Midwifery tutor talks about Uganda experience

By Kathleen Nallen uganda_kathleen_nallen_with_girl_crop

Last summer as part of the SONAS programme at Dundalk Institute of Technology (DkIT), I had the privilege of accompanying six nursing and midwifery students on a two-week trip to Uganda as guests of the Medical Missionaries of Mary (MMM). We were also accompanied by Mark Cunningham, a psychiatric nursing lecturer who at this stage is a veteran of such trips. The students' diverse backgrounds made the dynamics all the more interesting as each had varied experiences to share and had different expectations of the trip. The group bonded almost instantly as it set out on a communal adventure.

As we approached Entebbe Airport in southern Uganda it was difficult not to imagine the scenes of carnage on this very site so graphically depicted in the film 'The Last King of Scotland', based on Uganda's relatively recent history. Because the flight was arriving in evening time, we were met by Dr. Maura Lynch, MMM and stayed overnight in a local hostel normally used by travelling missionaries. It was clean and comfortable and after a nice meal we were all lulled into our first deep African sleep by the hypnotizing sound of crickets in the garden outside.

The following morning we commenced the four-hour journey to our base at Kitovu Hospital, which is two km from the town of Masaka, in southeast Uganda. We stopped off at a shopping centre in the capital, Kampala, where we changed money and got telephone credit. This bustling city appeared a contradiction in that it contained many westernised shopping centres and products (even Guinness!) but also had several of the hallmarks of a developing city. It appeared chaotic in terms of traffic regulations, with cars, bikes, pedestrians (and even chickens) going in all directions through the streets, run-down markets, smog, etc.

The road to Masaka was an education in itself and provided an opportunity to begin to soak up a sense of Uganda. Crossing the equator proved to be a bit of a novelty and so involved the customary photography. I remember being amazed at how green and lush the Ugandan countryside appeared and wondered why this could not be better exploited to reduce poverty levels. Travelling along the dusty road, images that will live long in the memory include:

  • Bicycles intricately laden with a vendor's complete collection of goods
  • Scooters with entire families travelling on them, including babies secured to older siblings' backs
  • Trucks overloaded with matoke, Uganda's staple food and with up to twenty men seated on top
  • The sinister sight of coffins for sale on several locations along the road, with sizes varying from infant to adult.

The other most striking and startling feature had to be the number of very small, ragged, barefoot children walking on their own along this barren road with no settlements in sight. The main purpose appeared to be to walk endless miles to fetch water with their jerry cans.

Following our arrival at Kitovu Hospital and the initial meeting and induction by the MMMs, the group divided in two for the duration of the trip, except for the weekend when the group was reunited. Mark accompanied three students to Makondo, an area fifty kms west of Masaka, whilst I was based at Kitovo Hospital with three others. We swapped around for the second week. In the town of Masaka, a vibrant inter-cultural community of Sisters provides a range of services to disadvantaged people, including children orphaned by AIDS, people suffering from substance abuse, street children and prisoners. At Makondo, the MMMs' work includes running a health centre, schools and outreach care to surrounding villages. During the trip the group got to experience all of these excellent services. From a midwifery perspective one of the highlights was visiting traditional birth attendants in their own homes. This was a very humbling experience and we were very impressed with the level of care they provided with minimal basic equipment.

Kitovu Hospital was established by the MMMs. However the administration and staffing of the hospital are now under the management of a local diocesan Congregation of Sisters. Dr. Maura Lynch, an MMM general surgeon, still works at Kitovu, where a new unit provides advanced surgical techniques to repair the condition known as vesico-vaginal fistula, which I will refer to later in this article.

One of the Assistant Directors of Nursing kindly gave us a tour of the hospital on the first morning. We were unanimously greeted and welcomed by everyone as they were genuinely pleased that we had chosen to gain some insights into their work and lives. During that week we experienced many positive aspects of life in Kitovu Hospital: the resilience of staff who continue to work with minimal resources and lack of basic equipment and medicine; their unwavering enthusiasm despite being faced on a daily basis with overwhelming morbidity and mortality rates; the joy experienced by the children, who spend endless weeks in the malnourishment unit, when the monotony was broken by colouring books and balloons we had taken with us; the efficiency of the laboratory in providing HIV test results, which ensures pre and post-test counselling on the same day.

