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Mother and children in hospital ward in Bbowa, Uganda.

A mother and her two children sit on an examining table at a hospital ward in Bbowa, Uganda, January 2009. Image: Paul Evans

For the women there is often little to no access to qualified health personnel or well equipped facilities. Where access to skilled midwives, antibiotics, obstetricians and medical intervention, are taken for granted, they are regarded as luxuries in many regions of Africa. Uganda is only one country of many particularly in need in Africa.

Challenges for midwives with transportation, improper or non-functional medical equipment and lack of doctors and supporting medical staff are ongoing.  Engaged campaign donations, along with specific state management and follow-through, are key to improving these and other conditions, including conditions that may lead to an increase in maternal mortality.

“The lack of midwifery health cadres in remote areas together with poor pre-service education are key bottlenecks that need to be further addressed in Uganda’s health policies. For instance, only 55 percent of facilities offering deliveries have a trained provider on site 24 hours per day, while 1 percent have a skilled provider on call 24 hours a day,” said the Millennium Development Goals Report for Uganda 2010.

While proper medical equipment is a tangible challenge, “Evidence suggests that only 5 percent of facilities have a vacuum extractor (used for assisted vaginal delivery) and only 10 percent have the kit needed to remove a retained placenta,” continues the 2010 report.

“But we can fix this,” outlines Esther as she talks about the specific function midwives hold for women who need their assistance, “if we invest in building proper health facilities, educate women to come to our clinics for check-ups and when they go into labor and if we can train more midwives, we can fix this.”

I talked with Esther in northern France as she attended the Women’s Forum Global Meeting to launch the AMREF – African Medical and Research Foundation “Stand Up for African Mothers” campaign, which aims to educate another 30,000 midwives throughout Sub-Saharan Africa by 2015.

With 50 years experience in health development, AMREF was founded in 1957 by three surgeons: Thomas Rees, Sir Michael Wood and Archibald McIndoe who were known as the Flying Doctor Service of East Africa, which later became AMREF, one of the continent’s most respected health development organisations.

Following the Women’s Forum for Economy and Society press conference and an official signing of the campaign’s petition to applause and flashing cameras, Esther and I sat down to talk in a quiet corner away from the crowds, dignitaries and PR people.

It was Esther’s first time outside Uganda. It was also her first time on an airplane. She flew – alone – from Kampala via Nairobi to Paris. “I’ve never seen an airport like that one in Nairobi,” she says shaking her head in disbelief. “So big and so busy! But I told myself: ‘Esther, don’t panic. Just do one thing at a time.’ And so here I am,” she smiles.

During our interview we talk of her job as a midwife and what her perfect day looks like (one in which none of the women she attends to is HIV positive); about flying and the feeling take-off leaves in one’s stomach; about her wayward husband and two kids that should have been three.

“I am here because I want the world to understand the importance of midwives in Africa,” she says. “When I was 29, I lost a baby because the only two midwives at our hospital were in the theatre (field) busy delivering babies. There was no one left to look after those of us in labor. My baby died because it went into distress and couldn’t be delivered quick enough. That is no reason for a baby to die…”

During a moment of silence Esther is lost to her memory which cocoons us. I am silent, helpless to offer any meaningful words to her. “I don’t want that to happen to any woman,” she outlines. “The lives of those women and babies are (now) in my hands.”

As an AMREF representative walks over to whisk Esther away from our interview and off to lunch, I ask whether she has bought any presents to take back home to her family. She shakes her head, eyes cast to the ground. “No, I don’t have my own money here so I can’t buy presents.” An uncomfortable silence follows as I realize that my question spotlights my own comfortable western life. “But they’ll be so happy to see me when I get back home, that is my present to them!” she beams.

Improving conditions for women who enter careers as nurse midwives must now include combined efforts inside and outside Uganda to properly recruit, train and enable midwives to reach their oftentimes vast miles of travel needed to serve districts that span rural areas. Following a Ministry of Health directive to improve education in Uganda then years ago nurse midwives now take three years to complete their studies as many women face uncountable conditions of hardship in the field. In spite of this, numerous women are not offered promotions to higher positions within the medical community.

“In order to achieve the best maternal health outcome there is need for skilled personnel with midwifery skills and a well functioning referral system,” says the current outline in the Millennium Development Goals Report for Uganda 2010.

Esther Madudu’s tireless work and desire to improve conditions for women inside Uganda is invaluable to her community and to the rest of the world.

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Asking for more stringent training for midwives in Uganda (2010), Enid Mwebaza and Dr. Jacinto Amandua of Uganda’s Ministry of Health along with Country Midwifery Adviser Irene Ikena, explain needs and solutions. More medical knowledge has been needed on-the-ground for nurse midwives who often manage bleeding and over-bleeding for women during childbirth with little to no medical equipment or resources. Hemorrhagic bleeding is a condition that is one of the the number one killers of mothers during and following childbirth in Uganda. This 1:54 minute, video is a May 2010 television news production of NTV Uganda.

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For more information on this topic:

Midwifery in Uganda – In-depth country analysis,” prepared as a background document for UNFPA – United Nations Population Fund – The State of the World’s Midwifery 2011 (launched June 2011);

Stand Up for African Mothers booklet,” AMREF, June 2010;

Tracking and monitoring the health workforce: a new human resources information system (HRIS) in Uganda,” WHO – World Health Organization – Human Resources for Health, February 2011;

AMREF – African Medical and Research Foundation website.

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Gender communications expert and WNN Brussels based journalist Sabine Clappaert has also published work  in De Morgen and Flanders Today (Belgium), Pink Ribbon magazine, The Bulletin, IPS News (UK/International) and Destiny Magazine (South Africa). Clappaert is dedicated to covering human rights issues and development as they intersect with women inside and outside Europe.

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Additional sources for this article has been provided by Ministry of Health Uganda, UNFPA – United Nations Population Fund, Makerere University Institute of Public Health Uganda, AMREF – African Medical and Research Foundation, NTV Uganda, Women’s Forum for Economy and Society and WHO – World Health Organization – Human Resources for Health Journal.

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