Sitting in Doha airport with a couple of hours to while away before I board for the final leg of my journey home I am reflecting on the last six weeks in Uganda. The maternity department has seen a flow of really difficult obstetric emergencies and I have encountered several situations I have never had to deal with before. Even as I left this morning, my Ugandan colleague was going to theatre to perform a caesarean section on yet another mother who had turned up with an intra-uterine fetal death. The baby’s arm had prolapsed out through the cervix so the operation would have been difficult to do.

I am left wondering at a world where so many babies die before birth. So many of these deaths would be preventable with a better health and transport infrastructure. I spent Friday with the outreach team doing an antenatal clinic in a really remote and mountainous area more than an hour away from Kisiizi. The dirt roads were riven with deep gullies and we were often driving over bare rocks. There is a government hospital nearer than Kisiizi but the women worry about going there to deliver because the one doctor employed there is often absent and they know that they will face another transfer if anything goes wrong so they prefer to make the difficult journey to Kisiizi. I can’t imagine how if feels to be bumped along those roads whilst having contractions, or to travel on the back of a boda (motor-bike taxi) in labour.

Kisiizi really struggles to recruit midwives, especially the more highly qualified registered midwives. The hospital cannot afford to pay the sort of premium it would take to attract this cadre of staff and many health workers prefer to work in larger towns and cities where there is the opportunity to moonlight in private clinics. So far this month there have been more than 200 deliveries and the few midwives Kisiizi does have are on their knees. They have to deal with very high risk complex cases with minimal resources, and there is rarely any let up. One midwife told me of a day when she personally delivered 13 babies. It is a great tribute to Kisiizi’s midwives that so many women in the community told me that they chose Kisiizi as their place of choice to deliver because the staff there were quick to help them.

It would have been all too easy for me to bury myself completely in clinical work and I did a fair bit, but I also tried to stand back a bit in order to spend as much time as I could teaching and training the staff and students about how to manage obstetric emergencies. I am not there most of the time, and simply rolling up my sleeves and working would not result in much of a sustainable improvement, tempting though it would be to do.

There are some initiatives going on which are aiming to bring about improvements. Many of the student enrolled midwives in the School of Midwifery at Kisiizi have government scholarships and it seems that there is a plan to recruit and train more midwives from remote communities in the hope that they will then stay and work in these areas. Time will tell if this results in improvements in recruitment and retention in remote areas.

I went to the ward early this morning before I left to update my database of usage of the mothers’ waiting home. The home has been open for 4 weeks during which 40 women have stayed there. We have tried to listen to the mothers and are making some changes as a result of what they tell us. A night watchperson will be employed as there have been instances where people have tried to enter the home and sleep there, some of whom are not pregnant or even female! It has become clear that a watchperson is needed to keep the women safe and give them peace of mind.

An obstetric fistula camp has been underway for the past week. Although obstetric fistulas are becoming less common than they were in the past, some of the women being operated on had untreated third or forth degree tears (a tear caused by childbirth involving the anal sphincter). Failure to recognize and repair such a tear after delivery results in faecal incontinence. I was told of one poor woman who had attended the camp who had suffered from faecal incontinence for 40 years. Her life must have been so miserable. I can imagine that inexperienced midwives, working unsupervised in units where facilities for perineal repair are limited and lighting may be restricted to a paraffin lamp or a torch, may struggle to identify these tears.

It seemed to me that I have been seeing more women who are HIV positive than has been the case over the past few years. There is still a stigma attached to diagnosis that leads to much silent suffering. The system for identification and treatment of HIV does seem to have improved and the new policy of staying on treatment for life once started means that far fewer babies will become infected via breast feeding as with much lower viral loads for treated mothers will ensure that milk becomes much less risky as a medium for the virus. Gaps in the system still remain and there are still women who turn up in labour who have not been tested.

I will be going back in Uganda to do some lecturing in Kampala in November but sadly won’t have time to get back to Kisiizi until next year. Please do continue to watch Kisiizi Partners for more news about the hospital though!