Even though we had been quite well prepared from the induction days in DkIT regarding what to expect in terms of culture, services, climate, food, etc., there were many experiences for which we were unprepared. Indeed on reflection, it would be as difficult to prepare for them as to adequately describe them. These included:

  • Adults and children dying on a daily basis from preventable and treatable illnesses such as TB, pneumonia, and malaria.
  • Lifeless children sprawled on large iron beds in the paediatric unit, many too sick to even open their eyes fully.
  • Patients with TB and AIDS being kept in tiny, dingy outhouses, which at home would not be considered suitable for animals.
  • Patients having to supply their own bed linen and food, many of whom have no means of doing either.
  • Bodies being brought home by a relative on a scooter, just wrapped in a blanket for burial in the back garden.

The midwifery students and I had a natural interest and orientation towards the maternity services and this also proved insightful. We observed many positive developments such as efficiently-run antenatal classes and clinics as well as the aforementioned HIV and other routine testing. The maternity unit itself and the service provided therein proved much more challenging to our philosophy of midwifery. We quickly came to realise that the women we met there were those capable of accessing it, indeed many after spending several days often on foot and in advanced labour.

Reviewing their records gave us the first insight into maternity care in Uganda. It was not unusual to see a 19-year-old on her 4th or 5th pregnancy. It was also not unusual for a woman to have given birth to 8 children with perhaps just 2 still alive. The Infant Mortality Rate in Uganda is 76.9 deaths/1,000 live births, compared with 4.9/1000 in Ireland (United Nations Population Division, 2006). The mortality rate for mothers in Uganda is 550/100,000 compared with 1/100,000 in Ireland (WHO, UNICEF, 2005). Again shockingly, most were dying from preventable and treatable conditions such as haemorrhage and sepsis. The unit itself was hugely under-resourced in every aspect. There were no cots for the babies; instead they were just placed on a blanket on the floor. There were also no curtains between the beds. From our background of protecting the woman's privacy and maintaining dignity, we found it extremely challenging to see women having vaginal examinations in a 14-bedded ward with people all around, and on one occasion with a man scrubbing the floor a few feet away. Initially from our perspective, we felt that in terms of funding, curtains would be a priority. However we quickly came to realise that in fact there were many more essential pieces of equipment needed more urgently, e.g. a blood pressure monitor, fetal stethoscope, and a vacuum pump for assisting at birth, etc. Medical cover was often provided by junior doctors and indeed by doctors who were not obstetricians. Management informed us that they have difficulty in retaining staff due to the working conditions.

For those who survive childbirth a very high percentage are left with debilitating consequences. One of the most devastating is a vesico-vaginal fistula (VVF), which is an opening between the bladder and vagina, usually as a result of prolonged and obstructed labour. This results in continual leakage of urine with surgery the only treatment option. The consequences of VVF are far-reaching, beyond the obvious distress cause by its physical effects. These women are generally abandoned by their husbands, families and communities, with some even associating it with a form of witchcraft. It is estimated that 140,000 women live in solitude with this condition in Uganda alone. On a positive note we were privileged to experience some of the pioneering and life-changing work carried out by Dr. Maura Lynch and her team of volunteer doctors in assessing and surgically treating many of those affected.

We also had some more impromptu insight into living with this condition when on our day off, we were taken on a safari in the same minibus which the previous day had taken a group of women with VVF from Rwanda to Kitovu Hospital for treatment. Despite vigorous cleaning by the driver, their remained the unmistakable, pungent odour of urine from the seats. This grew increasingly worse with the midday heat and by the time we got to the safari park we were all reeking of urine. Even though we joked about it, nobody really complained because we were all aware that for women who have a VVF this is what it is like for them all day, every day. At least the only 'treatment' we needed was a shower.

Overall the trip to Uganda was a very memorable one and this article provides just a brief snapsnot. Although we experienced an array of emotions, what remains is an overriding positive experience. Some of the lasting memories include the warmth and resilience of the Ugandan people in the face of such adversity, and the unrelenting, life-changing work carried out by the MMMs. Because it was my first trip to a developing country, the learning curve for me was really not much different to that of the students. Therefore I feel I can confidently encourage all students to avail of any such future opportunities. The learning that takes place is much broader than that which can be encompassed into a few neat learning objectives. It involves challenges to all aspects of one's development, e.g. professional, personal, social, cultural, spiritual, etc., which can only enhance one's contribution to life's journey.

Finally, I would like to thank the management of DkIT for supporting this worthwhile project, the MMMs for hosting us, the management of Our Lady of Lourdes Hospital, Drogheda for facilitating our postgraduate student midwives, Mark Cunningham for his support and companionship, and in particular the six students who accompanied us for their enthusiasm, attitude and good humour. They certainly did their families and DkIT proud.

Kathleen Nallen
Midwifery Lecturer, School of Nursing, Midwifery, Health Studies and Applied Sciences, Dundalk Institute of Technology