself safe. I think the consequences of being pregnant and getting Covid-19 are severe. It’s like you have an underlying condition. Covid-19 is really not anything new, it is just a major wake-up call on the essential things and it emphasizes the importance of general hygiene.


SOGH: In terms of breastfeeding, do you think there is anything in particular to pay attention to during Covid-19 pandemic?

PW: I think the general recommendation is that women continue breastfeeding. Again, I just want to emphasize the importance of making sure that the child is breastfed.


SOGH: How do you perceive the way the pandemic has been handled in other African countries and how do you think it will affect maternal mortality in Africa as a whole, particularly in the long term?

PW: In general, all African countries are almost struggling with maternal health and Covid-19 has not just put pressure on the economies but also on their health systems. And I think the risk of maternal mortality increasing in Africa is going to be quite high. I do not think that there is any country that is going to be spared. And the complication is that even the donors have problems. Imagine, how can America give aid when they are severely hit?  How can the UK give aid? So I think that those countries must also wake up. The population is going to put maximum pressure. I’m sure even in Sweden, it is going to happen that there will be more pressure from the Swedes demanding for more. Economies have started shrinking and even the rich countries are getting affected.  I mean, the US was getting aid from Russia, from China, for masks and stuff. So, it’s all complex. And we have poverty, weaker systems, infertility, adolescent pregnancy, things are going to become worse and difficult.


Professor Peter Waiswa was appointed a member of the WHO advisory board shortly after this interview and we at the Swedish Organization for Global Health congratulate him and wish him great success.

While Uganda seems to have it all put together on the Covid-19 front, there remains a storm raging in other systems, and the maternal health system, which was already struggling, is at the forefront of this battle. The truth remains that as the pandemic drags on, women and girls are losing access to the care that they need. It is saddening but this is a major indirect impact of the coronavirus pandemic. The maternal health system is falling into a deeper rut because decisions concerning Covid-19 are contributing to further neglect and Uganda is not alone in this!

We need to maintain care for mothers and their newborns within this period. This is why fundraising continues. Donate to our Mama and family project, a project focusing on maternal and child health in Uganda, and let’s help!

Our next blog post is going to be the second in our Covid-19 Impact Series and it will be focusing on Menstrual Health and Covid-19. Don’t miss it!


BY: Fiona Koeltringer and Avwerosuoghene Onobrakpeya


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